1 MARTIN HEALTH SYSTEM CREDENTIALING PROCEDURES MANUAL FOR ALLIED HEALTH PROFESSIONALS/DEPENDENT PRACTITIONERS Last Amended September 24, 2014 Approved 04/2012 Last reviewed in its entirety by Medical Staff Bylaws Committee: 7/16/14 Revised 11/15/12; 9/24/14
2 MARTIN HEALTH SYSTEM 2 The following definitions apply to this Manual. DEFINITIONS Affiliate shall refer to an entity which is owned in whole or in part by Martin Health System, or a subsidiary of Martin Health System and which has a legitimate need to credential and grant privileges to an Allied Health Professional (AHP)/Dependent Practitioner (DP). Allied Health Professional or AHP/Dependent Practitioner or DP. See Part 1.1. ARNP means an individual licensed as an R.N. in an expanded role as a nurse practitioner. Associate shall refer to an individual who is an employee of Martin Health System or any Affiliate. Board of Directors or Board means the governing body of the applicable Martin Health System affiliated entity responsible for overseeing the credentialing of AHPs/DPs in the applicable Martin Health System affiliated Facility. Except as provided herein and as appropriate to the context and consistent with the Bylaws of the entity and delegations of authority made by the Board, it may also mean any committee of the Board or any individual authorized by the Board to act on its behalf on certain matters. Bylaws mean the corporate Bylaws of the applicable entity. CNM means an individual licensed as an ARNP in an expanded role as a certified nurse midwife. Credentials Committee or CC shall mean the Credentials Committee of Martin Health System standing committee of the Board of Directors of Martin Health System charged with the responsibility of coordinating all Allied Health Professional/Dependent Practitioner and Medical Staff credentialing functions performed by Affiliated Facilities. CRNA means an individual licensed as an ARNP in an expanded role as a certified registered nurse anesthetist. Department Chairman/Service Chief, and similar references, shall refer to the Department Chairman or Service Chief of the Facility in which the AHP/DP is being credentialed and, where applicable Department Chairman and Service Chiefs do not exist, such references shall be construed as meaning the applicable Medical Director of a Facility or a Department within a Facility. Medical Staff Services Credentialing Specialist shall refer to an individual or group of individuals designated by Martin Health System Administration to accept and process applications by Physicians or AHPs/DPs requesting permission to provide specified services in a Facility. Entity shall refer to any enterprise which is legally affiliated with Martin Health System or legally affiliated with a subsidiary of Martin Health System not-for-profit Florida Corporation. Facility shall mean the Martin healthcare facilities, including all mobile units, where applicable, which are operated by an Affiliate and which grants clinical privileges to AHPs/DPs. Martin Health System shall, for the purposes of this manual, be used to collectively refer to all facilities operated by Martin Health System or any affiliate, where the context permits. It shall not be construed as referring to Martin Health System individually as a not-for-profit Florida corporation. Medical Executive Committee or MEC shall mean the Medical Executive Committee of the applicable Facility or, if no committee has been designated as the Medical Executive Committee, then each such
3 MARTIN HEALTH SYSTEM 3 reference shall be construed as including the highest level Facility committee whose membership includes healthcare providers credentialed and privileged to practice in the Facility. Medical Staff or Staff is the organizational component of the applicable entity that includes all practitioners who are appointed to it and are privileged to attend patients or to provide other diagnostic, therapeutic, teaching or research services at the entity s facilities. Medical Staff Bylaws and related manuals, Medical Staff Bylaws or Bylaws means and refers to all of the following documents as appropriate to the context: Bylaws of the Medical Staff. Medical Staff Medical Staff Fair Hearing Plan Medical Staff Organization Manual General Rules and Regulations of the Medical Staff. Medical Staff Member shall mean those practitioners granted Medical Staff membership and clinical privileges by a board to practice at a Facility which has an organized Medical Staff. AHPs /DPs are not Medical Staff members. Medical Staff President means that member of the Active Staff elected pursuant to the applicable Bylaws and Medical Staff Bylaws to be the principal elected officer of the Staff. If there is no Medical Staff or a principal elected officer to represent the Healthcare providers, all such references shall be construed as meaning the highest ranking physician representative of the applicable Facility. Medical Staff Services or MSS means the administrative unit of Martin Health System responsible for organizing and managing the administrative aspects of the credentialing and privileging processes and for providing support for the Medical Staff organizations, their officers and structural components in the fulfillment of their required functions. PA means an individual with a P.A. degree, who is licensed as a physician assistant, and who may provide medical services appropriate to his or her training, experience and skills under the supervision of a physician. Physician means an individual with an M.D. or D.O. degree, who is licensed to practice medicine. President means the individual appointed by the Board as the chief executive officer of the applicable entity to be responsible for the overall executive supervision and management of the entity. The President may, consistent with his responsibilities under the Bylaws, designate a representative to perform his responsibilities under the Medical Staff Bylaws and related manuals. Professional Affairs Committee or PAC means the Professional Affairs Committee of the Board. Psychologist means an individual with a doctoral degree in psychology from an accredited educational institution, who is licensed to practice psychology. Scope of Practice means extent of treatment, activity or influence defined for each AHP/DP. Special Notice means written notification sent, unless otherwise specified, by certified mail, return receipt requested, or by personal delivery service with signed acknowledgment of receipt. Written Notice means written notification sent, unless otherwise specified, by regular mail, electronic mail, facsimile transmission, delivery to the members boxes in the Hospital, or by personal delivery.
