July 30, 2020

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QUESTION:       
We recently received a request, from one of the Physician Assistants in our organization, asking that the Medical Staff Bylaws be amended to allow advanced practice clinicians (Nurse Practitioners, CRNAs, and Physician Assistants) to be members of the Medical Staff and to serve on committees, including the Credentials Committee and the Peer Review Committee.  Can you tell us what you are seeing around the country in these areas?

 

ANSWER:           There has been significant change around the role and responsibilities of advanced practice providers.  We can start with the terms that have been used to describe this group.  In the past, these practitioners were referred to as “physician extenders,” “mid-levels” or “allied health practitioners.”  Now, many organizations use the term “advanced practice professionals” or “advanced practice clinicians.”

Historically, any reference to “physician extenders” or “mid-levels” in the Bylaws was limited to a paragraph or two tucked away at the back of the document.  As the accreditation organizations began to require that these practitioners be credentialed and privileged through the medical staff or related process, many hospitals created parallel policies but still treated allied health practitioners as separate from the Medical Staff.

As advanced practice clinicians have become more integrated into the delivery of care in hospitals and integral to that care, we have seen their roles and responsibilities on the Medical Staff change.  Some Medical Staffs have created an Advanced Practice Clinician Staff that is not a category of the Medical Staff but is included in the Bylaws and addresses the prerogatives and responsibilities of these practitioners.

A small number of Medical Staffs, usually in critical access hospitals, have simply incorporated advanced practice clinicians into their existing Medical Staff categories.  More recently, in Bylaws that we draft, we include an Advanced Practice Clinician Staff as a category of the Medical Staff; however, much like the Courtesy Staff or Consulting Staff, the Advanced Practice Clinician Staff has limited prerogatives and responsibilities.

Another easy step towards inclusion is to allow advanced practice clinicians to be appointed to committees.  This will allow advanced practice clinicians the opportunity to participate in medical staff affairs in a meaningful way and to develop valuable leadership skills.

Since the number of advanced practice clinicians continues to grow, their training continues to evolve,  and their scope of practice continues to expand, creating an Advanced Practice Clinical Committee (staffed by both advanced practice clinicians and physicians) or adding advanced practice clinicians to the Credentials Committee could give your organization a leg up on these challenging issues.

Similarly, since hospitals must evaluate the clinical performance of advanced practice clinicians through the peer review process initially, on an ongoing basis, and when questions are raised, fostering the development of advanced practice clinicians so they can participate in this process makes a lot of sense.  Training advanced practice clinicians to perform case reviews and inviting advanced practice clinicians to serve on the Peer Review Committee are important discussion points.

Some Medical Staffs have decided to include an advanced practice clinician as a member of the Medical Executive Committee (with or without vote).  Identifying the right person to serve in this role is very important and that’s why it may be worth vesting this power in the Chief of Staff or the Medical Executive Committee.

In addition to serving on committees, advanced practice clinicians can be invited to attend department meetings and meetings of the Medical Staff.   In the organizations that we work with, typically, this participation is without the right to vote.

The bottom line is that these are important issues to discuss because they are not going away.  Before you make any changes to your bylaws, however, be sure to check state law.  Some states, like Pennsylvania, limit the Medical Staff to physicians and dentists, unless an exception is granted by the Department of Health.

Additionally, there are some limitations reflected in the CMS Interpretative Guidelines in terms of the Chief of Staff position; this position must be filled by an MD, DO, or, if permitted by State law, “a doctor of dental surgery, dental medicine, or podiatric medicine.”  With respect to the composition of the Medical Executive Committee, the Interpretative Guidelines say that a majority of the members must be MDs or DOs.

February 6, 2020

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QUESTION:      What do you recommend for the composition of the Credentials Committee and the terms for service for the members?
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ANSWER:         A Credentials Committee is best composed of experienced leaders, such as past chiefs of staff or other physicians who have had medical staff leadership experience.  Many Medical Staffs have representation from a variety of specialties to ensure that the committee has the expertise necessary to address difficult credentialing and privileging issues.  With the increasing number of advanced practice clinicians (e.g., nurse practitioners and physician assistants) providing services in hospitals, more and more Medical Staffs are appointing at least one advanced practice clinician to the Credentials Committee as a voting member and for that individual’s input and expertise on the topic of credentialing and privileging these providers.

Service on the Credentials Committee should be the primary medical staff obligation of the members and terms should be at least three years so that committee members have an opportunity to gain some experience and expertise in credentialing.  The terms should also be staggered so that there is always a repository of expertise on the committee.  This Credentials Committee’s primary responsibility is to review and make recommendations on applications for medical staff appointment and clinical privileges.  It can also oversee the development of threshold eligibility criteria for clinical privileges.

February 19, 2015

QUESTION:    Our pediatricians have asked that their Nurse Practitioners be permitted to be listed on the on-call list of the Hospital in lieu of their collaborating physician. Is this permissible under the Emergency Medical Treatment and Active Labor Act (“EMTALA”)?

ANSWER:    No. Nurse Practitioners (or other nonphysician practitioners) cannot be listed on the Emergency Department on-call coverage list. EMTALA requires hospitals to “maintain a list of ‘physicians’ who are on call for duty, after the initial Emergency Department examination, to provide treatment necessary to stabilize an individual with an emergency medical condition.” 42 U.S.C.A. §1395cc(a)(1)(I).

EMTALA specifically requires the physicians on a hospital’s medical staff to be individually listed to provide on-call services necessary to stabilize a patient.

Nurse Practitioners may not independently participate in the emergency on-call roster (formally or informally by agreement with their collaborating physicians) in lieu of the collaborating physician. The collaborating physicians (or their covering physician) must be listed for on-call coverage and must personally respond to all calls in a timely manner, in accordance with requirements set forth in the Bylaws and EMTALA On-Call Policy. Following discussion with the Emergency Department, the collaborating physician may direct a nurse practitioner to see the patient, gather data, and order tests for further review by the collaborating physician. However, the collaborating physician must still personally see the patient when requested by the Emergency Department physician.

A Nurse Practitioner (and other APRNs and Physician Assistants) may be used to assist the on-call physician in responding to call. Any decision to use any of these nonphysician practitioners to respond initially to the Emergency Department should be made by the on-call physician in conjunction with the Emergency Department physician.

If the on-call physician and the Emergency Department physician do not agree, the Emergency Department physician is the final decision-maker. (If the Emergency Department physician disagrees with the on-call physician’s decision to send a Nurse Practitioner or other nonphysician practitioner, the Emergency Department physician is to request the on-call physician to come in.) This decision must be based on the patient’s medical needs and the capabilities of the hospital, and must be consistent with hospital policies and/or protocols.

Nonphysician practitioners – qualified medical personnel (“QMP”) under EMTALA – can perform the medical screening examination under EMTALA. This also means that the QMP has been granted the clinical privileges necessary to perform the medical screening examination, and that the privileges come within the applicable state licensing regulations for that QMP category. The EMTALA requirement in this situation is that the hospital’s governing Board has approved, in writing, the category of nonphysician practitioners who will be performing the medical screening examination.

Join Charlotte Jefferies and Dan Mulholland in warm, sunny Orlando on March 19-20 for a workshop on Advanced Practice Clinicians!