RULES AND REGULATIONS OF THE ALLIED HEALTH PROFESSIONAL STAFF UNIVERSITY OF COLORADO HOSPITAL

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1 RULES AND REGULATIONS OF THE ALLIED HEALTH PROFESSIONAL STAFF UNIVERSITY OF COLORADO HOSPITAL I. PREAMBLE... 2 II. NATURE OF AHP STATUS... 2 III. PROFESSION-SPECIFIC CRITERIA AND QUALIFICATIONS... 3 A. ACUPUNCTURIST... 3 B. ANESTHESIOLOGIST ASSISTANT... 3 C. AUDIOLOGIST... 4 D. CERTIFIED NURSE PRACTITIONER... 4 E. CERTIFIED REGISTERED NURSE ANESTHETIST... 5 F. CHIROPRACTOR... 6 G. CLINICAL NURSE SPECIALIST... 6 H. DENTAL ASSISTANT... 7 I. ESTHETICIAN... 8 J. LICENSED CLINICAL SOCIAL WORKER... 8 K. OPTOMETRIST... 9 L. PHYSICAL THERAPIST... 9 M. PHYSICIAN ASSISTANT IV. BASIC RESPONSIBILITIES...10 V. APPLICATION FOR INITIAL APPOINTMENT...11 VI. APPLICATION FOR REAPPOINTMENT...11 VII. RELEASE OF INFORMATION...11 VIII. ALLIED HEALTH CREDENTIALS SUBCOMMITTEE REVIEW...11 IX. DURATION OF APPOINTMENT...12 A. INITIAL APPOINTMENT B. PROVISIONAL STATUS C. REAPPOINTMENT X. AUTOMATIC TERMINATION...12 XI. QUALIFICATION OR QUALITY CONCERNS...12 XII. PROCEDURAL RIGHTS

2 RULES AND REGULATIONS OF THE ALLIED HEALTH PROFESSIONAL STAFF The Medical Staff shall adopt such Rules and Regulations as may be necessary for proper conduct of the work of the Allied Health Professional Staff. Such Rules and Regulations shall be attached to and become a part of the Bylaws of the Medical Staff. Rules and Regulations may be amended as provided in Article XIV of the Bylaws of the Medical Staff. The Allied Health Credentials Subcommittee may make recommendations for consideration by the Medical Board regarding these Allied Health Professional Staff Rules and Regulations. Any Allied Health Professional may submit suggestions to the Allied Health Credentials Subcommittee for amendments to these Allied Health Professional Staff Rules and Regulations. I. PREAMBLE The purpose of the Allied Health Professional (AHP) Rules and Regulations is to: (1) establish guidelines for the conduct of AHPs who have been granted specified privileges by the Board of Directors ( Board ) of the University of Colorado Hospital Authority ( Hospital ); (2) establish guidelines for evaluation of individuals applying for appointment or reappointment as AHPs; and (3) outline processes relating to the qualifications of AHPs within the Hospital. All AHPs shall abide by the AHP Rules and Regulations as well as the policies, procedures, bylaws (including Medical Staff Bylaws and Rules and Regulations), guidelines, manuals, and other requirements of the Hospital. It is each AHP s sole responsibility to obtain, read, and understand said documents. The aforementioned documents do not constitute a contract of any kind whatsoever. All documents are subject to change at any time without prior notice, and shall be interpreted, applied and enforced within the sole discretion of the Hospital or those individuals to whom the Hospital delegates responsibility for interpretation, application or enforcement. II. NATURE OF AHP STATUS Individuals with this status are members of the Allied Health Professional Staff and are not members of the Medical Staff. AHP status shall confer on the appointee permission to perform only such specified privileges as have been granted by the Board. The Board shall grant privileges to provide specified services in the Hospital only to professionals who meet established minimum qualifications. Where appropriate, the Hospital and/or Medical Staff may establish particular qualifications required of appointees beyond the established minimum qualifications. These privileges may be revoked at the Board s discretion. No applicant or AHP shall engage in patient care in the Hospital unless the Board has granted him/her privileges to do so. The Medical Staff, at its sole discretion, shall determine what types of professionals are eligible for AHP status. The Board shall grant privileges to provide specified services in the Hospital only to professionals who meet established minimum qualifications. Where appropriate, the Hospital and/or Medical Staff may establish particular qualifications required of appointees beyond the established minimum qualifications. Currently, there are two (2) status categories of Allied Health Professional Staff: Independent and Supervised. The Medical Staff, at its sole discretion, shall determine the category to which each specialty belongs. The following professionals may be granted Independent status: Acupuncturist Audiologist Certified Nurse Practitioner Chiropractor Clinical Nurse Specialist 2

