Medical Staff Credentialing Procedures Manual. Reviewed: November 21, 2013

Transcription

1 Medical Staff Credentialing Procedures Manual Reviewed: November 21, 2013

2 PART ONE: APPOINTMENT PROCEDURES 1.1 PRE-APPLICATION A. No practitioner shall be entitled to membership on the medical staff or privileges merely by virtue of licensure, membership in any professional organization, or privileges at any other healthcare organization. B. A pre-application must first be requested from the Medical Staff Service Department. The applicant must state his/her intention for membership. The completed pre-application is processed to see if the applicant is requesting privileges for a service the Board of Directors has determined appropriate at the hospital. There must also be a need for this service as approved by the Medical Staff Development Plan through the Board. C. After receiving the pre-application, Medical Staff Services (MSS) personnel, under advisement of the Vice President for Medical Affairs (VPMA), shall review the pre-application to make sure the Applicant meets the basic qualifications to become a Member of the Medical Staff. Call coverage is reviewed, a report from the National Practitioner Data Bank (NPDB) is generated, Board Certification is researched, and a report from the U.S. Department of Health and Human Services Office of Inspector General (OIG) is generated. Also, the Intended Practice Statement is reviewed to see if there is a community or facility need. This statement provides the Hospital the opportunity to evaluate the Hospital s current and projected patient care needs, as well as the Hospital s ability to provide the physical, personnel, and financial resources that will be required if the application is acted upon favorably. D. The pre-application and accompanying verification completed by MSS is forwarded to the VPMA or designee. If approved, the full application and subspecialty privilege forms are mailed to the applicant. E. If the Applicant s pre-application does not meet the minimum requirements for Medical Staff Membership, or indicates that the Hospital is unable to accommodate the Applicant, as provided in the Bylaws, then the Applicant shall be informed in writing within thirty (30) days from the date the pre-application is stamped received. 1.2 QUALIFICATIONS FOR MEMBERSHIP AND/OR PRIVILEGES A. In Article 2 of the Medical Staff Bylaws of St. Dominic Hospital, there are General Qualifications listed. MSS, in conjunction with the Credentials Committee, will verify the information listed below when reviewing and processing a new application for medical staff appointment.

3 The following qualifications must be met by all applicants for medical staff appointment, reappointment or clinical privileges: 1. Demonstrate that he/she has successfully graduated from an approved school of medicine, osteopathy, dentistry, or applicable recognized course of training in a clinical profession eligible to hold privileges. 2. Have a current, unrestricted state or federal license as a practitioner, applicable to his or her profession, and providing permission to practice within the state of Mississippi; 3. Have a record that is free from current Medicare/Medicaid sanctions and not be on the OIG List of Excluded Individuals/Entities; 4. Have a record that is free of felony convictions or occurrences that would raise questions of undesirable conduct which could injure the reputation of the medical staff or hospital; 5. A physician applicant, MD or DO, must have successfully completed an allopathic or osteopathic residency program, approved by the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA) and be currently board certified or become board certified within five (5) years of completing formal training as defined by the appropriate specialty board of the American Board of Medical Specialties or the American Osteopathic Association; 6. Dentists must have graduated from an American Dental Association approved school of dentistry accredited by the Commission of Dental Accreditation; 7. Oral maxillofacial surgeons must have graduated from an American Dental Association approved school of dentistry accredited by the Commission of Dental Accreditation and successfully completed an American Dental Association approved residency program and be board certified or become board certified within five (5) years of completing formal training as defined by the American Board of Oral and Maxillofacial Surgery; 8. Possess a current, valid, unrestricted drug enforcement administration (DEA) number if applicable; 9. Have appropriate written and verbal communication skills; 10. Have appropriate personal qualifications, including applicant s consistent observance of ethical and professional standards. These standards include, at a minimum:

4 a. Abstinence from any participation in fee splitting or other illegal payment, receipt, or remuneration with respect to referral or patient service opportunities; b. A history of consistently acting in a professional, appropriate and collegial manner with others in previous clinical and professional settings. 11. CME Attestation - All initial and reappointment applicants will be required to sign a CME attestation which states proof of attendance and program content will be supplied upon request. St. Dominic Hospital s policy follows the Mississippi State Board of Medical Licensure s requirements of completing 40 CME hours every two years. B. The following qualifications must also be met by all applicants requesting clinical privileges: 1. Able to demonstrate information surrounding background, experience, training, current competence, knowledge, judgment, and ability to perform all privileges requested; 2. Upon request provide evidence of both physical and mental health that does not impair the fulfillment of his/her responsibilities of medical staff membership and the specific privileges requested by and granted to the applicant; 3. Any practitioner granted privileges must demonstrate the capability to provide continuous and timely care to the satisfaction of the MEC and Board; 4. Able to demonstrate recent clinical performance within the last twelve (12) months with an active clinical practice in the area in which clinical privileges are sought adequate to meet current clinical competence; 5. Provide evidence of professional liability insurance appropriate to all privileges requested and of a type and in an amount established by the Board after consultation with the MEC. C. Exceptions: 1. All practitioners who are current medical staff members and held privileges as of May 1, 1990 and who have met prior qualifications for membership and/or privileges shall be exempt from board certification requirements. 2. After consultation with the Medical Executive Committee (MEC), the Board of Directors may create additional exceptions if there is

