Monday, May 11, 2015

Special Topic. Support Personnel for Acupuncture Providers

key words:  support personnel, special topic, hospital practice

Subject:  How to use Support Personnel for Acupuncture Providers

If you could have support personnel assist you in your clinic (you are an L.Ac.), what would you have them do?  What kind of support would be best for you?  What does that look like (think ideal setting)?

Setting:  Hospital clinic, outpatient.  Imagine you and your clinic are preparing for a Joint Commission visit.  

Since the overall scenario is preparation for a Joint Commission visit, we will first include quality assurance factors and industry standards.
Second, (and mostly what I want to hear) is what your opinion and ideas or examples are of this.  The industry standards (or as much as I have been able to find so far--see below) are minimal.

For purposes of this discussion “Acupuncture Providers” are defined as:

1.        Are the only personnel who use acupuncture needles or perform acupuncture procedures in the clinic

2.       Have the following industry standards in training:

a.       Licensed Acupuncturist.  Graduated from an ACAOM-accredited master’s or doctorate degree program.  NCCAOM board certified.

 Questions to contemplate and RESPOND to:

1.  What would an Acupuncturist’s support personnel be like?  What would be their minimum training?
What rules and standards currently govern this?  What are some useful examples?


I.  Medical assistant or nurse (RN, nursing assistant, Medic, Corpsman)

Acupuncture specific training needed?

No.  not trained in an ACAOM-accredited program (ie, not an Acupuncturist).  Staff is simply training in the usual medical assistant or related nursing program training in their field, standard.

Duties and/or tasks for being support personnel include:
(medics, corpsmen, nurses, nursing assistants, or medical assistant staff who help)

                                                               i.      Bring patient to treatment room

                                                             ii.      Take vitals

                                                            iii.      Record vitals in electronic health record (EHR)

                                                           iv.      Set up acupuncture tx room 

1.       This may include but is not limited to:  set up clean field, clean cupping supplies, set out and put away other equipment such as e-stim machines and heat lamps

                                                             v.      Stand in/chaperone for provider as needed

                                                           vi.      One-on-one care as needed (ex:  in high anxiety patients or some patients with post-traumatic stress symptoms often request to not be left alone in a room.   Other kinds of special cases.  Support personnel may stay/sit in room with patient while needles are retained during treatment.)

                                                          vii.      Clean up tx room post-procedure

As “support personnel”, these personnel would be subject to the following trainings that may be tied into competencies or SOPs, if your clinic feels it is necessary:

                                                        viii.      Standard precautions

                                                           ix.      Biohazard training

                                                             x.      Sharps training

                                                           xi.      How to set up a clean field (see CNT manual reference)

                                                          xii.      How to store acupuncture needles

II.  Acupuncture student (someone currently enrolled in an ACAOM-accredited program)

                Must have business associate agreement, etc, paperwork on file with appropriate hospital office for internship, externship, etc, with related school training program.

                Other rules or regulations that may apply?

What does your support personnel document in the electronic health record (EHR)? 

1.What should the support personnel document in the EHR before Acupuncturist arrives?  Talk with your Acupuncture providers about what they want.  Recommend a minimum of appropriate vitals such as:   height, weight, blood pressure, pain level, chief complaint

b.      Anything after visit?

Check with your Acupuncture provider.  He or she may want to check in on symptom progress, homework, etc.

2.  Should support personnel have competencies to assist in acupuncture?

No.  Support personnel should not be assisting with actual needling.  There currently is no standard that supports this.  Use of acupuncture needles must be by trained personnel.  Currently the industry standard for trained personnel is:  licensed acupuncturist or physician who has completed a medical acupuncture program

3.       What would be in a pre-procedure checklist?

I recommend the following resources to help you write this:  
latest version of the Clean Needle Technique Manual
local hospital policies on handwashing 

What other resources would you add?
4.       What would be in a post-procedure checklist?

I recommend the same resources as in #3.  
Please write in the comments section other resources you would recommend.

Applying Clean Needle Technique (CNT) in an Acupuncture Treatment*
CleanNeedle Technique Manual for Acupuncturists: Guidelines and Standards for theClean and Safe Clinical Practice of Acupuncture. 7th edition.  

Semantics. Explaining the Credentialing, Privileging process for L.Ac.s as Licensed Independent Providers (LIPs)

Explaining Credentialing, Privileging, and Independently Practicing Provider
by Megan Kingsley Gale, EAMP, Dipl. O.M. (NCCAOM®)
Thank you to contributing subject matter advice by colleague Fuji McPherson, ARNP, DOM, Dipl. O.M. (NCCAOM®)
updated BLS code reference 2016.08.29

Explaining lingo and the hospital process.  This paper is to help inform a process that is new to our AOM community in general.  We hope this helps others learn the lingo and technicalities.

