APPENDIX A MEDICAL STAFF CREDENTIALING POLICY

Transcription

1 APPENDIX A MEDICAL STAFF CREDENTIALING POLICY 1

2 TABLE OF CONTENTS 12/4/07 Version ARTICLE I: MEDICAL STAFF MEMBERSHIP...3 A. QUALIFICATIONS FOR MEMBERSHIP AND CLINICAL PRIVILEGES General Qualifications Effect of Prior Adverse Professional Review Action Effect of Other Affiliations Non-Discrimination Professional Liability Insurance Requirement...8 B. MEDICAL CENTER NEED Lack of Facilities/Support Services Exclusivity, Employment and Professional Services Agreements Medical Staff Development Plan Effects of Declination...10 C. RESPONSIBILITIES OF MEDICAL STAFF MEMBERSHIP...10 D. TERMS OF APPOINTMENT Initial Appointment to Be Provisional Reappointment Failure to Timely Submit Application...13 E. LEAVES OF ABSENCE Requests for Leaves of Absence Termination of Leave and Request for Reinstatement Failure to Request Reinstatement...16 F. RESIGNATION...16 ARTICLE II: PROCESS FOR APPOINTMENT AND REAPPOINTMENT...17 A. GENERAL Effect of Application for Appointment/Reappointment Immunity from Liability Burden on the Applicant Assistance with Evaluation Reapplication Following Withdrawal of Application or Final Adverse Action Conditional Appointment/Reappointment/Privileges...21 B. NEW APPOINTMENT PRE-APPLICATION PROCESS...22 C. NEW APPOINTMENT APPLICATION PROCESS New Appointment Application Form Submission of the Application Processing the Application...26 D. REAPPOINTMENT Initiation of Reappointment Process Reappointment Application Form Evaluation of Applicant for Reappointment Processing the Application...33 ARTICLE III: ALLIED HEALTH PROFESSIONALS...38 A. GENERAL Categories of Allied Health Professionals Qualifications of Allied Health Staff Responsibilities of Allied Health Staff Membership

3 4. Prerogatives of Allied Health Staff...42 B. APPOINTMENT, REAPPOINTMENT AND CLINICAL PRIVILEGES Pre-application Process Application Process Reappointment/Additional Privileges Process Term of Appointment/Privileges Temporary Privileges Leaves of Absence...43 C. PROCEDURAL RIGHTS General Initiation of Disciplinary Review Action by Medical Executive Committee Action by Board...45 ARTICLE IV: CLINICAL PRIVILEGES...46 A. EXERCISE OF CLINICAL PRIVILEGES...46 B. DELINEATION OF CLINICAL PRIVILEGES Application Admitting Privileges Requests for Additions to Clinical Privileges...46 C. BASIS FOR PRIVILEGE DETERMINATIONS General Special Conditions for Dental Privileges Special Conditions for Podiatric Privileges Special Conditions for Allied Health Professionals...48 D. SERVICE RESPONSIBILITIES FOR DEFINING PRIVILEGES...49 E. NEW, EXPERIMENTAL OR MULTI-SPECIALTY PRIVILEGES New or Multi-Specialty Privileges Experimental Procedures/Services...49 F. REQUEST FOR UNAVAILABLE PRIVILEGES...50 G. TEMPORARY PRIVILEGES General Conditions and Authority for Granting Temporary Privileges Termination of Temporary Privileges Rights of the Individual with Temporary Privileges...54 H. DISASTER PRIVILEGES...54 I. EFFECT OF EMERGENCY...56 J. TELEMEDICINE PRIVILEGES...56 K. ANCILLARY SERVICES ORDERED BY NON-PRIVILEGED PHYSICIANS...57 ARTICLE V: CORRECTIVE ACTION...59 A. CRITERIA FOR INITIATION...59 B. ALTERNATIVES TO A PROFESSIONAL REVIEW RECOMMENDATION/ ACTION...59 C. SUMMARY (PRECAUTIONARY) SUSPENSION OR RESTRICTION...60 D. INVESTIGATION...61 E. ACTION ON THE INVESTIGATION REPORT...62 F. STATUTORY RISK MANAGEMENT PROCESS...62 G. AUTOMATIC SUSPENSION OR TERMINATION...63 H. AUTOMATIC RESIGNATION

4 I. ACTIONS INVOLVING AN INDIVIDUAL WITH AN IMPAIRMENT...64 J. ACTIONS INVOLVING AN INDIVIDUAL RESPONSIBLE FOR DISRUPTIVE CONDUCT

5 ARTICLE I: MEDICAL STAFF MEMBERSHIP A. QUALIFICATIONS FOR MEMBERSHIP AND CLINICAL PRIVILEGES 1. General Only Physicians, Dentists and Podiatrists who satisfy the threshold criteria detailed in this Section or as otherwise provided in these Bylaws or Related Documents, shall be eligible for consideration for Medical Staff membership and/or the grant of clinical privileges. The Medical Center shall utilize a specialized process, approved by the Medical Executive Committee and the Board, to evaluate whether an individual seeking Medical Staff appointment, reappointment or the grant of clinical privileges satisfies these eligibility requirements. For those individuals seeking initial Medical Staff appointment and/or the grant of clinical privileges (pre-applicant), a pre-application form shall be utilized to evaluate, to the extent possible, whether the pre-applicant meets eligibility requirements. If so determined, following consideration of the pre-application, the pre-applicant shall be provided a medical staff application form. In the event it is determined during the processing of the application that the individual is not qualified for medical staff membership or the grant of clinical privileges, further processing of such application shall cease and the application shall be returned to the originator as ineligible for further consideration with written notice of such. In the event the pre-application process fails to determine the pre-applicant s eligibility for Medical Staff membership, and it is subsequently determined during the application process that the individual is not qualified for such staff membership or the grant of clinical privileges, further processing of such application shall cease and the application returned to the originator as ineligible for further consideration with written notice of such. For current Members of the Medical Staff seeking reappointment and/or a renewal of or additional privileges, a reappointment application or an additional privilege application will be utilized to evaluate whether the applicant meets eligibility requirements. The due process rights detailed in the Fair Hearing Plan are not available when, because of ineligibility, any pre-applicant s request for a medical staff application form is declined or an application form is returned to any applicant on this basis or as otherwise provided in this Policy. 2. Qualifications The following qualifications are those minimally required for Medical Staff membership and/or the grant of clinical privileges and shall be considered threshold criteria for Medical Staff membership and/or the grant of clinical privileges: a. Demonstrate proof of graduation from an accredited School of Medicine, 5

6 Dentistry or Podiatry. All Foreign medical graduates must have successfully completed the Education Commission for Foreign Medical Graduate ( ECFMG ) verification from a foreign medical school and demonstrate proof of United States citizenship or a valid visa or work permit. b. Demonstrate either recognized specialty board certification, recognized specialty board certification eligibility or that the training requisite for recognized specialty board certification has been completed in the area(s) of proposed practice and that the individual is actively pursuing recognized specialty board certification. Recognized specialty boards are those approved by the Medical Center Board of Trustees and are listed below. Current medical staff members are required to maintain specialty Board certification in which they currently practice and hold privileges from one of the following specialty Boards: American Board of Allergy and Immunology American Board of Anesthesiology American Board of Colon and Rectal Surgery American Board of Dermatology American Board of Emergency Medicine American Board of Family Practice American Board of Internal Medicine American Board of Medical Genetics American Board of Neurological Surgery American Board of Nuclear Medicine American Board of Obstetrics and Gynecology American Board of Ophthalmology American Board of Oral and Maxillofacial Surgery American Board of Orthopedic Surgery American Board of Otolaryngology American Board of Pathology American Board of Pediatrics American Board of Pedodontics American Board of Physical Medicine and Rehabilitation American Board of Podiatric Surgery American Board of Plastic Surgery American Board of Preventive Medicine American Board of Prosthodontics American Board of Psychiatry and Neurology American Board of Radiology American Board of Surgery American Board of Thoracic Surgery American Board of Urology American Osteopathic Board of Emergency Medicine American Osteopathic Board of Family Medicine American Osteopathic Board of Internal Medicine American Osteopathic Board of Obstetrics and Gynecology American Osteopathic Board of Ophthalmology and Otolaryngology 6

7 American Osteopathic Board of Orthopedic Surgery American Osteopathic Board of Pathology American Osteopathic Board of Pediatrics American Osteopathic Board of Radiology Specialty Board certification must be obtained by the end of the fifth (5 th ) year after first becoming eligible to sit for the certifying examination. Should the Medical Staff Member lose qualifications to be able to sit for the examination during the five (5) years from which he/she was appointed to the medical staff, the Member is no longer eligible for Medical Staff membership and privileges. In such case, membership and privileges would be considered automatically withdrawn upon the date it becomes known that the Medical Staff Member is no longer qualified to sit for the specialty Board certification examination. Failure to maintain certification shall result in automatic referral to the Medical Executive Committee for review of privileges and membership. Current Members of the Medical Staff who completed training prior to May 21, 1985 and are unable to demonstrate proof of recognized specialty board certification or eligibility, shall be permitted to apply for Medical Staff reappointment as appropriate, provided all other threshold qualifications for medical staff membership are demonstrated. Exceptions regarding Board certification shall be reviewed and recommended by the Medical Executive Committee and approved by the Board of Trustees. c. If the applicable specialty board eligibility requirements do not include the successful completion of a residency program within that specialty, the applicant must demonstrate proof of completion of an approved postgraduate training program. All dentist pre-applicants must have successfully completed an approved post-graduate training program. For purposes of this Section, an approved postgraduate training program for physicians is a residency program fully accredited throughout the time period of training by the Accreditation Council for Graduate Medical Education (ACGME), the American Osteopathic Association or an equivalent organization in a country for which eligibility for licensure by endorsement is available by the Kansas Board of Healing Arts. An approved post-graduate training program for podiatrists is one fully accredited throughout the time period of training by the Council on Podiatric Medicine, the American Podiatric Medical Association, a successor agency to either of the foregoing, or by an equivalent professionally recognized national accrediting body in the United States or in a country for which eligibility for licensure by endorsement is available by the Kansas Board of Healing Arts. An approved post-graduate training program for dentists is one fully accredited throughout the time period of training by the Commission on Dental Accreditation, a successor agency to either of the foregoing, or by an 7