5 documented evidence that a practitioner demonstrates an equivalent competency in the areas of requested privileges. 1.3 APPLICATION The application must be in writing and on such forms as set forth in the Bylaws. Prior to the application being submitted, the Applicant will be provided a copy of, or access to a copy of, the Medical Staff Bylaws, and the Rules & Regulations of the Medical Staff At time of orientation, The Catholic Ethical and Religious Directives, and other hospital and medical staff policies and resolutions relating to clinical practice in the Hospital, will be given to the applicant. By signing the attestation on the last page of the application, the Applicant agrees in writing that his activities as a Member of the Medical Staff will be bound by such documents. Each Applicant will also be instructed on the mechanisms for appointment and granting of Clinical Privileges and renewal/revision of Clinical Privileges. 1.4 APPLICATION CONTENT Every application must contain a current photograph of the Applicant along with current curriculum vitae. The Applicant should provide the following documentation to Medical Staff Services at the time of application: A. Documentation of his educational background, experience, training and competence including but not limited to medical school(s), internship(s), residency (ies), board certifications(s), and Educational Commission for Foreign Medical Graduates (ECFMG) certification. B. Copies of States and Jurisdiction(s) for which he holds licensure. C. Copy of valid government-issued photo identification (driver s license or passport). D. All Hospitals including ambulatory surgery centers where he currently holds or has held Clinical Privileges. Also, the Applicant must provide whether his membership status or clinical privileges have ever been or are being denied, revoked, suspended, reduced, challenged or not renewed, voluntarily or involuntarily, at this or any other hospital or institution. E. Names of three (3) professional references (at least one must be a peer in the same specialty) qualified to make recommendations on Clinical Privileges requested.

6 F. Copy of DEA Registration and whether his DEA Registration or other registrations have ever been or is being revoked, challenged, restricted, suspended (voluntarily or involuntarily). G. Certificate(s) of insurance with documentation that he possesses current, valid professional liability insurance coverage with equivalent minimum limits of $1,000,000 per occurrence and $3,000,000 in the aggregate year. H. The Applicant must provide information about involvement in any professional liability action. This includes open claims within the last five (5) years. I. The Applicant must provide information about all final judgments or settlements of lawsuits involving the applicant. J. The Applicant must demonstrate his adherence to the ethics of his profession and his good reputation and character. K. The Applicant must provide requested documentation of his ability to perform requested Clinical Privileges. L. The Applicant must fully complete and explain all information requested on the application and, in the event questions arise, must make timely responses. M. The Hospital shall access the National Practitioner Data Bank and the Hospital or its legal counsel may access all malpractice insurance information regarding current coverage and claim status of the Applicant as necessary. N. The Applicant must provide information about successful or currently pending challenges to any licensure or registration (state or district, Drug Enforcement Administration, Controlled Substances Registration) or the voluntary relinquishment of such licensure or registration. O. The Applicant must provide information about voluntary or involuntary termination of medical staff membership or voluntary or involuntary limitations, denials, challenges or non-renewals, reduction, or loss of clinical privileges at another hospital. P. The Applicant must provide information about special training needed by Hospital staff to support the Applicant s Clinical Privileges, and special facility and/or support services needs in order for the Hospital to support the requested Clinical Privileges. Q. The Applicant shall report whether or not he has ever been excluded, debarred, or otherwise rendered ineligible to participate in Federal Health Care Programs. R. The Applicant must be Board Certified or eligible for Board Certification to be obtained following completion of formal training and within the guidelines of the specialty or subspecialty board.