These are terms not commonly used in private practice.  They are, however, terms used in hospital and medical center practice settings that make the difference between practicing as an independent provider (no direct medical supervision) and practicing as a technician.

What is a privileged health care practitioner?
The following is a general checklist for qualifications of a licensed medical provider who is being considered as a hospital hire and going through the process of credentialing and being granted a delineation of clinical privileges:

  • Licensed health care practitioner
  • State scope of practice allows for independent practice (e.g. acupuncturist, physical therapist, chiropractor, licensed clinical social worker)
  • Performs specific therapy regulated by medical board or health professions board
  • Holds a current, unrestricted license to practice in his/her field
  • Has a degree from an accredited education institution, recognized by the U.S. Department of Education
  • Successfully passed national board certification in the field of study
  • Participates in continuing education and peer record review processes
  • Consults with other licensed medical professionals

Supervised Health Care Provider

Same criteria as above with exception that privileges are under supervision and require co-signature by a privileged providers (includes physician assistants, students, health care providers under probation or in training).  This is different than a technician. 

What is a technician?

Non-privileged health care practitioners who are specifically trained to perform a specific procedure or task under supervision by a licensed and privileged practitioner.

Examples:  nursing assistants, medical technicians, physical therapy assistants, occupational therapy assistants

What is credentialing?

All health care providers who provide care at hospitals and medical centers must be credentialed. Credentialing is conducted by the hospital credentialing services/department which verifies the employee’s references, employment history and educational requirements have been satisfactorily met and that the provider is properly trained for clinical privileges. Once the practitioner has cleared the credentialing committee’s review process he or she is then granted clinical privileges to perform their requested skill set. Not all credentialed providers are given clinical privileges [e.g. students and residents in training, or health care practitioners specifically trained to perform a specific procedure (e.g. technicians) and supervised health care practitioners].

What is “privileged provider”?

Once you are granted clinical privileges, you are a privileged provider.  Or, you could say, your hospital has “credentialed you as a privileged provider”.

Clinical privileges are spelled out on the form/paperwork you are given as part of your entry into hospital service.  This is often called a “delineation of clinical privileges”.  Generally privileges are granted “on trial” for the first year.  If no grievous offenses or medical mismanagement occur, the privileges are renewed for 2 years.  Then, the provider fills out paperwork to renew every 2 years while a hospital employee.  These renewals are when you provide your credentialing department what they require (may vary by job and hospital a bit), but are generally:  continuing education verification, certification renewals, CPR and related mandatory certifications renewals, state license renewals.  These processes are referred to by The Joint Commission as focused professional practice evaluation (FPPE) and ongoing professional practice evaluation (OPPE).

Process of Becoming Credentialed and Granted Clinical Privileges
When an employee is hired and eligible for clinical privileges, the employee’s paperwork goes before the hospital’s “credentialing committee”.  This committee is often made of the medical center’s department heads and the hospital’s subject matter experts in the fields related to the new employee’s field of work.  This committee meets on a regular basis.  Every hospital varies on this.  The committee may meet weekly or monthly.  When the committee meets they review or (if a modality or field entirely new to the hospital) create, based on the new employee’s position description.  During this review a “delineation of clinical privileges” is created.  It is then approved by the local subject matter expert (SME) in the field and handed to the new employee’s supervisor.  This supervisor then reviews the “delineation of clinical privileges” with the new employee, they both sign the form.  This form goes in the employee’s file at the credentialing office.

Adding to your granted privileges at a facility

This is an old tradition for physicians.  For example, a physician, Jane, takes a continuing education course on a new procedure.  Jane wants to practice the new procedure at the hospital.  So Jane follows her hospital’s process for “adding clinical privileges”.  This usually involves paperwork about her class she fills out, she may need to pass some hands-on competency training to prove she is qualified in the new procedure, and her request for this additional clinical privilege is passed on the credentialing committee.  The committee reviews her request and paperwork.  The committee determines whether or not to grant her the new privileges.  If they do, a new “delineation of clinical privileges” or “addendum” is added to her “delineation of clinical privileges” paperwork at the credentialing office/department.

In the modern hospital, this is a process that any privileged provider can follow to add to his or her scope/work in their facility.

Keep in mind the credentialing department is governed locally by hospital policy and state law.  It is also governed by federal regulations which include, when applicable, HIPAA, privacy laws, and The Joint Commission.  When it comes down to nuts and bolts, credentialing prefers two main aspects:

1.        The path of least resistance

2.       The path toward greatest Quality Assurance objectives (the more measures of quality assurance, the less the liability the facility takes on).

To Review

1.        All privileged providers are able to work independently (without direct or indirect practice supervision) to diagnose, treat, and manage a health condition.

2.       All health care practitioners who work in a hospital setting go through their hospital’s credentialing process as part of the hospital employee hiring process.  Not all are granted clinical privileges (“privileged provider” status).

