APPENDIX A MEDICAL STAFF CREDENTIALING POLICY

Transcription

1 APPENDIX A MEDICAL STAFF CREDENTIALING POLICY 1

2 TABLE OF CONTENTS 12/4/07 Version ARTICLE I: MEDICAL STAFF MEMBERSHIP...3 A. QUALIFICATIONS FOR MEMBERSHIP AND CLINICAL PRIVILEGES General Qualifications Effect of Prior Adverse Professional Review Action Effect of Other Affiliations Non-Discrimination Professional Liability Insurance Requirement...8 B. MEDICAL CENTER NEED Lack of Facilities/Support Services Exclusivity, Employment and Professional Services Agreements Medical Staff Development Plan Effects of Declination...10 C. RESPONSIBILITIES OF MEDICAL STAFF MEMBERSHIP...10 D. TERMS OF APPOINTMENT Initial Appointment to Be Provisional Reappointment Failure to Timely Submit Application...13 E. LEAVES OF ABSENCE Requests for Leaves of Absence Termination of Leave and Request for Reinstatement Failure to Request Reinstatement...16 F. RESIGNATION...16 ARTICLE II: PROCESS FOR APPOINTMENT AND REAPPOINTMENT...17 A. GENERAL Effect of Application for Appointment/Reappointment Immunity from Liability Burden on the Applicant Assistance with Evaluation Reapplication Following Withdrawal of Application or Final Adverse Action Conditional Appointment/Reappointment/Privileges...21 B. NEW APPOINTMENT PRE-APPLICATION PROCESS...22 C. NEW APPOINTMENT APPLICATION PROCESS New Appointment Application Form Submission of the Application Processing the Application...26 D. REAPPOINTMENT Initiation of Reappointment Process Reappointment Application Form Evaluation of Applicant for Reappointment Processing the Application...33 ARTICLE III: ALLIED HEALTH PROFESSIONALS...38 A. GENERAL Categories of Allied Health Professionals Qualifications of Allied Health Staff Responsibilities of Allied Health Staff Membership

3 4. Prerogatives of Allied Health Staff...42 B. APPOINTMENT, REAPPOINTMENT AND CLINICAL PRIVILEGES Pre-application Process Application Process Reappointment/Additional Privileges Process Term of Appointment/Privileges Temporary Privileges Leaves of Absence...43 C. PROCEDURAL RIGHTS General Initiation of Disciplinary Review Action by Medical Executive Committee Action by Board...45 ARTICLE IV: CLINICAL PRIVILEGES...46 A. EXERCISE OF CLINICAL PRIVILEGES...46 B. DELINEATION OF CLINICAL PRIVILEGES Application Admitting Privileges Requests for Additions to Clinical Privileges...46 C. BASIS FOR PRIVILEGE DETERMINATIONS General Special Conditions for Dental Privileges Special Conditions for Podiatric Privileges Special Conditions for Allied Health Professionals...48 D. SERVICE RESPONSIBILITIES FOR DEFINING PRIVILEGES...49 E. NEW, EXPERIMENTAL OR MULTI-SPECIALTY PRIVILEGES New or Multi-Specialty Privileges Experimental Procedures/Services...49 F. REQUEST FOR UNAVAILABLE PRIVILEGES...50 G. TEMPORARY PRIVILEGES General Conditions and Authority for Granting Temporary Privileges Termination of Temporary Privileges Rights of the Individual with Temporary Privileges...54 H. DISASTER PRIVILEGES...54 I. EFFECT OF EMERGENCY...56 J. TELEMEDICINE PRIVILEGES...56 K. ANCILLARY SERVICES ORDERED BY NON-PRIVILEGED PHYSICIANS...57 ARTICLE V: CORRECTIVE ACTION...59 A. CRITERIA FOR INITIATION...59 B. ALTERNATIVES TO A PROFESSIONAL REVIEW RECOMMENDATION/ ACTION...59 C. SUMMARY (PRECAUTIONARY) SUSPENSION OR RESTRICTION...60 D. INVESTIGATION...61 E. ACTION ON THE INVESTIGATION REPORT...62 F. STATUTORY RISK MANAGEMENT PROCESS...62 G. AUTOMATIC SUSPENSION OR TERMINATION...63 H. AUTOMATIC RESIGNATION

4 I. ACTIONS INVOLVING AN INDIVIDUAL WITH AN IMPAIRMENT...64 J. ACTIONS INVOLVING AN INDIVIDUAL RESPONSIBLE FOR DISRUPTIVE CONDUCT