8 equivalent professionally recognized national accrediting body in the United States or in a country for which eligibility for licensure by endorsement is available by the Kansas Board of Healing Arts. d. Demonstrate proof of an unrestricted license to practice his/her profession by the Kansas Board of Healing Arts. For purposes of this Section, an unrestricted license is one free of any of the following conditions instituted by the Kansas Board of Healing Arts: probation, suspension, or requirements of special supervision, consultation or proctoring. e. Demonstrate eligibility to participate in all federal health care programs, as defined in the Medical Staff Bylaws. Those ineligible to participate, excluded, suspended or disbarred from participation in such programs, or those convicted of a criminal offense related to the provision of health care items or services whose eligibility to participate in such program has not been reinstated are ineligible for Medical Staff membership and/or clinical privileges. f. Document one s background, education, experience, training and demonstrated current clinical competence, adherence to the ethics of one s profession, good reputation and character, current physical and mental health as such relates to the ability to safely and competently perform the requested clinical privileges with or without reasonable accommodation, and the ability to work harmoniously with peers, Medical Center employees, and others sufficiently to evidence that all patients treated at the Medical Center shall receive quality care. For current Medical Staff members, evidence of current competence, experience and judgment shall also include, but not be limited to, documentation of continuing medical education, the results of performance improvement, risk management and peer review activities, consideration of the applicant s compliance with the responsibilities of Medical Staff membership during the previous term(s) of appointment, and recommendations of the Service Chief. For current Medical Staff members, evidence of the ability to work harmoniously with others shall include, but not be limited to, a review of the applicant s conduct and compliance with the responsibilities of Medical Staff membership during the previous term(s) of appointment, and recommendations of the Service Chief. g. Document compliance with Article I, Section A.6 of this Policy regarding professional liability insurance and demonstrate proof of and agree to maintain professional liability insurance coverage in the minimum amount of $1 million per occurrence/$3 million aggregate, which includes Kansas Health Care Stabilization Fund coverage, as applicable. If not statutorily required to participate in the Kansas Health Care Stabilization Fund, the individual agrees to maintain professional liability insurance coverage in the minimum amount of $1 million per occurrence/$3 million aggregate. 8

9 h. Provide evidence of and agree to maintain a current, valid Federal Drug Enforcement Administration registration (DEA certificate) and Kansas prescribing authority for controlled substances (as appropriate to the intended scope of practice). i. For all new applicants, reappointment and additional privilege applicants, demonstrate there is no pending recommendation at another health care facility to suspend, revoke or otherwise restrict Medical Staff membership or clinical privileges, including any summary or precautionary suspension. j. Agree to participate in and properly discharge Medical Staff responsibilities and assist the Medical Staff to fulfill its obligations related to patient care within the areas of their professional competence and credentials. k. Have never been convicted of, or entered a plea of guilty or nolo contendere to, any felony under federal or state law; or convicted of, or entered a plea of guilty or nolo contendere to, any healthcare-related misdemeanor under federal or state law. 3. Effect of Prior Adverse Professional Review Action Except as otherwise determined by the Medical Executive Committee and approved by the Board in light of special circumstances, a Member who has received a final adverse professional review action or voluntarily resigned appointment/privileges during the pendency of a professional review activity, shall not be eligible to reapply for appointment or, as applicable, for those clinical privileges which were the subject of the professional review action or professional review activity for a period of three (3) years from the date of the notice of the final adverse decision or the date of the voluntary resignation. When such individual is eligible to apply, the application shall be processed as an initial appointment in accordance with Article II of this Policy. 4. Effect of Other Affiliations No individual shall be entitled to Medical Staff membership merely because s/he holds a certain degree, is licensed to practice in Kansas or any other state, is a member of any professional organization, is certified by any specialty Board, or had, or presently has, medical staff membership or clinical privileges at another health care entity. 5. Non-Discrimination The Medical Center shall not discriminate in granting appointment, reappointment and/or clinical privileges on the basis of ancestry, race, creed, national origin, gender, faith, sexual orientation, or handicap. 9

10 6. Professional Liability Insurance Requirement a. All Members of the Medical Staff who are health care providers as defined by K.S.A , as amended, shall maintain the minimum level of coverage under the Kansas Health Care Stabilization Fund. b. Members of the Medical Staff are required to maintain professional liability insurance protections to cover the term of their appointment/privileges, including tail coverage as appropriate, by an insurance company that is licensed or authorized to conduct business in Kansas. Member must be able to show proof of tail coverage upon request. c. If a Medical Staff Member changes professional liability insurance carriers for any reason or has insurance coverage limited or terminated for any reason, the Medical Staff Member shall immediately notify Medical Staff Services of such event. B. MEDICAL CENTER NEED No individual shall be appointed or reappointed to the Medical Staff or granted clinical privileges if the Medical Center is unable to provide adequate facilities and support services for the applicant or his/her patients. The Board may decline to accept and/or, through the Credentials and Medical Executive Committees, decline, to process applications and recommend applicants for Medical Staff appointment, reappointment, and/or clinical privileges based on any of the following. 1. Lack of Facilities/Support Services Clinical privileges shall be granted only for the provision of care that is consistent with the scope of services, capacity, capabilities, and business plan of the Medical Center. 2. Exclusivity, Employment and Professional Services Agreements a. General The Medical Center shall not automatically confer appointment or reappointment and/or grant clinical privileges based on an individual s inclusion or consideration for inclusion in an exclusivity, employment or professional services agreement. Instead, each individual shall be considered for appointment, reappointment and/or clinical privileges based on whether the individual meets the qualifications for Medical Staff membership and whose education, training, experience and demonstrated current competence are sufficient, in the opinion of the Board as recommended by the Medical Executive Committee, to obtain the requested clinical privileges. Once appointed, reappointed and/or granted clinical privileges, the Member who is a party to any such agreement shall comply with the Medical Staff Bylaws, Rules and Regulations, Related Documents, and the Medical Center s Corporate Compliance Plan and Policies/Procedures to maintain such 10

11 appointment, reappointment and clinical privileges. The effect of expiration or other termination of an agreement upon a Member s Medical Staff appointment, reappointment and/or clinical privileges shall be governed by the Medical Staff Bylaws and Related Documents unless the Member s agreement with the Medical Center addresses the issue, in which case the terms of the agreement shall be given full force and effect. If the agreement is silent on the matter, then expiration of the agreement or other termination alone shall not affect the Member s appointment, reappointment and/or clinical privileges, except that any Member who is a party to an expired or terminated exclusivity agreement may not thereafter exercise any clinical privileges for which exclusive contractual arrangements have been made with others. Unless the agreement provides otherwise, a Member whose employment or professional services agreement is terminated for cause related to the Member s professional competence or conduct, shall be entitled to the procedural rights afforded in the Fair Hearing Plan, as to the Member s appointment, reappointment and/or clinical privileges. A Member whose agreement expires in accordance with its terms and is not renewed is not entitled to the procedural rights provided in the Fair Hearing Plan unless the agreement provides otherwise. b. Exclusivity Agreements Pursuant to Kansas law, the Board may determine, in the interest of quality patient care, efficient hospital operations, and as a matter of policy, that certain Medical Center clinical facilities may be used only on an exclusive basis in accordance with written agreements between the Medical Center and qualified Medical Staff members. Accordingly, the Medical Center shall not accept applications for appointment, reappointment or clinical privileges which relate solely to facilities or services covered by exclusivity agreements, unless the applicant qualifies under the existing agreement. 3. Medical Staff Development Plan The Board may decline to accept applications based on requirements or limitations in the Medical Center s Medical Staff Development Plan, which shall be based on the Medical Center s identified scope of patient care needs within its service area. The Medical Staff Development Plan shall be prepared at the discretion of and by the Board with input from the Medical Staff President and the Medical Executive Committee and may limit the number of Medical Staff appointees within Services, specialties and subspecialties of the Medical Staff and/or the recipients of clinical privileges. The Medical Staff Development Plan may be based upon written criteria developed with input from the Medical Staff President, Medical Executive Committee and Service Chairs and a finding by the President/Chief Executive Officer that such action would be in the best interests of patient care. The written criteria shall consider, as appropriate, the utilization of the Medical Center and each 11

12 Service, specialty or subspecialty, the average waiting time for scheduling elective procedures, the ability to enter into and financial benefit of entering into exclusive agreements for the provision of care, and other factors deemed appropriate in evaluating the desirability or necessity of limiting the number of Medical Staff appointees within a Service, specialty or subspecialty and/or the recipients of clinical privileges. Any such limitation decision shall be approved by the Board, shall be reviewed at least every two (2) years, and may be raised, lowered or rescinded by the President/Chief Executive Officer after consultation with the applicable Section Chief and concurrence by the Medical Staff President and the Medical Executive Committee and with approval by the Board. 4. Effects of Declination Refusal to extend, accept or review an application for Medical Staff appointment, reappointment or clinical privileges shall be based on the Medical Center s identified patient care needs and ability to accommodate, as described in this Section, shall not constitute a denial of appointment, reappointment or clinical privileges, and shall not entitle the individual to any procedural rights of Fair Hearing or appeal. Any portion of the application which is accepted (e.g. requests for clinical privileges that are not subject to a limitation) shall be processed in accordance with the processes described in this Policy and the Medical Staff Bylaws. C. RESPONSIBILITIES OF MEDICAL STAFF MEMBERSHIP By submitting an application for Medical Staff appointment, reappointment or clinical privileges, the applicant agrees to fulfill the following responsibilities: 1. supplement his/her application with additional information as requested by the Medical Staff Office, Service Chief, Credentials Committee, Medical Executive Committee and/or Board of Trustees and appear for any requested interviews regarding his/her application, or, subsequent to appointment, reappointment or the grant of clinical privileges, appear for any requested interviews related to questions regarding the applicant's competence or performance; 2. provide continuous care and supervision to his/her patients at the generally recognized professional level of quality and efficiency established by the Medical Center and respond to their needs within a reasonable time period under the circumstances or as otherwise specified in these Bylaws, including this Policy, and the Rules/Regulations or other Related Documents; 3. as the attending physician, coordinate care, treatment, and services among all consultants involved in a patient s care and treatment; 4. comply with Medical Center policies related to informed consent and patient rights as more fully described in the applicable Medical Center policies and the Medical Staff Rules/Regulations; 12

