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Feb 05 2011

The Joint Commission: Nurse Practitioners and Physician Assistants Must Be Credentialied Through the Medical Staff Process

Does your hospital currently credential advance practice registered nurses (APN) and physician assistants (PA) through your human resources department?


New Joint Commission standards will change the credentialing and privileging process for certain advance practice registered nurses (APN) and physician assistants (PA).


Previous Joint Commission standards afforded APNs and PAs equivalent credentialing and privileging processing through the HR department.   However, The Centers for Medicare & Medicaid Services (CMS) does not recognize the equivalent process, and The Joint Commission must align its standards to be consistent with CMS.  Under the new clarification guidelines, certain APNs and PAs must now be processed through the medical staff office, not HR.


According to the new Joint Commission Standards BoosterPak™, released in January.The Joint Commission states the following:


Those who provide “medical level of care” must use the medical staff process for credentialing and privileging, making all [medical staff] standards applicable (including recommendation by the organized medical staff and approval by the governing body, OPPE, and FPPE).




  • APNs should request privileges only for those responsibilities involving medical level of care and not those responsibilities already allowed under the RN scope of practice.

  • APNs and PAs who provide “medical level of care” must be credentialed and privileged through the medical staff standards process

  • APNs and PAs who do not provide “medical level of care” utilize the human resources “equivalent” process detained in HR.01.02.05, EPs 10–15.


The Joint Commission has not yet provided an implementation date for these changes.



The BoosterPak is available to accredited organizations on the Joint Commission Connect extranet.