5 ARTICLE I: MEDICAL STAFF MEMBERSHIP A. QUALIFICATIONS FOR MEMBERSHIP AND CLINICAL PRIVILEGES 1. General Only Physicians, Dentists and Podiatrists who satisfy the threshold criteria detailed in this Section or as otherwise provided in these Bylaws or Related Documents, shall be eligible for consideration for Medical Staff membership and/or the grant of clinical privileges. The Medical Center shall utilize a specialized process, approved by the Medical Executive Committee and the Board, to evaluate whether an individual seeking Medical Staff appointment, reappointment or the grant of clinical privileges satisfies these eligibility requirements. For those individuals seeking initial Medical Staff appointment and/or the grant of clinical privileges (pre-applicant), a pre-application form shall be utilized to evaluate, to the extent possible, whether the pre-applicant meets eligibility requirements. If so determined, following consideration of the pre-application, the pre-applicant shall be provided a medical staff application form. In the event it is determined during the processing of the application that the individual is not qualified for medical staff membership or the grant of clinical privileges, further processing of such application shall cease and the application shall be returned to the originator as ineligible for further consideration with written notice of such. In the event the pre-application process fails to determine the pre-applicant s eligibility for Medical Staff membership, and it is subsequently determined during the application process that the individual is not qualified for such staff membership or the grant of clinical privileges, further processing of such application shall cease and the application returned to the originator as ineligible for further consideration with written notice of such. For current Members of the Medical Staff seeking reappointment and/or a renewal of or additional privileges, a reappointment application or an additional privilege application will be utilized to evaluate whether the applicant meets eligibility requirements. The due process rights detailed in the Fair Hearing Plan are not available when, because of ineligibility, any pre-applicant s request for a medical staff application form is declined or an application form is returned to any applicant on this basis or as otherwise provided in this Policy. 2. Qualifications The following qualifications are those minimally required for Medical Staff membership and/or the grant of clinical privileges and shall be considered threshold criteria for Medical Staff membership and/or the grant of clinical privileges: a. Demonstrate proof of graduation from an accredited School of Medicine, 5

6 Dentistry or Podiatry. All Foreign medical graduates must have successfully completed the Education Commission for Foreign Medical Graduate ( ECFMG ) verification from a foreign medical school and demonstrate proof of United States citizenship or a valid visa or work permit. b. Demonstrate either recognized specialty board certification, recognized specialty board certification eligibility or that the training requisite for recognized specialty board certification has been completed in the area(s) of proposed practice and that the individual is actively pursuing recognized specialty board certification. Recognized specialty boards are those approved by the Medical Center Board of Trustees and are listed below. Current medical staff members are required to maintain specialty Board certification in which they currently practice and hold privileges from one of the following specialty Boards: American Board of Allergy and Immunology American Board of Anesthesiology American Board of Colon and Rectal Surgery American Board of Dermatology American Board of Emergency Medicine American Board of Family Practice American Board of Internal Medicine American Board of Medical Genetics American Board of Neurological Surgery American Board of Nuclear Medicine American Board of Obstetrics and Gynecology American Board of Ophthalmology American Board of Oral and Maxillofacial Surgery American Board of Orthopedic Surgery American Board of Otolaryngology American Board of Pathology American Board of Pediatrics American Board of Pedodontics American Board of Physical Medicine and Rehabilitation American Board of Podiatric Surgery American Board of Plastic Surgery American Board of Preventive Medicine American Board of Prosthodontics American Board of Psychiatry and Neurology American Board of Radiology American Board of Surgery American Board of Thoracic Surgery American Board of Urology American Osteopathic Board of Emergency Medicine American Osteopathic Board of Family Medicine American Osteopathic Board of Internal Medicine American Osteopathic Board of Obstetrics and Gynecology American Osteopathic Board of Ophthalmology and Otolaryngology 6

7 American Osteopathic Board of Orthopedic Surgery American Osteopathic Board of Pathology American Osteopathic Board of Pediatrics American Osteopathic Board of Radiology Specialty Board certification must be obtained by the end of the fifth (5 th ) year after first becoming eligible to sit for the certifying examination. Should the Medical Staff Member lose qualifications to be able to sit for the examination during the five (5) years from which he/she was appointed to the medical staff, the Member is no longer eligible for Medical Staff membership and privileges. In such case, membership and privileges would be considered automatically withdrawn upon the date it becomes known that the Medical Staff Member is no longer qualified to sit for the specialty Board certification examination. Failure to maintain certification shall result in automatic referral to the Medical Executive Committee for review of privileges and membership. Current Members of the Medical Staff who completed training prior to May 21, 1985 and are unable to demonstrate proof of recognized specialty board certification or eligibility, shall be permitted to apply for Medical Staff reappointment as appropriate, provided all other threshold qualifications for medical staff membership are demonstrated. Exceptions regarding Board certification shall be reviewed and recommended by the Medical Executive Committee and approved by the Board of Trustees. c. If the applicable specialty board eligibility requirements do not include the successful completion of a residency program within that specialty, the applicant must demonstrate proof of completion of an approved postgraduate training program. All dentist pre-applicants must have successfully completed an approved post-graduate training program. For purposes of this Section, an approved postgraduate training program for physicians is a residency program fully accredited throughout the time period of training by the Accreditation Council for Graduate Medical Education (ACGME), the American Osteopathic Association or an equivalent organization in a country for which eligibility for licensure by endorsement is available by the Kansas Board of Healing Arts. An approved post-graduate training program for podiatrists is one fully accredited throughout the time period of training by the Council on Podiatric Medicine, the American Podiatric Medical Association, a successor agency to either of the foregoing, or by an equivalent professionally recognized national accrediting body in the United States or in a country for which eligibility for licensure by endorsement is available by the Kansas Board of Healing Arts. An approved post-graduate training program for dentists is one fully accredited throughout the time period of training by the Commission on Dental Accreditation, a successor agency to either of the foregoing, or by an 7

