Resident Credentialing Policy Wayne State University

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1 Resident Credentialing Policy Wayne State University REQUIREMENTS FOR INITIAL RESIDENT APPOINTMENT Residency Office Responsibilities: 1. Resident Initial Appointment Recommendation Letter: Initial applications should be submitted by September 15th. Non-compliant residents will face suspension after September 30 th. Complete all requested information. Signature of program director required. Dates of appointment -- limited to one year only. 2. Supplemental Application for Resident Appointment completed by the applicant: All questions must be completed. For any questions responded to with YES (except #1a), additional documentation must be provided as specified. Must include original signature of applicant. 3. ERAS or Equivalent Program Application: A Program application will be provided for each resident/fellow beginning a residency/fellowship program. Applications should include the resident s curriculum vita. 4. Proof of Michigan licensure, temporary or permanent: Must be a copy of the current license indicating expiration date. License Verification Form must be completed. (see OHI policy #518 on Licensure/Certification) 5. Copy of Medical School diploma and ECFMG certificate if applicable. 6. Provide transcript of USMLE scores

2 7. Proof of ACLS/BLS certification 8. Copy of American Medical Association Profile 9. Letter of Physical Clearance from Human Resources 10. Letter of Liability Coverage 11. Checklist for Initial Resident Appointment

3 CHECKLIST FOR INITIAL RESIDENT APPOINTMENT WAYNE STATE UNIVERSITY DUE DATE SEPTEMBER 15th Applicant's Name: Program: Date Received: *Note that this form lists key words for required documents. Specific requirements are detailed in narrative section entitled "Requirements for Initial Appointment". Have Need Comments Residency Office Responsibilities: 1. PD Appointment Letter Title (including subspecialty) Inclusive Dates (1 year max) Health Statement Comments/Issues 2. ERAS Application w/ original signature Picture 3. Copy of USMLE Scores 4. Copy of Medical School Diploma 5. Copy of ECFMG Certificate if applicable 6. Copy of Michigan Limited License or

4 Michigan Permanent Physician License 7. License Verification Form 8. Copy of Controlled Substance License or DEA License 9. ACLS Certification 10. Supplemental Application Form 11. Copy of AMA Profile 12. Copy of TB Clearance 13. Copy of Liability Coverage

5 PROGRAM DIRECTOR LETTER OF RECOMMENDATION FOR INITIAL RESIDENT APPOINTMENTS Date: To: Medical Education Committee Oakwood Hospital and Medical Center Dear Sirs/Madams: I am recommending appointment of to the position of Oakwood Resident PGY: I II III IV V (circle one). This resident meets the Program s eligibility and selection criteria as per program and GMEC policy. The dates of appointment should be / / to / /. A statement of this applicant s physical and mental health is attached. Thank you for your consideration of this applicant. Yours Truly, Name of Program Director Director, Education Program Program C: resident file

6 REQUIREMENTS FOR RESIDENT REAPPOINTMENTS Residency Office Responsibilities: 1. Resident Reappointment Recommendation Form: Applications should be submitted by May 1 st. Non-compliant residents will face suspension after July 1st. Complete all requested information. Signature of program director required. Dates of appointment -- limited to one year only. 2. Supplemental Application for Residents Reappointment completed by the applicant: All questions must be completed. For any questions responded to with YES (except #1a), additional documentation must be provided as specified. Must include original signature of applicant. 3. Annual Evaluation of Applicant: Program Evaluation Forms will be provided for each resident/fellow currently enrolled. The latest summative evaluation of the resident will be provided. All evaluations must be provided with the reappointment request. 4. Proof of Michigan licensure, temporary or permanent: Must be a copy of the current license indicating expiration date. License Verification Form must be completed. (see OHI policy #518 on Licensure/Certification) 5. Secure malpractice claims history from Risk Management. 6. Provide transcript of USMLE scores

7 CHECKLIST FOR RESIDENTS REAPPOINTMENT WAYNE STATE UNIVERSITY DUE DATE MAY 1st Applicant's Name: Department: Date Requested: Program Responsibilities: 1. Residents Reappointment recommendation Have Need Comments 2. Inclusive Dates (1 year max) 3. Signature of Program Director 4. Supplemental Application Form 5. Documentation for YES responses 6. Original signature 7. Summative evaluation 8. Copy of Michigan license (Temporary or Permanent) 9. License Verification Form 10. Transcript of USMLE Scores (Scores not included in initial credentialing) 11. Secure evaluation forms for residents changing departments 12. Claims History 13. Procedure Log 14. Valid ACLS/BLS Card

8 RESIDENT REAPPOINTMENT RECOMMENDATION Reappointment Period Resident Member's Name Program (including subspecialty) Title Year in This Program (not PGY level) Current program (if different from above) Current year of training I have reviewed this resident member's performance and progress in the training program with him/her, in accordance with institutional policies and the specific ACGME (or other accrediting agency) requirements for this program. Also attached is a copy of the program s annual evaluation form in support of this reappointment request. I find this resident member's performance to be: Acceptable and recommend him/her for reappointment. Unacceptable and have instituted corrective action (see attached CAP). I am confident that these actions will resolve the problem and recommend him/her for reappointment with the stipulation that patient care responsibilities be limited as set forth in his/her corrective action plan. Unacceptable where deficiencies do not permit recommendation for reappointment.

