Biofeedback. Background. Procedure 68

Transcription

1 Procedure 68 Clinical PRIVILEGE WHITE PAPER Biofeedback Background Biofeedback is the process through which an individual learns how to change his or her physiological activity for the purposes of improving health and performance. In biofeedback, precise instruments measure physiological activity and report or feed back information to the individual. These instruments might measure brainwaves, heart function, breathing, muscle activity, or skin temperature. The feedback is used to facilitate changes in thinking, emotions, and behavior that persist over time even when the instrument and its measurements are removed. The National Institutes of Health endorses biofeedback treatment as an effective component of integrative and complementary medicine. It is most commonly used in conjunction with other traditional therapies. Published data supports the efficacy of biofeedback treatment for several medical problems such as migraine and tension headaches and urinary incontinence. According to the Association for Applied Psychophysiological Biofeedback (AAPB), some of the most common uses for biofeedback are: Alcoholism and addictions Anxiety Asthma Attention deficit hyperactivity disorder Closed head injury Depression Diabetes mellitus Enuresis Epilepsy Essential hypertension Headaches (migraine and tension) Incontinence (fecal and urinary) Insomnia Irritable bowel syndrome Learning disabilities Motion sickness Myofascial pain Neuromuscular disorders Raynaud s syndrome and disease Rheumatoid arthritis pain

2 Sleep disorders Stroke Temporomandibular dysfunction A typical biofeedback program consists of a clinical interview in which the biofeedback practitioner learns about the patient s life, family, work, sources of stress, coping skills, and medical and emotional problems. After the initial interview, the length of treatment varies, but many mental health and medical problems can be treated in eight to 12 sessions. Some medical problems, such as epilepsy, require more extensive treatment for example, two to three weekly sessions for up to 60 sessions. Physicians from a variety of medical specialties are eligible for certification in practicing biofeedback, but practitioners most commonly have backgrounds in psychiatry and physical medicine and rehabilitation. Others who can be certified to engage in biofeedback include dentists and dental hygienists, RNs, psychologists, physician s assistants, physical therapists, respiratory therapists, occupational therapists, social workers, chiropractors, sports medicine practitioners and exercise physiologists, speech pathologists, music therapists, and education and rehabilitation counselors. The Biofeedback Certification International Alliance (BCIA) certifies individuals who meet education and training standards in biofeedback. Certification is based on a practitioner s training and background in healthcare. BCIA certification is the only program recognized by the three major international biofeedback membership organizations, including AAPB. Involved specialties MDs and DOs, advanced practice professionals, and dentists Positions of specialty boards As biofeedback can involve practitioners from any number of medical specialties, please refer to the appropriate specialty board to determine training requirements and eligibility for privileges in biofeedback with regard to the practitioner s training, educational background, and experience. Positions of societies, academies, colleges, and associations BCIA BCIA offers certifications in the following three areas: Biofeedback Neurofeedback Pelvic muscle dysfunction biofeedback 2

3 BCIA offers different levels of certification based on an individual s healthcare background and how the different modalities will be utilized: Clinical certification is available for biofeedback, neurofeedback, and pelvic muscle dysfunction biofeedback for professionals with appropriate healthcare backgrounds who treat medical and/or psychological disorders, either independently under their license or under appropriate supervision Academic certification is available for biofeedback and neurofeedback within the United States for professionals who utilize biofeedback and/or neurofeedback in educational, research, or supervisory settings and who do not clinically treat medical or psychological disorders Technician certification is available for biofeedback and neurofeedback within the United States for professionals who use biofeedback and neurofeedback modalities under a BCIA-certified supervisor s license and who lack a clinical degree The clinical certification is open to professionals with degrees from BCIAapproved healthcare fields, including psychology, nursing (two-year RNs with license are eligible, but not licensed vocational nurses or licensed practical nurses), physical therapy, respiratory therapy, occupational therapy, social work, counseling, rehabilitation, chiropractic, recreational therapy, dental hygiene, physician s assistant (with certification or license), exercise physiology, speech pathology, and sports medicine. The following fields require a master s degree: music therapy and counseling education (MEd in counseling). Appropriately credentialed doctors of medicine and dentistry are also accepted. Degrees in healthcare fields other than those listed above must be submitted to a certification review committee. Requirements for entry-level certification are as follows: A human anatomy, human physiology, or human biology course from a regionally accredited academic institution covering the organization of the human body and all 11 systems. A 48-hour didactic education program specifically covering the topics listed below. The program must be taken from either a regionally accredited academic institution or a BCIA-accredited training program. (If coursework in instrumentation or professional conduct was taken through a prior accredited didactic workshop for a neurofeedback certification, these topics will not have to be repeated.) Orientation to biofeedback (four hours) Stress, coping, and illness (four hours) Psychophysiological recording (eight hours) Surface electromyographic applications (eight hours) Autonomic nervous system applications (eight hours) Electroencephalographic applications (four hours) Adjunctive interventions (eight hours) Professional conduct (four hours) 20 contact hours of BCIA-approved mentorship to learn to apply clinical bio- 3