3 Licensed Clinical Social Worker Psychotherapist Licensed Physical Therapist (UC Faculty Practice only) Optometrist The following professionals may be granted Supervised status: Anesthesiologist Assistant Certified Registered Nurse Anesthetist Dental Assistant Esthetician Physician Assistant III. PROFESSION-SPECIFIC CRITERIA AND QUALIFICATIONS A. Acupuncturist Acupuncturists provide services to patients/clients through the use of traditional Chinese medicine diagnostic and therapeutic methods to promote health and treat neurological, organic, or functional disorders. 2. Successful completion of education program accredited by the Accreditation Commission for Acupuncturist and Oriental Medicine (ACAOM). 3. Current Colorado license as an acupuncturist. 4. Current, unrestricted certification by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM). 5. Collaborative practice agreement with a physician currently appointed to the medical staff of this hospital to oversee the acupuncturist s practice in the hospital. 6. Certification in basic life support (BLS) and, if required by the hiring department, ACLS or other advanced cardiac life support (ACLS) if certification. 7. Evidence of current competency to perform requested specified services. B. Anesthesiologist Assistant Anesthesiologist Assistants (AA) are qualified to administer specific types of anesthesia for assigned cases under attending anesthesiologist supervision and provide pre-anesthesia evaluation and preparation, and post-anesthesia assessment. The exercise of clinical privileges requires a designated supervising attending anesthesiologist with clinical privileges at University of Colorado Hospital. All practice is performed under the supervision of an attending anesthesiologist. The attending anesthesiologist supervising clinical care must be physically present in the same anesthetizing location to provide consultation when requested and to be immediately available if needed. 2. Successful completion of a master s degree program, with master s degree awarded, accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP). 3

4 3. Current, unrestricted certification sponsored by the National Commission for Certification of Anesthesiologists Assistants (NCCAA). 4. Current certification in Advanced Cardiac Life Support (ACLS). 5. Demonstrated competence and adequate volume of experience reflective of the scope of privileges requested: minimum of 425 hours of practice in the past twelve (12) months/850 hours in the past twenty-four (24) months with acceptable results OR completion of an accredited program of anesthesia in the past twelve (12) months. 6. Current, unrestricted license effective July 1,. 7. Supervisory practice agreement with a designated supervising attending anesthesiologist with privileges at UCH. C. Audiologist Audiologists are uniquely qualified to provide a comprehensive array of professional services related to the assessment and habilitation/rehabilitation of persons with auditory and vestibular impairments, and to the prevention of these impairments. 2. Current Colorado license as an audiologist. 3. Graduation from an accredited master s or doctorate program in audiology. 4. Possession of a certificate of competency or board certification in audiology from a nationally recognized certification agency. 5. Compliance with the requirements of the Colorado Audiologist Practice Act. 6. Certification in basic life support (BLS) and, if required by the hiring department, ACLS or other advanced certification. 7. Evidence of current competency to perform requested specified services. D. Certified Nurse Practitioner Nurse Practitioners (NP) are certified advanced practice nurses who provide primary health care and specialized health services to individuals, families, groups, and communities. First time appointees must complete the application process to receive authorization to provide services as an Allied Health Professional. 2. Current Colorado license as a Registered Nurse, including registration in the advanced practice nurse registry. 3. Graduation from a master s program in nursing accredited by the Commission on Collegiate Nursing Education (CCNE) or the National League for Nursing (NLN). 4. Completion of a formal postgraduate nurse practitioner track or program in the applicant s specialty within a school of nursing granting graduate level academic credit. Evidence of successful completion will either be a certificate or a letter from the program director. 4

