PLATTE COUNTY MEMORIAL HOSPITAL MEDICAL STAFF CREDENTIALING POLICY ARTICLE I DEFINITIONS

Transcription

1 PLATTE COUNTY MEMORIAL HOSPITAL MEDICAL STAFF CREDENTIALING POLICY ARTICLE I DEFINITIONS The following definitions shall apply to terms used in this policy: (1) "Board" means the Board of Directors of Banner Health or any subcommittee thereof, as may be designated by the Board, who has the overall responsibility for the conduct of the hospital; (2) "Chief Executive Officer" (CEO) means the individual appointed by the Board to act on its behalf in the overall management of the hospital; (3) "MEC" means the Medical Executive Committee of the Medical Staff unless specifically written "Executive Committee of the Board"; (4) "Medical Staff" means all physicians dentists and podiatrists who are given privileges to treat patients at the hospital; (5) "Physicians" shall be interpreted to include both doctors of medicine ("M.D.'s") and doctors of osteopathy ("D.O.'s"); (6) "Dentist" shall be interpreted to include a doctor of dental surgery and doctor of dental medicine; (7) "Podiatrist" shall be interpreted to mean a doctor of podiatric medicine; and (8) Words used in this policy shall be read as the masculine or feminine gender, and as the singular or plural, as the content requires. The captions or headings are for convenience only and are not intended to limit or define the scope or effect of any provision of this policy. ARTICLE II APPOINTMENT TO THE MEDICAL STAFF ARTICLE II - PART A: QUALIFICATIONS FOR APPOINTMENT Section 1. General: Appointment to the Medical Staff is a privilege which shall be extended only to professionally competent individuals who continuously meet the qualifications, standards, and requirements set forth in this policy

2 2 of 24 and in such policies as are adopted from time to time by the Board. All individuals practicing medicine dentistry and podiatry in this hospital, unless accepted by specific provisions of this policy, must first have been appointed to the Medical Staff. Section 2. Specific Qualifications: Only physicians, dentists and podiatrists who satisfy the following conditions shall be qualified for appointment to the Medical Staff: (d) (e) are currently licensed to practice in the state of Wyoming; maintain an active office (i.e., one where patients are seen at least one day per week) within the geographic service area of the hospital as defined by the Board and also reside close enough to the hospital to fulfill their Medical Staff responsibilities and to provide timely and continuous care for their patients in the hospital; possess current, valid professional liability insurance coverage in such form and in amounts satisfactory to the hospital; except for those physicians dentists and podiatrists who are appointed to the Medical Staff as of April 17, 2003, have successfully completed an accredited ACGME/AOA residency training program in the specialty in which the applicant seeks clinical privileges, unless such requirement is waived by the Board in exceptional cases after considering the specific competence, training, and experience of the individual in question; can document the following with sufficient adequacy to demonstrate to the Medical Staff and the Board that he/she will provide care to patients at the generally recognized professional level of quality, in an economically efficient manner, taking into account patients needs, the available Hospital facilities and resources, and utilization standards in effect at the Hospital: (1) background, experience, training, demonstrated, ability, current competence, emotional stability, availability, and physical health and mental and emotional stability to perform the privileges requested, (2) adherence to the ethics of their profession, (3) good reputation and character, and (4) ability to work harmoniously with others sufficiently to present to the hospital that all patients treated by them at the hospital will receive quality care and that the hospital and its Medical Staff will be able to operate in an orderly manner. Section 3. No Entitlement to Appointment: No individual shall be entitled to appointment to the Medical Staff or to the exercise of particular clinical privileges in the hospital merely by virtue of the fact that such individual: is licensed to practice a profession in this or any other state, is a member of any particular professional organization, has had in the past, or currently has, Medical Staff appointment or privileges at any hospital, or

3 3 of 24 (d) resides in the geographic service area of the hospital as defined by the Board. Section 4. Nondiscrimination Policy: No individual shall be denied appointment on the basis of sex, race, creed, religion, color or national origin, or on the basis of any criteria unrelated to the delivery of quality patient care at the hospital, to the qualifications set forth in this Policy, or to the hospital's purposes, needs, and capabilities. ARTICLE II - PART B: CONDITIONS OF APPOINTMENT Section 1. Duties of Appointees: Appointment to the Medical Staff shall require that each appointee assume such reasonable duties and responsibilities as the Medical Staff or the Board shall require. Section 2. Professional Conduct: Individuals appointed to the Medical Staff shall be expected to relate in a positive and professional manner to other health care professionals, and to cooperate and work collegially with the Medical Staff leadership and hospital management and hospital personnel. ARTICLE II PART C: APPLICATION FOR INITIAL APPOINTMENT AND CLINICAL PRIVILEGES Section 1. Information: Applications for appointment to the Medical Staff shall be in writing, and shall be submitted on forms approved by the Board of Directors upon recommendation of the Medical Executive Committee. These forms shall be obtained from the CEO or designee. The application shall contain a request for specific clinical privileges desired by the Applicant and shall require detailed information concerning the Applicant's professional qualifications, including: (1) The names and complete addresses of at least three (3) Practitioners, as appropriate, who have had recent extensive experience in observing and working with the Applicant, and who can provide adequate information pertaining to the Applicant's present professional competence and character. These references may not be from Practitioners associated or about to be associated with the Applicant in professional practice or personally related to the Applicant. At least one (1) reference shall be from the same specialty area as the Applicant. (2) The names and complete addresses of the chiefs of each service or department of any and all hospitals or other institutions at which the Applicant has worked or trained (i.e., the Practitioners who served as chiefs at the time the Applicant worked in the particular department). If the number of hospitals the Applicant has worked in is great or if a number of years have passed since the Applicant worked at a particular Hospital, the Medical Executive Committee and the Board of Directors may take such factors into consideration.

