Amending Hospital Bylaws

 Guidelines for Updating Medical Staff Bylaws:
Credentialing and Privileging PAs

(Adopted 2012)

Executive Summary of Policy Contained in this Paper
Summaries will lack rationale and background information, and may lose nuance of policy.
You are highly encouraged to read the entire paper.

AAPA believes that

  •  PAs must seek delineation of their clinical privileges and that the process must be outlined in medical staff bylaws.
  •  PAs should be members of the medical staff.
  •  Medical staff bylaws should require that each PA be granted clinical privileges regardless of whether the PA is an employee of a practice or of the hospital.
  •  The criteria for delineating PA clinical privileges should be specified in the bylaws.
  •  AAPA opposes specialty certification examinations as a requirement for PA credentialing or privileging.
  •  Duration of appointments and privileges should be the same for physicians and PAs.
  •  Bylaws should give PAs the right to due process when actions taken by the medical staff or governing board adversely affect his or her clinical privileges.
  •  The criteria and process for disciplining PAs should be spelled out in the bylaws. The process should involve PA peers and conform to the process applied to physicians
  •  Bylaws should provide mechanisms to carry out quality assurance with respect to PAs. Peer review of PAs should be conducted by peers – ideally, other PAs in the same area of clinical specialty.
  •  Bylaws should require PA participation in continuing medical education that relates to their practice and their privileges.
  •  Bylaws should allow PA representation on medical staff committees, including the medical executive committee.
  •  Bylaws should include language enabling PAs to provide care during emergency or disaster situations.

Introduction

PAs are highly skilled professionals who practice in every medical and surgical specialty. They are employed by hospitals and healthcare systems, medical practices, hospital medicine groups, and emergency department staffing groups. PAs provide medical care almost anywhere in a hospital, including emergency departments, inpatient services, operating rooms, outpatient units and critical care/intensive care units. Requirements for PA practice are defined by state law and hospital policy. All state laws allow the flexibility of physicians being off-site as long as they are available via telecommunication. Most hospitals develop policies and definitions based on the language used in their state’s laws and regulations governing PA practice. Federal facilities and federally employed PAs, however, are governed by federal agency guidelines, not state law.

The criteria and process for granting clinical privileges to PAs is similar to the process for physicians and must be outlined in the medical staff bylaws. The organized medical staff is required to review and verify the credentials of practitioners to ensure that those who provide medical care are competent and qualified to provide specified levels of care. In order to provide patient care services in the hospital or other healthcare facilities, PAs must seek delineation of their clinical privileges, which are then granted by the medical staff, and ultimately, the governing body.

In most hospitals, the medical staff credentialing process involves simultaneous consideration of applications for medical staff membership and for clinical privileges. The following guidelines are intended to assist medical staffs in making appropriate changes to the bylaws that authorize the granting of membership and clinical privileges to PAs. They are intended to be a general guide that can be applied and adapted to suit the requirements of individual medical staffs. Where possible, sample language has been included.

Definition of PA

Medical staff bylaws usually begin with a section that includes definitions of terms. This section should include a definition of PA. It should generally conform to the definition used in state law and may reflect the definition used by AAPA. In the case of federally employed PAs, the legal definition is found in federal regulations or policies, rather than state law.

All states 1 require that a PA

  •  be a graduate of a PA program accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) or one of its predecessor agencies and/or
  •  pass the initial exam given by the National Commission on Certification of Physician Assistants (NCCPA),
  •  be licensed to practice as a PA.

Federally employed PAs must meet the first two criteria, but are typically not required to be licensed, as federal agencies are not governed by state laws. Many states and employers require current NCCPA certification. 2

The following definition serves as an example.

A PA is an individual who is a graduate of a PA program approved by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) or one of its predecessor agencies, and/or has been certified by the National Commission on Certification of Physician Assistants (NCCPA). The individual meets the necessary legal requirements for licensure to practice medicine as delegated by a licensed physician.

