Since Physician Assistants (PA) and Advanced Practice Registered Nurses (APRN) are not physicians, are organizations required to credential and privilege them via the requirements found in the Medical Staff (MS) chapter of the accreditation manual?

Yes, any provider recognized by state law and providing services as a 'Licensed Practitioner (LP)^^ or providing a medical level of care and decision-making(e.g. writing orders, directing care, etc) is required to be granted privileges prior to providing care, treatment or services. While Physician Assistants (PA) are generally not recognized by law/regulation as 'independent practitioners', they are subject to the same credentialing and privileging requirements outlined in the Medical Staff chapter of the manual. Examples of Care, Treatment or Services subject to the Medical Staff requirements may include, but are not limited to:

Writing orders for medications, tests, and procedures
Interpreting tests and treatments
Performing history and physicals
Wound debridement
Central line insertions
Assisting with interventional or surgical procedures

The requirements for conducting a Focused Professional Practice Evaluation (FPPE - MS.08.01.01) and an Ongoing Professional Practice Evaluation (OPPE - MS.08.01.03) also apply to these practitioners. When an Advanced Practice Registered Nurse (APRN) or PA functions in a limited role, such as an educator, and are not directing care as a LIP, the Medical Staff requirements would not apply.

^^It is the responsibility of the individual organization to determine, based on law/regulation, if the APRN or PA meet the following definition of a Licensed Practitioner: "An individual who is licensed and qualified to direct or provide care, treatment, and services in accordance with state law and regulation, applicable federal law and regulation, and organizational policy.

Manual: Critical Access Hospital Chapter: Medical Staff MS

Last reviewed by Standards Interpretation: November 23, 2022 Represents the most recent date that the FAQ was reviewed (e.g. annual review).

First published date: May 12, 2017 This Standards FAQ was first published on this date.

This page was last updated on November 23, 2022 with update notes of: Review only, FAQ is current Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.