Credentialing the Nurse Practitioner

What NPs and Employers Need to Know

Carolyn Buppert, MSN, JD


June 19, 2019

The Right Credentials for the Job

A typical job posting for a nurse practitioner (NP) position might call for an NP with experience in managing cardiac conditions. But it's not always clear to job-seeking NPs or prospective employers what type of NP would be best qualified to work in cardiology, or any specialty. Board certification is one criterion for competence, but NP board certifications aren't available in every specialty. At present, only one board exam in cardiology is available to NPs, from the American Board of Cardiovascular Medicine. It's for NPs who have 2 years of experience in cardiology.

Board certification is available to NPs in these practice areas:

  • Adult/Gerontology acute care

  • Adult/Gerontology primary care

  • Family (Primary care)

  • Pediatric primary care

  • Pediatric acute care

  • Neonatal care

  • Orthopedics

  • Women's health

  • Hospice/Palliative care

  • Oncology

  • Emergency care

  • School health

  • Wound/Ostomy/Continence care

  • Nephrology

  • Dermatology; and

  • Psychiatric/Mental health (child, adolescent and adult).

Numerous post-master's educational programs provide education and training in a specialty area but don't necessarily lead to board certification.

What combination of education and certification is necessary to document that the NP is qualified to perform a set of services or a specific procedure? For example, is an NP certified as a family NP qualified to work for a cardiology practice? Or should an NP who is evaluating and managing hospitalized patients be certified in acute care? If a family NP is working in a specialty, should the NP be limited to office visits or can the NP also evaluate and manage hospitalized patients? How about critical care?

The answers to these questions are going to depend on the specific requirements of the position and the specific education, training, and experience of the NP. Like physicians, NPs become qualified through both formal education and supervised on-the-job training. Employers should review the requirements of the position they want to fill against an NP's portfolio of education, certification, and training, and document that there is a good fit. NPs will want to develop their portfolios with an eye to the area of practice they aspire to, and document both formal education and on-the-job training.

The Employer's Perspective

Employers are required by law or accreditation bodies to address credentialing in certain ways. If the employer is a medical practice, there are few restrictions on or requirements relating to whom a group can hire. However, practices will want to hire individuals whose qualifications are consistent with state board of nursing (and, if applicable, board of medicine) rules and are defensible if challenged by a patient or if something goes wrong.

If a specialty practice hires an NP who is educated and certified in primary care, the practice will want to document formal, specialty-related continuing education programs that the NP attends and in-practice training sessions over the course of the NP's employment. Hospitals that hire NPs must satisfy the requirements of a variety of regulatory and accreditation agencies, including state medical and nursing boards, the Centers for Medicare & Medicaid Services (CMS), and the Joint Commission or other accrediting body. CMS requires hospitals to have their medical staff organization credential NPs and recommend them for privileging.

To set criteria for competence, hospital administrators need to identify the functions and procedures that NPs are performing or will be performing. The hospital then should conduct an analysis of the competencies needed and determine how those competencies can be measured and documented. Evaluation of NP credentials is not exactly parallel to evaluation of physician credentials, because NPs are not required by tradition or law to attend medical school or complete residency programs. However, a reasonable degree of parallel is achievable. NPs have access to a wide variety of post-master's continuing education and training. Employers can seek either an NP who has completed additional coursework and supervised and unsupervised practice that led to competency, or the employer can provide that education and training after hiring and before allowing the NP to practice without supervision.

An additional consideration for most employers is payer rules. Medicare pays for physician services provided by NPs when the NP is qualified according to Medicare's rules and when the NP is working within the scope of practice under state law. Medicare's required qualifications include possessing a master's degree in nursing and being certified by a nationally recognized certification body.

For each NP, employers should consider:

  • Does the NP meet CMS qualification requirements?

  • Does state law authorize the NP to perform the services required by the position?

  • If a hospital, do the bylaws allow an NP to perform each of the services required by the position?

  • What are the appropriate qualifications for this position in terms of education, certification, registrations, post-graduate education, and work history?

  • Does the NP possess the necessary licenses, certifications, and registrations to comply with state and federal law, accreditation standards, and payer requirements?

  • For any procedure listed in the position description or privileges list, do generally accepted measures of competence exist, either published in the medical literature or adopted by professional organizations? Does the NP meet those measures of competence?

  • Do the NP's credentials meet Joint Commission standards?

Additional, practical considerations when hiring NPs include:

  • Is the NP named on the federal exclusion list?

  • Is the NP constrained by a restrictive covenant from a previous employer?

  • Does the NP have a malpractice history?

  • Is the NP listed in the National Practitioner Data Bank?

In the decision-making process, the employer should consider how defensible the decision would be if the employer were sued and its credentialing and privileging process were challenged.

State Law

An employer's first step in the hiring/credentialing/privileging process should be to determine what functions and procedures an NP is authorized to practice under state law. For example, in Oregon, NPs may perform vasectomies. In Hawaii, NPs may assist at surgery. Some states specifically authorize NPs to sign do-not-resuscitate orders. Many boards of nursing have posted algorithms for determining whether a specific service is within the NP's scope of practice. The National Council of State Boards of Nursing (NCSBN) published a decision-tree tool in 2016.

The Joint Commission

Organizations seeking or maintaining accreditation will need to conform with the Joint Commission's standards on Ongoing Professional Performance Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE). The OPPE/FPPE process should parallel the organization's process for evaluating physicians, to the extent that the metrics are applicable to NPs. The hiring individuals and medical staff organization will need to determine which metrics are applicable, based on outside counsel or expertise within the organization.

The NP's Perspective

A NP has a personal interest in appropriate credentialing. NPs need to protect their licenses, and that means generally practicing in a way that is safe for patients and, specifically, practicing within one's scope of practice. NPs also want to avoid malpractice. So, an NP will want to be comfortable that an employer's position requirements fit with the NP's credentials, education, training, and experience, or that a good fit can be reached with additional education and training. The NCSBN's algorithm is useful in determining whether an activity or role is within an NP's scope. Briefly, the algorithm asks:

  • Is the activity consistent with state and federal law, evidence-based nursing, and the healthcare literature?

  • Are policies in place in the organization to support the NP's performance of the activity?

  • Has the NP completed the necessary education to safely perform the activity?

  • Does the organization provide appropriate resources for the NP?

  • Would a reasonable and prudent NP perform the activity in this setting?

  • Is the NP prepared to accept accountability for outcomes?

An NP who doesn't have all of the education and training needed for a position often can get it. It is important for NPs to document their continuing education and training, whether it is through a formal program or on-the-job training. If an NP's scope of practice is challenged, the NP will want to be able to get through the NCSBN's algorithm questions with "yes" answers.

It is imperative that employers credential and privilege NPs in a manner that assures patient safety, is defensible if challenged, meets payer requirements, and conforms with state law and accreditation requirements. Medicare and Joint Commission requirements indicate that it is best to aim for a process which parallels, as much as possible, the physician credentialing process.


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