CHRISTUS Santa Rosa HOSPITAL MEDICAL STAFF MEMBERSHIP, CREDENTIALING, PRIVILEGING AND DUE PROCESS MANUAL TABLE OF CONTENTS

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1 CHRISTUS Santa Rosa HOSPITAL MEDICAL STAFF MEMBERSHIP, CREDENTIALING, PRIVILEGING AND DUE PROCESS MANUAL TABLE OF CONTENTS I. APPOINTMENT AND REAPPOINTMENT PROCEDURE II. PROCEDURES FOR DELINEATING PRIVILEGES III. CORRECTION ACTION IV. PRACTITIONER RIGHTS V. FAIR HEARING PLAN VI. APPELLATE REVIEW VII. DUE PROCESS PROCEEDING VIII. ADOPTION AND AMMENDMENTS

2 0 0 0 Definitions: Please refer to the Bylaws for definitions I. APPOINTMENT AND REAPPOINTMENT PROCEDURE A. Pre-Application Requirements. Unless specifically authorized by the CEO, each potential applicant will complete an application request form and submit curriculum vitae which will be considered a pre-application. This pre-application will be submitted to the facility Administrator, for the primary practice site as determined by the applicant or designee, who will determine if the applicant meets the basic qualifications for staff membership as outlined in the Medical Staff Bylaws. Upon receipt and review of the request form and curriculum vitae the facility Administrator or his designee will promptly notify the applicant if an application may be offered. If the applicant does not meet the basic qualifications to be considered for the requested privileges, the applicant will be promptly notified. If the applicant meets the minimum requirements, the facility Administrator, or designee will send the applicant a Texas standardized application. The Practitioner will also be provided a copy of, or access to, the Medical Staff Bylaws, Rules and Regulations, Manuals and Policies and Procedures. Practitioners or other individuals who are not eligible to receive an application shall not be entitled to any procedural rights of review in connection with such ineligibility. B. Application Form. The applicant shall complete the Texas Standardized Credentialing Application ( TSCA ) and any facility specific addendum as specified, as may be amended from time to time. Each application shall include an acknowledgment by the Practitioner of the conditions of appointment as set forth in the Medical Staff Bylaws and any authorizations and releases necessary to effectuate those provisions.. In addition to the information submitted on the TSCA every applicant for initial appointment and reappointment must complete the addendum and provide the following: a) health status information: b) proof of professional liability insurance coverage as required by the Board and narrative information on malpractice claims history and experience (suits and/or settlements made, whether concluded or pending) during the past five () years for initial appointment and for reappointment the past two () years covering the appointment period. c) desired Department (and Section if available) assignment, d) desired Medical Staff category, active, courtesy, consulting, on-call, honorary, affiliate e) a completed core privilege form specifying specific clinical privileges being requested;

3 0 0 0 f) at least two () letters of recommendation in the form required from peers who have substantive knowledge of the Practitioner's professional competence, ethical character and any other matter requested. Only one of the references may be from an associate in practice with the applicant. g) a Medicare/Medicaid Acknowledgement Statement, h) a Priority Number Request Form, i) the Background Check Authorization j) A color photo and a copy of the applicant s current driver s license,. The applicant for appointment or reappointment shall update the information on the application form, including all changes in status during the processing of and/or during the term of appointment, within fifteen () days of notice of action or a status change is given. C. Effect of the Application. The Practitioner must sign the application and in so doing agrees to comply with the obligations of appointment, as well as:. attests to the correctness and completeness of all information furnished;. signifies his/her willingness to appear for interviews and provide requested information in connection with his/her application;. authorizes and consents to Hospital and Medical Staff representatives consulting with any third parties who may have information bearing on professional competence and conduct or other matters under review and to their inspecting all records and documents pertaining to such information; and. releases from any liability all those who, in good faith and without malice, provide, review or act on information regarding the Practitioner's competence, professional ethics, character, health status, and other qualifications for Medical Staff appointment and clinical privileges as provided in the Medical Staff Bylaws. D. Review and Approval Process.. Submission of Application. The application for appointment shall be submitted to the facility Physician Services Department which shall issue appropriate inquiries to third parties and perform primary source verification. An application shall not be considered complete until all requested information has been received. If the application remains incomplete six months after receipt, it will automatically be withdrawn and special notice issued to the applicant.

