Allied Health Professionals Employment, Credentialing, and Peer Review -- How To Navigate Through Murky Waters Shirley P. Morrigan, Esq. Foley & Lardner LLP 2029 Century Park East Los Angeles, California 90067-3021 Telephone: (310) 277-2223 [email protected] American Health Lawyers Association Medical Staff, Credentialing, and Peer Review and Labor and Employment Practice Groups Joint Annual Luncheon Philadelphia June 26, 2006 LACA_740876.1 Items for Today’s Discussion: • Who credentials AHPs – the Medical Staff or Human Resources? (or both?) • What if the Interdisciplinary Practice Committee (or any other committee that credentials AHPs) wants to credential a PA to do neurosurgery? • How should the Medical Staff Executive Committee interact with the Hospital Committee that credentials AHPs? • How should a Medical Staff address requests by persons to practice complementary medicine in the Hospital? • What kind of procedural rights should be offered to which type of AHPs and for what types of actions? 1 Introduction • Continuing trend Æ Increasing numbers of Allied Health Professionals (AHPs) in hospitals. – Sophisticated technological services have created new specialists. – Managed care has led to scrutiny by hospitals, payors, and physicians as to cost-effective services. 2 Introduction (cont’d) • Result Æ Proliferation of credentialed and limited-licensed practitioners. – Human Resources Department (HR) and Medical Staff Office (MSO) responsibilities have blurred. AHPs are not members of the Medical Staff and may not be hospital employees. 3 Introduction (cont’d) – Numerous questions have arisen: • What is an AHP? • What is the AHP affiliation with the hospital? • When Medical Staff members bring AHPs to the hospital, what are the hospital’s credentialing obligations? • Who is responsible for credentialing and reviewing AHP practice? 4 Introduction (cont’d) – Numerous questions (cont’d): • Is there a difference between credentialing and reviewing AHPs employed by the hospital versus non-employees? • What information is necessary for credentialing? • Must the hospital make Data Bank/ licensing board queries for AHPs? 5 Introduction (cont’d) – Numerous questions (cont’d): • Are AHPs covered by the Medical Staff Bylaws and fair hearing plan? • Must the hospital have a committee that credentials AHPs? Should it be a Medical Staff committee? 6 Who Are AHPs? • Non-Physician Providers Providing Direct Patient Care Services Who Are: – Licensed or certified by the state; or – Qualified by academic and clinical training and experience in a discipline. 7 Who are AHPs? (cont’d) – Numerous Examples of AHPs Clinical Psychologist Physician Assistant Nurse Practitioner RN/First Assistant MSW/LCSW MFT Nurse Anesthetist Nurse Midwife Licensed Midwife Acupuncturist Clinical Perfusionist Speech Pathologist Physical Therapist Speech Therapist Optometrist Occupational Therapist Psychology Technician Pharmacist Dietician Ophthalmology Technician Pathology Technician Respiratory Care Practitioner Orthopaedic Technologist Yoga Instructor Guided Imagery Practitioner Healing Touch Practitioner Massage Therapist 8 Who Are AHPs? (cont’d) – Numerous unlicensed, uncertified groups. • State Licensure; Board Certification; Private Certification. – Licensure Æ refers to a state-issued license. • e.g., RN, Psychologist, Licensed Clinical Social Worker 9 Who are AHPs? (cont’d) – State certification Æ refers to state recognition of certification by a specified private association or professional society. • e.g., Nurse Anesthetist – licensed RN certified by the state, based on certification by Council on Certification 10 Who are AHPs? (cont’d) – Private certification Æ AHP is not certified by the state but may be by a private organization. • Issue as to whether the individuals belong to a recognized category. • e.g., “Certified” Orthopaedic Physician Assistant. – Some Groups Æ no license or independent certification or accreditation but emerging as separate AHP category. 11 AHP Permission to Practice at a Hospital • AHPs are not members of the Medical Staff. – Qualified practitioners gain “AHP Status,” not Medical Staff membership. • Decisions must be made as to an entire category or subgroup, not as to one individual. 12 AHP Permission to Practice at a Hospital (cont’d) • Must follow a fair process for evaluating which categories will be permitted to practice. – Multi-disciplinary committee of Medical Staff reviews issues and submits recommendation to Board. – Board review, including written or oral input from persons proposing AHP categories and the broader medical community. 13 AHP Permission to Practice at a Hospital (cont’d) • Factors in Decision – Must establish reasonable and rational grounds for excluding certain practitioners that are not based on eliminating competition, e.g., antitrust. Need a convincing patient care and administrative justification for denial of a category. • Is this a “true” AHP category? • Does the hospital need the service? 14 AHP Permission to Practice at a Hospital (cont’d) • Factors in Decision (cont’d) • Is the hospital’s standard of practice higher than that which can be provided by the AHP? (e.g., will a nurse practitioner provide the same level of care as a Board-certified physician in neurosurgery?) • Is there a closed staff or an exclusive contract? 