MEDICAL STAFF CREDENTIALS MANUAL

Transcription

1 MEDICAL STAFF CREDENTIALS MANUAL Adopted by the Medical Staff: July 27, 2009 Adopted by the Board of Directors: July 31, 2009

2 AHMC ANAHEIM REGIONAL MEDICAL CENTER (ARMC) CREDENTIALS MANUAL TABLE OF CONTENTS ARTICLE I:... APPLICATION POLICY... 3 ARTICLE II:... PRE-APPLICATION PRE-APPLICATION RECEIPT OF PRE-APPLICATION... 3 ARTICLE III:... INITIAL APPOINTMENT LEGIBLE APPLICATION SIGNED APPLICATION/CONSENT PROCEDURE FOR PROCESSING APPLICATIONS FOR STAFF APPOINTMENT CREDENTIALS COMMITTEE ACTION MEDICAL EXECUTIVE COMMITTEE ACTION BOARD OF DIRECTORS ACTION CONFLICT RESOLUTION AD HOC JOINT CONFERENCE COMMITTEE COMPOSITION NOTICE OF DECISION REAPPLICATION AFTER ADVERSE APPOINTMENT DECISION TIMELY PROCESSING OF APPLICATIONS... 8 ARTICLE IV:... PROVISIONAL CATEGORY PROVISIONAL STAFF CATEGORY: QUALIFICATIONS PREROGATIVES PERFORMANCE EVALUATION OF PROVISIONAL MED. STAFF MEMBER (Proctoring) TERM OF PROVISIONAL STAFF ACTION AT CONCLUSION OF PROVISIONAL STAFF DOCUMENTATION EXTENSION OF PROVISIONAL APPOINTMENT MODIFICATION/TERMINATION OF CLINICAL PRIVILEGES: ARTICLE V:... REAPPOINTMENT INFORMATION COLLECTION AND VERIFICATION PROCEDURE FOR PROCESSING APPLICATIONS FOR REAPPOINTMENT CREDENTIALS COMMITTEE ACTION BASIS FOR RECOMMENDATION POINT SYSTEM QUALIFICATIONS RESPONSIBILITIES: FINAL PROCESSING NOTIFICATION OF ADVERSE ACTION IMPOSED REQUEST FOR MODIFICATION OF APPOINTMENT CATEGORY OR PRIVILEGES ARTICLE VI:... PRIVILEGES FOR IMPORTANT NEED ARTICLE VII:... LEAVE OF ABSENCE REQUESTS FOR LEAVES OF ABSENCE AT THE CONCLUSION OF THE LEAVE OF ABSENCE IF THE LEAVE OF ABSENCE WAS FOR MEDICAL REASONS BOARD OF DIRECTORS ACTION ARTICLE VIII:.. CREDENTIALING FOR NEW PROCEDURES OBJECTIVE POLICY DEFINITION PROCEDURE ARTICLE IX:... DISASTER CREDENTIALING... 15

3 Credentials Manual July 2009 Page 2 of PURPOSE SCOPE AND RESPONSIBILITY POLICY DEFINITION AND TERMS PROCEDURE REQUIRED DOCUMENTATION ON THE DISASTER PRIVILEGE APPROVAL FORM VERIFICATION PROCESS WHO GRANTS PRIVILEGES TEMPORARY BADGING OVERSIGHT TERMINATION OF DISASTER PRIVILEGES ARTICLE X:... TELEMEDICINE PRIVILEGES ARTICLE XI:... PRACTITIONERS PROVIDING CONTRACTUAL SERVICES EXCLUSIVITY POLICY: QUALIFICATIONS EFFECT OF STAFF APPOINTMENT TERMINATION EFFECT OF CONTRACT EXPIRATION OR TERMINATION ARTICLE XII:... MEDICAL STAFF HARASSMENT POLICY MEDICAL STAFF POLICY ON HARASSMENT ARTICLE XIII:.. ANNUAL REVIEW, ADOPTION AND AMENDMENT... 19

