PSYCHOLOGY Prvider-based Clinic (PBC) Delineatin f Clinical Privileges Criteria fr granting privileges: Graduate f an APA accredited dctral prgram in psychlgy Current license as a clinical psychlgist in the state f Tennessee APA r APPIC apprved internship in a clinical psychlgy r cunseling Individuals applying fr Clinical Psychlgy privileges must be free frm any pending legal r ethical charges by any state bard f licensing r lcal, state r natinal prfessinal rganizatin f psychlgists Diplmate status with the American Bard f Prfessinal Psychlgy is desired Applicants will be requested t prvide dcumentatin f practice and current clinical cmpetence as defined n the attached cmpetency grid. Applicants have the burden f prducing infrmatin deemed adequate by the hspital fr a prper evaluatin f current clinical cmpetence, and ther qualificatins and fr reslving any dubts. Current Clinical Cmpetence - MLH In additin t the required educatin, experience and/r training specified n each DOP (Delineatin f Privilege) frm, dcumentatin f current clinical cmpetence is required. TJC (The Jint Cmmissin) describes current clinical cmpetence as having perfrmed the privilege recently and perfrmed it well. Current clinical cmpetence is assessed prir t granting privileges initially and is reassessed when renewing privileges at reappintment fr maintenance f privileges. Current Clinical Cmpetence (CCC) may be lcatin specific (acute hspital care/surgery center (ASC) and/r age specific (adult, pediatric,nenatal). This shuld nt be cnfused with FPPE (Fcused Prfessinal Practice Evaluatin) FPPE: an evaluatin f clinical cmpetence f all new privileges as perfrmed at the specific licensed MLH facility (MHMH, MHOBH, Fayette, MECH) fr which they have been initially granted. This applies t privileges fr all new applicants as well as t new/additinal privileges fr current members. Bth FPPE and current clinical cmpetence assessments are privilege-specific. FPPE is cnducted during the perid after granting new/additinal privileges. FPPE must ccur at the MLH facility(ies) where privileges/membership are held. Current clinical cmpetence may be evaluated frm case lgs prvided by nn-mlh facilities. Current Clinical Cmpetence: Requirements fr New Applicants If applying directly frm training, r based n the training received in a frmal training prgram, prvider shuld submit case* lgs frm the prgram authenticated by the prgram directr alng with their recmmendatin attesting t the cmparable training, experience and qualificatins relative t the criteria fr the clinical privileges requested. If applying mre than 1 year after training cmpletin, submit the fllwing: Bard apprved: 12/21/16 1
Aggregate data frm a prvider based clinic fr the previus 12 mnth time perid, identifying the tp 10 diagnsis cdes and the number f patients per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Prcedure list frm a prvider based clinic fr the previus 12 mnth time perid, identifying the tp 10 CPT/ICD cdes and the number f prcedures per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Case lgs (see specificatins belw) fr any special privileges requested that meet the criteria specific fr the number f prcedures defined fr current clinical cmpetence. Current Clinical Cmpetence: Maintenance f Privileges fr Current Practitiners Practitiner shuld submit the fllwing: Aggregate data frm a prvider based clinic fr the previus 12 mnth time perid, identifying the tp 10 diagnsis cdes and the number f patients per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Prcedure list frm a prvider based clinic fr the previus 12 mnth time perid, identifying the tp 10 CPT/ICD cdes and the number f prcedures per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Case lgs (see specificatins belw) fr any special privileges requested that meet the specific number f prcedures defined fr current clinical cmpetence. Case Lgs All required case lgs and/r prcedure lists must cntain the fllwing infrmatin at a minimum: Date, patient identifier, CPT/ICD prcedure cde, diagnsis, cmplicatins, and dispsitin, and the facility name, name/title f the persn authenticating the lg, signature, date signed, and cntact infrmatin. If the infrmatin requested is nt available, please prvide an explanatin. *A case is defined as an episde f care either cgnitive r prcedural. Fr interpretive care, case is interpretatin f ne diagnstic study. OPPE (Onging Prfessinal Perfrmance Evaluatin) The Jint Cmmissin (TJC) requires OPPE peridically (mre frequently than annually) in the facility where membership/privileges are held. T assure OPPE requirements are satisfied, the practitiner must peridically exercise the privileges in the MLH facility(ies) where he/she has membership. OPPE must ccur regularly n patient encunters in the MLH facility(ies) where privileges/membership are held. Bard apprved: 12/21/16 2
