Advanced Practice Credentialing,
Privileging, Onboarding and Professional
Practice Evaluation for the PNP
Michelle M. Wilson, MS, CPNP-AC, PPCNP-BC
Lead Nurse Practitioner, Pre-Surgery Preparation Center Chair, Advanced Practice Provider Credentials Sub-Committee
Julie Tsirambidis, MSN, FNP-BC, PNP-PC
Director, Advanced Practice Center Nurse Practitioner, Akron Children’s Hospital Pediatrics
Disclosures
•
Speakers have no financial relationships to disclose.
•
Speakers will not discuss off label use and/or
investigational use of any drug or device in the
presentation.
Learning Objectives
•
Describe the process of advanced practice
credentialing, privileging, onboarding and professional
practice evaluation.
•
List the benefits of developing an advanced practice
structure that is inclusive of a credentialing committee
and medical staff membership with a professional
practice evaluation committee.
•
Discuss ways to measure provider competency in the
context of FPPE and OPPE process including peer
review.
Definitions
•
Credentialing
is the process of verifying
education, licensure and certification.
•
Privileging
is the process of granting the
authority to perform specific aspects of patient
care.
•
Onboarding
is the process of organizational
socialization.
•
Professional practice evaluation
is a screening
tool used to evaluate practitioners who have
been granted privileges.
Who are the Medical Staff ?
APRNs (CNP, CRNA, CNS, CNM)
Physicians
PAs
Psychologists
Podiatrists
Dentists
Optometrists
PharmD
Clinical Scientists (PhD)
Initial Credentialing and Privileging
•
Much paperwork!
•
Lead APPs mentor through the process
•
Applicant meets with Lead Medical Staff
Coordinator Credentialing Specialist
•
Master’s or DNP degree
•
National board certification
•
Collaborative agreement
•
CTP & DEA
Delineations
•
10 different APP delineations: PNP, FNP,
*NNP, Adult NP, CNS, *CRNA, *surgical,
PA-medical, Women's Health NP, & PMH NP
•
Core and special non-core privileges
•
Initial appointment, reappointment or
additional privilege/location request
•
Qualifications & limitations
The Process
•
Data gathering, collecting, verifying
•
Presenting applicant at Credentials
Sub-Committee (workgroup)
•
2 APP’s review the APP applicant files
•
Recommendations made
•
Formal presentation at Credentials Committee
Common Issues
•
New grads
•
Lack of relevant experience
•
Poor planning in filling the need
•
Lack of understanding of APRN formal training
•
No documentation to support privilege
request
•
No current practice
Medical Staff Membership
APRNs and PAs at Akron Children’s Hospital are credentialed and privileged as active members of the Medical Staff, with voting membership.
Pay similar dues as other medical staff peers
They carry provider billing numbers with Medicaid, Medicare, and commercial payers and are able to professional bill their services according to the payers’ fee schedule.
Serve on various medical staff and hospital wide committees
Participate in shared governance and reporting to MSEC through an APP Council.
The Advanced Practice Provider Center at Akron
Children’s Hospital supports the role of Advanced
Practice Registered Nurses (CRNA/CNP/CNS) and
Physician Assistants (PA-C).
The Center serves to provide expert resources on
practice, licensing, compliance, credentialing,
continuing education, training and development
to advanced practice services throughout the
organization.
What is the APP Center?