13 5. delegate, in his/her absence, the responsibility for diagnosis and/or care of his/her patients only to a Member in good standing of the Medical Staff who is qualified and approved by the Medical Center to undertake this responsibility by the grant of similar clinical privileges; 6. seek consultation whenever necessary, and in accordance with the requirements of the Medical Staff Rules and Regulations and policies of the Medical Center; 7. accept and respond to consult requests in the manner and time period consistent with the Medical Staff Bylaws, Rules and Regulations, and Related Documents; 8. work cooperatively and professionally with Members, Medical Center staff, Medical Center Administration and others so as not to adversely affect the delivery of patient care; 9. refuse to engage in fee splitting or improper inducements to obtain patient referrals; 10. abide by these Bylaws, including this Policy and the Fair Hearing Plan, and the Rules/Regulations or other Related Documents, the Medical Center Corporate Compliance Plan and all other rules, policies and procedures, guidelines, and other requirements of the Medical Staff and the Medical Center; 11. regularly attend assigned Committee meetings unless excused; 12. discharge such Medical Staff, Service, Committee, and Medical Center functions for which he/she is responsible based upon appointment, election, medical staff category or otherwise, including as appropriate, providing on-call coverage for the Emergency Department within his/her clinical specialty, accepting Committee assignments, and participating in performance improvement, peer review and risk management activities; 13. participate in any necessary training regarding the electronic medical record amd document completely, timely, legibly, and accurately in medical records as specifically required by the Medical Staff Rules and Regulation, in all other documents related to care provided in the Medical Center, and to similarly comply in all verbal and written communications with Medical Center representatives and Medical Staff Committees and representatives. Dishonesty or misrepresentations in any such document, record, or communication may be a basis for termination of Medical Staff membership and privileges, or other action as provided by these Bylaws and Related Documents, or in policies and procedures as adopted by the Board from time to time; 14. refrain from transferring any patient from the Medical Center unless such transfer is in the patient s best interest or unless the patient requests such transfer and comply with applicable laws and regulations affecting such transfers. All doubts regarding patient transfers are to be resolved in favor of patient safety and welfare; 13

14 15. cooperate with the Medical Center in matters involving its fiscal responsibilities and policies, including those relating to payment or reimbursement by governmental and third party payers; 16. participate in continuing education to maintain clinical skills and current competence; 17. notify within three working days the Medical Executive Committee, through Medical Staff Services, upon a change in any qualification for membership or clinical privileges, as listed in Article I, Section A.2 of this Credentialing Policy (including but not limited to becoming ineligible to participate in federal programs); 18. upon request by the Medical Executive Committee, the Board, or the Practitioner Health Committee, submit evidence of physical and/or mental health sufficient to fulfill these responsibilities of Medical Staff membership and permit the safe performance of the clinical privileges granted to the Member; 19. promptly notify and update the Practitioner Health Committee, through the Chairman of the Practitioner Health Committee, of any change in the Member s health status which could adversely impact his/her ability to safely carry out the requested or, in the case of a Member, granted privileges; 20. appear, if requested, for personal interviews regarding any question on the application for medical staff appointment, reappointment, additional privilege or clinical privileges; 21. promptly pay any medical staff dues in accordance with the requirements of the Medical Staff Bylaws, Rules and Regulations and/or Related Documents; and 22. perform such other responsibilities as the Hospital or the Medical Staff may require. D. TERMS OF APPOINTMENT All appointments, reappointments and the grant of clinical privileges shall be made by the Board upon recommendation of the Medical Executive Committee and shall be consistent with the Medical Staff Bylaws and this Policy. 1. Initial Appointment to Be Provisional All initial appointments shall be made and all initial clinical privileges shall be granted for up to twelve (12) months from the date of Board action. Such initial privileges shall be provisional in nature. Each Member granted provisional clinical privileges shall be evaluated in an ongoing manner in accordance with these Bylaws including this Policy, the Medical Staff Rules and Regulations, and Related Documents and the Medical Center s Performance Improvement and Risk Management Plans and other applicable policies and procedures, and shall cooperate with such monitoring and evaluation activities. The patient care provided by the provisional Member shall be consistent with the privileges granted. This monitoring and evaluation shall be for the purpose of determining the provisional Member s 14

15 eligibility for advancement from provisional status. At the conclusion of the provisional term, the Member's performance shall be evaluated by the Service Chief to recommend one of the following: a. continuation of provisional status for a time period as recommended by the Credentials and Medical Executive Committees, not to exceed two years (24 months); or b. reappointment without provisional status for a time period not to exceed two years (24 months); or c. termination of appointment and/or some or all of the Member s clinical privileges. Failure to advance from provisional status after two years (24 months) for reasons related to clinical competence or professional conduct may constitute an automatic termination of medical staff membership and clinical privileges. A provisional Member so terminated shall have the procedural rights afforded to him/her as provided in the Fair Hearing Plan. 2. Reappointment Reappointments with or without the grant of clinical privileges shall be for a period not to exceed two years (24 months). 3. Failure to Timely Submit Application In the event that reappointment and/or clinical privileges have not been renewed before the lapse of the current term due to the failure of the applicant to submit completed application forms, the membership and clinical privileges of the affected Member shall be deemed voluntarily surrendered. In such event, the Member shall be so notified and advised that the submission of a new application is required if continued membership and clinical privileges are required. Voluntary surrender of membership and/or clinical privileges shall not entitle the Member to a Fair Hearing and appeal. E. LEAVES OF ABSENCE 1. Requests for Leaves of Absence A Member may request a voluntary leave of absence from the Staff by submitting a written notice to the Medical Executive Committee for leaves greater than ninety (90) days. The request must state the reason(s) for the leave and the proposed beginning and ending dates of the leave, which may not exceed a maximum term of one (1) year unless good cause is shown and an exception is granted by the Medical Executive Committee. Approval of a leave of absence shall be upon recommendation of the Medical Executive Committee subject to approval by the 15

16 Board. During the period of leave, the Member shall not exercise clinical privileges at the Medical Center, and membership prerogatives and responsibilities shall be in abeyance, except for dues and any required application fees should they become due unless waived by the Medical Executive Committee. Prior to any approval of a leave of absence, the Member shall make arrangements to complete all medical record documentation deficiencies and attend to all other outstanding obligations of Medical Staff membership which may exist. When the reason(s) for the leave of absence indicate the leave is optional, the request shall be granted at the discretion of the Medical Executive Committee based on its evaluation of the abilities of the Medical Staff to fulfill the patient care needs that may be created by the absence of the Member requesting the leave. A leave of absence shall be granted to any Member in good standing, provided all incomplete medical records and Medical Staff and Medical Center matters have been concluded and the Member has made appropriate arrangements for the care of his/her patients during the leave, acceptable to the Medical Executive Committee and the Board. Exceptions shall be allowed only in the event a Member has a physical or psychological condition which prevents him/her from completing records or concluding other Medical Staff or Medical Center matters. If during the granted leave the Member s reappointment term is due to expire, the Member shall be required to submit an application for reappointment prior to such expiration in accordance with the Medical Staff Bylaws and Article II.D of this Policy. Such reappointment application shall be processed in accordance with Article II.D of this Policy as if the Member were not on leave. However, the Member shall not be permitted to practice the renewed clinical privileges until the process for reinstatement has been completed, as described in Article I.E.2 of this Policy. A leave of absence may be granted for the following reasons: a. Medical Leave of Absence A Member may request and be granted a leave of absence for the purpose of obtaining treatment for a medical or psychological condition, disability, or impairment. If a Member is unable to request a medical leave of absence because of a physical or psychological condition, the Medical Staff President or the Member s Service Chief may submit written notice on his/her behalf and the Member so informed in writing. Reinstatement of membership status and clinical privileges shall be subject to receipt of a written report from his/her treating physician that such Member is physically or mentally capable of performing the granted privileges, with or without accommodation. If accommodation is required, the written report shall state the nature of the required accommodation. The Member shall provide other such information as may be requested by the Medical Executive Committee and may be subject to certain monitoring conditions as determined by the Medical 16

17 Executive Committee. Approval of a leave of absence shall be upon recommendation of the Medical Executive Committee subject to approval by the Board. b. Military Leave of Absence A Member may request and be granted a leave of absence to fulfill military service obligations. Reinstatement of membership status and clinical privileges may be subject to certain monitoring conditions as determined by the Medical Executive Committee. c. Educational Leave of Absence A Member may request and be granted a leave of absence to pursue additional education and training. Reinstatement of membership status and clinical privileges may be subject to certain monitoring conditions as determined by the Medical Executive Committee. d. Personal/Family Leave of Absence A Member may request and be granted a leave of absence for personal reasons (e.g., to pursue a volunteer endeavor or for family reasons). Reinstatement of membership status and clinical privileges may be subject to certain monitoring conditions as determined by the Medical Executive Committee. 2. Termination of Leave and Request for Reinstatement At least forty-five (45) days prior to the termination of the leave of absence, or at any earlier time, the Member shall request reinstatement of Medical Staff membership and clinical privileges by submitting a written notice to the President of the Medical Staff. If the leave of absence has extended past the Member s reappointment term and s/he did not submit an application for reappointment while on leave, s/he shall also be required to complete such reappointment application in accordance with the Medical Staff Bylaws and Article II.D of this Policy and the reinstatement shall be processed as a reappointment. The written request for reinstatement shall include an attestation that no changes have occurred in the Member s qualifications for membership as listed in Article I.A.2 of this Policy, a summary of all medical education activities undertaken during the leave of absence, the scope and nature of any professional practice which occurred during the leave, and any other information as may be requested by the Medical Executive Committee. If changes in the Member s qualifications have occurred, a detailed description of the nature of such changes shall be provided in the written request for reinstatement. The Member requesting reinstatement shall also demonstrate current professional licensure, registration, and/or certifications necessary to the granted privileges and current professional liability insurance coverage. Verification queries shall be conducted by the Medical Staff Office as follows: a. American Medical Association; 17

18 b. Kansas Board of Healing Arts; c. Criminal background check/facis; d. National Practitioner Data Bank; e. Drug Enforcement Agency, as applicable; f. Office of Inspector General (OIG). The request for reinstatement shall be forwarded to the Member s Service Chief for a recommendation, which shall then be forwarded to the Credentials Committee for its recommendation, followed by a recommendation of the Medical Executive Committee which shall then be submitted to the Board for its approval. An adverse decision regarding reinstatement of Medical Staff membership or renewal of any clinical privileges held prior to the leave shall entitle the Member to a Fair Hearing and appeal as provided in these Bylaws, including this Policy, and the Fair Hearing Plan. 3. Failure to Request Reinstatement F. RESIGNATION Failure, without good cause, to request reinstatement prior to termination of the leave shall be deemed a voluntary resignation from the Medical Staff. A request for Medical Staff membership subsequently received from a Member deemed to have voluntarily resigned shall be submitted and processed in the manner specified for applications for initial appointment. Resignations from the Medical Staff shall be submitted in writing to the Medical Staff Office and shall state the date the resignation becomes effective. The resignation shall be accepted as in good standing provided all incomplete medical records and any open Medical Staff and Medical Center matters have been concluded. The Member s Service Chief, the Medical Executive Committee, and the Board shall review letters of resignation and determine if such acceptance is made when possible. Once submitted, a resignation may not be withdrawn until it has been considered by the Board. If a Member requests to withdraw a resignation before the resignation is accepted by the Board, the request for withdrawal shall also be forwarded to the Board for consideration. The Board may, but is not required to, honor the request for withdrawal of the resignation. Upon acceptance of the resignation by the Board, the Member shall be notified in writing. When a Medical Staff resignation is accepted or clinical privileges are relinquished during the course of a professional review activity related to issues of clinical competency or professional conduct, a report shall be submitted to the Kansas Board of Healing Arts and the National Practitioner Data Bank, as required by law. 18

