TY - JOUR
AU - Thrasher,, Kimberly
AB - Abstract Purpose. The rationale for and steps of pharmacist credentialing and privileging are described. Summary. As pharmacy evolves to include direct patient care, health care organizations are under increasing scrutiny to verify that their pharmacists are not only licensed to practice but are capable providers of direct patient care. Credentialing is a process conducted by a health care organization to review and verify a pharmacist’s credentials. Privileging authorizes a pharmacist to perform within a specified scope of practice. The steps in developing a process for pharmacist privileging consist of gathering background information from national, state, and local sources; defining the services a privileged pharmacist may provide; developing policies and procedures; and obtaining approval from the appropriate institutional bodies. An ad hoc committee convened by the American Society of Health-System Pharmacists in 2003 produced two documents, an application for privileging and a general privileging form, that may be used as templates by institutions or individuals developing a pharmacist-privileging process. Barriers to pharmacist privileging may be personal, institutional, and regulatory. Conclusion. As pharmacist roles continue to expand, there is increasing need to verify pharmacists’ ability to provide direct patient care services. One way to achieve this is for institutions to develop a pharmacist-privileging process that better aligns pharmacists with the methods used to authorize scopes of practice of other types of practitioners. Certification, Forms, Patient care, Pharmacists, Professional competence, Quality assurance The profession of pharmacy has changed rapidly over the past several decades, such that many pharmacists now care directly for patients. This transformation has been accompanied by evolving regulatory requirements, increased educational requirements, and recognition of pharmacists’ specialized body of knowledge. Organizations employing direct patient care pharmacists are under increasing scrutiny to verify that their pharmacists are not only licensed to practice but are competent providers of direct patient care services.1 There is growing recognition that obtaining a credential may be a way to document knowledge and skills, but each credential does not necessarily ensure competence in providing direct patient care services. For those intimately involved in the management of medication therapy, institutional privileging is a process that can be used to verify the credentials needed to practice in a specified clinical setting. The purpose of this article is to describe the rationale for credentialing and privileging and to define the steps involved in these processes. Background Since the early 1990s, articles have described pharmacists going through a credentialing and privileging process as part of their professional development.2,–6 These articles depicted experiences in both acute and ambulatory care settings but were generally limited to a specific institution. Recent developments in the profession have created a need for pharmacists and their employers to consider developing a privileging process. The Institute of Medicine and the American Society of Health-System Pharmacists (ASHP) both recognize the need for pharmacist expertise in the team approach to managing medication therapy.7,8 In planning for the future, ASHP stated in its 2015 Initiative that “pharmacists will manage medication therapy for patients with complex and high-risk medication regimens, in collaboration with other members of the healthcare team” for patients in ambulatory and acute care settings.8 One of the most recent developments affecting the profession is Medicare Part D, which allows pharmacists to bill for services related to medication therapy management (MTM) for Medicare beneficiaries. A consensus definition of MTM developed by 11 national pharmacy organizations in 2004 lists services such as “formulating a medication treatment plan” and “initiating, modifying or administering medication therapy.”9 This change has also brought about the development of current procedural and terminology billing codes specifically for use by pharmacists. It can be safely assumed that services documented through these codes will be analyzed by various quality- improvement groups for quality and risk analysis. Additionally, pharmacists providing these services, and their employers, will want to be sure that their credentials are in line with what is expected for the provision of MTM services. The recognition of pharmacists as medication therapy experts has prompted many states to modify their pharmacy practice acts to allow pharmacists to develop collaborative practice agreements with prescribers. In some agreements, the focus is on the pharmacist providing patient care for a particular disease, such as diabetes. This places increased responsibility on the employing organization to confirm that the pharmacist has the credentials to perform within a specialized scope of practice. At present, pharmacy licensure ensures a basic level of knowledge needed for safe and effective drug distribution and a limited scope of patient care services. Many believe that more