4 MARTIN HEALTH SYSTEM 4 Specified Services means the specific clinical functions or activities in the treatment of patients granted to an AHP/DP. Supervising Physician means a physician holding an unrestricted full medical license in Florida who has been designated as a Supervising Physician for an AHP/DP or who has developed and signed mutually agreed upon guidelines with a PA or nurse engaged in an expanded role and/or in prescriptive practice. Vice President for Medical Affairs or VPMA means the individual designated by the Board to hold this title, and who is the Chief Medical Officer of all Martin Health System facilities. The VPMA may, consistent with his responsibilities under the Bylaws, Medical Staff Bylaws and related manuals, and his employment arrangement, designate a representative to perform his responsibilities hereunder. CONSTRUCTION OF TERMS AND HEADINGS Pronouns having gender refer to persons of both sexes. The captions or headings in the Bylaws and related manuals are for convenience only and are not intended to limit or define the scope or effect of any provision herein.
5 MARTIN HEALTH SYSTEM 5 PART ONE. AUTHORIZATION AND CONTROL PROVISIONS 1.1 DEFINED GENERALLY An allied health professional ( AHP ) / dependent practitioner (DP) is an individual, other than a Medical Staff member, who is qualified by academic and clinical training and by prior and continuing experience and current competence in a discipline which the Board has determined to allow to practice in a Martin Health System affiliated Facility and who, at the time of initial application and continuously thereafter, satisfies the basic qualifications set forth in Section 1.2 of this Manual, and either: A. is licensed and permitted by the state and the Board to provide patient services in the Facility without the direction or contractual agreement with a physician (i.e., "Independent Practitioner"); or B. is licensed by the state to perform patient care services ordinarily performed by a physician under the direction of the physician and with mutually agreed upon guidelines (i.e., "Dependent Practitioner") CURRENT CATEGORIES OF ALLIED HEALTH PROFESSIONALS/DEPENDENT PRACTITIONERS Martin Health System permits the following categories of independent practitioners and physician-directed practitioners to be credentialed pursuant to this Manual to provide services in its affiliated facilities: A. Independent Practitioners: Psychologist B. Dependent Practitioners: Certified Nurse Midwife Certified Registered Nurse Anesthetist Advanced Registered Nurse Practitioner Physician Assistant For the purposes of this Manual, all other healthcare professionals scope of permitted services not referenced above shall be processed through the Human Resources Department and will be defined by a job description or contractual agreement, and this Manual shall not apply to them, including but not limited to: Surgical Assistants Audiologists LPN-Assistants Surgical Technicians RNFAs Pathology Assistants Cardiothoracic Perfusionists 1.2 QUALIFICATIONS OF ALLIED HEALTH PROFESSIONALS/Dependent Practitioners (Reference Medical Staff Bylaws Article Seven) Every AHP/DP who applies for or is exercising specified services must at the time of initial application for permission to practice and, if approved, continuously thereafter, demonstrate to the satisfaction of the appropriate Martin Health System authorities the following minimum qualifications (any individual Entity may require such additional qualifications it deems appropriate):
6 MARTIN HEALTH SYSTEM LICENSURE Current license, registration, certificate or such other credential, if any, as may be required by Florida law CONTROLLED SUBSTANCE REGISTRATION If applicable, currently valid U.S. Drug Enforcement Administration (DEA) and Florida controlled substances registrations PROFESSIONAL EDUCATION AND TRAINING As defined in the applicable threshold criteria for each specific AHP/DP specialty EXPERIENCE AND PROFESSIONAL PERFORMANCE Current experience, clinical results and utilization practice patterns, documenting the continuing ability to provide patient care services at an acceptable level of quality and efficiency in each applicable Facility COOPERATIVENESS Demonstrated ability to work cooperatively and in a professional manner with others (Staff members, members of other health disciplines, Hospital management and employees, the Hospital Board, visitors and the community in genera), specifically to include refraining from conduct which constitutes a pattern of disruption that could adversely affect the quality or efficiency of patient care services in the applicable Facility PROFESSIONAL ETHICS AND CONDUCT To be of high moral character and to adhere to generally recognized standards of professional ethics HEALTH STATUS A. Physical or Mental Impairment: Must be free of any mental or physical impairment that could interfere with the performance of all or any of the specified services requested or granted, unless reasonable accommodation can be made for such impairment consistent with the interests of sound patient care. In the event of a physical or mental impairment, the Practitioner shall promptly notify the VPMA so that a determination can be made as to whether or not there is a reasonable accommodation that can be made for the impairment that will permit the Practitioner to continue his/her duties. B. Substance/Chemical Abuse: To be free from abuse of any type of substance or chemical that interferes with, or presents a reasonable probability of interfering with, the Practitioner's ability to satisfy any of the qualifications required by this Part 1.2 or ability to perform any or all of the specified services requested or granted. Practitioner shall be subject to all drug testing policies then in effect for Associates COMMUNICATION SKILLS Ability to read, write and understand the English language, to communicate in the English language in an intelligible manner, and to prepare any authorized medical record entries and other required documentation in a legible manner FOR MARTIN HEALTH SYSTEM EMPLOYEES Associates of Martin Health System affiliates must also satisfy any additional requirements applicable to employment.