8 equivalent professionally recognized national accrediting body in the United States or in a country for which eligibility for licensure by endorsement is available by the Kansas Board of Healing Arts. d. Demonstrate proof of an unrestricted license to practice his/her profession by the Kansas Board of Healing Arts. For purposes of this Section, an unrestricted license is one free of any of the following conditions instituted by the Kansas Board of Healing Arts: probation, suspension, or requirements of special supervision, consultation or proctoring. e. Demonstrate eligibility to participate in all federal health care programs, as defined in the Medical Staff Bylaws. Those ineligible to participate, excluded, suspended or disbarred from participation in such programs, or those convicted of a criminal offense related to the provision of health care items or services whose eligibility to participate in such program has not been reinstated are ineligible for Medical Staff membership and/or clinical privileges. f. Document one s background, education, experience, training and demonstrated current clinical competence, adherence to the ethics of one s profession, good reputation and character, current physical and mental health as such relates to the ability to safely and competently perform the requested clinical privileges with or without reasonable accommodation, and the ability to work harmoniously with peers, Medical Center employees, and others sufficiently to evidence that all patients treated at the Medical Center shall receive quality care. For current Medical Staff members, evidence of current competence, experience and judgment shall also include, but not be limited to, documentation of continuing medical education, the results of performance improvement, risk management and peer review activities, consideration of the applicant s compliance with the responsibilities of Medical Staff membership during the previous term(s) of appointment, and recommendations of the Service Chief. For current Medical Staff members, evidence of the ability to work harmoniously with others shall include, but not be limited to, a review of the applicant s conduct and compliance with the responsibilities of Medical Staff membership during the previous term(s) of appointment, and recommendations of the Service Chief. g. Document compliance with Article I, Section A.6 of this Policy regarding professional liability insurance and demonstrate proof of and agree to maintain professional liability insurance coverage in the minimum amount of $1 million per occurrence/$3 million aggregate, which includes Kansas Health Care Stabilization Fund coverage, as applicable. If not statutorily required to participate in the Kansas Health Care Stabilization Fund, the individual agrees to maintain professional liability insurance coverage in the minimum amount of $1 million per occurrence/$3 million aggregate. 8

9 h. Provide evidence of and agree to maintain a current, valid Federal Drug Enforcement Administration registration (DEA certificate) and Kansas prescribing authority for controlled substances (as appropriate to the intended scope of practice). i. For all new applicants, reappointment and additional privilege applicants, demonstrate there is no pending recommendation at another health care facility to suspend, revoke or otherwise restrict Medical Staff membership or clinical privileges, including any summary or precautionary suspension. j. Agree to participate in and properly discharge Medical Staff responsibilities and assist the Medical Staff to fulfill its obligations related to patient care within the areas of their professional competence and credentials. k. Have never been convicted of, or entered a plea of guilty or nolo contendere to, any felony under federal or state law; or convicted of, or entered a plea of guilty or nolo contendere to, any healthcare-related misdemeanor under federal or state law. 3. Effect of Prior Adverse Professional Review Action Except as otherwise determined by the Medical Executive Committee and approved by the Board in light of special circumstances, a Member who has received a final adverse professional review action or voluntarily resigned appointment/privileges during the pendency of a professional review activity, shall not be eligible to reapply for appointment or, as applicable, for those clinical privileges which were the subject of the professional review action or professional review activity for a period of three (3) years from the date of the notice of the final adverse decision or the date of the voluntary resignation. When such individual is eligible to apply, the application shall be processed as an initial appointment in accordance with Article II of this Policy. 4. Effect of Other Affiliations No individual shall be entitled to Medical Staff membership merely because s/he holds a certain degree, is licensed to practice in Kansas or any other state, is a member of any professional organization, is certified by any specialty Board, or had, or presently has, medical staff membership or clinical privileges at another health care entity. 5. Non-Discrimination The Medical Center shall not discriminate in granting appointment, reappointment and/or clinical privileges on the basis of ancestry, race, creed, national origin, gender, faith, sexual orientation, or handicap. 9

