POLICY REGARDING ADVANCED PRACTICE NURSES, PHYSICIAN ASSISTANTS AND OTHER CREDENTIALED HEALTH CARE PROVIDERS

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1 MEDICAL-DENTAL STAFF BYLAWS, POLICIES, AND RULES AND REGULATIONS OF CHRISTIANA CARE HEALTH SERVICES, INC POLICY REGARDING ADVANCED PRACTICE NURSES, PHYSICIAN ASSISTANTS AND OTHER CREDENTIALED HEALTH CARE PROVIDERS Effective Date: November 2, 2009

2 TABLE OF CONTENTS PAGE 1. GENERAL A. DEFINITIONS B. TIME LIMITS C. DELEGATION OF FUNCTIONS SCOPE AND OVERVIEW OF POLICY A. 2.B. SCOPE OF POLICY...3 PROCESS FOR DETERMINING NEED FOR A NEW CATEGORY OF CHCPs B.1. Review of Need B.2. Additional Recommendations QUALIFICATIONS, CONDITIONS AND RESPONSIBILITIES A. QUALIFICATIONS A.1. Eligibility Criteria A.2. Waiver of Criteria A.3. Factors for Evaluation A.4. No Entitlement to Medical-Dental Staff Appointment A.5. Nondiscrimination Policy B. GENERAL CONDITIONS OF PRACTICE B.1. Assumption of Duties and Responsibilities B.2. Burden of Providing Information C. APPLICATION C.1. Information C.2. Grant of Immunity and Authorization to Obtain/Release Information CREDENTIALING PROCEDURE A. PROCESSING OF INITIAL APPLICATION TO PRACTICE A.1. Request for Application A.2. Submission of Application...13 ii

3 4.A.3. Initial Review of Application A.4. Review by Department Chair and/or Department Credentials Committee A.5. Medical-Dental Staff Credentials Committee Procedure A.6. Medical Executive Committee Recommendation A.7. Board Action B. 4.C. 4.D. CLINICAL PRIVILEGES B.1. General B.2. Provisional Clinical Privileges...18 TEMPORARY SCOPE OF PRACTICE OR TEMPORARY CLINICAL PRIVILEGES C.1. Request for Temporary Scope of Practice or Temporary Clinical Privileges C.2. Termination of Temporary Scope of Practice or Temporary Clinical Privileges...19 PROCESSING APPLICATIONS FOR RENEWAL TO PRACTICE D.1. Submission of Application D.2. Renewal Process CONDITIONS OF PRACTICE A. PHYSICIAN ASSISTANT OVERSIGHT BY SUPERVISING PHYSICIAN B. QUESTIONS REGARDING THE AUTHORITY OF A CHCP C. 5.D. RESPONSIBILITIES OF SUPERVISING PHYSICIAN...22 RESPONSIBILITIES OF SUPERVISING PROVIDER PEER REVIEW PROCEDURES FOR QUESTIONS INVOLVING CHCPs A. INVESTIGATIONS B.1. Initiation of Investigation B.2. Investigative Procedure B.3. Recommendation B. ADMINISTRATIVE SUSPENSION C. AUTOMATIC RELINQUISHMENT OF SCOPE OF PRACTICE OR CLINICAL PRIVILEGES D. LEAVE OF ABSENCE...27 iii

4 7. PROCEDURAL RIGHTS OF CHCPs A. PROCEDURAL RIGHTS, GENERALLY B. PROCEDURAL RIGHTS CCHS EMPLOYEES AMENDMENTS ADOPTION...30 iv

5 ARTICLE 1 GENERAL 1.A. DEFINITIONS The following definitions apply to terms used in this Policy: (1) ADVANCED PRACTICE NURSE includes nurse practitioners, certified nurse anesthetists, certified nurse midwives and clinical nurse specialists. (2) "BOARD" means the Board of Directors of CCHS, which has the overall responsibility for CCHS, or its designated committee. (3) "CHIEF EXECUTIVE OFFICER" ("CEO") means the individual appointed by the Board to act on its behalf in the overall management of CCHS. (4) "CCHS" means Christiana Care Health Services, Inc. (5) "CLINICAL PRIVILEGES" means the authorization granted by the Board to render specific patient care services. (6) COLLABORATIVE AGREEMENT means written verification of health care facility approved clinical privileges; or a health care facility approved job description; or a written document that outlines the process for consultation and referral between an advanced practice nurse and a licensed physician, dentist, podiatrist, or licensed Delaware health care delivery system. (7) CREDENTIALED HEALTH CARE PROVIDER ( CHCP ) means advanced practice nurses, physician assistants, optometrists and other health care providers who are not members of the Medical-Dental Staff but who are credentialed by the Medical-Dental Staff pursuant to this policy and authorized to provide services to patients at CCHS. (8) "CREDENTIALS POLICY" means CCHS's Medical-Dental Staff Credentials Policy. (9) "DAYS" means calendar days. (11) "MEDICAL-DENTAL STAFF" means all physician, dentist, oral surgeon, podiatrist, and psychologist who have been appointed to the Medical-Dental Staff by the Board. 1

