Beth Israel Deaconess Medical Center

Beth Israel Deaconess Medical Center Allied Health NP-PA Provider Credentialing

Title: Credentialing and Evaluation Process for Advanced Practice Nurses (specifically for Nurse Practitioners, Nurse Midwives, Nurse Anesthetists, Psychiatric Mental Health Clinical Specialists) and Physician Assistants as Allied Health Providers

Policy: OPSA-22

Purpose: The Medical Staff Bylaws define the disciplines that serve as allied health providers at BIDMC and/or its affiliated sites. Such providers are not members of the medical staff and neither request nor have the ability to hold medical staff membership or clinical privileges as defined by the bylaws and state regulations. Advanced practice nurses and physician assistants may practice as allied health providers under the supervision of only Active Staff members of the medical staff. This policy describes the process for the credentialing and subsequent evaluation of these staff as either employees of the medical center or an affiliated physician or group practice site, or as staff who are recognized through a specific service or contractual agreement with BIDMC. This credentialing process may be fulfilled by a vendor according to a service or contractual arrangement where an equivalent process is performed and the documentation is available to BIDMC as needed.

Policy Statement: Registered Nurses and Physician Assistants whose further education and experience qualify them to practice in the expanded role as defined by the Boards of Registration in Nursing and Medicine or the Board of Registration for Physician Assistants must meet these credentialing requirements in order to practice at BIDMC. The Chief of Service has identified these staff to practice within the scope of services of the department which has been formally approved by the Medical Executive Committee and the Board of Directors.

Definitions: -Allied Health providers are defined within the Medical Staff Bylaws of BIDMC as specific disciplines who work either independently (psychologists, acupuncturists, optometrists) or dependently (under supervision), including; advanced practice nurses, physician assistants, nurse anesthetists, nurse midwives, and other providers who work either directly or support patient care but are not members of the organized medical staff. Such staff are identified by the respective Chief of Service for the clinical department within their scope of services and are hired through Human Resources or procured through other arrangement.

-Credentialing refers to the process of verifying with the primary source, the qualifications, work experience and history of a licensed practitioner to provide patient care. This review is based upon an evaluation of the individual’s current and prior license(s), educational history, additional training, work experience, evaluation of competence and ability to perform the job duties and activities outlined within the job description.

OPSA-22 Page 1 of 9 The credentialing process is done collaboratively by the following departments:

1. BIDMC Clinical Department (Specialty of the Supervising Physician) 2. Contractual Vendor Organization and/or 3. Office of Professional Staff Affairs (OPSA)

-Payer credentialing is defined as the enrollment of the provider with various payers to allow the provider to bill for patient care services. The payer credentialing process is done by the BIDPO (Beth Israel Deaconess Physician’s Organization). The Chief of the Department would decide the billing status of the allied health provider according to the payer and regulatory authorities.

-Scope of Practice Guidelines are the description of those patient care activities that can be performed by the provider and have been created in collaboration with a supervising physician, Active Staff member of BIDMC. The provider’s scope of practice is based upon the credentials held, practice experience or certification and current competence to perform these activities. Standards for practice may be determined in accordance with, but not limited to, the following established criteria:  Licensure requirements defined by the Massachusetts Boards of Registration  Scope of practice as defined by the respective licensing boards  Nurse specialty certification standards  JCAHO requirements for allied health providers for credentialing and scope of practice  Approved practice guidelines/collaboration agreements (please see Addendum B for use in developing collaboration agreement)  Job description  Nursing standards required by BIDMC

Process: Advanced practice nurses and physician assistants are employees and, therefore, guided by the hiring entity’s process through its Human Resources office.

I. Human Resources Department Responsibility (BIDMC or affiliate):  The credentialing process begins with the initial screening and interview(s) of the potential provider by Human Resources staff. HR staff will then complete reference verifications, criminal background history and receive confirmation copies all credentials required for the job, e.g. license, special certification, DEA, etc.  Once the applicant has been confirmed for hire with the department, a notice will be sent to the Patient Care Services and Office of Professional Staff Affairs identifying the new hire information.