7 MARTIN HEALTH SYSTEM PROFESSIONAL LIABILITY INSURANCE If not a Martin Health System Associate, professional liability insurance coverage issued by a recognized company and of a type and in an amount equal to or greater than the limits established by the Board. 1.3 EFFECTS OF OTHER AFFILIATIONS (Reference Medical Staff Bylaws Article Seven 7.1-8) No AHP/DP shall be automatically entitled to provide any services merely because the Practitioner: A. is authorized to practice in this or in any other state; or B. is a member of any professional organization; or C. is certified by any clinical board or professional organization; or D. had, or presently has, specified clinical privileges/competencies or permission to provide the requested specified services at another healthcare facility or in another practice setting; or E. had, or presently has, those requested specified services or is employed at any Martin Health System affiliated Facility; or F. is or is about to become affiliated with a practitioner or another AHP/DP who is, or with a group of practitioners or AHPs/DPs one or more of whose members are, affiliated with a Martin Health System affiliated Facility through employment, contract, Medical Staff appointment or otherwise NONDISCRIMINATION: (Reference Medical Staff Bylaws Article Seven 7.1-9) No aspect of the AHP/DP affiliation with Martin Health System or particular clinical privileges/competencies shall be denied on the basis of: age; sex, race, creed, color, national origin, a handicap unrelated to the ability to fulfill patient care and required obligations; or any other criterion unrelated to the delivery of quality and efficient patient care in the Hospital facilities, to professional qualifications, or to the Hospital s purposes, needs and capabilities. 1.4 PREROGATIVES OF ALLIED HEALTH PROFESSIONALS/DEPENDENT PRACTITIONERS (Reference Medical Staff Bylaws Article Two [2.3-2; 2.3-5; 2.4; 2.4-2; 2.4-5; 2.4-9]) The prerogatives of an AHP/DP are to: A. perform such specified services as are defined by the appropriate Martin Health System authorities, and consistent with any limitations stated in the policies governing the AHP's/DPs practice in the applicable Facility and any other applicable Medical Staff, Board or Administrative policies; B. serve on committees, if so appointed, and with vote, if so specified by the appointing authority; C. attend, when invited, clinical meetings of the Medical Staff, a Department or other clinical unit when appropriate to his discipline; D. attend education meetings of the Medical Staff, a Department or other clinical unit; and E. exercise such other prerogatives as the appropriate Martin Health System authorities may accord AHPs/DPs in general or a specific specialty of AHPs/DPs. 1.5 LIMITATIONS OF ALLIED HEALTH PROFESSIONALS/DEPENDENT PRACTITIONERS AHPs/DPs are not: A. eligible to become members of the Medical Staff; or B. eligible to vote in meetings of, or hold office on the Medical Staff; or C. required to pay dues to the Medical Staff; or D. governed by the due process defined by the Fair Hearing Plan of the Medical Staff; or E. with the exception of Certified Nurse Midwives, eligible for admitting privileges.
8 MARTIN HEALTH SYSTEM OBLIGATIONS OF ALLIED HEALTH PROFESSIONALS/DEPENDENT PRACTITIONERS (Reference Medical Staff Bylaws Article Two [2.3-6; 2.4-3; 2.4-6] Each AHP/DP shall have a continuing obligation to at all times: A. provide patients with care or other services at the level of quality and efficiency professionally recognized as the appropriate standard of care by the Medical Staff and Board; B. provide or arrange for appropriate and timely medical coverage and care for patients for whom he is responsible; C. when necessary and as appropriate, notify Supervising Physician of the need to arrange for a suitable alternative for care and supervision of the patient; D. participate in quality assessment/improvement program, risk management, and corporate compliance activities appropriate to his discipline, and discharge such other related functions as may be required from time to time; E. when requested, attend clinical and education meetings of the Staff and of the Department and any other clinical units with which he is affiliated and any individual conference requested by any applicable Department Chairman/Service Chief, Medical Director of a special unit, or Medical Staff committee, or other Martin authorities; F. abide by the applicable sections of the Medical Staff Bylaws, this Manual and those appended to any particular specialty of AHP/DP, and all other relevant standards, policies, and rules of the Medical Staff, the Board, Administration and other applicable Martin Heath System authorities; G. prepare and complete in timely fashion, as appropriate and authorized, those portions of patients' medical records documenting services provided, and any other required records; H. provide upon request evidence of current Florida license/certificate, professional liability insurance coverage, and if applicable, Federal DEA and Florida controlled substances registration; I. immediately notify the Medical Staff Services Credentialing Specialist of: (1) Any criminal charges brought against the AHP/DP (other than minor traffic violations not involving a DUI charge); (2) any change made or formal action initiated that could result in a change in the status of his license/certificate to practice, professional liability insurance coverage; (3) all changes in employment or affiliation relationships involving a termination, disciplinary action or reduction in practice privileges with (i) a physician identified as one who supervises the AHP/DP, (ii) an affiliation with or privileges at any other institutional affiliation where he provides specified services; and (4) any change in the status of current or initiation of new malpractice claims involving his professional performance, and any change in health status that could affect his ability to perform safe and sound patient care; and J. refrain from any conduct or acts that are or could reasonably be interpreted as being beyond, or an attempt to exceed, the authorized scope of practice. K. unless otherwise specified in the relevant Threshold Criteria or Criteria for Clinical Competencies in the applicable specialty, to maintain permission to provide services the practitioner must have a minimum of forty (40) patient encounters per biennial review. As used herein, patient encounters mean any encounter with a patient where the practitioner is required to document the encounter. In the event of fewer encounters, the practitioner will be given a special notice advising of the foregoing and afford the practitioner thirty (30) days to provide documentation demonstrating compliance with this requirement. Failure to demonstrate compliance with the patient encounter requirement, the practitioner s permission to provide services and clinical competencies shall terminate. Such termination shall not be deemed to be a professional review action for purposes of reporting to the National Practitioner Data Bank under Title IV of public law ( the Healthcare Quality Improvement Act of 1986 ).
