TIFT REGIONAL MEDICAL CENTER MEDICAL STAFF POLICIES & PROCEDURES

Title: Allied Health Professionals Approved: 2/02 Reviewed/Revised: 11/04; 08/10; 03/11; 5/14 Definition TIFT REGIONAL MEDICAL CENTER MEDICAL STAFF POLICIES & PROCEDURES P & P #: MS-0051 Page 1 of 7 For the purpose of this policy, allied health professionals ("AHPs") are defined as patient care providers who are permitted (i.e., credentialed/authorized) to provide patient care services in Tift Regional Medical Center. These individuals may be independent or dependent. Independent AHPs (Medical Associate) Independent AHPs are healthcare professionals approved by the Board who have been licensed or certified by their respective licensing or certifying agencies and who desire to provide professional services in the Hospital. An independent AHP may be an independent contractor or, may be part of a group which has a contract with Tift Regional Medical Center for specific services. Independent AHP may provide patient care, in accordance with state licensure laws, without the supervision of a physician. This category primarily consists of, but is not limited to, the following: Clinical Psychologists (doctorate level) Dependent AHPs (Medical Assistant) Dependent AHPs provide care to patients under supervision and responsibility of a Physician who is a member of the Medical Staff of TRMC with Clinical Privileges in the clinical specialty applicable to the AHP s clinical functions. This category primarily consists of, but is not limited to, the following: Certified Registered Nurse Anesthetist Nurse Practitioners Physicians Assistants Certified Nurse Midwife I. Nature of Clinical Functions Authorization given to an Independent or Dependent AHP to perform clinical functions shall only entitle the AHP to perform those clinical functions which are specifically authorized by the Board. Authorization of AHPs to perform clinical functions shall only be extended if the Board, after formal consultation with the Medical Executive Committee, deems such authorizations to be necessary for the proper care and treatment of patients. Dependent AHPs may only perform clinical functions under the supervision of a sponsoring Staff Member and may not independently or jointly admit patients. Independent AHP may only see patients by direct order of a Staff Member and may not independently admit patients. II. Qualifications to Perform Clinical Functions No Allied Health Professional shall be automatically entitled to perform clinical functions, merely because he or she meets the qualifications described herein. Allied Health Professionals must also meet such minimum criteria established with regard to the specific licensure and certification of the Allied Health Professional. For an Allied Health Professional to be authorized to perform clinical functions, he or she must meet the following general qualifications: 1

1. Possess either a license from the State of Georgia or certification from the certifying entity recognized by the State of Georgia, which authorizes the Allied Health Professional to exercise clinical privileges or to perform clinical functions in the State of Georgia and which is currently in effect and not subject to any suspension, revocation, or limitation; 2. Meet the continuing education requirements required by the State of Georgia or appropriate certifying entity to maintain eligibility for said license or certification; 3. Meet recognized standards of training, experience, and ability as defined by the State of Georgia and/or the appropriate certifying entity; 4. Have demonstrated an ability to relate professionally and work cooperatively with peers and others in institutional settings in which he or she has worked; 5. Be free of or have under adequate control such that patient care is not likely to be adversely affected, any significant physical or behavioral impairment or any difficulty in communicating orally or in writing in the English language; 6. Be in a state of good health adequate to provide patients with care at a generally recognized professional level of quality and efficiency, consistent with current medical knowledge and clinical experience; 7. Have demonstrated an ability to conform to the bylaws, policies and procedures, and policies of institutional settings in which he or she has been associated and to discharge responsibilities at such institutions; and 8. Have provided evidence of the maintenance of adequate professional liability insurance in accordance with policy adopted by the Board; provided, however, that any change in required policy limits shall be subject to the approval of the Board and shall be reasonable in light of insurance company experience and policy limit requirements at comparable Georgia hospitals. III. Telemedicine Nurse Practitioners and Physician s Assistants who have Clinical Functions at TRMC under the supervision of a Physician with Telemedicine Privileges are eligible to apply for Telemedicine Privileges pursuant to Medical Staff Policy, MS-0054, Telemedicine Privileges. IV. Responsibilities/Duties Each Allied Health Professional shall: 1. Provide patients with care at the generally recognized professional level of quality and efficiency applicable to their profession in providing such services; 2. Provide care to patients within the scope of the clinical functions authorized by their respective Board; 3. Abide by the Bylaws and all other lawful standards, policies and procedures of the Hospital or the Staff as the same may be amended and communicated to him or her from time to time; 4. Prepare and complete in a timely manner any portion of medical or other records as are essential for providing quality patient care to patients to whom he or she in any way provides care in the Hospital; 5. Abide by the ethical principles of his or her profession; 6. Comply with all applicable laws and regulations; 7. Cooperate with the Medical Executive Committee, the Administration, and the Board on matters relating to patient care and the orderly operation of the business of the Hospital, in keeping with sound quality patient care and business practices; 8. Notify the Administration within thirty (30) days of the initiation of any malpractice or liability action against him or her and any settlement or conclusion of such action; 9. Notify the Administration within thirty (30) days of any "professional review action" taken by any "healthcare entity," as those terms are defined by National Practitioner Data Bank, that would be reportable under NPDB or any other action that would affect the exercise of an Allied Health Professional's clinical functions; and 10. Act in accordance with the job description or defined scope of practice filed by the supervising physician with the appropriate certifying or licensing agency, if applicable. 2

