Exploration of the Practices of Credentialing of Nurse Practitioners in Acute Care Hospital Settings

Abstract The nursing shortage, physician shortage, advancing age of the population, and concerns about equalizing access to health care have supported the movement of the Nurse Practitioner (NP) role into the acute care hospital setting (ACHS). Expansion of the role has resulted in efforts by regulatory and accreditation bodies to require standardized processes to ensure that credentialing and privileging supports the role of the NP in the acute care hospital setting. Historically credentialing processes have been developed with the physician role as the template. However, it is not clear that those processes support the role of the NP in the acute care setting. The purpose of the study is to understand and describe the processes by which Nurse Practitioners are credentialed and granted privileges to practice within the acute care hospital setting. A qualitative multi-sited case study approach was used to identify the rules and norms of the credentialing process of Nurse Practitioners. From three acute care hospitals, a purposeful sample of NPs (n=9) and other members of the credentialing bodies (n=3) were interviewed, a demographic survey completed, and documents defining structure collected. Analysis of the data included development of themes across the interviews and cross-case analysis for the three sites. Three major areas were identified that gave rise to specific themes: a) required activities that Nurse Practitioners must complete to receive organizational approval to practice in the advanced role; b) nurse practitioner perceptions of the credentialing process; and c) enhancement of the credentialing process for the Nurse Practitioner. Themes within the area of required activities that Nurse Practitioners must complete to receive organizational approval to practice in the advanced role are: a) required information for acute care credentialing; b) importance of timeliness of completing the process; c) steps for adding and maintaining competencies; d) people involved in the process; and e) common barriers to the credentialing process. Nurse practitioner perceptions of the credentialing process themes are: a) emotional responses of NPs to the credentialing process; b) fit of the credentialing process with the intended role of the NP; and c) involvement of the right people in the credentialing process. Themes within the area of enhancement of the credentialing process for the Nurse Practitioner are: a) reduction of barriers in the NP credentialing process; and b) external factors impacting the NP credentialing process. Cross-case analysis revealed these differences among the sites. Employed NPs and those not employed by the ACHS enter the credentialing process at the same point at two of the study sites. The human resources department is the entry point for employed NPs at the third site, while NPs not employed by the ACHS enter through the medical staff office. The same two sites have implemented a nurse credentialing committee as the first review of the completed application. The third site did not have a nurse credentialing committee at the time of the interviews. The governing body at Site One and Two is the final decision making body for credentialing. Site Three uses the governing body for NPs not employed by the ACHS and the human resources department for approval of employed NPs. The required documents for proof of education, licensure, and competency and other credentialing structures are similar across all three sites. Structure and content of the credentialing process for all three sites were similar. However, variation and barriers were identified by the participants. Findings from this study include opportunities to further standardize and enhance the credentialing process for NPs. Opportunities for standardization and enhancement include: a) communicate needed information about the credentialing process-during the NP educational experience; b) determine consistencies for core competencies and specialty competencies validation across disciplines; c) clearly define methods for obtaining and verifying new psychomotor competencies; d) advocate that the right people, not just functional groups, are involved in the credentialing process within the acute care setting; e) include a contact person for NP credentialing; f) automate and streamline required paperwork, remove confusing language, focus privileging forms on the specialty education of the NP; and g) promote the value of a central verification organization (CVO) to include NP credentialing to the national organizations that represent advance practice nurses. Continued refinement of the credentialing process as well as the implementation of strategies listed above that will enhance the process and may assist in reducing some of the barriers and frustrations identified in this study

Observation‐status patients in children's hospitals with and without dedicated observation units in 2011

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/111995/1/jhm2339.pd

Pediatric observation status: Are we overlooking a growing population in children's hospitals?