4 Department. The facility Physician Services Department shall forward a completed copy of the application and clinical privileges requested to the facility Department Chair/Section Chair in which the Practitioner has requested clinical privileges. The facility Department Chair/Section Chair shall review and investigate the Practitioner's qualifications and may interview the Practitioner and request any additional information as necessary. The facility Department Chair/Section Chair shall, within fourteen () days of receipt of the application and all requested information submit a recommendation to the facility Credentials & Privileges Committee in writing as to whether the Practitioner possesses the necessary qualifications and satisfies the Department's criteria to exercise the clinical privileges requested and whether any conditions should be imposed on his/her exercise of such privileges. If the facility Department Chair/Section Chair concludes that he/she cannot recommend the applicant or recommends restriction, he/she shall, he/she it shall include the reasons in the recommendation submitted to the facility Credentials & Privileges Committee.. Credentials & Privileges Committees/MEC and Medical Board review. The facility Credentials & Privileges Committee shall review the recommendations of the Department(s) and investigate the qualifications of the Practitioner and shall, within sixty (0) days of receipt of the completed application and all requested information, issue a written recommendation that the application be accepted, accepted with modifications, or denied. As necessary, the facility Credential &Privileges Committee may interview the Practitioner or may appoint a subcommittee to conduct additional investigation. Within sixty (0) days of receipt of the completed application and all requested information, the facility Credentials Committee shall forward the application and its written recommendation that the application be accepted, accepted with modification, or denied to the next scheduled meeting of the facility MEC.. Facility Medical Executive Committee. At its next regular meeting after receipt of a recommendation from the facility Credentials & Privileges Committee, the facility MEC shall review the recommendation, investigate further is necessary, the matter, and issue a favorable or adverse recommendation to the Medical Board. The facility MEC shall transmit to the Medical Board the completed application and all other documentation considered in arriving at its recommendation.. Medical Board. At its next regular meeting after receipt of the facility Medical Executive Committee s recommendation, the Medical Board shall review the recommendation. If the recommendation of the Medical Board is in support of the application the recommendation will be forwarded to the Board of Directors for action. If the recommendation of the Medical Board is adverse to the Practitioner, the President/CEO shall provide the Practitioner with a copy of the Medical Board s recommendation by Special Notice. The Practitioner shall be entitled to the Fair Hearing procedures, Section VIII, and all further procedures

5 0 0 0 procedures shall be in accord therewith.. No Activity. Physicians who are unable to provide the required case activity at appointment /reappointment or who do not have activity at CHRISTUS Santa Rosa Health Care may require proctoring in order to gain or renew privileges or may be subject to denial of privileges without prejudice.. Expedited Credentialing and Privileging Process To expedite initial appointments, reappointments, or renewal or modification of privileges, the Practitioner may be granted Temporary Privileges by a subcommittee of the Board, acting with full authority of the Board, as further described in the CSRHC Region Bylaws.. An applicant shall not be eligible for the expedited process if at the time of appointment or reappointment, any of the following has occurred: The applicant submits an incomplete application; The Medical Board makes a final recommendation that is adverse or has limitations; There is a current challenge or a previous challenge to licensure or registration; The applicant has received an involuntary termination of Medical Staff membership at another organization; or The applicant has received an involuntary limitation, reduction, denial, or loss of clinical privileges. E. Reappointment. Data Collection. Prior to consideration for reappointment, the facility Physician Services Department shall assemble current information from the Hospital on the Practitioner's professional activities, performance and conduct in the Hospital during the prior term of appointment. Such information shall be available to the Department and Committees reviewing the reappointment application and should include patterns of care as demonstrated in the findings of quality assurance/improvement activities; participation in relevant internal teaching and continuing education activities; level/amount of clinical activity (patient care contacts at the facility); timely accurate completion of medical records and compliance with all applicable records policies; compliance with all Medical Staff Bylaws, Rules and Regulations, Policies and patients and the Hospital; and cooperativeness in working with other Practitioners, Allied Health Professionals and Hospital personnel.. Submission of Application. At least one hundred twenty (0) days prior to the expiration of the term of Medical Staff appointment, each Medical Staff Practitioner shall be mailed an application for reappointment. Each Practitioner who desires reappointment shall, at least ninety (0) days prior to such expiration date, send the completed application for reappointment to the facility Credentials & Privileges Committee. An application shall not be considered complete until all requested information has been received. Following receipt of a complete application for