7 1.5 APPLICATION FEE An initial non-refundable application fee of three hundred dollars ($300.00) is required of each Applicant for Medical Staff Membership and Clinical Privileges. The check should be made payable to St. Dominic Hospital. An application will not be processed until the application fee is received or has been waived by the administration of the Hospital. 1.6 REFERENCES The application must include the names of at least three (3) individuals who have personal knowledge of the Applicant s current clinical ability, ethical character, health status and ability to work cooperatively with others and who will provide specific written comments on these matters upon request from Hospital or Medical Staff authorities. The references preferably need to be those who have recently worked with the applicant and have recently directly observed his/her professional performance. The hospital will directly contact the references and request information regarding current medical/clinical knowledge, technical and clinical skills, clinical judgment, interpersonal skills, communication skills, professionalism, and ability to perform (health status). 1.7 EFFECT OF APPLICATION The Applicant must sign the application and in so doing: A. Attests to the correctness and completeness of all information furnished; B. Signifies his willingness to appear for interviews in connection with his application; C. Agrees to abide by the terms of the Bylaws, Rules and Regulations, policies and procedures Manuals of the Medical Staff, The Catholic Ethical and Religious Directives, and those of the Hospital if granted Membership and/or Clinical Privileges, and to abide by the terms thereof in all matters relating to consideration of the Applicant without regard to whether or not Membership and/or Clinical Privileges are granted; D. Agrees to maintain an ethical practice and to provide continuous care to his patients, and attests in writing to his coverage arrangements; E. Authorizes and consents to Hospital representatives consulting with prior associates or others who may have information bearing on professional or ethical qualifications and competence and consents to their inspecting all records and documents that may be material to evaluation of said qualifications and competence; F. Releases from any liability all those who review, act on or provide information regarding the Applicant s competence, professional ethics, character, health

8 status, and other qualifications for Medical Staff appointment and Clinical Privileges; and G. Agrees to all of the basic obligations of Medical Staff set forth in the Medical Staff Bylaws. 1.8 PROCESSING THE APPLICATION A. APPLICANT S BURDEN The Applicant has the burden of producing adequate information for a proper evaluation of his experience, training, demonstrated ability, and health status, and of resolving any doubts about these or any of the qualifications required for Medical Staff Membership or the requested Medical Staff category, Department/Service assignment, or Clinical Privileges, and of satisfying any reasonable requests for information or clarification (including health examinations) made by appropriate Medical Staff or Board authorities. If there is undo delay in obtaining required information or if the hospital requires clarification of such information, the Medical Staff Office will request the applicant s assistance. The hospital has the sole discretion for determining what an adequate response is. If the applicant fails to respond adequately within 30 days, the hospital will deem the application as withdrawn voluntarily. The result will not be considered an adverse action. B. VERIFICATION OF INFORMATION The completed application is submitted to Medical Staff Services. MSS collects or verifies from the primary source whenever possible the reference, licensure, and other qualification evidence submitted and promptly notifies the applicant of any problems in obtaining the information required. By submitting the signed application, the Applicant authorizes MSS personnel or other representative of the Hospital to consult medical staff members and/or employees of other hospitals with which the applicant has been associated, and any other persons who may have information bearing on his professional conduct, competence, character, ability to perform the Clinical Privileges requested, and ethical qualifications for Medical Staff Membership. He further understands that the Hospital will gather information from the National Practitioner Data Bank in accordance with all pertinent statutes, rules, regulations and policies. The Office of the Inspector General (OIG) Sanction Report and the General Services Administration (GSA) Excluded Providers List will be checked to ensure that the Applicant is not listed.

9 When collection and verification is accomplished and the application is deemed complete, the Medical Staff Office shall present a copy of the application and all supporting materials to the medical department in which the Applicant seeks privileges for evaluation and approval, ensuring that a peer is included in the review process. Should new, additional or clarifying information be required for an application to be considered complete, the Applicant shall have thirty (30) days from the date of the request for the information to submit the information. If the application is not deemed complete within thirty (30) days of such request, it shall be deemed withdrawn. After the application is deemed complete as described in the Medical Staff Credentialing Procedures Manual, it will be forwarded to the Department Chairman, the Credentials Committee, the MEC, the QA/PI Committee and to the Board. The process for reviewing applications shall generally be completed within 60 days. C. MEDICAL STAFF INPUT Any Member of the Medical Staff may submit to the Credentials Committee, in writing and with full details, information relevant to the Applicant s qualifications for Membership and Clinical Privileges. Any Member who provides such written statement may also petition, or may be requested by, the Credentials Committee to appear before it in person to discuss the application. The organized medical staff will review and analyze all relevant information regarding each applicant s current licensure status, training, experience, current competence, and ability to perform the requested privileges. D. DEPARTMENT AND/OR SERVICE ACTION After the application is deemed complete, it will be forwarded to the Department Chairman. After review by the Department Chairman, he/she shall forward to the Credentials Committee a written confirmation that the Applicant meets all criteria for Medical Staff Membership and a recommendation concerning the appointment and/or delineation of Clinical Privileges of the Applicant. In cases where requested Clinical Privileges involve procedures performed in Hospital Departments other than those in which Departmental LIPs typically perform, the chairman may seek input from the medical director (and/or Committee Chair and/or Department Chair, if applicable) of that area before making a recommendation about the granting of Clinical Privileges. E. CREDENTIALS COMMITTEE ACTION

