PAs, APNs, and the medical staff office
Tips on how to credential and create leadership opportunities for these advanced practice professionals
With hospitals hiring more physician assistants (PA) and advanced practice nurses (APN), it is important for these advanced practice professionals to feel comfortable in their role and have a productive work environment. To do so, the medical staff office should focus on three areas:
- Creating opportunities for leadership
The Medical College of Wisconsin (MCW) struggled with these issues after it doubled its PA and APN pool in a four-year time period: From 2005 to 2009, the number rose from 80 to 170. With this influx of PAs and APNs, MCW soon realized that its existing processes needed an overhaul. To better meet the needs of its PAs and APNs, MCW streamlined credentialing processes and revised its delineation of privileging forms to better represent its scope of practice and meet Joint Commission standards.
Jon Mayer, MSN, MBA, department administrator in the Department of Surgery at MCW, manages the credentialing for all PAs and APNs in his department. His strategy when it comes to credentialing is to take a hands-on approach.
"My assistant and I personally manage the paperwork and follow up with institutions to see where the paperwork is that we need. I try to minimize the amount of paperwork applicants have to fill out. It is less painful that way and they are more likely to do it," explains Mayer.
He tracks the status of outstanding forms and paperwork by:
- Providing a FedEx envelope to the institution sending the form. If a form is sent in this envelope, Mayer can monitor it once it is shipped.
- Asking to be copied on any e-mail correspondences between the applicant and the institution.
By closely monitoring the status of application materials, Mayer says it is easier to figure out why any delays are occurring, such as a missing signature from a PA, APN, or notary (which is required for some forms). "APNs and PAs are busy people, and oftentimes they are not watching for e-mails daily. So I do it for them and then tell them when to send a harder push or prompt to the institution sending the form," he says.
Mayer also sets up meetings with APNs and PAs upon giving them their credentialing and privileging paperwork. If the applicant is local, Mayer meets with him or her in person. If not, he speaks with the applicant over the phone. Mayer says the meetings are helpful for applicants because he has seen the forms hundreds of times and knows their ins and outs; the applicant, on the other hand, is seeing the forms for the first time.
"If you send them an inch of paperwork, it can be daunting. If you do the paperwork with them, it can be done in less than 60 minutes," he says.
Mayer schedules a one-hour block for the meetings, but the average meeting only takes 45 minutes. Even if the full hour is needed, though, he says it is time well spent.
"People ask why I am hand-holding applicants. First of all, I know how busy they are. The last thing they want to do at 11 at night is fill out paperwork," says Mayer. "Plus, I look at it as a business decision. I place the value of recruitment to the surgery department very high. If I can increase an applicant's level of satisfaction with us by helping him or her and getting him or her credentialed and making money sooner, that is a positive business decision."
Need for leadership
According to Julie Raaum, APNP, the way MCW previously onboarded PAs and APNs, including credentialing and privileging, varied by department. In 2009, Raaum was hired as the director of PAs and APNs. She was charged with developing a scope of practice and a performance measurement tool for these professionals and developing recruitment and retention strategies. Results from a survey distributed to PAs and APNs highlighted the need for someone to provide them oversight that would cross department lines.
"When I was hired, I asked how many PAs and APNs there were, and the answer was ‘a lot.' So I had to start by finding out the state of the state," Raaum says.
She suggests sending a survey to PAs and APNs to find out what improvements they would like to see added to their work environment. MCW developed such a survey, and Raaum used it as her starting point to figure out how to make the college's APNs and PAs feel more comfortable. The common themes expressed by the survey respondents included:
- Better pay
- Benefits for part-time employees
- Performance reviews and feedback
- Continuing education opportunities
- Better collaboration/team approach
Raaum and a few colleagues grouped the issues identified by the survey into the following three categories:
Then, Raaum established a council of PAs and APNs for each category. An initial charter was set up, leadership retreats were held, and members were recruited for the councils. To see the guidelines used to form the councils, visit www.credentialingresourcecenter.com.
The three councils meet once per month; there is also a coordinating council that oversees the work done by the councils. Once a council identifies an issue, its members establish a work group to find a resolution. These work groups are chaired by a member of the council, but they comprise PAs and APNs who are not council members. The work groups provide leadership opportunities for PAs and APNs who do not want to make the commitment to sit on a council full time. Work groups are disbanded once an issue is resolved. Raaum says the groups provide both short- and long-term leadership experience for PAs and APNs.