comprehensive patient care generally requires additional credentials.10,11 A privileging process would, by assessing these credentials, effectively address a pharmacist’s ability to practice in a certain environment. Verifying pharmacists’ credentials and granting privileges could also help protect organizations against malpractice allegations.1 National standards for pharmacists to follow in developing a privileging process do not exist. However, models for other health care providers can be applied to pharmacists. This article is intended to help pharmacists understand the privileging process and help develop a system at their institution. Definitions There is much confusion within the pharmacy profession regarding what is meant by credentialing and privileging. The Council on Credentialing in Pharmacy (CCP) was formed in 1999 to provide leadership and guidance in this area. Currently, CCP comprises 15 national pharmacy organizations. In 2006, CCP published guidelines on credentialing pharmacy personnel, including technicians.12 Pharmacists interested in pursuing credentialing and privileging are encouraged to read these guidelines for further clarification on definitions. The definitions that are germane to this article are as follows: Competency. A competency is a specialized skill or knowledge that is required for proficiency in the profession. Credential. A credential is the documentation that verifies qualifications of the individual. For pharmacists, this would include diplomas, licenses, certificates, and certifications (disease specific, board certification, etc.). Credentialing. Credentialing is the process conducted by an organization to review and verify an individual’s credentials. Privileging. Privileging is a process conducted by a health care organization after review of credentials that authorizes an individual to perform within a specified scope of practice. Scope of practice. The scope of practice is the boundaries within which a professional has the ability to perform and is often regulated by state agencies, such as the professional licensing board. General steps in developing a process for pharmacist privileging Step 1. Gather background information Appropriate information for developing a privileging process includes data collected from national, state, and local sources. Perhaps the most influential and helpful sources of this information are recent manuals by the Joint Commission.13,14 Credentialing, privileging, and appointment to the medical staff are addressed extensively as an element of performance for hospitals in section MS.3.20 of reference 13 and for long-term care in section HR.4.1–4.50 of reference 14. State laws and regulations also yield important background information by showing how pharmacy practice and the scope of practice are defined by law.15,16 Forty-two states now authorize pharmacists to perform duties under collaborative practice agreements or other arrangements that go beyond the duties defined by traditional state pharmacy practice acts. In addition, many health care systems are using pharmacists to improve safety, quality, and efficiency with the implementation of new programs that expand the scope of pharmacist services to patients.17 Locally, it will help to obtain a copy of institution-specific medical staff bylaws, rules and regulations, or or whatever policies are used for institutional credentialing and privileging of other practitioners. Regulatory and external-review groups require a privileging process that is defined by the medical staff bylaws or an organization’s governing body. However, each organization may have different criteria for granting and renewing privileges. An organization’s medical staff is a self-governing body charged with overseeing the quality of care, treatment, and services delivered by institutionally privileged practitioners. The medical staff must verify credentials and privilege all licensed independent practitioners (LIPs). The Joint Commission defines an LIP as “any individual permitted by law and by the organization to provide care, treatment and services, without direction or supervision.”15 However, the Joint Commission does not determine who is an LIP; state law and hospital policy determine whether a practitioner can practice independently. Health care practitioners who are not LIPs may be privileged through the medical staff process or “a process that has been developed and approved by the hospital that is equivalent to the process and criteria set forth in the credentialing and privileging standards” of the Joint Commission.15 In many institutions, pharmacists are defined as “other allied health professionals” and thus are not considered LIPs. If the institution has not previously processed a pharmacist application for clinical privileges, it will be necessary to question how pharmacists have been classified at the institution and to determine if the method is consistent with the scope of practice defined by the state for pharmacists and other practitioners in the institution. Some physician groups have advocated against independent clinical privileges for pharmacists.18 In nonhospital health care settings, inquiry should be made concerning how physicians and other practitioners are privileged. Credentialing