4 feedback skills through learning self-regulation. 50 patient/client sessions. Case conference presentations. Written certification exam. Adherence to an ethical code of conduct, which also requires that unlicensed providers work under the supervision of an appropriately credentialed provider when working with a medical or psychological disorder. Certification can also be achieved by prior experience (rather than the entry-level path described above). Applicants for BCIA certification by prior experience must hold a current license/credential issued by the state in which the provider practices. This license/credential must be from one of the following clinical healthcare fields: psychology, medicine, dentistry, nursing (two-year RNs with license are eligible, but not LVNs or LPNs), physical therapy, respiratory therapy, occupational therapy, social work, counseling, rehabilitation, chiropractic, recreational therapy, dental hygiene, physician s assistant (with certification or license), exercise physiology, speech pathology, or sports medicine. Applicants for BCIA certification by prior experience must also meet the following requirements: A minimum of 100 hours of coursework, the majority from the last 10 years, that completely covers the 48 hours of BCIA Blueprint of Knowledge statements, with the remaining 52 hours completed in a BCIA-approved continuing education venue in any blueprint area(s). BCIA-approved continuing education includes courses taken from regionally accredited academic institutions, courses accredited by the national body of a BCIA-accepted healthcare profession (e.g., APA, AMA), and workshops given at the following recognized organizations annual meetings: AAPB, Biofeedback Federation of Europe, and International Society for Neurofeedback & Research. 3,000 patient hours over at least five years, which must be substantiated with a written statement of clinical practice and letters of recommendation that support the statement. Human anatomy/physiology coursework or other submission that formally demonstrates an understanding of the relation and function of bodily systems used in the applicant s specific biofeedback applications. At least 25 hours of mentoring with another professional that demonstrates a formal guidance in learning the application of clinical skills. Requirements for neurofeedback and pelvic muscle dysfunction biofeedback certifications vary slightly from the information provided above; complete information can be found on the BCIA website. Certifications are valid for four years for biofeedback and neurofeedback and three years for pelvic muscle dysfunction biofeedback. Recertification is granted upon application, payment of fees, documentation of accredited continuing edu- 4

5 cation specific to the blueprint (55 accredited hours, including three hours of ethics, for biofeedback/neurofeedback; and 36 accredited hours, including three hours of ethics, for pelvic muscle dysfunction biofeedback), and adherence to the Professional Standards and Ethical Principles of Biofeedback. AAPB The AAPB is a membership association that encourages biofeedback practitioners to become board certified via the BCIA, or have the training and experience comparable to that required for certification. The AAPB also provides information related to biofeedback and continuing education workshops and conferences for practitioners. ACGME The Accreditation Council for Graduate Medical Education (ACGME) mentions biofeedback in several of its training program requirement documents, but does not provide specific information regarding competency requirements for biofeedback. AOA The American Osteopathic Association (AOA) mentions biofeedback in several of its basic standards for training documents, but does not provide specific information regarding competency requirements for biofeedback. Positions of subject matter experts Christopher S. Cooper, MD, FAAP, FACS Iowa City, Iowa Christopher S. Cooper, MD, FAAP, FACS, is a professor of pediatric urology at the University of Iowa. He directs a pediatric urology clinic that incorporates biofeedback training as a treatment modality for children with voiding dysfunction. Cooper says that his institution does not currently award special privileges for biofeedback; however, he notes that appropriate training is essential for optimal patient outcomes. His training included a fellowship at the Children s Hospital of Philadelphia (CHOP), which has a robust pediatric urology biofeedback program. Cooper believes a clinician who practices biofeedback must have a strong background in anatomy and physiology, excellent understanding of the equipment he or she is using, and thorough training by other experienced practitioners on the specific biofeedback technique to be employed. Nurse practitioners who perform biofeedback in Cooper s clinic in Iowa completed on-site training at CHOP. 5