Advanced Practice Structure
APP Council
Chair - Julie Tsirambidis, MSN, CNP
The Advanced Practice Provider Council is a medical staff sub- committee of the Medical Staff Executive Committee (MSEC). The APP Council also serves as a Shared Governance Group and Council as part of a Magnet Designated organization. Duties: The APP Council reviews standards for APRN and PA providers and practice. The APP Council operates to decrease barriers to practice, and increase access and service to the delivery of health care of patients. It also provides the forum for the committees to exchange, create, and improve areas of clinical practice, continuing medical education efforts, community outreach, address state and national health policy, credentialing issues, and hospital initiatives. The APP Council recommends, revises, create policies, procedures, processes and forms to support APRN and PA practice at Akron Children’s Hospital. Composition:
The APP Council consists of a Chairperson: The APP Center Director will serve as the APP Council Chair, who is a member of the MSEC Committee and will report the operations of the APP Council. The Lead APP providers all of all divisions, The Chairs of each APP Council committee*, Three additional APP members at large (From divisions located within DOP including one APP located at an off-site Campus and from ACHP practices), Two medical staff physicians with vote, The CMO serves as a non-voting ad-hoc member, The CNO serves as an non-voting ad-hoc member, Additional ad-hoc members can be appointed by the APP Council chair without approval
APP Credentials Committee/Health Policy APP Council Treasurer Clinical Practice, Education, & Research Annual APP Conference Committee (Fall & Spring) Professional Development
Quality APP Outreach/Visibility Onboarding Committee
Advanced Practice Provider Credentials Committee
APP Council Chair
Michelle Wilson, MSN, CNP
• This committee is a subcommittee of the med staff credentialscommittee dedicated to the review of the APP medical staff applicant (includes APRN and PA providers) for membership, change in privileging, or reappointment issues.
• Responsible for the Quality Monitoring oversight and Standard Care
Arrangements and Supervisory Agreements yearly in collaboration with the Medical Staff Office.
• See full bylaw in med staff policies. • Meets monthly
Advanced Practice Providers Quality Committee
APP Council Chair Marlene Hardy-Gomez, MSN, CNP
•
This committee is part of the APP Council
•
Function is to oversee the quality assurance process and
oversight in conjunction with the APP Credentials group
and to create processes as needed
•
Chair sits on Med PI committee
•
Ongoing APP Quality Committee Chair will review and
update necessary changes to the practice specific
orientation plans with Lead APPs
•
Work in collaboration with Med PI Team
Design Benefits
•
Ability to advocate
•
Hear our voice
•
Visibility
•
Expert resources
•
Leadership and learning opportunities
•
Inclusive rather than exclusive
•
Forward motion
APP Onboarding & Orientation
Program
APP 90 Day Checklist to Practice created and
reviewed annually by the APP Council
Originates with APP Recruiter HR
Moves on to the Medical Staff office, Lead
APP, and Divisional Directors or delegates
Part of the FPPE process
APP Onboarding Program
APP Boot Camp Lecture Series Created and Reviewed Annually by the APP Center
The APP Boot Camp is a year-long series of lectures and events specifically designed for clinical growth, networking, and professional development of our Advanced Practice Professionals.
It is a high level on boarding program as part of the FPPE process and not intended to replace practice specific orientation, which is completed within practice specialty as part of the FPPE Document.
2015 moving to online
Quarterly networking APP meetings continue
APP Specialty Specific Orientation
•
Division Specific
•
Standardized template
•
Annually the Lead APP responsible for reviewing
content
•
Lead APP submits the orientation plan to APP Center
and medical staff office for new providers
•
Currently in place: NICU, PICU, Hospitalist Medicine,
Orthopedics, Plastic Surgery, Burn Surgery, General
Surgery, Neurology/ND, Cardiology, Anesthesia, Pre-Op
Surgery/PSP center, Primary Care, Endocrinology,
Palliative Medicine, Neurosurgery, Heme/Onc
What is “FPPE/OPPE” ?
•
Focused Professional Practice Evaluation
•
Ongoing Professional Practice Evaluation
FPPE
•
What is Focused Professional Practice Evaluation?
•
This is a set of credentialing and privileging standards
required by the Joint Commission.
•
Requires evaluation of practitioner competency at the
time of hire
•
A plan for a FPPE should be forwarded to the Medical
Staff Office during application for appointment
•
“Peer review process that provides meaningful
feedback about the provider’s practice, as well as
interpersonal relationships”
FPPE…more
•
New Joint Commission standards in 2008 that required
institutions to ensure the following:
•
Review of all new providers in the institution after they
are credentialed for special procedures
•
Providers maintain ongoing competency for the
procedures that they are credentialed for
•
A process is in place for a focused review of a provider
should an event trigger the need for such a review
•
The re-credentialing process includes a documentation
component that articulates that the provider has
maintained competency for the procedures
FPPE…more
•
What constitutes a FPPE?