6 0 0 0 reappointment, the application shall be processed in accord with the procedures set out in this Manual.. Failure to return a complete application for reappointment within the time periods required may result in non-consideration of the application and termination of appointment on the expiration date, without any procedural rights of review. Thereafter, the Practitioner shall be required to submit an initial application which shall be processed pursuant to procedures set out in this Manual.. Department/Section Review. The facility Department Chair/Section Chair shall review the reappointment application; primary source verifications, Practitioner profile information and all requested information and will submit a recommendation to the facility Credentials & Privileges Committee. If the facility Department Chair/Section Chair concludes that he/she cannot recommend the applicant for reappointment or recommends restriction, he/she shall include the reasons in the recommendation submitted to the facility Credentials & Privileges Committee.. Credentials & Privileges Committees. The facility Credentials & Privileges Committee shall review the recommendations of the Department(s), all requested information and issue a written recommendation that the reappointment application be accepted, accepted with modifications, or denied. As necessary, the facility Credential &Privileges Committee may interview the Practitioner or may appoint a subcommittee to conduct additional investigation. The facility Credentials & Privileges Committee's recommendation shall be forwarded to the facility MEC and shall be accompanied by the completed reappointment application, results of the investigation and all other documentation considered by the committee.. Facility Medical Executive Committee. At its next regular meeting after receipt of a recommendation from the facility Credentials & Privileges Committee, the facility MEC shall review the recommendation, investigate further if necessary, the matter, and issue a favorable or adverse recommendation to the Medical Board. The facility MEC shall transmit to the Medical Board the completed application and all other documentation considered in arriving at its recommendation.. Medical Board. At its next regular meeting after receipt of the facility Medical Executive Committee s recommendation, the Medical Board shall review the recommendation. If the recommendation of the Medical Board is in support of the application the recommendation will be forwarded to the Board of Directors for action. If the recommendation of the Medical Board is adverse to the Practitioner, the President/CEO shall provide the Practitioner with a copy of the Medical Board s recommendation by Special Notice. The Practitioner shall be entitled to the Fair Hearing procedures, Section VIII, and all further procedures shall be in accord therewith.. Status Pending Review. In the event a practitioner, who is seeking reappointment, is under investigation or is in the fair hearing process, the reappointment will be processed as per the normal procedure in order to continue privileges and

7 0 0 0 membership during the duration of the fair hearing process; provided however that any emergency corrective action or any other restrictions and conditions that have been imposed will remain in effect during processing and consideration of the application for reappointment, pending the outcome of any procedural rights of review and final action by the Board of Directors. E. Leave of Absence.. Request. A leave of absence may be granted to a Practitioner upon written request to the facility Chief of Staff, with a copy to his/her Department Chair/Section Chair and the facility Administrator, and approval by the Medical Board and Board of Directors. The request must recite the reason and expected duration of the requested leave of absence.. Reinstatement. A Practitioner may request reinstatement following an approved leave of absence upon submitting documentation of continuing compliance with all qualifications and obligations of appointment set forth in the Medical Staff Bylaws, through updating of the reappointment form. The request for reinstatement must be reviewed and approved by the facility MEC and recommendation sent to the Medical Board and the Board of Directors in accord with the procedures in this Manual.. Leave of Absence. A Practitioner may not practice at any CHRISTUS Santa Rosa Health Care facilities during his/her leave of absence.. Procedural Rights. Failure to grant reinstatement when the Practitioner has met all requirements for reinstatement shall entitle the Practitioner to the procedural rights of review specified herein. F. Resignation or Change in Staff Category. A Practitioner may at any time submit to the President of the Medical Staff, facility Chief of Staff or his/her Department Chair/Section Chair or the facility Administrator via the Medical Staff Office, a written request to resign on a stated date any or all clinical privileges and/or Medical Staff appointment or to change Medical Staff category. If the request is accepted by the Medical Board and Board of Directors, the change shall be effective on the date requested by the Practitioner and shall not require further action or review. G. Clinical Privileges for a New Procedure or Service Requests for clinical privileges or services not currently performed at a CHRISTUS Santa Rosa Hospital facility or for established procedures associated with a new technique or technology shall be granted as described below. The facility Credentials Committee shall determine whether the procedure, service or technology is distinctly new and qualifies for this category of credentialing.. The applicant shall make the facility Medical Staff Services Office and/or the facility

8 0 0 0 Chief of Staff aware of the request for a new procedure or service and be prepared to provide the facility Department Chair/Section Chair and the facility Credentials Committee with information pertaining to the procedure or service including clinical efficacy, community need, need for additional equipment and personnel, as well as, cost and potential for reimbursement.. After review of the recommendations from the facility Department Chair/Section Chair The facility Credentials Committee and the facility MEC shall determine whether to offer the procedure or service and make their recommendation known to the Board through the Medical Board.. With recommendation from the facility Department Chair/Section Chair the facility Credentials Committee shall then develop criteria to determine those individuals who are eligible to request the clinical privileges. The Credentials Committee shall conduct research and consult with experts to determine: a. The minimum education, training, and experience necessary to perform the procedure or service, b. The extent of proctoring and supervision that should occur if the privileges are granted, and c. Monitoring criteria once privileges are granted.. Once the credentialing criteria are established, application for the privilege shall proceed in accordance with the Medical Staff Bylaws and this Manual. H. Adding Clinical Privileges Whenever a Medical Staff appointee requests additional privileges for established procedures and existing technology, the following process shall be followed:. The applicant must request the privilege from the facility Credentials committee in writing.. The applicant must provide written evidence of relevant training and/or experience.. The facility Department Chair/Section Chair will review and make a recommendation related to the applicants request for additional privileges.. The facility Credentials Committee will review the competency documentation and recommendations of the facility Department Chair/Section Chair and, as needed, other practitioners who have supervised and observed the applicant perform the requested privilege or service.. The facility Credentials Committee shall forward a recommendation to the facility MEC which shall review the matter and forward a recommendation to the Medical Board and Board for final action.. Following approval by the Board, an appointment letter will be forwarded to the applicant