Specialty/Prcedure Delineatin f Privilege Frm Clinical Psychlgy - PBC Cre Educatin/Training Dcumentatin fr Initial Granting Graduate f an APA accredited dctral prgram in psychlgy Current license as a clinical psychlgist in the state f Tennessee APA r APPIC apprved internship in a clinical psychlgy r cunseling Individuals applying fr Clinical Psychlgy privileges must be free frm any pending legal r ethical charges by any state bard f licensing r lcal, state r natinal prfessinal rganizatin f psychlgists Diplmate status with the American Bard f Prfessinal Psychlgy is desired Initial Applicatin (Prf f current clinical cmpetence) Aggregate data frm primary practice facility fr the previus 12 mnth time perid indentifying the tp 10 diagnsis cdes and the number f inpatients per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Prcedure list frm primary practice facility fr the previus 12 mnth time perid identifying the tp 10 CPT/ICD cdes and the number f prcedures per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. FPPE Validatin f cmpetence after appintment and/r granting f a new r additinal privilege (T be cmpleted within ne year) First five cases. Maintenance Requirements MLH Data will be btained fr practitiners when available. The practitiner shuld supply additinal case lgs frm ther prvider based clinics, if necessary, t meet the minimum requirement(s) t be cnsidered fr the privilege. Aggregate data submitted shuld include the tp 10 diagnsis cdes, with the number f utpatients per cde, and prcedure lists indicating the tp 10 CPT/ICD cdes, with the number f prcedures per cde fr the previus 12 mnths. Any cmplicatins/pr utcmes shuld be identified and explained. Clinic Medical Directr recmmendatin will be btained frm primary practice clinic. Bard apprved: 12/21/16 3
Cre Clinical Psychlgist Privilege: Clinical privileges granted allw the individual t functin subject t any licensure requirements and/r legal limitatins, and t prvide diagnsis, evaluatin, treatment, and cnsultatin fr patients wh suffer mental, behaviral, r emtinal disrders, cnsistent with the legal definitins f the practice f psychlgical examinatin. Practitiner shall exercise judgment within the areas f practitiner s prfessinal cmpetence and t participate directly in the psychlgical treatment at the request f a member f the Medical Staff wh has respnsibility fr the patient s verall medical care. The practitiner may nt admit patients t the facility. The practitiner shall nt functin utside thse privileges granted. Inherent in cre privileges are the fllwing areas/prcedures: Prvisin f individual therapy Prvisin f grup therapy Psychlgical assessment, including mental status examinatins Psychlgical cnsultatin and treatment planning Prvisin f adaptatinal behavir alteratin techniques, including bifeedback and hypntherapy, and ther specific techniques within the limits f training and experience Write prgress ntes within the scpe f their license and assigned treatment respnsibility May serve n staff, departmental and hspital cmmittees withut vte when requested, and attend meetings f the staff and department t which they are assigned and exercise such prergatives which are adpted and apprved by the medical staff, any f its departments r cmmittees Bard apprved: 12/21/16 4
Psychlgy PBC Clinical Privileges Check belw the particular privileges desired in Psychlgy fr each facility: Please check () applicable age categries fr each privilege requested. Methdist Healthcare Memphis Hspitals (MHMH) Privilege Descriptin Germantwn, Le Bnheur Medical Center, Nrth, Suth & University, Outpatient Clinics & Diagnstic Facilities Infants Children & Nenates Adults & Adlescents Age Limitatins (29 days Adlescents (0-28 days) (13-& Abve) 2 Years) (2-18 years) Clinical Psychlgy Cre Special Privileges Limitatins Clinical privileges are granted nly t the extent privileges are available at each facility. Darkly shaded areas represent privileges nt available t any practitiner due t the privilege nt being ffered by the facility. Acknwledgement f practitiner I have requested nly thse privileges fr which by educatin, training, current experience and demnstrated perfrmance I am qualified t perfrm and fr which I wish t exercise at the facilities indicated abve, t the extent services are available at each facility, and I understand that: (a) in exercising any clinical privileges granted, I am cnstrained by facility and medical staff plicies and rules applicable generally and any applicable t the particular situatin (b) any restrictin n the clinical privileges granted t me is waived in an emergency situatin and in such situatin my actins are gverned by the applicable sectin f the medical staff bylaws r related dcuments Prvider's Signature Date Printed Name Bard apprved: 12/21/16 5