That leadership experience is what Raaum describes as a "welcomed, unintended consequence" of forming the councils. "At the college, there is identified professional career development for [PAs and APNs]. Council participation offers growth and development advancement opportunities for PAs and APNs as they learn about project management, leadership, or running a meeting," she says. "Department administrators say it is a winwin situation because PAs and APNs feel more valuable while department administrators have a new tool to retain employees."
Another benefit, according to Raaum, is the relationships formed among PAs and APNs, both across departments and across the two groups of advanced practice professionals. "They were forced to put down their baggage of ‘I am a nurse, you are not.' We learn from one another and grow as colleagues."
She adds that before the councils, many APNs and PAs did not feel a connection to the college. Raaum remembers having this feeling herself when she started working at MCW as a nurse. Because a physician hired her to work in his practice, she considered herself as his employee, not an employee of the college.
"The councils have provided a mechanism to engage with the college. So instead of having 180 small institutions, we now have 180 people who work for the college," says Raaum.
The councils also have some tangible wins under their belts. These include:
- A biannual meeting that brings all PAs and APNs together
- Honoring PAs and APNs with an annual excellence in practice award for each group
- A new privileging document and process that is representative of the practice
- A new, detailed job description template
- Giving PAs the ability to write prescriptions
The last accomplishment truly highlighted the success that the councils can have, says Raaum. The Wisconsin medical examining board states that if a PA and physician have a prescribing agreement that is reviewed and updated annually and addresses what class of medica-tion the PA is going to sign from, the PA does not need a cosignature on every prescription. However, the hos-pital's EMR system prevented PAs from signing their own prescriptions and required a cosignature from a physician. Raaum says the process was onerous for everyone involved.
"The council worked really hard to get approval from medical executives and with IT to implement security changes. That was a big win for us," she says.
Another success was creating a new privileging form. Raaum says the old form had about 35 privileges on it, and when PAs and APNs looked at it, they would scan it quickly and, not seeing their practice on the list, would select nothing. The new documents now identify core privileges, service-specific privileges, and special privileges in a logical and easy-to-understand format.
Raaum says the key was defining service-specific privileges for each department from which a PA or an APN could select. To do this, MCW used the Clinical Privilege White Papers, companion publications to Credentialing Resource Center Journal. The new form separates privileges by department so it is easier for PAs and APNs to find the privileges they need. The form is almost ready for distribution, and it will completely replace the old privileging form used for PAs and APNs.
Up until the summer of 2011, Moffitt Cancer Center had two separate privileging forms for PAs and APNs. An ad hoc committee that reviewed the forms found there were several duplications between the two forms but inconsistency in the delineation of privileges. Cindy Sparks, CPMSM, manager of medical staff services at Moffitt Cancer Center, says PAs and APNs would often request the same privilege but use different wording. As a result, it became confusing for members of the medical staff office to keep track of which privilege had which name.
Moffitt's credentials committee voted to consolidate the two forms into a single form that both PAs and APNs could use. Because the new form is less than a year old, PAs and APNs applying for reappointment still have questions about it. However, Sparks says there has not been any negative feedback.
The new privileging form lists core privileges first, then special privileges. It clearly specifies whether a privilege requires direct or indirect supervision. It also states which privileges require additional documentation to prove competency.
"This new form keeps them from checking off privileges they don't need. When they get to the section with specialty privileges that require extra documentation, they usually pick up the phone and call me instead of checking off privileges they do not need," says Sparks.
Sparks will advise the PA or APN on what is needed to prove competency, or will help set up training for certain procedures if the PA or APN does not have the training or the required documentation. A supervising physician is then in charge of completing the evaluation, makingsure the training is completed within a certain time frame. If the training is not completed in time, Sparks will check in to see whether the PA or APN needs more time or no longer needs the privilege.
Because it is a cancer center, Moffitt has many special procedures, so it is important to clearly define and differentiate the procedures and track who has privileges for what. Sparks says the new form helps MSPs stay organized and work more efficiently.
"Even though we have to keep track of the process if a PA or APN is asking for new privileges and going through training, it has proven to be a best practice," she says. "If we ever needed to go back and look at how someone got to perform a procedure, we can document that he or she went through training, has current competency, and has the privileges needed to perform that procedure."