Nu Nurse Practition titioner an and Ph Physician ician Ass Assistant Deline Delineatio tion of of Cor Core Priv ivileg ileges (DO (DOP) Core Obtain and document a health history; Perform and document complete, system ‐ focused, or symptom ‐ specific physical examination; Assess the need for and perform additional screening and diagnostic testing, based on initial Privileges assessment findings; Prioritize data collection; Perform daily rounds/clinic visits on assigned patient population; Document daily progress notes, plan of care, evaluation and discharge summary; Manage diagnostic tests through ordering and interpretation; Formulate differential diagnoses by priority; Prescribe appropriate pharmacologic and non ‐ pharmacologic treatment modalities. Utilize evidence ‐ based, approved practice protocols in planning and implementing care; Initiate appropriate referrals and consultations; Provide specialty specific consultation services upon request and within specialty scope of practice; Facilitate the patient’s transition between and within health care settings, such as admitting, transferring, and discharging patients. Demonstrate competency specific to the patient population of care, as indicated in area specific competency training, assessment and validation process.
Certified Certified Re Regist stered Nu Nurse Anes esthet thetis ist: Performance of pre ‐ anesthetic assessments including a pertinent medical history, physical examination, and review of medical records Formulation of an anesthetic care plan in consultation with the assigned anesthesiologist Induction and maintenance of anesthesia with all commonly used agents and monitoring devices; management of emergence from anesthesia; airway maintenance including bag/mask ventilation, laryngeal mask airways, and intubation of the trachea Anticipating and identifying common complications during the perioperative period, initiating treatment as indicated, and communicating problems to the anesthesiologist supervising the specific case or other appropriate staff members Anesthetic management of urgent and emergent conditions All elements of CRNA scope of practice as recommended by the AANA Scope and Standards for Nurse Anesthesia Practice document Certified Certified Nu Nurse Mi Midwife: Perform and document complete, system ‐ focused, or symptom ‐ specific physical examination; Assess the need for and perform appropriate screening and diagnostic testing. Formulate differential diagnoses by priority. Manage diagnostic tests through ordering and interpretation. Prioritize data collection. Perform daily rounds/clinic visits on assigned patient population. Document daily progress notes, plan of care, ongoing evaluation and discharge summary. Prescribe appropriate pharmacologic and non ‐ pharmacologic treatment modalities. Utilize evidence ‐ based, approved practice guidelines in planning and implementing care. Initiate appropriate referrals and consultations. Provide specialty specific consultation services upon request and within specialty scope of practice. Facilitate the patient’s transition between and within health care settings, such as admitting, transferring, and discharging. Core procedures as incorporated in ACNM Core Competencies for Basic Midwifery Practice, latest edition, are hereby incorporated by reference .
Provisional Status While waiting for credentialing and privileging Image goes here approval must remain in “provisional status”. Provisional status providers are required to have: Completed educational requirements for role • Obtained a board certification • Applied for state licensure • Applied for DEA/NPI • Applied for credentialing and privileging • Provisional status providers must: Not represent as NP, CNM, CRNA, PA • Work under direct supervision • Not submit orders under own name • Not write notes intended for billing • Follow ANA, state, specialty organization and • practice specific guidelines Access/enter eStar/epic as a “non ‐ • credentialed provider”
Additional (non ‐ core) Privileges Non ‐ core, usually procedural • Granted only after procedural competency demonstrated and application submitted • Must be medical necessary and supported by volume • Application required to request additional privileges • Can only be requested with initial privileges and in January, July and October • Advanced practice leader must request the application for you • Application completed by practitioner, AP leader and supervising physician • Must submit procedural log with application (MR#, date, procedure, supervisor) • Each procedure requires initial number of supervising procedures and number of procedures to • maintain privileges every two years High risk procedures require separate application: colposcopy, moderate sedation, circumcision, • acupuncture, nitrous oxide administration
Additional Privileges
Professional Liability Coverage Coverage through Vanderbilt Self ‐ Insured Image goes here • Trust 5.5 million • Vanderbilt Credentialing Services reviews • malpractice history Evidence of previous coverage • Collaborative practice critical • Claims such as failure to diagnose or failure • to consult/refer
Until privileges are approved, the APP must… A. Have 100% of charts reviewed by supervising MD or APRN/PA preceptor B. Perform all procedures under supervision C. Not make independent clinical decisions or diagnoses, write billing notes or prescriptions D. All of the above
After receiving initial privileges, practitioners are eligible for reappointment every… A. 1 year B. 2 years C. 3 years D. 4 years
If you hold a faculty appointment, how often are you up for reappointment? A. 1 year B. 2 years C. 3 years D. 4 years
State of Tennessee Guidelines Laws for maintaining APRN or PA license. VUMC privileges are immediately suspended with loss or expiration of license.