5 5. Eligibility or successful completion of the national certification examination administered by a nationally recognized credentialing organization in the appropriate specialty, and maintenance of current certification. If a certification examination does not exist for the practitioner s specialty, certification in a like specialty approved by the Allied Health Credentials Subcommittee must be obtained within one appointment cycle. New graduates must pass a certification examination within sixty (60) days of graduation. 6. Compliance with the requirements under the Colorado Nurse Practice Act. 7. Current certification in basic life support (BLS) and, if required by the hiring department, ACLS 8. The Articulated Plan and Attestation Statement must be provided to the Medical Staff Office at the time of appointment if the practitioner has full prescriptive authority. For new graduates or individuals in the process of completing the required hours for full prescriptive authority, the Articulated Plan and Attestation Statement and proof of prescriptive authority must be submitted to the Medical Staff Office within thirty (30) days of obtaining prescriptive authority. 9. Evidence of current competency to perform requested specified services. 10. Documentation of prescriptive authority granted by the Colorado Board of Nursing. Nurse Practitioners who have not been granted prescriptive authority by the Colorado Board of Nursing must obtain prescriptive authority within two (2) appointment cycles for full-time clinical FTE and within three (3) appointment cycles for part-time clinical FTE. 11. A DEA license is required to prescribe any medications. Medications cannot be prescribed in the electronic health record until the DEA license is obtained. E. Certified Registered Nurse Anesthetist Certified Registered Nurse Anesthetists (CRNA) are advanced practice nurses with current Registered Nurse licensure in the State of Colorado, who have been admitted to the Advanced Practice Registry of the Colorado Board of Nursing. CRNAs are qualified to administer specific types of anesthesia for assigned cases under supervision and provide pre-anesthesia evaluation and preparation, and postanesthesia assessment. The exercise of clinical privileges requires a designated supervising attending anesthesiologist with clinical privileges at University of Colorado Hospital. All practice is performed under the supervision of an attending anesthesiologist. The attending anesthesiologist supervising clinical care must be physically present in the same anesthetizing location to provide consultation when requested and to be immediately available if needed. 1. Current faculty appointment with the one of the Health Sciences Schools. 2. Successful completion of a baccalaureate or graduate degree program accredited by the American Association of Nurse Anesthetists (AANA) Council on Accreditation of Nurse Anesthesia Educational Programs. 3. Current and active Colorado License as a Registered Nurse, including registration in the Advanced Practice Registry. 4. Current, unrestricted certification by the National Board for the Certification and Re- Certification of Nurse Anesthetists (NBCRNA). New graduates must pass the certification examination within 60 days of graduation. 5

6 5. Current certification in Advanced Cardiac Life Support (ACLS). 6. Supervisory practice agreement with a designated supervising attending anesthesiologist with privileges at the Hospital. 7. Demonstrated competence and adequate volume of experience reflective of the scope of privileges requested: minimum of 425 hours of practice in the past twelve (12) months/850 hours in the past twenty-four (24) months with acceptable results OR completion of an accredited program of anesthesia in the past twelve (12) months. F. Chiropractor Doctors of Chiropractic (chiropractor) provide services to patients/clients who have impairments, functional limitations, disabilities, or changes in physical function and health status resulting from neurological and/or musculoskeletal injury, disease, or other causes. The chiropractor interacts and practices in conjunction with a variety of professionals, including physicians, nurses, educators, social workers, chiropractors, massage therapists, occupational therapists, and any other personnel involved with the patient/client. 1. Current faculty appointment with one of the Health Sciences School. 2. Current and active Colorado license as a chiropractor; 3. Post graduate degree with 4,200 hours of training from a Council on Chiropractic Education accredited chiropractic school. 4. Eligibility or successful completion of the national certification examination administered by a nationally recognized credentialing organization in the appropriate specialty. 5. Compliance to the Rules and Regulations of the Colorado State Board of Chiropractic Examiners. 6. Current certification in basic life support (BLS) and, if required by the hiring department, ACLS 7. Collaborative Practice Agreement with a member of the medical staff within the department in which the chiropractor practices. 8. Evidence of current competency to perform requested specified services. G. Clinical Nurse Specialist Clinical Nurse Specialists (CNS) are advanced practice nurses (APN) with current registered nurse licensure in the State of Colorado, who have been admitted to the Advanced Practice Registry of the Colorado Board of Nursing. The APN is prepared for an advanced role by virtue of additional knowledge, training and skills. First time appointees must complete the application process to receive authorization to provide services as an Allied Health Professional. 2. Current and active Colorado license as a Registered Nurse, including registration in the Advanced Practice Registry. Graduation from a master s program in nursing accredited by the National League for Nursing. 6

