When privilege redesign reveals the unexpected
More often than not, privilege-redesign projects reveal something unexpected: risky behavior. At least that’s how I view advanced practice professionals (APPs) being “trained up,” in other words, learning to perform additional procedures or practice in a different specialty, without privileging.
I support upskilling. But when this happens apart from any formal process and without privileging, APPs, their sponsoring physicians, and the healthcare organization are at risk.
While it can happen everywhere, I typically see this at community hospitals that lack formal training programs to support APPs’ growth. In many cases, training up happens unbeknownst to leadership, the Governing Board, or the medical staff services department.
Who’s considered an APP?
I get a lot of questions about who’s considered an APP. For this healthcare credentialing discussion, APP refers to non-physician healthcare professionals who provide medical care and need to be privileged through the medical staff process. Under the APP umbrella are PAs and advanced practice RNs, including certified registered nurse anesthetists, certified nurse midwives, nurse practitioners, and clinical nurse specialists.
Expanded APPs, expanded APP privileges
The number of APPs has grown exponentially during the past decade.
As of December 2019, there were 290,000+ licensed NPs in the US, up from 248,000 in 2017, while certified PAs increased by 28.6% over the past four years (according to the American Association of Nurse Practitioners and the American Academy of Physician Assistants, respectively).
Academic hospitals inherently have frameworks for on-site training. However, in community hospitals, this typically isn’t the case—yet they’ve got plenty of reasons for creating mechanisms to expand APPs’ privileges:
The pandemic, not to mention physician shortages and burnout, continues to increase APPs’ value within healthcare organizations.
Physicians understand APPs’ value and often seek to expand their role.
Hospitals realize how APPs can help manage increasing demands, easing physicians’ workload while improving the healthcare experience for both patients and providers.
Develop a policy that protects all parties
Absent an APP train-up policy, developing one is requisite. And it must be designed to protect patients, the organization, and practitioners, and address these considerations:
The Governing Board must sanction training up at non-training healthcare facilities.
The organization’s professional liability carrier and individual practitioners’ liability carriers must support and insure training up activities.
Appropriate patient consent is required.
Operationally, there must be a nimble mechanism/procedure to ‘independently’ privilege without the precepting limitation after the APP is deemed proficient in performing the procedure.
What’s in scope?
Federal and state regulations (and internal policies) determine both NPs’ and PAs’ scopes of practice. CMS and accrediting organizations, such as The Joint Commission, require that medical care providers are privileged through the medical staff process.
Yet, organizations often skip the privileging step, opting to train up APPs instead, reserving privileging for when competence is already confirmed. So, in training up APPs, there’s the issue of: “How can we grant privilege to APPs without evidence of current experience or competency?”
The devil is in the details, specifically in how the privilege being requested is described. Let’s use a core privilege example. A Family NP without previous acute care experience seeking Critical Care Privileges would request the “critical care core with preceptorship.” To borrow an analogy from my colleague, Dr. Rick Sheff, think of the difference between a full, unrestricted driver’s license vs. a learner’s permit for new drivers. The learner’s permit is similar to the permission given to the APP to undergo training of a new specialty area or a new procedure through privileging: they’re authorized to learn under a competent teacher, while not yet being competent themselves.
Winging it is dangerous
Allowing an APP to train-up outside of a formal training program without the authorization that comes through privileging, or winging it without a policy, may have a significant negative impact.
Without privileging them to expand their skills, you’re at risk. That takes the form of increased legal liability and potential claims of negligent credentialing. Though it may seem extreme, APPs practicing beyond their authorized scopes—their physician sponsors, too—could be disciplined by the healthcare organization and state licensing board with potential membership, privileges, or licensure loss or restriction.
With a policy to guide you, APPs can expand their skills while protecting patients, the healthcare organization, and the practitioner. And it all starts with authorization through the medical staff privileging process.
Level up your train-up
In creating a safe, sound policy-guided approach to expanding APPs skills, remember:
It’s all about process. Policy goals should reflect the culture, Governing Board position, and key considerations while facilitating a process to expand the skills of APPs. Revise privilege forms to reflect a mechanism to request privileges under a preceptorship.
If you see something, say something. When APP train up happens without a proper framework, you need to speak up and address it immediately.
The appropriate people are pivotal. Communicate with and actively educate the right people on the train-up policy to get buy in at every level. This includes the sponsoring physician and the APP, the managers of the applicable clinical units, the governing board and medical staff leaders with responsibility for the credentialing and privileging process.
With an intentional policy in place, you’re not only helping your APPs grow, you’re also increasing your healthcare organization’s effectiveness and delivering safe, high-quality care.