II. Hiring Department Responsibility:  The hiring department completes an initial review of the credentials and qualifications of the allied health provider.

OPSA-22 Page 2 of 9  At the time a decision to hire has been made and then accepted by the applicant, the department completes the BIDMC “Request for Allied Health Provider (NP,PA,CRNA,CNM) Application form” (either electronically or by paper), and determines if the allied health provider needs to be credentialed with payers. If yes, the box is checked “BIDPO payer enrollment” on the “Request for Allied Health Provider Application form” The payer enrollment application process will be initiated by BIDPO where this has been noted on the form. The fully completed form is then transmitted to the OPSA.  The hiring department ensures that a written collaboration agreement, also known as the “Practice Guidelines” are current. This agreement is signed by the provider, the supervising MD and the Medical Director (as applicable) and Department/Division Chief(s). A template has been created for these practice guidelines and approved for use by the Medical Executive Committee and the Board of Directors of BIDMC. All providers must use this format for their practice guidelines. The Chief includes the description of this practice in the department’s scope of services statement that is regularly reviewed and approved by the MEC and the Board of Directors.  The hiring department is responsible for ensuring that the provider is medically cleared by the BIDMC Occupational Health Office before the allied health provider can come in contact with patients.  The hiring department manager will complete an Annual Employee Performance Evaluation as required by BIDMC and/or its affiliated sites.  The provider and the department (or designee) will receive a copy of the acceptance letter and practice guidelines from the OPSA after final review by the Board of Directors.  Any subsequent change in the provider’s status will need a “Change of BIDMC Staff Status” form to be completed by the hiring department with the Chief’s approval. Such changes may include; adding a new patient care activity not originally contained within the practice guidelines, a new malpractice insurance carrier, legal name change, a new supervising physician, etc. Once completed, this form should be sent to the Office of Professional Staff Affairs.  If an allied health provider resigns but returns within six (6) months of their resignation, the Office of Professional Staff Affairs must be notified at which time the practitioner’s file will be re-verified for key content, to include, updates to curriculum vitae, malpractice history and current coverage, NPDB, license, etc).

III. Allied Health Provider Responsibility:

 The provider must submit the following to the OPSA upon hire: (Refer to attachment for content of credentials file) 1. Completed current “Integrated Massachusetts Credentialing Application” 2. Copy of Massachusetts license to practice 3. Copy of Massachusetts Controlled Substance Certificate (if prescribing) 4. Copy of Federal DEA Certificate (if prescribing)

OPSA-22 Page 3 of 9 5. Copy of BLS or ACLS/ATLS certification 6. Copy of all current Malpractice Face Sheets (BIDMC employees are covered by CRICO and do not need to produce this face sheet – but if covered by additional or other insurance carrier, a copy of current face sheet) 7. Practice Guidelines with original signatures of provider, Supervising Physician and Medical Director and/or BIDMC Department/Division Chief.  The provider must submit updated information as requested by the Office of Professional Staff Affairs to maintain their appointment. Updated information will include renewals of license, Mass Controlled Substance Certificate, Federal DEA, BLS/ACLS and malpractice carrier face sheet.  The provider must notify the Office of Professional Staff Affairs if there is a legal name change or a change in Supervising Physician or practice guidelines that were previously approved.  If the allied health provider does a department change but remains an employee, the Office of Professional Staff Affairs must be notified and provided with the name of the new supervising physician and new practice guidelines along with a reference letter from the previous supervising physician.  On an annual basis the allied heath provider will be asked to verify their practice guidelines with their supervising physician by completing the Allied Health Annual Confirmation form sent out by the Office of Professional Staff Affairs.

IV. Vendor Responsibility: Refer to the contract agreement for all processing requirements of any vendor who provides such allied health providers (such as temporary employment agency). When the credentials file is complete, it will be sent to the OPSA.

