CREDENTIALING AND HOSPITAL PRIVILEGING

In 1981 the Joint Commission, formerly known as the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), recognized the training and subsequent competency of oral and maxillofacial surgeons (OMSs) to perform routine history and physical examinations (H & P). Before this change, the admission and presurgical H & Ps of an OMS necessitated a counter signature of a physician, usually the patient’s family physician, the emergency room physician, or the anesthesiologist performing the presurgical review. This change lifted a significant barrier for the oral surgeons within the hospital arena, and it was a significant step forward in gaining autonomy with our surgical colleagues.

A survey of the membership of the American Association of Oral and Maxillofacial Surgeons (AAOMS) in 1993 indicated that 18% of the respondents were denied H & P privileges at one or more hospitals. These denials were almost exclusively based on restrictions outlined in the bylaws of the medical institutions. Of those respondents who were granted H & P privileges, 56% said that a change in the bylaws of the institution was necessary before they could perform histories and physical examinations. According to the Committee on Hospital Affairs of AAOMS, until 1996 the most common request for assistance on medical issues and disputes was regarding credentialing to perform the H & P exam. Since that time, inquiries regarding the privileging of cosmetic surgery procedures have moved to the forefront. Of course, there will always be “territorial” struggles at many institutions between the facial trauma specialists, certain cosmetic and aesthetic surgery disciplines, and protective providers who feel threatened by competition.

An OMS cannot be denied privileges to practice the specialty as it is known and defined, as long as the surgeon can document certification of training from an accredited residency program, demonstrate competency in the requested privileges, and be an individual of sound character and high ethical standards. The depth of this credentialing and privileging process will now be explored and reviewed.

BACKGROUND

The majority of OMSs practice their specialty under the auspices of a state license in dentistry. There are also many “double-degree” individuals who are licensed to practice by both the dental and medical boards of their states. A few surgeons will choose to practice solely under medical licensure. The day-to-day office practice of oral and maxillofacial surgery in the private outpatient setting requires only a current state license to practice, a valid sedation certificate, and a state permit to operate a small business. When an individual applies for admitting and surgical privileges at hospitals and ancillary surgery centers, there will certainly be applications to process, increased levels of background review, and provider scrutiny by the hospital credentialing committee. This, in itself, can be an arduous and frustrating task.

Hospitals and medical centers vary in the structure of their medical staff membership. Some institutions will have a Department of Dentistry in addition to a Department of Surgery, and the question always exists as to which department the OMS really belongs. Teaching hospitals that have an active oral and maxillofacial surgery residency program usually position the OMS program as a division of the Department of Surgery. University medical centers that have associated schools of dentistry will often place the OMS training program under the guidance of the dental school’s graduate education programs. Nevertheless, the hospital side of the equation must have the members of the medical staff conform to the bylaws, rules, and regulations of the institution for credentialing and granting of hospital privileges.

The oral surgeons who practice under their dental license will be categorized in a group of nonphysician licensed independent practitioners (LIP). This group includes dentists, podiatrists, optometrists, and clinical psychologists. Another group, limited licensed practitioners (LLP), is made up of individuals who can only practice under the supervision of a physician or by proscription; this group includes physician assistants, nurse practitioners, nurse anesthetists, midwives, physical therapists, and others. The oral surgeons are usually listed in the LIP grouping and should not be included in the LLP. The Joint Commission defines a licensed independent practitioner as “any individual permitted by law and by the hospital to provide patient care services without direction or supervision, within the scope of the individual’s license and consistent with individually granted clinical privileges.”

The medical staff membership of surgery centers and hospitals may be organized into preferred provider organizations (PPO) or independent practitioner associations (IPA) that are organized as medical corporations. Often times these structured organizations may attempt to control staff membership and may attempt to control voting rights for certain nonphysician individuals. OMSs must always be aware of these situations and must always confront obstacles to equal staff membership, including equal access to providing appropriate patient care and receiving equal reimbursement for services rendered.