6 (12) "MEDICAL EXECUTIVE COMMITTEE" means the Executive Committee of the Medical-Dental Staff. (13) "NOTICE" means written communication transmitted by regular U.S. mail, e- mail, facsimile, CCHS mail, or hand delivery. (14) "PERMISSION TO PRACTICE" means the authorization granted by the Board, to exercise a scope of practice and/or clinical privileges. (15) "PHYSICIAN" includes both doctors of medicine ("M.D.s") and doctors of osteopathy ("D.O.s"). (16) "PHYSICIAN ASSISTANT" ("PA") means an individual who has obtained the education, maintains PA certification, is licensed as a PA and provides medical services under the supervision of a physician. (18) "SCOPE OF PRACTICE" means the nature and extent of practice authorized under a health care provider s license and authorized by the Board or CEO, as applicable under the supervision of or in collaboration with, a designated Provider. (19) "SUPERVISION OF PHYSICIAN ASSISTANT" means the ability of the supervising Medical-Dental Staff member to provide or exercise control and direction over the services, activities, and duties of a physician assistant. (20) "SPECIAL NOTICE" means hand delivery, certified mail, return receipt requested, or overnight delivery service providing receipt. (21) "SUPERVISING PHYSICIAN " means a member of the Medical-Dental Staff with clinical privileges, who has agreed to supervise a Physician Assistant. (22) SUPERVISING PROVIDER means a credentialed advance practice nurse who has agreed to supervise a temporarily credentialed advanced practice nurse. 1.B. TIME LIMITS Time limits referred to in this Policy are advisory only and are not mandatory, unless it is expressly stated that a particular right is waived by failing to take action within a specified period. 2

7 1.C. DELEGATION OF FUNCTIONS When a function is to be carried out by a person in a particular office or by a committee, the person, or the committee through its chair, may delegate performance of the function to one or more qualified designees. ARTICLE 2 SCOPE AND OVERVIEW OF POLICY 2.A. SCOPE OF POLICY (1) This Policy addresses those CHCPs who are permitted to provide patient care services in CCHS. (2) This Policy sets forth the credentialing process and the general practice parameters for these individuals, as well as guidelines for determining the need for additional categories of CHCPs at CCHS. 2.B. PROCESS FOR DETERMINING NEED FOR A NEW CATEGORY OF CHCPs 2.B.1. Review of Need: (1) Whenever a CHCP requests to practice at CCHS, and the Board has not already approved the category of Provider for practice at CCHS, the CMO will appoint an ad hoc committee to evaluate the need for that category of CHCP. The ad hoc committee will report to the Medical Executive Committee, which will make a recommendation to the Board for final action. (2) As part of the process of determining need, the CHCP will be invited to submit information about the nature of the proposed practice, the reason access to CCHS is sought, and the potential benefits to the community of having such services available at CCHS. (3) The ad hoc committee may consider the following factors when making a recommendation as to the need for the services of a specific category of CHCP: (a) the nature of the services that would be offered; (b) any Delaware license or regulation which outlines the specific patient care services and/or activities that the CHCP is authorized by law to perform; 3

8 (c) (d) (e) (f) (g) (h) (i) any Delaware "nondiscrimination" or "any willing provider" laws that would apply to the CHCP; the patient care objectives of CCHS, including patient convenience; the community's needs and whether those needs are currently being met or could be better met if the services offered by the CHCP were provided at CCHS; the type of training that is necessary to perform the services that would be offered and whether there are individuals with more training currently providing those services; the availability of supplies, equipment, and other necessary CCHS resources; the need for, and availability of, trained staff to support the services that would be offered; and the ability to appropriately supervise performance and monitor quality of care. 2.B.2. Additional Recommendations: (1) If the ad hoc committee makes a recommendation that there is a need for the particular category of CHCP at CCHS, it will also recommend: (a) any specific qualifications and/or training that must be possessed beyond those set forth in this Policy; (b) a detailed description of a scope of practice or clinical privileges; (c) any specific conditions that apply to practice within CCHS; and (d) any supervision requirements, if applicable. (2) In developing such recommendations, the ad hoc committee will consult the appropriate department chair(s) and consider relevant Delaware law and may contact professional societies or associations. The ad hoc committee may also recommend the number of CHCPs of that type that are needed. 4

9 ARTICLE 3 QUALIFICATIONS, CONDITIONS AND RESPONSIBILITIES 3.A. QUALIFICATIONS 3.A.1. Eligibility Criteria: To be eligible to apply for initial and continued permission to practice, CHCPs must, where applicable: (1) have a current, unrestricted license, certification or registration to practice in Delaware and have never had a license, certification or registration to practice revoked or suspended; (2) If applicable, have a current, unrestricted DEA registration and Delaware controlled substance license; (3) be available in time and proximity to fulfill their professional responsibilities and provide timely and continuous care for patients in CCHS; (4) have current, valid professional liability insurance coverage in a form and in amounts satisfactory to CCHS; (5) have never been convicted of Medicare, Medicaid, or other federal or state governmental or private third-party payer fraud or program abuse or have been required to pay civil penalties for the same; (6) have never been and are not currently excluded or precluded from participation in Medicare, Medicaid or other federal or state governmental health care program; (7) have never had a scope of practice or clinical privileges denied, revoked, resigned, relinquished, or terminated by any health care facility or health plan for reasons related to clinical competence or professional conduct; (8) have never been convicted of, or entered a plea of guilty or no contest to, any felony or any misdemeanor relating to controlled substances, illegal drugs, insurance or health care fraud or abuse, or violence; (9) satisfy all additional eligibility qualifications relating to their specific area of practice that may be established by CCHS; and 5

