Publication/Presentation Date



Development of an Advanced Practice Clinician (APC) Onboarding and Credentialing Process for the Department of Surgery and Perioperative Services

Madison Fuss, Temple University

Cathyann Feher, RN, MSN


This quality improvement project focuses on the development of an orientation and evaluation process for new Advanced Practice Clinicians (APCs) in the Department of Surgery. Through the creation of a structured onboarding/credentialing process and systematic evaluation plan for APCs, it is hoped that all mid-level providers will better understand their roles and responsibilities as well as the expectations as set forth by the Department of Surgery. Further this process will promote the maintenance of core competencies.

Credentialing and onboarding are extremely important processes for the retention and success of APCs. APCs are often assimilated onto the staff of health care organizations in a disorganized manner due to the lack of a structured process for onboarding and credentialing. This can result in provider dissatisfaction and a high rate of turnover as well as decreased patient satisfaction. Having an established, structured onboarding process for surgical APCs can help to increase provider and patient satisfaction and promote retention. The clarification of expectations allows providers to opportunity to better understand the Lehigh Valley Health Network’s (LVHN) Department of Surgery practices. After the APC is oriented and appropriately credentialed, there is an ongoing professional practice evaluation (OPPE) that needs to be completed to ensure the APC remains clinically competent and adheres to the policies and procedures outlined by the Network. The provider and supervising physician will complete this evaluation twice a year. As part of the OPPE, the APC is responsible for reporting their continuing medical education (CME) credits to LVHN.


The initial step in creating an onboarding and credentialing process was to develop a Focused Professional Practice Evaluation (FPPE) for surgical APCs. The FPPE is divided into two parts, orientation and credentialing. The orientation helps to familiarize the APC to the network and Department of Surgery. Credentialing is necessary to secure privileges in the operating room and other units. At the outset, there was no set orientation program for mid-level providers in the Department of Surgery at LVHN. Therefore, information regarding APC training in other departments within LVHN was gathered and reviewed. Additional research was performed to seek out evidence pertaining to surgical APC credentialing and a draft FPPE was completed. To assist with the orientation process, a module on The Learning Curve (TLC) was created that focuses on policies and procedures to ensure that all of the providers are knowledgeable with respect to OR policies and procedures. Additional education sessions offered through the Surgical Education Center are also recommended to ensure clinical competency for surgical APCs. These sessions need to be completed before the surgical APC goes to the Operating Room (OR).

The OPPE was developed through a review and compilation of existing evaluation processes for APCs from different units at LVHN as well as research of existing publications and online resources. Based on this information, the six core competencies named by the Joint Commission of Health were utilized to create the basis of the OPPE for the surgical APCs. These competencies evaluate effective and appropriate application of medical knowledge, interpersonal and communication skills, patient care/ professionalism, practice-based learning, and systems-based practice. Based on the available research, several questions were developed for each competency that is to be evaluated. These competencies should be evaluated twice a year and the results shared with the APCs. This allows for appropriate feedback and early intervention if there are issues that arise. Additionally, the APC is afforded the opportunity to voice any concerns that he or she may have regarding their role.

Results and Discussion

To grant medical privileges, The Joint Commission of Health requires a FPPE to be completed by administration in the respective department during the orientation process. An onboarding checklist was created to offer guidance and provide sequential flow to the orientation process. The first part of this checklist is a 3 day orientation; Connections at LVHN, Lehigh Valley Physician Group Orientation, and Department of Surgery Orientation. At the DOS orientation, the APC receives their scrubs, pager, locker assignment, etc. The provider will complete Electronic Privacy Information Center (EPIC) and email training, as well as direction to complete all modules on TLC. Some of the modules include the new employee bundle and quarter core competencies (both network wide). All surgical APCs will then complete a module created for policy review. These policies must be read and signed. The credentialing process includes a tour of the OR, familiarization of the tracker system (at Cedar Crest), and further review of OR policies. All surgical APCs will then complete a scrubbing/gowning session and suture session in the Surgical Education Center. After this has been completed, the supervising physician will complete the proctoring form. At this time, appropriate privileges will be granted to the APC. The orientation and FPPE checklist are shown in Table 1.

The Joint Commission of Heath requires ongoing evaluations to be collected to review and improve provider-patient care. These evaluations will be used to determine the status of the provider’s privileges (maintain, limit, and revoke). The new OPPE form will be collected electronically bi-annually. One set of evaluations, in January, will be completed by the APC’s supervising physician in regards to the six core competencies stated above. There will be three choices for each competency: 1) Acceptable, 2) Needs Improvement, and 3) Unacceptable. The reports are then gathered and reviewed by administration in the Department of Surgery. The competencies and questions are shown in Table 2.

During the second cycle of OPPE collection in July, the APC will be responsible for submitting their OPPE self-report which will then be collected and reviewed. The APC is also responsible for updating their ongoing continuing medical education (CME) credits and renewal of their license to practice in a timely manner. By collecting the evaluations in addition to the CME report, LVHN will be able to show the Joint Commission of Health that the surgical APCs remain clinically competent and certified to practice medicine. Additionally, this information can be used in determining whether to maintain, limit or revoke certain privileges.