and privileging are no longer limited to inpatient settings. Long-term-care organizations, managed care organizations, large group practices, ambulatory care organizations, home care providers, and others are developing mechanisms to ensure standard qualifications and quality among practitioners.6,14,19,20 Once practitioners seek clinical privileges, they are bound by the requirements of the organization’s bylaws. Step 2. Define services The second step in privileging is to define the scope of care and services that may be provided by privileged pharmacists, including the amount of supervision by prescribers. For example, monitoring and documenting patient outcomes or medication reconciliation may be defined by the state pharmacy practice act as part of a pharmacist’s scope of practice. But a health system may authorize pharmacists to independently adjust or modify dosages, order and analyze laboratory tests, and schedule or refer patients as part of established pharmacy services. The local pharmacy and therapeutics (P&T) committee may authorize pharmacists to implement switches among medications or to change the route from i.v. to oral, thus requiring initiation or modification of therapy. Pharmacists may have responsibility for anticoagulation, hypertension, lipid or pain management, oncology, psychiatric, and other programs for acute and chronic problems. Many of these functions are done routinely by pharmacists and improve the process and quality of care, but the functions may be more efficient if they are acknowledged and authorized by the institution.21 Whether these functions are authorized by collaborative practice agreements, health-system policy, or some other mechanism should be considered. Step 3. Develop policies and procedures Policies and procedures for pharmacist privileging should include specific details regarding the privileging process. According to the Joint Commission, the privileging process typically entails “developing and approving a procedures list, processing the application, evaluating applicant-specific information, making recommendations to the governing body for applicant- specific delineated privileges, notifying the applicant and relevant personnel, and monitoring the use of privileges and quality of care issues.”13,14 Specific instructions on how pharmacist credentials will be verified should be included. Usually this is done by directly contacting the source of the credential (e.g., the state board of pharmacy, the Board of Pharmaceutical Specialties [BPS]). However, several national registries of practitioner data have been developed to assist in queries needed to verify applicant licensure information. In addition, registry information is available to assess providers who lose malpractice lawsuits or are subject to adverse actions involving licensure, privileges, or society memberships. These sources may be used to verify the credentialing information for an applicant in lieu of the primary source. The policy will need to clarify when the applicant’s verified credentials will be reviewed. Medical staff bylaws generally provide for credential review at the time of initial appointment (granting), during reappraisal of clinical privileges (renewing, reappointment, or revising), and after lengthy illness or another break in service. Privileging is usually governed by a health-system committee, such as the medical executive board or the credentialing committee. In smaller practice settings, this responsibility may fall to the medical director. How a privileging application moves through the system will be institution specific. Some procedures will mimic the privileging of other health care providers and will be reviewed by an institution-level committee. Other pharmacy privileging systems may involve an internal pharmacy process that requires only cursory approval outside the department. Other things to consider including in a privileging policy include (1) mechanisms for hearing and appealing adverse decisions regarding privileging, for focused peer review of practitioners’ performance, and for provisional, temporary, expedited, telemedicine, and disaster privileges, (2) requirements and documentation for continuing education and training, and (3) requirements for professional liability insurance. Step 4. Obtain approval The fourth and final step should be gaining approval of the privileging policy from appropriate bodies in an institution. Depending on the circumstances, this may include the P&T committee, the hospital credentialing committee, and the medical executive committee. Generally, the policy should be endorsed by pharmacy administration as well as the committees that approve other privileging documents. The director of pharmacy plays a crucial role in ensuring acceptance of a pharmacist- privileging model throughout an institution. Using the privileging model developed by ASHP In 2003, ASHP convened ad hoc committee charged with developing a model for pharmacist privileging that resulted in two documents, an application for privileging and a general privileging form.22 These documents are meant to be used as templates by institutions or individuals wishing to develop a pharmacist-privileging process. The credentialing template (Figure 11) should