10 (1) The Credentials Committee shall examine the application, supporting documentation, and any related information, in order to make a recommendation regarding the appointment and/or delineation of Clinical Privileges of the Applicant. (2) If the Credentials Committee requests an interview, the Applicant must participate. The Credentials Committee shall determine the extent of investigation necessary to make its recommendation. (3) The Credentials Committee shall obtain specific written recommendations from every applicable medical Department regarding the Applicant s ability to meet all criteria for Medical Staff Membership and for the delineation of the requested Clinical Privileges. (4) The Credentials Committee must make its recommendation within thirty (30) days after it concludes, using reasonable discretion, and its investigation regarding the completeness of the application. (5) The Credentials Committee shall forward to the Medical Executive Committee the completed application, the recommendation of the Chairman of the appropriate medical Department(s) and the Credentials Committee s recommendation concerning the appointment and/or delineation of Clinical Privileges of the Applicant. F. MEDICAL EXECUTIVE COMMITTEE ACTION (1) At its regular meeting, the Medical Executive Committee shall review the application for appointment and the previous recommendations and make its written recommendation to the Board (via the QA/PI Committee, a designated committee of the Board) concerning the appointment and/or delineation of Clinical Privileges of the Applicant. If the Medical Executive Committee recommends denial of appointment and/or Clinical Privileges or a restriction of Clinical Privileges, the reason(s) for such recommendation shall be stated. (2) If the Medical Executive Committee, in its discretion, finds it necessary for further consideration to defer making a recommendation upon the application, the Applicant will be so notified. The deferral may not exceed an additional thirty (30) days. Before the end of the thirty (30) day deferral, the Medical Executive Committee must make its recommendation(s) to the Board as described in Section 1.7 (F) (1) above. G. QA/PI COMMITTEE (BOARD COMMITTEE) ACTION (1) Following a positive recommendation from the Medical Executive Committee, the QA/PI Committee at its next monthly meeting will review and evaluate the qualifications and competence of the LIPs applying for

11 appointment. The positive decision of the QA/PI Committee is forwarded to the Board for ratification. H. EFFECTIVE TIME OF MEDICAL EXECUTIVE COMMITTEE ACTION (1) Deferral: If the Medical Executive Committee, in its discretion, finds it necessary for further consideration to defer making a recommendation upon the application, the Applicant will be so notified. The deferral may not exceed an additional thirty (30) days. Before the end of the thirty (30) day deferral, the Medical Executive Committee must make its recommendation(s) to the Board. (2) Favorable Recommendation: If the Medical Executive Committee s recommendation is favorable to the Applicant in all respects, the CEO or his designee shall promptly forward it, together with all supporting documentation, to the QA/PI Committee. (a) Adverse Recommendation: If at any time the Medical Executive Committee s recommendation is adverse to the Applicant, the Hospital President immediately so informs the Applicant by Special Notice, who is then entitled to the procedural rights as provided in Articles 10 and 11 in the Bylaws. I. BOARD ACTION (1) At its next regular meeting, the Board shall review the application for appointment and, if appropriate, ratify all positive QA/PI recommendations. If the QA/PI Committee s decision is adverse to an applicant, the matter is referred back to the Medical Executive Committee for further evaluation. If the Applicant was ineligible for the expedited process, the Board will review the previous recommendations and make a final decision concerning the appointment and/or delineation of Clinical Privileges of the Applicant. The Board s decision shall be final. (2) All Board decisions to appoint an Applicant to the Medical Staff shall include a delineation of the Clinical Privileges, which the Applicant may exercise, unless the applicant has only applied for Membership without Clinical Privileges as established in the Medical Staff Bylaws. (3) If the Board recommends denial of appointment or a restriction of Clinical Privileges, the reason(s) for such recommendation shall be stated. J. NOTICE OF FINAL DECISION (1) Notice of the Board s final decision is given through the President to the Medical Executive Committee, to the Applicant by Special Notice.

