Amending Hospital Bylaws

Greater investment in research infrastructures is needed to support knowledge generation, dissemination of best practices, and optimization of these voluntary, workplace-based educational innovations for PAs. 

Guidelines for Updating Medical Staff Bylaws: Credentialing and Privileging PAs 

(Adopted 2012, amended 2017, 2018) 

PRINTER FRIENDLY VERSION

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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 PAs must seek the right to exercise clinical privileges via the healthcare entity’s organized medical staff process. The process and criteria for a request for medical staff clinical privileges must be outlined in medical staff bylaws.
• AAPA believes PAs should be voting members of the medical staff. Bylaws should afford PA representation with full voting rights on medical staff committees, including the medical executive committee.
• AAPA believes medical staff bylaws should require that each PA wishing to provide medical care to the healthcare entity’s patients and seeks to be considered for clinical privileges regardless of the PA’s employment arrangements, whether the PA is directly employed by the entity granting the privileges or another independent entity.
• AAPA opposes specialty certification as a requirement for PA credentialing or privileging.
• AAPA believes the duration of medical staff appointments and clinical privileges should be the same for physicians and PAs.
• AAPA believes bylaws should give PAs the right to due process when actions taken by the medical staff or governing board adversely affect the PA’s clinical privileges.
• AAPA believes the criteria and process for peer review, grievances and corrective actions for PAs should be clearly articulated in the bylaws. The process should involve PA peers and conform to the process applied to physicians.
• AAPA believes bylaws should provide mechanisms to carry out quality assurance with respect toPAs. Peer review of PAs should be conducted by peers – ideally, other PAs in the same area of clinical specialty.
• AAPA believes bylaws should require PA participation in continuing medical education that relates to their practice and their privileges.
• AAPA believes bylaws should include language enabling PAs to provide care during emergency or disaster situations, as well as EMTALA specific provisions as required. 

Introduction

PAs are highly skilled medical professionals who practice in every medical and surgical specialty. PAs are employed by many different entities, including but not limited to: hospitals and healthcare systems, independent medical practices, hospital medicine groups, retail and convenient care practices and staffing agencies, or as independent contractors. PAs provide medical care in virtually every setting, including emergency departments, inpatient services, surgical suites, outpatient clinics and critical care/intensive care units. Requirements for PA practice are defined by state law and organizational policy. All state laws allow the flexibility of physicians to be off-site when a PA is providing care. Most organizations 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 must be outlined in the medical staff bylaws.(1) Like the process for physicians, 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 recommended for approval by the medical staff, and ultimately granted by the governing body. 

This policy is intended to guide the organized medical staff in making appropriate changes to the bylaws regarding medical staff membership and clinical privileges for PAs. The guidelines can be applied and adapted to suit the individual organization’s requirements and needs. Where possible, sample language has been included. 

Definition of PA

Medical staff bylaws usually begin with definitions of terms. This section should include a definition of PA. It should generally conform to the definition used in state law. In the case of federally employed PAs, the legal definition is found in federal regulations or policies, rather than state law. All states currently 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 (2)
• pass the initial exam given by the National Commission on Certification of PhysicianAssistants (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 require current certification for licensure. In some instances, employers may require current certification as a condition of employment.(3) 

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 as a PA. 

PAs as Members of the Medical Staff

PAs should be voting members of the medical staff. PAs provide a broad range of services that otherwise would be performed by physicians. They exercise a high level of medical 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 medical level of care functions in the hospital. Medical staff “membership” is not a pre-requisite for a hospital to grant PAs or physicians 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.(4) 

In the majority of states, the organized medical staff and hospital governing boards decide which types of practitioners will be granted medical staff membership. Medicare’s Conditions of Participation for Hospitals, as well as the Joint Commission Medical Staff Standards(4) allow PA medical staff membership. The Medicare Conditions of Participation for Hospitals clearly state that, in addition to MD and DO members, “In accordance with state law, including scope-of-practice laws, the medical staff may also include other categories of physicians…and non-physician practitioners who are determined to be eligible for appointment by the governing body.”(5) The Medicare surveyors’ manual further specifies that hospitals can appoint PAs to the medical staff.(6) State law should be consulted; as the makeup of medical staff membership is occasionally dictated there. 

On occasion, PAs have been 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 also uses this definition for allied health and classifies PAs as medical providers.(7) 

PAs should not be combined with other providers in non-specific, categorical 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.(8) Medical staff membership language might state: 

Membership on the medical staff shall be extended to PAs, physicians, dentists, podiatrists, advanced practice nurses, and clinical psychologists who continuously meet the qualifications, standards, and requirements set forth in these bylaws and who are appointed by the hospital’s governing body. 