19 ARTICLE II: PROCESS FOR APPOINTMENT AND REAPPOINTMENT A. GENERAL 1. Effect of Application for Appointment/Reappointment By applying for Medical Staff appointment, reappointment and/or clinical privileges, the applicant: a. authorizes representatives of the Medical Center and/or the Medical Staff to solicit and act upon information, including otherwise privileged or confidential information provided by third parties and/or entities bearing on his/her credentials and agrees that any information so provided shall not be required to be disclosed to the applicant if the third party providing such information does so only on the condition that the information be kept confidential; b. authorizes third parties to release information to representatives of the Medical Center and/or the Medical Staff, including otherwise privileged or confidential information, as well as reports, records, statements, recommendations, and other documents in their possession bearing on the applicant s credentials, and consents to the inspection and procurement by the Medical Center of such information, records and other documents; c. authorizes the Medical Center to maintain information concerning the applicant s age, training, board certification, licensure and other confidential information in a centralized physician database for the purpose of making aggregate physician information available for use by the Medical Center; d. authorizes the Medical Center to release confidential information, including peer review and/or performance improvement information, obtained from or about the applicant to peer review committees of the Medical Staff and Medical Center for purposes of reducing mortality and morbidity and for the improvement of patient care; e. agrees to appear for a personal interview at any reasonable time regarding any information pertaining to the application, as requested by any representative of the Medical Center and/or Medical Staff; f. upon request of the applicant, authorizes representatives of the Medical Center and/or the Medical Staff to release information, including otherwise privileged or confidential information bearing on the applicant s credentials, to other healthcare entities, who solicit such information for the purpose of evaluating his/her professional qualifications pursuant to a request for appointment, reappointment or clinical privileges; g. consents to the reporting by Medical Center representatives of any information which is required by law or regulation to be reported to the 19

20 National Practitioner Data Bank, the Kansas Board of Healing Arts, or any other similar entity; h. agrees that, if any adverse decision is made with respect to the application, s/he shall follow and exhaust the administrative remedies afforded by the Medical Staff Bylaws and the Fair Hearing Plan as a prerequisite to any other action, and that s/he shall have the burden of demonstrating that s/he meets the standards for appointment or continued appointment to the Medical Staff and/or for the clinical privileges requested; i. agrees to comply with and be bound by the Medical Staff Bylaws, this Policy, Related Documents, and the Medical Center s Corporate Compliance Plan and policies/procedures; j. agrees to comply with all applicable federal, state and municipal laws/regulations and hospital accreditation standards that apply to Medical Staff Members; k. agrees that the foregoing provisions are in addition to any agreements, understandings, covenants, waivers, authorizations or releases provided by law or contained in any other application or agreement. 2. Immunity from Liability a. Immunity and Release By applying for and/or accepting appointment to the Medical Staff and/or applying for, accepting and exercising clinical privileges, the applicant extends absolute immunity to, and releases from all claims, damages and liability: (1) any and all Medical Center and Medical Staff representatives for any statement, action taken, or recommendation made by same within the scope of their duties and in compliance with the Medical Staff Bylaws, this Policy and Related Documents, including disclosures made to other healthcare entities pursuant to the Medical Staff Bylaws, this Policy and Related Documents; and (2) any third party for releasing or disclosing information, including otherwise privileged or confidential information, to any Medical Center or Medical Staff representative concerning the applicant unless such information is false the third party has direct knowledge of the falsity. b. Scope of Immunity and Release The immunity so provided by the Medical Staff Bylaws, this Policy and Related Documents shall apply to all acts, communications, reports, recommendations, or disclosures performed or made in connection to the Medical Center s activities, including but not limited to: 20

21 (1) application for appointment, reappointment and clinical privileges, including inquiries from other healthcare entities regarding the credentials of a Member; (2) periodic performance appraisals undertaken for reappointment, requests for new privileges or pursuant to the Medical Center s performance improvement and risk management activities; (3) recommendations for and corrective actions taken, including professional review actions and the investigative processes resulting in same; (4) Fair Hearings and appellate review; (5) peer review and monitoring/evaluating activities for the purposes of maintaining quality patient care and appropriate professional conduct within the Medical Center; and (6) reporting to the National Practitioner Data Bank, Kansas Board of Healing Arts, and/or other similar entities as may be required by law or regulation. 3. Burden on the Applicant An applicant for Medical Staff appointment, reappointment and/or clinical privileges shall be responsible for producing adequate, accurate information to properly evaluate his/her experience, background, training, demonstrated competence, character, physical/mental health status and/or any other criteria or qualification specified in the Medical Staff Bylaws or this Policy, as determined by the Service Chief (or designee), Credentials Committee, Medical Executive Committee, or Board to resolve any doubts or conflicts regarding the application, and/or to clarify information as requested. An application for appointment, reappointment and/or clinical privileges shall not be considered a complete application until all requested information and documentation is provided, and an application may be deemed incomplete at any stage of the credentialing process if additional information is deemed necessary to effect a complete and adequate evaluation of the applicant. The applicable Service Chief, Credentials Committee, Medical Executive Committee and/or the Board may request an applicant appear for an informal interview regarding the application. Medical Staff Services shall provide written notice to the applicant of the information and/or interview request, the specific information requested and/or to be discussed, and the timeframe within which a response from the applicant is required. Failure by an applicant to appear for an interview or produce all additional requested information within thirty (30) days of the applicant s receipt of the written request to appear, the applicant will be deemed 21

22 to have voluntarily withdrawn his/her application. The applicant shall be notified by certified mail, return receipt requested that his/her application is barred from further processing and is considered withdrawn. Thereafter, if the applicant desires appointment, reappointment or clinical privileges, s/he shall be required to submit a new application for same. The new application shall not be processed unless all previously requested information is provided by the applicant. Any material misrepresentation of information by an applicant during the application process, either by commission or omission, shall render the application for appointment, reappointment and/or clinical privileges ineligible for further processing. When it appears at any stage of the application process that an applicant seeking initial appointment and/or clinical privileges has provided inaccurate information which may constitute an intentional material misrepresentation, processing of the application shall cease until the applicant is informally interviewed by the Credentials Committee. Such interview shall be conducted informally and the affected applicant shall be allowed to present information, but shall have no right to call witnesses unless specifically granted by the Credentials Committee in its sole discretion, or be represented by legal counsel. If, following such interview the Credentials Committee confirms an intentional material misrepresentation was made, the application shall be considered voluntarily withdrawn and the applicant shall not be eligible to reapply for appointment/clinical privileges at the Medical Center for three years from the date of the voluntary withdrawal. Such voluntary withdrawal and ineligibility shall not trigger Fair Hearing rights. The applicant shall be provided written notification of such by certified mail, return receipt requested. When it appears at any stage of the application process that an applicant seeking reappointment and/or clinical privileges has provided inaccurate information which may constitute an intentional material misrepresentation, processing of the application shall cease until the applicant is informally interviewed by the Credentials Committee. Such interview shall be conducted informally and the affected applicant shall be allowed to present information, but shall have no right to call witnesses or be represented by legal counsel unless specifically granted by the Credentials Committee in its sole discretion. If, following such interview the Credentials Committee confirms an intentional material misrepresentation was made, such conduct shall constitute an automatic resignation from the Medical Staff and the application deemed to be voluntarily withdrawn. In such instance, the applicant shall not be eligible to reapply for appointment/clinical privileges at the Medical Center for three years from the date of the automatic resignation. Such automatic resignation, voluntary withdrawal and ineligibility shall not trigger Fair Hearing rights. The applicant shall be provided written notification of such by certified mail, return receipt requested. 4. Assistance with Evaluation The Service Chief, the Credentials Committee, the Medical Executive Committee or the Board, as part of the review and evaluation of applications for Medical Staff 22

23 membership and/or clinical privileges, or the ongoing review/evaluation of performance of Members or those holding clinical privileges, may as part of those responsibilities: a. obtain the assistance of any independent consultant, including to interview the applicant/member under evaluation and/or participate in peer review activities; b. consider the results of performance improvement activities or outcomes data from other hospitals or health care entities regarding the applicant/member under evaluation; c. subject to appropriate protection of patient confidentiality, require the applicant/member under evaluation to produce copies medical records of patients treated by him/her from other health care settings other than the Medical Center for review/evaluation of the care provided; and/or d. require detailed statements, data and information concerning matters that may impact the qualifications, professional competence or conduct of the applicant/member under evaluation, including threatened pending legal or administrative proceedings. 5. Reapplication Following Withdrawal of Application or Final Adverse Action An applicant who has received a final adverse decision regarding, or who has withdrawn an application for appointment, reappointment or clinical privileges to avoid a possible adverse action, is ineligible to reapply, as applicable, for appointment, reappointment or clinical privileges for a period of at least three (3) years. Any re-application following this time period shall be processed as an initial application and the applicant must submit additional information, as may be required by the Service Chief, Credentials Committee, Medical Executive Committee and/or the Board, to satisfactorily demonstrate that the basis for any earlier adverse action or application withdrawal has been resolved. If the additional information submitted does not satisfactorily resolve the basis for the earlier adverse action or application withdrawal, or if it appears the new application is based on substantially the same information as when previously denied or withdrawn, then the application shall be deemed incomplete and not processed. The applicant shall be notified of such in writing by certified mail, return receipt requested. No hearing or appeals rights shall be available in this event. 6. Conditional Appointment/Reappointment/Privileges In lieu of recommending a professional review action, the Credentials and/or Medical Executive Committee may recommend appointment, reappointment and/or the grant of clinical privileges contingent upon the applicant s voluntary agreement to comply with certain conditions. Such conditions may be imposed due to professional conduct or clinical competence concerns. The applicant shall execute a document agreeing to such conditions as recommended by the Medical Executive 23