10 6. Professional Liability Insurance Requirement a. All Members of the Medical Staff who are health care providers as defined by K.S.A , as amended, shall maintain the minimum level of coverage under the Kansas Health Care Stabilization Fund. b. Members of the Medical Staff are required to maintain professional liability insurance protections to cover the term of their appointment/privileges, including tail coverage as appropriate, by an insurance company that is licensed or authorized to conduct business in Kansas. Member must be able to show proof of tail coverage upon request. c. If a Medical Staff Member changes professional liability insurance carriers for any reason or has insurance coverage limited or terminated for any reason, the Medical Staff Member shall immediately notify Medical Staff Services of such event. B. MEDICAL CENTER NEED No individual shall be appointed or reappointed to the Medical Staff or granted clinical privileges if the Medical Center is unable to provide adequate facilities and support services for the applicant or his/her patients. The Board may decline to accept and/or, through the Credentials and Medical Executive Committees, decline, to process applications and recommend applicants for Medical Staff appointment, reappointment, and/or clinical privileges based on any of the following. 1. Lack of Facilities/Support Services Clinical privileges shall be granted only for the provision of care that is consistent with the scope of services, capacity, capabilities, and business plan of the Medical Center. 2. Exclusivity, Employment and Professional Services Agreements a. General The Medical Center shall not automatically confer appointment or reappointment and/or grant clinical privileges based on an individual s inclusion or consideration for inclusion in an exclusivity, employment or professional services agreement. Instead, each individual shall be considered for appointment, reappointment and/or clinical privileges based on whether the individual meets the qualifications for Medical Staff membership and whose education, training, experience and demonstrated current competence are sufficient, in the opinion of the Board as recommended by the Medical Executive Committee, to obtain the requested clinical privileges. Once appointed, reappointed and/or granted clinical privileges, the Member who is a party to any such agreement shall comply with the Medical Staff Bylaws, Rules and Regulations, Related Documents, and the Medical Center s Corporate Compliance Plan and Policies/Procedures to maintain such 10

11 appointment, reappointment and clinical privileges. The effect of expiration or other termination of an agreement upon a Member s Medical Staff appointment, reappointment and/or clinical privileges shall be governed by the Medical Staff Bylaws and Related Documents unless the Member s agreement with the Medical Center addresses the issue, in which case the terms of the agreement shall be given full force and effect. If the agreement is silent on the matter, then expiration of the agreement or other termination alone shall not affect the Member s appointment, reappointment and/or clinical privileges, except that any Member who is a party to an expired or terminated exclusivity agreement may not thereafter exercise any clinical privileges for which exclusive contractual arrangements have been made with others. Unless the agreement provides otherwise, a Member whose employment or professional services agreement is terminated for cause related to the Member s professional competence or conduct, shall be entitled to the procedural rights afforded in the Fair Hearing Plan, as to the Member s appointment, reappointment and/or clinical privileges. A Member whose agreement expires in accordance with its terms and is not renewed is not entitled to the procedural rights provided in the Fair Hearing Plan unless the agreement provides otherwise. b. Exclusivity Agreements Pursuant to Kansas law, the Board may determine, in the interest of quality patient care, efficient hospital operations, and as a matter of policy, that certain Medical Center clinical facilities may be used only on an exclusive basis in accordance with written agreements between the Medical Center and qualified Medical Staff members. Accordingly, the Medical Center shall not accept applications for appointment, reappointment or clinical privileges which relate solely to facilities or services covered by exclusivity agreements, unless the applicant qualifies under the existing agreement. 3. Medical Staff Development Plan The Board may decline to accept applications based on requirements or limitations in the Medical Center s Medical Staff Development Plan, which shall be based on the Medical Center s identified scope of patient care needs within its service area. The Medical Staff Development Plan shall be prepared at the discretion of and by the Board with input from the Medical Staff President and the Medical Executive Committee and may limit the number of Medical Staff appointees within Services, specialties and subspecialties of the Medical Staff and/or the recipients of clinical privileges. The Medical Staff Development Plan may be based upon written criteria developed with input from the Medical Staff President, Medical Executive Committee and Service Chairs and a finding by the President/Chief Executive Officer that such action would be in the best interests of patient care. The written criteria shall consider, as appropriate, the utilization of the Medical Center and each 11

12 Service, specialty or subspecialty, the average waiting time for scheduling elective procedures, the ability to enter into and financial benefit of entering into exclusive agreements for the provision of care, and other factors deemed appropriate in evaluating the desirability or necessity of limiting the number of Medical Staff appointees within a Service, specialty or subspecialty and/or the recipients of clinical privileges. Any such limitation decision shall be approved by the Board, shall be reviewed at least every two (2) years, and may be raised, lowered or rescinded by the President/Chief Executive Officer after consultation with the applicable Section Chief and concurrence by the Medical Staff President and the Medical Executive Committee and with approval by the Board. 4. Effects of Declination Refusal to extend, accept or review an application for Medical Staff appointment, reappointment or clinical privileges shall be based on the Medical Center s identified patient care needs and ability to accommodate, as described in this Section, shall not constitute a denial of appointment, reappointment or clinical privileges, and shall not entitle the individual to any procedural rights of Fair Hearing or appeal. Any portion of the application which is accepted (e.g. requests for clinical privileges that are not subject to a limitation) shall be processed in accordance with the processes described in this Policy and the Medical Staff Bylaws. C. RESPONSIBILITIES OF MEDICAL STAFF MEMBERSHIP By submitting an application for Medical Staff appointment, reappointment or clinical privileges, the applicant agrees to fulfill the following responsibilities: 1. supplement his/her application with additional information as requested by the Medical Staff Office, Service Chief, Credentials Committee, Medical Executive Committee and/or Board of Trustees and appear for any requested interviews regarding his/her application, or, subsequent to appointment, reappointment or the grant of clinical privileges, appear for any requested interviews related to questions regarding the applicant's competence or performance; 2. provide continuous care and supervision to his/her patients at the generally recognized professional level of quality and efficiency established by the Medical Center and respond to their needs within a reasonable time period under the circumstances or as otherwise specified in these Bylaws, including this Policy, and the Rules/Regulations or other Related Documents; 3. as the attending physician, coordinate care, treatment, and services among all consultants involved in a patient s care and treatment; 4. comply with Medical Center policies related to informed consent and patient rights as more fully described in the applicable Medical Center policies and the Medical Staff Rules/Regulations; 12