12 (2) A decision and notice to appoint includes: (a) (b) (c) (d) Medical Staff category to which the Applicant is appointed; Department and Service to which he is assigned; Delineation of the Clinical Privileges which the Applicant may exercise; and Any special conditions attached to the appointment. (3) If the decision of the Board Adversely affects the appointment and/or Clinical Privileges of the Applicant, see Articles 10 and 11 of the Bylaws. K. TIME PERIODS FOR PROCESSING The process for initial appointments will generally be completed within sixty (60) days of receipt of the application in the Medical Staff Office, to include approval by the Board and/or the QA/PI Committee. The overall process may be broken down into the following timeframes: (a) (b) (c) (d) (e) (f) Medical Staff office: Forwards within 30 days of receipt of completed application Department Chairman: Forwards within 30 days of receipt of application Credentials Committee: Forwards within 30 days following the completion of the investigation Medical Executive Committee: Forwards within 30 days unless deferred an additional 30 days at MEC discretion QA/PI Committee: Reviews application at next monthly meeting following receipt of the application from MEC Board of Directors: At next regular meeting following the receipt of recommendations from the QA/PI Committee, the Board considers appointment applications (expedited and otherwise). Positive QA/PI Committee recommendations of Applicants credentialed through the expedited process are eligible for ratification. If there is a negative

13 committee recommendation, the Board shall review the application prior to making a decision. These timelines are deemed guidelines and are not directives such as to create any rights for a LIP to have an application processed within these precise periods. If the provisions of Articles 10 and 11 of the Bylaws are activated, the time requirements provided therein govern the continued processing of the application. L. CRITERIA TO EXPEDITE APPLICANTS If the Applicant has been on staff at St. Dominic s previously and left in good standing, some or all of the above criteria may or may not be waived if recommended for approval by the Department Chairman/Vice Chairman and Credentials Committee. Completed application shall be categorized according to findings identified in the interview process. (1) Category One Applicants (Expedited Applicant also known as problem free application) (a) Criteria 1. All requested information has been returned promptly; 2. There are no negative or questionable recommendations; 3. There are no discrepancies in information received from the applicant or references; 4. The Applicant completed a traditional education/training sequence; 5. There have been no disciplinary actions or legal sanctions; 6. There have been no final judgments adverse to the Applicant in a professional liability action; 7. The Applicant has an unremarkable Medical Staff/employment history; 8. The Applicant has submitted a reasonable request for Clinical Privileges based on experience, training, and competence and is in compliance with applicable criteria; 9. The Applicant reports an acceptable health status;

14 10. The Applicant has never been sanctioned by a third-party payer (e.g. Medicare, Medicaid, etc.) 11. The Applicant has never been convicted of a felony; 12. The Applicant is requesting Clinical Privileges consistent with his specialty; and 13. The Applicant s history shows an ability to relate to others in a harmonious and collegial manner. (b) Procedure for Expedited Appointment 1. The Medical Staff office receives and processes the application. 2. The appropriate Department Chairman/Vice Chairman reviews the completed application and forwards a recommendation to the Credentials Committee Chair. 3. The Credentials Committee forwards its reports with findings and recommendations to the Medical Executive Committee. 4. The MEC s recommendation is forwarded to the QA/PI Committee, which forwards a recommendation to the Board. 5. The Board s representatives on the QA/PI Committee report to the Board at its next regular meeting and the Board ratifies all positive decisions made by the QA/PI Committee. The Board s decision is final. Note: If the Department Chairman/Vice Chairman recommendation is negative or differs from that of the Credentials Committee or MEC members, the application is automatically classified as Category Two and is processed accordingly. Also, if the Applicant has been on staff at St. Dominic s previously and left in good standing, some or all of the above criteria may or may not be waived if recommended for approval by the Department Chairman/Vice Chairman and Credentials Committee. (2) Category Two Applicants If one or more of the criteria for category 1 are not met, the application will be treated as a category 2. This category will follow the normal process of approval and review (department chair, the Medical Staff

15 credentials committee, the MEC, and the Board of Directors. At all stages in the review process, the burden in on the applicant to provide evidence that he or she meets the criteria for membership on the medical staff and for the granting of requested privileges. Applicant is usually ineligible for the expedited process if at the time of appointment any of the following has occurred: The Applicant submits an incomplete application; The Medical Executive Committee makes a final recommendation that is adverse or with limitation; There is a current challenge or a previously successful challenge to licensure or registration; The Applicant has received a voluntary or involuntary termination of Medical Staff Membership at another organization; The Applicant has received voluntary or involuntary limitation, reduction, denial, or loss of Clinical Privileges; or There has been a final judgment adverse to the Applicant in a professional liability action. (a) Procedure for Category Two Applicants 1. The Medical Staff office receives and processes the application. 2. The application is forwarded to the appropriate Department Chief/Vice Chief for review and recommendation. The Department Chief/Vice Chief reviews the application to make sure it meets the established standards for Membership and Clinical Privileges. 3. The Department Chief/Vice Chief forwards the application to the Credentials Committee for review and recommendation. 4. The Credentials Committee then forwards the application to the MEC for review and recommendation. 5. The MEC forwards the application with its recommendation to the QA/PI Committee. QA/PI Committee forwards its recommendation to the Board for final action. 1.9 APPLICATION CLOSED Applications are considered closed when:

16 A. References, including peer and hospital affiliations, are not returned within 45 days after submission B. Answers to questions or explanations are not obtained from the applicant in writing within 30 days A final letter will be mailed to the applicant stating if items are not received within 10 days the application will be considered closed. PART TWO: REAPPOINTMENT PROCEDURES 2.1 INFORMATION COLLECTION AND VERIFICATION A. FROM MEDICAL STAFF MEMBER APPLYING FOR REAPPOINTMENT All appointments, except for provisional, are for a period not to exceed two years. On or before two months (60 days) prior to the date of expiration of a Medical Staff Member s appointment, the Medical Staff Office shall notify the LIP of his appointment expiration date. The Applicant must furnish a complete application for reappointment to the Medical Staff, providing sufficient time to process the application, and to include: (1) Complete information to update his file on the items listed in above in the Appointment Section of this Manual; (2) Any continued training and education external to the Hospital during the preceding appointment period; (3) Specific request for the Clinical Privileges sought upon reappointment, with any basis for changes; and (4) Requests for changes in Medical Staff category or Department/Service assignments. Failure to provide this information, without good cause, is regarded as voluntary resignation from the Medical Staff and results in automatic termination of Membership at the expiration of the current term unless the time for return of the reappointment form is explicitly extended for not more than 45 days by action of the Medical Executive Committee. A LIP whose Membership is so terminated is entitled to the procedural rights provided in Articles 10 and 11 of the Bylaws for the sole purpose of determining the issue of good cause.

17 2.2 COMPETENCY Once the reappointment application is deemed complete the Medical Staff Office will verify this reappointment information, and notifies the LIP of any information inadequacies or verification problems. This process is an objective evidence based process. The LIP then has the burden of producing adequate information and resolving any doubts about the data. A. The applicant must successfully complete the FPPE period during the Provisional year in order to be eligible for reappointment. This data will be used to measure current clinical competence. B. The Medical Staff Office along with the Department Chairman/Service Chief will review information pertaining to the applicant s OPPE and if applicable FPPE in order to make recommendations to the Credentials Committee. 1) Ongoing Professional Practice Evaluation (OPPE) is defined as routine monitoring of current competency for current medical staff members (peer review). According to Joint Commission s Standards, ongoing professional practice evaluation information is factored into the decision to maintain existing privilege, to revise existing privilege, or to revoke an existing privilege prior to, or at the time of renewal. Additional evaluation will be conducted when: a sentinel event or near miss is identified during concurrent or retrospective review an unusual clinical pattern of care is identified during a quality review 2.3 FROM INTERNAL SOURCES 2) OPPE will be conducted in a timely manner. The goal is for routine cases to be completed within 90 days of the data the chart is reviewed by the Quality/Performance Improvement Department and complex cases to be completed within 120 days. Exceptions may occur based on case complexity or reviewer availability. As a part of the reappointment process, performance improvement indicators will be collected for each Medical Staff Member applying for reappointment and forwarded along with the file for review by the Department Chairman. Performance improvement (PI) data will include (but is not limited to) medical assessment and treatment of patients, use of medications, use of blood and blood components, use of operative and other procedures, efficiency of clinical practice patterns, and significant departures from established patterns of clinical practice.

18 2.4 DEPARTMENT AND SERVICE ACTION The Department Chairman will examine the following factors including, but not limited to, as appropriate: the individual s quality assurance profile; maintenance of timely, accurate and complete medical records; his attendance at required Committee meetings; his service on Medical Staff and Hospital committees when requested; his ethics; his compliance with the Hospital Bylaws and Medical Staff Bylaws; his relations with other LIPs, AHPs, and other Hospital associates; his patterns of care, proficiency, effective utilization of Hospital resources, appropriate consideration of economic factors and utilization of Clinical Privileges as demonstrated by reviews and evaluations; any formal or informal peer/focused review issues that were reviewed during the previous two (2) years; information received from the National Practitioner Data Bank about him in response to the Hospital s query; and information received from his insurance carrier in response to the Hospital s query about coverage and claim status. All criteria reviewed for initial appointment will be updated and reviewed again. Before the end of the LIP s of appointment and allowing sufficient time for processing of the application, the Department Chairman(s) shall forward to the Credentials Committee a written confirmation that the Applicant meets all criteria for reappointment to the Medical Staff and a recommendation concerning the reappointment and/or delineation of Clinical Privileges of the Applicant. If the Department Chairman(s) recommends denial of reappointment or a change in Clinical Privileges, the reason(s) for such recommendation shall be stated. 2.5 SUBSEQUENT ACTION The remainder of the reappointment process, following action by the Department and Service, shall follow the same guidelines established for appointment in Section 1 of this Manual. This includes requirements established in this manual and in the Bylaws. 2.6 TIME PERIODS FOR PROCESSING On or before three months (90 days) prior to the date of expiration of a Medical Staff Member s appointment, the Medical Staff Office shall notify the LIP of his appointment expiration date. The Applicant must furnish a complete application for reappointment to the Medical Staff, providing sufficient time to process the application. 2.7 EXPEDITED REAPPOINTMENT Reappointments will only be granted an expedited reappointment date based on the meeting date of the Medical Executive Committee if there is need based upon when the Board of Directors meet and when the reappointment term expires. PART THREE: CLINICAL PRIVILEGES