9 MARTIN HEALTH SYSTEM 9 Failure to satisfy any of these obligations is grounds, as warranted by the circumstances, for termination or nonrenewal of permission to provide specified services or for such other disciplinary action as deemed appropriate under the circumstances. 1.7 TERMS AND CONDITIONS OF PERMISSION TO PROVIDE SERVICES An AHP/DP shall be individually assigned to the clinical Department/Service appropriate to his/her professional training and authorized scope of practice. The AHP/DP is subject to an initial probationary period, formal periodic reviews, termination of permission to provide specified services, and disciplinary procedures as set forth in this Manual. An AHP s/dp s authorized specified scope of practice within any Department/Service is subject to the rules and regulations of that Department/Service and to the authority of the Department Chairman/Service Chief. The quality and efficiency of the care provided by AHPs/DPs within any such Department/Service shall be monitored and reviewed. 1.8 LIMITATIONS ON SCOPE OF PRACTICE Limitations may be placed on the AHP's/DP s authorized scope of practice in the Facility as deemed necessary either for the efficient and effective operation of the Facility or any of its departments or services, or for management of personnel, services and equipment, or for quality or efficient patient care, or as otherwise deemed by the Board or other appropriate Martin Health System authorities to be in the best interests of patient care INDEPENDENT AHP/DP SPECIFIED SERVICES The specified services available to any type of AHPs/DPs shall be established by the Board in accordance with applicable state and federal laws, subject to review and approval as provided herein, and with input from the Credentials Committee (CC), Medical Executive Committee (MEC), Professional Affairs Committee (PAC), and any applicable Department Chairman/Service Chief, appropriate representatives from Administration, and/or representatives from applicable AHP/DP specialties DEPENDENT AHP/DP SPECIFIED SERVICES Written guidelines defining the specified services that may be provided by each specialty of Dependent AHP/DP shall be established in accordance with applicable state and federal laws by the appropriate Martin Health System authorities, subject to review and approval as provided herein, and with input, as applicable, from the Medical Staff, Administration, the Facility's other professional staffs, and applicable AHP/DP specialties SPECIFIC SERVICES AUTHORIZATION REQUIRED AHPs/DPs will receive a written document establishing the specific services the AHP/DP is being granted permission to provide. This document will identify the applicable Facilities. A. qualifications applicable to the specified services authorized and special requirements that attach to those services; B. specification of specialties and ages of patients that may be seen; C. description of the services to be provided and procedures to be performed, including any special equipment, procedures or protocols that specific tasks may involve, and responsibility for charting services provided in the patient's medical record; D. if applicable, specific guidelines governing the issue of prescriptions or medication orders; E. the degree of physician supervision required; F. the circumstances in which physician consultation or referral is required; and G. provisions for managing emergencies.