This quality improvement project focused on the onboarding, credentialing, and ongoing evaluation of surgical APCs at LVHN. With the creation of an onboarding checklist and OPPE form, the Department of Surgery can ensure that all of their mid-level providers are meeting all core competencies, staying up to date within their chosen field of practice and providing quality care for the patients in our community. Additionally, these processes are in alignment with the guidelines set up by the Joint Commission of Health.


I would like to thank Cathyann Feher, Director of Department of Surgery, for providing me with this opportunity and being a wonderful mentor through the entire process. Thank you for setting up numerous experiences for me and providing guidance throughout the entirety of my project. Thank you to the Department of Surgery for creating this experience for study and observation. I would also like to thank numerous employees that assisted me during this project, Sarah Wenrich PA-C., Jeanne Luke, Director of Perioperative Internship and Clinical Development, Hope Johnson, Director of Perioperative Services, and Dana Hacker. Special thanks to Timothy McCann in assisting me through the technical parts of this project. Thank you to Hubert Huang and Diane Leuthardt for organizing this research program.


The Joint Commission. (2013, March). Standards boosterpak for focused professional practice

evaluation/ ongoing professional practice evaluation (FPPE/OPPE). Retrieved June

2014 from LVH intranet.

Table 1. APC Onboarding and FPPE Checklist





Start date:


Completion date:

Site Mentor:


Ensure APC is credentialed with Hospital medical staff prior to start date.

Schedule appointment to get photo taken with Janet Seifert @ 610-402-8590.

Ensure provider has access to the X-Drive.


LVHN Orientation (Connections)

LVPG Orientation (if needed)

Department of Surgery Orientation

  • Pick up lab coat, scrubs, pager, and OR locker assignment.

Medical Record Training

Coding Compliance

Computer Training:

  • EPIC
  • E-mail communication

TLC Core Bundles

  • Quarter Core Competencies
  • Policy Review
  • Radiation Course & Badge Form Completion (as needed)

Presentation from APC Executive Council

Campus Maps & Tour of OR

  • OR Tracker System (Cedar Crest only)

Surgical Education Center

  • Scrubbing/Gowning Session
  • Suture Session

Proctoring form completed during first 12 months of employment


Review Key Policies on TLC

  • Operation Room Rules and Regulations
  • Dress Code
  • Surgical Attire
  • Gowning and Gloving
  • Surgical Scrub
  • Physician Ticket to the OR
  • Identification of Patient and Site
  • Positioning of the Surgical Patient
  • Standard Precautions
  • Preinduction Briefing/Debriefing Process
  • Sharps Disposal
  • Fire in Operating Room (Code Yellow)
  • Malignant Hypothermia Crisis
  • Interpreters/Communication Assistance
  • Telephone and Verbal Orders

I have received New employee orientation and understand each of the policies and procedures. I understand the importance of following these procedures in order to participate as a successful member of the Department of Surgery.

Physician Assistant Signature _______________________________________ Date _________________

Supervising Physician Signature _____________________________________ Date _________________

Please return to the Department of Surgery when completed.

Mailing Address

Lehigh Valley Health Network

Department of Surgery

One City Center

707 Hamilton Street

P.O. Box 1806

Allentown, PA 18106

Main Phone Number: 484-862-3252

Fax: 484-862-3276

Lehigh Valley Health Network

Department of Surgery

One City Center

707 Hamilton Street

P.O. Box 1806

Allentown, PA 18106

Listing of Administration Main Phone Number: 484-862-3252

LVHN Department of Surgery Fax: 484-862-3276

Michael Pasquale, M.D.

Department Chair


Linda Altricher

Executive Secretary to Dr. Pasquale


Patrick Toselli, D.O.

Vice Chair (LVH-M)

Michael Mortiz, M.D.

Senior Vice Chair, Operations

Michael Badellino, M.D.

Vice Chair for Education Affairs

John Hong, M.D.
Vice Chair for Research

Raymond Singer, M.D., M.M.E., C.M.E.

Vice Chair for Operations- Quality

Cathyann Feher, RN, MSN



Leyna Ortiz

Admin. Secretary


Cathleen Webber, RN, MSHA

Program Manager-Quality


Robert Ruhf

Surgical Education Center Coordinator


Table 2.Competencies for OPPE

Patient Care

- Competently and appropriately participates in surgical procedures including:

  • The use of sterile technique
  • Assistance with patient positioning and draping
  • Assistance with tissue retraction
  • Assistance with wound closure

Medical Clinical Knowledge

- Follows operating room policy and procedure

- Interacts appropriately and knowledgably with all surgical patients

- Demonstrates knowledge of surgical procedures

Practice Based Learning and Improvement

- Mindful of improvement measures

- Adapts to changing clinical situations

- Demonstrates self-learning

- Facilitates student learning when appropriate

Systems Based Practice

- Uses medical information and understanding to provide patient care efficiently

Interpersonal Communication Skills

- Communicates with patients and families using AIDET

- Interacts appropriately with colleagues


- Provides assistance to the physician while maintaining ethical practices

- Is sensitive to the patient and their needs

- Demonstrates PRIDE behaviors


Mentor: Cathyann Feher, RN, MSN


Department of Surgery, Research Scholars (Acknowledgements and Co-authored Publications), Research Scholars - Posters


Best Quality Improvement Project: Third Place

Document Type