7 3. Eligibility or successful completion of the national certification examination administered by a nationally recognized credentialing organization in the appropriate specialty, and maintenance of current certification. If a certification examination does not exist for the practitioner s specialty, certification in a like specialty approved by the Allied Health Credentials Subcommittee must be obtained within one appointment cycle. New graduates must complete within sixty (60) days of graduation. 4. Compliance with the requirements of the Colorado Nurse Practice Act. 5. Current certification in basic life support (BLS) and, if required by the hiring department, ACLS 6. The Articulated Plan and Attestation Statement must be provided to the Medical Staff Office at the time of appointment if the practitioner has full prescriptive authority. For new graduates or individuals in the process of completing the required hours for full prescriptive authority, the Articulated Plan and Attestation Statement and proof of prescriptive authority must be submitted to the Medical Staff Office within thirty (30) days of obtaining prescriptive authority. 7. Evidence of current competency to perform requested specified services. 8. Documentation of prescriptive authority granted by the Colorado Board of Nursing. Clinical Nurse Specialists who have not been granted prescriptive authority by the Colorado Board of Nursing must obtain prescriptive authority within two (2) appointment cycles for full-time clinical FTE and within three (3) appointment cycles for part-time clinical FTE. 9. A DEA license is required to prescribe any medications. Medications cannot be prescribed in the electronic health record until the DEA license is obtained. *Prior to October 2002, Nurse Doctorates (NDs) may be designated as Clinical Nurse Specialists by the Colorado Board of Nursing. H. Dental Assistant Dental/Oral/Maxillofacial Surgical Assistants are specially trained individuals who provide assisting services for the Doctor of Dental Medicine (DMD) or Doctor of Dental Surgery (DDS) in a variety of treatment procedures. 1. Current faculty appointment with the University of Colorado School of Dental Medicine. 2. Supervisory practice agreement with a dentist member of the Medical Staff within the Department of Dental Medicine. 3. Documentation of successful completion of one of the following: an accredited dental assistant training program or dental hygiene program and a minimum of six (6) months onthe-job training in a dental office under the direct supervision of a dentist; or completion of a clinical training program (e.g., RN or LPN) and evidence of a minimum of six (6) months on-the-job training under the direct supervision of a dentist; or five (5) years or more documented on the job training under the direct supervision of a dentist. 4. Current registration with the Colorado Division of Registrations as a Surgical Assistant. 5. Current certification in basic life support (BLS) and, if required by the hiring department, ACLS 6. Evidence of current competency to perform requested specified services. 7

8 I. Esthetician Non-physician Licensed Estheticians are health care professionals currently certified by the Colorado Board of Cosmetology for skin care. An esthetician provides instruction and counseling to individuals regarding skin care, works in collaboration with other health care providers to provide and coordinate skin care services, and gives facials, manicures, pedicures, and other beauty treatments. 2. Active certification/license to practice as a registered cosmetician in the State of Colorado. 3. Education from a program accredited by the National Accrediting Commission of Cosmetology Arts and Sciences (NACCAS). 4. Graduation from a barber school or beauty school approved by a minimum of 550 hours in an esthetician course of study. Specialty services requirements: Microdermabrasion, fourteen (14) hours additional training; cosmetic resurfacing, twenty-four (24) hours additional training. 5. Supervisory practice agreement with a physician member of the medical staff within a department in which the esthetician practices. 6. Documentation of experience and current competence to perform requested services. 7. Current certification in basic life support (BLS) and, if required by the hiring department, ACLS J. Licensed Clinical Social Worker Licensed Clinical Social Workers (LCSW) are professionals who apply social work therapy and methods for the purpose of prevention, assessment, diagnosis, and intervention with individual, family, group, organizational, and societal problems, including alcohol and substance abuse and domestic violence, based on the promotion of biopsychosocial developmental processes, person-in environment transactions, and empowerment of the client system. Social work theory and methods are based on known accepted principles that are taught in professional schools of social work in colleges or universities accredited by the council on social work education. 2. Current Colorado license as a licensed clinical social worker. 3. Master s or doctorate degree in social work from an accredited educational social work program. 4. Practice of social work for at least two (2) years under the supervision of a licensed independent social worker or licensed clinical social worker. 5. Successful completion of an examination as prescribed by the board. 6. Compliance with the requirements under the Colorado LCSW Practice Act. 7. Current certification in basic life support (BLS) and, if required by the hiring department, ACLS 8. Evidence of current competency to perform requested specified services. 8