Tennessee Rules and Regulations for Advanced Practice Physician Assistants Image goes here Department of Health ‐ PA • Board of Medical Examiners • Nurse Practitioners, Midwives, CNS Board of Nursing • Board of Medical Examiners • CRNAs Board of Nursing • Board of Medical Examiners •
Tennessee Law Tennessee Board of Nursing Advanced Practice Nurses Image goes here and Certificate of Fitness to Prescribe http://publications.tnsosfiles.com/rules/1000/1000 ‐ 04.20150622.pdf Tennessee Board of Medical Examiners Rules and Regulations for Nurse Practitioner Prescription Writer http://publications.tnsosfiles.com/rules/0880/0880 ‐ 06.pdf Tennessee Rules and Regulations for Physician Assistants http://publications.tnsosfiles.com/rules/0880/0880 ‐ 03.20160621.pdf Review Rules and Regulations for Tennessee (copies in your orientation folder )
0880 ‐ 6 ‐ .02 CLINICAL SUPERVISION REQUIREMENTS It is the intent of these rules to maximize the collaborative Image goes here practice of certified nurse practitioners and supervising physicians in a manner consistent with quality health care delivery. A supervising physician or a substitute supervising • physician must possess a current, unencumbered license to practice in the state of Tennessee. Supervision does not require the continuous and • constant presence of the supervising physician; however, the supervising physician must be available for consultation at all times or shall make arrangements for a substitute physician to be available. A supervising physician and/or substitute supervising • physician shall have experience and/or expertise in the same area of medicine as the certified nurse practitioner.
0880 ‐ 6 ‐ .02 CLINICAL SUPERVISION REQUIREMENTS It is the intent of these rules to maximize the collaborative Image goes here practice of advanced practice nurse with certificate of fitness to prescribe and supervising physicians in a manner consistent with quality health care delivery. 20% chart review monthly • 100% chart review of controlled substances • Protocols for practice, reviewed every 2 years • Supervising physician must be readily available for • consultation; site visit at least every 30 days Collaborative agreement on file with state (previously • known as Notice and Formulary)
Chart Review Image goes here 20% chart review monthly State does not specify guidelines on chart review other than it must be completed • VUMC practitioners complete chart review in alignment with area workflow • Attestation not required for indicating chart review • 100% chart review of controlled substances State requires this review within 10 days of prescription and the MD signature on chart within 30 days • Examples of eStar chart review include: Using mandatory attending’s admission and discharge notes and co ‐ signatures as chart review • Stating “I have reviewed this patient’s chart and plan of care with Dr. XXXX” on your own notes • Practitioner pulling eStar report of all notes written in the month. These notes indicate which chart were • reviewed and signed by an MD. These reports can be generated any time needed. Specific notes, needing close attention by MD can be sent to MD for review and attestation, using “co ‐ sign” • click box on note Chapter 0880 ‐ 6 ‐ .02, Tennessee Board of Medical Examiners Rules and Regulations http://state.tn.us/sos/rules/0880/0880 ‐ 06.pdf
Protocols Protocols are mandated by the Tennessee Board of Medical Examiners and are defined as written guidelines for Image goes here medical management. Shall be jointly developed and approved by the supervising physician and nurse practitioner; • Shall outline and cover the applicable standard of care; • Shall be reviewed and updated biennially; • Shall be maintained at the practice site; • Shall account for all protocol drugs by appropriate formulary; • Shall be specific to the population seen; • Shall be dated and signed; and • Copies of protocols and formularies shall be maintained at the practice site and shall be made available upon • request for inspection by the respective boards. ** CRNAs do not have protocols secondary to Anesthesia Care Team Model Chapter 0880 ‐ 6 ‐ .02, Tennessee Board of Medical Examiners Rules and Regulations http://state.tn.us/sos/rules/0880/0880 ‐ 06.pdf
Protocols Protocol Warehouse Image goes here https://int.vanderbilt.edu/vumc/CAPNAH/APSC/APRNprot ocolswarehouse/default.aspx Access provided by Office of Advanced Practice after • completion of Advanced Practice Orientation Practitioner is attached to service line’s protocols • New protocols can be written using template. We • have a practice template, procedure template and reference text (or online reference) template Resources for writing protocols and EBM toolbox • available on OAP website
