Practice Tips

Advanced practice providers (APP) include advanced practice registered nurses (APRN), nurse practitioners (NP), certified nurse-midwives (CNM), certified registered nurse anesthetists (CRNA), clinical nurse specialists (CNS), and physician assistants (PA).

State laws define the scope of practice for APPs; the employer determines the services within that scope of practice these practitioners may provide.

For specific state regulations for Maine, New Hampshire, Vermont, and Massachusetts, please access the informational resources listed at the end of this tip.

Hospitals and physician practices should provide appropriate policies, procedures, and, when applicable credentialing of APPs while employing, contracting with, collaborating with, or supervising these providers.

The following information addresses items to be considered:

Competency

• Require APPs to have the appropriate licensure, experience, education, and training for their position.
  • Evaluate and validate before hire.
  • Information may be available from licensure boards on restrictions, prior investigations, contracts for drug, alcohol, or mental health issues with licensure. Consider adding this to the applications as required disclosure.
• Proctor for a specified time after hire and when a new procedure is requested/performed.
• Assess proficiency on an ongoing basis.

Practice Elements

Develop a written job description, collaborative practice agreement, or plan of supervision, when appropriate, that addresses the following elements:

• Scope of Practice:
  • Outline the scope of practice for APPs to include:
    • A clearly defined and mutually agreed-upon role of these providers.
    • Defined parameters for:
      • Independent management.
      • Collaborative management.
      • Referrals/consults.
    • Prescriptive and dispensing authority.
    • The mechanism to assure that APPs are working within the defined scope of practice.
    • The quality review and competence evaluation process utilized to determine the quality of care provided and the competence to function within the defined scope of practice.
• Collaboration:
  • MMIC strongly suggests an ongoing collaboration between APPs and physicians in the practice on an as-needed basis, such as during a patient visit or when consultations arise regarding patient care and treatment planning.
  • Establish a formal collaboration process on a weekly/monthly basis with case selections by the APP and physician.
  • In policy, define accessibility to the collaborating physician(s).
• Quality Review:
  • Establish a mechanism to evaluate the APP’s competency.
    • Require an appropriate level of clinical licensure.
    • Require oversight through ongoing case review as required by state law, regulation, or facility/practice policy.
    • Review a percentage of the APP’s medical records per month and provide feedback with recommendations.
    • Check state and federal regulations, including rural health designations and hospital bylaws, to determine if physician co-signature is required as evidence of supervision, collaboration, and required quality review.
• Adherence to Organizational Policies:
  • Require adherence to established hospital and office practice policies.

Certified Nurse-Midwives

For pregnancies primarily managed by a nurse-midwife, schedule at least one patient visit with a physician. This allows the patient to be familiar with a physician who may attend a spontaneous labor and delivery or an unexpected event.

CRNA

Adhere to federal law. It is noted that federal regulations require CRNAs to practice under the supervision of the operating practitioner or an anesthesiologist who is immediately available unless the state has received an exemption from this regulation. As of 2021, nineteen states, including New Hampshire, have obtained this exemption.

Resources

There are many resources available to assist in the development of job descriptions, delineation of privileges, and scope of practice policies and procedures for mid-level providers, including:

Rules and Regulations of the State Board of Nursing on Advance Practice Registered Nurses from the state(s) in which you practice:
Maine - (207) 287-1133
New Hampshire - (603) 271-2323
Vermont - (802) 828-2396
Massachusetts - (617) 973-0900

Rules and Regulations of the State Board of Medicine on Physician Assistants from the state(s) in which you practice:
Maine - (207) 287-3601
New Hampshire - (603) 271-1203
Vermont - (802) 657-4227
Massachusetts - (781) 816-8200

Information on credentialing, standards of practice, and core competencies from the appropriate national organizations:

American Academy of Nurse Practitioners (512) 442-4262
PO Box 12846
Austin, TX 78711
http://www.aanp.org

American Academy of Physician Assistants (703) 836-2272
2318 Mill Road, Ste. 1300Alexandria, VA 22314-1552
http://www.aapa.org

American Association of Nurse Anesthetists (847) 692-7050
222 South Prospect Ave.
Park Ridge, IL 60068-4001
http://www.aana.com/

American College of Nurse-Midwives (240) 485-1800
8403 Colesville Rd., Suite 1550
Silver Spring, MD 20910
http://www.midwife.org