10 (10) as pertinent, have a written agreement with a Supervising Provider or a collaborative agreement; these agreements must meet all applicable requirements of Delaware law and CCHS policy. 3.A.2. Waiver of Criteria: (1) Any individual who does not satisfy an eligibility criterion may request that it be waived. The individual requesting the waiver bears the burden of demonstrating that his or her qualifications are equivalent to, or exceed, the criterion in question. (2) The Board may grant waivers in exceptional cases after considering the findings of the Credentials Committee, the Medical Executive Committee, or other committee designated by the Board, the specific qualifications of the individual in question, and the best interests of CCHS and the community it serves. The granting of a waiver in a particular case is not intended to set a precedent for any other individual or group of individuals. (3) No individual is entitled to a waiver or to a hearing if the Board determines not to grant a waiver. (4) A determination that an individual is not entitled to a waiver is not a "denial" of scope of practice or clinical privileges. 3.A.3. Factors for Evaluation: (1) Only those individuals who can document that they are highly qualified in all regards will be granted permission to practice. The following factors will be evaluated as part of the appointment and reappointment processes and used in rendering a decision: (a) Patient Care: CHCPs are expected to provide patient care that is compassionate, appropriate and effective for the promotion of health, prevention of illness, treatment of disease, and care at the end of life. (b) Medical/Clinical Knowledge: CHCPs are expected to demonstrate knowledge of established and evolving biomedical, clinical and social sciences, and the application of their knowledge to patient care and the education of others. 6

11 (c) Technical Skills CHCPs are expected to be able to appropriately perform technical procedures within their specialty. (d) Practice-Based Learning and Improvement: CHCPs are expected to be able to use scientific evidence and methods to investigate, evaluate, and improve patient care practices. (e) Interpersonal and Communication Skills: CHCPs are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families, and other members of health care teams. (f) Professionalism: CHCPs are expected to demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity and a responsible attitude toward their patients, their profession and society. (g) Systems-Based Practice: CHCPs are expected to demonstrate both an understanding of the contexts and systems in which health care is provided, and the ability to apply this knowledge to improve and optimize health care. (2) In evaluating these factors, the Advance Practice Nurse Council and/or the Medical-Dental Staff shall consider the following factors among others: (a) the quality of relevant training, experience, demonstrated current competence (including medical/clinical knowledge, technical and clinical skills), and clinical judgment, and an understanding of the contexts and systems within which care is provided; (b) adherence to the ethics of their profession, continuous professional development, an understanding of and sensitivity to diversity, and responsible attitude toward patients and their profession; (c) good reputation and character; (d) ability to work harmoniously with others, including, but not limited to, interpersonal and communication skills sufficient to enable them to maintain professional relationships with patients, families and other members of health care teams; 7

12 (e) ability to safely and competently perform the clinical privileges or scope of practice requested; (f) lack of present substance abuse; and (g) recognition of the importance of, and willingness to support, CCHS's commitment to quality care and recognition that interpersonal skills and collegiality are essential to the provision of quality patient care. 3.A.4. No Entitlement to Medical-Dental Staff Appointment: CHCPs will not be appointed to the Medical-Dental Staff or entitled to the rights, privileges, and/or prerogatives of Medical-Dental Staff appointment unless otherwise provided for under this Policy. 3.A.5. Nondiscrimination Policy: CCHS shall not make credentialing and recredentialing decisions based on an applicant's race, religion, ethnic/national identity, gender, age, disability, marital status, sexual orientation or genetic information. 3.B. GENERAL CONDITIONS OF PRACTICE 3.B.1. Assumption of Duties and Responsibilities: As a condition of being granted permission to practice and as a condition for continued permission to practice, CHCPs specifically agree to the following: (1) to provide continuous and timely care to all patients for whom the individual has responsibility; (2) to abide by all bylaws, policies and rules and regulations of CCHS and Medical- Dental Staff; (3) to abide by the scope of practice defined by his or her license, Delaware Law, and by the authorization to practice granted by CCHS. (4) to accept committee assignments, participation in quality improvement and peer review activities, and such other reasonable duties and responsibilities as assigned; 8