list all credentials important for the work a pharmacist will perform in an institution. These credentials will vary with the institution and the responsibilities of the pharmacist. This paperwork will also include all information necessary to review the applicant’s credentials. Credentialing review is the process of obtaining, verifying, and assessing the qualifications of an applicant to provide patient care, treatment, and services in or for a health care organization. Figure 1. Open in new tabDownload slide Open in new tabDownload slide Model credentialing template.22 Figure 1. Open in new tabDownload slide Open in new tabDownload slide Model credentialing template.22 Verifying credentials should be designed to ensure that (1) the individual requesting privileges is the same person identified in the credentialing documents, (2) the applicant has attained the credentials claimed, (3) the credentials are current, and (4) none of the credentials is being challenged. The information gathered will dictate the types of care, treatment, and services or procedures that a practitioner will be authorized to perform. Most of the information on this form will be used to verify work experience and will need to be accompanied by supporting documentation. The developed template is comprehensive and includes many things that may not be necessary at a given institution. It is important to compare this document with institution-specific credentialing forms and other gathered information to see what is needed at a particular institution. The application for privileging (Figure 22) is a companion document to the credentialing template. Privileges granted to an applicant are based not only on the applicant’s qualifications but also on the proposed setting of the services to be provided. Privileges are setting specific because they require consideration of the site’s characteristics, such as facilities, equipment, and number and type of qualified support personnel. In addition, the independence of the pharmacist’s decision-making will determine the scope of privileges requested and granted. Figure 2. Open in new tabDownload slide Open in new tabDownload slide Model privileging template.22 Figure 2. Open in new tabDownload slide Open in new tabDownload slide Model privileging template.22 Depending on the privileging process developed at an institution, the privileging application may be completed concomitantly with the credentialing document or may be completed after credentials are verified. This form gives specific information on what types of services a pharmacist will provide, along with information on how the pharmacist will be reprivileged. Again, the template is comprehensive, and not all aspects will be required at different institutions. At a minimum, the privileging document should provide (1) the scope of privileges, including the types of patients, level of care, and level of supervision, (2) the setting in which privileges are granted, (3) the mechanism and time period for re-credentialing (must at least be every two years), and (4) the signatures of appropriate personnel. Potential barriers to pharmacist privileging While some pharmacists have taken steps to become privileged, most pharmacists practicing in health systems have not. Barriers to pharmacist privileging may be personal, institutional, and regulatory. Personal barriers At present, privileging is a voluntary process for pharmacists. The voluntary nature may lead to inconsistent requirements by facilities and may promote misunderstanding of the process and its benefits. Of the four primary elements evaluated for credentialing—academic preparation, type of licensure, postgraduate training, and other traineeships or certificate programs—two are (again) voluntary. Leadership, endorsement, and education by national organizations are essential to eliminating this barrier. Institutional barriers Many institutions’ bylaws concerning privileging do not address pharmacists. However, most credentialing processes can be modified or fine-tuned to fit pharmacists and their scope of practice. Pharmacists will have to take the lead to make sure they are included in an institution’s credentialing apparatus. Other institutional barriers may result from the requirements of the numerous regulatory organizations and the particular agenda and focus of each. There is often little agreement on minimum standards for initial privileging or the time periods and criteria for renewal. Requiring credentials to be accredited by a national organization may minimize concerns by institutional committee members unfamiliar with pharmacy professional credentials, as may providing an accurate scope of practice and having a physician advocate. Regulatory barriers The focus of several regulatory organizations and professional organizations on pharmacist postlicensure credentialing has led to a multiplicity of testing and evaluation mechanisms, resulting in confusion for pharmacists, other health care professionals, and the public. BPS, formed in 1976, certifies pharmacists practicing in five specialties. BPS remained the lone pharmacy board certification body until 1997, when the Commission for Certification in Geriatric Pharmacy was formed. In 1998, the National Institute