4 Credentials Manual July 2009 Page 3 of 19 ARTICLE I: APPLICATION POLICY 1.1 As a general policy, this Hospital permits application to the medical staff from licensed medical and osteopathic physicians, dentists, clinical psychologists and podiatrists. 1.2 It is currently the policy of the Board of Directors that any physician, dentist or podiatrist or clinical psychologist meeting the basic criteria for the granting of an application may apply for Membership. 1.3 It is the policy of this Hospital to provide applications for appointment to the medical staff to individuals who have completed an application request form and demonstrate the following: That they are currently licensed to practice in the State of California as a M.D., D.O., D.D.S., D.P.M. or Ph.D That they maintain professional liability insurance, covering requested privileges, in an amount specified by the Board of Directors That they have successfully completed an approved residency program as set forth in Article II, (Medical Staff Membership), Section 2.2D (Qualifications for Membership of the Bylaws) or be in the last 6 months of an approved residency program of at least 3 years duration; That they have actively practiced six (6) of the last twelve (12) months (in residency or private practice) unless otherwise directed by the Board of Directors; That they have actively practiced in an accredited Hospital at least two (2) of the past five (5) years. Three (3) months of recent experience in a full-time clinical residency will be considered equivalent That they have established or plan to establish a residence and/or office within a reasonable distance of the hospital to provide continuous care for their patients commensurate with their practice privileges That they provide evidence of acceptable alternate patient coverage; That if they are applying for privileges in a Department contracted with the Hospital to provide exclusive services (i.e., Pathology, Anesthesiology, Emergency Medicine or Radiology); they provide a written request for application from the Department Medical Director. ARTICLE II: PRE-APPLICATION 2.1 PRE-APPLICATION All requests for applications for appointment to the medical staff will be forwarded to the Medical Staff Office. Upon receipt of a request for an application, the Medical Staff Office will provide the potential applicant with an application request form. Potential applicant must demonstrate that they meet all the basic qualifications as noted in Article 1.3 of the Credentials Manual, and: 2.2 RECEIPT OF PRE-APPLICATION Upon receipt of a completed pre-application request form, the Medical Staff Office representative will verify its contents and will, if the requirements of Article 1, of this Manual are met, forward a copy of the current application, along with the appropriate documents to the applicant in accordance with Section of this Manual. In the event the requirements are not met, the potential applicant will be notified and given an opportunity for an informal discussion with the Chief of Staff and the Chief Executive Officer. Such informal discussion shall not be deemed to be a hearing as that term is used in Article XI of the Medical Staff Bylaws. In the event the requirements of this Section are not met, the applicant shall not be entitled to the procedures provided in Article XI of the Medical Staff Bylaws.

5 Credentials Manual July 2009 Page 4 of 19 ARTICLE III: INITIAL APPOINTMENT 3.1 LEGIBLE APPLICATION Application for staff appointment is to be submitted by the applicant. The application must be legible and on such form as designated by the Credentials Committee, approved by the Medical Executive Committee and the Board of Directors. 3.2 SIGNED APPLICATION/CONSENT The applicant must sign the application and in so doing: Signifies his/her willingness to appear for interviews if requested in regard to his/her application; Authorizes Medical Staff Office representatives to consult with others who have been associated with him/her and/or who have information bearing on his/her competence and qualifications; Consents to Medical Staff Office representatives' inspection of all records and documents that may be material to an evaluation of his/her professional qualifications and competence to carry out the clinical privileges (s)he requests, of his/her physical and mental health status, and of his/her professional and ethical qualifications; Releases from liability all Medical Staff Office representatives for their acts performed in evaluation of him/her or his/her Credentials; Releases from any liability all individuals and organizations who provide information, including otherwise privileged or confidential information to Medical Staff Office representatives concerning his/her competence, professional ethics, character, physical and mental health, emotional stability, and other qualifications for staff appointment and clinical privileges; Authorizes and consents for representatives from other hospitals, medical associations, licensing boards, and other organizations concerned to provide information on the performance and the quality and efficiency of patient care by the applicant relevant to such matters that the entity may have concerning him/her, and releases such representatives from liability for so doing; Signifies that (s)he has received and read (or been given the opportunity to read) the Bylaws, Rules and Regulations of the Medical Staff and other pertinent Manuals, that (s)he agrees to be bound by the terms thereof if he/she is granted Membership and/or clinical privileges, and to be bound by the terms thereof in all matters relating to consideration of his/her application without regard to whether or not he/she is granted Membership and/or clinical privileges; and Agrees to provide and update the information requested on the original application and subsequent re-applications or privilege request forms (specifically, including but not limited to Hospital appointments, voluntary or involuntary relinquishment of Medical Staff Membership or clinical privileges or licensure status, voluntary or involuntary limitation, reduction or loss of clinical privileges at another Hospital, involvement in liability claims, any change in professional liability coverage or license/dea restrictions including both current and pending investigations, accusations filed and challenges). 3.3 PROCEDURE FOR PROCESSING APPLICATIONS FOR STAFF APPOINTMENT Upon approval of the pre-application, all eligible applicants will be provided an application for appointment to the medical staff; privileges request forms, and a detailed list of requirements for completion of the application. A complete set of Medical Staff Bylaws, Rules and Regulations and pertinent Manuals will be provided or made available to the applicant as well The application is reviewed for completeness upon receipt. Should it be identified to be incomplete, the applicant is sent a letter informing him/her of the forty-five (45) day deadline as delineated in (below).