THE SPECIALTY

The scope of practice of the OMS is certainly broad, and there is a wide range of procedures, many of which overlap with other dental and medical specialties. OMSs, however, are the only LIPs with verified competency in physical diagnosis, as recognized by the Joint Commission in its 1997 medical staff standard MS.6.2.1. It states that “qualified oral and maxillofacial surgeons may perform the medical history and physical examination, if they have such privileges, in order to assess the medical, surgical, and anesthetic risks of the proposed operative and other procedures.” In addition, the Joint Commission continues and defines a qualified OMS as “an individual who has successfully completed a postgraduate program in oral and maxillofacial surgery accredited by a nationally recognized accrediting body approved by the United States Department of Education. As determined by the medical staff, the individual is also currently competent to perform a complete history and physical examination in order to assess the medical, surgical, and anesthetic risks of the proposed operative and other procedures.”

In January of 2005, the Centers for Medicare and Medicaid Services (CMS) proposed rule changes that affected the list of practitioners eligible to perform the history and physical examination, authenticate verbal orders, secure medications, and complete postanesthesia evaluations. The wording of the existing list of practitioners with these privileges had been replaced with the term “physician” as defined by the Social Security Act. At the time of this proposed change, an alert was issued to the AAOMS membership, which elicited more than 175 comments to the H & P changes. In response to these comments, the CMS issued a statement saying “it was not our intent for this revised language to lead to a reduction in the pool of professionals who are qualified to perform the H & P. For clarification in this final rule, the specific reference to oromaxillofacial surgeons has been retained. However, based on hospital policy and State law, the pool of other qualified individuals can be restricted.” The AAOMS issued a second member alert message in December 2006, notifying the membership that the final revision of the CMS retains the reference to OMSs as being eligible to perform the complete H & P. This was another significant victory for the specialty of OMS and a credit to AAOMS working for its membership.

The specialty of oral and maxillofacial surgery is recognized by the American Dental Association (ADA). Oral and maxillofacial surgery advanced training programs are accredited by the Commission on Dental Accreditation (CODA), which is a funded, albeit independent, organization of the ADA. CODA is recognized and accredited by the U.S. Department of Education and the Commission on Postsecondary Education. Similarly the other surgical specialties are organized under the umbrella of the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA). These surgical specialties are accredited by the Accreditation Committee for Graduate Medical Education and similar accrediting bodies for osteopathy and podiatry.

The reliability and respectability of the specialty dental boards are embraced by the existence and validity of CODA. Although voluntary, CODA is accredited by the Department of Education and the Council on Postsecondary Education. The process involved in receiving these accreditations ensures that the oversight of advanced training is valid and valuable. Of the 29 members of CODA, four are appointed by the ADA, four are appointed by the American Association of Dental Schools, and four are appointed by the American Association of Dental Examiners. There are four public members, one dental student, one dental hygienist, one dental laboratory technician, and one member appointed by each of the eight recognized dental specialties. This structure of checks and balances ensures impartial oversight and excellent quality in the specialty education programs. Contrary to this structured process of specialty oversight, there are also unrecognized boards in medicine and dentistry, such as the American Board of Cosmetic Surgery and the American Board of Implant Dentistry.

The Joint Commission recognizes that specialty “board certification is an excellent benchmark and is considered when delineating clinical privileges” (1997 MS.5.15.2). The American Board of Oral and Maxillofacial Surgery (ABOMS) is the equivalent specialty board for oral surgeons as the member boards of the American Board of Medical Specialties are to their respective specialties. The ADA is to the ABOMS as the ABMS is to the medical specialty boards. There should not be any justification for denial of hospital privileges, credentials, or staff membership based on the uniqueness of the fact that ABOMS does not belong to the ABMS organization. The ABOMS examination process is a very intense, thorough, and all-encompassing evaluation of the knowledge base of its applicants, and recognition of board certification is indeed an accomplishment. The ABOMS examination process can definitely stand shoulder to shoulder with any surgical specialty examination process. Several years ago the ABOMS board of directors voted to offer and require a recertification examination every 10 years for those members attaining board certification after the year 1990. This change was made to ensure that the ABOMS membership continues to stay abreast of the current knowledge base and scope of practice of the specialty of oral and maxillofacial surgery.