9 9. Collaborative practice agreement with a member of the medical staff within the department in which the (LCSW) practices. K. Optometrist Doctors of Optometry (OD), or Optometrists, are persons who engage in the prescribing of visual training or orthoptics, or the prescribing of any contact lenses, or the fitting or adaptation of such contact lenses to the human eye, or the use of scientific instruments to train the visual system or any abnormal condition of the eyes for the correction or improvement of, or the relief to, the visual function, or who holds oneself out as being able to do so. 2. Current Colorado license as an optometrist. 3. Graduation from an accredited doctor of optometry program recognized or approved by the Council on Post-Secondary Accreditation or the US Commission of Education. 4. Fulfilled Advanced Ocular Therapy (AOT) requirements to be able to treat glaucoma and anterior uveitis. 5. Board certified or eligible for certification through the national optometrist organization. 6. Compliance with the requirements of the Colorado Optometrist Practice Act. 7. Current certification in basic life support (BLS) and, if required by the hiring department, ACLS 8. Evidence of current competency to perform requested specified services. 9. A DEA license is required to prescribe any medications. Medications cannot be prescribed in the electronic health record until the DEA license is obtained. L. Physical Therapist Physical Therapists (PT) provide services to patients/clients who have impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes. The PT interacts and practices in conjunction with a variety of professionals, including physicians, dentists, nurses, educators, social workers, occupational therapists, speech-language pathologists, audiologists, and any other personnel involved with the patient/client. The PT identifies risk factors and behaviors that may impede optimal functioning. The PT provides prevention services and promotes health, wellness, and fitness. The PT provides consultations, education, critical inquiry, and administration of programs. The PT directs and supervises physical therapy services, including support personnel. 2. Current Colorado license as a physical therapist. 3. Professional education at the college or university level: successful completion of a physical therapist education program accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE). *The CAPTE limited its scope in 2002 to accredit only those professional programs that award the post-baccalaureate degree. 9

10 4. Eligibility or current certification through the American Board of Physical Therapy Specialties (ABPTS). 5. Compliance with the requirements under the Colorado Physical Therapist Practice Act. 6. Current certification in basic life support (BLS) and, if required by the hiring department, ACLS 7. Evidence of current competency to perform requested specified services. M. Physician Assistant Physician Assistants (PA) are health care professionals certified by the National Commission on Certification of Physician Assistants and licensed by the State of Colorado with a designated supervising physician who is credentialed at the Hospital, and also holds a supervising registration certificate with the State. The scope of specified services granted Physician Assistants will vary depending on the training, experience, and competency of the individual as well as the privileges of the supervising physician, and shall be consistent with Colorado statute. 2. Current license to practice as a physician assistant in the State of Colorado. 3. Graduation from a physician assistant program accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA). A baccalaureate degree is required, a master s degree is preferred. 4. Compliance with the Rules and Regulations of the Colorado State Board of Medical Examiners. 5. Certification by the National Commission on Certification of Physician Assistants (NCCPA). 6. Certification in basic life support (BLS) and, if required by the hiring department, ACLS or other advanced certification. 7. Supervisory practice agreement with a physician member of the medical staff within the department in which the PA practices. 8. Evidence of current competency to perform requested specified services. 9. A DEA license is required to prescribe any medications. Medications cannot be prescribed in the electronic health record until the DEA license is obtained. IV. BASIC RESPONSIBILITIES Each AHP shall: 1. Provide his/her patients with care at the generally recognized professional level of quality and efficiency. 2. Abide by the ethical principles of his/her profession. 3. Perform only such functions for which he/she has been privileged. 4. Seek consultation, supervision and direction whenever necessary or as required by law or the AHP s collaborative or supervisory practice agreement. 5. Prepare and complete in timely fashion, as determined by the Hospital, the patient record and other required records for all patients for whom he/she in any way provides care in the Hospital. 10