9 0 0 by the facility Administrator describing the addition of clinical privileges. II. PROCEDURE FOR DELINEATING PRIVILEGES A. Requests. Each application for appointment and reappointment to the Medical Staff must contain a request for the specific clinical privileges desired by the Practitioner. Specific requests must also be submitted for temporary privileges. B. Processing Requests. All requests for clinical privileges will be processed according to the procedures outlined herein, as applicable. Requests for clinical privileges from dentists and podiatrists are processed in the same manner as requests from physicians. C. General Competency Evaluation (GCE) Applicants and members of the medical staff must satisfactorily exhibit the six () general competencies at the time of appointment and reappointment. The general competencies of the practitioner can be ascertained in several ways:. Peer references that affirmatively attest to the general competencies of the practitioner, along with a positive recommendation for appointment or reappointment to the medical staff.. The decision of the facility Department, Credentials Committee, and the Medical Executive Committee (MEC) that the practitioner exhibits the general competencies based on the practitioner s relevant education, training and experience and known information about the practitioner s performance.. Specific information that may arise out of ongoing and/or focused evaluation of a practitioner that affirmatively or adversely speaks to that practitioner s general competencies.. A practitioner who is unable to satisfactorily exhibit the general competencies outlined in this policy may be subject to the focused evaluation of his or her professional practice, as described in this policy. a. Patient Care Practitioners are expected to provide patient care that is compassionate, appropriate & effective for promotion of health, prevention of illness, treatment of disease, & care at end of life. b. Medical/Clinical Knowledge Practitioners are expected to demonstrate knowledge of established & evolving biomedical, clinical &social sciences, and the application of their knowledge to patient care and the education of others.

10 0 c. Practice-based Learning & Improvement Practitioners are expected to be able to use scientific evidence and methods to investigate, evaluate, and improve patient care practices. d. Interpersonal & Communication Skills Practitioners are expected to demonstrate interpersonal & communication skills that enable them to establish & maintain professional relationships w/patients, families, & other members of health care teams. e. Professionalism Practitioners are expected to demonstrate behaviors that reflect commitment to continuous professional development, ethical practice, understanding and sensitivity to diversity, & responsible attitude toward their patients, their profession, & society. f. Systems Based Practice Practitioners are expected to demonstrate both an understanding of contexts & systems in which health care is provided, & ability to apply this knowledge to improve and optimize health care. D. Privilege Determinations. The Practitioner shall be considered and granted clinical privileges upon demonstration of current competence. Privileges are granted consistent with the Practitioner's documented training and/or experience in requested categories of treatment and/or procedures, his/her therapeutic results and the conclusions drawn from quality assessment. The Practitioner shall have the burden of establishing his/her qualifications and competence to exercise the clinical privileges being requested. Failure to submit requested information or adequate documentation shall result in the request not being considered and the Practitioner shall therefore not be entitled to any procedural rights of review as a result of such non-consideration. Each Practitioner appointed to the Medical Staff is entitled to exercise only those clinical privileges specifically granted to him/her by the Board. E. Telemedicine. For the purpose of this policy, telemedicine is defined as official readings of images, tracings, or specimens provided by licensed independent practitioners through a telemedicine link. These clinical services are provided by consultation, contractual arrangements, or other agreements. Practitioners who provide interpretative or consultative telemedicine services are credentialed and privileged through the Medical Staff process. The service site may use credentialing information from the remote site where the practitioner who provides professional services is located provided that the remote site is an accredited organization by The Joint Commission.. Procedure for Telemedicine privileges a. The facility Chief of Staff, Department Chair/Section Chairs, and/or Medical Directors may recommend to facility administration the need and source of telemedicine services. b. The nature and scope of telemedicine services provided are defined in writing. If the contracted individuals are credentialed and privileged by a Joint Commission-accredited organization, the contract will require that only those services are provided by licensed

11 0 0 0 independent practitioners are within the scope of his or her privileges at the outside organization. The individuals under the control of the Joint Commission-accredited organization are required to complete a medical staff application in accordance with this Manual. The Joint Commission-accredited organization may provide the Facility with the primary source verification used to complete the application. The facility may use the provided primary source verification from the remote accredited site and any additional primary source verification needed to determine appointment to the Medical Staff. c. If the contract is with individuals who are not credentialed and privileged by a Joint Commission accredited organization all licensed independent practitioners who will be providing telemedicine services will be required to complete a medical staff application in accordance with the Medical Staff Bylaws. Medical Staff membership is not required. d. The facility Performance Improvement Committee evaluates the contracted telemedicine service to determine whether it is being provided according to the contract and clinical services offered are consistent with commonly accepted quality standards. The facility retains overall authority for services furnished under a telemedicine contract. F. Disaster Privileges Disaster privileges may be granted only when the Emergency (Disaster) Preparedness Management Plan has been activated, and the available Medical Staff cannot manage all immediate patient needs.. During disaster(s) in which the Emergency (Disaster) Preparedness Management Plan has been activated, the facility President/CEO or his or her designee(s), the facility Chief of Staff or his or her designee(s), as described in the Plan, has the option to grant disaster privileges to individuals presenting appropriate identification. Decisions regarding such privileges shall be made on a case-bycase basis. Privileges expire upon termination of the disaster.. Appropriate identification presented shall include, at a minimum, one of the following: A current picture facility ID card that clearly identifies professional designation A current license to practice Primary source verification of the license Identification indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT), or MRC, ESAR-VHP, or other recognized state or federal organizations or groups 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 Identification by current Hospital or Medical Staff member(s) who possess personal knowledge regarding volunteer s ability to act as a licensed independent practitioner during a disaster