24 Committee, which shall accompany the Medical Executive Committee s recommendation to the Board regarding the applicant s appointment, reappointment and/or clinical privileges. The Board shall have final authority regarding such appointment, reappointment and/or the grant of clinical privileges subject to the conditions recommended by the Medical Executive Committee. The applicant s voluntary execution of the document detailing such conditions shall not entitle him/her to the procedural entitlements described in the Fair Hearing Plan and the imposition of such conditions shall not cause a report to the National Practitioner Data Bank. B. NEW APPOINTMENT PRE-APPLICATION PROCESS 1. An individual requesting initial Medical Staff membership and/or clinical privileges shall be initially provided a pre-application form to evaluate whether the preapplicant is eligible for Medical Staff membership and the grant of clinical privileges in the general area in which the pre-applicant seeks privileges. 2. The pre-application form must be completed in its entirety before it shall be processed. Failure by the pre-applicant to provide all requested and/or supplemental information within thirty (30) days of a request for such information shall render the pre-application voluntarily withdrawn by the pre-applicant. 3. If a completed pre-application form is returned to the Medical Staff Office, the following verification queries shall be conducted, at a minimum: a. American Medical Association; b. Kansas Board of Healing Arts; c. Criminal background check; d. OIG sanction report; e. National Practitioner Data Bank (NPDB); f. ECFMG confirmation (if foreign medical school graduate); g. Drug Enforcement Agency, if applicable. The submitted pre-application form, responses to all requested information, and the results of all verification queries shall be reviewed by a representative of Medical Staff Services, in consultation with the applicable Service Chief, Credentials Committee Chairperson and/or Medical Staff President (or designee), as necessary, to determine eligibility for Medical Staff membership and clinical privileges. Evaluation of the pre-application shall consider whether the pre-applicant meets the threshold eligibility criteria for Medical Staff appointment and whether the Medical Center has a need for the type of services the pre-applicant proposes to perform and has available the appropriate facilities and support personnel. Pre-applicants who are determined ineligible for Medical Staff membership shall be so notified by certified mail, return receipt requested and an application for membership shall not be provided. Eligible pre-applicants shall be provided an application for Medical Staff appointment/clinical privileges, which shall be a form approved by the Medical Executive Committee upon recommendation of the 24

25 Credentials Committee. A copy of the Medical Staff Bylaws, this Policy, the Medical Center s Corporate Compliance Plan and selected Medical Center policies/procedures shall be provided with the application form. C. NEW APPOINTMENT APPLICATION PROCESS 1. New Appointment Application Form An application for Medical Staff appointment and/or clinical privileges shall only be provided to those individuals who, through the pre-application process, demonstrate threshold eligibility for appointment/privileges in according with the Medical Staff Bylaws, this Policy and Related Documents. Further, only those applicants for appointment and/or clinical privileges who indicate an intention to utilize the Medical Center as required by the Medical Staff category to which membership is desired and who agree to abide by the conditions of membership, the Medical Staff Bylaws, this Policy, Related Documents and the policies/procedures of the Medical Center shall be considered for appointment/privileges. Individuals who indicate an intention to apply for clinical privileges that are subject to an exclusive contract or who would belong to a Service in which the Medical Center is not accepting applications or for which privileges are otherwise unavailable shall not be eligible to apply for such privileges. The application form shall contain a request for the specific clinical privileges sought, shall be signed by the applicant, notarized, and shall require detailed information to be verified from primary sources, including the following, in addition to the responses to queries obtained during the pre-application process: a. identifying and demographic information regarding the applicant including the applicant s Medicare Provider UPIN and the geographic location of the applicant s residence and office(s), which may be supplied on a current curriculum vitae; b. the names and addresses of at least four peers of the applicant, who have had significant recent experience observing and working with the applicant, and who can provide adequate, reliable, non-confidential information pertaining to the applicant s clinical experience and ability, ethical character, ability to work with others and other qualifications for Medical Staff appointment, or as otherwise provided on the privilege application form; c. a list of the applicant s past and present hospital or other health care entity affiliations at which the applicant has worked or trained and the scope of clinical privileges granted by such entities (if the number of the applicant s institutional affiliations is great or if a number of years have passed since the applicant s affiliation, the Credentials Committee, Medical Executive Committee and Board may take into consideration the applicant s good faith effort to supply this information); 25

26 d. if the applicant is a foreign medical school graduate, a good faith effort shall be made to verify the applicant s education and training through primary sources, in accordance with Medical Staff Services policy and practices; e. a complete chronological listing of the applicant s educational history from high school graduation forward, including a request for copies of recent continuing education certificates, professional and educational appointments, employment history, and/or other professional positions held; f. if the applicant is/has been a member of the armed forces, a good faith effort shall be made to verify such participation through primary sources, in accordance with Medical Staff Services policy and practices; g. information regarding the applicant s professional liability insurance carrier(s) during the most recent twenty-four (24) month period, the amount of such coverage, whether the applicant has ever had professional liability coverage refused, limited or cancelled, and whether such insurance coverage extends to the clinical privileges the applicant seeks to exercise at the Medical Center; h. information regarding the applicant s malpractice claims history and experience and involvement in professional liability actions (including claims and settlements), pursuant to the applicant s consent to the release of information by his/her present and any past professional liability insurance carriers and a waiver of any related privilege; i. information as to whether the applicant s medical staff membership or clinical privileges have ever been voluntarily or involuntarily relinquished, denied, revoked, reduced, suspended, subjected to probationary conditions, reduced or not renewed by any other hospital or health care entity, and whether any proceeding is pending or has been instituted which, if decided adversely to the applicant would result in any of the foregoing; j. information as to whether the applicant has ever withdrawn his/her application for medical staff appointment, reappointment, or employment, or resigned from any hospital medical staff, group medical practice, managed care plan or association, ambulatory surgery facility, or any other type of health care entity; k. information as to whether the applicant s membership in any local, state or national professional society has ever been voluntarily or involuntarily relinquished, suspended, modified, denied, terminated, restricted, or is currently being challenged; l. information as to whether the applicant s license to practice his/her profession in any state, or Drug Enforcement Administration (DEA) registration, is or has ever been voluntarily or involuntarily relinquished, suspended, modified, terminated, restricted, or is currently being challenged; 26

27 m. an attestation by the applicant that his/her health status is such that s/he is able to perform all the requested privileges, with or without reasonable accommodation, according to accepted standards of professional practice; n. completion of a health questionnaire and attestation that the applicant s immunization status is current for various diseases as delineated in the Medical Staff Rules/Regulations and/or Medical Center policies/procedures (such health related information shall remain sealed and segregated from the application and shall not be considered until after a recommendation for appointment/clinical privileges has been made by the Medical Executive Committee); o. information as to whether the applicant has ever been convicted of a felony under any state or federal law and/or any misdemeanor for a health law related crime, with details regarding such conviction(s); p. if applicable, information regarding the applicant s foreign citizenship and United State s visa status; r. documentation of all the applicant s current licenses to practice, as well as DEA registration, medical/dental/podiatric school diploma, and certificates from all completed post-graduate training programs; s. information concerning the applicant s involvement in any professional misconduct of license discipline proceedings in this state or any other state, which may be closed or still pending; t. information concerning the suspension or termination of the applicant, for any period of time, to participate in Medicare, Medicaid, or any other government - sponsored program or any private or public medical insurance program, and information as to whether the applicant is currently under investigation; u. submission of the applicant s statement pledging to provide or arrange for the provision of continuous care for his/her patients if granted staff appointment and/or clinical privileges and the identity of a Member in the same specialty with substantially the same privileges as requested by the applicant who has granted permission to provide alternate coverage for the applicant; v. execution by the applicant of the following: (1) a release form permitting the disclosure of professional practice or outcomes data regarding the applicant to be directed to healthcare entities that currently privilege the applicant; (2) a release and immunity from liability form; (3) disclosure and conflict of interest forms; 27

28 (4) as a condition of consideration for initial and continued appointment, an attestation for the applicant to provide to Medical Staff Services, with or without request, any new or updated information that is pertinent to the applicant s professional qualifications or any question on the application form, including but not limited to any change in licensure, professional liability insurance or DEA status; any change in Federal Health Program participation, or any exclusions or sanctions imposed or recommended by a federal or state agency; and/or the receipt of a Quality Improvement Organization sanction; and (5) an acknowledgement that the applicant has received and read the Medical Staff Bylaws, Credentialing Policy, Fair Hearing Plan, Medical Staff Rules/Regulations, and Medical Center Corporate Compliance and Risk Management Plans and, if granted appointment, reappointment and/or clinical privileges agrees to comply with and be bound by the terms of such documents and, whether or not granted appointment and/or clinical privileges, agrees to be bound by the terms thereof in all matters related to consideration of the application: w. completion of specialized form specifically requesting the clinical privileges sought by the applicant; and x. other information as may be required by the Service Chief, Credentials Committee, Medical Executive Committee and/or the Board. 2. Submission of the Application The notarized application for Medical Staff appointment and/or clinical privileges shall be submitted to the Medical Staff Office accompanied by payment of any required application processing fee. An applicant must also provide with the application a current photograph and state or federal photo identification. 3. Processing the Application a. Verification of Information Medical Staff Services shall attempt to expeditiously verify the information submitted by the applicant by confirmation with primary sources in good faith and to the extent possible, in accordance with Medical Staff Office policies/procedures. The date the applicant signed the application and the date of the query findings from the American Medical Association, Kansas Board of Healing Arts, criminal background check, OIG, National Practitioner Data Bank, Drug Enforcement Agency, as applicable and ECFMG (if foreign medical graduate) shall be current within six (6) months at the time the application is reviewed by the Credentials Committee. If this six month time period is exceeded, the applicant shall be required to submit a new application and verification queries shall be repeated. 28

29 Medical Staff Services shall promptly notify the applicant by registered mail, return receipt requested, of any problems/delays in the data collection/verification efforts and the applicant shall bear the burden to assist with the data collection, as requested. If the applicant does not respond to such request for assistance within thirty (30) days of such request, the application shall be considered voluntarily withdrawn in accordance with Article III.A.3 of this Policy and the applicant so notified. b. Service Chief Procedure No later than thirty (30) days from completion of the application verification process, Medical Staff Services shall transmit the application and all supporting information to the Service Chief (or designee) of the Service in which the applicant seeks privileges when the former reasonably believes all necessary information to process the application has been supplied and such information verified. The Service Chief (or designee) shall review the applicant s credentials and requested privileges and determine if additional information is required of the applicant in order to adequately evaluate the applicant s credentials. The Service Chief (or designee) may require a meeting with the applicant to accomplish this evaluation and continue the application processing. If additional information and/or a meeting is required, the applicant shall be notified and shall bear the burden of meeting with the Service Chief (or designee) and/or producing the additional information in accordance with Article II.A.3 of this Policy. Until such information is supplied, that aspect of the appointment application or request for clinical privileges shall be deemed incomplete. Following receipt of any further requested information, the Service Chief (or designee) shall issue a written recommendation regarding whether the applicant has established and satisfied all of the necessary qualifications for membership and for the clinical privileges sought, and the basis for such recommendation. The Service Chief s (or designee s) recommendation shall be transmitted to the Credentials Committee. c. Credentials Committee Procedure The Credentials Committee shall examine the submitted application and all supporting documentation regarding the applicant s character, education and training, current clinical competence, qualifications, ethical standing and other criteria, and shall determine, based on references provided by the applicant, the recommendation of the Service Chief, and from other sources available to the Committee, whether the applicant has established and satisfied all of the necessary criteria for membership and the requested clinical privileges. The Credentials Committee shall prepare a written recommendation for the Medical Executive Committee regarding appointment, staff category, assigned Service, and clinical privileges to be granted (with the imposition of any special conditions, as indicated). In the event the recommendation is adverse to the applicant, the Credentials Committee shall state the supporting reasons. To the extent reasonably 29