THE SPECIALTY

The scope of practice of the OMS is certainly broad, and there is a wide range of procedures, many of which overlap with other dental and medical specialties. OMSs, however, are the only LIPs with verified competency in physical diagnosis, as recognized by the Joint Commission in its 1997 medical staff standard MS.6.2.1. It states that “qualified oral and maxillofacial surgeons may perform the medical history and physical examination, if they have such privileges, in order to assess the medical, surgical, and anesthetic risks of the proposed operative and other procedures.” In addition, the Joint Commission continues and defines a qualified OMS as “an individual who has successfully completed a postgraduate program in oral and maxillofacial surgery accredited by a nationally recognized accrediting body approved by the United States Department of Education. As determined by the medical staff, the individual is also currently competent to perform a complete history and physical examination in order to assess the medical, surgical, and anesthetic risks of the proposed operative and other procedures.”

In January of 2005, the Centers for Medicare and Medicaid Services (CMS) proposed rule changes that affected the list of practitioners eligible to perform the history and physical examination, authenticate verbal orders, secure medications, and complete postanesthesia evaluations. The wording of the existing list of practitioners with these privileges had been replaced with the term “physician” as defined by the Social Security Act. At the time of this proposed change, an alert was issued to the AAOMS membership, which elicited more than 175 comments to the H & P changes. In response to these comments, the CMS issued a statement saying “it was not our intent for this revised language to lead to a reduction in the pool of professionals who are qualified to perform the H & P. For clarification in this final rule, the specific reference to oromaxillofacial surgeons has been retained. However, based on hospital policy and State law, the pool of other qualified individuals can be restricted.” The AAOMS issued a second member alert message in December 2006, notifying the membership that the final revision of the CMS retains the reference to OMSs as being eligible to perform the complete H & P. This was another significant victory for the specialty of OMS and a credit to AAOMS working for its membership.

The specialty of oral and maxillofacial surgery is recognized by the American Dental Association (ADA). Oral and maxillofacial surgery advanced training programs are accredited by the Commission on Dental Accreditation (CODA), which is a funded, albeit independent, organization of the ADA. CODA is recognized and accredited by the U.S. Department of Education and the Commission on Postsecondary Education. Similarly the other surgical specialties are organized under the umbrella of the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA). These surgical specialties are accredited by the Accreditation Committee for Graduate Medical Education and similar accrediting bodies for osteopathy and podiatry.

The reliability and respectability of the specialty dental boards are embraced by the existence and validity of CODA. Although voluntary, CODA is accredited by the Department of Education and the Council on Postsecondary Education. The process involved in receiving these accreditations ensures that the oversight of advanced training is valid and valuable. Of the 29 members of CODA, four are appointed by the ADA, four are appointed by the American Association of Dental Schools, and four are appointed by the American Association of Dental Examiners. There are four public members, one dental student, one dental hygienist, one dental laboratory technician, and one member appointed by each of the eight recognized dental specialties. This structure of checks and balances ensures impartial oversight and excellent quality in the specialty education programs. Contrary to this structured process of specialty oversight, there are also unrecognized boards in medicine and dentistry, such as the American Board of Cosmetic Surgery and the American Board of Implant Dentistry.

The Joint Commission recognizes that specialty “board certification is an excellent benchmark and is considered when delineating clinical privileges” (1997 MS.5.15.2). The American Board of Oral and Maxillofacial Surgery (ABOMS) is the equivalent specialty board for oral surgeons as the member boards of the American Board of Medical Specialties are to their respective specialties. The ADA is to the ABOMS as the ABMS is to the medical specialty boards. There should not be any justification for denial of hospital privileges, credentials, or staff membership based on the uniqueness of the fact that ABOMS does not belong to the ABMS organization. The ABOMS examination process is a very intense, thorough, and all-encompassing evaluation of the knowledge base of its applicants, and recognition of board certification is indeed an accomplishment. The ABOMS examination process can definitely stand shoulder to shoulder with any surgical specialty examination process. Several years ago the ABOMS board of directors voted to offer and require a recertification examination every 10 years for those members attaining board certification after the year 1990. This change was made to ensure that the ABOMS membership continues to stay abreast of the current knowledge base and scope of practice of the specialty of oral and maxillofacial surgery.