13 (5) to constructively participate in the development, review, and revision of clinical protocols and pathways pertinent to his or her specialty, including those related to national patient safety initiatives and core measures; (6) to comply with adopted protocols and pathways or document reasons for variance; (7) to provide, with or without request, new or updated information to Medical- Dental Staff Services as it occurs, pertinent to any question on the application form; (8) to immediately submit to a blood and/or urine test, or to a complete physical and/or mental evaluation, if at least two Medical-Dental Staff leaders (or one Medical-Dental Staff leader and one member of Administrative leadership) are concerned with the individual's ability to safely and competently care for patients. The health care professional(s) who performs the testing and/or evaluations will be selected by the Medical-Dental Staff leadership; (9) to acknowledge that the individual has had an opportunity to read a copy of this Policy and any other applicable bylaws, policies, rules and regulations (including applicable departmental rules) and agrees to be bound by them; (10) to appear for personal interviews as may be requested; (11) to refrain from illegal fee splitting or other illegal inducements relating to patient referrals; (12) to refrain from assuming responsibility for diagnosis or care of hospitalized patients for which he or she is not qualified or without adequate supervision; (13) to refrain from deceiving patients as to his or her status as a CHCP; (14) to seek consultation when appropriate; (15) to participate in monitoring and evaluation activities; (16) to complete, in a timely manner, all medical and other required records containing all information required by CCHS; (17) to perform all services and conduct himself or herself at all times in a cooperative and professional manner; (18) to satisfy applicable continuing education requirements; (19) to promptly pay any applicable dues and assessments; and 9

14 (20) that any misstatement in, or omission from, the application form is grounds for CCHS to stop processing the application. If permission to practice has been granted prior to the discovery of a misstatement or omission, clinical privileges or scope of practice may be deemed to be automatically relinquished. In either situation, there will be no entitlement to the procedural rights in Article 7 of this Policy. The individual will be informed in writing of the nature of the misstatement or omission and permitted to provide a written response. The Credentials Committee will review the individual's response and provide a recommendation to the Medical Executive Committee. The Medical Executive Committee will recommend to the Board whether the application should be processed further or the individual permitted to continue practicing at CCHS. 3.B.2. Burden of Providing Information: (1) CHCPs seeking permission to practice will have the burden of producing information deemed adequate by CCHS for a proper evaluation of current competence, character, ethics, and other qualifications and for resolving any doubts about such qualifications. (2) CHCPs seeking permission to practice at CCHS have the burden of providing evidence that all the statements made and information given on the application are accurate. (3) It is the responsibility of the individual seeking permission to practice at CCHS to provide a complete application, including adequate responses from references. An incomplete application will not be processed. 3.C. APPLICATION 3.C.1. Information: (1) The applications for CHCPs will be approved by the Medical Executive Committee and the Board. (2) The applications will require detailed information concerning the applicant's professional qualifications. In addition to other information, the applications will seek the following: 10

15 (a) information as to whether the applicant's scope of practice or clinical privileges and/or affiliation has ever been voluntarily or involuntarily relinquished, withdrawn, denied, revoked, suspended, subject to probationary or other conditions, reduced, limited, terminated, or not renewed at any hospital or health care facility or is currently being investigated or challenged; (b) information as to whether the applicant's license or certification to practice any profession in any state or DEA registration or any state controlled substance license is, or has ever been, voluntarily or involuntarily relinquished, suspended, modified, terminated, or restricted or is currently being investigated or challenged; (c) information concerning the applicant's professional liability litigation experience, including past and pending claims, final judgments or settlements, and the substance of the allegations, as well as the findings and the ultimate disposition; and (d) current information regarding the applicant's ability to safely and competently exercise the scope of practice or clinical privileges he or she has requested, including information regarding present illegal drug use. (3) The applicant will sign the application and job description, and certify that he or she is able to perform the scope of practice or clinical privileges requested and the responsibilities of CHCPs. 3.C.2. Grant of Immunity and Authorization to Obtain/Release Information: By applying for permission to practice, the CHCP expressly accepts the following conditions during the processing and consideration of the application, whether or not granted, and as an ongoing condition of practice, if granted: (1) Immunity: To the fullest extent permitted by law, the individual releases from any and all liability, extends absolute immunity to, and agrees not to sue CCHS, any member of the Medical-Dental Staff, their authorized representatives, and appropriate third parties for any matter relating to scope of practice or clinical privileges or the 11

16 individual's qualifications for the same. This includes any actions, recommendations, reports, statements, communications, or disclosures involving the individual that are made, taken, or received by CCHS, its authorized agents, or appropriate third parties. (2) Authorization to Obtain Information from Third Parties: The CHCP specifically authorizes CCHS, Medical-Dental Staff leaders, and their authorized representatives (1) to consult with any third party who may have information bearing on the individual's professional qualifications, credentials, clinical competence, character, ability to perform safely and competently, ethics, behavior, or any other matter reasonably having a bearing on his or her qualifications for scope of practice or clinical privileges, and (2) to obtain any and all communications, reports, records, statements, documents, recommendations or disclosures of third parties that may be relevant to such questions. The individual also specifically authorizes third parties to release this information to CCHS and its authorized representatives upon request. (3) Authorization to Release Information to Third Parties: The individual also authorizes CCHS representatives to release information to other hospitals, health care facilities, managed care organizations, and their agents when information is requested in order to evaluate his or her professional qualifications for scope of practice, clinical privileges, and/or participation at the requesting organization/facility. (4) Procedural Rights: The CHCP agrees that the procedural rights set forth in this Policy will be the sole and exclusive remedy with respect to any professional review action taken by CCHS. (5) Legal Actions: If, notwithstanding the provisions in this Section, an individual institutes legal action and does not prevail, he or she agrees to reimburse CCHS, any member of the Medical-Dental Staff, and any other agent named in the action for all costs incurred in defending such legal action, including reasonable attorney's fees. 12