PAs as Members of the Medical Staff

AAPA believes that PAs should be members of the medical staff. PAs are providers of a broad range of services that otherwise would be performed by physicians. They exercise a high level of decision-making and autonomy in providing patient care as members of medical and surgical teams. Medical staff privileges enable/authorize clinicians to diagnose illness and perform other functions in the hospital. Medical staff “membership” is not a pre-requisite for a hospital to grant physicians or PAs clinical privileges. However, medical staff membership allows PAs a voice in developing and implementing hospital and medical staff policies and ensures participation in programs to review the quality and appropriateness of patient care. It is important that PAs participate in the system in which medical care policies are made and communicated.3

In the majority of states, medical staff and hospital governing boards decide which types of practitioners will be medical staff members. Both the Joint Commission Medical Staff standards and Medicare’s Conditions of Participation for Hospitals allow PA membership on medical staffs. The Joint Commission’s Comprehensive Accreditation Manual for Hospitals states: “The governing body and the medical staff define medical staff membership criteria, which…may include licensed independent practitioners and other practitioners.” The Medicare Conditions of Participation for Hospitals clearly state that, in addition to MD and DO members, the medical staff “may also be composed of other practitioners appointed by the governing body.”4 The Medicare surveyors’ manual further specifies that hospitals can appoint PAs to the medical staff.4 State law should be consulted; the makeup of medical staff membership is occasionally dictated there.5

Sometimes PAs are erroneously categorized as allied health professionals or under nursing structures. PAs, by definition, are providers of medical care and, as such, are not part of the allied health field or nursing profession. The National Commission on Allied Health, convened by an act of Congress in 1992, defined an allied health professional as “a health professional (other than a registered nurse or PA)….” The federal Bureau of Health Professions uses this same definition and classifies PAs as medical providers. [42USCS §295p; Title 42. The Public Health and Welfare, Chapter 6A – Public Health Services]

AAPA believes that PAs should not be combined with other providers in non-specific, inclusive terms such as “midlevel practitioner,” “advanced practice clinician,” or “advanced practice provider.” PAs should utilize, and encourage employers (e.g., hospitals, HMO’s, clinics), third party payers, educators, researchers, and the government to utilize, the term “physician assistant” or PA for clarity and accuracy.6

Medical staff membership language might state:

Membership on the medical staff shall be extended to physicians, dentists, podiatrists, PAs, and clinical psychologists who continuously meet the qualifications, standards, and requirements set forth in these bylaws and who are appointed by the hospital Board of Directors.

Credentialing PAs

Medical staff bylaws specify professional criteria for medical staff membership and clinical privileges. The Joint Commission specifies four core criteria that should be met when credentialing licensed independent practitioners, including:

  •  current licensure
  •  relevant training or experience
  •  current competence and
  •  the ability to perform privileges requested.

This serves as a reasonable guideline. As applied to PAs, these criteria might include:

  •  evidence of national certification
  •  letters from previous employers, supervising physicians, PA peers, or PA programs attesting to scope and level of performance
  •  verified logs of clinical procedures
  •  personal attestation as to physical and mental health status
  •  evidence of adequate professional liability insurance
  •  information on any past or pending professional liability or disciplinary actions
  •  a letter from a sponsoring physician (MD or DO) who is a member of the medical staff.

When credentialing a PA, a query should be made to the National Practitioner Data Bank (NPDB) regarding the individual’s medical liability and disciplinary histories. Entities that make malpractice payments on behalf of PAs have been required to report that information to the NPDB since its inception in 1990. Since March 2010, employers and regulators have been required to report to the NPDB adverse professional review actions taken against PAs. Queries about licensure actions taken against PAs can be made to the Federation of State Medical Boards (FSMB). Though all state licensing boards are encouraged to report disciplinary actions to the FSMB, it is impossible to ascertain whether all actions are reported, so it is important that hospitals also query individual boards in all states where the PA has been licensed.

The American Medical Association’s (AMA) Physician Profile Service also offers PA credentials verification. Credentialing professionals can confirm a PA’s education program attendance and graduation dates, national certification number and status, current and historical state licensure information, and AAPA membership status. The Joint Commission has deemed that the information provided by the AMA Physician Profile service is equivalent to primary source information. 

PA Privileges

The fundamental premise of the PA profession is a solid educational foundation in medicine and surgery that prepares PAs to work with physicians in any specialty or care setting. The medical staff bylaws should require that each PA be granted clinical privileges regardless of whether the PA is an employee of a practice or of the hospital. Medical staff membership should not be a requirement for granting of clinical privileges. This is in accordance with Joint Commission standards and the Medicare Conditions of Participation for Hospitals.

The medical staff bylaws should stipulate that all clinical privileges granted to a PA should be consistent with all applicable state and federal laws and regulations and that a PA may provide medical and surgical services as delegated by a physician. Typically, privileges for a PA are delineated using a form and process identical to or very similar to that used for physicians. Because PAs provide medical services, the physician form and privileging system is a useful template for developing a system of granting PA privileges.