6 Cooper says that staying up to date with current literature and participating in continuing medical education programs are important to maintain competence in the pediatric urology biofeedback field, although his institution does not mandate a specific number of continuing education credit hours. Patricia S. Benfield, MHDL, CBIS-CI, CRT, CCAA Hickory, N.C. Patricia S. Benfield, MHDL, CBIS-CI, CRT, CCAA, is a certified brain injury specialist and cognitive rehabilitation therapist who uses neurofeedback (a form of biofeedback) in her practice working with individuals who have acquired brain injuries and other neurological conditions. She is also president of the North Carolina Biofeedback Society. Benfield believes that BCIA is the current gold standard for certification in biofeedback and agrees with the BCIA s Blueprint of Knowledge regarding specific training requirements. She notes that many biofeedback practitioners may not currently be BCIA certified because the BCIA process is relatively new and recently revised, even though the practice of biofeedback itself has been gaining ground since the 1970s. Thus, many well-trained biofeedback practitioners may be qualified through experience unrelated to the BCIA. Benfield states that training for biofeedback practitioners, regardless of BCIA certification, should include a good understanding of the anatomical aspects and potential confounding elements of the practice, theoretical basis for the different treatment approaches, a focus on the ethics of biofeedback and putting the patient first, and appropriate mentorship by an experienced practitioner. Benfield also agrees with the BCIA s policy for recertification, noting that because biofeedback practitioners come from so many different disciplines with their own continuing education requirements, it is important to formalize biofeedbackspecific requirements. Positions of accreditation bodies CMS CMS has no formal position concerning the delineation of privileges for biofeedback. However, the CMS Conditions of Participation (CoP) define a requirement for a criteria-based privileging process in (c)(6) stating, The bylaws must include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges (a)(6) states, The governing body must assure that the medical staff 6

7 bylaws describe the privileging process. The process articulated in the bylaws, rules or regulations must include criteria for determining the privileges that may be granted to individual practitioners and a procedure for applying the criteria to individual practitioners that considers: Individual character Individual competence Individual training Individual experience Individual judgment The governing body must ensure that the hospital s bylaws governing medical staff membership or the granting of privileges apply equally to all practitioners in each professional category of practitioners. Specific privileges must reflect activities that the majority of practitioners in that category can perform competently and that the hospital can support. Privileges are not granted for tasks, procedures, or activities that are not conducted within the hospital, regardless of the practitioner s ability to perform them. Each practitioner must be individually evaluated for requested privileges. It cannot be assumed that every practitioner can perform every task, activity, or privilege specific to a specialty, nor can it be assumed that the practitioner should be automatically granted the full range of privileges. The individual practitioner s ability to perform each task, activity, or privilege must be individually assessed. CMS also requires that the organization have a process to ensure that practitioners granted privileges are working within the scope of those privileges. CMS CoPs include the need for a periodic appraisal of practitioners appointed to the medical staff/granted medical staff privileges ( [a][1]). In the absence of a state law that establishes a time frame for the periodic appraisal, CMS recommends that an appraisal be conducted at least every 24 months. The purpose of the periodic appraisal is to determine whether clinical privileges or membership should be continued, discontinued, revised, or otherwise changed. The Joint Commission The Joint Commission has no formal position concerning the delineation of privileges for biofeedback. However, in its Comprehensive Accreditation Manual for Hospitals, The Joint Commission states, The hospital collects information regarding each practitioner s current license status, training, experience, competence, and ability to perform the requested privilege (MS ). In the introduction for MS , The Joint Commission states that there 7