17 (6) Authorization to Share Information Among Components of the System: The individual specifically authorizes CCHS and its components to share credentialing and peer review information within the system pertaining to the individual's clinical competence and/or professional conduct. This information may be shared at initial appointment or reappointment and at any other time during the individual's appointment. ARTICLE 4 CREDENTIALING PROCEDURE 4.A. PROCESSING OF INITIAL APPLICATION TO PRACTICE 4.A.1. Request for Application: (1) Any individual requesting an application for permission to practice as a CHCP will be sent information that outlines the eligibility criteria for permission to practice and the application form. (2) A CHCP who is in a category of Providers that has not been approved by the Board to practice at CCHS will be ineligible to receive an application. A determination of ineligibility does not entitle the CHCP to the procedural rights outlined in Article 7 of this Policy. 4.A.2. Submission of Application: (1) A completed application, with copies of all required documents, must be returned to the Medical-Dental Staff Office within 30 days after receipt of the application if the CHCP desires further consideration. The application must be accompanied by the application processing fee, if one is required. (2) An application will be deemed to be complete when all questions on the application form have been answered, all supporting documentation has been supplied, and all information has been verified. An application will become incomplete if the need arises for new, additional or clarifying information any time during the evaluation. 13

18 (3) Any application that continues to be incomplete 30 days after the applicant has been notified of the additional information required will be deemed to be withdrawn. It is the responsibility of the applicant to provide a complete application, including adequate responses from references. An incomplete application will not be processed. 4.A.3. Initial Review of Application: (1) As a preliminary step, the Medical-Dental Staff Office will review the application to determine that the individual satisfies all threshold criteria. An individual who fails to meet the eligibility criteria set forth in Section 3.A.1 of this Policy will be notified that his or her application will not be processed. (2) The Medical-Dental Staff Office will also review the application to determine if all questions have been answered, all references and other information or materials have been received, and pertinent information provided on the application has been verified with primary sources. Information will be verified in accordance with Joint Commission and NCQA Standards, with the primary source being preferred whenever possible. If an application is complete, it will be transmitted, along with all supporting documentation, to the applicable department chair and/or Department Credentials Committee. 4.A.4. Review by Department Chair and/or Department Credentials Committee: (1) The Medical-Dental Staff Office will transmit the completed application and all supporting materials to the appropriate department chair and/or Department Credentials Committee. The chair and, if applicable, Department Credentials Committee will prepare a written report regarding whether the applicant has satisfied all of the qualifications for the scope of practice or clinical privileges requested. (2) In preparing this report, the department chair and, if applicable, Department Credentials Committee has the right to meet with the applicant, and the Supervising Provider (if applicable), to discuss any aspect of the application, qualifications, and requested scope of practice or clinical privileges. The 14

19 department chair and, if applicable, Department Credentials Committee may also confer with experts within the department and outside of the department in preparing the report (e.g., other physicians, appropriate supervisor within the department, nurse managers). (3) The department chair and, if applicable, Department Credentials Committee will be available to answer any questions that may be raised with respect to that chair's report and findings. 4.A.5. Medical-Dental Staff Credentials Committee Procedure: (1) The Staff Credentials Committee will review and consider the report prepared by the department chair and, if applicable, Department Credentials Committee and may interview the applicant. Thereafter, the Staff Credentials Committee will make a recommendation. (2) After determining that an applicant is otherwise qualified for permission to practice, the Staff Credentials Committee shall review the applicant's Confirmation of Ability to Practice form to determine if there is any question about the applicant's ability to practice. If so, the Staff Credentials Committee may require the applicant to undergo a physical and/or mental health examination by a physician(s) satisfactory to the Committee. The results of this examination will be made available to the Staff Credentials Committee for its consideration. Failure of an applicant to undergo an examination within a reasonable time after being requested to do so in writing by the Staff Credentials Committee will be considered a voluntary withdrawal of the application and all processing of the application will cease. The Staff Credentials Committee may refer an application to the Provider Health Committee for assistance in assessing the results of the examination and more generally the ability of the applicant to safely and competently practice. (3) The Staff Credentials Committee's recommendation will be forwarded to the Medical Executive Committee or the President of the Medical-Dental Staff, as applicable. 15

20 4.A.6. Medical Executive Committee Recommendation: (1) For each applicant seeking to practice as a CHCP, at its next regular meeting, after receipt of the written findings and recommendations of the Staff Credentials Committee, the Medical Executive Committee will: (a) adopt the findings and recommendations of the Staff Credentials Committee; or (b) refer the matter back to the Staff Credentials Committee for further consideration and responses to specific questions raised by the Medical Executive Committee prior to its final recommendation; or (c) state its reasons in its report and recommendation, along with supporting information, for its disagreement with the Staff Credentials Committee's recommendation. (2) The recommendation of the Medical Executive Committee will be forwarded to the Board. (3) If the recommendation of the Medical Executive Committee would entitle the applicant to the procedural rights set forth in Article 7, the Chief Medical Officer ("CMO") will send the applicant special notice. The CMO will then hold the application until after the applicant has completed or waived the procedural process outlined in this Policy. 4.A.7. Board Action: (1) The Board may delegate to a committee, consisting of at least two Board members, to take action on the clinical privileges requested if there has been a favorable recommendation from the Staff Credentials Committee and the Medical Executive Committee and there is no evidence of any of the following: (a) a current or previously successful challenge to any license or registration; (b) an involuntary termination, limitation, reduction, denial, or loss of appointment or privileges at any other hospital or other entity; or (c) an unusual pattern of, or an excessive number of, professional liability actions resulting in a final judgment against the applicant. 16

