In order to provide patient care services in the hospital, physician assistants and their supervising physicians must seek delineation of their clinical privileges. The criteria and process for granting clinical privileges to physician assistants is similar to the process for physicians and should be outlined in the medical staff bylaws.

In most hospitals, the medical staff credentialing process involves simultaneous consideration of applications for medical staff membership and for clinical privileges. The following guidelines are intended to assist medical staffs in making appropriate changes to the bylaws that authorize the granting of membership and clinical privileges to physician assistants. They are intended to be a general guide that can be applied and adapted to suit the requirements of individual medical staffs. Where possible, sample language has been included.

DEFINITION OF PHYSICIAN ASSISTANT

Medical staff bylaws usually begin with a section that includes definitions of terms. This section should include a definition of physician assistant. It should generally conform to the definition used by the American Academy of Physician Assistants. In the case of federally employed PAs, the legal definition is found in federal regulations or policies, rather than state law.

All states require that a physician assistant be a graduate of a PA program accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) or one of its predecessor agencies, that they pass the initial exam given by the National Commission on Certification of Physician Assistants (NCCPA), and/or that they be licensed to practice as a physician assistant. Federally employed PAs must meet the first two criteria, but need not be licensed. Some states and employers require current NCCPA certification.

The following definition serves as an example.

A physician assistant (PA) is an individual who is a graduate of a physician assistant program approved by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) or one of its predecessor agencies, and/or has been certified by the National Commission on Certification of Physician Assistants (NCCPA). The individual meets the necessary legal requirements for licensure to practice medicine with physician supervision.

PAs ON THE MEDICAL STAFF

Physician assistants should be members of the medical staff. Physician assistants are providers of physician services. They exercise a high level of decision-making and autonomy in providing patient care, though they practice as supervised members of physician-directed teams. Membership on the medical staff enables providers to diagnose illness and perform other functions in the hospital. It allows providers a voice in developing and implementing hospital and medical staff policies and ensures participation in programs to review the quality and appropriateness of patient care. It is important that PAs participate in the system in which medical care policies are made and communicated.

Sometimes medical staff attorneys mistakenly believe that standards from the Joint Commission on Accreditation of Health Care Organizations (JACHO) prohibit physician assistant membership on the medical staff. The standards state that the medical staff includes physicians and may include other licensed independent practitioners. According to JACHO correspondence with the AAPA, that is not meant to be exclusive language and medical staffs may choose to include PAs as members. The Medicare Conditions of Participation for Hospitals clearly state that in addition to MD and DO members, the medical staff “may also be composed of other practitioners appointed by the governing body.” State law should be consulted; sometimes the makeup of medical staff membership is dictated there.

Physician assistants are providers of medical care and should not be categorized under nursing. Similarly, categorization under allied health is inappropriate. The AAPA is not alone in this viewpoint. The National Commission on Allied Health, convened by the act of Congress in 1992, defined an allied health professional as “a health professional (other than a registered nurse or physician assistant) who has received a certificate, an associate degree, a bachelor’s degree, a master’s degree, a doctoral degree, or post baccalaureate training in a science related to health care…etc.” The federal Bureau of Health Profession uses this same definition, excluding PAs from the allied health professions and classifying them as medical care providers.

Medical staff membership language might state:

Membership on the medical staff shall be extended to physicians, dentists, podiatrists, physician assistants, and clinical psychologists who continuously meet the qualifications, standards, and requirements set forth in these bylaws and who are appointed by the hospital Board of Directors.

CREDENTIALING PHYSICIAN ASSISTANTS

Medical staff bylaws specify professional criteria for medical staff membership and clinical privileges. The JCAHO specifies four core criteria that should be met when credentialing licensed independent practitioners,, including current licensure, relevant training or experience, current competence (defined as letters from authoritative sources attesting to the applicant’s scope and level of performance), and the ability to perform privileges requested. This serves as a reasonable guideline. As applied to physician assistants, these criteria might include evidence of current state licensure, relevant training and/or experience; national certification; letters from previous employers, supervising physicians, or PA programs attesting to scope and level of performance; attestation as to physical and mental health status; evidence of adequate professional liability insurance, information on any past or pending professional liability or disciplinary actions, and a supervising physician (MD or DO) who is a member of the medical staff.

PHYSICIAN ASSISTANT PRIVILEGES

The medical staff bylaws should require each PA to have clinical privileges and proper physician supervision regardless of whether the PA is an employee of a practice or of the hospital. Medical staff membership should not be a requirement for granting of clinical privileges. This is in accordance with JCAHO standards and the Medicare Conditions of Participation for Hospitals.

The medical staff bylaws should stipulate that all clinical privileges granted to a physician assistant should be consistent with all applicable state and federal laws and regulations and that a physician assistant may provide medical and surgical services as delegated by a supervising physician. Typically, privileges for a physician assistant are delineated using a form and process identical to or very similar to that used for their supervising physician. Because PAs provide physician services, the physician form and privileges system is a useful template for developing a system of granting PA privileges.