Credentialing PAs

Medical staff bylaws specify professional criteria for medical staff membership and clinical privileges. 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. 
• As applied to PAs, these criteria might include:
• evidence of graduation from an ARC-PA (or predecessor) accredited PA program
• evidence of national certification • letters from previous employers, physicians, PA peers, or PA program faculty attesting to scope and level of performance
• verified logs of clinical procedures, previous competency evaluations, or attestations from previous employers about competence
• 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. 

When credentialing a PA, a query should be made to the National Practitioner Data Bank (NPDB) regarding the individual’s medical malpractice payments and any adverse action against medical licensure and clinical privileges. 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 as well as the Federation Credentials Verification Service (FCVS) offers PA credentials verification. Credentialing professionals should confirm a PA’s education program completion and graduation dates, national certification number and status, and current and historical state licensure information. 

PA Privileges

The PA profession is rooted in a solid educational foundation in medicine and surgery that prepares PAs to practice in any specialty or care setting. The medical staff bylaws should require that each PA be granted clinical privileges by whom that PA is employed. As previously noted, medical staff membership should not be a requirement for granting of clinical privileges. 

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. 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 and surgical services, their privileges mirror those of the physicians. 

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 procedures for hearing and appeal. 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. 

Privilege determinations – at reappointment or other interim times – might also include observed clinical performance, quality improvement data, and other outcome metrics as determined by the hospital and the organized 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 required to be evaluated using a focused professional practice evaluation (FPPE) for new privileges or expansion of privileges and ongoing professional practice evaluation (OPPE) for bi-annual reappointment.(9) 

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. Increasing responsibilities as a PA gains experience are a natural progression and the key to effective integration of PAs in the delivery of healthcare. Additionally, evolving medical interventions and technology are continuously being developed and may require a new delineation of privileges to implement. Thus, like physicians, PAs may need to request additional privileges. 

Competency surrounding such privileges should be determined at the practice/department level based on the PA’s education and experience. 

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, PA, or other healthcare provider 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 as a requirement for PA credentialing or privileging.(10) 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. 

Duration and Renewal of Appointments

Duration of appointments and privileges should be the same for physicians and PAs. The renewal/reappointment 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 the PA’s clinical privileges. The Medicare Conditions of Participation for Hospitals Interpretive Guidelines(11) as well as accreditation standards from the Joint Commission(12) specifically require 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 adverse decisions against PAs should be articulated 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 requested to participate in the evaluation.

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. These requirements should correlate with state law, certification and licensure requirements, as applicable.

Committees

Bylaws should allow PA representation with full medical staff prerogatives with voting rights on all standing medical staff committees, including but not limited to the medical executive committee, credentials committee, quality and safety committees, peer review committees, pharmacy and therapeutics committee, and emergency response committees.

Discrimination

The fundamental criteria for medical staff membership or clinical privileges should be directlyrelated 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 color, creed, race, religion, age, ethnic or national origin, political beliefs, disability, socioeconomic status, sex, sexual orientation, or gender identity. 

EMTALA Provisions

The Emergency Medical Treatment and Labor Act of 1986 (EMTALA) regulations require that hospital bylaws identify who is considered “qualified medical personnel” for the following areas: medical screening exams(13), certifying false labor(14), emergency call(15) and transferring patients.(16) The EMTALA law and regulations require that the hospital’s written policies must specify that PAs are qualified personnel. Individual PAs must have privileges to perform these EMTALA functions. 

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 the chief executive’s 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 113 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 or physician acting in an emergency or disaster situation shall be exempt from the hospital’s usual bylaws provisions to the extent allowed by state law in disaster or emergency situations. 

Conclusion

• PAs must seek delineation of their clinical privileges. The process and criteria for which must be outlined in medical staff bylaws.
• PAs should be voting members of the medical staff.
• Medical staff bylaws should require that each PA be granted clinical privileges to provide medical care to patients in the facility, regardless of by whom that PA is employed.
• 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 organized medical staff or governing board adversely affect the PA’s clinical privileges.
• The criteria and process for corrective action should be spelled out for PAs 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 standing medical staff committees, including the medical executive committee, credentialing committees, and others.
• Bylaws should include language enabling PAs to provide care during emergency or disaster situations. 

Endnotes

(1) See Centers for Medicare & Medicaid Services (CMS) Requirements for Hospital Medical Staff Privileging, Survey and Certification Letter 05-04, November 12, 2004, 114 https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/SurveyCertificationGenInfo/Downloads/SCletter05-04.pdf and correlating Regulations 42CFR§ 482.12 and § 482.22 https://www.gpo.gov/fdsys/pkg/CFR-2015-title42-vol5/xml/CFR-2015- title42-vol5-part482.xml#seqnum482.22 

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

(3) Upon graduation from an accredited PA program, PAs must pass an initial certifying exam. To maintain current certification, PAs must complete 100 hours of continuing medical education every two years and pass a recertification every ten years. 

