QUESTION:
We are involved in an overhaul of our medical staff governance documents. We put together a task force of system leaders to guide us through the process, including an advanced practice professional (APP). Historically, our documents only referenced APPs in a single article.
The task force is being challenged to be more inclusive and integrate APPs throughout the documents, including as members of the medical staff, and as members of key committees like the Credentials Committee, Medical Executive Committee and the Peer Review Committee. What are you seeing around the country?
ANSWER:
We are seeing change – you might even say a transformation – with respect to how APPs are addressed in medical staff governance documents. As you suggest, historically, APPs were mentioned in a separate article of the bylaws or perhaps there was a separate policy to address how to credential and privilege them.
As licensing statutes have changed and, as the role of APPs in providing care in hospitals has continued to expand, questions about their involvement in the Medical Staff are now routinely being discussed and debated. As is often the case, there is no single right answer. Each organization has flexibility and discretion to decide whether, when and how to incorporate APPs into their bylaws, with some exceptions.
Let’s start with the exception which is the requirement that APPs (including advance practice nurses and physician assistants), who provide a medical level of care, must be credentialed and privileged through the medical staff process. Additionally, since APPs are granted privileges, their performance must be evaluated through the peer review process.
These requirements lend support for integrating APPs into your medical staff governance documents so you don’t need companion documents to address requirements pertaining to them. However, whether they are members of the Medical Staff and what role they play on the Medical Staff is another question.
In our experience, many Medical Staffs are including an APP category in the Bylaws for “convenient reference” but clearly state: “The APP Staff is not a category of the Medical Staff.” More recently, we have seen Medical Staffs add an APP category (akin to the Courtesy or Consulting Staff) to the Bylaws. This would afford APPs membership status but their rights and prerogatives would be very limited (e.g., no right to vote at the Medical Staff or department level, no ability to serve in a leadership position).
A few Medical Staffs are going a step further and identifying APPs as members of each category of the Medical Staff as long as they meet the patient contact or other criteria. In these situations, to ensure compliance with the Conditions of Participation and accreditation standards, the Bylaw typically note that APPs are not eligible to serve as an officer or department chairperson. The rules are different at critical access hospitals.
As you suggest, other key issues are whether to include APPs on committees like the Credentials Committee, Medical Executive Committee, and the Peer Review Committee. While we won’t say there is a national consensus, we are definitely seeing a movement in this direction including a designated spot on these committees for an APP (usually appointed by the Chief of Staff or Medical Executive Committee). Some Medical Staffs still want to clarify that the APPs are present to address APP issues but must leave when there is a credentialing or peer review issue pertaining to a physician, but most are not this restrictive. And my personal bias is if you make an APP a member of a committee and expect them to show up and participate, they should have a right to vote.
And these are the easy issues. The much tougher issues involving APPs are around required training, clinical privileges, and changes in practice. We’ll leave these for another day.