6 Credentials Manual July 2009 Page 5 of A report will be made to the Credentials Committee which will include applications received The following documentation is necessary for an application to be considered complete. It is the applicant's responsibility to provide: A. A legible (completed), signed and dated application, required attachments and privilege request form; B. A current photo C. A copy of current DEA certificate, if applicant has one; D. A copy of current professional liability insurance policy in the minimum amounts of one (1) million per occurrence and three (3) million aggregate, that covers requested privileges (06/02) E. A complete and current Curriculum Vitae. F. Documentation of relevant training and experience for clinical privileges requested; G. Present Board Status; i.e.: copy of certificates or copy of letter from the appropriate specialty board indicating board admissibility; H. The names and current addresses of at least three (3) peers who have recently worked with the applicant and directly observed his/her professional performance over a reasonable period of time, (a minimum of one year) and who can and will provide reliable information regarding current clinical ability, ethical character and ability to work with others. References must be from peers who practice in a field similar to the applicant; and, if possible, one or more of the references should be from a member of the medical staff of ARMC. I. Payment of the application fee of $ J. Documentation of CME activity to support the clinical privileges requested. K. Professional Sanctions: Information as to whether any of the following have ever been or are in the process of being reviewed, denied, revoked, suspended, reduced, not renewed or voluntarily relinquished: 1) Staff Membership and status or clinical privileges at any other Hospital or health care institution. 2) Membership/fellowship in local, state, or national professional organizations. 3) Specialty Board certification/eligibility. 4) License to practice any profession in any jurisdiction. 5) DEA Certificate. If any such actions ever occurred or are pending, the particulars thereof shall be included. L. Administrative Remedies: By submission of an application to the medical staff the practitioner agrees that, in the event that an adverse ruling is made with respect to his/her staff Membership, staff category and/or clinical privileges, he/she will exhaust the administrative remedies afforded by these Bylaws before seeking other remedies. M. Professional Liability Incidents: A full disclosure of any claims, complaints, or causes of action lodged against applicant which conceivably could be considered relevant to a consideration of his/her qualifications for Medical Staff Membership including, but not limited to those currently pending, as well as those paid, compromised, settled or subject to an agreement to settle or otherwise concluded. The applicant shall also report any decisions by administrative agencies, arbitration awards or court judgments that have found him/her guilty of a crime (excluding minor traffic violations) or liable for any personal injury, bodily injury or death caused by his/her intention act or omission to act, negligence, error or omission in the practice of his/her profession or his/her rendering or unauthorized professional services. The required disclosures shall be broad enough to include without limitation, any incident, the defense of which is generally covered, in whole or in part, by the standard form professional liability policy, whether or not applicant was or is covered by such a policy. N. Misrepresentations: Misrepresentation or material omissions of any information required or submitted in the application or reappointment process shall constitute cause for denial of appointment or reappointment or revocation of Medical Staff Membership and/or clinical privileges. O. Acknowledgment of release and immunity provisions: A signed statement that the applicant agrees to the scope and extent of the authorization, confidentiality, immunity and release provisions as defined in Article XI of the Medical Staff Bylaws.

7 Credentials Manual July 2009 Page 6 of 19 P. Proof of Coverage: Proof of adequate alternate coverage for patients in the applicant's absence If all information required above in Section is not submitted by the applicant within forty-five (45) days of receipt of the application, it may be considered administratively closed and no further processing will take place. This will be reported to the Credentials Committee Upon receipt of the completed application, the Credentials Coordinator will verify its contents from the primary source and collect additional information as follows: A. Information from all prior and current insurance carriers concerning claims, suits and settlements (if any) during the past five (5) years; B. Administrative (employment verification) from all significant past settings and clinical (peer) references; C. Documentation of: relevant training and/or experience, current clinical competency, and the ability to perform the privileges requested. D. Verification of the licensure status in all current or past States in which the applicant held a license; E. Information from the National Practitioners' Data Bank established pursuant to the Healthcare Quality Improvement Act of 1986; and F. Verification from the source of residency training, medical school and Hospital affiliations. While it is the policy of the ARMC Medical Staff Office to make a valid attempt to obtain verification directly from the last training institution pertinent to privileges requested, the AMA (for Allopathic physicians) or AOA (for Osteopathic physicians) is used for verification of medical school, internship and residency provided that there are no identified issues. These documents are used to verify the last applicable level of training only in situations when the institutions do not respond. G. Any identified professional sanctions will be researched with the appropriate agencies. H. ECFMG / USMLE (for physicians who completed medical school outside of the US and Canada). In the event there is undue delay in obtaining the required information, the Credentials Coordinator will request assistance from the applicant. During this time period, the "time periods for processing" the application will be appropriately modified. It shall be the applicant's obligation to obtain the required information or assure that it is submitted and received by the Hospital. Failure of an applicant to adequately respond to a request for assistance will, after forty-five (45) days, result in termination of the application process as outlined in above and result in the application being filed administratively incomplete. Such termination shall not entitle the applicant to a hearing or appeal, unless specifically provided by Article XI When the application and all verifications are complete, the file will then be summarized by the Credentials Coordinator and presented for review and recommendation to the Department Chair/designee. If the provider is a member of a Section, the Section Chair must review prior to the Department Chair The applicable Department Chair/designee (following review and recommendation from the Section chair if applicable) will review the entire file and make a recommendation in writing as to membership and/or clinical privileges to be granted which will be forwarded to the Credentials Committee The Credentials Committee s recommendations, along with all supporting documentation shall be presented to the Medical Executive Committee in accordance with section 3.4 of this manual. The Medical Executive Committee shall consider the recommendation and any other relevant information and take action on the recommendation as set forth in Section 3.5 of this Manual. 3.4 CREDENTIALS COMMITTEE ACTION The committee shall transmit to the Medical Executive Committee its recommendations as to staff appointment, and if appointment is recommended as to staff category, department affiliation and clinical