30 possible, the timeframe for completion of the Credentials Committee activity on the application shall be at the next regularly scheduled meeting of the Committee following receipt of the Service Chief recommendation. The Credentials Committee may require a meeting with the applicant to discuss any aspect of the application. If additional information and/or a meeting is required, the applicant shall be notified and shall bear the burden of appearing before the Committee and/or producing the additional information or in accordance with Article II.A.3 of this Policy. Until such information is supplied, that aspect of the appointment application or request for clinical privileges shall be deemed incomplete. d. Medical Executive Committee Procedure The Medical Executive Committee shall receive from the Credentials Committee and review the application, supporting materials the recommendations of the Service Chief and Credentials Committee, and any such other available information as may be relevant to the applicant s qualifications. The Medical Executive Committee shall prepare a written recommendation for the Board regarding appointment, staff category, assigned Service, and clinical privileges to be granted (with the imposition of any special conditions, as indicated). In the event the recommendation is adverse to the applicant, the Medical Executive Committee shall state the supporting reasons. To the extent reasonably possible, the timeframe for completion of the Medical Executive Committee activity on the application shall be at the next regularly scheduled meeting of the Committee following receipt of the Credentials Committee recommendation. The Medical Executive Committee may require a meeting with the applicant to discuss any aspect of the application. If additional information and/or a meeting is required, the applicant shall be notified and shall bear the burden of appearing before the Committee and/or producing the additional information or in accordance with Article II.A.3 of this Policy. Until such information is supplied, that aspect of the appointment application or request for clinical privileges shall be deemed incomplete. A favorable recommendation by the Medical Executive Committee regarding appointment/clinical privileges shall be contingent upon review and ascertainment that the applicant s health status is such that s/he is able to perform the procedures for which s/he has requested privileges, with or without accommodation, according to accepted standards of professional practice, as attested to by the applicant on the application form. Following a recommendation by the Medical Executive Committee to appoint and/or grant clinical privileges, the Chair of the Practitioner Health Committee or the Medical Staff President shall review the Health Questionnaire completed by the applicant prior to any action by the Board. If information is contained therein suggesting the applicant may have a health impairment which might reasonably prevent the applicant from 30

31 performing the requested privileges according to accepted standards of professional practice, the application shall not be forwarded to the Board for action. Instead, the application shall be referred to the Practitioner Health Committee which shall evaluate the issue in accordance with the process described in the Medical Staff policy titled Practitioner Health Policy, and make a recommendation to the Medical Executive Committee. Following such evaluation and recommendation by the Practitioner Health Committee, the Medical Executive Committee shall reconsider the request for appointment and/or clinical privileges in light of this new information before making a recommendation to the Board. Such recommendation and subsequent Board action shall be in accordance with Article II, Section C.3.d.(1) and Article II, Section C.3.e of this Policy. As may be deemed appropriate by the Practitioner Health Committee or the Medical Executive Committee, a recommendation to the Board for appointment, reappointment and/or clinical privileges may be made contingent upon the applicant's agreement to monitoring if a pre-existing health problem warrants such monitoring. (1) Effect of Medical Executive Committee Recommendation (a) (b) (c) Deferral The Medical Executive Committee may defer making a recommendation regarding an application where the deferral is not solely for the purpose of causing a delay. A decision to defer further consideration of the application shall state the reasons for deferral, provide direction for further investigation, and state time limits for such further investigation. As soon as practical after the deferral, a favorable or adverse recommendation regarding the application shall be made. The Medical Executive Committee may delegate the responsibility for further consideration to the Credentials Committee or Service Chief as appropriate. Favorable Recommendation When the recommendation of the Medical Executive Committee is favorable to the applicant, the application shall be promptly forwarded to the Board for action at the Board s next regularly scheduled meeting. Adverse Recommendation If the recommendation of the Medical Executive Committee is adverse to the applicant, the applicant shall be notified in writing of such by the Medical Staff President, delivered by certified mail, return receipt requested. Such notice shall contain the information prescribed in Article I, Section B of the Fair Hearing Plan. No such adverse recommendation shall require forwarding to the Board until after the applicant has 31

32 waived or exercised his/her rights under the Fair Hearing Plan. e. Action by the Board Unless subject to the provisions of the hearing and appeals provisions of the Fair Hearing Plan, the Board shall act on the application at its next regularly scheduled meeting following receipt of the recommendation from the Medical Executive Committee. If the Board adopts the recommendation of the Medical Executive Committee, it shall become the final action of the Board. If the Board does not adopt the recommendation of the Medical Executive Committee, the Board may either refer the matter back to the Medical Executive Committee with instructions for further review/evaluation and a timeframe for responding back to the Board or the Board may take action on its own initiative. The Board may take action on its own initiative using the same type of criteria considered by the Medical Executive Committee but only after informing the Medical Executive Committee of its intent and allowing a reasonable period of time for response by the Medical Executive Committee. If the Board refers the matter back to the Medical Executive Committee, the Medical Executive Committee shall review the matter as instructed by the Board and shall forward its subsequent recommendation to the Board. If the Board then adopts the recommendation of the Medical Executive Committee, it shall become the final action of the Board. All decisions to appoint shall include a delineation of clinical privileges, the assignment of Staff category and Service affiliation, noting any applicable conditions placed on the appointment or grant of clinical privileges. The applicant shall be provided written notification of such action. f. Time Guidelines for Acting All individuals and groups required to act on an application for appointment/clinical privileges deemed to be complete shall do so in good faith and, except for good cause, complete their actions within the following time frames: Medical Staff Services.. 60 days Service Chief...30 days Credentials Committee... Next regular meeting Medical Executive Committee... Next regular meeting Board Next regular meeting These timeframes are considered guidelines only and do not create any right for an applicant to have an application processed within these precise periods of time; provided, that this provision shall not apply if the Fair Hearing Plan is triggered by an adverse recommendation or action, when is such case the time requirements set forth in the Fair Hearing Plan shall govern the 32

33 D. REAPPOINTMENT continued processing of the application. 1. Initiation of Reappointment Process At least one hundred sixty (160) days prior to the date of expiration of an individual s appointment and/or clinical privileges, Medical Staff Services shall inform the individual of the pending expiration date and provide a reappointment application form. No later than one hundred twenty (120) days prior to the expiration date, the applicant for reappointment shall submit a completed reappointment application to Medical Staff Services. 2. Reappointment Application Form The application for reappointment shall be made on a specialized form approved by the Credentials Committee and shall be substantially similar to the application for appointment described in Article II, Section C.1 of this Policy. The reappointment form shall require the applicant to specifically request the clinical privileges s/he is seeking for the pending reappointment term; however, additional clinical privileges may be requested at any time. 3. Evaluation of Applicant for Reappointment a. General An applicant for reappointment to the Medical Staff and/or the renewal/addition of clinical privileges shall be evaluated regarding his/her professional competence and clinical judgment in the treatment of patients since last appointed to the Medical Staff; recommendations from peers specifically addressing current competence; references and other data, as applicable, from other hospitals and healthcare entities with which the applicant is affiliated, including the voluntary or involuntary termination of Medical Staff membership or the voluntary or involuntary limitation, reduction or loss of clinical privileges at such other facilities; continued physical and mental health sufficient to perform the procedures for which clinical privileges are sought, maintenance of professional liability insurance coverage in compliance with the Medical Staff Bylaws and this Policy; the applicant s professional conduct since his/her last reappointment; his/her participation in continuing education; the applicant s clinical activity at the Medical Center since last appointed to the Medical Staff; maintenance of specialty Board Certification or re-certification; compliance with the Medical Staff Bylaws, Rules/Regulations, this Policy, Related Documents and the Medical Center s Corporate Compliance and Risk Management Plans and applicable policies/procedures since last appointed to the Medical Staff; the applicant s pledge to provide continuous care for his patients; other information obtained through performance profiling activities, as described below, including but not limited to the applicant s malpractice claims history and resource utilization activities at 33

34 the Medical Center since last appointed to the Medical Staff; ability to work cooperatively with peers, Medical Center employees and the Board; general character of the applicant s relationships with patients and the Medical Center; and other criteria as appropriate to evaluate the applicant s clinical competency and professional conduct. b. Performance Profiling Performance profiling shall occur in an ongoing matter and the data evaluated as part of the reappointment process and on a periodic basis during the term of appointment, as appropriate. The data measurements and profiling established by the Medical Staff shall include clinical and other indicators directly attributable to quality and patient outcomes. Measures and their resultant analysis and performance improvement activities shall be managed within the established peer review and performance improvement Committees of the Medical Staff. Applicant-specific information from performance improvement activities shall be considered and compared to aggregate information when these measures are appropriate for comparative purposes in evaluating the applicant's professional performance, judgment, clinical and/or technical skills. Any results of peer review regarding the individual's clinical performance shall also be included. Epidemiological and statistical methods may be utilized to compare individual practice patterns on dimensions of cost, service use, or quality (including process and outcome) of care, and may consider resource consumption and quality of care by an individual through an examination of patterns of health care delivery. Performance profiles, including the results of performance-based measures such as patterns of treatment, health care outcomes, and patient satisfaction shall be taken into account in evaluating the applicant for reappointment. The data, measures and profiles may include, but are not limited to, clinical and other information regarding each applicant's: (1) quality and appropriateness of patient care, including patient care outcomes; (2) utilization of Medical Center resources and facilities; (3) timely, legible, accurate and clinically pertinent medical record documentation; (4) attendance and participation in Medical Staff Committee and Service meetings, as appropriate; (5) attainment/maintenance of specialty Board certification and recertification; (6) attainment of continuing education requirements; 34

