OO6

 

Exemplary Professional Practice OO6

 

Provide a description and/or policies, or equivalent evidence of, the process by which the CNO (or designee) participates in the following:

  • Credentialing, privileging, and evaluating of all Advanced Practice Registered nurses (APRNs).
  • Reprivileging of all APRNs. Include the frequency of reprivileging.

 

 

CNO Participation in Credentialing, Privileging, and Evaluation of APRNs

Allied health professionals, including advanced practice registered nurses (APRN), are credentialed and privileged through the Medical Executive Committee with approval from the Catholic Health Initiatives (CHI) St. Vincent Hot Springs (SVHS) Board of Directors. APRNs are subject to the terms and conditions of the guidelines, rules, and regulations of the medical staff bylaws and are included in the category of “Allied Health Professionals.” APRNs are qualified by their training and are permitted to practice within the scope of privileges offered. (Evidence OO6-1, CHI SVHS Medical Staff Bylaws and Rules and Regulations, pgs. 10-14, 18-19)

 

Teresa Lambert, MBA, BSN, RN, Vice President of Patient Care Services/Assistant Chief Nursing Officer (role of CNO) CHI SVHS, participates in the credentialing and privileging/re-privileging of APRNs in the following ways:

 

Performance evaluations of APRNs are conducted annually. The collaborative sponsoring physician completes the evaluation, with feedback on performance obtained from a nurse manager or clinical director designated by Lambert. In departments with APRNs, the designated nurse leader has an in-person discussion with the sponsoring physician about the APRN’s clinical nursing practice before the physician completes the APRN’s evaluation.

 

In addition, the CHI SVHS performance evaluation process is an ongoing systematic, data-based approach to evaluating APRNs’ performance and accountabilities to address opportunities for improvement. The process consists primarily of two parts:

  • Ongoing Professional Practice Evaluation (OPPE): The routine monitoring and evaluation of current competency for practitioners with granted privileges.

  • Focused Professional Practice Evaluation (FPPE): The confirmation of current competency of new practitioners or new privileges granted to current practitioners (e.g., proctoring) or confirmation of competency related to potential concerns raised from the OPPE.

 

Practitioner performance measures have been selected to complete the OPPE. These measures address six General Performance Indicators, are appropriate to the practitioner’s specialty, reflect APRN performance, are measurable and collectable, and are attributable to individual APRNs. An FPPE may be initiated if the results of the OPPE indicate a potential issue with an APRN’s performance compared to performance thresholds or targets.

 

The Medical Staff Credentialing Committee reviews OPPEs and FPPEs. Action plans for improvement are discussed collaboratively in the Medical Executive Committee, with final approval given by the CHI SVHS Board of Directors. Lambert is an active participant in all three governing bodies. In collaboration with the chief medical officer and Medical Affairs Office, Lambert is responsible for reviewing and resolving issues with an APRN (performance or otherwise).

 

Re-privileging and Frequency of Re-privileging of APRNs

APRNs are re-privileged every two years or more frequently, following the same process used for initial credentialing and privileging. (Evidence OO6-1, CHI SVHS Medical Staff Bylaws and Rules and Regulations, pgs. 20-21)