BACKGROUND: Inpatient administrative datasets often exclude observation stays, as observation is considered to be outpatient care. The extent to which this status is applied to pediatric hospitalizations is not known. OBJECTIVE: To characterize trends in observation status code utilization and 1‐day stays among children admitted from the emergency department (ED), and to compare patient characteristics and outcomes associated with observation versus inpatient stays. DESIGN: Retrospective longitudinal analysis of the 2004–2009 Pediatric Health Information System (PHIS). SETTING: Sixteen US freestanding children's hospitals contributing outpatient and inpatient data to PHIS. PATIENTS: Admissions to observation or inpatient status following ED care in study hospitals. MEASUREMENTS: Proportions of observation and 1‐day stays among all admissions from the ED were calculated each year. Top ranking discharge diagnoses and outcomes of observation were determined. Patient characteristics, discharge diagnoses, and return visits were compared for observation and 1‐day stays. RESULTS: The proportion of short‐stays (including both observation and 1‐day stays) increased from 37% to 41% between 2004 and 2009. Since 2007, observation stays have outnumbered 1‐day stays. In 2009, more than half of admissions from the ED for 6 of the top 10 ranking discharge diagnoses were short‐stays. Fewer than 25% of observation stays converted to inpatient status. Return visits and readmissions following observation were no more frequent than following 1‐day stays. CONCLUSIONS: Children admitted under observation status make up a substantial proportion of acute care hospitalizations. Analyses of inpatient administrative databases that exclude observation stays likely result in an underestimation of hospital resource utilization for children. Journal of Hospital Medicine 2012; © 2012 Society of Hospital MedicinePeer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/93720/1/1923_ftp.pd

Differences in designations of observation care in US freestanding children's hospitals: Are they virtual or real?

OBJECTIVE: To characterize practices related to observation care and to examine the current models of pediatric observation medicine in US children's hospitals. DESIGN: We utilized 2 web‐based surveys to examine observation care in the 42 hospitals participating in the Pediatric Health Information System database. We obtained information regarding the designation of observation status, including the criteria used to admit patients into observation. From hospitals reporting the use of observation status, we requested specific details relating to the structures of observation care and the processes of care for observation patients following emergency department treatment. RESULTS: A total of 37 hospitals responded to Survey 1, and 20 hospitals responded to Survey 2. Designated observation units were present in only 12 of 31 (39%) hospitals that report observation patient data to the Pediatric Health Information System. Observation status was variably defined in terms of duration of treatment and prespecified criteria. Observation periods were limited to <48 hours in 24 of 31 (77%) hospitals. Hospitals reported that various standards were used by different payers to determine observation status reimbursement. Observation care was delivered in a variety of settings. Most hospitals indicated that there were no differences in the clinical care delivered to virtual observation status patients when compared with other inpatients. CONCLUSIONS: Observation is a variably applied patient status, defined differently by individual hospitals. Consistency in the designation of patients under observation status among hospitals and payers may be necessary to compare quality outcomes and costs, as well as optimize models of pediatric observation care. Journal of Hospital Medicine 2012;. © 2011 Society of Hospital Medicine.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/91108/1/949_ftp.pd

Pediatric Gastrostomy Tube Placement: Lessons Learned from High-performing Institutions through Structured Interviews.

Introduction: Gastrostomy tube (GT) placement is one of the most common operations performed in children, and it is plagued by high complication rates. Previous studies have shown variation in readmission and emergency room visit rates across different children\u27s hospitals, with both low and high outliers. There is an opportunity to learn how to optimize outcomes by identifying practices at high-performing institutions. Methods: Surgeons and nurses routinely involved in GT care at 8 high-performing pediatric centers were identified. We conducted structured interviews focusing on the approach to GT education, technical aspects of GT placement, and postoperative management. Summary statistics were performed on quantitative data, and the open-ended responses were analyzed by 2 independent reviewers using content analysis. Results: Several common practices among high-performing centers were identified (standardized approach to education, availability by phone and in clinic to manage GT-related issues, and empowering families to feel confident with troubleshooting and dealing with GT problems). There was substantial variation in operative technique and postoperative care. The participants expressed that technical aspects of operative placement and postoperative management of feedings and common complications are not as important as education, availability, and empowerment in optimizing outcomes. Conclusions: We have identified common themes among pediatric centers with favorable outcomes after GT placement. Identifying which components of GT care are associated with optimal outcomes is critical to our understanding of current practice and may help identify opportunities to improve care quality

