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.
      • Guidelines for the care of high-risk patients.
    • 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 ongoing collaboration between APPs and physicians in the practice on a regular 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).
  • Include a collaborative/practice agreement, as applicable, as a proactive risk management approach to increase medical professional liability insurability and decrease safety events.
  • Ensure the agreement is readily available within the credentialing file.
• 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 2024, twenty-five states have obtained this exemption. Even in states where this exemption is used, supervision requirements remain complicated.

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
https://www.maine.gov/boardofnursing/laws-rules/index.html

New Hampshire - (603) 271-2323
Scope of Practice | NH Office of Professional Licensure and Certification

Vermont - (802) 828-2396
Nursing Statutes, Rules & Resources

Massachusetts - (617) 973-0900
Laws and regulations for the Board of Registration in Nursing | Mass.gov

Rules and Regulations of the State Board of Medicine on Physician Assistants from the state(s) in which you practice:

Maine - (207) 287-3601
Rules & Statutes | Maine Board of Licensure in Medicine

New Hampshire - (603) 271-1203
Board of Medicine Laws and Rules | NH Office of Professional Licensure and Certification

Vermont - (802) 657-4227
Statutes, Rules, Policies, and Newsletters | Vermont Department of Health

Massachusetts - (781) 816-8200
Board of Registration of Physician Assistants | Mass.gov
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. 1300 Alexandria, 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
409 12th St SW, Suite 600

Washington, DC 20024-2188
http://www.midwife.org