The process for granting clinical privileges is usually discussed in four places in the bylaws; the article concerned with clinical privileges, the article describing the structure of the credentials committee, the article describing the duties of department chairmen, and the article describing hearing procedures. The process of granting clinical privileges may vary considerably from one hospital to another, but generally the process should: 1) be completed in a timely fashion; 2) if they exist, department chairmen should make specific recommendations for clinical privileges; 3) an appeal mechanism for adverse decisions should exist; and 4) the governing board should have ultimate authority to grant clinical privileges. An application for renewal of clinical privileges should be processed in essentially the same manner as that for granting initial privileges.

The criteria for delineating clinical privileges should be specified in the bylaws. They are usually the same as those used for credentialing: evidence of current state licensure, relevant training and experience, national certification, letters from authoritative sources attesting to the individual’s ability to perform certain privileges, attestation as to physical and mental health status, evidence of adequate liability insurance, and information on any past or pending professional liability or disciplinary actions. Privilege determinations – at reappointment or other interim terms – might also include observed clinical performance, quality improvement data, and other documented results of quality improvement activities required by the hospital and medical staff.

Other requirements of physician members of the medical staff also may apply to PAs. For instance, if a department chair approves physician privilege requests before they are submitted to the medical staff credentials committee, the same should apply to PAs. If demonstrated, documented competency is required for physicians requesting new privileges, the same should be requires of PAs.

When credentialing a PA, a query should be made to the National Practitioner Data Bank regarding their medical liability history. Entities that make malpractice payments on behalf of PAs must report that information to the NPDB. Employers and regulators are not required to report to the NPDB adverse professional review actions taken against PAs. As a result, that information in the NPDB is incomplete. Queries about licensure actions taken against PAs can be made to the Federation of State Medical Boards (FSMB). Though all state licensing boards are encouraged to report disciplinary actions to the FSMB, it is impossible to ascertain whether all actions are reported, so it is important that hospitals also query individual licensing boards.

DURATION AND RENEWAL OF APPOINTMENTS

Duration of appointments and privileges should be the same for physicians and physician assistants. The renewal process also should be similar.

DUE PROCESS

The bylaws should give the physician assistant the right to request the initiation of due process procedures when actions taken by the medical staff or the governing board adversely affect his or her clinical privileges. Hospital accreditation standards from JCAHO specifically state that medical staffs must establish a fair hearing and appeals process for addressing adverse decisions made against medical staff members and others holding clinical privileges. The process should include PA peer reviewers.

CORRECTIVE ACTION

The criteria and process for disciplining physician assistants should be spelled out in the bylaws. The process should involve PA peers and conform to the process applied to physician members of the medical staff.

QUALITY ASSURANCE

The bylaws should provide for effective mechanisms to carry out quality assurance responsibilities with respect to physician assistants. These mechanisms should include regular monitoring and evaluation by the supervising physician. Peer review of PA practice should be conducted by peers – ideally other physician assistants in the same area of clinical specialty. If the staff does not include other PAs in the same specialty, PA peers from outside the hospital should be called in.

CONTINUING EDUCATION

The medical staff bylaws should require participation by physician assistants in continuing medical education that relates, at least in part, to their regular practice and to their clinical privileges.

COMMITTEES

Bylaws should allow physician assistant membership on medical staff committees.

DISCRIMINATION

The fundamental criteria for medical staff membership or clinical privileges should be directly related to the delivery of quality medical care, professional ability and judgment, and community need. Medical staff membership or particular clinical privileges should not be denied on the basis of gender, color, creed, race, religion, age, ethnic or national origin, political beliefs, disability, socioeconomic status, or sexual orientation.

PARTICIPATION IN DISASTER AND EMERGENCY CARE

The bylaws should include language enabling physician assistants to provide care during emergency or disaster situations. The bylaws should state that the chief executive or his or her designee may grant temporary clinical privileges when appropriate and that emergency privileges may be granted when the hospital’s emergency management plan has been activated. The hospital’s emergency preparedness plan should include physician assistants in its identification of care providers authorized to respond in emergency or disaster situations.

Bylaws language might state:

In case of an emergency, any member of the medical staff, house staff, and any licensed health practitioner, limited only by the qualifications of their license and regardless of service or staff status, shall be permitted to render emergency care. They will be expected to do everything possible to save the life of a patient, utilizing all resources of the hospital as necessary, including the calling of any consultations necessary or desirable. Any physician assistant acting in an emergency or disaster situation shall be exempt from the hospital’s usual requirements of physician supervision to the extent allowed by state law in disaster or emergency situations. Any physician who supervises a physician assistant providing medical care in response to such an emergency or declared disaster does not have to meet the requirements set forth in these bylaws for a supervising physician.

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