p9 staff namss has launched a new online

May 2013Volume 23Issue No. 5

TrendspoTTing

Medical Staff Briefing

Delineation of privileges is one of those evergreen battles in the world of medical staff services—an ever-moving target that requires excellent best practices, but changes so often and so quickly that every organization must find its own tactics for privilege tracking.

For one Montana health system, this challenge has inspired its medical staff office to find and develop a best practice concept that has been well received by providers and administration alike.

“We have been in flux, trying to move away from old laundry lists of privileges and trying to create more criteria-based privileges over time,” says Kay Brown, CPMSM, CPCS, director of medical staff services at St. Vincent Healthcare in Billings, Mont.

This is obviously a moving target, says Brown. “You’re never done. Medicine changes. Things move from specific privi-

leges to core privileges over time,” she says. In order to find some stability, however, Brown’s organization re-

searched not only specific privileging recommendations and requirements through resources such as HCPro’s Clinical Privilege White Papers, but also pursued comparisons with similar institutions.

“We always ask, what are other organizations doing out there? This might be a new procedure here, but where did the physician do their

Delineation of privileges: An ever-moving target

Proctoring, FPPE, and approval lettersFPPE is deeply linked to the long-standing practice of proctoring. Learn about one California hospital’s process of communicating with its practitioners to ensure proper proctoring.

NAMSS announces PASS programNAMSS has launched a new online repository for letters of good standing. Get the details about this nationally available option inside.

The role of the CRNA Read an extensive discussion of the CRNA’s relationship to the medical staff office.

Who needs departments anyway?William K. Cors, MD, MMM, FACPE, continues his ongoing series on medical myths by taking a look at voting.

P5

P9

A training resource for medical staff leaders and professionals

P10

P12

The percentage of CRNAs who are male, as opposed to the 10% of nurses who are male industrywide in the United States.

The percentage of all anesthetics given to patients each year in the United States by CRNAs.

40%

65%

The number of states that have opted out of Medicare’s physician supervision requirement for nurse anesthetists.

17

2 hcpro.com May 2013 © 2013 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.


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Follow UsFollow and chat with us about all things healthcare compliance, management, and reimbursement. @HCPro_Inc

Questions? Comments? Ideas?

Contact Contributing Editor Matt Phillion at [email protected].

“You’re never done. Medicine changes. Things move from specific privileges to core privileges over time.”

Kay Brown, CPMSM, CPCS

“They want someone to reach out to them. There’s a lot of good synergy between the medical staff offices and GME programs to share information.” Kay Brown, CPMSM, CPCS

Quick Hits

Medical Staff Briefing (ISSN: 1076-6022 [print]; 1937-7320 [online]) is published monthly by HCPro, Inc., 75 Sylvan St., Suite A-101, Dan-vers, MA 01923. Subscription rate: $389/year or $700/two years; back issues are available at $25 each. • MSB, P.O. Box 3049, Peabody, MA 01961-3049. • Copyright © 2013 HCPro, Inc. All rights reserved. Print-ed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978-750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781-639-1872 or fax 781-639-7857. For renewal or subscription infor-mation, call customer service at 800-650-6787, fax 800-639-8511, or email [email protected]. • Visit our website at www.hcpro.com. • Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. • Opinions expressed are not necessarily those of MSB. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

editorial advisory board

Alpesh N. Amin, MD, MBA, FACPExecutive DirectorHospitalist ProgramVice Chair for Clinical Affairs & Quality Dept. of Medicine University of California, Irvine

Michael Callahan, Esq.Katten Muchin Rosenman, LLP Chicago, Ill.

William K. Cors, MD, MMM, FACPE Chief Medical Quality OfficerPocono Health System East Stroudsburg, Pa.

Sandra Di VarcoMcDermott Will & Emery, LLP Chicago, Ill.

Roger A. Heroux, MHA, PhD, CHEFounding PartnerHospitalist Management Resources, LLC HMR ED Call Panel Solutions Pensacola Beach, Fla.

Jonathan Lovins, MD, SFHMHospitalist and Assistant Clinical Professor of Medicine Duke University Health System Durham, N.C.

Assoc. Editorial DirectorTodd Hutlock

Contributing EditorMatt [email protected]

Sally Pelletier, CPMSM, CPCSSenior Consultant and Director of Credentialing ServicesThe Greeley Company Danvers, Mass.

William H. Roach Jr., JDMcDermott Will & Emery Chicago, Ill.

Richard E. Rohr, MD, MMM, FACP, FHMDirector of Hospitalist ProgramsGuthrie Healthcare System Sayre, Pa.