Collaborative Agreement Collaborative agreement with supervising physician Image goes here required to be on file with the state Must be up to date with current collaborative • physician(s) New online process available through TN Department • of Health website If If onlin online sit site is is not not wo working, ma may still ill use use old old paper paper • Noti Notice ce and and Fo Formulary Practitioner responsibility to send to state • Practitioner responsibility to send to Vanderbilt • Credentialing Services Keep a copy on file at all times •
https://nppes.cms.hhs.gov/NPPES/Welcome.do
DEA Registration Required for all VUMC practitioners Image goes here DEA holders must register in CSMD within 30 days • Controlled substance prescriptions monitored closely • by state DEA must be current in order to eprescribe in eStar • VUMC waiver in rare circumstances. Letter submitted • to credentialing committee by chair for waiver. https:///www.deadiversion.usdoj.gov/webforms/validateL ogin.jsp * CRNAs are currently not required to have a DEA number secondary to Anesthesia care team model.
DEA Misappropriation Collaborative agreement with supervising physician Image goes here required to be on file with the state Immediately notify supervisor, administrative and • clinical directors Notify pharmacy program director • Complete veritas report • Pharmacy program director will conduct investigation and notify the following: Risk management • HR consultant for nursing • Law enforcement/ VUPD • Nursing administrative director for professional • practice Medical administration • Board of Nursing • Board of Medical Examiners • DEA • CSMD •
CSMD DEA holders must register with CSMD within 30 days if Image goes here you provide care to TN patients >15 days per year. Must check CSMD before prescribing a new course of • opioids and/or benzodiazepines and annually for ongoing treatment Requires supervising physician and supervising • physician’s drivers license when completing registration in CSMD A clinic delegate can be assigned to check CSMD • Documentation of checking CSMD must be in chart • Required to report evidence of diversion, doc • shopping to TN CSMD Exceptions to checking CSMD include: hospice • patient, single 3 day course, medical specialty patients with low abuse potential, direct administration in hospital or nursing home and licensed veterinarians for non ‐ humans
Prescribing in Tennessee Tennessee has major issues with opioid prescribing, overdose and death.
State of Tennessee Prescription Safety ePrescription Safety Act 2012 • Continuing education requirement of 2 contact hours every 2 years including chronic pain • guidelines and education on opioids, benzodiazepines, barbiturates, carisoprodol TN Bill 396 restricts controlled substance prescriptions to 30 day non ‐ refillable, written only if • schedule indicated on collaborative agreement (notice and formulary) All practitioners who hold DEA must register with Controlled Substance Monitoring Database • (CSMD) TN Together Act of 2018 •
Drug Overdose Data 2016 Report
Drug Overdose Data 2017 Report
Drug Overdose Deaths 2012 ‐ 2017
Tennessee Department of Health Neonatal Abstinence Syndrome Annual Report 2017 https://www.tn.gov/content/dam/tn/healt h/documents/nas/NAS%20Annual%20Rep ort%202017%20FINAL.pdf
Tennessee Department of Health Neonatal Abstinence Syndrome Annual Report 2017 https://www.tn.gov/content/dam/tn/healt h/documents/nas/NAS%20Annual%20Rep ort%202017%20FINAL.pdf
OAP can help with CME! Resources for Tennessee controlled Image goes here substance prescribing mandated education: https://vumc.cloud ‐ cme.com • Other CME resources available on OAP • website
What do you need if your license is audited? 1. Current national certification (NOT state Image goes here license; example: from ANCC, AANP, NBCRNA) 2. ONE item from the Registered Nurse proof of competence list https://www.tn.gov/content/dam/tn/health/ documents/ContinuedCompetenceRequire ments.pdf 3. TWO contact hours of continuing education designed specifically to address controlled substance prescribing practices including the Tennessee Chronic Pain Guidelines http://tn.gov/health/article/nursing ‐ coedu 4. Copy of current Collaborative Request/APRN Supervisory Request (formerly Notice and Formulary) if prescribing https://lars.tn.gov/datamart/mainMenu.do
Prescribing Tips Image goes here Prescribing guidelines vary by state • Respect granted authority and DO NOT • provide for friends and family. Collab Collaboratin ing ph physic icia ian sho should be be in indicated on on • pr prescrip escriptio tion Many health care clinics and hospitals have • transitioned to e ‐ Prescribing. Can reduce errors; however, NEVER rely solely on the computer software to do your vigilance for you!