12 The scope of services provided shall be within the individual s education, training and experience. Physicians given disaster privileges will be assigned to a medical staff(s) member who will mentor and oversee the medical care delivered and who shall report to the Chief of Staff or their designee regarding issues of questioned competency.. A physician granted disaster privileges will be identified through a facility identification badge.. Primary source verification of licensure will begin as soon as the immediate situation is under control and is completed within hours from the time the volunteer practitioner presents to the organization. In the extraordinary circumstances that primary source verification cannot be completed in hours, it is expected that it be done as soon as possible. In this extraordinary circumstance, there must be documentation of the following: why primary source verification could not be performed in the required time frame; evidence of a demonstrated ability to continue to provide adequate care, treatment and services; and an attempt to rectify the situation as soon as possible. Primary source verification of licensure would not be required if the volunteer practitioner has not provided care, treatment and services under the disaster privileges.. Within hours, the facility Administrator and/or the Chief of Staff shall make a decision based on the information obtained regarding the professional practice of the volunteer, related to the continuation of the disaster privileges initially granted. G. Temporary Privileges. The facility Administrator, or designee, shall have the authority to grant, in conjunction with the President of the Medical Staff, facility Department/Section Chief, or facility Chief of Staff temporary clinical privileges under the following two () circumstances. Once granted, the applicant shall exercise such privileges under the supervision of the facility Department/Section Chief and for the duration of the temporary privileges only. An individual is not entitled to any procedural rights of review because his/her request for temporary privileges is refused or because all or any portion of his/her temporary privileges are terminated.. Fulfillment of an Important Patient Care Need. Temporary privileges may be granted on a case by case basis when there is an important patient care need that mandates an immediate authorization to practice, for a limited period of time, while the full credentials information is verified and approved. Examples would include, but are not limited to: a) Locum Tenens coverage for vacation or illness or b) Care to specific patient by a Practitioner with skill not possessed by a current facility Medical Staff member.

13 0 0 0 c) In these circumstances, temporary privileges may be granted by the CEO, or designee, upon recommendation of the Department Chair/Section Chair, facility Chief of Staff or the President of the Medical Staff provided there is verification of: i) Current licensure ii) Current competence iii) Current malpractice insurance. Pendency of Application. When an applicant with a complete, clean application is awaiting review and recommendation by the MEC, Medical Board and approval by the Board of Directors temporary privileges may be granted for a limited period of time, not to exceed ninety (0) days, by the facility Administrator upon recommendation of the Department Chair/Section Chair, facility Chief of Staff or the President of the Medical Staff provided that there is verification of the following: a. Current Texas licensure b. Current malpractice insurance c. Relevant training or experience d. Current competence d. Ability to perform the privileges requested e. The results of National Practitioner Data Bank query have been obtained and evaluated and f. The applicant has: i) a complete application ii) no current or previously successful challenge to licensure or registration iii) not been subject to involuntary termination of medical staff membership at another organization iv) not been subject to involuntary limitation, reduction, denial, or loss of clinical privileges H. Denial or Termination of Temporary Privileges. Any individual authorized to impose emergency corrective action as described in the Corrective Action and Fair Hearing Manual may terminate any or all temporary privileges at any time. The facility Department Chair/Section Chair shall assist any patient(s) remaining in the facility in the selection of a Practitioner to provide care until discharge or transfer. Any action involving temporary privileges taken on behalf of the facility MEC or the Medical Board in the course of their professional review activity shall not be considered a complete or final professional review action. The Practitioner shall not be entitled to any procedural rights of review as a result of denial of a request for temporary privileges, the imposition of any conditions on the exercise of temporary privileges, or termination of temporary privileges. I. Out of State License. A physician licensed in another state who has been granted permission to practice in the State of Texas by the appropriate licensing board such as the Texas State Board of Medical Examiners may be granted temporary privileges with the approval of the facility Department Chair/Section Chair and the facility Administrator for a period not to exceed thirty (0) days to assist staff physicians in learning or performing new procedures or