Jodi A. Schirling, CPMSMAlfred I. duPont Institute Wilmington, Del.

Richard A. Sheff, MDPrincipal and Chief Medical OfficerThe Greeley Company Danvers, Mass.

Raymond E. Sullivan, MD, FACSWaterbury Hospital Health Center Waterbury, Conn.

This document contains privileged, copyrighted informa-tion. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, any use, disclo-sure, forwarding, copying, or other communication of the contents is prohibited without permission.

online

Ore. governor signs medical lawsuit mediation billOn March 18, Gov. John Kitzhaber signed a bill that creates a new process for patients, physicians, and healthcare providers to mediate disputes over med-ical errors, according to Oregon Live.The House and Senate overwhelmingly approved the bill with the Senate voting 26-3 and the House voting 55-1.

www.hcpro.com/MSL-290320-871

Lawmakers continue to weigh in on physician shortage, ACALawmakers continue to weigh in on the question of who can provide what kinds of healthcare. As a result of the Affordable Care Act (ACA), legislators and medical professionals are worried there will not be enough physicians in Florida to treat patients, according to The Sun Sentinel.

As many as 2.5 million Floridians could be added to the 15 million who already have health insurance by January 1, 2014, the date by which most adults are required to have coverage.

www.hcpro.com/MSL-290091-871

From The Field


3May 2013 hcpro.com© 2013 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.

fellowship? What do their privileges look like at that institution?” says Brown. “We don’t want to reinvent the wheel.”

It’s not just about saving time, though—Brown’s organization wants to make sure for each newly pre-sented privileging request, its own requirements are consistent with what practitioners are required to comply with out in the field. The best place to start, she says, is with education or training programs.

“They’ve been testing it, and if they’re a fellowship, chances are they’ve worked through the processes of the criteria,” Brown says. “Why try to guess when they’ve done that amount of work?”

As an added bonus, these educational programs usually welcome questions about their existing requirements.

“They want someone to reach out to them,” says Brown. “There’s a lot of good synergy between the medical staff offices and GME programs to share information.”

Obtaining buy-in Once they gather the initial research, Brown and her

colleagues bring this information back to those who will be involved in finalizing the requirements—physi-cian leaders and the providers who have requested those privileges.

“So we say, ‘Okay, let’s sit down and talk. How does this compare to your expectations?’ ” Brown says.

This allows Brown’s group to establish a good groundwork for getting buy-in from practitioners.

The medical staff office should not be perceived as the sole driver in the development of criteria for delineation of privileges, says Brown. “That’s the responsibility of our physicians. We lay some ground-work and then they have to own what’s there.”

The process is not always perfect, she says. Some-times the medical staff will approve the delineation of privileges, but when the time comes for privilege re-newal, questions will arise surrounding the inclusion of certain criteria that might not make sense in practice. But this is all part of the ever-evolving development process.

The organization’s most recent foray into the de-lineation of privileges for pain management is a good example.

“This includes so many departments,” says Brown. “Trying to reach an agreement has been interesting, but we’re building a consensus.”

The aim is for practitioners with pain management privileges to be able to say this is their pain privilege delineation so that they don’t have differing standards from anesthesia to neurosurgery.

“We’re not quite there yet,” says Brown, noting that it is an ongoing and highly interactive process. “If my requirements for a particular privilege between two departments [are] consistent, that makes it a valid cri-teria. We work closely with all departments who might require this privilege.”

Who to involveThis entire process does not work without the right

people sitting at the table. Of course, for each new set of privileges, the “who” can vary.

“Every time we do this, it’s different,” says Brown. “We can’t have a set council, per se. We need to know who has a horse in this particular race and reach out to those departments.”

Brown and her colleagues discuss who they want to include in the developmental process and identify which physicians they will need as leads.

“We give them the information, and they provide us with feedback,” says Brown.

Rarely, however, do these providers literally sit “at the table.” The organization relies heavily on virtual communication throughout the development process to keep things moving, as it can be very difficult, given providers’ hectic schedules, to gather everyone in the same room at the same time.

Providers need to be involved as early as possible, though, Brown says. “It’s not a good thing to hear, ‘Where did this come from?’ ” she says.

The benefit of identifying those lead physicians is not just having their expertise to help develop the delinea-tion of privileges. Those physicians will then go back to their departments to get feedback from their peers and colleagues.

“Each physician goes back to their department for their review—it’s not just our small consensus group,” Brown says. “It goes out to the entire department for approval and then moves up the chain to the creden-tials committee,” and then on to the medical executive



committee. Once departmental consensus is achieved, Brown

says, the process moves quickly. The credentials com-mittee will turn a critical eye to the delineation of privi-leges, asking the expected questions: Is it reasonable? Can we credential to it? Every so often something will cause a blip on the radar, which will require further re-view, but these are usually minor revisions that Brown and her colleagues are able to resolve with the depart-ment in question.