8 Credentials Manual July 2009 Page 7 of 19 privileges to be granted as approved by the appropriate department chair(s) and any special conditions to be attached to the appointment. 3.5 MEDICAL EXECUTIVE COMMITTEE ACTION At its next regularly scheduled meeting, after receipt of the Credentials Committee recommendations, or as soon thereafter as possible, the Medical Executive Committee shall take action on the recommendations. The Medical Executive Committee may recommend that the Board of Directors affirm, reject or modify the recommendations or defer the decision for further consideration Deferral: Action by the Medical Executive Committee to defer the application for further consideration must be followed up at the next regularly scheduled Medical Executive Committee meeting with a subsequent recommendation for appointment with specified clinical privileges or for rejection for staff Membership Favorable Recommendation: When the recommendation of the Medical Executive Committee is favorable to the applicant, the Chief of Staff shall present it to the Board of Directors for final action. All recommendations for approval shall specify the Section/Department affiliation, clinical privileges and any special conditions to be attached to the appointment Adverse Recommendation: When the recommendation of the Medical Executive Committee is adverse to the applicant the Chief of Staff shall immediately so inform the practitioner by special notice and the practitioner shall be entitled to the procedural rights set forth in Article XI of the Medical Staff Bylaws. 3.6 BOARD OF DIRECTORS ACTION The Board of Directors may accept, reject of modify the recommendation of the Medical Executive Committee or may refer the matter back to the Medical Executive Committee for further consideration, stating the purpose for such referral and setting a reasonable time limit for making a subsequent recommendation. The following procedure shall apply with respect to action on the application: If the Medical Executive Committee issues a favorable recommendation and: A. The Board of Directors concurs in that recommendation, the decision of the Board shall be deemed final action. B. The final proposed action of the Board of Directors is unfavorable, the Chief Executive Officer shall give the applicant written notice of the final proposed action. If the Board s final proposed action is a ground for a hearing under the Bylaws Section 9.7 the applicant shall be entitled to the procedural rights set forth in Article XI of the Medical Staff Bylaws, if specifically provided for. If the applicant waives his or her procedural rights, the decision of the Board of Directors shall be deemed the final action In the event the recommendation of the Medical Executive Committee, or any significant part of it is unfavorable to the applicant, and the recommendation is a ground for hearing under Bylaws Section 9.7, the procedural rights set forth in Article XI of the Medical Staff Bylaws, shall apply, A. If the applicant waives his or her procedural rights, the recommendation of the Medical Executive Committee shall be forwarded to the Board of Directors for final action. The Board of Directors shall affirm the recommendation of the Medical Executive Committee if the decision is found to be supported by substantial evidence. B. If the applicant requests a hearing following the adverse Medical Executive Committee recommendation pursuant to this section or an adverse Board of Directors final proposed action pursuant to Section 3.6.1B, the Board of Directors shall take final action only after the applicant has exhausted his or her procedural rights as established by Article XI of the Medical Staff Bylaws. The Board of Directors decision shall be in writing and shall specify the reasons for the action taken.

9 Credentials Manual July 2009 Page 8 of CONFLICT RESOLUTION Whenever the Board of Director's final decision, pursuant to Section 3.6, is contrary to the Medical Executive Committee's recommendation, pursuant to Section 3.5, the Board of Directors shall submit the matter for review and recommendations to an Ad Hoc Joint Conference Committee. That committee shall provide a written recommendation to the Board of Directors within thirty (30) days of receipt of the matter unless good cause exists for extending that time period. Within thirty (30) days after receiving the written recommendation of the Joint Conference Committee, the Board of Directors shall make a final decision on the application. 3.8 AD HOC JOINT CONFERENCE COMMITTEE COMPOSITION The Ad Hoc Joint Conference Committee referred to the Section 3.7 shall be composed of three (3) Members of the Board of Directors, appointed by the chairman of the Board of Directors, and three (3) Members of the Medical Staff, appointed by the Medical Executive Committee. 3.9 NOTICE OF DECISION Notice of the Board of Director's final decision shall be given to the applicant through the Chief Executive Officer, to the Chief of Staff and to the Chair of the appropriate Department/Sub-section A decision and notice to appoint shall include: A. The staff category to which the applicant is appointed. B. The Department and/or Section to which he/she is assigned. C. The clinical privileges he/she may exercise. D. Any special conditions attached to the appointment REAPPLICATION AFTER ADVERSE APPOINTMENT DECISION An applicant who has received a final adverse decision to deny appointment and or clinical privileges, or who has withdrawn his/her application after an adverse recommendation by the Medical Executive committee shall not be eligible to reapply to the Medical Staff for a period of two (2) years. Any such application shall be processed as an initial application and the applicant shall submit such additional information as the Medical Staff or the Board of Directors may require demonstrating that the basis for the earlier adverse action or recommendation no longer exists TIMELY PROCESSING OF APPLICATIONS Applications for Medical Staff appointments shall be considered in a timely manner by all persons and committees required by these Bylaws to act thereon. While special or unusual circumstances may constitute good cause and warrant exceptions, the following time periods provide a guideline for routine processing of complete applications: Evaluation, review and verification of the application and all supporting documents; not more than one hundred twenty (120) days after the receipt of all requested documentation; Review and recommendation by the Department Chair and Credentials Committee: not more than sixty (60) days after receipt of all requested documentation from the Medical Staff Office; Review recommendation by the Medical Executive Committee: not more than thirty (30) days after receipt of recommendation from Department Chair and Credentials Committee Final Action: not more than ninety (90) days after receipt of Medical Executive Committee recommendations or conclusion of hearings. ARTICLE IV: PROVISIONAL CATEGORY 4.1 PROVISIONAL STAFF CATEGORY: QUALIFICATIONS The Provisional Medical Staff shall consist of Practitioners who meet the qualifications of of the Bylaws and immediately prior to their application and appointment were not Members (or were no longer Members) in good standing of the Medical Staff.

