October 3, 2022

Volume XII, Number 276

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October 03, 2022

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The Joint Commission: Nurse Practitioners and Physician Assistants Must be Credentialed Through the Medical Staff Process

Does your hospital currently credential advance practice registered nurses (APN) and physician assistants (PA) through your human resources department?

New Joint Commission standards will change the credentialing and privileging process for certain advance practice registered nurses (APN) and physician assistants (PA).

Previous Joint Commission standards afforded APNs and PAs equivalent credentialing and privileging processing through the HR department.   However, The Centers for Medicare & Medicaid Services (CMS) does not recognize the equivalent process, and The Joint Commission must align its standards to be consistent with CMS.  Under the new clarification guidelines, certain APNs and PAs must now be processed through the medical staff office, not HR.

According to the new Joint Commission Standards BoosterPak™, released in January. The Joint Commission states 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).

  • APNs should request privileges only for those responsibilities involving medical level of care and not those responsibilities already allowed under the RN scope of practice.
  • APNs and PAs who provide “medical level of care” must be credentialed and privileged through the medical staff standards process
  • APNs 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.

The Joint Commission has not yet provided an implementation date for these changes.

The BoosterPak is available to accredited organizations on the Joint Commission Connect extranet.

©2022 von Briesen & Roper, s.cNational Law Review, Volume I, Number 38
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About this Author

von Briesen & Roper’s Health Law Section provides comprehensive legal services to the health care industry nationwide as both general counsel and special project counsel. Our clients include integrated delivery systems, academic medical centers, community hospitals, Catholic-sponsored hospitals, rural and critical access hospitals, imaging centers, physicians and multi-specialty clinics, specialty hospitals, ancillary suppliers, home health agencies, nursing homes, hospices, assisted living facilities, mental health and AODA facilities, DME suppliers, laboratories,...

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