The medical staff office “will make the revision, email the department identifying the suggestion, and ask if it causes any concern,” says Brown.

Using electronic voting, they are more often than not able to come to a quick resolution.

Having one point person keep an ear to the ground is indispensable to keeping the process manageable and streamlined, she says. This staff person will identify when the organization is bringing in a new physician and when new privileges need to be researched.

“The physician will identify an area they are request-ing privileges [in] and we will ask, ‘Where does this fit?’ ” says Brown.

This way, the medical staff office is able to start the process months ahead of time.

Brown says they recently had an addition to the medical staff and discovered as they prepared to bring him on board that their surgical privileges form didn’t contain everything they would need for the privileges he was requesting.

He was a community physician, but he was bringing a different set of skills than we had previously worked with, she says.

While he was in the application process, Brown’s department began developing a new form that would meet the needs of this physician.

“You have to build your infrastructure to allow for that kind of change,” she says. “You can’t just add an item to a laundry list—I’m not a fan of laundry lists because if it’s not on the list, you can’t do it. What if it’s a variation of something on the list?”

There needs to be a combination laundry/core privileges list while being able to identify your existing procedures and build flexibility into your processes.

Keeping an eye on what practitioners are actually doing can help you spot trends as well.

“We monitor their cases—not just how many, but what do they do,” Brown says. “Our department chairs will look at those lists and say, ‘Let’s look at the delin-eations of privileges and make sure they’re appropriate for the scope of services.’ ”

What comes next Those professionals in charge of delineation of

privileges must also weigh mixed signals from the various regulators about the preferred privileging method. For example, there has been some feed-back from the field that CMS does not prefer core privileging as a model and is leaning back toward laundry lists. What is the best course of action when you aren’t sure what the regulators are going to prefer?

“I think you can do a blend of the two,” says Brown. “Cluster your privileges, so it’s not a laundry list, but not a core privilege concept. Identify procedures that are affiliated within a cluster so that if you have a physi-cian who doesn’t do head surgery, but does do spine surgery, you can identify the appropriate procedures” for him.

In the end, you must devise a system that is ap-propriate for your facility, knowing the standards are there. You must meet the intent of the standard without relying on a cookie-cutter privileging concept at every facility.

“Every physician community practices a little differ-ently,” says Brown.

You may have a family practitioner who doesn’t do OB. But in other regions, family practitioners perform C-sections. Look at your community as a whole to develop the appropriate privileges. Don’t just rubber-stamp your privileges.

If you’re just getting started with revising or devel-oping your delineation of privileges, Brown advises starting small.

“Chew on the elephant one toe at a time. Don’t try to walk in and fix everything. Identify your priorities,” says Brown. “Where are your risks? Where can you really make an impact on patient safety?”

It may take you a couple of years to develop delinea-tions of privileges for all practice areas and procedures, but targeting the high-risk ones first will have the big-gest and earliest impact.



Proctoring, FPPE, and the notification processSince The Joint Commission launched the FPPE

concept and the related OPPE, hospitals have struggled to find their ideal method for performing and tracking these processes.

For certain states, however, FPPE was more of a name change than a new concept—California, for ex-ample, had been requiring proctoring since the 1980s. So how does FPPE look and work in an organization with several decades of proctoring experience under its belt?

“This method of observation is not new in Califor-nia,” says Graciela Lopez, CPMSM, director of the medical staff services department (MSSD) at City of Hope in Duarte, Calif. “Despite the years, proctoring is still one of the methods the medical staff uses to deter-mine and validate competence.”

Proctoring remains a requirement for new and existing practitioners requesting clinical privileges, as a condition for privilege renewal, and for privileges performed so infrequently that current competency is not feasible, she says.

“It’s a process that complements and enhances safe patient care,” says Lopez.

But let’s flash forward to the notification process and the complexities it can include.

“We’ve tried various methods over the years, but the most efficient process to complete proctoring is through effective communication with all involved—if the method of proctoring is clear, then tracking it’s not a problem,” says Lopez.

The organization had the advantage of being famil-iar with the proctoring process prior to the advent of The Joint Commission’s FPPE, so compliance with the overall process has gone fairly well, she says.

“Having support from medical staff leadership and administration is very helpful, too,” she adds. “It’s a

team effort.” In fact, it was an administrator who helped in-

spire looping leadership into the proctoring process pre-FPPE.