21 Any decision reached by the Board Committee to grant the scope of practice or clinical privileges requested will be effective immediately and will be forwarded to the Board for ratification at its next meeting. (2) When there has been no delegation to the Board Committee, upon receipt of a recommendation that the applicant be granted clinical privileges or scope of practice requested, the Board may: (a) grant the applicant the clinical privileges or scope of practice as recommended; or (b) refer the matter back to the Credentials Committee or Medical Executive Committee or to another source inside or outside CCHS for additional research or information; or (c) reject or modify the recommendation. (3) If the Board determines to reject a favorable recommendation, it should first discuss the matter with the Chair of the Staff Credentials Committee and the Chair of the Medical Executive Committee. If the Board's determination remains unfavorable to the applicant, the CMO will promptly send special notice to the applicant that the applicant is entitled to request a hearing. 4.B. CLINICAL PRIVILEGES 4.B.1. General: The clinical privileges recommended to the Board will be based upon consideration of the following: (1) the quality of education, relevant training, experience, demonstrated current competence (including medical/clinical knowledge, technical and clinical skills), clinical judgment, interpersonal and communication skills, and professionalism with patients, families and other members of the health care team and peer evaluations relating to the same; (2) ability to perform the privileges requested competently and safely; (3) information resulting from ongoing and focused professional practice evaluation, performance improvement and other peer review activities, if applicable; 17

22 (4) adequate professional liability insurance coverage for the clinical privileges requested; (5) CCHS's available resources and personnel; (6) any previously successful or currently pending challenges to any licensure or registration, or the voluntary or involuntary relinquishment of such licensure or registration; (7) any information concerning professional review actions or voluntary or involuntary termination, limitation, reduction, or loss of appointment or clinical privileges at another hospital; (8) Provider-specific data as compared to aggregate data, when available; (9) morbidity and mortality data, when available; and (10) professional liability actions, especially any such actions that reflect an unusual pattern or excessive number of actions. 4.B.2. Provisional Clinical Privileges: (1) All initial clinical privileges, regardless of when granted, will be provisional for a period of 12 months or, if deemed to be necessary by the Staff Credentials Committee, a longer period not to exceed a maximum of 24 months. (2) During the provisional period, the individual's exercise of the provisional clinical privileges will be evaluated by the chair of the department in which the individual has clinical privileges. The evaluation may include chart review, monitoring of the individual's practice patterns, proctoring, external review and information obtained from other Providers. (3) During the provisional period, the individual must participate in the care of a sufficient number of patients so as to permit the department chair and Staff Credentials Committee to evaluate the individual's competence to exercise the newly granted privilege(s). (4) At the end of the provisional period, if the CHCP's performance is satisfactory, the CHCP's department chair will approve the CHCP for continued privileges. If the CHCP's performance is unsatisfactory, the department chair shall recommend to the Staff Credentials Committee that the individual's privileges be terminated. 18

23 4.C. TEMPORARY SCOPE OF PRACTICE OR TEMPORARY CLINICAL PRIVILEGES 4.C.1. Request for Temporary Scope of Practice or Temporary Clinical Privileges: (1) A temporary scope of practice or temporary privileges may be granted by the CMO, upon recommendation of the President of the Medical-Dental Staff, when a CHCP has submitted a completed application and the application is pending review by the Medical Executive Committee and the Board, following a favorable recommendation of the Staff Credentials Committee (or its Chair). Prior to a temporary scope of practice or temporary privileges being granted in this situation, the credentialing process must be complete, including, where applicable, verification of current licensure, relevant training or experience, current competence, ability to exercise the scope of practice or privileges requested, and compliance with criteria, and consideration of information from the National Provider Data Bank. In order to be eligible for a temporary scope of practice, or temporary privileges, an individual must demonstrate that there are no current or previously successful challenges to his or her licensure or registration and that he or she has not been subject to involuntary termination of membership, or involuntary limitation, reduction, denial, or loss of scope of practice or clinical privileges, at another health care facility. (2) Prior to a temporary scope of practice or temporary privileges being granted, the individual must agree in writing to be bound by all applicable bylaws, rules and regulations, policies, procedures and protocols. (3) A temporary scope of practice or temporary privileges will be granted for a specific period of time, not to exceed 120 days, and will expire at the end of the time period for which they are granted. 4.C.2. Termination of Temporary Scope of Practice or Temporary Clinical Privileges: (1) The CMO may, at any time after consulting with the President of the Medical- Dental Staff, or the Chair of the Staff Credentials Committee or the department chair, terminate a temporary scope of practice or temporary privileges for any reason. 19