14 0 0 0 treatments. J. Allied Health Professionals.. General. Qualified individuals in the Allied Health Professional categories approved by the Board of Directors may be granted clinical privileges in accord with the procedures and requirements set forth in this Manual. Allied Health Professionals are not eligible for Medical Staff appointment and are not entitled to any procedural rights of review afforded to Practitioners. Recognizing that each facility under the Santa Rosa Hospital system may have different patient needs each facility MEC may determine the categories of AHP which may practice within the specific facility.. Duties. Each Allied Health Professional shall be assigned to a facility Department and must comply with any Hospital requirements, as well as Medical Staff requirements, including: a) providing emergency services and consultation as required by the facility Department or facility MEC; b) retaining appropriate responsibility within his/her area of professional competence for the care and supervision of patients for whom he/she is providing services, subject to the authority of the patient's attending Practitioner; and c) cooperating and participating in performance improvement, quality assurance, team and committee activities of the facility Department, Medical Staff and/or Hospital. d) Fulfilling those responsibilities required by the Rules and Regulations, and if not so specified, meeting those responsibilities specified in this Manual as are generally applicable to the more limited practice of the Allied Health Professional. The decision on whether each applicant will practice independently or dependently will be determined by the applicant s current licensure, registration or certification as well as facility MEC policy.. Pre-Application Requirements. Applications for clinical privileges for Allied Health Professionals shall be provided only to individuals in disciplines or categories that have been approved by the Board of Directors and who can document current licensure, registration or certification, as well as professional liability insurance if required by the Board. The Allied Health Professional shall be provided with a copy of or access to the Medical Staff Bylaws and the Rules and Regulations. Individuals who are not eligible to receive an application shall not be entitled to any procedural rights of review in connection with such ineligibility.. Criteria for Clinical Privileges. Prior to offering or granting clinical privileges, each facility Department must recommend, in writing, the minimum or threshold qualifications and criteria for exercise of the privileges. Qualifications and criteria may relate to training, experience, specialty or sub-specialty certification and other pertinent factors. Recommended qualifications and criteria must be approved by the facility Credentials & Privileges Committee,

15 0 0 0 the facility MEC, the Medical Board and by the Board of Directors and shall form the basis for clinical privileges recommendations.. Application Form. The application forms for initial clinical privileges and renewal shall be approved by the facility Administrator after consultation with the facility MEC which shall send a recommendation to the Medical Board, and shall require substantially the same information as Medical Staff applications for Practitioners.. Credentialing. Applications from Allied Health Professionals shall be processed in accord with the facility credentialing procedures used for Practitioners. The facility Credentials & Privileges Committee and facility MEC and Medical Board may delegate the credentialing functions for Allied Health Professionals to subcommittees. Allied Health Professionals shall be subject to the requirements of this Manual.. Corrective Action. Allied Health Professionals shall be subject to the corrective action procedures used for Practitioners. In the event of an adverse recommendation, the professional shall not be entitled to the procedural rights of review afforded to Practitioners, but shall be afforded the right to an interview as set forth herein.. Procedural Rights of Review. Notwithstanding any provisions in the Medical Staff Bylaws or this Manual to the contrary, Allied Health Professionals shall not be entitled to the procedural rights of review afforded to Practitioners. In the event of an adverse recommendation pertaining to an Allied Health Professional, the professional shall be informed of the recommendation by Special Notice and shall have thirty (0) days to submit a written request for an interview with the facility MEC, Medical Board or the Board, whichever issued the adverse recommendation. a) The interview shall be scheduled within thirty (0) days of receipt of a timely request and shall be held by the facility MEC or a subcommittee. The Allied Health Professional may submit any information prior to or during the interview pertaining to his/her qualifications to exercise the clinical privileges being requested. The professional may not be accompanied by an attorney. b) The facility MEC, Medical Board or Board may change their recommendation as a result of the interview and, if so, shall give the Allied Health Professional Special Notice of the decision. The decision of the Board is final III. CORRECTIVE ACTION Automatic Action. Occurrence of any of the following events shall operate as an automatic limitation, suspension or termination of the Practitioner's clinical privileges and/or Medical Staff appointment as specified below. Automatic action shall not preclude other corrective action on the same or similar grounds. Failure of a Practitioner to report the occurrence of any of the events shall be grounds for corrective action, in addition to any automatic action.