“One former administrator had made a comment that it would be helpful if we provided a copy of our tracking tool to the various clinical departments and peer review committees,” says Lopez. “Sometimes peer pressure and friendly competition between depart-ments do wonders.”

Notification and FPPEIt falls on the medical staff office to make sure the

proctoring/FPPE process is firing on all cylinders. “It can be a very intense process,” says Lopez.

“We do a lot of work behind the scenes. Again, hav-ing a clear, fair, and transparent proctoring process makes the follow-up and notification process seam-less. Prior to the granting of clinical privileges by the board, the department chair would have identified the method of proctoring, confirmed the number of cases to be proctored, and who the assigned proctor will be.”

“We then prepare an appropriate board letter to the practitioner with emphasis on the proctoring require-ments and time frame for completion,” says Lopez.

Specifics are provided ahead of time in writing— whenever possible, the first cases must be proctored; overall, proctoring requirements must be met within the first 12 months of the date the privileges were granted. If a practitioner does not complete proctoring requirements within the expected time frame solely due to lack of volume, then the clinical privileges being proctored are deemed voluntarily withdrawn, unless an extension is granted by the medical executive commit-tee (MEC) at its sole discretion.

“Identify where your risks are in your organization and focus on those to make sure your delineation of privileges are robust,” Brown says.

Lastly, make sure to cultivate physician champions. “These are the people who will say, ‘I’ve reviewed it,

it’s okay, and this is why we’re doing this,’ ” says Brown. “Find someone who is passionate about the procedure and let them know, ‘We can do this, but we need your help.’ When you take it to committee, they will defend you or the process or the form.” H



The MSSD tracks the practitioner’s name, staff sta-tus, assigned department, and proctoring requirements on a tracking tool (an Excel sheet works).

“An aggregated proctoring list is routinely pre-sented to the credentialing committee and MEC,” says Lopez.

These peer review committees are kept abreast of who is on the list and who has partially completed proctoring. The committees normally delegate a de-partment representative to follow up with the respec-tive practitioners as a means to emphasize the need to complete proctoring requirements.

To augment notification, a department-specific proctoring list is presented as part of each department quality assurance meeting for tracking purposes.

Follow-up letters are sent to practitioners who remain on the pending proctoring list on a monthly basis, with a copy to the department chair/division chief.

A termination or release of proctoring requirements is processed through the medical staff mechanism, subject to confirmation by the board. A separate board letter is prepared informing the practitioner that no further proctoring is required—or if additional proctor-ing is necessary.

All about communicationVoluntary withdrawal of clinical privileges due to

failure to complete proctoring based on lack of volume is not considered an adverse or punitive action, Lopez notes. As stated above, if a specific clinical privilege is not exercised within 12 months and the practitioner does not request a formal extension, the affected privi-leges are considered to have been voluntarily with-drawn per medical staff policy.

The MSSD provides advanced written notifications to the practitioner and respective department chair/divi-sion chief should this occur.

“A final letter is sent from the MSSD to the practi-tioner stating that lack of proctoring completion will result in voluntary withdrawal of specific privileges and that a notification will be sent to the credentials com-mittee for action,” says Lopez.

The final board letter confirms acceptance of a voluntary withdrawal of specific privileges due to lack of volume; excerpts from the medical staff bylaws

supporting the action is included in the letter. “In this circumstance, we inform practitioners that

loss of clinical privileges is not considered an adverse action based on medical disciplinary cause or reason and that the action is not reportable to any regulatory agency,” says Lopez.

The practitioner’s clinical privileges are then updated in the medical staff privileging system. The relinquish-ment of privileges is not necessarily a permanent action.

In fact, the board letter notifying that the privileges will be voluntarily relinquished includes language informing the practitioner that if he or she anticipates performing a related procedure in the near future, a formal request must be made and submitted to the MSSD and proctoring must be timely performed and completed.

We must consider the tone of the notification letters regarding proctoring, says Lopez.

“We try to keep a balance in the tone of our letters,” she says. “We simply state the facts and follow the medical staff bylaws and related policies and proce-dures; we have not had anyone state that they were never notified” about the status of their proctoring process.

And while voluntary relinquishment of clinical privi-leges is based on administrative reasons rather than disciplinary, it is always addressed with the utmost scrutiny and respect.

“We do not take the proctoring process lightly. We always check and verify,” says Lopez.

Instances in which there is a narrow window of opportunity to practice a specific procedure are not rare in the organization for several reasons. There are situations where the failure to complete proctor-ing is not the fault of the practitioner. For example, the focus of a practitioner who seeks privileges has been oriented to research rather than clinical prac-tice. Or a procedure is fairly uncommon and the practitioner has not had the opportunity to perform the required number of cases within the 12-month time frame.

