Certification and Credentialing — What Does it Mean to the Patient?

Certification and Credentialing — What Does it Mean to the Patient?

Jean M. Nardini

Certification and credentialing are designed to ensure that health professionals in all roles are qualified, capable, and prepared to perform the services for which they are employed or given permission to provide. Credentialing is a process by which professionals provide evidence that they are qualified to perform designated clinical activities. Nursing is bound by both internal mechanisms (e.g., mission, values, position description, and practice standards) and external mechanisms (e.g., Code of Ethics, Practice Act, Board of Registration Rules and Regulations, and Standards of Practice) that define competent practice. Establishing systems for assessing and affirming the competency of all providers is required of organizations accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) by the Conditions of Participation for hospitals and facilities that receive Medicare reimbursement and increasingly by other third-party payers.

Although nurses know the full benefits of certification and credentialing, what does it really mean to patients? In a nutshell, it should be obvious that a high level of patient care is provided by a qualified provider who is knowledgeable about the patient’s needs. But before patients are convinced that this is the case, nurses and health care providers must address a number of socioeconomic, environment, and political issues that have kept us from developing effective systems to assess competency. We must also unite to promote the benefits of certification and credentialing to patients, government organizations, insurers, and even within our own health care system.

Credentialing

As nurses, we are familiar with position descriptions and performance appraisals. Credentialing refers to the process by which individuals or institutions or one or more of their programs are designated by a qualified agent as having met minimum standards at a specified time (American Nurses Association [ANA], 1979). Credentialing is an administrative procedure to examine information about a practitioner’s education, certification, training, continuing education, and experience or actions by the Board of Registration. Credentials relate to the qualification of an individual to practice in their state within the scope of practice for that individual’s profession. Credentials are marks or “stamps” of quality and achievement communicating to employers, payers, and consumers what to expect from a “credentialed” nurse; specialist; course or program of study; hospital or health service; or health care product, technology or device. Unlike other professionals, nursing has three entry levels.

There are a number of factors in the political and socioeconomic environments that are stimulating the growth and direction of credentialing in the late 20th century. Principals among these factors are globalization, competition, consumerism, and telecommunication. Globalization, the mobile society, the deemphasis of national boundaries, and free trade among nations, are major forces of the 1990s (Ascher, 1997; Canadian Council of Technicians and Technologists [CCTT], 1997). Telecommunications have advanced at record breaking speed to provide avenues for the movement of personnel and services. Professionals practice “virtually” in multiple jurisdictions.

Certification

It is equally important for employers of nurses and technicians — be they managed care organization, hospitals, dialysis chains or independent facilities — to know what nurse and patient care technician credentials mean and to make them a condition of employment. Employers will be marketing the number of certified nurses they have in their facilities. The marketing of certified technicians is just around the corner. Certifications will become a must if employers want to market themselves as a providing the highest quality of health care services. Competent practitioners perform work at an acceptable level of knowledge and skill in the best interest of patients (consumers). They make correct judgements and interact with other professionals.

The JCAHO standards can serve as a framework for human resource management. A concern for patients’ rights is central to improving patient outcomes. HR.2 mandates that the hospital (facility) provides an adequate number of staff members whose qualifications are consistent with job responsibilities. The intents are that: (a) education and training are consistent with applicable legal and regulatory requirements and hospital (facility) policy; (b) individuals are licensed, certified or registered; and (c) individuals’ knowledge and experience are appropriate for their assigned responsibilities. Evidence of these elements must be present for each employee.

Efforts to Promote Certification

Increased efforts should be pursued by certification organizations such as the Nephrology Nursing Certification Commission (NNCC, formerly NNCB) to inform consumers, government and insurers of the importance of nursing and technician certification. The relationship between certification and patient outcomes is the singular most important issue in the future of nursing and technician certification. ANNA and NANT (National Association of Nephrology Technicians) drafted a position paper in 1996 stating “certification should be reserved for voluntary private sector programs that attest to the competency of individual health professions. Both associations strongly urge patient care technicians, dialysis technologists, and registered nurses to pursue certification by a nationally recognized organization as soon as eligible by certification body rules.”

In the last 2 years, ANNA and NANT formed a collaborative task force to promote standardized education, training, and competency assessment for nephrology technicians. ANNA supported the development of the ANNA/NANT Standardized Training Program Instructor’s Guide, the Standardized Training Program Promotional Video, and the Learner’s Guide. The Competency Assessment Exam is now in development by the Center for Nursing Education and Testing (C-NET) and NNCC. NANT has agreed to endorse this exam for a period of 3 years. This type of collaborative effort should result in protecting patients as we now have certified, responsible personnel delivering safe and quality care.