ACCREDITATION AND CERTIFICATION

The majority of OMSs perform their routine daily procedures in an office clinic environment or other similar outpatient ambulatory setting. Many practitioners have even incorporated outpatient operating rooms, capable of supporting general anesthesia surgical cases, within the walls of their clinical structure. In 1997 Medicare granted approval status to several accrediting agencies for ambulatory surgical centers. Therefore, the ambulatory care manuals published by agencies, such as the Joint Commission and the American Association for Ambulatory Health Care, may prove helpful to OMSs operating in their offices or similar outpatient facilities. The offices of OMSs and other surgical specialists can be accredited by either of these organizations as single practices, group practices, or outpatient surgery centers. Providers, at their own initiative, can request a survey and apply for facility accreditation.

An OMS who possesses a medical degree is eligible for fellowship status in the American College of Surgeons (ACS); however, there is no specialty section within ACS for those who do qualify. Even though most OMSs perform facial plastic surgery, they likewise are not eligible for membership in the American Academy of Facial Plastic and Reconstructive Surgery, unless they hold a medical degree. The same restriction is true for the two societies representing head and neck surgeons. There is an American Board of Facial Plastic and Reconstructive Surgery that is not recognized by ABMS, but is usually given equivalent status to ABMS member boards. Again, certification is only available to the medical-degreed oral surgeon. There is one cosmetic surgery organization that has welcomed membership from surgical specialists of diverse backgrounds, and that is the American Academy of Cosmetic Surgery. This group does not make any distinction between the “single-degree” and the “double-degree” OMS and will invite all who meet the qualifications for membership and fellowship status.

The Joint Commission recognizes that there are many paths for obtaining and maintaining “training, competency, and ability.” The Joint Commission, the American Medical Association (AMA), the ACS, and the American College of Physicians all recognize the overlap among specialties as acceptable and even advantageous. The American Society of Cosmetic Surgeons has embraced the policies of these professional organizations and concurs that overlap of specialties performing cosmetic surgical procedures is in the best interest of the patients.

California enacted legislation in 1997 to require accreditation of all facilities where any form of parenteral sedation or anesthesia is administered that has the probability of inducing a loss of the patient’s protective reflexes. If a provider has a current permit to administer general anesthesia or conscious sedation from the state board of dental examiners, the dental office is exempt from this requirement. The majority of states now require a valid sedation permit for dentists and OMSs who perform light sedation, deep sedation, and/or general anesthesia in an office or hospital setting. There are several requirements to fulfill when applying for a sedation permit: show documentation of appropriate anesthesia education and training; hold a current basic life support certification and, in most instances, proof of advanced cardiac life support training; and pass an inspection of the facility, including the use of available emergency equipment. In many states, part of the office inspection process will include a practical application of an anesthesia technique on a routine dental and/or surgical procedure in the presence of the evaluator. These anesthesia permits are usually renewable on a 1- to 3-year basis, with the office reinspection varying between 5 to 10 years.

As of this writing, the ADA’s Council on Dental Education and Licensure (CDEL) and the Committee on Anesthesia have proposed changes to the published anesthesia guidelines and policy statement. The emphasis is, as always, on patient safety, and the proposed changes refocus the guidelines based on the anesthetic’s effects on the central nervous system and not on the route of administration. In addition, an important change is the ability to rescue a patient from an unintended deeper level of sedation. Such training is not included in the standard dental school curriculum and cannot adequately be taught in a continuing education program. Furthermore, AAOMS issued a letter of support stating that such knowledge and skill can only be acquired in a postdoctoral training program that requires competency in the administration of anesthesia as part of the residency training curriculum. OMS graduates of accredited residency training programs definitely fulfill the above requirements. However, providers always need to be cognizant of state policies and the guidelines of accrediting agencies when pursuing credentials and privileges in anesthetic techniques.