10 Credentials Manual July 2009 Page 9 of PREROGATIVES The Provisional Medical Staff Member shall be entitled to the prerogatives provided in Article of the Medical Staff Bylaws PERFORMANCE EVALUATION OF PROVISIONAL MED. STAFF MEMBER (Proctoring) Each provisional Medical Staff Member shall undergo a period of performance evaluation as described in the Department Rules and Regulations to which the practitioner has applied. The evaluation shall be for the purpose of evaluating the following: A. Proficiency in the exercise of clinical privileges initially granted and B. Over-all eligibility for continued Medical Staff Membership and advancement within the Medical Staff categories. The evaluation of provisional Medical Staff Members shall follow whatever frequency and format each Department deems appropriate in order to adequately evaluate the provisional Medical Staff Member including, but not limited to, concurrent or retrospective chart review, mandatory consultation, and/or direct observation. Appropriate records shall be maintained. The results of the observation shall be communicated by the Department Chair to the Credentials Committee. Should the provisional member have been a previous member of the Active Staff at AHMC Anaheim Regional Medical Center who was deemed to have completed his/her proctoring requirements prior to leaving staff and reapplies within five (5) years from the original date of departure, upon the determination of the Credentials Committee, the practitioner could then be recommended for privileges without proctoring if the physician in question provides performance data showing maintenance of current competence and acceptable clinical outcomes from those facilities where the physician was practicing during this interim period TERM OF PROVISIONAL STAFF A member shall remain in the Provisional Staff category for a minimum period of twelve (12) months. This term may be extended for up to one (1) year in accordance with Section 4.3 of this document ACTION AT CONCLUSION OF PROVISIONAL STAFF A. If the provisional Medical Staff Member has satisfactorily demonstrated ability to exercise the clinical privileges initially granted and otherwise appears qualified for continued Medical Staff Membership, the member shall be eligible for placement in the active or courtesy category of the medical staff, as appropriate, upon the recommendation of the Medical Executive Committee and approval of the Board of Directors. B. In all other cases, the Credential(s) committee shall make its report to the Medical Executive Committee, which, in turn, shall make a recommendation to the Board of Directors regarding a modification or termination of clinical privileges and/or Medical Staff Membership. All initial appointments and clinical privileges as well as any new clinical privileges granted to an existing medical staff appointee are provisional for a period of one (1) year during which time all individuals with provisional privileges may be subject to review of their clinical performance by the Department chair. The Department chair will conduct his/her reviews in accordance with procedures adopted by the Credentials Committee. Hearing rights shall be afforded the practitioner if such rights are provided under Article XI of the Medical Staff Bylaws. 4.2 DOCUMENTATION Six months prior to the end of a provisional period, the Medical Staff Services Office will notify the practitioner, by written notice, of the date his/her provisional period will expire. This notice will remind the practitioner of the documents he will be required to submit to identify the successful conclusion of the provisional period. The practitioner must submit to the Credentials Committee, sixty (60) days prior to the end of his/her provisional period, all necessary documents required for advancement to the desired/appropriate category of staff.