10 MARTIN HEALTH SYSTEM 10 Each AHP/DP and each Supervising Physician must agree in writing that the AHP/DP will not provide any services in any Martin Health System Facility unless the AHP/DP has been granted specific written permission to provide, and that the failure to at all times comply with this restriction shall be grounds for the immediate revocation of permission to provide any or all specified services, and to take such other disciplinary action as is deemed appropriate by the applicable Martin Health System authorities. 1.9 SUPERVISING PHYSICIAN PHYSICIAN SUPERVISOR QUALIFICATIONS All Physicians who wish to use a Dependent Practitioner to assist with the provision of services to patients at any Martin Health System facility must submit a formal written request to Medical Staff Services and receive formal written notice of approval from the Board of Directors regarding the specific services the Dependent Practitioner may provide before utilizing the Dependent Practitioner. The physician supervisor of an AHP/DP must be a member of the Medical Staff, who is trained and legally authorized to act in that capacity, and who must agree to supervise the activities of the AHP/DP in accordance with this Manual, the applicable Bylaws, Medical Staff Bylaws, and all applicable Martin Health System policies, procedures and applicable laws and regulations. If the AHP/DP is to work with a group of physicians, the group shall designate a primary Supervising Physician and an alternate Supervising Physician SUPERVISING PHYSICIAN S OBLIGATIONS Any physician supervising a physician-directed AHP/DP in the care of a specific patient must: A. be a member of the Medical Staff and accept full legal and ethical responsibility for the AHP's/DP s performance; B. accept full responsibility for the proper conduct of the AHP/DP within the Facility, in accordance with all Bylaws, policies and rules of the Facility and Medical Staff, and for the correction and resolution of any problems that may arise; C. be immediately available in person or by telephone to provide further guidance when the AHP/DP performs any task or function; D. maintain ultimate responsibility for directing the course of the patient's medical treatment; E. assure that the AHP/DP provides services in accordance with accepted medical standards; F. May not delegate duties or responsibilities to the Dependent Practitioner that they have not been granted or are not considered competent to perform. G. provide active and continuous overview of the AHP's/DP s activities in the Facility to ensure that directions and advice are being implemented; H. abide by all bylaws, policies and rules governing the use of AHPs/DPs in the Facility, and the AHP's/DP s authorized scope of practice in the Facility; I immediately notify the Medical Staff Services Credentialing Specialist in the event any of the following occur;
11 MARTIN HEALTH SYSTEM the scope or nature of his professional arrangement with the AHP/DP changes; 2. his legal authority to supervise the AHP/DP is revoked, limited, or otherwise altered by action of the applicable state licensing authority; 3. notification is given of investigation of the AHP/DP or of his/her supervision of the AHP/DP by the applicable state licensing authority; 4. his/her professional liability insurance coverage is changed insofar as coverage of the acts of the AHP/DP is concerned or the AHP's/DP s professional liability insurance coverage is changed; J. comply with all laws and regulations and all policies, procedures and restrictions specific to the AHP/DP; K. When a Supervising Physician is unable or unavailable to be the principal medical decision maker, it is the obligation of the Supervising Physician and AHP/DP to inform and provide to Medical Staff Services written confirmation from another physician who has agreed to assume temporary supervisory responsibilities with respect to the AHP/DP. The temporary assumption of supervisory responsibilities must be in place prior to the principle Supervisor s taking his/her leave. If the AHP/DP is an Employed/Associate of a Martin Health System affiliate, the Supervising Physician must notify the Department of Human Resources of the need to replace the Supervising Physician. For affiliate Employed/Associate AHPs/DPs, the VPMA is responsible for assigning a temporary Supervising Physician and notifying Medical Staff Services and Human Resources. Regardless of the AHP/DP status (Employed/Associate or Non-Employed), if a temporary supervising physician is not immediately available/assigned, the AHP/DP permission to provide services and clinical privileges/competencies will be immediately suspended until such time as the Supervising Physician returns or a temporary Supervising Physician is named. The Suspension shall not exceed ninety days; thereafter, the AHP/DP will be deemed to have voluntarily resigned and relinquished all clinical privileges/competencies. Reinstatement of the AHP s/dp s permission to provide services and clinical privileges/competencies may occur anytime during the time frame referenced and only upon receipt of the official notice of the Supervising Physician s return or upon assigning a temporary new Supervising Physician. L. For all patients who are seen initially on admission to the Hospital by a Physician Assistant or Advanced Registered Nurse Practitioner, the Dependent Practitioner can perform the initial assessment, but the supervising physician must see the patient within 24 hours of admission, sign off on orders, H & P, and write an initial progress note. Thereafter, the Supervising Physician must see all inpatients once every 48 hours at a minimum and provide evidence of such within the Progress Notes or Orders section of the patient s Medical Record. ICU patient admissions must be seen timely by the supervising physician regardless of the length of the ICU admission; and thereafter at least once each 24 hours. [NOTE: CNM/CRNA s: Due to the scope and nature of their practice, this provision shall not apply to CNMs and CRNAs so long as the care is provided pursuant to an established protocol and is within the licensed scope of practice.] Examples of appropriate documentation would include self-entry or co-signing; including date and time; the Physician Assistant s or Advanced Registered Nurse
12 MARTIN HEALTH SYSTEM 12 Practitioner s progress note indicating agreement with said PA/ARNP s documentation. [NOTE: CNMs: Due to the scope and the nature of their practice, this provision shall not apply to CNMs so long as the care is provided pursuant to the established protocol and is within the licensed scope of practice.] M. CONSULTATIONS: a) The Supervising physicians will not refer Initial consultations to the Dependent Practitioner unless it is for a specific service for which the Dependent Practitioner has been approved to provide b) The Dependent Practitioner must consult with the Supervising Physician and document all consultations prior to discharge from the Hospital, including the Emergency Room. c) If a patient seen by the AHP/DP in the ER requires transfer to another facility, the Supervising Physician must speak directly with the Emergency Department physician LEVEL OF SUPERVISION Indirect Supervision is defined as supervision of the Dependent Practitioner accomplished by easy availability of the Supervising Physician to the Dependent Practitioner, which includes the ability to communicate directly (telecommunication is acceptable). The Supervising Physician must be within a reasonable physical proximity. Direct Supervision is defined as the physical presence of the Supervising Physician on the premises, so that the Supervising Physician is immediately available to the Dependent Practitioner ORIENTATION OF AHP/DP As referenced in the Threshold Criteria for Permission to Provide Services, approval of an AHP's/DP s application shall be conditional upon satisfactory completion of an orientation process then in effect, which must occur within six (6) months of the date permission is granted and prior to the AHP/DP exercising any privileges in a Facility IDENTIFICATION At all times while on Facility premises, the AHP/DP shall wear the identification badge provided by Martin Health System clearly identifying the AHP/DP by name and professional designation EVALUATION OF INDIVIDUAL ALLIED HEALTH PROFESSIONAL/DEPENDENT PRACTITIONER APPLICATIONS AFFILIATE EMPLOYED/NON-EMPLOYED AHP/DP The procedure for evaluating an application from an AHP/DP or a prospective AHP/DP is set forth in Part Two of this Manual. Affiliate Employed AHP/DP shall also be subject to the Facility s Human Resources policies. Evaluation of the application shall include review and reports by the same authorities as provided in Part Two of this Manual. An offer of employment may be extended with conditions that the prospective applicant successfully completed the credentialing process as provided herein.