4 4 of 24 (3) Information as to whether the Applicant's medical staff appointment or clinical privileges have ever been voluntarily or involuntarily relinquished, withdrawn, denied, revoked, suspended, subjected to probationary or other conditions, reduced or not renewed at any other hospital or health care facility. (4) Information as to whether the Applicant has ever voluntarily or involuntarily withdrawn his/her application for appointment, reappointment, and clinical privileges, or resigned from a medical staff before final decision by a hospital's or health care facility's governing board. (5) Information as to whether the Applicant's license to practice any profession in any state, or Drug Enforcement Administration ("DEA") or other controlled substance registration is or has ever been voluntarily or involuntarily suspended, modified, terminated, restricted or is currently being challenged. The submitted application shall include a list or copy of all the Applicant's current licenses to practice, as well as copies of DEA and other controlled substance registration, medical or dental school diploma, and certificates from all post graduate training programs completed. (6) Information as to whether the Applicant has currently in force professional liability insurance coverage, the name of the insurance company, and the amount and classification of such coverage, and whether said insurance coverage covers the clinical privileges the Applicant seeks to exercise at the Hospital. (7) Information concerning the Applicant's professional liability litigation experience, specifically information concerning pending matters, final judgments, or settlements: (A) the substance of the allegations, (B) the findings, (C) the ultimate disposition, and (D) any additional information concerning such proceedings or actions as the Medical Executive Committee may deem appropriate. (8) A consent to the release of information from the Applicant's present and past professional liability insurance carriers. (9) Information concerning any professional misconduct proceedings involving the Applicant in the State of Wyoming or any other state, whether such proceedings are closed or still pending. (10) Information concerning the suspension or termination for any period of time of the right or privilege to participate in Medicare, Medicaid, any other government sponsored program, or any private or public medical insurance program, and information as to whether the Applicant is currently under investigation. (11) Current information regarding the Applicant's ability to safely and competently exercise the clinical privileges requested and perform the duties and responsibilities of Medical Staff appointment, with or without an accommodation, including, without limitation, information regarding the Applicant's physical and mental health status and any health impairments (including alcohol and/or drug dependencies). (12) Information as to whether the Applicant has ever been named as a defendant in a criminal action and/or convicted of a crime with details about any such instance.

5 5 of 24 (13) A complete chronological listing of the Applicant's professional and educational appointments, employment, or positions. (14) Information on the citizenship and/or visa status of the Applicant. (15) The Applicant's signature. (16) Such other information as the Medical Executive Committee, or the Board of Directors may require. The history of malpractice verdicts and the settlement of malpractice claims, as well as pending claims, will be evaluated as criteria for appointment, reappointment, and the granting of clinical privileges. However, the mere presence of verdicts, settlements, or claims shall not, in and of themselves, be sufficient to deny appointment or particular clinical privileges. The evaluation shall consider the extent to which verdicts, settlements, or claims evidence a pattern of care that raises questions concerning the Applicant's clinical competence, or whether a verdict, settlement, or claim in and of itself, represents such deviation from standard medical practice as to raise overall questions regarding the Applicant's clinical competence, skill in the particular clinical privilege, or general behavior. Section 2. Basic Responsibilities and Requirements for Applicants and Appointees: As a condition of consideration of an application for Medical Staff appointment or reappointment, and as a condition of continued Medical Staff appointment and the exercise of clinical privileges, if granted, every applicant and appointee shall specifically agree to the following: (d) (e) (f) to practice a branch of health care or a specialty which is consistent with the purposes, treatment, philosophy, methods and resources of the Hospital and for which the Hospital has a current need; to provide appropriate continuous care and supervision to all patients within the hospital for whom the individual has responsibility; to provide, upon request of the Hospital or its Medical Staff, appropriate and necessary emergency or non-emergency medical treatment within the scope of such applicant s or appointee s privileges to any patient seeking such treatment, regardless of such patient s ability to pay; to abide by all bylaws, policies, and rules and regulations of the Medical Staff and hospital as shall be in force during the time the individual is appointed to the Medical Staff; to work cooperatively and professionally with the Hospital, its professional staff and the Medical Staff and refrain from disruptive behavior which has or could interfere with patient care or the smooth operation of the Hospital and its Medical Staff; to accept committee assignments and such other reasonable duties and responsibilities as shall be assigned;

6 6 of 24 (g) (h) (i) (j) (k) (l) (m) (n) (o) (p) (q) (r) (s) (t) to provide, with or without request, new or updated information to the CEO or designee, as it occurs, that is pertinent to any question on the application form; to attest that the applicant has had an opportunity to read a copy of the Medical Staff Bylaws of the hospital, this, and the Rules and Regulations of the Medical Staff as are in force at the time of application, and that the applicant has agreed to be bound by the terms thereof in all matters relating to consideration of the application without regard to whether or not appointment to the Medical Staff and/or clinical privileges are granted; to appear, if requested, for personal interviews in regard to the application; that any misrepresentation or misstatement in, or omission from the application whether intentional or to agree, shall constitute cause for automatic and immediate rejection of the application resulting in denial of appointment and clinical privileges and in the event that an appointment has been granted prior to the discovery of such misrepresentation, misstatement or omission, such discovery may result in summary dismissal from the Medical Staff; to use the hospital and its facilities sufficiently to allow the hospital, through assessment by appropriate Medical Staff committees and service chiefs, to evaluate in a continuing manner the current competence of the appointee; to agree that the hearing and appeal procedures set forth in The Fair Hearing Plan shall be the sole and exclusive remedy with respect to any professional review action taken at this hospital; to refrain from illegal fee splitting or other illegal inducements relating to patient referral; to refrain from delegating responsibility for diagnoses or care of hospitalized patients to any individual who is not qualified to undertake this responsibility or who is not adequately supervised; to refrain from deceiving patients as to the identity of an operating surgeon or any other individual providing treatment or services; to seek consultation whenever necessary; to promptly notify the CEO, or a designee, and the Chief of Staff of any change in eligibility for payments by third-party payers or for participation in any federally funded program including any sanctions imposed or recommended by the federal Department of Health and Human Services, and/or the receipt of a PRO citation and/or quality denial letter concerning alleged quality problems in patient care to abide by generally recognized ethical principles applicable to the applicant's or appointee's profession and the standards for hospitals promulgated by The Joint Commission (TJC); to participate in the monitoring and evaluation activities of clinical services; to complete in a timely manner the medical and other required records for all patients as required by the Medical Staff bylaws, rules and regulations, this policy and other applicable policies of the hospital;