15 AHP Permission to Practice at a Hospital (cont’d) • Some facilities permit AHPs to assist physicians who employ them, even though an AHP category has not been approved by Board. SHOULD NOT HAPPEN. 16 Scope of AHP Practice at Hospital • Determine which documents govern AHP activities. – Can limit governing documents to AHP Rules and Regulations or Medical Staff Bylaws can also govern AHP activity. – Advantage of including Medical Staff Bylaws is ability to make general Bylaws provisions govern AHP activities and conduct (e.g., contents of application, leave of absence, reinstatement, temporary privileges or prerogatives). 17 Scope of AHP Practice at Hospital (cont’d) • What to include in the governing document(s)? – Decide if Practice Prerogatives or Clinical Privileges will be offered for each AHP category. • JCAHO requires certain AHP categories receive Clinical Privileges not Practice Prerogatives, e.g., Physician Assistants, Nurse Midwives, Nurse Practitioners and Nurse Anesthetists. 18 Scope of AHP Practice at Hospital (cont’d) – Determine qualifications for each AHP category. • Develop a reasonable and rational process for deciding if an AHP category requires licensure, certification (state or private) or training or experience. –If certification is required, decide which specific agency’s or association’s certification is required. 19 Scope of AHP Practice at Hospital (cont’d) –If nothing is required, develop criteria delineating required qualifications for person (e.g., high school diploma, prior experience). –Avoid running afoul of antitrust laws by making qualifications for AHP categories more stringent than that of others, e.g., requiring CPR certification of an AHP even though physicians are not required to have CPR certification. Unlikely an AHP will ever run a code in a hospital! 20 Scope of AHP Practice at Hospital (cont’d) –Be practical Æ don’t require certain qualifications simply because others in hospital are required, e.g., AHP required to be CPR certified simply because hospital employees are required to be CPR trained. Again, it is unlikely an AHP will ever run a code in a hospital! 21 Scope of AHP Practice at Hospital (cont’d) – Delineate scope of activities permissible for each category. • Never include the list in the Rules and Regulations: create a separate document. Changes in activities are made to list without having to formally amend Rules and Regulations. • Incorporate list by reference in Rules and Regulations. 22 Scope of AHP Practice at Hospital (cont’d) – Determine level of prior experience required for qualification in each category. • Categories for practitioners who obtain extensive clinical experience during training may not need additional experience post graduation to qualify for category e.g., PAs. 23 AHP Qualifications and the Credentialing Process • General Qualifications EVERY AHP Must Satisfy. – Documents his/her current licensure or other legal credentials in a category of AHP that has been approved for practice prerogatives or clinical privileges at hospital; 24 AHP Qualifications ... (cont’d) – Documents his/her experience, background, training, demonstrated ability, physical health status and mental health status, with sufficient adequacy to demonstrate that any patient treated by him/her shall receive care of the generally recognized professional level of quality, and that s/he is qualified to provide a needed service within the hospital; 25 AHP Qualifications ... (cont’d) – Is determined on the basis of documented references, to adhere strictly to the ethics of his/her profession, as applicable, to work cooperatively with others, and to be willing to participate in and properly discharge responsibilities as determined by the IDP, Medical Executive Committee, and the Board; – Participates in continuing education applicable to his/her specialty as required by his/her licensing/certification board and of the IDP; 26 AHP Qualifications ... (cont’d) – Demonstrates acceptable professional liability insurance and coverage (including specific procedures); and – Maintains a relationship with one or more supervising physicians, dentists, or podiatrists as appropriate. – No physician, dentist or podiatrist who has not completed observation requirements and been released form observation should supervise any AHP.27 AHP Qualifications ... (cont’d) – No new applicant or current AHP can be excluded from federally funded programs. – Require Continuing Disclosure. • AHP shall notify the hospital immediately if AHP’s license, certification or other legal credential has been suspended, revoked or placed on probation or has been charged with a felony or lost practice prerogatives at another hospital. 28 AHP Qualifications ... (cont’d) • Require initial and reappointment applicants to submit a complete application. Return to applicant if not complete with deadline for completion. Applicant’s failure to meet deadline creates cause to terminate application process or file the application “administratively incomplete.” 