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Ask the expert: What should the governing board consider when developing or revising a policy covering AHPs?

Credentialing Resource Center Connection, July 15, 2011

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Developing or revising your AHP practice policy takes a lot of work and research. Create a taskforce of the board to tackle these challenges.

The board-level task force should carefully consider the following questions:

• What is the current policy regarding individuals authorized to provide care? Should it change?
• If the policy changes, what effect will the addition of this discipline have on the disciplines already included?
• What statutes are applicable to the addition of services from the healthcare provider (e.g., licensure, registration, supervision, collaborating agreements)?
• What types of services would the addition of this practitioner allow the organization to provide? Does the hospital or the public want or need these services?
• What changes in staffing or education of current staff will be required if the organization accepts the new service/practitioner?
• How does the contemplated service/practitioner enhance the mission and vision of the organization?
• Is there a community need for this service?
• Is there an institutional need to provide this service?
• Can the need be supplied by practitioners already available within the community?
• Where would the proposed services be provided (e.g., in the acute care or outpatient setting, or at a separate ambulatory clinic)?
• What would the scope of service be?
• Will the organization allow any number of applicants to provide this service? Or will the organization limit the number of individuals providing the service to evaluate the service/ practitioner and the demand and effect of the addition?
• Should the practitioners providing the service be employed, or should the service be provided on a contractual basis?
• Do employees or individuals under contract already provide these services?
• Are the qualifications, scope of services, and competence of the new group equivalent to those already employed under contract?
• What will be the required minimum qualifications for practitioners who will be providing the service?
• What applicable regulatory and accreditation standards (CMS/state licensing/Joint Commission/
• National Committee for Quality Assurance) apply to the authorization to practice for this category?
• Will the practitioner be allowed to function independently within the organization? If so, will the discipline be under the jurisdiction of medical staff membership/privileges? Are revisions necessary to medical staff governance documents? If not, will the individual(s) be credentialed in accordance with an administrative policy?
• Will changes be necessary to this policy?
• What additional equipment or staff will be necessary?
• What mechanism will be used to monitor the competence of the individual providing the services?
• Will this service be reimbursed by third-party payers? If not, what financial effect will services have on the patient? The institution?
• Who will have the final authority to approve these practitioners’ requests for access to the organization?
• What steps need to be considered to guide the initiation of this service? (An action plan should be developed reflecting the necessary steps.)

This week’s question and answer are from Core Privileges for AHPs, Second Edition by Sally Pelletier, CPMSM, CPCS.
 

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