The process for granting clinical privileges is usually discussed in four places in the bylaws: the article concerned with clinical privileges, the article describing the structure of the credentials committee, the article describing the duties of department chairs, and the article describing hearing procedures. The process of granting clinical privileges may vary considerably from one hospital to another, but generally the process should include the following: 1) completion in a timely fashion; 2) department chairs, if they exist, should make specific recommendations for clinical privileges; 3) an appeal mechanism for adverse decisions; and 4) the governing board should have ultimate authority to grant clinical privileges. An application for renewal of clinical privileges should be processed in essentially the same manner as that for granting initial privileges.

The criteria for delineating clinical privileges should be specified in the bylaws. They are usually the same as those used for credentialing: evidence of current state licensure, relevant training and experience, national certification, letters or other verification from authoritative sources attesting to the individual’s ability to perform certain privileges, attestation as to physical and mental health status, evidence of adequate liability insurance, and information on any past or pending professional liability or disciplinary actions. Privilege determinations – at reappointment or other interim times – might also include observed clinical performance, quality improvement data, and other documented results of quality improvement activities required by the hospital and medical staff.

Other requirements of physician members of the medical staff also may apply to PAs. For example, if hospital policy requires that a department chair approves physician privilege requests before they are submitted to the medical staff credentials committee, then the same should apply to PAs. .For Joint Commission-accredited hospitals, PAs, like physicians, are evaluated using a focused professional practice evaluation (FPPE) for new privileges or performance improvement and ongoing professional practice evaluation OPPE) for bi-annual reappointment.

Expanding Privileges

PAs are educated in the medical model of evaluation, diagnosis, and treatment. They are committed to life-long learning through clinical experience and continuing medical education. Recognition that new tasks and responsibilities can be taught and delegated to the PA by physicians as a PA gains experience, and as the physician and PA grow as a team, are key to effective utilization of PAs. As such, PAs may need to request additional privileges; this process should mirror as that of the physicians requesting additional privileges

Specialty and Subspecialty Privileges

When PAs request privileges for specialized procedures or other highly technical, specialty-related care, their qualifications should be assessed just as they would be for any other privilege – verification of specialized training in the clinical setting, previous privileges, relevant CME, a documented skills assessment, or performance of procedures under direct proctoring by a physician or PA granted privileges to perform the procedure.

AAPA is committed to lifelong learning and encourages advanced educational opportunities (such as Pediatric Advanced Life Support (PALS) or Advanced Trauma Life Support (ATLS)), as well as verification of specific course completion, However, AAPA does oppose specialty certification examinations as a requirement for PA credentialing or privileging. The PA profession currently does not have a system of specialty credentialing like the specialty boards system developed by physicians. Because there are other ways to assess PA competency, AAPA believes imposing specialty boards or specialty exams is unnecessary and would undermine the basic construct of the profession, which is to be broadly educated medical providers with the versatility and adaptability to meet changing health care needs. Many PAs fulfill their national certification CME requirement by attending highly specialized courses specific to their area of practice.

Duration and Renewal of Appointments

Duration of appointments and privileges should be the same for physicians and PAs. The renewal/re-appointment process should also be aligned with that required of physicians.

Due Process

The bylaws should give the PA the right to request the initiation of due process procedures when actions taken by the medical staff or the governing board adversely affect his or her clinical privileges. Hospital accreditation standards from the Joint Commission specifically state that medical staffs must establish a fair hearing and appeals process for addressing adverse decisions made against medical staff members and others holding clinical privileges. The process should include PA peer reviewers.

Corrective Action

The criteria and process for disciplining PAs should be spelled out in the bylaws. The process should involve PA peers and conform to the process applied to physicians.

Quality Assurance

The bylaws should provide for effective mechanisms to carry out quality assurance responsibilities with respect to PAs. Peer review of PA practice should be conducted by peers  ideally other PAs in the same area of clinical specialty. If the staff does not include other PAs in the same or similar specialty, PA peers from outside the hospital should be called in.

Continuing Education

The medical staff bylaws should require participation by PAs in continuing medical education that relates, at least in part, to their regular practice and to their clinical privileges.

Committees

Bylaws should allow PA representation on medical staff committees, including the medical executive committee

Discrimination

The fundamental criteria for medical staff membership or clinical privileges should be directly related to the delivery of quality medical care, professional ability and judgment, and community need. Medical staff membership or particular clinical privileges should not be denied on the basis of gender, color, creed, race, religion, age, ethnic or national origin, political beliefs, disability, socioeconomic status, or sexual orientation.