13 5. delegate, in his/her absence, the responsibility for diagnosis and/or care of his/her patients only to a Member in good standing of the Medical Staff who is qualified and approved by the Medical Center to undertake this responsibility by the grant of similar clinical privileges; 6. seek consultation whenever necessary, and in accordance with the requirements of the Medical Staff Rules and Regulations and policies of the Medical Center; 7. accept and respond to consult requests in the manner and time period consistent with the Medical Staff Bylaws, Rules and Regulations, and Related Documents; 8. work cooperatively and professionally with Members, Medical Center staff, Medical Center Administration and others so as not to adversely affect the delivery of patient care; 9. refuse to engage in fee splitting or improper inducements to obtain patient referrals; 10. abide by these Bylaws, including this Policy and the Fair Hearing Plan, and the Rules/Regulations or other Related Documents, the Medical Center Corporate Compliance Plan and all other rules, policies and procedures, guidelines, and other requirements of the Medical Staff and the Medical Center; 11. regularly attend assigned Committee meetings unless excused; 12. discharge such Medical Staff, Service, Committee, and Medical Center functions for which he/she is responsible based upon appointment, election, medical staff category or otherwise, including as appropriate, providing on-call coverage for the Emergency Department within his/her clinical specialty, accepting Committee assignments, and participating in performance improvement, peer review and risk management activities; 13. participate in any necessary training regarding the electronic medical record amd document completely, timely, legibly, and accurately in medical records as specifically required by the Medical Staff Rules and Regulation, in all other documents related to care provided in the Medical Center, and to similarly comply in all verbal and written communications with Medical Center representatives and Medical Staff Committees and representatives. Dishonesty or misrepresentations in any such document, record, or communication may be a basis for termination of Medical Staff membership and privileges, or other action as provided by these Bylaws and Related Documents, or in policies and procedures as adopted by the Board from time to time; 14. refrain from transferring any patient from the Medical Center unless such transfer is in the patient s best interest or unless the patient requests such transfer and comply with applicable laws and regulations affecting such transfers. All doubts regarding patient transfers are to be resolved in favor of patient safety and welfare; 13

14 15. cooperate with the Medical Center in matters involving its fiscal responsibilities and policies, including those relating to payment or reimbursement by governmental and third party payers; 16. participate in continuing education to maintain clinical skills and current competence; 17. notify within three working days the Medical Executive Committee, through Medical Staff Services, upon a change in any qualification for membership or clinical privileges, as listed in Article I, Section A.2 of this Credentialing Policy (including but not limited to becoming ineligible to participate in federal programs); 18. upon request by the Medical Executive Committee, the Board, or the Practitioner Health Committee, submit evidence of physical and/or mental health sufficient to fulfill these responsibilities of Medical Staff membership and permit the safe performance of the clinical privileges granted to the Member; 19. promptly notify and update the Practitioner Health Committee, through the Chairman of the Practitioner Health Committee, of any change in the Member s health status which could adversely impact his/her ability to safely carry out the requested or, in the case of a Member, granted privileges; 20. appear, if requested, for personal interviews regarding any question on the application for medical staff appointment, reappointment, additional privilege or clinical privileges; 21. promptly pay any medical staff dues in accordance with the requirements of the Medical Staff Bylaws, Rules and Regulations and/or Related Documents; and 22. perform such other responsibilities as the Hospital or the Medical Staff may require. D. TERMS OF APPOINTMENT All appointments, reappointments and the grant of clinical privileges shall be made by the Board upon recommendation of the Medical Executive Committee and shall be consistent with the Medical Staff Bylaws and this Policy. 1. Initial Appointment to Be Provisional All initial appointments shall be made and all initial clinical privileges shall be granted for up to twelve (12) months from the date of Board action. Such initial privileges shall be provisional in nature. Each Member granted provisional clinical privileges shall be evaluated in an ongoing manner in accordance with these Bylaws including this Policy, the Medical Staff Rules and Regulations, and Related Documents and the Medical Center s Performance Improvement and Risk Management Plans and other applicable policies and procedures, and shall cooperate with such monitoring and evaluation activities. The patient care provided by the provisional Member shall be consistent with the privileges granted. This monitoring and evaluation shall be for the purpose of determining the provisional Member s 14