11 Credentials Manual July 2009 Page 10 of EXTENSION OF PROVISIONAL APPOINTMENT If an initial appointee or a practitioner is unable to obtain the statements required of her/him with respect to a particular clinical privilege because her/his case load at the Hospital was inadequate to demonstrate ability to exercise that privilege and (s)he submits to the Credentials Committee a statement to this effect describing his/her case load, signed by the chair of the applicable Department, the practitioner's provisional period may be extended for an additional twelve months period by approval of the Credentials Committee. Only one (1) such extension is possible and the provisional period cannot be extended beyond 24 months from initial appointment to staff. 4.4 MODIFICATION/TERMINATION OF CLINICAL PRIVILEGES: A modification or termination of clinical privileges, in whole or in part, shall not entitle a member to a hearing or appeal, unless specifically provided by Article XI of the Medical Staff Bylaws. ARTICLE V: REAPPOINTMENT 5.1 INFORMATION COLLECTION AND VERIFICATION FROM STAFF APPOINTEES: To allow for timely receipt, processing, and review of a reappointment, a minimum of five (5) months prior to the expiration of a current appointment, the Medical Staff Office will mail a reappointment packet to the appointee. The appointee shall furnish, in writing: A. Complete information to update her/his file on items listed in his/her original application (See Section of this Manual); B. Continuing training and education relevant to the specialty, experience and demonstrated ability during the preceding period; C. Specific request for the clinical privileges sought on reappointment, supported by documentation of current competence, with any basis for changes; Privileges previously approved but no longer performed, may be deleted. D. Requests for changes in staff category or Department assignments, if any; E. Attestation of physical and mental health as required to perform privileges requested. F. CMEs to support the privileges requested. G. Re-application fee, if applicable Status at time of Reappointment: Fee Status at time of Reappointment: Fee Provisional $400 Consulting $400 Active $200 Honorary None Senior Active (25 years Plus) None Affiliate * $400 Courtesy $400 Community Non-Admitting * $400 H. Any other information that may be requested by the Medical Staff for purposes of evaluating the member for reappointment. Receipt of Reappointment: A. If upon review by the Medical Staff Office, the reappointment is incomplete, the physician will have an additional thirty (30) days to supply the required information. B. If the required information is not received in the Medical Staff Office in thirty (30) days, recommendation will be forwarded to the Credentials Committee to accept a voluntary resignation. C. The Credentials Chair will notify the appointee of this recommendation by certified mail. Should the appointee wish to maintain membership and privileges, s(he) may request reinstatement by submission of the necessary information to the Medical Staff Office within fifteen (15) days of the date of the Credentials Committee meeting where recommendation was made to accept voluntary resignation.

12 Credentials Manual July 2009 Page 11 of 19 Non Receipt of Reappointment: A. If the reappointment is not received in the Medical Staff Office within sixty (60) days of the date the reappointment application is mailed, recommendation to accept a voluntary resignation will be forwarded to the Credentials Committee. B. The Credentials Chair will notify the appointee of this recommendation by certified mail. C. Should the appointee wish to maintain membership and privileges, s(he) may request reinstatement by submission of a complete reappointment application to the Medical Staff Office within fifteen (15) days of the date of the Credentials Committee meeting where recommendation was made to accept voluntary resignation. D. Failure, without good cause, to provide this information is deemed a voluntary resignation from the staff and automatically results in expiration of appointment at the expiration of the current term. Following the expiration of the appointment, should the appointee wish to maintain membership and/or privileges at ARMC, (s)/he must complete an initial application for staff privileges which will require processing as outlined under Initial Applications. Temporary privileges will not be requested during the processing of such application. In the event membership so expires for the reason set forth herein, the procedures set forth in Article XI of the Medical Staff Bylaws shall not apply. A practitioner may request a review of such expiration by the Credentials, but such review shall not constitute a "hearing" as that term is used in Article XI of the Medical Staff Bylaws FROM INTERNAL AND/OR EXTERNAL SOURCES: A representative of the Medical Staff Office collects from each staff appointee's Credentials file and other relevant sources information regarding the individual's professional and collegial activities, performance and conduct in this Hospital and/or other Hospitals. Such information includes, without limitation: at lease one peer reference, patterns of care as demonstrated in findings of quality improvement activities; medical records/hospital reports; continuing education activities; attendance at a required general medical staff meeting; service on the medical staff, Department, and Hospital committees; timely and accurate completion of medical records; compliance with all applicable Bylaws, Policies, Rules, Regulations and Procedures of the Hospital and staff and all other information deemed relevant by the Medical Staff for the purpose of evaluating the member for reappointment All documents shall be reviewed and verified as described in Article III of this Manual The Credentials Coordinator will compile a summary of clinical activity, meeting attendance and quality improvement information for each appointee due for reappointment. 5.2 PROCEDURE FOR PROCESSING APPLICATIONS FOR REAPPOINTMENT The Credentials Coordinator shall review all pertinent information and prepare a summary of findings for each appointee due for reappointment The Chair of the appropriate Section and/or Department will review the re-appointment application documentation and make recommendations in writing to the Credentials Committee as to membership and/or the privileges and renewal thereof The Chair of the Credentials Committee will have the opportunity to review the completed file including all documentation and recommendations from the department mentioned above before the Credentials Committee meeting CREDENTIALS COMMITTEE ACTION The Credentials Committee shall review information available on each member being considered for reappointment including the Department Chair s and Peer Reviewer recommendations, at its next scheduled meeting, or as soon as practicable thereafter, and shall transmit to the Medical Executive Committee a written report with recommendations that appointment be either renewed; renewed with modified staff category, Department affiliation, and/or clinical privileges; or termination. The

