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Hospital Privileges for NPs

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With an ever-widening scope of practice and professional responsibility, more and more nurse practitioners are obtaining hospital privileges. There are a number of benefits to this. Hospital privileges improve the continuity of care for patients by allowing you to actively participate in their inpatient care. Hospital privileges also improve the image of nurse practitioners among patients and colleagues. Privileges can also be a workplace bargaining tool, particularly with physicians who are in rural locations where there is little hospital coverage. It is reasonable to negotiate for a higher base salary or for a percentage of collected hospital revenue.

History of Credentialing
Obtaining hospital privileges is referred to as credentialing. During the credentialing process, a group of physicians in the department of medicine reviews your qualifications and decides whether to grant privileges. The first advanced practices nurses to obtain hospital credentialing were Oregon nurse midwives in the 1970s.

At around the same time, Oregon also passed legislation allowing NPs to seek hospital privileges. The law stated that nurse practitioners were subject to the credentialing hospital's bylaws and that a hospital could limit the scope of practice, require monitoring by physicians or require that nurse practitioners co-admit with a physician. Since that time, many states have enacted similar legislation.

The Application Process
Before you apply for hospital privileges, carefully consider the associated responsibilities, benefits and drawbacks. To initiate the process, call the medical staff affairs office where you are seeking privileges. Many hospitals mandate that the nurse practitioner desiring privileges send a letter introducing herself to the chair of the department and explaining why privileges are desired. Once this letter is received, an application is sent to the nurse practitioner.

The application is generally 10 to 15 pages long and includes a variety of questions about practice setting and education. Personal references, two or three forms of photo identification and an official copy of your NP license and certification are usually required. The license and certification may need to come directly from the board of nursing and the certifying body (possibly at a fee). Duplicate copies usually are not acceptable.

Whereas not every state requires certification for NP licensure, most hospitals mandate national certification. A resume or curriculum vitae, a copy of a DEA certificate (where allowed by state law), malpractice certificate and life support certifications are also required. Documentation of a negative Mantoux test performed within the year (or a negative chest x-ray if the Mantoux is positive) must be supplied. All childhood and adult immunizations must be up to date and records provided.

In addition to the application, a "sponsoring physician" form may be required. This form needs to be completed and signed by one or two physicians. Ideally, the sponsoring physician works with you in practice. When this is not possible, you can hire a consulting physician. The form provides written documentation that you have secured one or two physicians who will ultimately be responsible for "supervising" the care of hospital-based patients. It may also contain information reviewing hospital policy for co-signature of orders and notes. Most hospitals mandate that nurse practitioner's notes and orders be signed every 24 hours, even in states where physician collaboration is not required by law.

The hospital may require a fee of $100 to $500 to process your application for privileges. Most employers pay this fee. Next, medical staff affairs personnel review the application and verify its contents. The next step is usually a mandatory interview of approximately 1 hour in length. It may be conducted by the chair of the department of medicine and other physicians from the department. Once the interview has been completed, the chair of the department will make a request to the board of directors to either accept or deny your application. The entire application process, from inception to the granting of privileges, generally takes 3 to 6 months, although reports of 1 year are not unusual.

Levels of Privileges
After you complete the credentialing procedure, you will be awarded a specific level of hospital privileges. In most facilities, two levels of privileges exist.

Full privileges allow you to admit patients yourself, make rounds on your patients and discharge them without supervision or co-signature. Nurse practitioners rarely obtain such privileges. Nurse practitioners are usually awarded associate or ancillary privileges. While varying from facility to facility, clinicians with associate privileges must admit a patient to a collaborating or supervising physician, not to the nurse practitioner herself. In addition, co-signature of notes and orders is usually mandated.

While I am a strong proponent of nurse practitioners being credentialed to provide hospital care, not all nurse practitioners need hospital privileges. Your decision about whether to obtain privileges depends on the location of your practice, your type of practice, and your level of comfort around hospital-based care.

If your practice is in a state where nurse practitioners are recognized by managed care organizations as primary care providers or you work in or own a nurse practitioner-run practice, it may be very important to obtain privileges. Conversely, if you are employed in a setting where nurse practitioners are not supported or rewarded for the additional skills necessary for the management of hospitalized patients, privileges may not be necessary.

Your Responsibilities
A nurse practitioner's responsibilities in an acute-care setting include an admission history and physical examination. This must be performed and dictated within 24 hours of admission. Other responsibilities include admission orders, daily rounds, review of daily laboratory tests, review of x-rays and reports, medication management and consultations with specialists and staff nurses. In addition, you will be responsible for working with ancillary services such as physical therapy, coordinating patients' care to achieve a timely yet appropriate discharge, and then discharging the patient. Discharge summaries, like the admission history and physical examination, must be dictated within 24 hours of discharge.

Once hospital privileges have been obtained, you may be required to attend medical staff meetings. These are generally held every 1 to 2 months. You will also be required to furnish an updated malpractice certificate (obtained by calling your malpractice company) and updated licenses, DEA numbers and certifications as they are renewed.

You will be also be asked to complete a modified application every few years to provide any new information about a change in address, phone number and any malpractice claims made against you. If you have privileges and change employers, you must complete a new supervising physician form or face the loss of these rights.

Overcoming Barriers
Barriers to obtaining hospital privileges are significant but definitely surmountable. Many physicians involved in the credentialing process are unfamiliar with nurse practitioners and their role. Even registered nurses may be confused by the NP's role in a hospital setting. In addition, even in states where nurse practitioners can practice without a collaborating physician, notes and orders must be co-signed. There are additional responsibilities for the nurse practitioner with hospital privileges that may include overnight calls and additional work hours, particularly at the beginning or end of the day to make rounds on patients.

Many nurse practitioner programs do not educate students to provide hospital care, and these skills need to be developed.

I recommend that you round routinely with your collaborating physician or a nurse practitioner colleague before applying for privileges to get a sense of the role and responsibilities.

It is also helpful to round with a collaborating physician for the first 3 to 6 months after you obtain privileges. Such collaboration increased my knowledge and improved my skills immensely.

Wendy Wright is a family nurse practitioner at Merrimack Village Family Practice in Merrimack, N.H., a senior lecturer at Fitzgerald Health Education Associates, and the immediate past president of NPACE. Reach her at WendyARNP@aol.com.




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