V. Office of Professional Staff Affairs Responsibility:

 The application packet is sent to the provider upon receipt of BIDMC Request for Allied Health Provider Application Form. Any questions related to the completion of the application may be directed to the OPSA staff.  The provider must return a complete application packet with all required documents and attachments to the OPSA within 10 business days of receipt.  Upon completion of all required verifications, the new applicant’s credentials file is organized, reviewed for completeness and accuracy, then prepared for review and sent for acceptance in this order:  Chief of Clinical Department  Allied Health Credentialing Committee  Medical Staff Credentials Committee  Medical Executive Committee  BIDMC Board of Directors

 After the provider has been accepted by the Board of Directors, a letter is sent to

OPSA-22 Page 4 of 9 the provider by the Office of Professional Staff Affairs with a copy of the accepted practice guidelines as well as to the supervising MD and to the Chief of the respective department.  The credentials files will then be maintained by the Office of Professional Staff Affairs for content, accuracy and updates for as long as the file is active. An annual confirmation of the Practice Guidelines and the Supervising Physician will be conducted for each provider and an evaluation will be completed by the Supervising Physician.  Copies of the current licensure, MCSR certificate, federal DEA certificate, any special certification or malpractice carrier face sheet will be maintained by the Office of Professional Staff Affairs, or available through the CVO.  Monthly queries will be made to the licensing boards and OIG (Office of Inspector General) for any sanctions that have been published against a provider and an annual query will be made to the NPDB (National Practitioner Data Bank) for any adverse actions taken by any entity. Any adverse reports will be sent to the Chief, the Allied Health Credentials Committee for review and recommendation and subsequently to the Credentials Committee of the Medical Staff, Medical Executive Committee and Board of Directors.  All resigned files will be sent to and maintained by the archiving service.

VII. Supervising Physician Responsibilities: (See attachments 2. and 3.)

● The supervising physician is solely responsible for supervising and evaluating the advanced practice nurse or physician assistant according to their written practice guidelines. At a minimum, the guidelines must be reviewed and confirmed as still in effect on an annual basis. Supervision must be on-going or at regular intervals that reasonably assess the competence of the provider.

● The evaluation should include an assessment of the clinical knowledge, skill and abilities of the provider, a review of the patient outcomes, prescribing practices, adherence to policies and procedures of the department and medical center, participation in quality and safety initiatives and compliance with patient record documentation requirements, recommendations from peers and co-workers, whenever possible.

● Information that identifies the allied health providers who are supervised and evaluated by an Active Staff member will be included in the reappointment credentials file for each such supervising physician.

VIII. BIDPO Responsibility:

OPSA-22 Page 5 of 9  Once the notification of an allied health provider applicant is received, BIDPO will send a BIDPO/Health Plan Enrollment application packet to the new provider for completion, signature and return to BIDPO. BIDPO will pre- populate as much data onto these applications as possible prior to mailing to the provider.  Upon return of the packet to BIDPO, a quality control review is done to make sure the enrollment applications are completed, signed and all additional documents requested by BIDPO are received. BIDPO will contact the hiring department and/or provider directly if applications are incomplete or if any requested additional documentation remains missing.  Upon formal acceptance notice from the OPSA, BIDPO will send the enrollment applications to the health plans for processing.  The hiring departments will be updated on health plan enrollment progress on a weekly basis via a weekly report from BIDPO.

Vice President Sponsors: Ken Sands, MD, Senior Vice President

Responsible Persons: (Author/Owner/Chair) Anne Marie Jarvey, OPSA Patricia Folcarelli, Patient Care Services

Originally Approved By: Jayne Sheehan/Dianne Anderson, Senior VPs Operations Council: Michael Epstein, MD, Chief Operating Officer Medical Executive Committee: Mary Ann Badaracco, MD, Chairman

Original Date Approved: 6-16-2004

Revisions: (Dates) 11-1-2006, 9-2007, 2-2008

Next Review Date: 11/2009

References: Board of Registration in Nursing 244 CMR 4.00 Board of Registration of Physician Assistants 263 CMR 5.00 Board of Registration in Medicine 243 CMR 2.08 and 2.10