7 7 of 24 (u) (v) (w) (x) (y) (z) (aa) (bb) to work cooperatively with Medical Staff appointees, Allied Health Professionals, nurses and other hospital personnel so as not to adversely affect patient care; to promptly pay any applicable Medical Staff dues and assessments; to participate in continuing education programs at the hospital (both for his/her own benefit and for the benefit of other professionals and hospital personnel); to authorize the release of all information necessary for an evaluation of the individual's qualifications for initial or continued appointment, reappointment, and/or clinical privileges; to agree not to sue the hospital, the Medical Staff, or anyone acting by or for the hospital and its Medical Staff for any matter relating to the application for appointment, reappointment, or clinical privileges, or relating to the evaluation of the applicant's qualifications on any matter related to appointment, reappointment, or clinical privileges; to extend absolute immunity to the hospital, its Medical Staff, and all individuals acting by or for the hospital and/or its Medical Staff for all matters relating to appointment, reappointment, and clinical privileges or the individual's qualifications for the same; to work cooperatively with the medical staff and the administration to meet and practice within the guidelines established by the Hospital, its Medical Staff or the local professional review organization, to minimize or eliminate disallowed admissions, to eliminate technical diagnoses, entry and coding errors, to order or utilize supporting and ancillary services only when necessary, and to shorten length of stay at the Hospital where medically appropriate; and to notify the CEO of the revocation or suspension of his/her professional license, or the imposition of terms of probation or limitation of practice by any state licensing agency; his/her loss of staff membership or loss, curtailment or restriction of privileges at any hospital or health care institution; the cancellation or restriction of his/her professional liability coverage or DEA number; an adverse determination by a peer review organization or a third-party payer reimbursement program concerning his/her quality of care; a commencement of a formal investigation or the filing of charges by the Department of Health and Human Services or any law enforcement agency or health regulatory agency of the United States or the State of Wyoming, or any other state; or the filing of a claim against the applicant or appointee alleging professional liability at the Hospital. Section 3. Burden of Providing Information: The applicant shall have the burden of producing information deemed adequate by the hospital for a proper evaluation of competence, character, ethics, and other qualifications, and of resolving any doubts about such qualifications. The applicant shall have the burden of providing evidence that all the statements made and information given on the application are true and correct. Until the applicant has provided all information requested by the hospital, the application for appointment or reappointment will be deemed incomplete and will not be further processed. Should information provided in the initial application for appointment change during the course

8 8 of 24 of an appointment year; the appointee has the burden to provide information about such change to the MEC sufficient for the MEC's review and assessment. Section 4. Grant of Immunity and Authorization to Obtain/Release Information: The following statements form a part of this policy and are express conditions applicable to any Medical Staff applicant, any appointee to the Medical Staff, and to all others having or seeking clinical privileges at the hospital. By applying for appointment, reappointment, or clinical privileges, the applicant expressly accepts these conditions during the processing and consideration of the application, whether or not appointment or clinical privileges are granted. This acceptance also applies during the time of any appointment or reappointment. Immunity: To the fullest extent permitted by law, the applicant or appointee releases from any and all liability, extends absolute immunity to and agrees not to sue the hospital, its authorized representatives, and any third parties as discussed in this section, with respect to any acts, communications or documents, recommendations or disclosures involving the applicant or appointee, concerning the following: (1) applications for appointment or clinical privileges, including temporary privileges; (2) evaluations concerning reappointment or changes in clinical privileges; (3) proceedings for suspension or reduction of clinical privileges or for revocation of Medical Staff appointment, or any other disciplinary sanction; (4) summary suspension; (5) hearings and appellate reviews; (6) medical care evaluations; (7) utilization reviews; (8) other activities relating to the quality of patient care or professional conduct; (9) matters or inquiries concerning the applicant's or appointee's professional qualifications, credentials, clinical competence, character, mental or emotional stability to perform the applicant s requested privileges or the appointees privileges, physical condition, ethics or behavior; or (10) any other matter that might directly or indirectly relate to the applicant's or appointee's competence, to patient care, or to the orderly operation of this or any other hospital or health care facility. Authorization to Obtain Information: The applicant or appointee specifically authorizes the hospital and its authorized representatives to consult with any third party who may have information bearing on the individual's professional qualifications, credentials, clinical competence, character, mental or emotional stability, physical condition, ethics, behavior, or any other matter reasonably having a bearing on the applicant's or appointee's satisfaction of the criteria for initial and continued appointment to the Medical Staff. This authorization also covers the right to inspect or obtain any and all communications, reports, records, statements, documents, recommendations or disclosures of said third parties that may be relevant to such questions. The individual also specifically authorizes said third parties to release said information to the hospital and its authorized representatives upon request.