19 3.1 DEPARTMENT AND SERVICE RESPONSIBILITY Each Department and Service, as appropriate, must define, in writing, the procedures, conditions and problems that fall within its clinical area, including different levels of severity or complexity when appropriate. These definitions must be coordinated by the Credentials Committee and approved by the Medical Executive Committee and Board, must be periodically reviewed and revised, and form the basis for delineating Clinical Privileges within the Department and Service. Special procedures (i.e. biopsies, aspirations, endoscopies, dialysis, hyperalimentation, chemotherapy, Swan Ganz, etc.) that may be performed at the Hospital must also be defined and Clinical Privileges specifically requested and delineated for these. As part of the request for Clinical Privileges, each applicant pledges that in dealing with cases outside his training and usual area of practice, he/she will seek appropriate consultation or refer to an LIP who has expertise in such cases and acknowledges that this request is circumscribed by Hospital and Medical Staff policies concerning the management of patients in intensive care units and by such other special policies as may be adopted from time to time. 3.2 PROCEDURE FOR DELINEATING PRIVILEGES A. REQUESTS Each application for appointment or reappointment to the Medical Staff must contain a request for the specified Clinical Privileges desired by the Applicant or Medical Staff Member. Specific requests must be submitted for modifications of privileges in the interim between reappraisals. B. PROCESSING REQUESTS Requests for Clinical Privileges will be processed according to the procedures outlined in Parts One and Two of this Manual, as applicable. If the physician is requesting a new privilege that has not been granted to him in the past, the privilege request form must be completed. PART FOUR: DISASTER PRIVILEGES 4.1 DEFINITIONS Disaster Privileges may be granted when the Emergency Management Plan has been activated and the organization is unable to handle the immediate patient needs. 4.2 PROCEDURE A. Disaster Privileges shall be granted in conformity with Mississippi Law. Disaster Privileges may be granted when the Emergency Management Plan has been activated and the Hospital is unable to handle immediate patient needs. In the

20 event of a declared disaster, the following guidelines will be used to emergently credential LIPs who are not Members of the Medical Staff. B. If the immediate emergency situation is not under control, the credentials verification procedure described in the Bylaws may be delayed, and the Chief Executive Officer, Chief of Staff, or a designee of either may grant Disaster Privileges prior to verifying the LIP s credentials, upon presentation of any of the following: (1) A current hospital ID card; (2) A current license to practice and a valid picture ID issued by a state, federal, or regulatory agency; (3) Identification indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT), the Medical Reserve Corps (MRC), the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP), or the recognized state or federal response organization or group. (4) Identification indicating that the individual has been granted authority to render patient care, treatment, and services in disaster circumstances (such authority having been granted by a federal, state, or municipal entity); or (5) Presentation by current hospital or medical staff member(s) with personal knowledge regarding the LIP s identity. C. The practitioner will be given a valid identification badge through the Medical Staff Services Department with a separate color background distinguishing the practitioner differently from other appointed practitioners. The performance of the practitioner will be monitored through the focused review and/or proctoring process per the Medical Staff Policy on Focused Professional Practice Evaluation. D. The hospital will determine within 72 hours of the practitioner s arrival if his/her disaster privileges will continue and will notify the practitioner immediately E. Within 72 hours or after the immediate emergency situation is under control and continued care is required, information concerning non-staff LIPs is to be collected on the Emergent/Urgent Patient Care Need Credentialing Form, attached to the Hospitals Emergency Management Plan, and given to Medical Staff Services for processing; in addition the following will be required: (1) Verification of Medical License. Mississippi Medical Licenses will be verified online at Verification of the state licensure will be accomplished online at the appropriate state licensing agency website or by telephone contact with the appropriate state licensing agency.