V. Application for Clinical Functions A. Pre-Application Process 1. Any AHP seeking clinical functions at Tift Regional Medical Center shall be provided with a Pre- Application Form and a copy of the qualifications needed to perform clinical functions (See Section II). The AHP Pre-Application Form will request sufficient information so as to allow the Chief Medical Officer ( CMO ) to determine whether or not an AHP meets the necessary qualifications. 2. Completed AHP Pre-Application Forms shall be submitted to the CMO, who shall determine whether or not the AHP meets the necessary qualifications. 3. In the event an applying AHP does not meet the necessary qualifications, then such person is ineligible to apply for clinical functions, and the CMO shall notify the applicant of his/her ineligibility to receive clinical functions. A determination that an AHP does not meet the necessary qualifications does not entitle the applicant to seek or request a hearing or other form of due process which may be provided by applicable bylaws, policies, or procedures. 4. In the event the CMO determines, based on information provided in the Pre-Application Form, that the applicant meets the necessary qualifications, then the CMO shall send the applicant an application for clinical functions, which shall be completed as provided in part B of this Section V. B. Process 1. Submitting an Application. All applications by an Allied Health Professional for clinical functions shall be submitted in writing at least sixty (60) days prior to the date clinical functions are desired. Such Application shall be signed by the applicant and the sponsoring Staff Member when applicable, and shall be submitted on a form authorized by the Board, and provided to the applicant by the Medical Staff Office. The Board may require all applicants to submit a pre-application on a form approved by the Chief Executive Officer. 2. Completed Application. The completed application and a non-refundable application fee of One Hundred and 00/100 Dollars ($100.00) shall be made payable to Tift Regional Medical Center and shall be submitted to the Chief Executive Officer or his designee. The application shall not be considered complete until the Chief Executive Officer, with the full cooperation of the applicant, has received necessary references and materials required to be submitted as covered by this Policy. The completed application will be forwarded to the CMO for review and recommendation. Following recommendation by the CMO, the application is ready for review and recommendation by the Medical Executive Committee. 3. Executive Committee Action. The Medical Executive Committee will examine the evidence of licensure, character, professional competence, and qualifications through information contained in the references. Within thirty (30) days from the date that the application is reviewed by the Executive Committee, the MEC shall transmit to the Board, through the Chief Executive Officer, a written recommendation that the application be granted, denied, or deferred for a maximum period of sixty (60) days for further consideration. 4. Board Action. Whenever the Board receives a recommendation from the Executive Committee on an application from an AHP for Clinical Functions, the Board shall take final action thereon within thirty (30) days of receipt of the Executive Committee's recommendation. The Chief Executive Officer shall notify the applicant promptly in writing of the Board's final action. 3