11 6. Attend meetings of the department or committees when requested to do so by the appropriate department or committee chairperson and under conditions established by the AHPs. 7. Perform such other responsibilities as are required by Colorado law. 8. Participate in peer review activities as required by the Hospital. 9. Abide by the Medical Staff Rules & Regulations as they may pertain to the practice of the AHP, the Hospital s policies and procedures, and the Hospital s Code of Conduct. 10. Any AHP who is named in a professional liability claim or action shall report the circumstances of the claim or action to his/her Hospital Department(s), to the Medical Staff Office, and to the Office of Professional Risk Management. Reporting shall occur at the time of notification of the claim or action, and at a minimum, the AHP shall also report final judgments or settlements. There shall be adherence to the requirements of the National Practitioner Data Bank (NPDB) and to the State of Colorado reporting requirements. V. APPLICATION FOR INITIAL APPOINTMENT Only AHPs in the aforementioned categories are eligible to request privileges and to complete an application to be considered for AHP status. Such AHPs are solely responsible for providing any and all information and documentation required by the Hospitals. The application, when deemed complete, processed and verified by the Medical Staff Office, shall be presented to the Allied Health Credentials Subcommittee for review. Offers made for AHP positions that require credentialing will be contingent upon successful completion of the credentialing process. VI. APPLICATION FOR REAPPOINTMENT Applications for reappointment must be completed and filed with the Medical Staff Office upon receipt of said documents. It is each AHP s responsibility to complete and submit an application for reappointment in a timely manner. Criteria for reappointment include meeting the minimum qualifications plus: a. Proof of approved continuing education per specialty certification. b. Successful review and evaluation of continued competency. c. Justification for a requested change in privileges. VII.RELEASE OF INFORMATION Each AHP providing services in the Hospitals, or applying to provide such services, shall furnish to the Hospital any and all information that the Hospital deems necessary for processing applications for appointment, reappointment, or for interim evaluations of the AHP s practice, and shall execute appropriate authorizations for release of such information to the Hospital as necessary. In addition, as a condition of AHP status at the Hospital, the AHP authorizes the Hospital to disclose in good faith, upon appropriate request and as permitted by law, any and all information that the Hospital has pertaining to the AHP, and the AHP releases the Hospital, its employees, agents and representatives, from any claims, costs, or damages for such disclosure. VIII. ALLIED HEALTH CREDENTIALS SUBCOMMITTEE REVIEW The Allied Health Credentials Subcommittee shall review each applicant s file and may seek input from whatever sources it deems appropriate. As soon as practical after conclusion of the review, the Allied Health Credentials Subcommittee will prepare a report of its recommendations, indicating the AHP category and the department affiliation. The recommendations, whether positive or negative, shall be forwarded to Medical Staff Credentials Committee for their review and recommendation. The Credentials Committee s recommendations will be forwarded to the Medical Board, which will make a final 11