29 AHP Qualifications ... (cont’d) • Application should be processed by Medical Staff or Human Resources in the same way: – Verify education, past experience, peer references, licensure or certification, and liability insurance Æ require original sources for each. 30 AHP Qualifications ... (cont’d) – Modified Medical Staff requirements. • Exception: JCAHO Standard MS. 4.20 requires all “licensed independent practitioners” be privileged through the same Medical Staff process. • What is a “licensed independent practitioner?” • Recommend applying this standard to Psychologists, LCSWs, PAs, Nurse Midwives, Nurse Anesthetists, and 31 Nurse Practitioners. AHP Qualifications ... (cont’d) – Follow same process for AHPs who are employed by a physician. – “Sponsor’s Statement” alone is not enough. – Employer agrees to notify if relationship ends. 32 AHP Qualifications ... (cont’d) • What to Query: – Must query NPDB for licensed health care practitioners or those “otherwise authorized” by the state to practice; – Query state boards for licensed, certified, or registered AHPs; – Process should be delineated in Medical Staff Bylaws or in separate AHP Rules and Regulations incorporated by reference into the Bylaws. 33 AHP Qualifications ... (cont’d) • Denial of application (not administrative): May report to NPDB for licensed/ credentialed AHPs. – Develop consistent policies so reports are made for serious events that should become part of national system. 34 AHP Qualifications ... (cont’d) • Application Approval Process: – Application to MSO or HR where credentialing materials gathered, original sources contacted and documents verified Æ (AHP Committee) Æ Section or Department Æ Credentials Committee Æ MEC Æ Board. 35 AHP Qualifications ... (cont’d) • Temporary Practice Prerogatives or Clinical Privileges. – Same issues as for physicians. – Must follow Medical Staff Bylaws requirements. – Make sure Bylaws are JCAHO-compliant. 36 AHP Qualifications ... (cont’d) • Supervisor’s Statement of Responsibility. – Supervisor agrees in writing that Supervisor will: (i) be responsible for AHP supervision and all care provided by AHP including AHP’s acts and omissions; (ii) assure that the AHP provides only services for which s/he has received practice prerogatives or clinical privileges; 37 AHP Qualifications ... (cont’d) (iii) indemnify and hold hospital, its officers, directors, employees, representatives, agents and Medical Director harmless; (iv) assist with review of AHP’s credentials and performance evaluations; (v) notify hospital immediately upon termination of relationship with AHP. – Agreements do not relieve hospital of responsibility for care provided! 38 Limitations and Fair Procedure Rights for AHPs • AHPs are NOT: – eligible to become Medical Staff members (except psychologists); – required to pay Medical Staff dues, but may be required to pay AHP dues; – generally entitled to fair procedure rights, but not the same as those for Medical Staff. 39 Limitations ... Rights for AHPs (cont’d) • EXCEPTIONS to General Fair Procedure Rules. – JCAHO requires hospitals to offer all “licensed independent practitioners” hearing and appeal rights, including: • Physician Assistants and Nurse Practitioners receive a fair hearing process, which need not be the same as the Medical Staff (and should not). • JCAHO has indicated that hearings need to be conducted by an unbiased group and that appellate review be conducted 40 by the Board. Limitations ... Rights for AHPs (cont’d) • Recommend hospital develop “minor” hearing and appeal rights for AHPs who are not licensed independent practitioners when adverse action involves: – medical disciplinary cause or reason; – professional competence. Benefit − avoids AHP jumping straight to court for adverse action. 41 The AHP-Hospital Relationship • Regardless of type of affiliation, hospital has obligations regarding credentialing and oversight. – Hospital is responsible for all care provided and must have mechanisms in place to ensure competence (“corporate negligence liability;” licensing and accreditation standards.) – Mechanisms may differ, depending on the categories of AHP, but the obligation remains. 42 AHP Committee – Medical Staff Relationship • AHP Committee as a Medical Staff committee – Highly recommended. – Can be a subcommittee of Credentials Committee. • Advantages of AHP Committee as Medical Staff Committee. – Confidentiality may be protected or privileged by state law. – Members benefit from certain practice prerogatives and immunities. – May facilitate broader Medical Staff involvement and hospital-wide scope of oversight. 43 Supervision and Performance Review by the Medical Staff • Recommend assigning each AHP to a department or division. – AHP should be subject to an initial observation period and ongoing proctoring, monitoring and chart review, by another AHP or a physician, dentist or podiatrist. • Specify time period or number of cases for initial observation. 