21 (2) Verification of DEA Registration. DEA drug schedules will be obtained from AMA profiles. (3) AMA Physician Profile. This profile provides primary source verification of medical school graduation, internship, residency and fellowship programs. (4) OIG, GSA and SDN Excluded Provider Data Bases will be accessed. (5) Board Certification will be verified with Certifacts and other primary source verification, if applicable. (6) The National Practitioner Data Bank will be accessed. For more information about Disaster Privileges, please refer to the Medical Staff Bylaws. F. If, however, the emergent volunteer s licensure, certification or registration cannot be verified within 72 hours, he or she will no longer be permitted to provide services. 4.3 OTHER INFORMATION A. The Emergent/Urgent Patient Care Need Credentialing Form will be presented to the President, the Chief of Staff, or a designee of either, for approval of Disaster Privileges. B. A Medical Staff ID Badge will be issued once Disaster Privileges have been granted. C. Medical Staff Services will construct a credential file for each non-staff LIP containing all of the documentation listed above. The medical staff describes in writing a mechanism for direct observation, mentoring, clinical record review, and other to oversee the professional performance of volunteer practitioners who receive disaster privileges. D. All privileges granted pursuant to this section will expire at the time the President declares the disaster is over. PART FIVE: FOCUSED PROFESSIONAL PRACTICE EVALUATION (FPPE) AND PROCTORING 5.1 MEDICAL STAFF OVERSIGHT A. The Credentials Committee is charged with the responsibility of monitoring compliance with FPPE and Proctoring. It accomplishes this oversight through receiving regular status reports related to the progress of all practitioners required

22 to be elevated under this as well as any issues or problems involved in implementation of this policy. The Department Chair/Service Chief shall be responsible for overseeing the proctoring process for all applicants assigned to their department/service. B. The medical staff committees involved with Ongoing Professional Practice Evaluation (OPPE) will provide the Credentials Committee with data systemically collected for OPPE that is appropriate to confirm current competence for these practitioners during the FPPE period. 5.2 CRITERIA FOR FPPE FPPE may be initiated under the following circumstances: A. Newly credentialed physicians: The Department Chairman and/or Service Chief will recommend a representative number of cases to be reviewed within the first days of appointment with designed review to include LOS, admitting diagnoses, discharge diagnoses, discharge disposition submitted by physician and a review of the preceding by a peer on staff no business or family relationship. B. Additional approved privileges: submit a representative number of cases involving the new privilege within first days of appointment of the new privilege; reviewed by a peer or committee as assigned C. Variance that is trended outside standard for measures that are a part of ongoing review (OPPE). May be single practitioner or a department as a whole. D. Quality measures that fall outside or are consistently trending outside of established targets or goals. E. Consistently reported variances in care outside or establish, approved standards of care. F. Consistent medical record/documentation deficiencies G. Behavioral related variances that have followed the internal corrective action prove. H. Repeated and consistent concern with care, safety, and communication. When questions arise regarding a currently privileged practitioner s ability to provide safe, high quality patient care. Circumstances necessitating a focused evaluation or triggers that may initiate an evaluation include: Certain low volume procedures Sentinel or other egregious events Validated complaints or occurrence reports Significant variances from acceptable practice patterns; and/or Significant variances in regard to comparative peer performance data. Concerns regarding a practitioner s clinical practice and/or competence shall be acted upon immediately. For more information, please refer to the FPPE Policy, the Medical Staff Peer Review Policy, etc.

23 PART SIX: MISCELLANEOUS 6.1 DEFINITIONS The capitalized terms in this Manual are as defined in the Bylaws unless otherwise indicated by the context of the usage of the term. Terms used in this Manual will be read as the masculine or feminine gender and as the singular or plural, as the context requires. The captions or headings in this Manual are for convenience only and are not intended to limit or define the scope or effect of any provision within this Manual. 6.2 EFFECT OF BYLAWS ON THIS MANUAL This Manual supplements provisions in the Bylaws. Any inconsistency between this Manual and the Bylaws will be resolved in favor of the Bylaws. PART SEVEN: AMENDMENT 7.1 This Medical Staff Credentialing Procedures Manual may be amended or repealed, in whole or in part, following initial adoption by the Board by one of the following mechanisms: A resolution of the Medical Executive Committee with approval by the Board; A resolution of the Organized Medical Staff, recommended to and adopted by the Medical Executive Committee with approval by the Board. This Medical Staff Credentialing Procedures Manual shall be reviewed and approved annually by the Medical Executive Committee. Initial Policy Date November 20, 2008 Revised Date(s) February 19, 2009; August 20, 2009; September 22, 2011; August 23, 2013 Reviewed Date(s) November 21, 2013 Recommended by Approved by Credentials Committee Medical Executive Committee and Board of Directors