“If a certain procedure is done infrequently, it is not the fault of the physician not to be able to complete proctoring. In this case, the practitioner, through his or her department chair/division chief may submit a



Sample Notification Letter

Dear Dr. [name]:

I am pleased to inform you that the recommendation of the medical executive committee (MEC), our board of directors acting

through its credentialing committee on [date], has approved your appointment to the provisional staff category of the medical staff.

Pursuant to section [section number] of the bylaws, you will remain in the provisional staff category for 24 months, after which time

the MEC will determine your eligibility for advancement to the [staff category] in accordance to Section [section number] of the by-

laws. Your appointment is effective as of [date].

You have been assigned to the [department/division], with privileges as delineated on the enclosed Privilege Delineation Form.

Proctoring requirement: [Organization name] recognizes proctoring as the basis for determining professional competence of

newly appointed medical staff members. Some privileges granted to you may require documented proof of satisfactory proctor-

ing before you can exercise those privileges independently; proctoring must commend you with respect to the first cases per-

formed at [hospital/facility].

Date ________________________________________________

Name of degree ______________________________________

Name of facility _____________________________________

Department or division _______________________________

Address line 1 _______________________________________

Address line 2 _______________________________________

timely request to the credentials committee for ad-ditional time to complete proctoring before the 12 months expire,” says Lopez. “The request must be in writing, describe the good cause reasons for the exten-sion, and specify the additional time desired.”

TroubleshootingFPPE and proctoring might not be an easy task

sometimes, but it’s something every organization must be committed to observe, not only for regulatory com-pliance but for patient safety.

“It is one additional measure to demonstrate that we are doing everything possible to confirm a prac-titioner’s competence,” says Lopez. Proctoring is an information-gathering measure. “We’ve already verified a practitioner’s clinical expertise through the comprehensive credentialing and privileging functions, proctoring is one additional element to fulfill.”

The method of proctoring will likely vary per practi-tioner, which can create additional complexity for the medical staff office.

“The chair has the prerogative to implement addi-tional proctoring requirements—it is always useful to depict the minimum proctoring requirements within

each respective privilege delineation form—this allows the practitioner and the MSSD to efficiently identify the proctoring requirements for each privilege ahead of time,” she says.

With so many procedures and so many physicians, have there ever been any issues with maintaining communication?

“I have not experienced many issues at this institu-tion,” says Lopez. “We are fortunate to have excellent practitioners who understand and support the proctor-ing process. We also have the support from administra-tion and medical staff leadership. We have institutional policies and procedures in place that guide the proctor-ing process.”

It is important to remember that proctoring isn’t just to evaluate technical and cognitive skills, Lopez says. In the process, the medical staff can assess a practitioner’s ability to collaborate with others, communication skills, professional behaviors, etc. Proctoring and the notification process do not need to be laborious; otherwise we could miss the most important focus of this activity: validation of current competence to sustain high quality of care and patient safety. H



Sample Notification Letter (cont.)

Proctoring of privileges granted must be satisfactorily completed with document received by the medical staff services

department no later than twelve (12) months from the date of granting the privilege or privilege will be deemed to have been

voluntarily withdrawn by you. Please immediately contact your department chair or division chief to arrange for proctoring of

privileges required.

ID badge requirement: As part of [organization name] safety and security plan, you are required to wear a hospital-issued

photo identification (ID) badge, which is to be readily visible at all times on [organization] grounds. This badge is necessary to gain

access to restricted areas on campus through use of the reader function embedded in the ID badge. Please promptly contact

[ organization name]’s security department at [contact information] if you have not already obtained a photo ID badge.

Participation in orientation program requirement: You are required to participate in a “clinician orientation program,”

which must be completed within 30 days of initial appointment. This orientation covers key information necessary to support

your practice at [organization/hospital], including important education on the medical staff bylaws and rules and regulations,

patient care– related policies, patient safety measures, medical records, case management, patient advocacy, and risk man-

agement. You must also complete live classroom training as it pertains to [organization name]’s information systems, pharmacy

services, and dictation practices. If you have not already fulfilled these requirements, please contact the medical staff services

department at [contact information] to speak with the credentialing coordinator to coordinate this activity. If you do not com-

plete this orientation in a timely manner, your medical staff membership and clinical privileges will be automatically suspended.

Corporate compliance and HIPAA training: As part of [hospital/organization]’s corporate compliance plan, new applicants

to the medical staff must complete corporate compliance and HIPAA training and provide a certification of completion to the

medical staff services department within sixty (60) days of initial appointment. Please contact the corporate compliance office

at [contact information] for information regarding this requirement.