13 Credentials Manual July 2009 Page 12 of 19 committee may also recommend that the Medical Executive Committee defer action on the reappointment. Where non-reappointment or a change in clinical privileges is recommended, the reasons for such recommendations shall be stated and shall be fully supported with relevant facts. All recommendations shall satisfy the requirements of Section of this document BASIS FOR RECOMMENDATION Periodically, at the time of reappointment, the Medical Staff shall appraise its current members and their qualifications. Each recommendation concerning the reappointment of a member, and the clinical privileges to be granted upon reappointment shall be based upon such member's professional ability and clinical judgment in the treatment of patients; findings of QA activities by Department ; his/her professional ethics; his/her discharge of staff obligations; his/her compliance with the Medical Staff Bylaws and Rules and Regulations; attendance at medical Staff meetings and participation in staff affairs; his/her cooperation with other practitioners, Hospital personnel, patients, and the public; his/her use of Hospital's facilities for his/her patients; his/her maintenance of timely, accurate and complete records; and other matters bearing on his/her ability and willingness to contribute to quality patient care in the Hospital. Recommendation for continued Medical Staff Membership will also be based upon the point system identified in POINT SYSTEM 1. Admissions/Consultations/Surgeries(Primary or First Assistant over 2 years) point points points points At least one point from this category must be used to obtain/maintain Active Status. 2. Committee Meeting Attendance and Participation (over 2 years) 50% attendance at 1 Committee 1 point 50% attendance at 2 Committees 2 points 50% of 3 or more Committees 3 points 3. Department/Sections Meeting Attendance (over 2 years) 1-24% Attendance of meetings held 1 point 25-49%Attendance of meetings held 2 points 50% attendance 3 points At least one point from this category must be used to obtain/maintain Active Status 4. Attendance at General Staff Meetings 1 point 5. One point may be allowed during each two year period for all staff categories for proctoring or retrospective peer review. The need and system for assignment for peer review and proctoring will be determined by the Chair of each department. Physicians in the specialties of Anesthesiology, Radiology, Radiation Oncology, Pathology and Emergency Medicine will automatically be granted three (3) points for admissions. Physicians in the specialties of psychiatry, allergy, dermatology and clinical psychologists will automatically be granted three (3) admission points. Attending physicians will get admissions credit when their patient is admitted and treated by another specialist or sub-specialist, whenever such information is retrievable QUALIFICATIONS Members of the medical staff who currently hold or seek to hold the category of Active status are required to have a minimum of six (6) points in a two (2) year period as specified in the Bylaws, Article III, Section 3.2.1A. Active staff members must earn at least 1 point in two years for patient activity and for attending department/section meetings.

14 Credentials Manual July 2009 Page 13 of 19 Members of the medical staff who currently hold the category of Courtesy Status are required to have a minimum of two (2) points during a two (2) year period as specified in the Bylaws Article III, Section 3.3.1A RESPONSIBILITIES: A. It is the responsibility of the applicant to supply documentation of the first six (6) qualifying points for Active Category, or the first two (2) qualifying points for Courtesy-Category. B. It is the responsibility of the Chair of the Department or his representative to verify the documentation submitted FINAL PROCESSING Thereafter, the procedure provided in Section 3.4 of this Manual shall be followed. For purposes of reappointment, the terms "applicant" and "appointment" used in those sections shall be read, respectively, as "member" and "reappointment" NOTIFICATION OF ADVERSE ACTION IMPOSED Any practitioner against whom termination, reductions, restrictions, denials or other sanctions on Medical Staff Membership or clinical privileges of any kind have been finally imposed by any other health care institution or sanctions imposed by the Medical Board agrees to inform the Chief Executive Officer immediately and not wait until the time of reappointment REQUEST FOR MODIFICATION OF APPOINTMENT CATEGORY OR PRIVILEGES A staff appointee, either in connection with reappointment or at any other time, may request modification of his/her staff category, Department assignment, or clinical privileges by submitting a written application/request to the Credentials Committee. A request for modification is processed in the same manner as a reappointment. All requests for increased privileges must be accompanied by information demonstrating appropriate training and current clinical competence in the specific privilege requested. ARTICLE VI: PRIVILEGES FOR IMPORTANT NEED 6.1 Request for temporary Privileges to fulfill an Important Patient Care Need: It is the responsibility of the physician requesting these privileges to provide the following documentation prior to consideration: Completion of an Application for Temporary Privileges to Fulfill an Important Patient Care Need. Proof of current professional liability insurance appropriate for privileges requested in the amount established by the Board of Directors. Copy of a current California Medical License Copy of a current DEA. 6.2 Upon receipt of the above, the Medical Staff will obtain verification of the following: Reference letter from at least one peer knowledgeable of the practitioner s performance, clinical judgment, and technical skills. at least one current hospital affiliation current California licensure National Practitioner Data Bank Report OIG Report, including no exclusions from any health care program funded in whole or in part by the Federal Government, or any state health care program, including, but not limited to, Medicare or MediCal. 6.3 Conditions, Terminations and Rights related to these privileges are as outlined in the Bylaws, Article IV, Section 4.3, Temporary Privileges.