9 9 of 24 Authorization to Release Information: The applicant or appointee specifically authorizes the hospital and its authorized representatives to release such information to other hospitals, health care facilities and their agents, who solicit such information for the purpose of evaluating the applicant's or appointee's professional qualifications pursuant to a request for appointment and/or clinical privileges. ARTICLE II - PART D: PROCEDURE FOR INITIAL APPOINTMENT Section 1. Pre-Application Process: An application for appointment to the Medical Staff shall only be sent upon request to those individuals who, according to the Medical Staff Bylaws and this policy, are eligible for appointment and clinical privileges because they meet the objective threshold criteria for appointment and clinical privileges consideration; who desire to provide care and treatment to patients for conditions and diseases for which the hospital has facilities and personnel; and who indicate an intention to utilize the hospital as required by the staff category to which they desire appointment. A Request for Medical Staff Application form which requests proof that the objective threshold criteria for appointment and clinical privileges consideration can be met by the individual. A completed Request for Medical Staff Application form must be returned to the CEO or designee within thirty (30) days after receipt of same if the individual desires further consideration. Those individuals who meet the objective threshold criteria for consideration for appointment to the Medical Staff and clinical privileges shall be given an application. Individuals who fail to meet these criteria shall not be given an application and shall be so notified. Section 2. Submission of Application: The application for Medical Staff appointment shall be submitted by the applicant to the CEO or a designee. It must be accompanied by payment of such processing fees as may be recommended by the MEC and approved by the Board. After reviewing the application to determine that all questions have been answered, and after reviewing all references and other information or materials deemed pertinent, and after verifying the information provided in the application with the primary sources, the CEO or designee shall transmit the complete application and all supporting materials to the MEC. An application shall be deemed to be complete when all questions on the application form have been answered, all supporting documentation has been supplied, and all information verified. An application shall become incomplete if the need arises for new, additional, or clarifying information anytime during the evaluation. Any application that continues to be incomplete ninety (90) days after the applicant has been notified of the additional information required shall be deemed to be withdrawn and no further action will be taken with respect to such application. It is the responsibility of the applicant to provide a complete application, including adequate responses from references. An incomplete application will not be processed. The CEO or a designee shall post or circulate the name of the applicant so that each Medical Staff appointee may have an opportunity to submit to the MEC, in writing, information bearing on the

10 10 of 24 applicant's qualifications for staff appointment or clinical privileges. In addition, any current Medical Staff appointee shall have the right to appear in person before the MEC to discuss in private and in confidence any concerns the appointee may have about the applicant. Section 3. Medical Executive Committee Procedure: (d) (e) (f) The MEC shall examine evidence of the applicant's character, professional competence, qualifications, prior behavior, and ethical standing and shall determine, through information contained in references given by the applicant and from other sources available to the committee, whether the applicant has established and satisfied all of the necessary qualifications for appointment and for the clinical privileges requested. As part of the process of making its recommendation, to the extent permitted by law, the MEC may require the applicant to undergo a physical and/or mental examination by a physician or physicians satisfactory to the MEC. The results of any such examination shall be made available to the MEC for its consideration. Failure of an applicant to undergo such an examination within a reasonable time after being requested to do so, shall constitute a voluntary withdrawal of the application for appointment and clinical privileges. All processing of the application shall cease. As part of the process of making its recommendation, the MEC may request a meeting with the applicant to discuss the applicant's application, qualifications, and clinical privileges requested. The MEC may use the expertise of any member of the medical staff, or an outside consultant, if additional information is required regarding the applicant's qualifications. If the MEC's recommendation for appointment is favorable, the MEC shall recommend appointment. All recommendations to appointment must specifically recommend the clinical privileges to be granted, which may be qualified by any probationary or other conditions or restrictions as deemed appropriate by the committee. If the recommendation of the MEC is delayed longer than ninety-(90) days, the Chairperson of the MEC shall send a letter to the applicant, with a copy to the CEO, explaining the reasons for the delay. Section 4. Favorable MEC Recommendation: If the MEC's recommendation is to appoint the applicant and to grant the requested clinical privileges, it shall send its recommendation and written findings in support thereof to the Board, through the CEO. Upon receipt of a favorable recommendation from the MEC that the applicant be granted appointment and the requested clinical privileges, the Board (or its designated committee) may: (1) appoint the applicant and grant clinical privileges as recommended; or (2) refer the matter back to the MEC or to another source inside or outside the hospital for additional research or information; or (3) reject the recommendation in which event, the determination and the reasons in support thereof, shall be sent to the CEO, who shall promptly notify the applicant in writing, certified mail, return receipt requested. The Board shall make no final decision until the

11 11 of 24 applicant has exercised or waived the right to a hearing and appeal as outlined in this policy. Whenever the Board of Directors determines that it will decide a matter contrary to the Executive Committee s recommendations, the matter will be submitted to a Joint Conference Committee in accordance with the Banner Health Corporate Bylaws for review and recommendation before the Governing Board makes a final decision. Section 5. Unfavorable MEC Recommendation: If the MEC's recommendation is unfavorable and would entitle the applicant to request a hearing pursuant to the Fair Hearing Plan, it shall be forwarded to the CEO who shall promptly notify the applicant in writing, certified mail, return receipt requested. The recommendation shall not be forwarded to the Board until the applicant has exercised or waived the right to a hearing as provided in the Fair Hearing Plan. Section 6. Initial Appointment: All initial appointments to the Medical Staff (regardless of the category of the Medical Staff to which the appointment is made), and all initial clinical privileges may be subject to such period of monitoring as shall be determined by the MEC and as more particularly set forth in the Medical Staff Bylaws and in the Banner Health Medical Staff Focused Professional Practice Evaluation (FPPE) Policy. In the event of concerns regarding the practitioner s patient care activity or the monitored/proctored cases or if the practitioner does not successfully complete the FPPE process, the CEO will provide him or her with special notice of the adverse result and of his or her entitlement to the procedural rights provided in the Fair Hearing Plan. ARTICLE II - PART E: CLINICAL PRIVILEGES Section 1. General: (d) (e) Medical Staff appointment or reappointment as such shall not confer every clinical privilege or right to practice at the hospital. Each individual who has been appointed to the Medical Staff shall be entitled to exercise only those clinical privileges specifically granted by the Board. The grant of clinical privileges shall carry with it acceptance of the obligations of such privileges, including emergency service and other rotational obligations established to fulfill the hospital's responsibilities under the Emergency Medical Treatment and Active Labor Act and/or other applicable requirements or standards. Clinical privileges shall be voluntarily relinquished only in the manner that provides for the orderly transfer of such obligations. The clinical privileges recommended to the Board shall be based upon consideration of the following:

12 12 of 24 (1) the applicant's education, training, experience, demonstrated current competence and judgment, references, utilization patterns, and health status (as such health status may pertain to the ability to safely perform the privileges requested or privileges granted); (2) the applicant's ability to meet all current criteria for the requested clinical privileges; (3) availability of qualified physicians or other appropriate appointees to provide medical coverage for the applicant in case of the applicant's illness or unavailability; (4) adequate levels of professional liability insurance coverage with respect to the clinical privileges requested; (5) the hospital's available resources and personnel; (6) any previously successful or currently pending challenges to any licensure or registration, or the voluntary/involuntary relinquishment of such licensure or registration; (7) any information concerning professional review actions, voluntary or involuntary termination of Medical Staff appointment or voluntary or involuntary limitation, reduction, or loss of clinical privileges at another hospital; and (8) other relevant information, including a written report and findings by the MEC or the Board. (f) (g) The applicant shall have the burden of establishing qualifications for and competence to exercise the clinical privileges requested. Clinical privilege forms will be reviewed on an annual basis by the Medical Executive Committee (MEC) to ensure that sufficient space, equipment,staffing, and financial resources are in place or available within a specified time frame to support each requested privilege. Section 2. Clinical Privileges for Dentists: The scope and extent of surgical procedures that a dentist may perform in the hospital shall be delineated and recommended in the same manner as other clinical privileges. Surgical procedures performed by dentists shall be under the overall supervision of the Operating Room Medical Director. A medical history and physical examination of the patient shall be made and recorded by a physician who holds an appointment to the Medical Staff before dental surgery shall be scheduled for performance, and a designated physician shall be responsible for the medical care of the patient throughout the period of hospitalization. The dentist shall be responsible for the dental care of the patient, including the dental history and dental physical examination as well as all appropriate elements of the patient's record. Dentists may write orders within the scope of their license and consistent with the Medical Staff Rules and Regulations, and in compliance with the hospital and Medical Staff Bylaws and this Policy. Section 3. Clinical Privileges for Podiatrists: Privileges granted to podiatrists shall be based on their training, equivalent experience and demonstrated competence and judgment. The scope and extent of surgical procedures that each podiatrist may perform shall be specifically delineated and granted in the same manner as all other surgical privileges. Surgical procedures performed by podiatrists shall be under the overall supervision of the Chief of Surgery. All podiatric patients shall receive the same basic medical appraisal as patients admitted to other surgical services. A physician Member shall be responsible for the medical care at the time of admission and during the hospitalization.

13 13 of 24 Section 4. Educational Program Affiliates, Residents, and Medical Students: Educational Program Affiliates, Residents, and Medical Students are those individuals who are serving assignments, as part of their formal training with a Medical Staff member. Residents shall be graduates of approved medical schools, osteopathic schools, or dental schools recognized by the Wyoming Board of Medical Examiners and in a program approved by the Liaison Committee on Graduate Medical Education. Medical students shall be students in approved medical schools, osteopathic schools, or dental schools recognized by the Wyoming Board of Medical Examiners. Educational Program Affiliates, Residents, and Medical Students are those individuals whose services will include participation in the management of patients only under the supervision or direction of a member of the Medical Staff. Persons in these categories shall not be required to seek Allied Health or Medical Staff status on an individual basis but will operate through their contractual agreements of their programs with the hospital or clerkships through their educational programs. Section 5. Clinical Privileges for New Procedures: Whenever a Medical Staff appointee requests clinical privileges to perform a new procedure or service not currently being performed at the hospital, the following process shall be followed: (d) The matter shall first be referred to the Board who, after receiving recommendations from the MEC shall make a preliminary determination whether the new procedure or service is one that will be offered to patients. One factor to be considered in reaching this determination is whether the hospital has the capabilities to perform the procedure in question. Should the Board determine to offer the procedure, the next step is for the MEC to investigate the new procedure and to develop criteria for those individuals who should be permitted to perform the new procedure. Specifically, the MEC or designee shall conduct research and shall consult with experts -- both those on the hospital's Medical Staff and those outside the hospital -- and develop recommendations regarding (1) the minimum education, training, and experience necessary to perform the procedure in question, and (2) the extent of monitoring and supervision that should occur. The MEC shall forward its recommendations to the Board for final action. The Board shall then establish the minimum criteria and qualifications necessary to be able to perform the procedure in question. Once the foregoing steps are accomplished, specific requests from medical staff appointees who wish to perform the procedure in question shall be handled in accordance with Article III, Part B of this Policy ("Procedures for Requesting Increase in Clinical Privileges"). ARTICLE II - PART F: VOLUNTARY RELINQUISHMENT OF PRIVILEGES Section 1. Request to Relinquish Clinical Privileges: A Medical Staff appointee who desires to voluntarily relinquish any one (1) or more of the clinical privileges granted at any time during the appointment period may submit a written request to the MEC specifying the clinical privilege(s) to be relinquished.