•
The FPPE is a review of the provider’s practice that involves
an evidenced based verification of a provider’s knowledge,
skills, and behavior.
•
When does a FPPE occur… “What triggers a FPPE?”
•
Following the credentialing of a new provider (~6 months)
in the institution to ensure that the provider is doing well &
performing the procedures for which he/she is credentialed
•
Following a significant patient event involving the provider,
as a result of a critical patient complaint, or at the request
of the practice site based on ongoing practice concerns
Our FPPE Policy
•
The Medical Staff Office is responsible for providing
submitted completed FPPE’s to the Credentials
Committee for approval of the completion of this
review period
•
The CC will evaluate the data provided & any concerns
will be noted in the minutes
•
On direction of CC Chair, Medical Staff office will assist
in correspondence to the Department Chair/Director
regarding any potential concerns.
•
Concerns addressed as per the Hospital Peer Review
Policy
OPPE
•
What is Ongoing Professional Practice Evaluation?
–Process by which organizations look at the
practice of the individual providers on an ongoing
basis and screen how well they are doing
–The ongoing process of evaluating clinical
competency in an effort to identify performance
improvement needs on a timelier basis
Our OPPE Policy
• OPPE conducted for all practitioners granted clinical privileges using multiple sources of performance data
• Interval not to exceed every nine (9) months
• Review of privileges evaluated at reappointment
• Criteria used: Review of assessment, treatment, clinical procedures, medication management, consults, tests of patients, as well as review of performance thresholds specific to specialty and as defined by the department, division chair/director
• OPPE Submitted to Quality Department
• Recommendations from an OPPE: No further action, need for additional info, Trigger for a FPPE, relinquish existing certain privileges
• Copies kept in confidential QM Files in Quality Department with summary of outcome in the MSS Office and provider file
Ohio Law & Rule for QM for APRN
OAC 4723-8-05
• Comply with CE requirements for state and national licensure
• Review & sign SCA annually
• Verify licensure of each collaborating physician via the OSMB or employer
• Participate in a Quality Assurance Process which includes:
–Annual chart review with semi-annual prescribing pattern review –Discussion of results of chart reviews, between a collaborating physician or a designated member of a quality assurance committee of the organization and the APRN.
• Process for patient evaluation of care (patient survey)
• Documentation of participation in an ongoing, systematic quality assurance process at organization shall satisfy the requirements of OAC 4723.8.05(D)
What do we do at our organization?
•
Until 2015, we underwent a parallel and
FPPE & OPPE Process?
• Not consistent• Current Landscape…fragmented and redundant
• HR Eval done annually separate of clinical evaluation
• SCA renewals done by APP Credentials Committee with medical staff office assistance
• QM Forms individual provider’s responsibility
• FPPEs not consistently tracked and forms are not easily identified • We meet OPPE criteria based on Ohio law but we are not all
speaking the same language, our forms are utilized for FPPE & OPPE purposes
• Proposed process will streamline process and allow for identification of improvements to practice & meaningful data
FPPE & OPPE design for APPs
•
FPPE/OPPE Work Group as part of the Quality
APP Council Committee
•
National and State benchmarks with outside APP
organizations
•
Templates reviewed
•
Reviewed our policy on FPPE and OPPE review
•
Looked at divisions who are doing this well
•
Drafts for generic and practice specific areas
designed
Our Decision?