44 Supervision and Performance Review by the Medical Staff (cont’d) – Must comply with department or division standards. – Written list of specified practice prerogatives or clinical privileges that may be performed by each category of AHP must be developed by (AHP Committee and) Credentials Committee and used as a guide in supervising and evaluating AHP. 45 Supervision and Performance Review by the Medical Staff (cont’d) • Supervisor must complete periodic evaluations which become part of Medical Staff and any employment file. – Hospital Employees: Supervised by physician or AHP assigned by Department. Notification to HR and MSO. – Others: Observed by employer and hospital staff. 46 Reappointment – Follow same time intervals as Medical Staff, for both HR-credentialed and MSO-credentialed. – Require submission of complete application for reappointment, updating all information from previous appointment. 47 Reappointment (cont’d) – Performance and Skills: • Require department, HR and sponsoring or employing physician, podiatrist, or dentist to provide MSO with information regarding performance both for employees and for non-hospital employed AHPs. • Implement a system of proctoring and monitoring of clinical activity and chart review. This will require cooperation between Medical Staff and hospital administration. • Employees, annual performance reviews should be part of reappointment process. 48 HCQIA and the AHP • Reporting is permissive. • Immunity applies to physicians and dentists. • Immunity probably applies to Medical Staff committees. – Not administrative committees. 49 HCQIA and the AHP (cont’d) • Federal court – if an AHP is able to gain access (e.g., through allegations of racial discrimination): – Then activities probably are not immunized under HCQIA. – State laws that privilege or protect peer review proceedings will probably not apply, although negotiation can be done with counsel about scope (e.g., of requests for documents). 50 HCQIA and the AHP (cont’d) • Therefore, must exercise great caution with review of AHPs. – Watch out for the influence of competitors! – Make sure standards are objective and clear and applied in an equal, even-handed manner. 51 Coalition for Patient Rights Press Release • 6/8/06 Formed a group with the following goals: – Ensure consumers have access to the health care providers of their choice. – Oppose what they said were efforts by physician groups to limit the scope of practice for non-physicians. – Respond to initiatives by AMA and other physician groups to restrict the ability of nonphysician practitioners to continuing practicing in areas in which they are already licensed. • Rosa Gonzales, Director, American Nurses Association 52 Coalition for Patient Rights (cont’d) • 24 organizations, represents more than 3 million health care professionals, such as: – psychologists – nurses – chiropractors • Main purpose is to act as a bulwark against the efforts of the AMA’s Scope of Practice Partnership (SOPP), a legislative, regulatory, and judicial advocacy made up of the AMA, 6 national medical specialty societies, and the state medical associations from California, Colorado, Maine, Massachusetts, New Mexico, and Texas. 53 Coalition for Patient Rights (cont’d) • Mitchell Tobin, Senior Director of Professional Practice Affairs for the American Association of Nurse Anesthetists, said that the AMA has adopted more than 7 resolutions in the past decade that would restrict the scope of practice for AHPs. – Attempted to restrain the ability of licensed psychologists to prescribe medications. – Attempted to required physician supervision for nurse anesthetists. 54 Coalition for Patient Rights (cont’d) • At its annual House of Delegates meeting in 2005, the AMA Board of Trustees adopted Resolution 814, which called on the SOPP “to study the qualifications, education, academic requirements, licensure, certification, independent governance, ethical standards, disciplinary processes, and peer review of the limited licensure health care providers and limited independent practitioners.” • Tobin says the AMA and other groups are “ratcheting up” with the creation of the SOPP, “declaring war” on non-physician providers. 55 Coalition for Patient Rights (cont’d) • Ultimately, according to Ms. Gonzales, the debate is about reimbursement and how practitioners can bill for their services. • According to Tobin, the stated rationale for the physician partnership is to restrict the scope of practice by non-physicians to protect the public health. • “It is unfair to say that any of these activities threaten patient safety,” he said. 56 Coalition for Patient Rights (cont’d) • Tobin said he thinks the expansion of nonphysician services challenges organized medicine’s sense of security. • It is “outrageous” that the physician groups are attempting to restrict patients’ access to non-physician services….” (Tobin) • Further, he said, allied health care providers are “indispensable” to underserved populations, including rural areas and the growing number of seniors. 57 Coalition for Patient Rights (cont’d) • “We respect individual physicians.” • “All of our groups work cooperatively with individual physicians every day.” • “We need to work together to help patients.” • The AMA’s actions are draining resources, time, and money that could be better directed toward patient care. (Tobin) 58
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