35 (7) patient satisfaction feedback; (8) monitoring and evaluation results of indicators established by the Joint Commission, the Medical Staff, or the Medical Center; (9) attribution to sentinel events, medical errors or other risk occurrences; and, (10) the number of the applicant s patient encounters within the Medical Center. 4. Processing the Application a. Verification of Information Medical Staff Services shall attempt to expeditiously verify the information submitted by the applicant by confirmation with primary sources in good faith and to the extent possible, in accordance with Medical Staff Office policies/procedures. The date the applicant signed the application and the date of the query findings from the American Medical Association, Kansas Board of Healing Arts, criminal background check, OIG, National Practitioner Data Bank, Drug Enforcement Agency as applicable, and ECFMG (if foreign medical graduate) shall be current within six (6) months at the time the application is reviewed by the Credentials Committee. If this six-month time period is exceeded, the applicant shall be required to submit a new application and verification queries shall be repeated. In such event, the applicant s current appointment term and/or grant of clinical privileges may expire before the application is processed through the Board. The applicant shall not be permitted to exercise privileges at the Medical Center until the reappointment and/or grant of clinical privileges is made final by Board action. Medical Staff Services shall promptly notify the applicant by registered mail, return receipt requested, of any problems/delays in the data collection/verification efforts and the applicant shall bear the burden to assist with the data collection, as requested. If the applicant does not respond to such request for assistance within thirty (30) days of such request, the application shall be considered voluntarily withdrawn in accordance with Article II.A.3 of this Policy and the applicant so notified. b. Service Chief Procedure No later than thirty (30) days from completion of the application verification process, Medical Staff Services shall transmit the verified reappointment application and/or request for clinical privileges along with all supporting information to the Service Chief (or designee) of the Service in which the applicant seeks reappointment/privileges. The Service Chief (or designee) shall review the applicant s credentials and requested privileges and determine if additional information is required of the applicant in order to adequately evaluate the applicant s credentials. The Service Chief (or 35

36 designee) may require a meeting with the applicant to accomplish this evaluation and continue the application processing. If additional information and/or a meeting is required, the applicant shall be notified and shall bear the burden of meeting with the Service Chief (or designee) and/or producing the additional information in accordance with Article II.A.3 of this Policy. Until such information is supplied, that aspect of the appointment application or request for clinical privileges shall be deemed incomplete. Following receipt of any further requested information, the Service Chief (or designee) shall issue a written recommendation regarding whether the applicant has established and satisfied all of the necessary qualifications for reappointment and for the clinical privileges sought, and the basis for such recommendation. The Service Chief s (or designee s) recommendation shall be transmitted to the Credentials Committee. c. Credentials Committee Procedure The Credentials Committee shall examine the submitted application for reappointment and/or clinical privileges and all supporting documentation regarding the applicant s character, education and training, current clinical competence, qualifications, ethical standing and other criteria, and shall determine, based on references provided by the applicant, the recommendation of the Service Chief, and from other sources available to the Committee, whether the applicant has established and satisfied all of the necessary criteria for membership and the requested clinical privileges. The Credentials Committee shall prepare a written recommendation for the Medical Executive Committee regarding appointment, staff category, assigned Service, and clinical privileges to be granted (with the imposition of any special conditions, as indicated). In the event the recommendation is adverse to the applicant, the Credentials Committee shall state the supporting reasons. To the extent reasonably possible, the timeframe for completion of the Credentials Committee activity on the application shall be at the next regularly scheduled meeting of the Committee following receipt of the Service Chief recommendation. The Credentials Committee may require a meeting with the applicant to discuss any aspect of the application. If additional information and/or a meeting is required, the applicant shall be notified and shall bear the burden of appearing before the Committee and/or producing the additional information in accordance with Article II.A.3 of this Policy. Until such information is supplied, that aspect of the appointment application or request for clinical privileges shall be deemed incomplete. d. Medical Executive Committee Procedure The Medical Executive Committee shall receive from the Credentials Committee and review the reappointment application and/or request for clinical privileges, supporting materials, the recommendations of the Service Chief and Credentials Committee, and any such other available information as may be relevant to the applicant s qualifications. The Medical Executive 36

37 Committee shall prepare a written recommendation for the Board regarding appointment, staff category, assigned Service, and clinical privileges to be granted (with the imposition of any special conditions, as indicated). In the event the recommendation is adverse to the applicant, the Medical Executive Committee shall state the supporting reasons. To the extent reasonably possible, the timeframe for completion of the Medical Executive Committee activity on the application shall be at the next regularly scheduled meeting of the Committee following receipt of the Credentials Committee recommendation. The Medical Executive Committee may require a meeting with the applicant to discuss any aspect of the application. If additional information and/or a meeting is required, the applicant shall be notified and shall bear the burden of appearing before the Committee and/or producing the additional information in accordance with Article II.A.3 of this Policy. Until such information is supplied, that aspect of the appointment application or request for clinical privileges shall be deemed incomplete. A favorable recommendation by the Medical Executive Committee regarding appointment/clinical privileges shall be contingent upon review and ascertainment that the applicant s health status is such that s/he is able to perform the procedures for which s/he has requested privileges, with or without accommodation, according to accepted standards of professional practice, as attested to by the applicant on the application form. Following a recommendation by the Medical Executive Committee to reappoint and/or grant clinical privileges, the Chair of the Practitioner Health Committee or the Medical Staff President shall review the Health Questionnaire completed by the applicant prior to any action by the Board. If information is contained therein suggesting the applicant may have a health impairment which might reasonably prevent the applicant from performing the requested privileges according to accepted standards of professional practice, the application shall not be forwarded to the Board for action. Instead, the application shall be referred to the Practitioner Health Committee which shall evaluate the issue in accordance with the process described in the Medical Staff policy titled Practitioner Health Policy, and make a recommendation to the Medical Executive Committee. Following such evaluation and recommendation by the Practitioner Health Committee, the Medical Executive Committee shall reconsider the request for reappointment and/or clinical privileges in light of this new information before making a recommendation to the Board. Such recommendation and subsequent Board action shall be in accordance with Article II, Section D.3.d.(1) and Article II, Section D.3.e of this Policy. As may be deemed appropriate by the Practitioner Health Committee or the Medical Executive Committee, a recommendation to the Board for appointment, reappointment and/or clinical privileges may be made contingent upon the applicant's agreement to monitoring if a pre-existing health problem warrants such 37

38 monitoring. (1) Effect of Medical Executive Committee Recommendation (a) (b) (c) Deferral The Medical Executive Committee may defer making a recommendation regarding an application where the deferral is not solely for the purpose of causing a delay. A decision to defer further consideration of the application shall state the reasons for deferral, provide direction for further investigation, and state time limits for such further investigation. As soon as practical after the deferral, a favorable or adverse recommendation regarding the application shall be made. The Medical Executive Committee may delegate the responsibility for further consideration to the Credentials Committee or Service Chief as appropriate. Favorable Recommendation When the recommendation of the Medical Executive Committee is favorable to the applicant, the application shall be promptly forwarded to the Board for action at the Board s next regularly scheduled meeting. Adverse Recommendation If the recommendation of the Medical Executive Committee is adverse to the applicant, the applicant shall be notified in writing of such by the Medical Staff President, delivered by certified mail, return receipt requested. Such notice shall contain the information prescribed in Article I.B of the Fair Hearing Plan. No such adverse recommendation shall require forwarding to the Board until after the applicant has waived or exercised his/her rights under the Fair Hearing Plan. e. Action by the Board Unless subject to the provisions of the hearing and appeals provisions of the Fair Hearing Plan, the Board shall act on the application at its next regularly scheduled meeting following receipt of the recommendation from the Medical Executive Committee. If the Board adopts the recommendation of the Medical Executive Committee, it shall become the final action of the Board. If the Board does not adopt the recommendation of the Medical Executive Committee, the Board may either refer the matter back to the Medical Executive Committee with instructions for further review/evaluation and a timeframe for responding back to the Board or the Board may take action on its own initiative. The Board may take action on its own initiative using the same type of criteria considered by the Medical Executive Committee but 38

39 only after informing the Medical Executive Committee of its intent and allowing a reasonable period of time for response by the Medical Executive Committee. If the Board refers the matter back to the Medical Executive Committee, the Medical Executive Committee shall review the matter as instructed by the Board and shall forward its subsequent recommendation to the Board. If the Board then adopts the recommendation of the Medical Executive Committee, it shall become the final action of the Board. All decisions to reappoint shall include a delineation of clinical privileges, any change in assignment of Staff category and Service affiliation, noting any applicable conditions placed on the reappointment or grant of clinical privileges. The applicant shall be provided written notification of such action. f. Time Guidelines for Acting All individuals and groups required to act on an application for reappointment/clinical privileges deemed complete shall do so in good faith and, except for good cause, complete their actions within the following time frames: Medical Staff Services. 60 days Service Chief. 30 days Credentials Committee... Next regular meeting Medical Executive Committee... Next regular meeting Board... Next regular meeting These timeframes are considered guidelines only and do not create any right for an applicant to have an application processed within these precise periods of time; provided, that this provision shall not apply if the Fair Hearing Plan is triggered by an adverse recommendation or action, when in such case the time requirements set forth in the Fair Hearing Plan shall govern the continued processing of the application. No term of reappointment or grant of clinical privileges shall extend beyond twenty-four (24) months and such reappointment/clinical privileges shall automatically lapse when such timeframe is exceeded. 39

40 ARTICLE III: ALLIED HEALTH PROFESSIONALS A. GENERAL 1. Categories of Allied Health Professionals a. Sponsored Allied Health Professionals 1) Sponsored Allied Health Professionals are individuals not eligible for Medical Staff membership, who practice a profession in a category approved by the Board and are sponsored by a Member(s) of the Medical Staff. Sponsored Allied Health Professionals shall be appointed to the Allied Health Staff and granted delineated clinical privileges pursuant to provisions of this Article and shall render care only to those patients under the care of a Member(s) and be subject to the supervision of such Member(s). The requirements of this Article do not extend to Medical Center staff with written job descriptions. (2) Sponsored Allied Health Professionals shall have only such limited duties, responsibilities and prerogatives as are specifically set forth herein and in the Medical Staff Rules/Regulations. Sponsored Allied Health Professionals may provide patient care services only to the extent of the clinical privileges granted and within their areas of professional competence as qualified by licensure, certification or other designation/approval and in accordance with Kansas law and regulations. The sponsoring Member shall assume mutual responsibility for the conduct of and clinical care provided by the Sponsored Allied Health Professional within the Medical Center, and shall be responsible for acquainting such individual to the Rules, Regulations and policies of the Medical Staff and Medical Center which may be applicable to the Allied Health Professional. A Sponsored Allied Health Professional shall be assigned to the Clinical Service to which his or her sponsor is assigned and shall be subject to all applicable requirements of such Service. Sponsored Allied Health Professionals are not required to remit dues. (3) The Board shall determine the categories of Sponsored Allied Health Professionals eligible for clinical privileges, which shall include, but not be limited to, the following categories: (a) (b) (c) (d) (e) (f) (g) Audiologist; Certified Nurse Midwife (who may be sponsored only by Members who are obstetricians/gynecologists); Licensed Practical Nurse; Nurse Anesthetist (CRNA); Advanced Registered Nurse Practitioner as defined by Kansas law; Operating Room Technician; Scrub Technician; 40