15 eligibility for advancement from provisional status. At the conclusion of the provisional term, the Member's performance shall be evaluated by the Service Chief to recommend one of the following: a. continuation of provisional status for a time period as recommended by the Credentials and Medical Executive Committees, not to exceed two years (24 months); or b. reappointment without provisional status for a time period not to exceed two years (24 months); or c. termination of appointment and/or some or all of the Member s clinical privileges. Failure to advance from provisional status after two years (24 months) for reasons related to clinical competence or professional conduct may constitute an automatic termination of medical staff membership and clinical privileges. A provisional Member so terminated shall have the procedural rights afforded to him/her as provided in the Fair Hearing Plan. 2. Reappointment Reappointments with or without the grant of clinical privileges shall be for a period not to exceed two years (24 months). 3. Failure to Timely Submit Application In the event that reappointment and/or clinical privileges have not been renewed before the lapse of the current term due to the failure of the applicant to submit completed application forms, the membership and clinical privileges of the affected Member shall be deemed voluntarily surrendered. In such event, the Member shall be so notified and advised that the submission of a new application is required if continued membership and clinical privileges are required. Voluntary surrender of membership and/or clinical privileges shall not entitle the Member to a Fair Hearing and appeal. E. LEAVES OF ABSENCE 1. Requests for Leaves of Absence A Member may request a voluntary leave of absence from the Staff by submitting a written notice to the Medical Executive Committee for leaves greater than ninety (90) days. The request must state the reason(s) for the leave and the proposed beginning and ending dates of the leave, which may not exceed a maximum term of one (1) year unless good cause is shown and an exception is granted by the Medical Executive Committee. Approval of a leave of absence shall be upon recommendation of the Medical Executive Committee subject to approval by the 15

16 Board. During the period of leave, the Member shall not exercise clinical privileges at the Medical Center, and membership prerogatives and responsibilities shall be in abeyance, except for dues and any required application fees should they become due unless waived by the Medical Executive Committee. Prior to any approval of a leave of absence, the Member shall make arrangements to complete all medical record documentation deficiencies and attend to all other outstanding obligations of Medical Staff membership which may exist. When the reason(s) for the leave of absence indicate the leave is optional, the request shall be granted at the discretion of the Medical Executive Committee based on its evaluation of the abilities of the Medical Staff to fulfill the patient care needs that may be created by the absence of the Member requesting the leave. A leave of absence shall be granted to any Member in good standing, provided all incomplete medical records and Medical Staff and Medical Center matters have been concluded and the Member has made appropriate arrangements for the care of his/her patients during the leave, acceptable to the Medical Executive Committee and the Board. Exceptions shall be allowed only in the event a Member has a physical or psychological condition which prevents him/her from completing records or concluding other Medical Staff or Medical Center matters. If during the granted leave the Member s reappointment term is due to expire, the Member shall be required to submit an application for reappointment prior to such expiration in accordance with the Medical Staff Bylaws and Article II.D of this Policy. Such reappointment application shall be processed in accordance with Article II.D of this Policy as if the Member were not on leave. However, the Member shall not be permitted to practice the renewed clinical privileges until the process for reinstatement has been completed, as described in Article I.E.2 of this Policy. A leave of absence may be granted for the following reasons: a. Medical Leave of Absence A Member may request and be granted a leave of absence for the purpose of obtaining treatment for a medical or psychological condition, disability, or impairment. If a Member is unable to request a medical leave of absence because of a physical or psychological condition, the Medical Staff President or the Member s Service Chief may submit written notice on his/her behalf and the Member so informed in writing. Reinstatement of membership status and clinical privileges shall be subject to receipt of a written report from his/her treating physician that such Member is physically or mentally capable of performing the granted privileges, with or without accommodation. If accommodation is required, the written report shall state the nature of the required accommodation. The Member shall provide other such information as may be requested by the Medical Executive Committee and may be subject to certain monitoring conditions as determined by the Medical 16

17 Executive Committee. Approval of a leave of absence shall be upon recommendation of the Medical Executive Committee subject to approval by the Board. b. Military Leave of Absence A Member may request and be granted a leave of absence to fulfill military service obligations. Reinstatement of membership status and clinical privileges may be subject to certain monitoring conditions as determined by the Medical Executive Committee. c. Educational Leave of Absence A Member may request and be granted a leave of absence to pursue additional education and training. Reinstatement of membership status and clinical privileges may be subject to certain monitoring conditions as determined by the Medical Executive Committee. d. Personal/Family Leave of Absence A Member may request and be granted a leave of absence for personal reasons (e.g., to pursue a volunteer endeavor or for family reasons). Reinstatement of membership status and clinical privileges may be subject to certain monitoring conditions as determined by the Medical Executive Committee. 2. Termination of Leave and Request for Reinstatement At least forty-five (45) days prior to the termination of the leave of absence, or at any earlier time, the Member shall request reinstatement of Medical Staff membership and clinical privileges by submitting a written notice to the President of the Medical Staff. If the leave of absence has extended past the Member s reappointment term and s/he did not submit an application for reappointment while on leave, s/he shall also be required to complete such reappointment application in accordance with the Medical Staff Bylaws and Article II.D of this Policy and the reinstatement shall be processed as a reappointment. The written request for reinstatement shall include an attestation that no changes have occurred in the Member s qualifications for membership as listed in Article I.A.2 of this Policy, a summary of all medical education activities undertaken during the leave of absence, the scope and nature of any professional practice which occurred during the leave, and any other information as may be requested by the Medical Executive Committee. If changes in the Member s qualifications have occurred, a detailed description of the nature of such changes shall be provided in the written request for reinstatement. The Member requesting reinstatement shall also demonstrate current professional licensure, registration, and/or certifications necessary to the granted privileges and current professional liability insurance coverage. Verification queries shall be conducted by the Medical Staff Office as follows: a. American Medical Association; 17