Attachments: 1. The Content of Credentialing for Allied Health Providers 2. Letter Template for Annual Confirmation 3. Performance Profile / Supervising MD Review

The Content of Credentialing

OPSA-22 Page 6 of 9 for Allied Health Providers

Primary Source Verifications:

Item Primary Source

Ma. State license Board of Registration in Nursing/Medicine, etc. Other state licenses Other state licensing boards Drug Enforcement Authorization Federal Drug Enforcement Administration Mass. Controlled Substance Certificate Department of Public Health

College/Graduate School Educational Institution/Affiliated Hospital Specialty Board Certification Specialty Board Special other training/education Source providing certificate (required for practice of special procedure)

Queries to Authorized Agencies:

Medicare/Medicaid Sanctions Federal Office of Inspector General Malpractice Claims History All malpractice carriers Disciplinary Actions on Licensure All state licensing boards Disciplinary Actions at Affiliations All practice sites Healthcare affiliation actions/settlements National Practitioner Data Bank (NPDB) Criminal History FACIS-vendor database

Peer references 1 Supervisory and 2 Peers

All practice locations Complete the following assessment and provide information concerning:

Pending or final:  Disciplinary Action?  Disciplinary Action by any other state licensing board?  Disciplinary Action by a professional society?  Medical Malpractice claim or action?  Criminal proceeding?  Monitoring or treatment for drug or alcohol misuse?

Demonstrated satisfactory:  Professional performance/clinical competence and the ability to perform the Practice Guidelines  Technical skills  Character  Physical competence/mental competence  Compliance with bylaws, policies, procedures  Relationship with peers  Relationship with patients  Legible and timely medical record completion

Attachment 1. Attachment 2.

OPSA-22 Page 7 of 9 To: Supervising Physician

From: , Director Office of Professional Staff Affairs Beth Israel Deaconess Medical Center

Re: Confirmation of Practice for Advanced Practice Nurses and Physician Assistants

The Office of Professional Staff Affairs maintains all credentials files for physicians and Allied Health Care providers. Advanced practice nurses and physician assistants provide care to patients according to specific practice guidelines that are developed in collaboration with their Supervising Physician.

On an annual basis, we need to confirm that these practice guidelines remain in effect and that the Supervising Physician is unchanged.

As a Supervising Physician we ask that you please provide us with the information noted below and complete a review of the current practice of this provider (form attached).

Please Complete and Return this form:

 Yes, the attached practice guidelines reflect the current practice of ______.  Yes, ______, MD remains as Supervising Physician. Please sign and date the confirmed practice guidelines and return to the OPSA.

 NO, these practice guidelines have changed. Please send a signed copy of the new practice guidelines.  NO, the Supervising Physician has changed to ______. (Print Name) Signed: ______Date:______Print Name:______

Return this form (and attachments) to: Office of Professional Staff Affairs Beth Israel Deaconess Medical Center Palmer 619 330 Brookline Avenue Boston, Ma. 02215 phone: 617-0390 or fax: 617-632-0370

OPSA-22 Page 8 of 9 Advanced Practice Nurse/Physician Assistant Performance Profile Supervising MD Review

Practitioner Name: ______Date: ______

Department/Division: ______Service Location: ______Based upon my on-going supervision of this practitioner and the review of his/her professional practice, I have found the following:

Professional/Ethical Behavior: □ Satisfactory □ if Unsatisfactory, please comment:

Interpersonal Skills with patients, families: □ Satisfactory □ if Unsatisfactory, please comment:

Adherence to Current Practice Guidelines: □ Satisfactory (including, clinical knowledge, abilities, skills and prescribing practices) □ if Unsatisfactory, please comment:

Adherence to Policies/Procedures/Guidelines: □ Satisfactory (including, timeliness, completeness and accuracy of patient record documentation) □ if Unsatisfactory, please comment:

Communication Skills with peers, other care providers: □ Satisfactory □ if Unsatisfactory, please comment:

______Overall Assessment of Provider:

______Name of Supervising MD:______(Print) Signature: ______

OPSA-22 Page 9 of 9