Participation in Disaster and Emergency Care

The bylaws should include language enabling PAs to provide care during emergency or disaster situations. The bylaws should state that the chief executive or his or her designee may grant temporary clinical privileges when appropriate and that emergency privileges may be granted when the hospital’s emergency management plan has been activated. The hospital’s emergency preparedness plan should include PAs in its identification of care providers authorized to respond in emergency or disaster situations. Bylaws language might state:

In case of an emergency, any member of the medical staff, house staff, and any licensed health practitioner, limited only by the qualifications of their license and regardless of service or staff status, shall be permitted to render emergency care. They will be expected to do everything possible to save the life of a patient, utilizing all resources of the hospital as necessary, including the calling of any consultations necessary or desirable. Any PA acting in an emergency or disaster situation shall be exempt from the hospital’s usual requirements of physician supervision to the extent allowed by state law in disaster or emergency situations. Any physician who supervises a PA providing medical care in response to such an emergency or declared disaster does not have to meet the requirements set forth in these bylaws for a supervising physician.

 Conclusion

  • PAs must seek delineation of their clinical privileges; the process must be outlined in medical staff bylaws.
  •  AAPA believes that PAs should be members of the medical staff.
  •  Medical staff bylaws should require that each PA be granted clinical privileges regardless of whether the PA is an employee of a practice or of the hospital.
  •  The criteria for delineating PA clinical privileges should be specified in the bylaws.
  •  AAPA opposes specialty certification examinations as a requirement for PA credentialing or privileging.
  •  Duration of appointments and privileges should be the same for physicians and PAs.
  •  Bylaws should give PAs the right to due process when actions taken by the medical staff or governing board adversely affect his or her clinical privileges.
  •  The criteria and process for disciplining PAs should be spelled out in the bylaws. The process should involve PA peers and conform to the process applied to physicians
  •  Bylaws should provide mechanisms to carry out quality assurance with respect to PAs. Peer review of PAs should be conducted by peers – ideally, other PAs in the same area of clinical specialty.
  •  Bylaws should require PA participation in continuing medical education that relates to their practice and their privileges.
  •  Bylaws should allow PA representation on medical staff committees, including the medical executive committee.
  •  Bylaws should include language enabling PAs to provide care during emergency or disaster situations.

 

 

Endnotes

1 Several states have no explicit educational requirement. However, because those states require national certification and because only graduates of accredited programs are eligible for the national certification exam, the certification requirements in the laws of those states are the functional equivalent of an educational requirement.

2 Upon graduation from a PA program, PAs must pass the NCCPA’s initial certifying exam, the Physician Assistant National Certifying Examination (PANCE). To maintain current certification, PAs must complete 100 hours of continuing medical education every two years and pass the Physician Assistant National Recertification Examination (PANRE) every six years.

3 CMS -3244-P, October 24, 2011 Medicare and Medicaid Programs; Reform of Hospital and Critical Access Hospital Conditions of Participation (proposed rule) states: “Alternatively, a hospital could establish categories within its medical staff to create distinctions between practitioners who have full membership, and a new category for those who could be classified as having an ‘associate’, ‘special’ or ‘limited’ membership. Such a structure is neither required nor suggested; we are providing it here as a possible way to align all of its practitioners under the ‘Medical Staff’ rules.” https://www.cms.gov/CFCsAndCoPs/Downloads/CMS3244P.pdf

4 Standard 42CFR482.22(a) Code of Federal Regulations. Title 42-Public Health, Chapter IV-Centers for Medicare and Medicaid Services, Department of Health and Human Services. (10-1-10 Edition) Retrieved December 9, 2011. http://www.gpo.gov/fdsys/pkg/CFR-2010-title42-vol5/pdf/CFR-2010-title42-vol5-sec482-22.pdf

5 Centers for Medicare and Medicaid Services. State Operations Manual, Appendix A-Survey Protocol, Regulations and Interpretive Guidelines for Hospitals, (Rev. 75, 12-02-11) Standard 482.22(a). Tag A-0339. Retrieved December 9, 2011 http://www.cms.gov/manuals/downloads/som107ap_a_hospitals.pdf

6 AAPA 2011-2012 Policy Manual, HP-3100.1.3 and HP 3100.1.3.1, adopted 2008. http://www.aapa.org/uploadedFiles/content/About_AAPA/PM-11-12-Final.pdf