Fictional Example of Credentialing Process:

Anna applies to a job posting for an Acupuncturist at Helping Hospital.  Anna is the first Licensed Acupuncturist at Helping Hospital.  Anna is hired.  Since she is a “clinician”, her hiring packet is turned over from Human Resources to the credentialing department.  The credentialing department does not have a process in place for an “Acupuncturist clinician”, so the credentialer takes the employee packet to his department head.  The department head, Mr. John, is thorough and interested in a challenge.  He decides, with enthusiasm, to create a path for this Acupuncturist to work, per her job posting description, as a “practitioner of Traditional Chinese Medicine, evaluating patients, making appropriate referrals, recognizing red flags, developing treatment plans”.

Mr. John’s thought process:

1.        This language categories the position as an “independent practicing provider” and "licensed independent practitioner (LIP)".

a.       Joint Commission standards on independent providers, credentialing, and privileging:

                                                               i. "An 'LIP' is a licensed independent practitioner, defined as an individual, as permitted by law and regulation, and also by the organization, to provide care and services without direction or supervision within the scope of the individual's license and consistent with the privileges granted by the organization."[TJC's WhoWhat . . . of Credentialing" related LIP blogpost]      

b.       Generally, health care providers qualify as independent providers and are eligible for granting of privileging with the following general guidelines: 

2.       Is there an occupational code for Acupuncturists?  If there is, it would greatly simplify my work of creating a credentialing packet for this employee.

a.       What he found:  Yes, there is.

b.      Occupational Code.  U.S. Department of Labor, Bureau of Labor and Statistics

                                                               i.      29-1291—Acupuncturists.  [more on our BLS code process history] 

                                                             ii.      Group 29-0000 is the major group, “Healthcare practitioners”

                                                            iii.      Group 29-1000 is the minor group, “Health diagnosing and treating practitioners” [This is another check in the box for eligibility for granting of clinical privileges.]

                                                           iv.      Also, Mr. John notes, BLS O*Net lists the occupation as “Job Zone Five:  extensive preparation needed”.  This again verifies his path of “independent practitioner” and “eligible for clinical privileges”.

3.       What certifications does this Acupuncturist have?  What are the standards in this field?  Are there national standards?  What is the state law scope of practice?  Does she have a state license in her field?  What is it?

a.       Mr. John looks over Anna’s resume.  On her resume she notes she has NCCAOM® board certification, a “Diplomate in Oriental Medicine”. 

b.      This is a certification, Mr. John notes.  He does an internet search for “NCCAOM” and finds

                                                               i.      National Certification Commission Acupuncture and Oriental Medicine (NCCAOM®).

1.        Mr. John notes—a national certification standard.  Quality assurance points here!

                                                             ii.       Then he finds the link to “Fact Sheets” and looks up “Diplomate in Oriental Medicine

                                                            iii.      He finds a link to Frequently Asked Questions page, and finds the first 2 FAQs helpful:

1.       Why NCCAOM® certification?  And “what is the difference between state licensure and NCCAOM® certification?”  

                                                           iv.      On another link he finds a page that describes “what are the national standards in Acupuncture and Oriental Medicine”.  Jackpot!  Thinks Mr. John.

“Okay,” thinks Mr. John.  “Well, the most useful pieces I have found and learned from so far for what I need to do in creating this credentialing packet and creating a path to credentialing and privileging for this independent practicing health care provider have been the (1) occupational code and (2) the NCCAOM® website’s national standards.

4.       “Now I need to check in on state scope of practice and license”, Mr. John thinks. “Does she list her license on her resume?”  He goes back to her resume and notes her license.  She lists it as “Licensed Acupuncturist/East Asian Medicine Practitioner xxxx, Washington state, expires  xx/xx/year”.  The facility, Helping Hospital, is located in Washington State.  So, Anna already has a local license.  Since Mr. John is familiar with looking up licenses on the state site, he enters her license and follows the links.  One of the links takes him to the state scope of practice law (revised code of Washington or RCW) for her field, Acupuncturist.  He reads it and notes how it compares to her hospital job position description, the federal occupational code, and the national standard.

5.       What other quality assurance standards can apply to this job position and thereby the credentialing packet? 

a.       General:  CPR, bloodborne pathogen training, state license

                                                               i.      He notes in her resume her CPR certificate is current.

                                                             ii.      Mr. John notes her NCCAOM® certification includes a specialized Quality Assurance training and certificate in needle safety and bloodborne pathogen safety, called Clean Needle Technique.  He adds this information to his paperwork.

6.        "Aha!  I have the information I need!", says Mr. John.  He sits down with the following information to create her credentialing packet and from there a draft of recommended clinical privileges list (to be brought before the credentialing committee for revisions and approval):

a.       Federal occupational code

b.      State scope of practice

c.       National Board certification (NCCAOM®)

                                                               i.      Includes the quality assurance standard of Clean Needle Technique and blood borne pathogen training

Joint Commission fact sheet 

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