Professional Code of Conduct observed: [Hospital/organization] medical staff rules and regulations reference a Professional

Code of Conduct and Ethical Obligations. (You have been previously provided with a copy of the medical staff bylaws and these

rules and regulations in their entirety.) The medical staff has also approved and implemented two (2) additional policies regard-

ing appropriate conduct, the Behavior Standards Policy and the Clinical Practice Expectations Policy. Copies of these documents,

which are available on [organization]’s intranet under [location], are now enclosed with this letter as a reminder of the importance

of establishing and maintaining good relations with colleagues and patients.

It is my pleasure to welcome you to [organization/hospital]. I hope that you will establish a productive and meaningful practice

with our organization. Please do not hesitate to contact me if I can be of assistance.

Sincerely,

Name _______________________________________________

Title _________________________________________________

Address _____________________________________________

Contact information __________________________________

Enclosure(s) ____________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

Source: Based on language used by City of Hope, Duarte, Calif. Reprinted with permission.



NAMSS announces primary source verification database

The National Association of Medical Staff Services (NAMSS) has announced the launch of its NAMSS PASS™ tool. NAMSS PASS (Practitioner Affiliation Sharing Source) is a secure, online repository intended to provide a quick and easy method to access primary source affiliation history for practitioners its members credential.

According to the official announcement and website, NAMSS PASS has been vetted by a number of high- level MSPs as well as members of the organization’s board of directors. Also involved in the vetting process is leading health law firm Horty, Springer, and Mattern.

Users are able to log onto the NAMSS PASS site to explore the system, gain access to practitioner affiliation histories, and print “good standing” letters, if available for that practitioner, from any contributing hospitals.

What users need to knowNAMSS has provided a list of five must-know an-

swers to common questions about NAMSS PASS: • It is intended to speed up the credentialing process.

By allowing users to print letters of good standing, organizations can remove the long process of fax-ing or mailing for individual requests, waiting for responses, and making additional requests for veri-fication. On the other end of the spectrum, organi-zations receiving queries are afforded a faster and more secure way to share their information.

• It is not intended to be credentialing software. It is meant to be a primary source practitioner affiliation database, not a replacement for other credentialing software options. (The official site says that an addi-tional feature can be added to allow your existing cre-dentialing software to interface with NAMSS PASS.)

• It is not intended to require additional tech support from your organization. Additional time and assis-tance for IT can be difficult to obtain. NAMSS PASS is not something that exists on your desktop, but rather a secure online database. You will be able to upload practitioner information through Excel®.

• It resolves the issue of defining “good standing.” The definition of “good standing” varies widely

across the industry despite the ubiquitous need for letters of good standing for the credentialing pro-cess. NAMSS PASS has developed a common def-inition for this concept that will be applied to all participating entries.

• It does not require additional agreements or releas-es from the practitioners you credential. Accord-ing to the official site, NAMSS PASS is a method to streamline the process of sharing affiliation infor-mation and letters of good standing, two activities you are already doing. In all likelihood, your prac-titioners have already given permission to perform these tasks and share this information.

Filling the gap in online information NAMSS has been working to solidify the industry’s

concept of what an ideal credentialing solution would contain. The organization has identified 13 items it considers “critical data elements”: 1. Identity verification2. Residency, and fellowship enrollment/completion

date3. Education Commission for Foreign Medical

Graduates information4. Military information5. Professional licensure held in all states 6. DEA registration and state Department of Public

Safety certification7. Board certification status8. Practitioner affiliation history9. Criminal background check10. HHS-OIG and GSA sanction checks11. NPDB12. Malpractice carriers13. Insurance carrier certificate/reports

When it comes to #8, the practitioner affiliation his-tory, NAMSS PASS hopes to fill an existing gap. There is currently nothing on the national level providing a unified database for this information.

For more information on NAMSS PASS, visit www.namss.org/NAMSSPASS/tabid/425/Default.aspx. H



The CRNA and the medical staff officeWhat education and certifications are required?

Editor’s note: This is the fourth and final article in MSB’s allied health practitioner series by Patricia A. Furci, RN, MA, Esq., and Samuel J. Furci, MPA, of Furci Associates, LLC, in West Orange, N.J.

Medical staff offices have been privileging and credentialing nurse anesthetists for a very long time. Nurse anesthetists have been providing anesthesia care to patients in the United States for approximately 150 years. However, the credential CRNA (certified regis-tered nurse anesthetist) did not come into existence until 1956.