(4) Joint Commission Hospital Accreditation Manual, Standard MS.01.01.01, EP 3: “The medical staff bylaws include the following requirements, in accordance with Element of Performance 3: Qualifications for appointment to the medical staff. Note: For hospitals that use Joint Commission accreditation for deemed status purposes: The medical staff must be composed of doctors of medicine or osteopathy. In accordance with state law, including scope of practice laws, the medical staff may also include other categories of physicians as listed at 482.12(c)(1) and non-physician practitioners who are determined to be eligible for appointment by the governing body.” 

(5) CMS -3244-P, October 24, 2011 Medicare and Medicaid Programs; Reform of Hospital and Critical Access Hospital Conditions of Participation (proposed rule) provides the following commentary from CMS: “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 

(6) 42CFR482.22(a) Centers for Medicare and Medicaid Services State Operations Manual, Appendix ASurvey Protocol, Regulations and Interpretive Guidelines for Hospitals, (Rev. 151, 11-20-15) A-0339, Standard 482.22(a), Retrieved December 2, 2016: “Non-physician practitioners Furthermore, the governing body has the authority, in accordance with State law, to grant medical staff privileges and membership to non-physician practitioners. The regulation allows hospitals and their medical staffs to take advantage of the expertise and skills of all types of practitioners who 115 practice at the hospital when making recommendations and decisions concerning medical staff privileges and membership.” http://www.cms.gov/manuals/downloads/som107ap_a_hospitals.pdf 

(7) 42USCS §295p; Title 42. The Public Health and Welfare, Chapter 6A – Public Health Services 

(8) AAPA 2016-2017 Policy Manual, HP-3100.1.3 and HP 3100.1.3.1, [adopted 2008, reaffirmed 2013]. https://www.aapa.org/workarea/downloadasset.aspx?id=2147486552 

(9) Joint Commission Hospital Accreditation Manual, Standard MS.08.01.03: “Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), torevise existing privilege(s), or to revoke an existing privilege prior to or at the time of renewal.” 

(10) AAPA 2016-2017 Policy Manual, Flexibility as a Hallmark of the PA Profession: The Case Against Specialty Certification [Adopted 2002, reaffirmed 2007, amended 2012] Cited at HP-3200.4.2 – paper on page 195 https://www.aapa.org/workarea/downloadasset.aspx?id=2147486552 

(11) Medicare Conditions of Participation Interpretive Guidelines, A-0341/§482.22(a)(2) “Each practitioner who is a member of the medical staff or who holds medical staff privileges is subject to the medical staff’s bylaws, rules, and regulations, in addition to all the requirements of the Medical Staff Condition of Participation. The medical staff and the governing body must enforce its medical staff requirements and take appropriate actions when individual members or other practitioners with privileges do not adhere to the medical staff’s bylaws, regulations, and rules. They must likewise afford all members/practitioners who hold privileges the protections and due process rights provided for in the bylaws, rules and regulations.” https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf 

(12) Joint Commission Hospital Accreditation Manual, Standard MS.10.01.01 There are mechanisms including a fair hearing and appeal process for addressing adverse decisions regarding reappointment, denial, reduction, suspension, or revocation of privileges that may relate to quality of care, treatment, and services issues. 

(13) 42 CFR §489.24(a)(1)(i) 

(14) 42 CFR §489.24(b) Definitions 

(15) In its guidance about on-call duties, CMS provides some specifics about PAs taking call: see the State Operations Manual Appendix V – Interpretive Guidelines – Responsibilities of Medicare Participating Hospitals in Emergency Cases (Rev. 60, 07-16-10) §489.20(r)(2) and §489.24(j) https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/som107ap_v_emerg.pdf page 31: “If it is permitted under the hospital’s policies, an on-call physician has the option of sending a representative, i.e., directing a licensed non-physician practitioner as his or her representative to appear at the hospital and provide further assessment or stabilizing treatment to an individual. This determination should be based on the 116 individual’s medical need and the capabilities of the hospital and the applicable State scope of practice laws, hospital by-laws and rules and regulations.” 

(16) The EMTALA regulations allow “qualified medical personnel” other than physicians to order the transfer of emergency patients. If a PA certifies transfer of an unstable patient to another emergency department, the law requires that the PA first consult with a physician before ordering the transfer. Subsequently, the physician must co-sign the order within a timeframe specified in hospital policy. See 42 CFR § 489.24 (e)(ii)(C): “If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based.” https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol5/pdf/CFR-2011-title42-vol5-sec489-24.pdf