24 (2) The granting of a temporary scope of practice or temporary privileges is a courtesy. Neither the denial nor termination of a temporary scope of practice or temporary privileges will entitle the individual to the procedural rights set forth in Article 7. 4.D. PROCESSING APPLICATIONS FOR RENEWAL TO PRACTICE 4.D.1. Submission of Application: (1) The grant of a scope of practice, and the grant of clinical privileges, is a courtesy and, if granted, will be for a period not to exceed two years. A request to renew a scope of practice or clinical privileges will be considered only upon submission of a completed renewal application. (2) At least three months prior to the date of expiration of the CHCP's scope of practice or clinical privileges, the Medical-Dental Staff Office will notify the individual of the date of expiration and provide the individual with a renewal application. (3) Failure to return a completed application at least two months prior to the expiration of the individual's scope of practice or clinical privileges will result in automatic expiration of such scope of practice or clinical privileges at the end of the then current term. (4) Once an application for renewal of scope of practice or clinical privileges has been completed and submitted to the Medical-Dental Staff Office, it will be evaluated following the same procedures outlined in this Policy regarding initial applications. 4.D.2. Renewal Process (1) The procedures pertaining to an initial request for clinical privileges, including eligibility criteria and factors for evaluation, will be applicable in processing requests for renewal. (2) As part of the process for renewal of clinical privileges, the following factors will be considered: 20

25 (a) (b) (c) (d) (e) an assessment prepared by the Collaborating or Supervising Provider, if applicable; an assessment prepared by a peer; results of CCHS's performance improvement and peer review activities, taking into consideration, when applicable, Provider-specific information concerning other individuals in the same or similar specialty (provided that, other Providers shall not be identified); resolution of any verified complaints received from patients or staff; and any focused professional practice evaluations. ARTICLE 5 CONDITIONS OF PRACTICE 5.A. PHYSICIAN ASSISTANT OVERSIGHT BY SUPERVISING PHYSICIAN (1) Physician Assistants may function in CCHS only so long as they have a Supervising Physician. (2) Any activities permitted to be performed at CCHS by a physician assistant will be performed only under the supervision or direction of the Supervising Physician. (3) It will be the responsibility of the Supervising Physician to countersign all medical record entries made by his or her supervised physician assistant in accordance with applicable policies and rules and regulations. (4) If the Medical-Dental Staff appointment or clinical privileges of a Supervising Physician are resigned, revoked or terminated, the supervised physician assistant s scope of practice will automatically terminate. The Credentials Committee may, however, recommend that the physician assistant be permitted to arrange for another Supervising Physician. (5) As a condition of a scope of practice or clinical privileges, the physician assistant and the Supervising Physician must provide CCHS with notice of any revisions or modifications that are made to the supervision agreement. This notice must be provided to the CMO within three days of any such change. 21

26 (6) The constant physical presence of the supervising practitioner is not required in the supervision of a physician assistant, provided that the supervising practitioner is readily accessible by some form of electronic communication and that the supervising practitioner can be physically present with the physician assistant within 30 minutes. Depending upon the specific clinical activity of the physician assistant, a shorter response time may be required. 5.B. QUESTIONS REGARDING THE AUTHORITY OF A CHCP (1) Should any member of the Medical-Dental Staff, or any employee of CCHS who is licensed or certified by the state, have a reasonable question regarding the clinical competence or authority of a CHCP to act or issue instructions outside the presence of the Supervising or Collaborating Provider, such individual will have the right to request that the Supervising or Collaborating Provider validate, either at the time or later, the instructions of the CHCP. Any act or instruction of the CHCP will be delayed until such time as the individual with the question has ascertained that the act is clearly within the scope of practice granted to the individual. (2) Any question regarding the conduct of a CHCP will be reported to the President of the Medical-Dental Staff, the Chair of the Credentials Committee, the relevant department chair, or the CMO for appropriate action. The individual to whom the concern has been reported shall also discuss the matter with the Supervising or Collaborating Provider. 5.C. RESPONSIBILITIES OF SUPERVISING PHYSICIAN (1) The Supervising Physician, a member of the Medical-Dental Staff will remain responsible for all care provided by the physician assistant or, as applicable, other CHCP, in CCHS. (2) The number of physician assistants acting under the supervision of one Supervising Physician at any particular time, as well as the care they may provide, will be consistent with applicable Delaware statutes and regulations and any other policies adopted by CCHS. A Supervising Physician employing a physician 22