18 b. Kansas Board of Healing Arts; c. Criminal background check/facis; d. National Practitioner Data Bank; e. Drug Enforcement Agency, as applicable; f. Office of Inspector General (OIG). The request for reinstatement shall be forwarded to the Member s Service Chief for a recommendation, which shall then be forwarded to the Credentials Committee for its recommendation, followed by a recommendation of the Medical Executive Committee which shall then be submitted to the Board for its approval. An adverse decision regarding reinstatement of Medical Staff membership or renewal of any clinical privileges held prior to the leave shall entitle the Member to a Fair Hearing and appeal as provided in these Bylaws, including this Policy, and the Fair Hearing Plan. 3. Failure to Request Reinstatement F. RESIGNATION Failure, without good cause, to request reinstatement prior to termination of the leave shall be deemed a voluntary resignation from the Medical Staff. A request for Medical Staff membership subsequently received from a Member deemed to have voluntarily resigned shall be submitted and processed in the manner specified for applications for initial appointment. Resignations from the Medical Staff shall be submitted in writing to the Medical Staff Office and shall state the date the resignation becomes effective. The resignation shall be accepted as in good standing provided all incomplete medical records and any open Medical Staff and Medical Center matters have been concluded. The Member s Service Chief, the Medical Executive Committee, and the Board shall review letters of resignation and determine if such acceptance is made when possible. Once submitted, a resignation may not be withdrawn until it has been considered by the Board. If a Member requests to withdraw a resignation before the resignation is accepted by the Board, the request for withdrawal shall also be forwarded to the Board for consideration. The Board may, but is not required to, honor the request for withdrawal of the resignation. Upon acceptance of the resignation by the Board, the Member shall be notified in writing. When a Medical Staff resignation is accepted or clinical privileges are relinquished during the course of a professional review activity related to issues of clinical competency or professional conduct, a report shall be submitted to the Kansas Board of Healing Arts and the National Practitioner Data Bank, as required by law. 18

19 ARTICLE II: PROCESS FOR APPOINTMENT AND REAPPOINTMENT A. GENERAL 1. Effect of Application for Appointment/Reappointment By applying for Medical Staff appointment, reappointment and/or clinical privileges, the applicant: a. authorizes representatives of the Medical Center and/or the Medical Staff to solicit and act upon information, including otherwise privileged or confidential information provided by third parties and/or entities bearing on his/her credentials and agrees that any information so provided shall not be required to be disclosed to the applicant if the third party providing such information does so only on the condition that the information be kept confidential; b. authorizes third parties to release information to representatives of the Medical Center and/or the Medical Staff, including otherwise privileged or confidential information, as well as reports, records, statements, recommendations, and other documents in their possession bearing on the applicant s credentials, and consents to the inspection and procurement by the Medical Center of such information, records and other documents; c. authorizes the Medical Center to maintain information concerning the applicant s age, training, board certification, licensure and other confidential information in a centralized physician database for the purpose of making aggregate physician information available for use by the Medical Center; d. authorizes the Medical Center to release confidential information, including peer review and/or performance improvement information, obtained from or about the applicant to peer review committees of the Medical Staff and Medical Center for purposes of reducing mortality and morbidity and for the improvement of patient care; e. agrees to appear for a personal interview at any reasonable time regarding any information pertaining to the application, as requested by any representative of the Medical Center and/or Medical Staff; f. upon request of the applicant, authorizes representatives of the Medical Center and/or the Medical Staff to release information, including otherwise privileged or confidential information bearing on the applicant s credentials, to other healthcare entities, who solicit such information for the purpose of evaluating his/her professional qualifications pursuant to a request for appointment, reappointment or clinical privileges; g. consents to the reporting by Medical Center representatives of any information which is required by law or regulation to be reported to the 19

20 National Practitioner Data Bank, the Kansas Board of Healing Arts, or any other similar entity; h. agrees that, if any adverse decision is made with respect to the application, s/he shall follow and exhaust the administrative remedies afforded by the Medical Staff Bylaws and the Fair Hearing Plan as a prerequisite to any other action, and that s/he shall have the burden of demonstrating that s/he meets the standards for appointment or continued appointment to the Medical Staff and/or for the clinical privileges requested; i. agrees to comply with and be bound by the Medical Staff Bylaws, this Policy, Related Documents, and the Medical Center s Corporate Compliance Plan and policies/procedures; j. agrees to comply with all applicable federal, state and municipal laws/regulations and hospital accreditation standards that apply to Medical Staff Members; k. agrees that the foregoing provisions are in addition to any agreements, understandings, covenants, waivers, authorizations or releases provided by law or contained in any other application or agreement. 2. Immunity from Liability a. Immunity and Release By applying for and/or accepting appointment to the Medical Staff and/or applying for, accepting and exercising clinical privileges, the applicant extends absolute immunity to, and releases from all claims, damages and liability: (1) any and all Medical Center and Medical Staff representatives for any statement, action taken, or recommendation made by same within the scope of their duties and in compliance with the Medical Staff Bylaws, this Policy and Related Documents, including disclosures made to other healthcare entities pursuant to the Medical Staff Bylaws, this Policy and Related Documents; and (2) any third party for releasing or disclosing information, including otherwise privileged or confidential information, to any Medical Center or Medical Staff representative concerning the applicant unless such information is false the third party has direct knowledge of the falsity. b. Scope of Immunity and Release The immunity so provided by the Medical Staff Bylaws, this Policy and Related Documents shall apply to all acts, communications, reports, recommendations, or disclosures performed or made in connection to the Medical Center s activities, including but not limited to: 20