The DUNE Far Detector Vertical Drift Technology, Technical Design Report

International audienceDUNE is an international experiment dedicated to addressing some of the questions at the forefront of particle physics and astrophysics, including the mystifying preponderance of matter over antimatter in the early universe. The dual-site experiment will employ an intense neutrino beam focused on a near and a far detector as it aims to determine the neutrino mass hierarchy and to make high-precision measurements of the PMNS matrix parameters, including the CP-violating phase. It will also stand ready to observe supernova neutrino bursts, and seeks to observe nucleon decay as a signature of a grand unified theory underlying the standard model. The DUNE far detector implements liquid argon time-projection chamber (LArTPC) technology, and combines the many tens-of-kiloton fiducial mass necessary for rare event searches with the sub-centimeter spatial resolution required to image those events with high precision. The addition of a photon detection system enhances physics capabilities for all DUNE physics drivers and opens prospects for further physics explorations. Given its size, the far detector will be implemented as a set of modules, with LArTPC designs that differ from one another as newer technologies arise. In the vertical drift LArTPC design, a horizontal cathode bisects the detector, creating two stacked drift volumes in which ionization charges drift towards anodes at either the top or bottom. The anodes are composed of perforated PCB layers with conductive strips, enabling reconstruction in 3D. Light-trap-style photon detection modules are placed both on the cryostat's side walls and on the central cathode where they are optically powered. This Technical Design Report describes in detail the technical implementations of each subsystem of this LArTPC that, together with the other far detector modules and the near detector, will enable DUNE to achieve its physics goals

The DUNE Far Detector Vertical Drift Technology, Technical Design Report

DUNE is an international experiment dedicated to addressing some of the questions at the forefront of particle physics and astrophysics, including the mystifying preponderance of matter over antimatter in the early universe. The dual-site experiment will employ an intense neutrino beam focused on a near and a far detector as it aims to determine the neutrino mass hierarchy and to make high-precision measurements of the PMNS matrix parameters, including the CP-violating phase. It will also stand ready to observe supernova neutrino bursts, and seeks to observe nucleon decay as a signature of a grand unified theory underlying the standard model. The DUNE far detector implements liquid argon time-projection chamber (LArTPC) technology, and combines the many tens-of-kiloton fiducial mass necessary for rare event searches with the sub-centimeter spatial resolution required to image those events with high precision. The addition of a photon detection system enhances physics capabilities for all DUNE physics drivers and opens prospects for further physics explorations. Given its size, the far detector will be implemented as a set of modules, with LArTPC designs that differ from one another as newer technologies arise. In the vertical drift LArTPC design, a horizontal cathode bisects the detector, creating two stacked drift volumes in which ionization charges drift towards anodes at either the top or bottom. The anodes are composed of perforated PCB layers with conductive strips, enabling reconstruction in 3D. Light-trap-style photon detection modules are placed both on the cryostat's side walls and on the central cathode where they are optically powered. This Technical Design Report describes in detail the technical implementations of each subsystem of this LArTPC that, together with the other far detector modules and the near detector, will enable DUNE to achieve its physics goals

DUNE Offline Computing Conceptual Design Report

This document describes Offline Software and Computing for the Deep Underground Neutrino Experiment (DUNE) experiment, in particular, the conceptual design of the offline computing needed to accomplish its physics goals. Our emphasis in this document is the development of the computing infrastructure needed to acquire, catalog, reconstruct, simulate and analyze the data from the DUNE experiment and its prototypes. In this effort, we concentrate on developing the tools and systems thatfacilitate the development and deployment of advanced algorithms. Rather than prescribing particular algorithms, our goal is to provide resources that are flexible and accessible enough to support creative software solutions as HEP computing evolves and to provide computing that achieves the physics goals of the DUNE experiment