Independent nurse practitioners
Change is constant in healthcare – particularly from a regulatory and compliance perspective. So, keeping up with, and enacting, change within your organization can feel daunting.
One change sparking a lot of recent dialogue with my hospital clients focuses on Advanced Practice Registered Nurses (APRNs). Many states allow APRNs to practice independently (and more states may head in this direction). The question often put to me is:
“If APRNs can practice independently, does that mean we MUST make them members of the medical staff?”
The easy answer is no. There is no mandate that APRNs must be members of the medical staff in states that allow independent practice.
But maybe this question is a catalyst for a better, more relevant one: should they be members of the medical staff? This one warrants discussion, so keep reading.
No mandate required—the impact on your organization
Before diving in further, let’s get clear on definitions. When I say “APRN,” I’m talking about Nurse Practitioners, Certified Nurse Midwives, Certified Registered Nurse Anesthetists and Clinical Nurse Specialists – because those are the titles typically being granted the ability to practice independently.
But since we’re talking about what professionals could or should be members of the medical staff, we need to include Physician Assistants (PAs) in the mix. While PAs are not granted independent practice rights as often as APRNs, doctors on the medical staff tend to think about these professionals – APRNs and PAs – together. Therefore, I’ll use Advanced Practice Professionals (APPs) when talking about this combined group.
So – if evolving state legislation is a catalyst for talking about medical staff membership, I’d advise you to start thinking about how this affects your organization, if you haven’t already. As of today, nearly half of all US states have granted APRNs “independent practice.”
It’s a cultural decision
The only required profession to be on the medical staff is physicians, although the vast majority of medical staffs also include dentists and podiatrists as members. It’s a cultural choice – and that same opportunity could exist for APPs if the medical staff determines it’s the right decision. But in my experience, it’s been more about “this is what we’ve always” done vs. “this is what we should do.”
Generally speaking, the smaller the hospital, the more likely APPs are granted membership. This membership has not been tied to whether the APPs have been granted independent practice, but how they are seen within their own medical communities. I’ve also observed that larger hospitals, including at least one Academic Medical Center that I am aware of, have made APPs medical staff members. But this is less common.
This membership has not been tied to whether the APPs have been granted “independent practice,” but how they are seen within their own medical communities.
The cultural component is critical and speaks to your medical staff’s preferences and organizational norms. Ask yourself, how would my organization view bringing more professionals onto the medical staff? Would it be supported? If not, why not?
Guardrails “protect” physicians
I’ve run into some medical staffs that are not supportive of making APPs members of the medical staff. While one group of people wants to add them, the others are afraid of being outvoted by the APPs. I always reassure the physicians that there are guardrails in place that will not allow the APPs to “take over” the medical staff.
Here’s why. Per regulation, for acute care hospitals:
APPs can’t be responsible for the organization and conduct of the medical staff. That must fall to either a physician, dentist, or podiatrist. 1
If the medical staff has an executive committee, then the majority of voting members must be MDs or DOs. 2
The Joint Commission requires that department chairs must be board certified or have comparable competence. 3
It’s no surprise that once medical staffs realize these guardrails exist, most are less fearful of making APPs members of the medical staff. It becomes a less contentious decision for many organizations.
What’s right for your organization?
There isn’t a right or wrong answer – it’s a question of what’s right for your organization. Consider these pros and cons about making APPs members of the medical staff and ask if doing so would align or conflict with your current culture.
Pros and cons
Reasons for making APPs members:
Granting membership provides recognition for the integral part APPs play in the functioning of the hospital by those granted privileges. Today, many APPs are performing activities once only performed by physicians.
Bringing APPS on as members may be a good recruiting tool as you compete for APPs with rival institutions.
Considerations for not making APPs members:
Although they may be “independent” as noted by the state, they are not independent when working in a hospital that is a Medicare-participating facility. CMS states that all Medicare and Medicaid patients admitted by APPs (with a small carve-out for midwives) must be under the care of a doctor of medicine or osteopathy 4. Therefore, they do not function as physicians with the ultimate responsibility for the care of the patient.
EMTALA regulations do not allow non-physicians to serve on the EMTALA call roster in the Emergency Department. Therefore, APPs do not have the same medical staff responsibilities as the physician members of the medical staff.
If APPs were members, then they would necessarily need to have the same fair hearing and appeal rights as all other members, rather than a simpler process that can be used for non-members.
It’s only a matter of time
Regardless of whether a state allows APPs to practice independently or not, this regulatory tide is forcing medical staffs to talk about granting APPs membership. If your organization isn’t thinking about your approach to this issue—it should be.
Based on recent legislative changes impacting APRNs and the increased lobbying efforts I’m seeing in support of PAs practicing independently, it’s only a matter of time until your team needs to make a decision about what’s the right cultural fit for your organization.
1 The Centers for Medicare & Medicaid Services, in Tag A-0347 at 42 CFR 482.22(b)
2 The Centers for Medicare & Medicaid Services, in Tag A-0347
3 The Joint Commission, in MS.01.01.01, EP 36
4 The Centers for Medicare & Medicaid Services, in Tag A-0066, at 42 CFR §482.12(c)(2)
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