for Standards in Pharmacist Credentialing was established by leaders from four national organizations. CCP is a coalition of 15 national pharmacy organizations founded in 1999 to provide guidance on credentialing programs in pharmacy.10 The variety of offerings by these groups may provide the guidance, authorization, and credentials needed, and indeed they have benefited thousands of pharmacists. Perhaps the work of these organizations will lead to a more coherent and comprehensive approach to pharmacist credentialing. One program under development by the government, the Federal Credentialing Program, was originally established to guide physicians and dentists through credentialing; this program may be expanded to include pharmacists and other health care professionals.23 Conclusion As pharmacist roles continue to expand and more pharmacists become involved in direct patient care, there is increasing need to verify pharmacists’ ability to provide certain services. One way to achieve this is for institutions to develop a process for pharmacist privileging. This process will better align pharmacists with the methods used to determine the competence of other types of practitioners. References 1 Merrigan D. Internal approach to competency-based credentialing for hospital clinical pharmacists. Am J Health-Syst Pharm . 2002 ; 59 : 552 –8. Crossref Search ADS PubMed 2 Hutchison LC, Wolfe JJ, Padilla CB et al. Clinical privileges program for pharmacists. Am J Hosp Pharm . 1992 ; 49 : 1422 –4. PubMed 3 Swanson KM, Hunter WB, Trask SJ et al. Pharmacist career ladder with clinical privilege categories. Am J Hosp Pharm . 1991 ; 48 : 1956 –61. PubMed 4 Guillory KM, Denning PN. Hospital pharmacists’ actions and medical staff credentialing. Am J Hosp Pharm . 1994 ; 51 : 1350 –3. PubMed 5 Galt K. Credentialing and privileging for pharmacists. Am J Health-Syst Pharm . 2004 ; 61 : 661 –70. Crossref Search ADS PubMed 6 Claxton KL, Wojtal P. Design and implementation of a credentialing and privileging model for ambulatory care pharmacists. Am J Health-Syst Pharm . 2006 ; 63 : 1627 –32. Crossref Search ADS PubMed 7 Aspden P, Wolcott J, Bootman JL, eds. Preventing medication errors. Washington, DC: National Academy Press; 2006 . 8 American Society of Health-System Pharmacists. 2015 Goals. www.ashp.org/s_ashp/quart2c.asp?CID=421&DID=463 (accessed 2006 Dec 20). 9 Bluml B. Definition of medication therapy management: development of professionwide consensus. J Am Pharm Assoc . 2005 ; 45 : 566 –72. Crossref Search ADS 10 Keely JL. Pharmacist scope of practice. Ann Intern Med . 2002 ; 136 : 79 –85. Crossref Search ADS PubMed 11 American College of Clinical Pharmacy. Future clinical pharmacy practitioners should be board certified specialists. Pharmacotherapy . 2006 ; 26 : 1816 –25. Crossref Search ADS PubMed 12 Credentialing in pharmacy. Washington, DC: Council on Credentialing in Pharmacy; 2006 Jul. 13 Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2006 . 14 Comprehensive accreditation manual for long term care. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2005–6 . 15 American Society of Health-System Pharmacists. List of states by statutory and regulatory authority. www.ashp.org/s_ashp/docs/files/GAD_cdtm8-06chart.pdf (accessed 2006 Dec 20). 16 Carmichael JM, Cichowlas JA. The changing role of pharmacy practice—a clinical perspective. Ann Health Law . 2001 ; 10 : 179 –90. PubMed 17 Kaboli PJ, Hoth AB, McClimon BJ et al. Clinical pharmacist and inpatient medical care. A systematic review. Arch Intern Med . 2006 ; 166 : 955 –64. Crossref Search ADS PubMed 18 Pharmacist scope of practice. American College of Physicians–American Society of Internal Medicine position paper. Ann Intern Med . 2002 ; 136 : 79 –85. Crossref Search ADS PubMed 19 Guidelines for designing a credentialing and privileging process in long term care. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2003 Mar. 20 Carmichael JM, Alvarez A, Chaput R et al. The establishment and outcomes of a model primary care pharmacy system. Am J Health-Syst Pharm . 2004 ; 61 : 4472 –82. 21 Carmichael JM. Do pharmacists need prescribing privileges to implement pharmaceutical care? Am J Health-Syst Pharm . 1995 ; 52 : 1699 –701. Crossref Search ADS PubMed 22 American Society of Health-System Pharmacists. Credentialing in pharmacy. www.ashp.org/s_ashp/quart2c.asp?CID=1229&DID=1271 (accessed 2006 Dec 20). 23 Enhancing the Workforce Work group. Federal Credentialing Program: final report. www.quic.gov/workforce/enhance/finalrpt.htm (accessed 2007 Aug 27). Author notes The following members of the Ad Hoc Committee To Develop Qualified Provider Models are acknowledged for their role in developing the templates: Cindi Brennan, Karen Gorman, Rita Jew, Christene Jolowsky, Patricia Kienle, and Philip Rogers. Copyright © 2007, American Society of Health-System Pharmacists, Inc. All rights reserved.
TI - Pharmacist privileging in a health system: Report of the Qualified Provider Model Ad Hoc Committee
JO - American Journal of Health-System Pharmacy
DO - 10.2146/ajhp070149
DA - 2007-11-15
UR - https://www.deepdyve.com/lp/oxford-university-press/pharmacist-privileging-in-a-health-system-report-of-the-qualified-lf9EYNJpvf
SP - 2373
VL - 64
IS - 22
DP - DeepDyve
ER -