The Rights of Prescription Writing Image goes here Right patient • Right drug • Right dose (strength per unit dose) • Right dosage schedule, dosing interval, times of day • Right route of administration • Right date • Right number of refills • Right duration of treatment • Right to informed consent • Right to refuse treatment • Right to be knowledgeable •
Universal Components Image goes here Prescriber’s Printed Name and Address • DEA # • Patient Name • Date • Drug, Dose, Units, Route, Frequency • Indication • Quantity to Dispense (dispense as written or • substitute allowed) Refill information • Signature •
John Brown AGPCNP-BC Karen Jones MD 136 Wright Way Nashville, TN 37202 587-822-5536 DEA # 123920392187 Name: John A. Smith Address 123 Meadow Lane, Nashville, TN 37216 Date 08/23/2013 Rx (please print) Lisinopril 20mg #30 Sig: 1 tablet by mouth daily Indication: for blood Dispense as written Substitution allowed pressure _____John Brown_____________ ____________________________ 3 REFILL TIMES PRN NR LABEL
Prescription pad essentials Image goes here Information of collab llaboratin ting MD MD and • NPs: ‐ name ‐ address ‐ phone number If multiple physicians listed, id identify fy • collab llaboratin ting MD MD by by check checkmark ark or or cir circling ling MD MD name name
Institutional Guidelines Medical Staff, Nursing and Vanderbilt Medical Group Bylaws
Institutional Guidelines VUMC Nursing Bylaws https://vanderbilt.policytech.com/dotNet/documents/?docid=10788 Vanderbilt Medical Group (VMG) Bylaws (billing providers) https://vanderbilt.policytech.com/dotNet/documents/?docid=12212 VUMC Medical Staff Bylaws https://vanderbilt.policytech.com/dotNet/documents/?docid=12352 VUMC Policies https://vanderbilt.policytech.com/ VU Faculty Manual https://vanderbilt.edu/faculty ‐ manual/
Clinician Documentation Policy 10 ‐ 20.13 Documentation Standards for Clinicians • Complete, accurate EHR supports safe care • Timeliness requirements • Within 24 hours of admission or • consultation Prior to any operation or procedure • Within 3 days of discharge • Daily for Inpatient progress notes • Outpatient progress notes within 4 • business days following encounter Delinquent = incomplete > 14 days after date of • triggering event Incomplete > 28 days = temporary suspension of • privileges https://vanderbilt.policytech.com/dotNet/docum • ents/?docid=15971
Benefit Staff and Staff VMG Faculty Health, Dental, Vision same same Short ‐ term disability Base provided by employer. Buy ‐ up coverage N/A; Salary continuation up to 6 months at paid by employee. chair/dean’s discretion; Long ‐ term disability same same Supplemental life same same AD&D same same Retirement (mandatory) After 1 year, 3% mandatory and employer Immediate 3% mandatory and match (*VMG match; members have 6.47% mandatory and 3% match); Retirement (voluntary) May contribute up to 2% with equivalent May contribute up to 2% with equivalent employer employer match; match; PTO Accrual based on exemption and years of N/A; Vacation/time away department dependent; service; Grandfathered sick time If hired prior to 1/1/2014, grandfathered sick N/A bank. No accruals. Parental leave Concurrent with FMLA/TMLA; 2 weeks paid Concurrent with FMLA/TMLA; 6 weeks paid (any leave (can request flexPTO, grandfathered sick additional paid leave as approved by chair/dean); time and/or file for short ‐ term disability); Nonacademic and academic leave Guidelines for each as outlined in faculty manual. with and without pay All requests require chair/dean’s approval; Resignation notice Standard professional notice 120 days in writing