DEFINITIONS AND RESOURCES

OMSs should familiarize themselves with the definitions of both dentistry and the specialty of oral and maxillofacial surgery. In 1997, the House of Delegates of the ADA recognized the need for a national standard and, for the first time, defined the practice of dentistry. Resolution 33H establishes the definition of dentistry as “the evaluation, diagnosis, prevention and/or treatment (non-surgical, surgical or related procedures) of diseases, disorders and/or conditions of the oral cavity, maxillofacial area and/or the adjacent and associated structures and their impact on the human body; provided by a dentist, within the scope of his/her education, training and experience, in accordance with the ethics of the profession and applicable law.” Each individual state has a Dental Practice Act (DPA), and the definition of dentistry does vary from state to state. The most favorable language for a DPA definition is similar to the state of Maryland, which includes any procedures “in the curricula of an accredited dental school or in an approved dental residency program of an accredited hospital or teaching institution.” Table 18-1 provides the language of the states and their respective definitions of dentistry and/or activities of the dentist.

TABLE 18-1
Dental Practice Act Definitions of a Dentist or Dentistry
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State Relevant Language
Alabama To diagnose, treat, prescribe, or operate for any disease, pain, deformity, deficiency, injury, or physical condition of the teeth or jaws or adjacent structures
Alaska Diagnoses, treats, operates on, corrects, attempts to correct, or prescribes for a disease, lesion, pain, injury, deficiency, deformity, or physical condition, malocclusion or malposition of the human teeth, alveolar process, gingiva, maxilla, mandible, or associated tissues
Arizona With specific reference and application to the teeth, gums, jaws, oral cavity, or tissue adjacent thereto in living persons
Arkansas Examination, diagnosis, treatment, repair, prescription and/or surgery of or for any disease, disorder, deficiency, deformity, condition, lesion, injury, or pain of the human oral cavity, teeth, gingiva, and soft tissues and the diagnosis, the surgical adjunctive treatment of the diseases, injuries, and defects of the human jaws and associated structures
California Diagnosis and treatment, by surgery or other method, of diseases and lesions and the correction of malpositions of the human teeth alveolar process, gums, jaws, or associated structures; such diagnosis or treatment may include all necessary related procedures and the use of drugs, anesthetic agents, and physical evaluation
Colorado Performs or attempts or professes to perform any dental operation or oral surgery… diagnoses or professes to diagnose, prescribes for or professes to prescribe for, treats or professes to treat disease, pain, deformity, deficiency, injury, or physical condition of the human teeth or jaws or adjacent structures
Connecticut Performs any operation in or makes examination of, with intent of performing or causing to be performed any operation in the mouth and surrounding and associated structures… who diagnoses and treats diseases or lesions of the mouth and surrounding and associated structures
Delaware Diagnoses or treats diseases or lesions of human teeth, jaws, or oral tissues mechanically, medicinally, or surgically or by the use of radiograms, x-rays, or fluoroscopic methods, or attempts to correct malposition thereof
District of Columbia Diagnosis, treatment, operation, or prescription for any disease, disorder, pain, deformity, injury, deficiency, defect, or other physical condition of the human teeth, gums, alveolar process, jaws, maxilla, mandible, or adjacent tissues or structures
Florida Examination, diagnosis, treatment planning, and care of conditions within the human oral cavity and its adjacent tissues and structures. It includes the performance or attempted performance of any dental operation or oral or oral maxillofacial surgery and any procedure adjunct thereto
Georgia
Jun 3, 2016 | Posted by in Oral and Maxillofacial Surgery | Comments Off on CREDENTIALING AND HOSPITAL PRIVILEGING
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