13 MARTIN HEALTH SYSTEM 13 PART TWO. APPLICATION PROCEDURE FOR ALLIED HEALTH PROFESSIONAL/DEPENDENT PRACTITIONER 2.1 APPLICATION AND CONTENT (Reference Medical Staff Credentialing Procedure Manual Part One) An application for permission to provide specified services must be submitted to the Medical Staff Services Credentialing Specialist by the AHP/DP in writing, signed, and on the approved forms. The application must furnish complete information concerning at least the following: A. Personal Information: Full name, Social Security number, addresses, telephone (landlines/cell) numbers, address(es) for all offices and residence. B. Physician Supervision Information: Name of the physician/group who employs the AHP/DP, if applicable, and the names of the physician members of the Medical Staff who will supervise the AHP/DP. Each such physician or, in the case of a group, the group s official designee, must sign the Supervising Physician acknowledgment form accompanying the application for the AHP/DP. C. Education: School name and location, major, degrees awarded, and dates attended for all undergraduate and/or professional/other graduate schools relevant to the specified services/clinical privileges/competencies requested. D. Postgraduate/Continuing Education: Institution/school name and location, title and summary description or content of program, program director, dates attended, date completed. E. Professional Licenses/Registration/Certifications: A current and valid license/registration/certificate issued by the State of Florida to practice within the specialty of application; All past and currently valid other State Professional licensures or certifications; Date of certification by the professional college or board, where applicable (e.g., National Commission on Registration of Physician Assistants); Current professional college/board certificate, where applicable; If applicable to area of practice, current valid U.S. DEA and Florida Controlled Substances registrations. F. Chronology of Professional Career (all present and prior): Facility affiliations, other institutional affiliations, employment with solo/group/partnership practice, with name, nature and location of each, inclusive dates, and experience at each in the specified services being requested. The chronology must cover all periods from professional education and training to current. G. Professional Society Memberships: Current and pending. H. Actions (full details must accompany application): Any Pending or completed action(s) involving denial, revocation, suspension, reduction, limitation, probation, nonrenewal, involuntary or voluntary relinquishment (by resignation or expiration) of or withdrawal of application for any of the following: license or certificate to practice any profession in any state or country; Drug Enforcement Administration or other controlled substances registration (if applicable); membership or fellowship in local, state or national professional societies/organizations; academic appointment; hospital/other institutional affiliation;
14 MARTIN HEALTH SYSTEM 14 authority to provide services; authority to perform privileges; board certification. I. Pending Disciplinary Investigations: Any currently pending disciplinary investigations by any healthcare entity, third party payment source, professional society or any government or other regulatory body. J. Professional Liability Insurance: Current professional liability insurance coverage and information on malpractice claims history and experience (claims, suits and settlements made, concluded and pending), including the names and addresses of present and past insurance carriers. A copy of the face sheet of the current policy showing the insured's name, coverage amounts, and any coverage limitations or exclusions must accompany the application. Any pending or completed action involving denial, revocation, cancellation, suspension, reduction, limitation of professional liability insurance. All insurance policies must satisfy the current Board policies regarding such coverage. K. Health Status: Details of any current or prior physical or mental condition or chemical (alcohol, drug or other) dependence that could affect or has affected the practitioner s ability to provide professional services (i.e., that is related to the capability to perform the clinical privileges requested). L. Criminal Charges: Any current criminal charges (other than motor vehicle violations) and any drug or alcohol-related charges (including motor vehicle violations) pending against the applicant and any past charges including their resolution. M. Release and Immunity: Notification of the authorization, release and immunity provisions of the appropriate sections of the Bylaws, Medical Staff Bylaws, and this Manual, and their applicability to consideration of the AHP's/DP s application and the provision of clinical privileges/competencies in the Facility and evidence of the applicant's agreement with them. N. Compliance with Requirements: Acknowledgment by the AHP/DP and by the Supervising Physician that they will abide by this Manual, the Bylaws, and any other applicable rules, regulations, policies and procedures of the Medical Staff and Facility in all matters relating to the AHP's provision of clinical privileges in the Facility. O. Supervising Physician Acknowledgement: Supervising Physician acknowledgment to assume and carry out the obligations required to adequately supervise the AHP/DP, and a specific agreement to the requirements of Section of this Manual. P. References: The names of at least one (1) professional in the Practitioner s own discipline and of one (1) physician, not newly associated (less than one (1) year) or about to become associated with the applicant in professional practice or personally related to the applicant, who have personal knowledge of the applicant's current clinical ability, ethical character, and ability to work cooperatively with others and who will provide specific written comments on these matters upon request from the Facility or Medical Staff authorities. The named individuals must have acquired the requisite knowledge through recent (within the past three (3) years) observation of the applicant's professional performance over a reasonable period of time and should also have an acute care hospital affiliation.