Many changes have occurred in the areas of educa-tion, board certification, and ultimately credentialing in the nurse anesthetist specialty that are significant to the processing of initial appointments and reappoint-ment applications.

Nurse anesthetist overviewAccording to the American Association of Nurse

Anesthetists (AANA), CRNAs are anesthesia profes-sionals who administer approximately 65% of all anes-thetics given to patients each year in the United States. In the majority of urban and suburban settings, nurse anesthetists work in a collaborative team practice with physician anesthesiologists.

However, CRNAs are often the sole anesthesia pro-viders in approximately two-thirds of all rural hospitals in the United States, and in some states, CRNAs are the sole providers in nearly all rural hospitals.

When anesthesia is administered by a nurse anes-thetist, it is recognized as the practice of nursing; when administered by an anesthesiologist, it is recognized as the practice of medicine. Anesthesiology nursing was the first recognized specialty practice area of nursing.

Regardless of whether their educational background is in nursing or medicine, all anesthesia professionals provide anesthesia the same way.

According to the AANA, there are more than 40,000 CRNAs in the United States and more than 40% of nurse anesthetists are men, compared with less than 10% of nursing as a whole.

CRNAs can practice in every setting in which anes-thesia is delivered: traditional hospital surgical suites and obstetrical delivery rooms; primary and specialty hospitals; ambulatory surgery centers; the offices of dentists, podiatrists, ophthalmologists, plastic sur-geons, and pain management specialists; as well as U.S. military, Public Health Services, and Department of Veterans Affairs healthcare facilities in the United States and at military bases around the world.

EducationHistorically, CRNAs in the United States received an

anesthesia bachelor’s degree, diploma, or certificate. Education has been governed by the Council on Ac-creditation (COA) of Nurse Anesthesia Educational Program, and as early as 1976, the COA was developing requirements for degree programs.

In 1981, the COA developed recommendations for the development of master’s degree programs, and in 1982, it became the official position of the AANA that registered nurses must be baccalaureate prepared and then attend a master’s-level anesthesia program. At that time, many programs started phasing in advanced degree requirements.

All programs were required to transition to a mas-ter’s degree beginning in 1990 and complete the pro-cess by 1998.

Currently, the American Association of Colleges of Nursing has endorsed a position statement that will move the current entry level of training for nurse anesthetists in the United States to the doctor of nursing practice (DNP) or doctor of nurse anesthesia practice (DNAP). This move will affect all advanced practice nurses, with a mandatory implementation by 2015.

In August 2007, the AANA announced its support of this advanced clinical degree as an entry level for all nurse anesthetists, but with a target date of 2025.

In accordance with traditional grandfathering rules, all those in current practice will not be affected. Several nurse anesthesia programs have already upgraded to the DNP or DNAP entry level format.



Since all programs will be converting to a doctor-ate level education, the length of the programs, in most cases, will need to increase from the original 24-month requirement or exceed 36 months per the recommendation of the COA of Nurse Anesthesia Programs.

Upon graduation from an accredited CRNA program, graduates are able to take the National Council Licen-sure Exam. Once the graduates pass the exam, they are certified to practice as a nurse anesthetist anywhere in the United States. However, they must still apply for the advanced registered nurse practitioner (ARNP) credential with a specialization as a nurse anesthetist from their state board of nursing.

Board certification

The certification and recertification process is governed by the National Board on Certification and Recertification of Nurse Anesthetists (NBCRNA). The NBCRNA exists as an autonomous nonprofit incorpo-rated organization to prevent any conflict of interest with the AANA. This provides assurance to the public that CRNA candidates have met unbiased certification requirements that have exceeded benchmark qualifica-tions and knowledge of anesthesia.

CRNAs also have continuing education require-ments and recertification every two years thereafter, plus any additional requirements of the state in which they practice. To be recertified, CRNAs must obtain a minimum of 40 hours of approved continu-ing education every two years, document substantial anesthesia practice, maintain current state licensure, and certify that they have not developed any condi-tions that could adversely affect their ability to prac-tice anesthesia.

Scope of practice The degree of independence or supervision by a

licensed provider (e.g., physician, dentist, or podia-trist) varies with state law. Some states use the term “collaboration” to define a relationship where the physician is responsible for the patient and provides medical direction for the nurse anesthetist. Other states require the consent or order of a physician or other qualified licensed provider to administer the anesthetic.

No state requires supervision specifically by an anesthesiologist.

The licensed CRNA is authorized to deliver compre-hensive anesthesia care under the particular Nurse Practice Act of each state. Their anesthesia practice consists of all accepted anesthetic techniques including general, epidural, spinal, peripheral nerve block, seda-tion, or local.