C. Information Requested. Application for clinical functions by Allied Health Professionals shall require the following information: 1. Dependent AHP - The name of the sponsoring physician and a copy of the job description or defined scope of practice filed by the sponsoring physician with the licensing or certifying agency, if applicable; 2. Independent AHP - A letter from a Staff Member recommending individual for staff membership. 3. A request for specific delineated clinical functions (written descriptions of patient care activities) desired by the Allied Health Professional. 4. Names of at least three persons who provide the same type of services as the applicant and who can provide adequate information regarding the application's current professional competence and ethical character from persons who have direct knowledge of the applicant's professional performance and/or have had responsibility for supervising his or her performance. 5. Information regarding whether the applicant's clinical privileges or clinical functions have ever -- on a voluntary or involuntary basis -- been denied, revoked, suspended, diminished or not renewed at this or any other hospital or institution, whether the applicant's Drug Enforcement Administration or other controlled substance registration, if applicable, has ever -- on a voluntary or involuntary basis -- been revoked, suspended or diminished, and whether his or her membership in local, state, or national societies, or his or her license or certification to practice any healthcare profession in any jurisdiction, has ever -- on a voluntary or involuntary basis -- been denied, suspended or terminated; 6. A statement that the applicant has received, understands and agrees to abide by the Medical Staff Bylaws, Policies and Procedures, and any other written policies of the Staff and the Hospital Compliance Program and Code of Conduct, which the Medical Staff Office, acting on behalf of the Medical Executive Committee, shall supply to each applicant upon application. By such statement, the applicant agrees to be bound by the terms of said Bylaws, Policies and Procedures, Compliance Program and Code of Conduct, and any other written policies if he or she is granted clinical functions, and to be bound by the terms thereof in all matters relating to the consideration of his or her application, whether or not he or she is granted clinical functions; 7. A statement that the applicant agrees to abide by the Hospital Bylaws, which the Administrator's office shall supply to each applicant upon request. 8. A statement whereby the applicant acknowledges that he or she, in the event of disciplinary action or removal of privileges, has been notified of the provisions for Fair Hearing and Appellate Review of Allied Health Professionals as outlined in MS-0043; 9. A statement of his or her willingness to appear for an interview in regard to his or her application; 10. A statement disclosing any present mental or physical conditions that may pose a threat to the health or safety of others that cannot be eliminated by reasonable accommodation; 11. A statement whereby the applicant certifies that he or she maintains professional malpractice insurance coverage in at least such amount as may be required by applicable provisions of this Policy, the Bylaws, the Hospital Authority bylaws or other Hospital policies, and which specifies the amount of said coverage, and the name and address of the malpractice insurer if such coverage is a requirement for clinical functions sought by the applicant. The application shall further require information concerning any malpractice claims against the applicant, any amount paid by or on behalf of the applicant upon final judgment or settlement of such claim, and the basis of the claim if such payment was made. The applicant shall contain a statement whereby the applicant agrees to notify the Chief Executive Officer promptly of any changes in said professional malpractice insurance, any claims against said professional malpractice insurance which result in payment to the claimant, and any adverse final judgments or settlements in any professional liability action; and 12. Evidence that the applicant meets all applicable training, education and licensure requirements established by resolution of the Board. 4

D. Effect of Application of Allied Health Professional. By submitting an application or reapplication form, the Applicant acknowledges, understands, consents and agrees to the following: 1. The Applicant has the burden of producing adequate information for proper evaluation of his/her application. 2. The Applicant has the continuing responsibility to resolve any questions, concerns, or doubts regarding any and all information in the application and to provide updated information as requested and understands that if he/she fails to produce this information, the Hospital will not be required to evaluate or act upon his/her application. 3. The Hospital and its representatives will investigate the information in his/her application and the Applicant consents and agrees to such investigation and to the disciplinary reporting and information exchange activities of the Hospital as part of the verification and credentialing process. 4. The Applicant authorizes the Hospital and its representatives and designated agents to obtain and act upon information regarding his/her competence, qualifications, training, evaluation, professional and clinical ability, character, conduct, ethics, judgment, mental and physical health status, emotional stability, utilization practices, professional licensure, or certification, and any other matter related to the Applicant's qualification. 5. The Applicant authorizes the release by those who may have information bearing on his/her qualifications, to consult with the Hospital and its representatives and designated agents and to report, release, exchange and share information and documents with the Hospital, for the purpose of evaluating his/her application and qualifications. 6. The Applicant consents to and authorizes the inspection of records and documents (including medical review and peer review) that may be material to his/her application, qualifications and ability to carry out the Clinical Functions requested. Applicant authorizes person(s)/organizations with custody of said records and documents to permit said inspection and copying as necessary for evaluation of his/her application. Applicant agrees to appear for interviews, if required or requested by the Hospital. 7. The Applicant consents to and authorizes the release by the Hospital to other healthcare entities and interested persons on request of information the Hospital may have concerning his/her (including but not limited to peer review information provided to another healthcare entity for peer review purposes), as long as such release is done in good faith and without malice. Applicant releases from all liability the Hospital, its representatives and designated agents from any claim for damages of whatever nature for any release of information made in good faith by the Hospital or its representatives or agents. 8. The Applicant releases from liability, to the fullest extent permitted by law, all persons and entities for their acts performed in a reasonable manner in conjunction with investigating and evaluating his/her application and qualifications, and waives all legal claims of whatever nature against the Hospital and its representatives and designated agents acting in good faith and without malice in connection with the investigation of his/her application and qualifications. 9. The Applicant acknowledges that he/she has been informed of and hereby agrees to abide by, the Medical Staff Bylaws, Policies and Procedures, the Hospital Compliance Program and Code of Conduct. Applicant agrees to conduct his/her practice in accordance with applicable laws and ethical principles of his/her profession. 10. Any investigations, actions or recommendations of any committee or the Board with respect to the evaluation of applicant's application and any periodic reappraisals or evaluations will be undertaken as a medical review and/or peer review committee and in fulfillment of the Hospital's obligations under Georgia law to conduct a review of professional practices in the facility, and are here fore entitled to any protections provided by law. 11. Consents to a psychiatric or other medical evaluation and a chemical test or test of blood, breath, urine and other bodily substances for the purpose of determining his or her ability to render or participate in patient care, where such tests or evaluation are relevant to the applicant's ability to exercise the clinical privileges or clinical functions requested and are requested at any time during the application process by the Chief Executive officer, the Chief of Staff, or the CMO. 5