16 0 0 0 A. Grounds ) License: If a Practitioner's license is revoked, his/her Medical Staff appointment and all clinical privileges are immediately terminated. If the Practitioner's license is suspended, his/her Medical Staff appointment and all clinical privileges are suspended for the term of the license suspension. If the Practitioner's license is limited or restricted, any affected clinical privileges are similarly limited or restricted for the term of the license limitation or restriction. If a Practitioner is placed on probation by his/her Texas licensing board, his/her voting and office-holding privileges are automatically suspended for the term of the probation. If a practitioner fails to provide proof of current licensure, his/her appointment and clinical privileges are immediately suspended; however once the Practitioner shows proof of a current licensure his/her appointment and clinical privileges will be immediately reinstated.. ) Controlled Substances Registration: Whenever a Practitioner's state or federal authority to prescribe controlled substances is revoked, suspended or limited for cause, his/her clinical privileges to prescribe controlled substances shall be similarly revoked, suspended, or limited. If a practitioner s fails to provide proof of current DEA and/or DPS due to an administrative delay, such as failure to timely pay the fee, his/her appointment and clinical privileges to prescribe are immediately suspended. ) Professional Liability Insurance: Whenever a Practitioner fails to maintain professional liability insurance as required by the Board, all clinical privileges are immediately suspended pending receipt of documentation acceptable to the facility Administrator that insurance has been reinstated and the required insurance coverage has been secured for any period during which insurance had lapsed. Failure to provide such documentation within thirty (0) days shall automatically terminate his/her Medical Staff appointment and privilege. ) Medical Records Completion: Failure to complete medical records within the time limits established by the Medical Staff Rules and Regulations and Hospital policies, shall automatically suspend (except with respect to his ability to care for patients already in the Hospital and those previous to suspension who were scheduled for admission or procedures)the Practitioner s right to admit patients and to provide any other professional services and shall remain so suspended until all delinquent medical records are completed. B. Procedural Rights of Review. Except as otherwise described in this Manual and Medical Staff Bylaws, the Practitioner shall not be entitled to any procedural rights of review for any automatic action. C. Reinstatement following an Automatic Action

17 0 0 0 ) License: A Practitioner whose license is reinstated after revocation or suspension must seek initial appointment in accord with the Medical Staff Bylaws. Where licensure restrictions are terminated, before full clinical privileges are restored the facility MEC shall review the matter pursuant to the corrective action procedures and may file a request for routine corrective action. Clinical privileges shall not be restored until resolution of the request for corrective action. ) Controlled Substances Registration: When a controlled substances registration is restored following revocation, suspension, or limitation, before full clinical privileges to prescribe are restored, the facility MEC shall review the matter pursuant to the corrective action procedures and may file a request for routine corrective action. Clinical privileges shall then not be restored until resolution of the request for corrective action. Where controlled substances registration is restored following revocation, suspension, or limitation due to an administrative oversight, as described above, the privileges will be restored once proof of current registration is provided. ) Professional Liability Insurance: Upon presentation of a certificate of insurance as required by the Medical Staff Bylaws to the facility Administrator within thirty (0) days (including coverage for any periods during which insurance lapsed), the automatic suspension shall terminate. If the suspension exceeds thirty (0) days, it shall automatically become a termination of Staff appointment and the Practitioner shall be required to seek initial appointment in accord with the Medical Staff Bylaws. ) Medical Records Completion: Upon completion of medical records as required in the Rules and Regulations, the automatic suspension of admitting and consulting privileges shall terminate. A Practitioner who involuntarily resigns Medical Staff appointment and clinical privileges for failure to comply with medical records completion requirements shall be required to seek initial appointment in accord with the Bylaws. D. Notice. The facility Administrator shall notify the Practitioner, the facility MEC, the Medical Board and Department Chair/Section Chair of termination or an automatic action. Emergency Corrective Action A. Grounds. Whenever a Practitioner's conduct requires that immediate action be taken to protect the life or to reduce the substantial likelihood of injury or damage to the health or safety of a patient, a Practitioner, associate, or other person present in the Hospital: ) the President of the Medical Staff, the facility Chief of Staff or a facility Department Chair/Section Chair may, with the concurrence of the facility Administrator, immediately suspend all or any portion of the clinical privileges of the Practitioner, or

18 0 0 0 ) The facility Administrator, in consultation with the President of the Medical Staff and the facility Chief of Staff, may immediately suspend all or any portion of a Practitioner's clinical privileges B. Imposition of emergency corrective action is an initial step in the professional review activity, but is not a complete or final professional review action in and of itself. C. Investigation. The facility Administrator shall give the Practitioner Special Notice of the imposition of emergency corrective action. Within fifteen () days of the emergency corrective action being imposed, the facility MEC shall appoint a committee to investigate the grounds for the action, which shall include an interview with the Practitioner, and issue a recommendation to the facility MEC and the Medical Board to (a) continue the emergency corrective action; (b) terminate the emergency corrective action and initiate routine corrective action; or (c) terminate the emergency corrective action and take no further action. D. Facility MEC. At its next regular meeting, of if necessary at a special called meeting, after receipt of the investigating committee s report and recommendation, the facility MEC shall make a recommendation to the Medical Board of Directors regarding the imposition of corrective action. The Medical Board may, but is not required to, afford the Practitioner an interview and may conduct additional investigation before issuing its recommendation. The recommendation may include, without limitation: ) rejecting the request for corrective action; ) issuing a warning letter of admonition, or letter of reprimand; ) imposing a term of probation which is defined as mandatory chart review; ) imposing continuing medical education requirements; ) reducing, limiting, suspending, or revoking clinical privileges; or ) suspending or revoking staff appointment E. When the recommendation of the Medical Board is not adverse to the Practitioner, the Medical Board shall inform the facility Administrator of its recommendation and the facility Administrator shall forward the recommendation to the Practitioner. F. When the recommendation of the Medical Board is adverse to the Practitioner, the Medical Board shall inform facility Administrator and the facility Administrator shall notify the Practitioner by Special Notice and provide the Practitioner with a copy of the Medical Board's recommendation. The Practitioner shall be entitled to the procedures provided for herein, and all further procedures shall be in accord therewith. G. The individual or medical staff committee who impose an emergency corrective action may, at any time, terminate the emergency corrective action, and convert the recommendation to one for routine corrective action, in which case