Benefit Staff Faculty Tuition assistance (hired before Children – 70% Children – 70% 9/1/12) Employee – 70% Employee – 47% Spouse – 47% Spouse – 47% Tuition assistance (hired after Children – 55% Children – 55% 9/1/12) Employee – 70% Employee – 47% Spouse – 47% Spouse – 47% Tuition assistance • 1 course/semester = 3/yr • 1 course/semester = 3/yr (1 semester – Fall, Spring, Summer) (1 semester – Fall, Spring, • 3 credit hrs/4 hrs w/lab Summer) • Eligible 3 months after hire • 3 credit hrs/4 hrs w/lab • Contingent upon evidence of • Consult with Department Chair or completion with a “C” or better Division Director • Consult with Supervisor
KRONOS For exempt salary employees
Compliance Modules If you are School of Medicine faculty, please go to this link and log in to your compliance training • profile: https://medschool.vanderbilt.edu/faculty/foto If you are VUMC medical staff, please go to the Learning Exchange at this link and click on “my • courses”: https://learningexchange.vumc.org/ If you are School of Nursing faculty, please go to the Learning Exchange at this link and click on “my • courses”: https://learningexchange.vumc.org/ School of Nursing Faculty: Be sure to use your VUMC VUNet ID (vs. VU). If there are any problems with pulling up your modules, please email the learning exchange: • LearningExchange@vanderbilt.edu For 2019, you should be assigned the following modules: • Annual Compliance Curriculum: Fraud, Waste and Abuse and Topics Annual Compliance Requirements: Bloodborne Pathogens & Infection Prevention Annual Compliance General Requirements Annual Compliance: Safety Curriculum Culture of Service: Service Recovery Procedural Minimal Sedation and Analgesia
Vanderbilt Resuscitation Program Advanced Cardiovascular Life Support (ACLS) • Basic Life Support for Healthcare Providers (BLS) • Additional Courses Available • https://ww2.mc.vanderbilt.edu/resuscitation/ •
Vanderbilt Resuscitation Program Certifications tracked in CATS Database • https://webapp.mis.vanderbilt.edu/cats/ • Login using VuNet ID • Click – My Credentials on left ‐ hand side • Certifications will be listed in middle of page •
Vanderbilt Learning Exchange
Joint Commission National Patient Safety Goals Image goes here Vanderbilt Joint Commission Handbook
2018 2018 TJ TJC Reco comme mmendation ons fo for Im Improvement Ti Titr tratio ion or order ders mus must: • consistently contain all • be administered as ordered required elements which • be documented by the administering include: nurse the medication o Starting rate of infusion (e.g., • carefully denote order parameters dose/min); for accuracy o Incremental units the rate can be increased/ decreased; • be carefully reviewed by clinician when renewing titration orders o Frequency for incremental doses/rate change; * Titration orders may include a bolus o Maximum rate of infusion; and dose, if appropriate. o Objective clinical endpoint (e.g., RASS)
Split/Shared Encounters Image goes here Encounter between MD & NP • Not applicable to medical students, nurses, • residents Not applicable to consultations, procedures or • critical care services Service must be medically necessary. • Service must be within scope of practice/licensure • of NP. NP service & MD service may occur jointly or at • independent times on same day calendar day. Both must complete a face to face encounter in • order to bill as a shared/split visit. Both NP & MD should document what each • personally performed. Total documentation by both NP & MD should • support the level of service reported.