15 Credentials Manual July 2009 Page 14 of 19 ARTICLE VII: LEAVE OF ABSENCE Individuals appointed to the Medical Staff, for good cause, requiring them to temporarily cease practice in this community, may be granted a leave of absence by the Board of Directors for a definitely stated period of time not to exceed one (1) year. Absence for longer than one (1) year shall constitute a voluntary resignation of Medical Staff appointment and clinical privileges unless written request is made by the practitioner for an exception to be is made by the Board of Directors upon recommendation of the Medical Executive Committee. During the period of time of the leave, the staff appointee s clinical privileges, prerogatives and responsibility are suspended, however, the requirement of annual dues will continue unless waived by the Medical Executive Committee. 7.1 REQUESTS FOR LEAVES OF ABSENCE These shall be made to the Department Chair in which the individual applying for leave holds clinical privileges, and shall state the beginning and the ending dates of the requested leave. The request shall be transmitted to the Medical Executive Committee for recommendation and the Board of Directors for approval. 7.2 AT THE CONCLUSION OF THE LEAVE OF ABSENCE The individual may be reinstated, upon filing a written statement with the Chief of Staff summarizing the professional activities undertaken during the leave of absence. The individual shall also provide such other information as may be requested by the medical staff at that time, including submission of a reappointment application. All information shall then be forwarded to the Section/Department Chair for review and then to the Credentials Committee. After considering all relevant information, the Credentials Committee shall then make a recommendation regarding reinstatement to the Medical Executive Committee, which shall, thereafter, make a recommendation to the Board of Directors for final action. 7.3 IF THE LEAVE OF ABSENCE WAS FOR MEDICAL REASONS The appointee must submit a report from his/her attending practitioner indicating that the appointee is physically and/or mentally capable of resuming a Hospital practice and exercising the clinical privileges requested. The appointee shall also provide such other information as may be requested by the Hospital or medical staff at that time. All information shall then be forwarded to the Credentials Committee. After considering all relevant information, the Credentials Committee shall then make a recommendation regarding reinstatement to the Medical Executive Committee, which shall, thereafter, make a recommendation to the Board of Directors for final action. 7.4 BOARD OF DIRECTORS ACTION In acting upon the request for reinstatement, the Board of Directors may approve reinstatement either to the same or different staff category, and/or may limit or modify the clinical privileges to be extended to the individual upon reinstatement. ARTICLE VIII: CREDENTIALING FOR NEW PROCEDURES 8.1 OBJECTIVE To outline the process regarding requests from Medical staff members for privileges to perform a new procedure not previously done at AHMC Anaheim Regional Hospital and Medical Center. 8.2 POLICY All requests to perform a new procedure shall be subject to a collective assessment by the appropriate clinical department, the medical Executive Committee and the Governing Board. 8.3 DEFINITION A New Procedure is defined as a procedure or technique or variation of a procedure or technique, each in their broadest sense, not previously performed by members of the medical staff or a change in a procedure or technique that is sufficient to require additional training as determined by the applicable Department/Section Chair. An example of a new procedure or variation would be the use of new surgical instruments which requires additional training as determined by the Department/Section Chair.

16 Credentials Manual July 2009 Page 15 of PROCEDURE Requests to perform a new procedure at AHMC Anaheim Regional Medical Center will be evaluated by the appropriate clinical section/department, the Medical Executive Committee and the Governing Board taking into consideration the following elements: a. Community need b. Alternative approaches c. Efficacy d. Effectiveness e. Hospital-specific capabilities f. Risks g. Accuracy of monitoring equipment h. Possible uses and misuses An initial request to perform a new procedure shall be submitted to the member s assigned section/department for determination of whether the section/department wishes to perform the requested procedure at AHMC Anaheim Regional Medical Center. The Application to Request a New Procedure/Technology Form (Addendum A ) must be completed. a. The respective clinical section/department may determine that a new procedure is an extension of a current procedure(s) already being performed, a new procedure for the requesting specialty, which requires development of credentialing criteria or a new procedure which may be performed by multiple specialties and therefore requires the development of interdepartmental credentialing criteria. b. If the respective clinical section/department determines that a new procedure could improve patient care, it shall individually or collectively with other specialties seeking the privilege, develop and submit respective criteria sufficient for credentialing individuals in the procedure. c. The respective clinical section/department shall have the right to require the member to meet with the section/department to discuss his/her request to perform a new procedure Credentialing criteria for new procedures shall include the following requirements: a. Documentation of a completed approved residency in the specialty(ies) within which the procedure is ordinarily expected to be performed. b. A certificate obtained at a CME training course, if training was not included in residency. c. Proof of proctoring or satisfactory performance of cases. The number of cases and time frame of proctoring to be determined by the clinical section/department Requests for clinical privileges will be forwarded to the appropriate clinical chair when the Medical Staff member has submitted the following information: a. A request for additional privileges either by letter or via the reappointment process. b. Documentation to support that all elements of the credentialing criteria, as outlined in section 3.0 of this document have been met A query to the National Practitioner Data Bank will be performed following receipt of a request for additional privileges The appropriate clinical section/department chair will evaluate the member s request for privileges and forward a recommendation to the Credentials Committee. ARTICLE IX: DISASTER CREDENTIALING 9.1 PURPOSE To provide a process to credential/privilege volunteer practitioners and/or allied health professionals (AHP) in the event of a disaster whereby the HICS plan has been activated and the hospital is unable to meet immediate patient care needs.