15 MARTIN HEALTH SYSTEM 15 Q. Such other information or references as may be established in the specific policies governing the specialty for which application is being made. 2.2 EFFECT OF APPLICATION (Reference Medical Staff Credentialing Procedure Manual Part One 1.4) The AHP/DP must sign the application, and in so doing: A. attests to the correctness and completeness of all information furnished and acknowledges that any misstatement or misrepresentation in or omission from the application, whether intentional or not, constitutes grounds for denial of permission to provide requested services or for automatic revocation of previously authorized permission (in the event it was granted prior to the discovery of the misstatement, misrepresentation, or omission); B. signifies his/her willingness to appear for interviews in connection with the application; C. agrees to abide by the terms of this Manual, the Bylaws and related manuals, rules, regulations, policies and procedure manuals of the Medical Staff (as applicable) and those of the Facility; D. agrees to maintain ethical behavior and to refrain from misrepresenting his position, status, clinical privileges or scope of authorized service to any patient, Facility visitor, Facility employee, Medical Staff member, or any other person affiliated with or coming in contact with the Facility; E. agrees to notify, promptly and in writing, the Medical Staff Services Credentialing Specialist of any change in any of the information provided on the application, to include any actions or investigations in any way related to the applicant s professional license or permit to practice, DEA or state controlled substance registration, professional liability insurance coverage, membership/employment status or clinical privileges at this or other institutions/facilities/organizations, or the status of current or initiation of new malpractice claims; F. authorizes and consents to Facility representatives consulting with prior associates or others who may have information bearing on professional or ethical qualifications and competence and consents to their inspecting all records and documents that may be material to evaluation of said qualifications and competence; G. releases from any liability all those who, in good faith and without malice, review, act on or provide information regarding the applicant s background, experience, clinical competence, professional ethics, character, health status, and other qualifications; and H. agrees to not provide any services in a Martin Health System Facility unless having first been granted specific written permission to provide such services by the appropriate Martin Health System authorities. For purposes of this section, the term "Facility representative" means: the Board of the Facility and any member or committee thereof; the CEO, CMO or their respective designees; the Medical Staff and any member, officer, clinical unit or committee thereof; registered nurses and other employees of the Facility and all Affiliates; and any individual authorized by any appropriate authority of the Medical Staff or Facility to perform specific information gathering, analysis, use or disseminating functions.
16 MARTIN HEALTH SYSTEM PROCESSING THE APPLICATION Processing the AHP/DP application will be performed in the same manner and have the same effect as that of the Medical Staff : Applicant s Burden Verification of Information Medical Staff Input Department/Service Evaluation THRU Processing each Application Category 1.6 Reapplication after Adverse Credentialing Decision CATEGORIZING APPLICATIONS: (Reference Medical Staff Part One 1.5-5) After the application and its supporting documentation have been reviewed by the Martin Health Systems applicable Department Chairperson/Chief of Service, the Director of Medical Staff Services will place the application into one (1) of three (3) categories as defined below. (a) Category One Applications: 1. All application information is promptly verified; 2. Written primary source verification for (at minimum) the immediate past 10 years for all employment, affiliations and work history must be received and fully positive; 3. All professional references are fully positive; 4. a) There is no history of any prior malpractice settlements or judgments, or b) There is a history of one prior malpractice settlement or judgment not exceeding $10,000, or c) a history of one malpractice settlement or judgment in excess of $10,000 that occurred more than 10 years prior to the date of application; 5. There is no history of prior disciplinary actions, licensure restrictions, or any other professional investigations; 6. All requested competencies are consistent with the practitioner s training, experience, and established criteria; 7. All input received from the Martin Health Systems Credentialing Staff and Dependent Practitioner s Supervising Physician is fully positive. (b) Category Two Applications: Applications which do not satisfy the requirements to be considered a Category One application, but otherwise satisfy each of the following criteria, shall be considered Category Two applications: 1. All application information is promptly verified, or difficulties occur during the verification of application information, but all such information is verified; 2. All references are fully positive, or are generally positive but contain some information suggesting minor problems (Written primary source verification for (at minimum) the immediate past 10 years for all employment, affiliations and work history must be received);