Incident To Billing Medicare Incident To Criteria: Image goes here MD must personally perform the initial service & • remain actively involved in the course of treatment MD must be present in the office suite and • perform a face to face encounter. MD is delegating work to the NP • MD and NP must be in the same specialty. • Incident To applies to the office/clinic setting (not applicable in the inpatient setting) Cannot be used when: Seeing new patients • Seeing established patients with new problems • Physician not physically present in office suite • Physician not performing face to face encounter •
National Guidelines Licensure, Accreditation, Education and Certification
APRN Consensus Model Uniform model of regulation for advanced practice Image goes here • Designed to align licensure, accreditation, • certification, education (LACE) Consensual title for advanced practice: APRN • 4 roles, 6 populations : Across continuum, Adult ‐ • Gero Primary/Acute; Pediatric Primary/Acute; Neonatal, Psychiatric, Women’s health/gender related Enables practicing to full extent of education and • licensure Uniformity eases mobility among states, benefits • APRN and enhances patient care Credential is legal tag; demonstrates successful • acquisition of board certification. • http://www.mc.vanderbilt.edu/documents/CAPNAH/files/APR NConsensusModelFinal09.pdf
VUMC Enterprise Cybersecurity Remaining Joint Commission Compliant with Patient Information MH ‐ CURE MFA (MultiFactor Authentication) MDM (Mobile Device Management)
MH ‐ CURE What is Care Team Communications? Care team Communications(CTC) is our initiative that is using the MH ‐ CURE application which allows for • an improved process of communication using smartphones and clinical work stations to enhance communication with the patient and the interdisciplinary care team. Who will use MH ‐ CURE? Initial users for this implementation will include registered nurses, care partners, medical receptionists • and telemetry technicians within designated areas at Vanderbilt University Hospital. Users are described in one of three categories: • Shared Device User: The shared device user will use a hospital issued iPhone with the MH ‐ CURE • application each day that they work in their unit. Shared device users include registered nurses and care partners. Desktop Application User: The desktop user will use designated workstations on their unit in which • the MH ‐ CURE application has been installed. Desktop users include medical receptionists and telemetry technician. Bring Your Own Device (BYOD) User: The BYOD user will use their personal IOS or Android device in • which the MH ‐ CURE will be downloaded to their personal phone. BYOD users will be providers. User Guides https://ww2.mc.vanderbilt.edu/mobileheartbeat/49594 •
Professional Practice Evaluation What is FPPE and OPPE?
Professional Practice Evaluation Ongoing Professional Practice Evaluation Image goes here (OPPE), MS.08.01.01 • To move from cyclical to continuous evaluation of a practitioner's performance to identify practice trends that impact quality, patient safety and determine whether a practitioner is competent to maintain existing privileges or needs referral for a focused review. Focused Professional Practice Evaluation (FPPE), MS.08.01.03 • To verify competency, when applying for new privileges (ie. new hire) and whenever questions arise regarding the practitioner's professional performance.
Focused Professional Practice Evaluation (FPPE) A period of focused review (JC standard MS.08.01.01). Time limited • Assigned proctor, usually a peer • When a practitioner has the credentials to suggest competence, but additional information or a period of evaluation is needed to confirm competence in the organization’s setting. Implemented for all newly requested privileges Practitioners new to the organization • Existing practitioners applying for new privileges • When practice issues are identified that affect the provision of safe, high ‐ quality patient care Triggered from an ongoing evaluation or clinical practice trends • Triggered by a single incident or sentinel event • How do we measure FPPE? Chart review, direct observation, simulation, peer review, 360 discussions •
Ongoing Professional Practice Evaluation (OPPE) To move away from the procedural, cyclical process in which practitioners are evaluated when privileges are initially granted and every 2 years thereafter. To continuously evaluate a practitioner’s performance • To identify professional practice trends that impact on quality of care and patient safety. • To decide whether a practitioner is competent to maintain existing privileges or needs • referral for FPPE Clearly defined quality review process to evaluate each practitioner’s practice. Type of data collected may be general but also must include data that is determined by • individual departments and be individual practice specific Can include both subjective and objective data • Must occur more than once a year, usually every 6 ‐ 8 months •
To practice a sample OPPE, please scan this code or go to this link: https://redcap.vand erbilt.edu/surveys/ ?s=N3XJ7N8WTR
VUMC Patient Experience Provider Star Ratings For Outpatient Providers • with >300 encounters per year Stars are indicated if • there are >3 comments
Which of the following is NOT true regarding Professional Practice Evaluation? A. OPPE occurs every 6 months (April and October) B. FPPE verifies competence for a newly hired APRN/PA C. FPPE does not use direct observation as a means to evaluate competency D. FPPE is reactivated when questions arise regarding an established practitioner’s performance
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