8 must be a reliable and consistent system in place to process applications and verify credentials. The organized medical staff must then review and evaluate the data collected. The resultant privilege recommendations to the governing body are based on the assessment of the data. The Joint Commission introduces MS by stating, The organized medical staff is responsible for planning and implementing a privileging process. It goes on to state that this process typically includes: Developing and approving a procedures list Processing the application Evaluating applicant-specific information Submitting recommendations to the governing body for applicant-specific delineated privileges Notifying the applicant, relevant personnel, and, as required by law, external entities of the privileging decision Monitoring the use of privileges and quality-of-care issues MS further states, The decision to grant or deny a privilege(s) and/or to renew an existing privilege(s) is an objective, evidence-based process. The EPs for standard MS include several requirements as follows: The need for all licensed independent practitioners who provide care, treatment, and services to have a current license, certification, or registration, as required by law and regulation Established criteria as recommended by the organized medical staff and approved by the governing body with specific evaluation of current licensure and/or certification, specific relevant training, evidence of physical ability, professional practice review data from the applicant s current organization, peer and/or faculty recommendation, and a review of the practitioner s performance within the hospital (for renewal of privileges) Consistent application of criteria A clearly defined (documented) procedure for processing clinical privilege requests that is approved by the organized medical staff Documentation and confirmation of the applicant s statement that no health problems exist that would affect his or her ability to perform privileges requested A query of the NPDB for initial privileges, renewal of privileges, and when a new privilege is requested Written peer recommendations that address the practitioner s current medical/clinical knowledge, technical and clinical skills, clinical judgment, interpersonal skills, communication skills, and professionalism A list of specific challenges or concerns that the organized medical staff must evaluate prior to recommending privileges (MS , EP 9) A process to determine whether there is sufficient clinical performance information to make a decision related to privileges A decision (action) on the completed application for privileges that occurs 8

9 within the time period specified in the organization s medical staff bylaws Information regarding any changes to practitioners clinical privileges, updated as they occur The Joint Commission further states, The organized medical staff reviews and analyzes information regarding each requesting practitioner s current licensure status, training, experience, current competence, and ability to perform the requested privilege (MS ). In the EPs for standard MS , The Joint Commission states that the information review and analysis process is clearly defined and that the decision process must be timely. The organization, based on recommendations by the organized medical staff and approval by the governing body, develops criteria that will be considered in the decision to grant, limit, or deny a request for privileges. The criteria must be consistently applied and directly relate to the quality of care, treatment, and services. Ultimately, the governing body or delegated governing body has the final authority for granting, renewing, or denying clinical privileges. Privileges may not be granted for a period beyond two years. Criteria that determine a practitioner s ability to provide patient care, treatment, and services within the scope of the privilege(s) requested are consistently evaluated. The Joint Commission further states, Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privileges, or to revoke an existing privilege prior to or at the time of renewal (MS ). In the EPs for MS , The Joint Commission says there is a clearly defined process facilitating the evaluation of each practitioner s professional practice, in which the type of information collected is determined by individual departments and approved by the organized medical staff. Information resulting from the ongoing professional practice evaluation is used to determine whether to continue, limit, or revoke any existing privilege. HFAP The Healthcare Facilities Accreditation Program (HFAP) has no formal position concerning the delineation of privileges for biofeedback. The bylaws must include the criteria for determining the privileges to be granted to the individual practitioners and the procedure for applying the criteria to individuals requesting privileges ( ). Privileges are granted based on the medical staff s review of an individual practitioner s qualifications and its recommendation regarding that 9

10 individual practitioner to the governing body. It is also required that the organization have a process to ensure that practitioners granted privileges are working within the scope of those privileges. Privileges must be granted within the capabilities of the facility. For example, if an organization is not capable of performing open-heart surgery, no physician should be granted that privilege. In the explanation for standard related to membership selection criteria, HFAP states, Basic criteria listed in the bylaws, or the credentials manual, include the items listed in this standard. (Emphasis is placed on training and competence in the requested privileges.) The bylaws also define the mechanisms by which the clinical departments, if applicable, or the medical staff as a whole establish criteria for specific privilege delineation. Periodic appraisals of the suitability for membership and clinical privileges is required to determine whether the individual practitioner s clinical privileges should be approved, continued, discontinued, revised, or otherwise changed ( ). The appraisals are to be conducted at least every 24 months. The medical staff is accountable to the governing body for the quality of medical care provided, and quality assessment and performance improvement ( ) information must be used in the process of evaluating and acting on re-privileging and reappointment requests from members and other credentialed staff. DNV DNV has no formal position concerning the delineation of privileges for biofeedback. MS.12 Standard Requirement (SR) #1 states, The medical staff bylaws shall include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to those individuals that request privileges. The governing body shall ensure that under no circumstances is medical staff membership or professional privileges in the organization dependent solely upon certification, fellowship, or membership in a specialty body or society. Regarding the Medical Staff Standards related to Clinical Privileges (MS.12), DNV requires specific provisions within the medical staff bylaws for: The consideration of automatic suspension of clinical privileges in the follow- 10

