TJC changes MS.08.01.01 and MS.08.01.03: ‘Medical’ APRN and PA to be privileged through med staff process

New Joint Commission standards will change the credentialing and privileging process for advance practice registered nurses (APRN) and physician assistants (PA), according to the new Joint Commission Standards BoosterPak™, released in January.

MS.08.01.01 and MS.08.01.03 standards outline focused professional practice evaluation (FPPE) and ongoing professional practice evaluation (OPPE) requirements, respectively. Previous Joint Commission standards afforded APRNs and PAs an equivalent credentialing and privileging process to the medical staff services process. The Centers for Medicare & Medicaid Services, however, does not recognize the equivalent process. The Joint Commission elected to forgo this practice as well. Under the new clarification guidelines, certain APRNs and PAs must now be privileged through the medical staff process.

The Joint Commission states (in Section B3 of the BoosterPak) the following:

Those who provide “medical level of care” must use the medical staff process for credentialing and privileging, making all [medical staff] standards applicable (including recommendation by the organized medical staff and approval by the governing body, OPPE, and FPPE).

• APRNs should request privileges only for those responsibilities involving medical level of care and not those responsibilities already allowed under the RN scope of practice.
• APRNs and PAs who provide “medical level of care” must be credentialed and privileged through the medical staff standards process
• APRNs and PAs who do not provide “medical level of care” utilize the human resources “equivalent” process detained in HR.01.02.05, EPs 10–15.

As The Joint Commission distinguishes different types of allied health professionals, some medical staff offices might be concerned about the added processing for APRNs and PAs who provide “medical level of care.” The Joint Commission has not yet provided an implementation date for these changes.

FPPE and OPPE first appeared in January 2007 in the hospital and critical access hospital accreditation program manuals. With these requirements, The Joint Commission aimed to create a more objective and evidence-based credentialing and privileging process.

However, many hospitals today continue to struggle with FPPE and OPPE implementation. The BoosterPak explains that surveyors will ask about the medical staff credentialing and privileging process: how it relates to peer review, if you consistently evaluate competence of all licensed practitioners, and how you communicate the scope of privileges to be appropriately carried out. Surveyors will look for at your organization’s credentialing files, medical staff bylaws, rules and regulations, and medical executive committee minutes for documentation.

The Joint Commission also states it recognizes that “[d]etermining data collection for APRNs and PAs may require more effort as they tend to not be tracked by coding practices,” according to the BoosterPak’s tips for MS.08.01.03, EP1.

Non-Joint Commission-accredited organizations should also take note, as many organizations follow suit with the accrediting body to maintain compliance across multiple agencies.

The BoosterPak is available to accredited organizations on the Joint Commission Connect extranet. As the second in an expanding series, this BoosterPak details standards for hospitals, including critical access hospitals, to better interpret regulation. (The first BoosterPak focused on MM.03.01.01, which provided guidance for safe medication storage.) The Joint Commission plans to release more BoosterPaks in the future, according to a January 12  Joint Commission Online brief.

Editor’s note: This post was updated on Tuesday, February 8, 8:52 a.m.