E. Responsibility of Applicant. The applicant shall have the responsibility of producing adequate information for a proper evaluation of his or her competence, character, ethics, and other qualifications, and for resolving any doubts about such qualifications, and said application shall not be considered completed for purposes of processing until such satisfactory information is provided by the applicant and verified by the Chief Executive Officer, acting as the designee of the Staff. F. Application for Additional Clinical Functions. Application for additional clinical functions by an allied health professional must be in writing with appropriate documentation of training. Such applications shall be processed in the same manner as applications for initial clinical functions as outlined in Section A above, and shall require verification of current state licensure and NPDB query. In addition, aggregate applicant-specific data may be utilized in evaluating requests for additional/modification of privileges. G. Temporary Clinical Functions/Locum Tenens Clinical Functions Temporary Clinical Functions are granted on a case by case basis under specific circumstances. Applications for Temporary Clinical Functions or Locum Tenens Clinical Functions shall be submitted at least thirty (30) days prior to the date such Clinical Functions are needed. H. Reapplication/Renewal of Clinical Functions 1) Renewal of Clinical Functions shall be for a period of two (2) years, with Clinical Functions expiring at midnight on the last day of the calendar month in which the Practitioner's birthday falls. The Chief Executive Officer or his or her designee, shall, at least ninety (90) days prior to the expiration date of the Staff appointment of any AHP, provide such Practitioner with an application for renewal for use in considering reappointment. Any Practitioner who desires renewal of his or her Clinical Functions shall, at least sixty (60) days prior to such expiration date, send his or her application for renewal to the Chief Executive Officer or his or her designee, who, upon verifying that the form is complete, shall forward the application for renewal to the next scheduled meeting of the Medical Executive Committee. 2) The application for renewal form shall contain information necessary to maintain a current file on the AHP's healthcare-related activities. This application for renewal shall include the following information: Reasonable evidence of current physical and mental health status; The name and address of any other healthcare institution or hospital where the AHP has provided healthcare services during the preceding two-year period, and the specific healthcare services that were authorized or exercised by the AHP at said institution or hospital; Sanctions of any kind, on a voluntary or involuntary basis, imposed by any other healthcare institution, hospital, or licensing authority; Details concerning the status of professional malpractice insurance coverage, claims, suits, and settlements (including, without limitation, the name of the insurance carrier, the amount of coverage, whether covered by a sponsoring physician, and the policy dates). Current information regarding the AHP's continuing training, education and experience, including evidence of completion of continuing medical education required by state or federal law or regulation; and The Independent AHP may be asked to provide a peer recommendation at the time of reappointment. 6

3) Failure to complete and return the Renewal form by the last day of the month in which his or her birthday falls will be deemed a voluntary relinquishment of Clinical Privileges or Clinical Functions held by such individual. 4) Upon verification by the Medical Staff Office that the application for renewal is complete, the renewal information will be forwarded to the Medical Director for review. The Medical Director will then, in turn, forward the renewal information to the Medical Executive Committee for review and recommendation. The Medical Executive Committee shall, in turn, review the renewal information and make its recommendation to the Board. The Board shall review such information and, through the Chief Executive Officer, shall give written notification of its decision on the reapplication to the AHP. In the event of a decision for denial of renewal of Clinical Functions, the AHP shall be entitled to Fair Hearing and Appellate Review Process as outlined in Medical Staff Policy and Procedure # MS-0043. 7