In a 1998 editorial in Nurseweek, Editor in Chief Barbara Bronson Gray also promoted the importance of developing ongoing and effective systems to assess competency. She stated: “There’s a sea of change happening in the attitude Americans have about trusting a care provider. The more we’ve all been talking about quality health care, the more the public has been listening. And now consumers — who are increasingly savvy about the complexity of the term quality — are asking how they should learn if their nurse, physician, or provider is indeed competent … Should passing one initial licensing exam give any healthcare professional a lifelong ticket to practice?” (p. 8).

ANNA Testimony

At a recent special U.S. Senate Committee on Aging hearing on June 26, 2000, the Senate heard testimony from patients on the quality of care in dialysis. Patients questioned the competency of staff as well as the ratio of technicians to patients.

ANNA’s response to the Senate Committee on Aging included our concern with:

* maintaining quality care;

* who is providing the care and education that ESRD patients receive;

* ESRD patients access to care in rural areas;

* the scope and timeliness of data collected by the ESRD networks; and

* the provision of quality care in dialysis facilities.

ANNA believes every patient has the right to professional nursing care that encompasses all aspects of the nursing process. ANNA also believes that RNs must be the health care professional directing the education process for ESRD patients regarding dialysis (hemo and peritoneal), and the education of technicians. RNs provide essential education to ESRD patients regarding their diagnosis, dialysis, prevention of complications, treatments medications, and care of access devices. Because RN staffing rations are stretched to the limit in most facilities and hospitals (nursing shortage and/or economics), it is becoming increasingly difficult to provide all the education that patients need initially and on a continual basis. This education should not be delegated to technicians.

At a recent Oregon Administrative Rule for Hemodialysis Technicians (August 28, 2000) meeting, ANNA submitted comments based on our concern for our patients, our members, and our technician colleagues (ANNA, 2000). The issue focused on the regulation that allowed technicians to access patients through a central venous catheter. We offered the 1997 position papers by both ANNA and NANT that stated “we (ANNA and NANT) agree that the activities of patients care that should be delegable by the nurse include: cannulation of peripheral vascular access, administration of intradermal lidocaine, intravenous heparin and intravenous normal saline, initiation, monitoring and discontinuation of the dialysis treatment” (ANNA & NANT, 1997, p. 1).

ANNA does not support unlicensed personnel to access major vessels (central venous catheters); this is even beyond the scope of practice of LPNs in most states. We requested that Oregon revise the regulation to be consistent with the positions of the professional and allied health organizations that are most knowledgeable in this area.

Patient Needs Must Come First

It is essential that effective systems to assess competency continue to be developed and that patient needs are carefully matched with provider skills. The concept of credentialing engages the full circle of accountability to patients, peers, and our profession. Nephrology nurses and ANNA must unite to promote the benefits of certification and credentialing to patients, government organizations, insurers, and even within our own health care system. Remember, these effective systems will ensure that patient needs are indeed being placed first.

ANNA’s Mission

The mission of ANNA is to advance the professional development of registered nurses practicing in nephrology, transplantation and related therapies and to promote the highest standards of patient care.

References

American Nephrology Nurses’ Association (ANNA). (2000). Testimony before the Oregon Administrative Rule for Hemodialysis Technicians, Portland, OR

American Nephrology Nurses Association (ANNA) & The National Association of Nephrology Technicians/Technologists (NANT). (1997). Joint position statement of the American Nephrology Nurses’ Association and the National Association of Nephrology Technicians/Technologists on the use of unlicensed personnel in dialysis. Pitman, NJ: Authors.

American Nurses Association (ANA). (1979). The study of credentialing in nursing: A new approach. Kansas City, MO: American Nurses Association.

Ascher, B. (1997). Is quality assurance in education consistent with international trade agreements? Paper presented at conference, Trade Agreements, Higher Education and the Globalization of the Professions: A Multinational Disclosure on Quality Assurance and Competency, Montreal, Quebec, Canada.

Canadian Council of Technicians and Technologists (CCTT). 1997. Utopia is a world-wide system that recognizes professional technical competence: Is it achievable? Ottawa: Canadian Council of Technicians and Technologists.

Gray, B.B. (1998, November 19). Editor’s note: Does your heart race when you hear the words competency testing? If so, you’re not alone. Nurseweek, p. 8. (Online at http://www.nurseweek.com/ednote/98/981119.html).

COPYRIGHT 2000 Jannetti Publications, Inc.

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