27 assistant or other CHCP will make all appropriate filings with the State Board of Medicine regarding the supervision and responsibilities of the physician assistant or other CHCP to the extent that such filings are required. (3) It will be the responsibility of an employer Supervising Physician to provide, arrange for, or assure professional liability insurance coverage for the physician assistant or other CHCP in amounts required by the Board. The insurance must cover any and all activities of the CHCP in CCHS. The Supervising Physician will furnish evidence of such coverage to CCHS. The CHCP will provide care in CCHS only while such coverage is in effect. 5.D. RESPONSIBILITIES OF SUPERVISING PROVIDER (1) While an advanced practice nurse is fulfilling licensure requirements, he or she shall be supervised by a Supervising Provider, who may be a member of the medical staff or another appropriate provider. (2) During the period of supervision, the Supervising Provider shall be responsible for the patient care provided. (3) The Supervising Provider shall report on the advanced practice nurse s performance to the Board of Nursing with a copy sent to the CCHS Advance Practice Nurse Council and the Medical Staff Services Office. ARTICLE 6 PEER REVIEW PROCEDURES FOR QUESTIONS INVOLVING CHCPs 6.A. INVESTIGATIONS 6.A.1. Initiation of Investigation: (1) When a question involving clinical competence or professional conduct of a CHCP cannot be resolved at the department level, it shall be referred to the Medical Executive Committee and/or the APN Council (with a report to the Medical Executive Committee). The pertinent committee will review the matter and determine whether to conduct an investigation or to direct the matter to be handled pursuant to another policy, or to proceed in another manner. 23

28 (2) The President of the Medical-Dental Staff will keep the CMO and, if pertinent, the CNO fully informed of the progress of the investigation and all actions taken. 6.A.2. Investigative Procedure: (1) The Medical Executive Committee and/or the APN Council may investigate the matter itself, delegate the investigation to an ad hoc committee or appoint an individual to conduct the investigation. The investigating committee (or individual) will be composed of individuals who do not have a relation to the matter, the involved individuals or any other conflict of interest. (2) The investigating committee will have the authority to review relevant documents and interview individuals. (3) The investigating committee will also have the authority to use outside consultants, if needed with the permission of the CMO. (4) The investigating committee may require a physical and/or mental examination of the individual by a health care professional(s) acceptable to it. (5) The individual will have an opportunity to meet with the investigating committee before it makes its report. Prior to this meeting, the individual will be informed of the general questions being investigated. At the meeting, the individual will be invited to discuss, explain, or refute the questions that gave rise to the investigation. A summary of the interview will be prepared. This meeting is not a hearing, and none of the procedural rules for hearings will apply. (6) The investigating committee will make a reasonable effort to complete the investigation and issue its report within 45 days of the commencement of the investigation, provided that an outside review is not necessary. When an outside review is necessary, the investigating committee will make a reasonable effort to complete the investigation and issue its report within 30 days of receiving the results of the outside review. These time frames are intended to serve only as guidelines. (7) At the conclusion of the investigation, the investigating committee will prepare a report with its findings, conclusions, and recommendations. 24

29 (8) If the APN Council conducts the investigation, it shall report its findings to the Medical Executive Committee. 6.A.3. Recommendation: (1) The Medical Executive Committee may accept, modify, or reject any recommendation it receives from an investigating committee. Specifically, the Medical Executive Committee may: (a) determine that no action is justified; (b) issue a letter of guidance, counsel, warning, or reprimand; (c) impose a requirement for monitoring or consultation; (d) recommend additional training or education; (e) recommend reduction of clinical privileges; (f) recommend suspension of clinical privileges for a term; (g) recommend revocation of clinical privileges; or (h) make any other recommendation that it deems necessary or appropriate. (2) The Medical Executive Committee shall determine whether the conduct at issue should be referred for review under the procedures set forth in the Peer Review Policy. (3) If the practitioner involved in a peer review matter refuses to participate in the peer review process and/or a performance improvement plan, or if it is determined by the Peer Review Committee (PRC) that a performance improvement plan may not be adequate to address the issues identified in a particular matter, or if the performance improvement plan is not successful in addressing the issue, the PRC shall refer the matter back to the Medical Executive Committee for review and corrective/remedial action. (4) A recommendation by the Medical Executive Committee or Board that would entitle the individual to request a hearing will be forwarded to the CMO, who will promptly inform the individual by special notice. The CMO will hold the 25

30 recommendation until after the individual has completed or waived a hearing and appeal. (5) If the Medical Executive Committee makes a recommendation that does not entitle the individual to request a hearing, it will take effect immediately and will remain in effect unless modified by the Board. (6) When applicable, any recommendations or actions that are the result of an investigation or hearing and appeal will be monitored by Medical-Dental Staff leaders on an ongoing basis through CCHS's performance improvement activities or pursuant to the applicable policies regarding conduct, as appropriate. 6.B. ADMINISTRATIVE SUSPENSION (1) The CMO, the Chair of the Medical Executive Committee, and the appropriate department chair will each have the authority to impose an administrative suspension of all or any portion of the scope of practice or clinical privileges of any CHCP whenever a question has been raised about such individual's clinical care or professional conduct. (2) An administrative suspension will become effective immediately upon imposition, will immediately be reported in writing to the CMO and the Chair of the Medical Executive Committee, and will remain in effect unless or until modified by the CMO or Medical Executive Committee. The imposition of an administrative suspension does not entitle a CHCP to the procedural rights set forth in Article 7 of this Policy. (3) Upon receipt of notice of the imposition of an administrative suspension, the CMO and President of the Medical-Dental Staff will forward the matter to the Medical Executive Committee which will review and consider the question(s) raised and thereafter make a recommendation to the Board regarding whether the suspension should be continued, whether the CHCP s scope of practice should be restricted, and/or whether the CHCP s affiliation with CCHS should be terminated. 26

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