12 recommendation to the Hospital Board of Directors. The Hospital Board of Directors shall grant final approval or denial for the application. Should an application be denied, the applicant shall be given notice and shall have immediate rights to appeal as set forth in these Rules and Regulations. IX. DURATION OF APPOINTMENT All appointments to the AHP Staff shall be made in accordance with appointment provisions in the Medical Staff Bylaws. A. Initial Appointment All initial appointments to AHP status and privileges to provide specified services shall be for a provisional period, during which time the practitioner shall be subject to focused professional practice evaluation (FPPE) in accordance with the Professional Practice Evaluation policy. Initial appointment shall not exceed two (2) years. B. Provisional Status AHPs shall be observed during the provisional period. The performance of Supervised AHPs will be reviewed by the Supervising Physician. The performance of Independent AHPs shall be reviewed by a physician designated by the Department Chair or Division Chief. The Department Chair/ Division Chief/Program Director, shall make a recommendation for the AHP to be removed from provisional status. Any AHP who has not met the minimum requirements for AHP status, such as prescriptive authority, specialty certification, etc. shall not be eligible for removal from provisional status until completion of the requirements; however, the provisional period shall not exceed two (2) years. C. Reappointment Reappointments to the AHP Staff shall be for a period not to exceed two (2) years from the original appointment date or the date of the last reappointment, during which time the practitioner shall be subject to Professional Practice Evaluation (PPE) according to policy. X. AUTOMATIC TERMINATION Termination, suspension or limitation of the required licensure, certification or specific requirements for employment, including loss of faculty appointment, shall result in automatic termination of AHP status. Automatic termination is not appealable except to show that the required licensure, certification or specific requirements for employment have not been terminated, suspended or limited. XI. QUALIFICATION OR QUALITY CONCERNS The Allied Health Credentials Subcommittee will review any complaints or concerns involving qualifications to provide services. Any complaints or concerns involving quality of care shall be directed to the Risk Management (RM) Department or the Clinical Excellence & Patient Safety (CEPS) Department. Such investigation shall be done in accordance with the Hospital s quality improvement programs. The Risk Management or Clinical Excellence & Patient Safety Departments will provide information regarding their investigation and recommendations to the Allied Health Credentials Subcommittee. The affected AHP shall cooperate in the investigation and supply information and documentation as requested. As soon as practical after review of the investigation, the Allied Health Credentials Subcommittee shall forward its report and recommendations to the Credentials Committee for their recommendation. XII. PROCEDURAL RIGHTS In the event that an AHP is denied AHP privileges or his/her permission to perform services is restricted, suspended or revoked due to credentialing or quality of care concerns, the AHP shall have the right to appeal such adverse action to the Allied Health Credentials Subcommittee. The AHP must request such appeal in writing to the Chair of the Allied Health Credentials Subcommittee within five (5) business days of receipt of notice that his/her permission to perform services is restricted, suspended or revoked. The 12

13 Allied Health Credentials Subcommittee shall appoint a Peer Review Subcommittee to investigate and review the action taken, and make recommendations to the Allied Health Credentials Subcommittee. The Peer Review Subcommittee shall consist of two individuals who are qualified in the same allied health discipline as the appellant and one individual from University of Colorado Hospital Administration. The AHP shall be given the opportunity to present his/her position to the Peer Review Subcommittee. The Peer Review Subcommittee shall provide written recommendations to the Allied Health Credentials Subcommittee as soon as feasible after conclusion of its review. The Allied Health Credentials Subcommittee shall make a decision as soon as possible and shall provide the AHP written notice of its decision. In the event its decision remains adverse to the AHP, the AHP may further appeal to the President of the Medical Staff by submitting his/her appeal in writing to the Medical Staff President within five (5) business days of receipt of the Subcommittee s decision. The AHP may meet with the Medical Staff President to discuss the matter. The Medical Staff President shall notify the AHP of his/her decision on appeal in writing, copied to the Chair of the Allied Health Credentials Subcommittee. Any decision made by the Medical Staff President must be ratified by both the Medical Board and the Board of Directors. The Medical Staff President shall be the final decision-making authority on the appeal, unless such decision is not ratified by the Medical Board and Board of Directors, in which case the Board of Directors shall be the final decision-making authority on appeal. In the event that the AHP is a University of Colorado Hospital employee, and the conduct upon which adverse action was taken is not related to credentialing or quality of care issues (such as absenteeism, insubordination, etc.), the AHP must follow the University of Colorado Hospital Employee Appeal policy. It shall be the University of Colorado Hospital s sole right to determine which appeals process applies, i.e., the University of Colorado Hospital Employee Appeal process or the process as described in this Section 5-4 and such determination is not subject to appeal. 13

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