March 12, 2015

QUESTION:    We just received an application for privileges from a nurse practitioner. As part of her application, she submitted a copy of her “Collaborative Practice Agreement” which stated that “the intent of this document is to authorize the nurse practitioner to practice” at various sites, including our hospital. This doesn’t seem right to us. What can we do?

ANSWER:    In most hospitals, advanced practice registered nurses and physician assistants (advanced practice clinicians) have become an integral and invaluable part of the treatment team. However, there continues to be challenges in credentialing and privileging advanced practice clinicians created by differing standards, expectations, and training.

As with all practitioners, you should establish threshold qualifications for advanced practice clinicians.   We recommend that you develop these qualifications in advance and include them in your medical staff credentials policy.   Typically, threshold qualifications will require evidence of a Collaborative Practice Agreement (for advanced practice nurses) and a Supervision Agreement (for physician assistants).

Specific education, training and experience criteria can be included in the delineation of privileges (“DOP”). The DOP should also address exactly what the advanced practice clinicians are permitted to do in the hospital. It is a good idea to address the role of advanced practice clinicians in consultations, emergency on-call coverage, calls regarding their collaborating or supervising physician’s hospitalized inpatients, daily inpatient rounds, and orders. In all of these areas, medical staff leadership should recommend, and the hospital adopt, standards that best meet the needs of patients treated at the hospital.

Importantly, in establishing threshold qualifications, and in developing the DOP, you will be guided by the relevant licensing statutes. However, it is important to remember that even if the licensing statute allows an advanced practice clinician broad authority to practice, the hospital can impose a more limited scope of practice. The same is true for the Collaborative Practice Agreement and the Supervision Agreement. These documents may be drafted as broadly as legally permissible, but that does not mean that the hospital must allow the same broad practice in its acute care setting.

Finally, consistent with federal and state law, the hospital cannot allow the Collaborative Practice Agreement (or the Supervision Agreement) to “authorize” practice in the hospital. That authorization can only be granted by the Board of the hospital following a full and complete review and a recommendation by the Medical Executive Committee. In this particular case, you would be well advised to inform both the nurse practitioner and her collaborating physician that any language “authorizing” practice in the hospital should be stricken from the Collaborative Practice Agreement.

For more information about advanced practice clinicians, Join Dan Mulholland and Charlotte Jefferies on March 19-20, 2015 in Orlando for the Advanced Practice Clinicians Workshop.