Policy and Procedure. McMinnville Free Clinic

Transcription

1 Policy and Procedure McMinnville Free Clinic CREDENTIALING AND PRIVILEGING APPROVED: 8/27/12 LAST REVIEW DATE: 8/27/12 Policy McMinnville Free Clinic (MFC) will credential and privilege each provider according to Federal Tort Claims Act (FTCA) PIN-2004-xxx by verifying licensure, certification, education, experience, competency and/or registration of each volunteer health care professional, including, but not limited to: medical or nursing assistants (MAs, CNAs), medical social workers (MSWs), licensed practical nurses (LPNs), registered nurses (RNs), physician s assistants (PAs), nurse practitioners (NPs), physicians/chiropractors (MDs or DOs), prior to volunteer service and every two years. In addition, peer review activities will be performed at least every two years of the volunteer s service. Procedure Definitions Primary source verification: verification of an individual health care practitioner s reported qualification by the original source or an approved agent. Examples of primary source verification of credentials include direct correspondence, telephone verification, or internet verification from the original qualification source or reports from credentials verification organizations (CVOs). Secondary source verification: verification by methods not considered acceptable for primary source verification. Examples of secondary source verification of credentials include viewing the original credential, a notarized copy of the credential, or a copy of the credential (when the copy was made from an original by an authorized participant of the organization s credentialing process). Licensed independent practitioner (LIP): a physician, dentist, nurse practitioner, nurse midwife, or any other individual permitted by law and the organization to provide care and services without direction or supervision, within the scope of the individual practitioner s license and consistent with individually granted clinical privileges.

2 Procedure 1. Prior to practitioner providing patient care services and every two years during reassessment, MFC will have completed the credentialing process. MFC will provide primary source verification for licensed healthcare professionals (for example, through Oregon State Medical Board for physicians and Oregon State Board of Nursing for NPs, NMs, RNs, LPNs, and CNAs) to verify licensure to practice and/or any restrictions on licensure. 2. MFC will provide secondary source verification of government issued picture identification, DEA registration, and applicable certifications (eg. family practice certification, BLS). MFC will make and retain copies of applicable licenses and certifications, including medical & nursing licenses, board certifications, BSL & ACLS certifications, DEA registration, and other licenses, certifications, and registrations as applicable. 3. Specific to LIPs: a. During the credentialing process, MFC will primary source verification of relevant education, training, or experience. b. MFC will query the National Practitioner Data Bank regarding each volunteer LIP or have the LIP provide results of a self-query and document findings. MFC will annually review each LIP s history of prior and current FTCA malpractice claims. c. MFC will determining practitioner s health fitness or the ability to perform the requested privileges via a statement from the individual that is confirmed either by the director of a training program, chief of staff/service of a hospital where the individual has privileges, or a licensed physician designated by the organization d. The initial privileging of an LIP involves the assessment of his/her current competence in the specific scope or content of patient care services he/she is to provide at MFC. Therefore, during the initial privileging period, LIP s will be supervised by a clinician who possesses privileges in the particular procedures or management guidelines, and will document first-hand, one-on-one review of practitioner s competence in particular procedures or management guidelines. Alternatively, if the LIP has a qualified reference (a clinician possessing a degree of expertise in the particular procedures or protocols beyond the level of expertise of most new primary care providers) who can and will attest to their competence, competence can be verified by telephone by the medical director, and documented as such.

3 e. Approval authority: MFC s Board of Directors will state in writing its determination that an LIP meets credentialing and privileging requirements, based on the recommendation of the Medical Director, and the determination will be filed in the volunteer s file prior to adding the volunteer to the LIP volunteer list. f. MFC will provide each volunteer health care professional with a digital copy of PIN , and that his/her questions regarding FTCA medical malpractice coverage have been addressed. 4. Temporary privileging: MFC will strive to complete the privileging process prior to the LIP being allowed to provide patient care services. However, in order to meet important patient care needs for a limited period of time or to issue privileges for new volunteer free clinic health care professionals (no more than 60 days), temporary privileging may occur. a. To issue temporary privileges, MFC staff will provide primary verification of: i. Current licensure and that lack of any history of current or previous successful challenges to licensure ii. Relevant training and experience iii. Current competence in the specific scope or content of patient care services he/she is to provide and ability to perform the privileges requested iv. NPDB history v. Lack of any history of involuntary termination of medical staff membership at another organization vi. Lack of any history of involuntary limitations, reduction, denial, or loss of clinical privileges vii. LIP meets qualifications of all other policies and procedures of MFC b. Privileges will not be provided (and patient care is not permitted) if: i. The LIP fails to provide all information necessary for the privileging process ii. Free clinic staff fails to verify performance data and other information in a timely manner. OTHER HEALTH CARE PRACTITIONERS

4 1. Initial credentialing of other health care practitioners includes secondary verification of applicable education and training and querying the NPDB, as applicable. 2. The initial privileging of another licensed or certified practitioner involves the assessment of his/her current competence in the specific scope or content of patient care services he/she is to provide at the free clinic. MFC may assess current competency through an orientation process during which a supervisor evaluates the practitioner s clinical qualifications and performance based on his/her job description. 3. The Board of Directors will designate the Medical Director and clinic coordinators as having authority to review other licensed or certified health care practitioners and state in writing his/her determination that the licensed or certified health care practitioner meets credentialing and privileging requirements, based on MFC policies and procedures. This determination should be based on the review of credentialing information and the supervisor s evaluation of the practitioner s clinical qualifications and performance. REASSESSMENT OF CREDENTIALING AND PRIVILEGING LIPs 1. Reassessment of credentialing and privileging of LIPs and other licensed or certified health care professionals will occur every two years or whenever a question should arise as to competence of an individual. Reassessment is to include: a. Primary source verification of current licensure, registration or certification; b. Secondary source verification of: i. Adherence to the free clinic s policies, procedures and rules ii. Relevant education training and experience (if changed since initial appointment) iii. The practitioner s ability to perform the care, treatment and services he/she has been providing and will be providing in the future at the free clinic iv. Lack of any restrictions on privileges at any other health care organization c. An assessment of current competency to include:

5 i. A synopsis of peer review results from the prior 2 year period and/or any relevant performance improvement information (for LIPs); or ii. The supervisor s evaluation of performance (for other licensed or certified health care practitioners). d. Querying the NPDB, as applicable. 2. MFC will notify each LIP and other licensed or certified health care practitioner in writing of its conclusions regarding the reassessment of the practitioner s credentials and privileges. An appeal may be made by the LIP or other licensed or certified health care practitioners if the free clinic decides to discontinue or deny his/her clinical privileges. This policy has been reviewed and accepted by the McMinnville Free Clinic Board of directors on August 27, Mary Hill, RN, Secretary Jacqui Cooke, FNP, CNM, President