14 14 of 24 The procedure set forth in this Part shall not apply to situations where the appointee has been deemed by the hospital to have voluntarily relinquished privileges pursuant to this policy, the Medical Staff bylaws, rules and regulations or the hospital bylaws or policies. Likewise, voluntary relinquishment of clinical privileges while under an investigation or in exchange for not conducting an investigation shall be considered a "surrender" of such privileges, and shall be so reported when so required. Section 2. Procedure for Relinquishment of Clinical Privileges: Upon the receipt of a request to relinquish one or more clinical privileges, the MEC shall review the request and forward a copy of the recommendation to the Board for final action. The MEC may request a meeting with the appointee involved if the decrease of the clinical privileges would create a deficiency in available hospital services. A report of such meeting shall be submitted to the Board with the recommendation of the MEC. The Board shall act on the request and its decision shall be reported in writing by the CEO to the appointee, and the MEC. The decision of the Board shall specify a specific date by which relinquishment of clinical privilege(s) shall become effective. Failure to request relinquishment of any clinical privileges pursuant to this Part or to adhere to the effective date specified by the Board for the relinquishment of the clinical privileges in question shall constitute grounds for professional review action pursuant to the Medical Staff Bylaws. ARTICLE II - PART G: PROCEDURE FOR TEMPORARY CLINICAL PRIVILEGES Section 1. Conditions: Temporary privileges may be granted only in the circumstances and under the conditions described below, only to an appropriately licensed practitioner, only when the information available substantially supports a favorable determination regarding the requesting practitioner's qualifications, and only after the practitioner has satisfied the professional liability insurance requirement of these Bylaws. The Chief of the Medical Staff may impose special requirements of supervision and reporting. Under all circumstances, the practitioner requesting temporary privileges must agree to abide by these Bylaws, Rules and Regulations, and policies of the Medical Staff and Banner Health. Section 2. Medical Staff Applicant: Upon receipt of a completed application for Medical Staff membership from an appropriately licensed practitioner, upon verification of education and training, Wyoming licensure and malpractice liability coverage, querying the National Practitioner Data Bank, receipt of reference attesting to current clinical competency, and (d) a recommendation for approval by the MEC or the Chief of the Medical Staff, the CEO may grant temporary admitting and clinical privileges to the applicant for up to ninety (90) days. Section 3. Care of Specific Patient: Temporary clinical privileges may be granted by the CEO to practitioners who do not intend to become members of the Medical Staff for the care of a specific patient under the following terms and conditions: The applicant for temporary clinical privileges shall advise the Chief of the Medical Staff of his or her

15 15 of 24 qualifications, the extent to which he or she complies with the standards required by the Medical Staff Bylaws and the other Medical Staff documents, and the specific privileges desired, and he or she shall furnish proof of education and training, licensure and proof of adequate professional liability insurance coverage. Under such circumstances, upon verification of education and training, Wyoming licensure, and malpractice liability insurance, querying the National Practitioner Data Bank, receipt of references attesting to current clinical competency, and (d) the recommendation of the Chief of the Medical Staff, the CEO may grant temporary clinical privileges. Such temporary privileges shall be restricted to the treatment of not more than two (2) patients in any consecutive twelve (12) month period, after which the practitioner must apply for Medical Staff appointment, and shall be restricted to the care of the specific patients for which they are granted. Section 4. Locum Tenens: A practitioner may be granted temporary clinical privileges to serve as a locum tenens practitioner under the following conditions: (d) (e) Locum tenens practitioners are practitioners who provide periodic locum tenens coverage for a service. Locum tenens practitioners shall have delineated clinical privileges issued as temporary privileges. Locum tenens practitioners are not appointed to the Medical Staff and shall not be eligible to serve on Medical Staff committees, to vote or to hold office. A member of the active staff desiring to utilize a locum tenens practitioner shall advise the CEO of the name and address of the proposed locum tenens practitioner and the period of time during which the member of the active staff will be absent from the community. It is the responsibility of the member of the active staff to insure that the proposed locum tenens practitioner complies, in all respects, with the provisions of the Medical Staff Bylaws and the other Medical Staff documents. Locum tenens coverage may be used by the hospital to cover a service where there is a deficiency in the number of practitioners or lack of coverage. The locum tenens practitioner shall complete and sign an application for appointment to the Medical Staff and shall request temporary clinical privileges. The applicant shall meet the qualifications set forth in this policy. By signing the application, the locum tenens practitioner agrees to be bound by the Medical Staff Bylaws, the other Medical Staff documents and applicable policies and procedures of the hospital and the Medical Staff. Upon (1) verification of education and training, Wyoming licensure and malpractice liability insurance, (2) querying the National Practitioner Data Bank, and (3) receipt of references attesting to current clinical competency, the CEO may grant temporary privileges to a locum tenens practitioner to care for patients in the hospital, with the recommendation of the Chief of the Medical Staff, only for a period not to exceed ninety (90) days following the granting of said privileges. If the locum tenens coverage exceeds ninety (90) days, or is recurring, the locum tenens practitioner may submit another request for temporary privileges at the end of ninety (90) days. If a locum tenens practitioner is providing services at the hospital for an extended period of time, the locum tenens practitioner shall apply for membership on the Medical Staff in accordance with this Article II. Section 5. Training and Assessment:

16 16 of 24 Temporary privileges also may be granted to a practitioner to teach and/or proctor a procedure or treatment, to a potential applicant for Medical Staff membership during his or her site visit, or to a member of the Medical Staff to be proctored for a new procedure or treatment that he or she wishes to add. Section 6. Termination of Temporary Clinical Privileges: The CEO may, at any time and without notice, revoke temporary privileges, and the CEO shall revoke the temporary privileges of a practitioner when requested in writing to do so by the Chief of the Medical Staff. Revocation of temporary privileges shall not be subject to review by any committee of the Medical Staff or the Board, and such termination shall not be the subject of any proceedings under the Fair Hearing Plan, as supplemented and modified by the Appellate Review Policies adopted by the Board. Where appropriate or necessary, the Chief of the Medical Staff shall arrange for the continued care of patients who have been admitted by a practitioner whose temporary privileges have been terminated. ARTICLE II PART H: EMERGENCY CLINICAL PRIVILEGES In the event of a medical emergency, any member of the Medical Staff, to the degree permitted by his or her license and regardless of Medical Staff status, shall be permitted to do everything reasonably possible to save the life of a patient, using every available facility of the hospital. When such emergency situation no longer exists, such member of the Medical Staff must request the privileges necessary to continue to treat the patient. In the event such privileges are denied, or such member of the Medical Staff desires not to request such privileges, the patient shall be assigned to an appropriate member of the Medical Staff by the Chief of the Medical Staff. For the purposes of this Article II, Part H, an "emergency" is defined as a condition in which serious permanent harm or death would result to a patient and any delay in administering treatment would add to that danger. ARTICLE II PART I: DISASTER MANAGEMENT Upon the recommendation of the Chief of the Medical Staff or another member of the MEC, the CEO, or his or her designee, may grant temporary privileges to a practitioner who is volunteering in the event of a mass disaster when the emergency management plan of the hospital has been activated and the hospital is unable to meet immediate patient needs, but only after the identity of the practitioner has been verified. The minimum acceptable sources of identification for the practitioner providing emergency care include a valid license or a passport and at least one (1) of the following: a current picture hospital identification card that clearly identifies the volunteer practitioner's professional designation; a current license to practice medicine in the United States; identification indicating that the volunteer practitioner is a member of a Disaster Medical Assistance Team (DMAT), the Medical Reserve Corps (MRC), the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR- VHP), or other recognized federal or state organization or group; or (d) identification indicating that the volunteer practitioner has been granted authority to render patient care, treatment, and services in disaster circumstances (such authority having been granted by a federal, state, or municipal entity). Whenever possible, practitioners who are volunteering will be assigned by the Chief of the Medical Staff, or his/her designee, to a member of the Medical Staff for oversight of the care provided, which oversight may be done by direct observation and/or clinical record review. Such temporary privileges shall last for the duration of the disaster or for ninety (90) days, whichever occurs first. Verification of the credentials of any practitioner granted disaster privileges will begin as soon as the immediate situation is under control and will be completed within seventy-two (72) hours from the time the volunteer practitioner presents to the Hospital, if possible. If extraordinary circumstances, such as no means of communication or lack of resources, prevent the primary source verification from being completed within seventy-two (72) hours,

17 17 of 24 the CEO, or his or her designee, shall document (1) the reason for the delay, (2) evidence of a demonstrated ability on the part of the volunteer practitioner to provide adequate care, treatment and services, and (3) all attempts to rectify the situation as soon as possible. The hospital shall make a decision, based on the information obtained regarding the professional practice of the volunteer practitioner, within seventy-two (72) hours related to the continuation of the disaster privileges initially granted to such volunteer practitioner. The verification process will be the same as described in this Article II, Part G. Furthermore, notwithstanding any existing delineation of privileges or scope of authority, members of the Medical Staff, hospital employees and volunteers are authorized to take whatever steps they reasonably believe are necessary to save or preserve the life or health of patients or the public health during a mass disaster. ARTICLE II - PART J: TELEMEDICINE Telemedicine Privileges means the authorization granted to a practitioner by the Board to render a diagnosis of a patient at the hospital through the use of electronic communication or other communications technologies. The practitioner will not be a member of the Medical Staff and may not provide direct patient care. Any practitioner who wishes to be considered for Telemedicine Privileges will provide the following documentation to the CEO, or his or her designee: 1. Signed consent and release/authorization form; 2. Current Wyoming license to practice medicine; 3. Curriculum Vitae; 4. Current copy of DEA and state controlled substance certificate, if applicable; 5. Current copy of professional liability insurance coverage certificate in such minimum amount as may be required by the hospital; 6. Evidence of no exclusion from any federal health care program; 7. Evidence of medical staff appointment and clinical privileges in good standing at another TJC accredited or equivalent hospital/organization; and 8. Such additional information as may be requested by the hospital. The following verifications will be completed by the CEO, or his or her designee: 1. Query to the National Practitioner Data Bank; 2. Query to determine that the practitioner has not been excluded from any federal health care program; 3. Verification of the practitioner s medical staff status at the practitioner's primary TJC accredited or equivalent hospital/organization;