9 In addition, I have reviewed this resident member s clinical competence and acquisition of the skills identified for this level of training in the program curriculum and recommend that: He/she be advanced to the next level of training with patient care responsibilities commensurate with his/her training and experience with increasing independence as appropriate for his level and training. he/she be retained at the current level of training with patient care responsibilities limited as set forth in his/her corrective action plan for the following reasons: The condition of this resident s physical and mental health is: Satisfactory for patient care responsibilities. Some physical and/or mental health issues which are being accommodated in the following manner: Signature, Program Director: Date: Signature, Designated Institutional Official: Wayne State University Date: Approved by the Graduate Medical Education Committee of OHI: Director of Medical Education Date Oakwood Healthcare System

10 SUPPLEMENTAL APPLICATION FOR RESIDENT APPOINTMENT Please print legibly or type all information. MUST ATTACH CURRENT PHOTOGRAPH. Name Social Security No. Work Address Telephone Home Address Telephone Current Program Current Title New Program (if changing) New Title Please respond to the following questions. If you answer YES to any of these questions, except for question #1, you must provide a full explanation of the details on a separate sheet, including date, place, reason, and disposition of the matter, as well as other, relevant information. YES NO 1. Health Status: If you perform invasive procedures, have you complied with the U.S. Public Health Service recommendation to know your health status regarding blood borne pathogens such as hepatitis B and human immunodeficiency virus? Do you currently suffer from any physical, mental, or emotional problems which affect, or is likely to affect, your ability to perform your duties as a residents member or which may place a patient at risk? YES NO Do you take any medication or drugs (including alcohol or any form of drug, legal or illegal) which affect, or is likely to affect

11 your ability to perform your duties as a residents member or which may place a patient at risk? 2. Have you ever been denied clinical privileges by or appointment to any health care facility or managed care entity? 3. Has your membership status or clinical privileges by another health care provider or managed care entity ever been revoked, suspended, reduced, or not renewed? 4. Has your membership in a local, state, or national medical society or other professional society ever been suspended, terminated, or denied? 5. Has any state licensing board revoked, suspended, limited, or denied a certificate or license to you or taken any other disciplinary action? Please attach a copy of your current medical license. 6. Have you ever voluntarily relinquished your professional license (including DEA), any or all clinical privileges, or membership in a medical society or association: a) While under investigation by the health care entity, or b) In return for not conducting such investigation or proceeding. 6. Has your narcotic license ever been revoked, suspended, or limited in any way? 7. Have you ever been denied a DEA registration number or been issued a restricted registration? If currently registered, give number and state of issue. Controlled Substance Number License Number Expiration Expiration

12 YES NO 9. Malpractice information: Have you ever had a malpractice claim filed against you or is a claim currently pending against you? Has a lawsuit ever been settled on your behalf? Has a verdict ever been rendered against you in a malpractice lawsuit? Have you ever been denied professional liability coverage? If yes, to any, please provide claimants name, date of suit, allegations, and any payments made on a separate piece of paper and attach. 10. Have you ever been suspended, excluded, or debarred from participation or otherwise, sanctioned or had civil monetary penalties levied against you by a Medicare, Medicaid, or other Federal program? Do you have outstanding payments with Medicare? 11. Have you ever been convicted, entered into a plea bargain, or pled Nolo Contendere to a felony, crime of moral turpitude, healthcare fraud or other crime related to governmentally financed healthcare programs, or criminal abuse or neglect of patients? 12. Do you currently have clinical privileges at any other institution(s)? Should the answer to any of these questions change, I understand that I am under a continuing obligation to notify my Program Director and the Graduate Medical Education Committee of such change or changes in writing so long as I remain a member of the residency program.

13 I hereby make application for appointment/reappointment to the residency programs of the Oakwood Healthcare System. I understand and agree that I, as an applicant for Resident membership, have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics, and other qualifications and for resolving any doubts about such qualifications. I fully understand that any significant misstatements in or omissions from this application constitute cause for denial, modification, or revocation of my appointment and/or clinical privileges. I confirm that all information submitted by me in this application is true to my best knowledge and belief. Further, should reasonable question exist regarding my physical or mental ability to perform the privileges granted, I agree to undergo a mental or physical examination if requested and, if this shows evidence of mental or physical impairment, to provide evidence that the impairment does not interfere with my professional competence. I agree to the release of my credentialing and privileging information by the Credentials Committee and its staff office for such purposes where authorized by such contract and/or endorsed by the Health System in accordance with established policy. My credentialing and privileging information may be released only for the purpose of my being credentialed under an institutional contract or for credentialing by an arm of the University, unless otherwise explicitly authorized by me in writing. All reasonable efforts will be made to maintain the confidentiality of my information and to preserve any legal privilege afforded the information. If granted clinical privileges, I agree, as a Resident in the Oakwood Healthcare System, to abide by the established practices, procedures, and policies of the Medical Centers and those of its programs, clinical departments, and other institutions to which I may be assigned. Further, I pledge to maintain an ethical practice, abiding by the ethical principles set forth by the American Medical Association, with my patient s interest at the center of the care I render to him or her. Signature of Applicant Date of Application

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