The scope of CRNA practice is commonly further defined by the practice location’s clinical privilege and credentialing process, anesthesia department poli-cies, or practitioner agreements. Clinical privileges are based on the scope and complexity of the expected clinical practice, CRNA qualifications, and CRNA expe-rience. This allows the CRNA to provide core services and activities under defined conditions with or without supervision.

Irrespective of the practice setting, all CRNAs are educated to the same high standards to deliver safe an-esthesia care, for all patients of all age groups. They are licensed in all states and serve as commissioned officers in all branches of the military as well as the U.S. Public Health Service.

Legislation passed by Congress in 1986 made nurse anesthetists the first nursing specialty to be accorded direct reimbursement rights under the Medicare pro-gram. In 2001, CMS published a rule in the Federal Register that allows a state to be exempt from Medi-care’s physician supervision requirement for nurse anesthetists after appropriate approval by the state governor.

To date, 17 states have opted out of the federal requirement, instituting their own individual require-ments instead.

Conclusion

In the United States, the CRNA is an advanced practice registered nurse who has acquired graduate-level education and board certification in anesthesia or one who has a certification or diploma or who has been grandfathered into the profession. No matter what credential they currently hold, it is clear that CRNAs are certain to hold a doctorate degree in the future as they continue to take their place among the ranks of the highly respected CRNAs who will mold the healthcare history of our next century. H



MS governance: Myths & misconceptionsMyth #5: Only active staff can vote

by William K. Cors, MD, MMM, FACPE

One of the most common myths regarding medical staff governance is that only active staff can vote. The reality is there is no restriction as to who can vote: not from the CMS Conditions of Participation (CoP), not from The Joint Commission, not from any other national regulatory or accreditation body. Who can vote is entirely up to the medical staff to decide.

Despite the freedom allowed in this area, most medical staffs adopt an “exclusive” approach in which they try to restrict the vote to those members who care for a significant number of patients at the hos-pital. This is the rationale behind the frequently seen “active staff category” judged by the number of con-tacts a staff member has with the hospital. Contacts are variously defined as inpatient admissions, inpa-tient consultations, inpatient or outpatient surgeries/procedures, referrals to ED for admission, referrals for diagnostic studies, or some other formula.

Increasingly, however, many medical staffs see the evolving landscape of practice change. They see many primary care physicians who have little or no volume in the inpatient setting but refer significant numbers of patients for testing, consultation, or admission to the hospitalists or specialists. Although they may not meet criteria for active staff, the medical staff still feels they should be involved in medical staff governance. This view advocates an “inclusive” approach and extends voting to these non-active staff members as well.

This leads to the numerous misconceptions and myths about staff categories. First, the only require-ment from both CMS [CoP 482.22(c)(2)] and The Joint Commission (MS.01.01.01, EP 15) is that there be a statement of the duties and prerogatives of each staff category. There is no mandate for any particu-lar staff category system, nor is there a requirement that clinical privileges be linked in any way to a specific staff category. It is truly up to the medical staff to design what works best for governance. Many

medical staffs have a hodgepodge of categories that are holdovers from decades-old requirements to try to accommodate any number of physicians with dif-ferent circumstances or needs. The names may differ from place to place but generally include categories such as active, adjunct, provisional, courtesy, consult-ing, honorary, or emeritus staff. The definitions are confusing. The links to activities and responsibilities may be tenuous. At the end of the day, it just causes unnecessary confusion.

A best practice is to move to two or possibly three staff categories. The first would be an active category based on specific criteria of longevity of service and/or level of clinical activity. The second would be an associate category that would include everyone who meets the criteria for the active category. Then, in a given circumstance, a decision can be made as to whether voting rights are exclusive (active category) or inclusive (active and associate categories). A third option could be an honorary category for physicians whom the medical staff or board wishes to honor for past service.

One hospital took an entirely different approach to voting by stating that anyone can vote regardless of staff category provided the member attended at least 50% of medical staff meetings the prior year. More medical staffs are expanding voting beyond hands raised or paper ballots at a meeting to allow votes sub-mitted electronically or by fax. Finally, another hospi-tal struggling with meeting attendance but reluctant to change quorum requirements at general medical staff meetings sends out proposed bylaws changes in advance with a notice that failure to respond prior to the meeting electronically or by fax shall constitute a vote in favor of the proposed change.

Next month, we’ll examine how medical staff membership, clinical privileges, medical staff catego-ries, and medical staff responsibilities become unnec-essarily entwined to learn the realities and best practices behind the myths and misconceptions. H

p9 staff namss has launched a new online

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