•
Integrate the entire FPPE and OPPE process via a
newly designed committee called PPEC
(professional practice evaluation committee)
•
Consists of physicians, APPs, quality office, CMO,
President of Medical Staff, Credentials Committee
Chair, Director APC, and more…
•
One quality process for ALL medical staff
providers
•
APP designed templates were utilized as the
organization’s FPPE & OPPE standard templates
Proposed FPPE Model
• Following each Board meeting, the MSSO will list those medical staff members (Physicians, Psychologists, and APPs)
• We utilized a MIDAS electronic system for our FPPE and OPPE now
• Remember: FPPE start date begins with first patient contact
• The FPPE contents are broad enough to encompass the “domains” required and the Ohio law for APRN and PA providers
• The FPPE policy states that the division chair or delegate is responsible for ensuring this quality meeting occurs (A Lead APP may be involved)
• The PPEC oversees the completion of the work
• The focused evaluation will be considered completed when the FPPE documents have been submitted electronically to the quality office
• A summary sheet will be kept in each provider’s credentialing folder in the MSS Office
• PPEC will maintain this date and APP credentials and CC can obtain access to those who are still delinquent in completion
• The CTP externship and provisional period are reviewing during the FPPE period, and if found inadequate, then a more detailed review may be requested of the provider (An online education module outlining the provider’s responsibility during this time period is available on CareLearning and is part of the 2015 onboarding boot camp)
• The SCA will have the new quality language discussed (ORC states for APRNs- the SCA will outline the externship requirements)
• The practitioner will be notified of the status of his/her review whether it is complete or continued
• Significant findings are reported to the Med PI Committee
OPPE at our institution…
Q: Who must complete an OPPE?
A: All Credentialed medical staff providers in
the organization
Will be done every 9 months
•
Annual HR Evaluation for APPs remains in
placed for now
•
OPPE will be done in Midas and signed off by
Division Director
Reminder
Quality Chart/Rx Reviews as previously outlined
…will no longer “exist”
•
These chart review templates still exist and
may be used by the division if requested
•
5-10 charts reviewed- # based on division
policy
•
However, only the checkbox of completion or
non completion is marked inside MIDAS
Summary…Quality Requirements
• Done via our FPPE Process, and via the OPPE thereafter.. See FPPE/OPPE
presentation for APPs
• APRN Chapter 4723-8-05: Documentation of participation in an ongoing, systematic quality assurance process at an institution, organization, or agency shall satisfy the requirements of paragraph (D) of this rule (see 4723-8-05 (D) (1-3)
• Prescriptive externship oversight is outlined in the APRN’s SCA (“during the externship period of prescribing, the APRN will adhere to the FPPE process and guidelines as outlined in the medical staff policy”
• OAC PA Chapter 4730-1-05: Quality Assurance Process in alignment with our new FPPE/OPPE process
• PA Prescriptive provisional period requires oversight of practice by supervising physician during the initial period as outlined in Chapter 4730-2-04
FPPE Model regarding privileges…
• Core privileges only upon entry into the institution
• Credentialed for special non-core procedures after identified time frame or ability to demonstrate competency at time of initial credentialing
–The identified time frame will vary by service area- depends on orientation time period, case logs, etc
• There will need to be documentation of the direct supervised procedures through which the individual provider obtains signatures by physician/APP
–Procedural logs completed
–Application for non core privilege if not on current list
• FPPE within 6 months
• Review by Lead APP and/or Division/Medical Director
–MIDAS document has checkboxes- the following items can be scanned for additional reference or housed in Quality Office in hard files
• Additional chart reviews
• Boot Camp Completion •90 Day Checklist to Practice •HR requirements •Orientation Competencies •Documentation of procedures
•
Medical Staff Alignment!
Physician, Podiatry, Psychologist, APRN, PA,
Clinical Scientist, PharmD
Thank You
“Coming together is a beginning.
Keeping together is progress.
Working together is success.”
- Henry Ford
Questions?
References
• Hittle, K. (2010). Understanding certification, licensure and credentialing: a guide for the new nurse practitioner. Journal of Pediatric Health Care, 24(3), 203-206.
• Hravnak, M. (2009). Credentialing and privileging for advanced practice nurses. AACN Advanced Critical Care, 20(1), 12-14.
• Kleinpell, R. M., Hravnak, M., Hinch, B. & Llewellyn, J. (2008). Developing an advanced practice nursing credentialing model for acute care facilities. Nursing Administration Quarterly, 32(4), 279-287.
• Ohio Board of Nursing. (2014). OAC 4723-8-05 Quality assurance standards. Retrieved from http://codes.ohio.gov/oac/4723-8-05.
• Smolenski, M. C. (2005). Credentialing, certification and competence. Journal of the American Academy of Nurse Practitioners, 17(6), 201-204.
• The Joint Commission. (2010). Credentialing and privileging your hospital
medical staff-examples for improving compliance (2nded). Oakbrook, Illinois: Joint Commission Resources, 1-78.