17 MARTIN HEALTH SYSTEM The application satisfies the malpractice settlement/judgment criteria for a Category One application, or there is a history of one (1) malpractice settlement or judgment in excess of $10,000 that occurred within the immediate past 10 years; 4. No prior disciplinary action, licensure restrictions or any other professional investigations, or a history including professional investigations which have been fully and completely resolved and which resulted in no disciplinary action or restrictions of any kind; 5. (a) All requested competencies are consistent with the practitioner s training, experience, and established criteria; or (b) Due to lack of experience or inability to provide documentation of clinical experience or specialized training to support the practitioner s competency/ qualifications, a Focused Evaluation will be imposed as part of the Provisional Period. The focused evaluation will be time limited and may include, but not be limited to, a preceptorship/proctorship for a period not to exceed twelve months or until such time as satisfactory evidence exists to support the practitioner s competence to perform the requested procedure (whichever comes first). 6. All input received from the Martin Health Systems Credentialing Staff and Dependent Practitioner s Supervising Physician is fully positive or is generally positive but contains some information suggesting minor problems. (c) Category Three Applications: All applications which do not satisfy the criteria for being considered Category One applications or Category Two applications shall be considered Category Three applications PROCESSING CATEGORY ONE/TWO/THREE APPLICATIONS Processing the relevant Category AHP/DP application will be performed in the same manner and have the same effect as that of the Medical Staff Credentialing Procedures Manual: Processing Category One Applications Processing Category Two Applications Processing Category Three Applications Contents of Reports and Basis for Recommendations and Actions: Will be performed in the same manner and have the same effect as that of the Medical Staff Credentialing Procedures Manual Conflict Resolution: Will be performed in the same manner and have the same effect as that of the Medical Staff Notice of Final Decision: Will be performed in the same manner and have the same effect as that of the Medical Staff Time Periods for Processing: Will be performed in the same manner and have the same effect as that of the Medical Staff
18 MARTIN HEALTH SYSTEM REAPPLICATION AFTER ADVERSE CREDENTIALS DECISION: Will be performed in the same manner and have the same effect as that of the Medical Staff TERM OF SERVICE Permission to provide specified services may be amended or revoked by the CEO at any time. Appointments/Reappraisal and grants of clinical privileges/competencies are for a period of up to two years with the exceptions referenced in the Medical Staff Bylaws 7.3 Term of Appointment and Reappraisal: (a) new appointees are subject first to an initial provisional period as provided in Medical Staff Bylaws Section 7.4 and upon satisfactory conclusion of that period are placed in the appropriate reappointment/reappraisal cycle as determined by the Hospital's system of staggered reappointment/reappraisal which may result in the appointment period that immediately follows satisfactory conclusion or waiver of the provisional period being less than two (2) full years; (b) the Professional Affairs Committee after considering the recommendation of the applicable Departments/Services, the Credentials Committee, and the Medical Executive Committee may set a more frequent reappraisal period for the exercise of particular clinical privileges/competencies in general, for AHPs/DPs who have reached a defined age, or for AHPs/DPs who have identified health disabilities; (c) disciplinary action involving membership and/or clinical privileges/competencies may be initiated and taken in the interim under the appropriate provisions of the Medical Staff Bylaws and the related manuals; and (d) in the case of a practitioner providing professional services by contract/employment (see Medical Staff Bylaws Section 7.6), termination or expiration of the contract/employment may result in a shorter period of membership or clinical privileges/competencies if that is the effect under the Medical Staff Bylaws Section PRACTITIONERS PROVIDING CONTRACTUAL PROFESSIONAL SERVICES: Will be subject to and have same effect as the Medical Staff Bylaws Practitioners Providing Contractual Professional Services 7.6.
19 MARTIN HEALTH SYSTEM 19 PART THREE. PROVISIONAL PERIOD The Provisional Period will be performed in the same manner and have the same effect as the Medical Staff Bylaws 7.4 Provisional Period; 7.5 Procedures for Appointment/Reappointment and Concluding the Provisional Period; and Medical Staff Part Four Conclusion and Extension of Provisional Period.
20 MARTIN HEALTH SYSTEM 20 PART FOUR. REEVALUATION/REAPPRAISAL PROCEDURES The Reevaluation/Reappraisal process for the AHP/DP will be performed in the same manner and have the same effect as that of the Medical Staff Part Two thru 2.9: 2.1: Information Collection and Verification From Staff Member From Internal Sources 2.2 Department/Service Evaluation 2.3 Categorizing Reappointment Applications 2.4 Processing Category One Reappointment Applications 2.5 Processing Category Two Reappointment Applications 2.6 Processing Category Three Reappointment Applications 2.7 Basis for Recommendations and Action 2.8 Time Periods for Processing 2.9 Requests for Modification of Status/Privileges PART FIVE: SYSTEMS AND PROCEDURES FOR DELINEATING CLINICAL PRIVILEGES/COMPETENCIES The Delineation of Clinical Privileges/Competencies will be performed in the same manner and have the same effect as the Medical Staff Part Three Systems and Procedures for Delineating Clinical Privileges.
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