The following article is written by Virginia McCollum, RN, guest blogger for the Joint Commission's Ambulatory Health Care Blog. It has been adapted and reprinted with permission.
The multiple credentialing and privileging tasks for ambulatory care organizations are found in Joint Commission ambulatory care standard HR.02.01.03. These are the steps needed to attain and maintain accreditation under the Ambulatory Care Accreditation Program of The Joint Commission. They also represent good practices for any ambulatory surgery center.
The process is needed when the provider is licensed to provide care without supervision. For example, a licensed physician is able to practice/provide care, treatment or services without supervision — by law. A RN/LPN is licensed to provide care with supervision, within the regulations of their license. Some states have different professions as practicing with or without supervision. For example, registered nurse practitioners, in 14 states, are licensed as without supervision, and in the rest of the states, with supervision. It is regulated by the individual state law and regulations. They can be found in each state's official website.
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Here is a list of 14 tasks/requirements to ensure that your patients are receiving care from credentialed individuals who are privileged by your organization to practice without supervision.
1. Define the scope of the care your organization is providing.
2. Identify which practitioners are considered licensed independent practitioners (LIP), who will then be required to be credentialed and/or privileged. Check your individual state law and regulations — your state 'practice act' defines if the license allows the profession to 'practice independently' or 'may practice with supervision'.
3. Identify the scope of practice for each type of licensed independent practitioner in accordance with your law and regulation. Scope is the term for the task/privilege the LIP will be providing to your patients.
4. Define the qualifications, (based on your scope of care, or the services you are providing) that the LIP must possess to be privileged to practice in your facility. Simply said: What qualifications do you want the LIP to have in order to provide care in your organization? For example:
- Education, training and experience;
- Specialty areas of practice;
- Board certification, etc.
The Joint Commission does not require any defined qualification; your organization determines what is required. The qualifications need to be specific to the privilege being granted for safe, competent patient care.
5. Each practitioner needs to formally request privileges to provide specific care or treatments. Methods include:
- Use of a formal application;
- Letter of request; and
- Conversation with the medical director who documents the request.
6. Obtain required credentialing information for credentialing core criteria:
- Current license, including all actions against the license;
- Primary source verification (PSV) of relevant education, training and experience;
- Current competence (letters from practitioners personally acquainted with the applicant's performance); and
- Querying (asking for/requesting formally) the National Practitioner Data Bank (NPDB) for sanctions against the LIP license.
7. NEXT — Transfer information from the organization that has done the primary source verification, to your files.
8. Verify any organization-specific requirements such as:
- Board certification, if required;
- DEA (Drug Enforcement Administration) certification with expiration date; and
- Current malpractice insurance and expiration.
9. Obtain a written statement from the licensed independent practitioner covering:
- That no health problems exist that could affect his/her ability to perform requested privileges. (Does not have to be a physical — can be simply a statement. Your organization decides. For example, consider ADA — Americans with Disabilities Act);
- Challenges to licensure or registration;
- Any voluntary or involuntary relinquishment of license or registration;
- Voluntary and involuntary termination of medical staff membership at another organization;
- Any voluntary or involuntary limitation, reduction, or loss of clinical privileges; and
- Any professional liability actions that resulted in a final judgment against the applicant.
10. Medical director assesses the information to determine if it meets the required qualifications.
11. The medical director obtains formal approval from the appropriate leaders (governing body, administrator, medical director — your organization determines your governance, and rules and regulations of your organization) with a recommendation to the governing body to privilege an individual to practice in the facility.
This can be documented in governing body meeting minutes, but remember to document which privileges are granted, the appointment or privileging time period — not to exceed two years.
12. Notify the practitioner in writing of the decision.
13. Document and maintain evidence of the appointment in the practitioner's credentials file.
14. Develop a system to keep the information which is subject to change – such as licensure, DEA certification, and board certification — current.
I know this looks like a very intimidating list, but it is all necessary to properly credential and privilege your LIPs. It takes a very organized person to keep all information in order and then follow-up with re-privileging every two years. The credentialing of education/training is only updated if the LIP has attended additional training or credentials.
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