18 18 of Verification of the practitioner's medical license(s) in the practitioner s primary state and the state in which telemedicine services will be provided (when applicable); and 5. Verification of the practitioner's current DEA status, when applicable, and verification of the practitioner's current board status (when applicable). (d) The MEC will confer with the chair(s) of the applicable Medical Staff committee(s) regarding the clinical services that may be offered through telemedicine. The CEO, with input from the MEC, will determine the specific services to be provided at the hospital via telemedicine. The MEC will make a recommendation to the Board regarding whether the practitioner's request for Telemedicine Privileges should be granted. The decision of the Board will be final. (e) (f) Practitioners may be granted Telemedicine Privileges for a period not to exceed two (2) years and will be required to submit an application for reappointment prior to the expiration of his or her Telemedicine Privileges. A practitioner who has been granted Telemedicine Privileges will immediately report to the CEO the loss or suspension of any license, certificate or authorization described in Article II, Part I, Paragraph above. Such loss or suspension will result in the immediate and automatic relinquishment of any and all Telemedicine Privileges with no right to a hearing or an appeal as outlined in the Fair Hearing Plan. If telemedicine services are being provided at the hospital through a contracted group, it will be the responsibility of the contracted group to notify the CEO, or his or her designee, of any practitioner who requires Telemedicine Privileges and of any practitioner who no longer needs to maintain Telemedicine Privileges. (g) If any practitioner who has been granted Telemedicine Privileges intends to direct patient care or to provide hands-on patient care, such practitioner will be required to apply for Medical Staff membership and clinical privileges at the hospital prior to the provision of any such direct patient care. ARTICLE III ACTIONS AFFECTING MEDICAL STAFF APPOINTEES ARTICLE III - PART A: PROCEDURE FOR REAPPOINTMENT All terms, conditions, and procedures relating to initial appointment shall apply to continued appointment and clinical privileges and to reappointment. Section 1. Application: Each current appointee who is eligible to be reappointed to the Medical Staff shall be responsible for completing the reappointment application form. The reappointment application shall be furnished to the appointee by the CEO or a designee at least six (6) months prior to the expiration of the appointee's current appointment period. The

19 19 of 24 completed reappointment application shall be submitted to the CEO or a designee at least three (3) months prior to the expiration of the appointee's current appointment period. Failure to submit an application by that time may result in automatic expiration of the Member's appointment and clinical privileges at the end of the then current appointment period. Reappointment, if granted by the Board, shall be for a period of not more than two (2) years, with birth dates being used as the reappointment date. An application shall 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 shall become incomplete if the need arises for new, additional, or clarifying information anytime during the evaluation. Any application that continues to be incomplete ninety (90) calendar days after the Applicant has been notified of the additional information required shall be deemed to be withdrawn and no further action shall be taken with respect to such application. It is the responsibility of the Applicant to provide a complete application, including adequate responses from references. An incomplete application will not be processed. Section 2. Factors to be considered: Each recommendation concerning reappointment of an individual currently appointed to the Medical Staff shall be based upon such appointee's: (d) (e) (f) (g) (h) (i) (j) ethical behavior, clinical competence, and clinical judgment in the treatment of patients; attendance at Medical Staff and committee meetings, and participation in staff duties; compliance with the Bylaws, Policies, and Rules and Regulations of the Medical Staff and the hospital; behavior at the hospital, including cooperation with Medical Staff and hospital personnel as it relates to patient care, the orderly operation of this hospital, or general attitude toward patients, the hospital and its personnel; use of the hospital's facilities for patients, taking into consideration the individual's comparative utilization patterns; the applicant's ability to safely and competently exercise the clinical privileges requested and perform the duties and responsibilities of medical staff appointment, with or without an accommodation; capacity to satisfactorily treat patients as indicated by the results of the hospital's quality improvement activities or other reasonable indicators of continuing qualifications; satisfactory completion of such continuing education requirements as may be imposed by law, this hospital, or applicable accreditation agencies; current professional liability insurance status and pending malpractice challenges, including claims, lawsuits, judgments, and settlements; current licensures, including currently pending challenges to any license or registration;

20 20 of 24 (k) (l) (m) voluntary or involuntary termination of Medical Staff appointment or voluntary or involuntary limitation, reduction, or loss of clinical privileges at another hospital; relevant findings from the hospital's quality improvement activities; and other reasonable indicators of continuing qualifications. To be eligible to apply for renewal of clinical privileges, an individual must have performed sufficient procedures, treatments, or therapies in the previous appointment term to enable the MEC to assess the applicant's current clinical competence for the privileges requested. Section 3. MEC Procedure: (d) (e) (f) (g) The MEC shall review all pertinent information available, including all information provided by the Medical Staff, Risk and Quality and from hospital management, for the purpose of determining its recommendations for staff reappointment, for change in staff category, and for the granting of clinical privileges for the ensuing appointment period. As part of the process of making its recommendation, the MEC may require that an individual currently seeking reappointment to undergo a physical and/or mental examination by a physician or physicians satisfactory to the MEC either as part of the reapplication process or at anytime during the appointment period to aid it in determining whether clinical privileges should be granted or continued. The results of such examination shall be available for the MEC's consideration. Alternatively, the MEC may refer the matter in accordance with the Physician Health Policy. Failure of an individual seeking reappointment to undergo such an examination within a reasonable time after being requested to do so in writing by the MEC shall constitute a voluntary relinquishment of all clinical privileges until such time as the MEC has received the examination results and has had a reasonable opportunity to evaluate them and make a recommendation thereon. The MEC shall have the right to require the appointee to meet with the committee to discuss any aspect of the individual's reappointment application, qualifications, or clinical privileges requested. The MEC may use the expertise of any member of the medical staff or an outside consultant if additional information is required regarding the appointee's qualifications for reappointment. Upon completion of its review, the MEC shall make a recommendation regarding the appointee s application for reappointment. If the Medical Executive Committee's recommendation is to reappoint the Applicant and to grant the requested clinical privileges, it shall send its recommendation and written findings in support thereof to the Board of Directors. All recommendations to reappoint must also specifically recommend the clinical privileges to be granted, which may be qualified by any probationary or other conditions or restrictions relating to such clinical privileges. Upon receipt of a favorable recommendation from the MEC that the individual be granted reappointment and the requested clinical privileges, the Board (or its designated committee) may: (1) reappoint the individual and grant clinical privileges as recommended; or