19 0 0 0 the procedures herein shall apply. Routine Corrective Action A. Grounds. When a Medical Staff Member engages in conduct, whether within or outside of the Hospital, that: ) is reasonably likely to be detrimental to patient safety ) violate Medical Staff Bylaws, Rules or Regulations, Policies and Procedures, or accepted professional standards of practice or conduct; or ) violate any medical staff policies relative to Professional Conduct and/or Physician Health, then corrective action against the Practitioner may be imposed. B. Interview. Before corrective action is formally requested against a Practitioner, the individual or Committee authorized to request corrective action may afford the Practitioner an interview, at which the circumstances prompting consideration of corrective action are discussed and the Practitioner is permitted to present relevant information in his/her own behalf. This interview is not a hearing or procedural right of the Practitioner and need not be conducted according to the procedural rules provided. C. Request. ) Corrective action must be requested in writing by an officer of the Medical Staff, a Medical Staff Committee, a Department Chair/Section Chair, or the facility Administrator. ) A request for routine corrective action shall be submitted in writing to the facility MEC, signed by the requesting party and include the specific reason or basis for the request, as well as a description of the conduct or events prompting the request. D. Investigation. Upon receipt of a request for routine corrective action, the facility MEC shall review the request and initiate an investigation, to be performed by the facility MEC itself, a subcommittee, a special committee or a Department ("investigating committee"). ) In determining whether adequate grounds for corrective action exist, the investigating committee shall consider all available evidence and shall not be limited to the examination of any particular incident or event, or to incidents or events occurring within the Hospital or the System. ) The Practitioner for whom corrective action has been requested shall be advised of the request by the facility MEC by Special Notice and shall have an opportunity to appear before the investigating committee in the course of its investigation. At such appearance, the Practitioner shall be invited to provide information about any matter(s) being considered by the investigating committee. This appearance shall not constitute a hearing, shall be preliminary in nature, and none of the procedural rights of review shall apply. The Practitioner may not be accompanied by an attorney. The Practitioner shall not be entitled to be present

20 0 0 0 be present during interviews with any witnesses, or committee deliberations or voting, nor may he/she tape record his/her appearance. ) Within thirty (0) days of initiation of the investigation, the investigating committee shall make a written report to the facility MEC regarding the investigation and describing grounds for or against corrective action. E. Facility MEC. At its next regular, or if necessary at a special called, meeting after receipt of the investigating committee s report and recommendation, the facility MEC shall make a recommendation to the Medical Board regarding the imposition of corrective action. The Medical Board may, but is not required to, afford the Practitioner an interview and may conduct additional investigation before issuing its recommendation. The recommendation may include, without limitation: ) rejecting the request for corrective action; ) issuing a warning letter of admonition, or letter of reprimand; ) imposing a term of probation which is defined as mandatory chart review; ) imposing continuing medical education requirements; ) reducing, limiting, suspending, or revoking clinical privileges; or ) suspending or revoking staff appointment F. When the recommendation of the Medical Board is not adverse to the Practitioner, the Medical Board shall inform the facility Administrator who shall inform the Practitioner. G. When the recommendation of the Medical Board is adverse to the Practitioner, the Medical Board shall inform the facility Administrator and the Administrator shall notify the Practitioner by Special Notice and provide the Practitioner with a copy of the Medical Board's recommendation. The Practitioner shall be entitled to the procedures provided for herein, and all further procedures shall be in accord therewith. Impairment. As per the Physician Health Policy the facility MEC or facility Administrator may require a Practitioner to undergo a physical or mental examination or testing if there is reason to suspect that the Practitioner's ability to exercise clinical privileges may be impaired. Privileges at other Facilities. Any corrective action taken against a Practitioner or Allied Health Professional at a Facility within the System shall apply to all facilities of the System where the Practitioner or Allied Health Professional has clinical privileges. IV. PRACTITIONER RIGHTS A. General. In the event a Practitioner is unable to resolve with his/her facility Department Chair/Section Chair a particular situation, issue or concern, that Practitioner may 0

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