Credentialing and Privileging

Credentialing and privileging (C & P) is a process that all physicians who wish to admit and treat patients in a hospital have to undergo. Due to the nature of their practices, CNMs and CRNAs are familiar with the C & P process; however, other APNs traditionally have not been expected to undergo this process.  While the C & P process is ponderous, there are many reasons that all APNs should insist that a mechanism be developed for them.  First of all, the C & P process refutes the notion that a "nurse is a nurse is a nurse.”  Secondly, Joint Commission strongly recommends that providers such as APNs and PAs go through the process.

Many hospitals struggle with the best way handle the C & P process for APNs. Some have the APNs complete the process entirely through their institution’s medical staff office. Others have a process that is completed through their nursing office and forwarded to the medical staff office.  Some hospitals let the human resources department handle the process; however, not all human resource departments are sufficiently trained to do so.

The C & P process reminds us that when APNs "order” medications in the hospital, it is not the same as "prescribing” as delineated in the Nursing Act. Prescribing is the act of writing a prescription that a patient takes to his/her pharmacy for outpatient use.  Ordering is a process that exists in the inpatient setting.  The definition of prescribing is delineated in the Pharmacy Act, whereas that same act does not address the act of ordering in a hospital. Ordering of medications (as opposed to writing orders in general) isn't really covered in the Hospital Licensing Act, either.

It should be noted that even when there was no mechanism for APNs to "prescribe" Schedule II medications, several hospitals had chosen to credential and privilege their APN employees to order some Schedule II medications.  For example, some CNMs have a collaborative agreement and privileging document that alludes to their ability to "provide pain management for the purpose of labor and delivery"; as a result, they are in a position to order morphine and other Schedule II analgesic agents. Concomitantly, this provision would be noted in the CNM’s C & P application.

The other issue is whether APNs can write orders in a hospital. Unless an APN has undergone the C & P process, s/he could only "write" any orders is like any other RN in the hospital; namely, as a telephone order, "T.O. J.Jones, MD/C. Rassi, CNS." Many hospitals rely on this "old-fashioned" way of doing things rather than ponder the thorny issues of how APNs should be allowed to practice in a hospital, which often requires a change in medical staff bylaws.