11 ing circumstances: revocation/restriction of licensure; revocation, suspension, or probation of a DEA license; failure to maintain professional liability insurance as specified; and noncompliance with written medical record delinquency/deficiency requirements Immediate and automatic suspension of clinical privileges due to the termination or revocation of the practitioner s Medicare/Medicaid status Fair hearing and appeal The Interpretive Guidelines also state that core privileges for general surgery and surgical subspecialties are acceptable as long as the core is properly defined. DNV also requires a mechanism (outlined in the bylaws) to ensure that all individuals provide services only within the scope of privileges granted (MS.12, SR.4). Clinical privileges (and appointments or reappointments) are for a period as defined by state law or, if permitted by state law, not to exceed three years (MS.12, SR.2). Individual practitioner performance data must be measured, utilized, and evaluated as a part of the decision-making for appointment and reappointment. Although not specifically stated, this would apply to the individual practitioner s respective delineation of privilege requests. CRC draft criteria The following draft criteria are intended to serve solely as a starting point for the development of an institution s policy regarding biofeedback. Minimum threshold criteria for requesting privileges in biofeedback Basic education: MA or MS Minimal formal training: Successful completion of coursework in anatomy and physiology, training on equipment to be used, and mentorship by experienced practitioners on the specific biofeedback technique to be employed, and/or certification in biofeedback by the BCIA, and the appropriate medical training depending on the extent of privileges requested and level of BCIA certification obtained (i.e., technician, academic, or clinical). Required current experience: Demonstrated current competence and evidence of the successful performance of an adequate number of biofeedback procedures in the past 12 months or completion of training in the past 12 months. References If the applicant is recently trained, a letter of reference should come from the director of the applicant s training program. Alternatively, a letter of reference may come from the applicable department chair and/or clinical service chief at 11

12 the facility where the applicant most recently practiced. Reappointment Reappointment should be based on unbiased, objective results of care according to a hospital s quality assurance mechanism. Applicants for reappointment must demonstrate that they have maintained competence through ongoing participation in continuing medical education programs. Continuing education related to biofeedback should be required. For more information Accreditation Council for Graduate Medical Education 515 North State Street, Suite 2000 Chicago, IL Telephone: Fax: Website: American Group Psychotherapy Association 25 East 21st Street, 6th Floor New York, NY Telephone: Website: American Osteopathic Association 142 East Ontario Street Chicago, IL Telephone: Website: Biofeedback Certification International Alliance W 44th Avenue, Suite 310 Wheat Ridge, CO Telephone: Fax: Website: Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, MD Telephone: Website: 12

13 DNV Healthcare, Inc. 400 Techne Center Drive, Suite 350 Milford, OH Website: Healthcare Facilities Accreditation Program 142 East Ontario Street Chicago, IL Telephone: Website: The Joint Commission One Renaissance Boulevard Oakbrook Terrace, IL Telephone: Fax: Website: Editorial Advisory Board Clinical Privilege White Papers Associate Editorial Director Todd Hutlock Managing Editor Katrina Gravel William J. Carbone Chief Executive Officer American Board of Physician Specialties Atlanta, Ga. Darrell L. Cass, MD, FACS, FAAP Codirector, Center for Fetal Surgery Texas Children s Hospital Houston, Texas Jack Cox, MD Senior Vice President/Chief Quality Officer Hoag Memorial Hospital Presbyterian Newport Beach, Calif. Stephen H. Hochschuler, MD Cofounder and Chair Texas Back Institute Phoenix, Ariz. Bruce Lindsay, MD Professor of Medicine Director, Cardiac Electrophysiology Washington University School of Medicine St. Louis, Mo. Sally J. Pelletier, CPCS, CPMSM Director of Credentialing Services The Greeley Company, a division of HCPro, Inc. Danvers, Mass. Beverly Pybus Senior Consultant The Greeley Company, a division of HCPro, Inc. Danvers, Mass. Richard A. Sheff, MD Chair and Executive Director The Greeley Company, a division of HCPro, Inc. Danvers, Mass. The information contained in this document is general. It has been designed and is intended for use by hospitals and their credentials committees in developing their own local approaches and policies for various credentialing issues. This information, including the materials, opinions, and draft criteria set forth herein, should not be adopted for use without careful consideration, discussion, additional research by physicians and counsel in local settings, and adaptation to local needs. The Credentialing Resource Center does not provide legal or clinical advice; for such advice, the counsel of competent individuals in these fields must be obtained. Reproduction in any form outside the recipient s institution is forbidden without prior written permission. Copyright 2013 HCPro, Inc., Danvers, MA