21 (1) application for appointment, reappointment and clinical privileges, including inquiries from other healthcare entities regarding the credentials of a Member; (2) periodic performance appraisals undertaken for reappointment, requests for new privileges or pursuant to the Medical Center s performance improvement and risk management activities; (3) recommendations for and corrective actions taken, including professional review actions and the investigative processes resulting in same; (4) Fair Hearings and appellate review; (5) peer review and monitoring/evaluating activities for the purposes of maintaining quality patient care and appropriate professional conduct within the Medical Center; and (6) reporting to the National Practitioner Data Bank, Kansas Board of Healing Arts, and/or other similar entities as may be required by law or regulation. 3. Burden on the Applicant An applicant for Medical Staff appointment, reappointment and/or clinical privileges shall be responsible for producing adequate, accurate information to properly evaluate his/her experience, background, training, demonstrated competence, character, physical/mental health status and/or any other criteria or qualification specified in the Medical Staff Bylaws or this Policy, as determined by the Service Chief (or designee), Credentials Committee, Medical Executive Committee, or Board to resolve any doubts or conflicts regarding the application, and/or to clarify information as requested. An application for appointment, reappointment and/or clinical privileges shall not be considered a complete application until all requested information and documentation is provided, and an application may be deemed incomplete at any stage of the credentialing process if additional information is deemed necessary to effect a complete and adequate evaluation of the applicant. The applicable Service Chief, Credentials Committee, Medical Executive Committee and/or the Board may request an applicant appear for an informal interview regarding the application. Medical Staff Services shall provide written notice to the applicant of the information and/or interview request, the specific information requested and/or to be discussed, and the timeframe within which a response from the applicant is required. Failure by an applicant to appear for an interview or produce all additional requested information within thirty (30) days of the applicant s receipt of the written request to appear, the applicant will be deemed 21

22 to have voluntarily withdrawn his/her application. The applicant shall be notified by certified mail, return receipt requested that his/her application is barred from further processing and is considered withdrawn. Thereafter, if the applicant desires appointment, reappointment or clinical privileges, s/he shall be required to submit a new application for same. The new application shall not be processed unless all previously requested information is provided by the applicant. Any material misrepresentation of information by an applicant during the application process, either by commission or omission, shall render the application for appointment, reappointment and/or clinical privileges ineligible for further processing. When it appears at any stage of the application process that an applicant seeking initial appointment and/or clinical privileges has provided inaccurate information which may constitute an intentional material misrepresentation, processing of the application shall cease until the applicant is informally interviewed by the Credentials Committee. Such interview shall be conducted informally and the affected applicant shall be allowed to present information, but shall have no right to call witnesses unless specifically granted by the Credentials Committee in its sole discretion, or be represented by legal counsel. If, following such interview the Credentials Committee confirms an intentional material misrepresentation was made, the application shall be considered voluntarily withdrawn and the applicant shall not be eligible to reapply for appointment/clinical privileges at the Medical Center for three years from the date of the voluntary withdrawal. Such voluntary withdrawal and ineligibility shall not trigger Fair Hearing rights. The applicant shall be provided written notification of such by certified mail, return receipt requested. When it appears at any stage of the application process that an applicant seeking reappointment and/or clinical privileges has provided inaccurate information which may constitute an intentional material misrepresentation, processing of the application shall cease until the applicant is informally interviewed by the Credentials Committee. Such interview shall be conducted informally and the affected applicant shall be allowed to present information, but shall have no right to call witnesses or be represented by legal counsel unless specifically granted by the Credentials Committee in its sole discretion. If, following such interview the Credentials Committee confirms an intentional material misrepresentation was made, such conduct shall constitute an automatic resignation from the Medical Staff and the application deemed to be voluntarily withdrawn. In such instance, the applicant shall not be eligible to reapply for appointment/clinical privileges at the Medical Center for three years from the date of the automatic resignation. Such automatic resignation, voluntary withdrawal and ineligibility shall not trigger Fair Hearing rights. The applicant shall be provided written notification of such by certified mail, return receipt requested. 4. Assistance with Evaluation The Service Chief, the Credentials Committee, the Medical Executive Committee or the Board, as part of the review and evaluation of applications for Medical Staff 22