Risk Reduction Resources

Advanced Practice Providers (APPs): Governance, Competency, and Quality Considerations

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Purpose

Advanced practice providers (APPs) include advanced practice registered nurses (APRNs), nurse practitioners (NPs), certified nurse-midwives (CNMs), certified registered nurse anesthetists (CRNAs), clinical nurse specialists (CNSs), and physician associates (PAs).

Scope-of-practice requirements, clinical authority, documentation requirements, consultation expectations, and other practice parameters vary by profession, state law, practice setting, payer requirements, accreditation standards, and organizational policies. Healthcare organizations should consult applicable laws, regulations, licensing boards, accreditation standards, and organizational policies when developing policies governing APP practice.

Organizations that employ, contract with, credential, privilege, or otherwise utilize APPs should establish processes that promote patient safety, quality care, professional accountability, and regulatory compliance.

Competency

Organizations should establish processes to verify and maintain APP competency, including:

• Verification of current licensure, certification, education, training, and experience.
• Credentialing and background verification before hiring, appointment, or granting privileges.
• Review of publicly available licensure actions, restrictions, disciplinary findings, or other relevant professional practice information.
• Orientation and onboarding processes appropriate to the APP's role and responsibilities.
• Ongoing performance evaluations and competency assessments.
• Additional training, mentoring, or competency validation when new procedures, services, technologies, or responsibilities are introduced.

Scope of Practice and Clinical Responsibilities

Organizations should clearly define APP roles and responsibilities through job descriptions, privilege delineations, credentialing criteria, and organizational policies, as appropriate.

Consider addressing:

• Authorized clinical services and procedures.
• Patient populations served.
• Prescriptive authority, when applicable.
• Referral, consultation, and escalation processes.
• Documentation requirements.
• Expectations for practicing within applicable legal, regulatory, and organizational requirements.
• Processes for monitoring compliance with approved privileges and responsibilities.

Additional requirements, limitations, privileges, consultation expectations, and documentation requirements may vary by profession, specialty, practice setting, organizational policy, accreditation standards, payer requirements, and applicable state or federal law. Organizations should periodically review these requirements to ensure ongoing compliance.

Care Coordination and Communication

Organizations should establish processes that support effective communication and coordination among members of the healthcare team.

Consider:

• Defining expectations for consultation and referrals.
• Establishing processes for addressing complex or high-risk clinical situations.
• Clarifying the availability of clinical resources and support personnel.
• Promoting interdisciplinary communication to support continuity of care and patient safety.
• Establishing documentation requirements for consultation, referral, collaboration, or supervisory arrangements when required by law, regulation, accreditation standards, payer requirements, or organizational policy.
• Maintaining required agreements, protocols, or practice arrangements within credentialing or personnel files, as applicable.

Quality and Safety

Organizations should establish mechanisms to evaluate clinical performance and quality of care, including:

• Ongoing verification of licensure and professional qualifications.
• Peer review and quality assessment activities consistent with organizational quality improvement programs.
• Periodic review of clinical documentation and patient care outcomes.
• Feedback processes that support professional development and continuous improvement.
• Monitoring compliance with applicable laws, regulations, accreditation standards, payer requirements, and organizational policies.
• Review of patient safety events, near misses, and other quality indicators, as appropriate.
• Determining whether documentation review, co-signature, consultation, or other oversight requirements apply based on state law, federal regulations, accreditation standards, payer requirements, or organizational policy.

Adherence to Organizational Policies

APPs should comply with applicable organizational policies, procedures, clinical protocols, documentation standards, and professional practice requirements.

Organizations should periodically review APP-related policies and procedures to ensure alignment with current laws, regulations, accreditation standards, and organizational objectives.

Medical Staff

Organizations need to carefully consider whether APPs are voting members of the Medical Staff and their role on Medical Staff Committees. While some organizations prefer to reserve this category for physicians only, others find value in establishing a uniform process for quality oversight, peer-review protections, disciplinary and hearing processes, as well as credentialing.

Independent Practice

APPs who practice independently should maintain processes that support compliance with applicable professional, legal, regulatory, and patient safety requirements. This includes understanding and practicing within the scope of authority granted by applicable state law and licensing requirements.

Independent APPs should consider:

• Maintaining current licensure, certification, continuing education, and other professional requirements.
• Understanding applicable scope-of-practice, prescriptive authority, consultation, referral, and documentation requirements.
• Establishing appropriate processes for consultation, referral, and escalation when a patient's clinical needs exceed the APP's scope, competency, or available resources.
• Maintaining policies and procedures appropriate to the services provided and practice setting.
• Periodically evaluating clinical competency, documentation, patient outcomes, and patient safety concerns.
• Maintaining appropriate professional liability coverage and understanding applicable payer, contractual, and regulatory requirements.
• Reviewing changes in laws, regulations, licensing board requirements, and professional standards that may affect the APP's practice.

Maine

New Hampshire

New Hampshire Physician Associate Scope of Practice – RSA 328-D:3-b

Massachusetts

Massachusetts APRN Prescriptive Authority Requirements and Practice Guidelines

Massachusetts Board of Registration in Nursing

Massachusetts Board of Registration of Physician Assistants

Vermont

Vermont Board of Medical Practice – Physician Assistants

Vermont Board of Medical Practice – Applications, Licensing & Fees

National Professional Organizations

American Association of Nurse Practitioners (AANP)

American Academy of Physician Associates (AAPA)

American Association of Nurse Anesthesiology (AANA)

American College of Nurse-Midwives (ACNM)

Disclaimer

This document is intended for educational and risk management purposes only. Requirements related to APP scope of practice, consultation, collaboration, supervision, credentialing, privileging, documentation, and prescriptive authority may vary by profession, state law, practice setting, payer requirements, accreditation standards, and organizational policies. Organizations should consult legal counsel and applicable regulatory authorities when developing or revising policies governing APP practice.

Updated on: 10/2026