41 (h) (i) (j) (g) (h) (i) Orthopedic Assistant; Pathology Assistant; Registered Nurse; Physician Assistant; Research Coordinator Clinical; and Research Coordinator Non-Clinical. b. Non-Sponsored Allied Health Professionals (1) Non-sponsored Allied Health Professionals are individuals not eligible for Medical Staff membership who practice a profession in a category approved by the Board. Non-sponsored Allied Health Professionals render care pursuant to an order of a Member(s), as limited by the clinical privileges granted to them and consistent with their demonstrated professional competence as determined by licensure, certification or other designation/approval and in accordance with Kansas law and regulations. Non-sponsored Allied Health Professionals shall be assigned to a Service as deemed appropriate to the type of care rendered, shall be subject to all applicable requirements of such Service, and shall be accountable to the Service Chief. Non-sponsored Allied Health Professionals are required to remit dues. (2) The Board shall determine the categories of Non-sponsored Allied Health Professionals eligible for clinical privileges, which shall include, but not be limited to the following categories: (a) (b) Audiologist; Psychologist. 2. Qualifications of Allied Health Staff To be eligible for clinical privileges, an Allied Health Professional shall: a. be the type of Allied Health Professional approved for clinical privileges by the Board; b. provide evidence of adequate education, training and experience with respect to the services intended to be provided and as determined by the Board for each type of Allied Health Professional; c. hold a license, certificate or other credential in good standing as may be required by applicable Kansas law and the Medical Staff Bylaws; d. provide proof of malpractice insurance with the minimum amount of $200,000 per occurrence/$600,000 aggregate and participate in the HealthCare Stabilization Fund as appropriate; 41

42 e. submit a copy of the protocol agreed upon and executed by the Allied Health Practitioner and, if applicable, the sponsoring/responsible Member(s) authorizing the medical aspects of care delegated to such Allied Health Practitioner or as may be required by law; and f. meet all other requirements imposed by the Board as may be specific for the type of Allied Health Professional. 3. Responsibilities of Allied Health Staff Membership a. An Allied Health Professional must meet the basic responsibilities for Allied Health Staff membership, which shall be considered necessary to maintain Allied Health Staff membership, as follows: (1) supplement his/her application with additional information as requested by the Medical Staff Office, Service Chief, Credentials Committee and/or Medical Executive Committee and appear for any requested interviews regarding his/her application, or, subsequent to appointment, reappointment or the grant of clinical privileges, appear for any requested interviews related to questions regarding the applicant's competence or performance; (2) provide patient care services within the scope of the Allied Health Staff Member s granted privileges at the generally recognized professional level of quality and efficiency established by the Medical Staff, Medical Center and the Allied Health Staff Member s licensing or certifying agency; (3) as appropriate to the Allied Health Staff Member s granted privileges, seek consultation whenever necessary, and in accordance with the requirements of the Medical Staff Bylaws and Rules/Regulations and policies of the Medical Center; (4) work cooperatively and professionally with Members, Medical Center staff, Medical Center Administration and other so as not to adversely affect the delivery of patient care or obstruct efficient operations of the Medical Center; (5) as applicable to the Allied Health Staff Member, abide by the Medical Staff Bylaws, Rules/Regulations, Related Documents, Corporate Compliance Plan and all other policies, procedures, and other requirements of the Medical Staff and the Medical Center; (6) as applicable to the Allied Health Staff Member s granted privileges, document completely, timely, legibly, and accurately in medical records as specifically required by the Medical Staff Rules and Regulation, in all other documents related to care provided in the Medical Center, and also in all verbal and written communications 42

43 with Medical Staff and Medical Center representatives. Dishonesty or misrepresentations in any such document, record, or communication may be a basis for termination of Allied Health Staff membership and privileges, or other adverse action permitted by these Bylaws and Related Documents, or in policies and procedures as adopted by the Board from time to time; (7) as appropriate to the category of Allied Health Staff Member, cooperate with the Medical Center in matters involving its fiscal responsibilities and policies, including those relating to payment or reimbursement by governmental and third party payers; (8) as appropriate to the category of Allied Health Staff Member, participate in continuing education to maintain clinical skills and current competence; (9) promptly notify and update the Medical Executive Committee, through the Medical Staff Services, upon a change in any qualification for Allied Health Staff membership or clinical privileges; (10) promptly notify and update the Practitioner Health Committee, through the Chairman of the Practitioner Health Committee, of any change in the Allied Health Staff Member s health status which could adversely impact his/her ability to safely carry out delineated privileges. Upon request by the Medical Executive Committee or the Board, submit evidence of physical and/or mental health sufficient to fulfill these responsibilities of Allied Health Staff membership and permit the safe performance of the clinical privileges granted to the Allied Health Staff Member; and (11) perform such other responsibilities as the Medical Staff or Medical Center may require. b. participate as requested in performance improvement/risk management/peer review program activities and in discharging related duties as may be required from time to time; c. attend clinical and educational meetings as may be required of Allied Health Staff membership, by the Medical Staff, and/or by the Medical Center as requested as well as meetings of Committees of which s/he is a member or has been requested to participate; and d. refrain from any actions or conduct that are, or may reasonably be interpreted as being beyond, or an attempt to exceed, the Allied Health Staff Member s scope of practice under Kansas law or as authorized by the Board. 43

44 4. Prerogatives of Allied Health Staff Allied Health Staff shall have the ability to: a. provide specifically designated patient care services under the direction of a Medical Staff Member or within the limitations imposed by Kansas law/regulation; b. exercise such other prerogatives as the Board grants, upon recommendation of the Medical Executive Committee; and c. participate on Medical Staff and/or Medical Center Committees when appointed or requested, without the privilege of voting or holding office, except as may be specifically allowed by the Medical Staff Bylaws or Rules/ Regulations or Medical Center policy and procedure. B. APPOINTMENT, REAPPOINTMENT AND CLINICAL PRIVILEGES The process for Allied Health Staff appointment and the grant of clinical privileges shall incorporate by reference all the general criteria for Medical Staff appointment, reappointment, and clinical privileges as specified in Article II.A of this Policy and as further delineated below. 1. Pre-application Process An application for Allied Health Staff membership and privileges shall only be provided to those individuals who, through the pre-application process, demonstrate threshold eligibility for privileges in accordance with the Medical Staff Bylaws, this Policy, the Rules/Regulations of the Medical Staff and Related Documents. Further, only those applicants who agree to abide by the conditions of their Allied Health Staff membership and granted privileges, the Medical Staff Bylaws, this Policy, the Rules/Regulations, Related Documents and the policies/procedures of the Medical Center shall be considered for the grant of clinical privileges. Applicants for the sponsored type of Allied Health Professional must submit evidence of sponsorship by a Member during the pre-application process. The Allied Health Staff pre-application process shall be conducted in reasonable conformance with the process described in Article II, Section B of this Policy describing the pre-application process for Medical Staff applicants. 2. Application Process If the pre-application process determines the pre-applicant eligible for Allied Health Staff membership and clinical privileges, such pre-applicant shall be provided an application form for clinical privileges. The Allied Health Staff clinical privileges application process shall be conducted in reasonable conformance with the process described in Article II, Section C of this Policy describing the process for initial appointment and grant of clinical privileges for Medical Staff applicants. 44

45 Additionally, the Senior Vice President of Nursing shall review all applications of Allied Health Practitioners licensed or regulated by the Kansas Board of Nursing, and provide input regarding the qualifications and clinical competence of such applicants to representatives of the Medical Staff responsible for considering and recommending clinical privileges. 3. Reappointment/Additional Privileges Process The process for renewing and requesting additional Allied Health Staff clinical privileges shall be conducted in reasonable conformance with the processes described in Article II, Section D of this Policy describing the process for Medical Staff reappointment and renewal of clinical privileges, and in Article II, Section B.3. of this Policy describing the process for requesting additional clinical privileges. Additionally, the Senior Vice President of Nursing shall review all applications of Allied Health Practitioners licensed or regulated by the Kansas Board of Nursing, and provide input regarding the qualifications and clinical competence of such applicants to representatives of the Medical Staff responsible for considering and recommending clinical privileges. 4. Term of Appointment/Privileges The initial term of appointment shall be provisional, for a period not to exceed one year. Article I, Section D of this Policy regarding terms of appointment shall apply to Allied Health Professionals. A sponsored Allied Health Professional s term of appointment/privileges shall automatically terminate upon the resignation or termination of the sponsoring Member s appointment/privileges or upon termination of any employment and/or contract relationship the Allied Health Professional may have with the sponsoring Member. Such automatic termination shall not trigger the procedural rights described in Section C of this Article. If the sponsoring Member has been granted a leave of absence, the sponsored Allied Health Professional may request and be granted a leave of absence for the same time period granted to the sponsored Member, but under no condition may exercise clinical privileges at the Medical Center in the absence of the sponsoring Member. 5. Temporary Privileges Allied Health Professionals are eligible for temporary privileges if all other conditions for the granting of such privileges are met, as described in Article IV, Section G of this Policy. Temporary privileges may be terminated at will by the Board. 6. Leaves of Absence Allied Health Professionals may request and be granted leaves of absence in accordance with the process described in Article I, Section E of this Policy. 45

46 C. PROCEDURAL RIGHTS 1. General Allied Health Staff are subject to Article V of this Policy, titled Corrective Action. However, Allied Health Staff are not entitled to the procedural rights as provided in the Fair Hearing Plan. An Allied Health Professional may request a disciplinary review with the Medical Executive Committee when a recommendation is made by that Committee to deny, revoke, suspend, restrict or reduce the appointment/privileges of the Allied Health Professional as a result of a professional review activity. Failure to request the disciplinary review in writing and hand delivered or delivered by special notice to the President/Chief Executive Officer within fifteen (15) days of receipt of notice of the recommendation by the Medical Executive Committee shall be deemed a waiver of the Allied Health Professional s right to a disciplinary review with the Medical Executive Committee. Nothing in this Article or any other Section of the Medical Staff Bylaws, this Policy, the Rules/Regulations or Related Documents shall be construed as giving an Allied Health Professional the right to a disciplinary review if the Allied Health Professional fails to meet eligibility criteria for appointment/privileges. 2. Initiation of Disciplinary Review Upon receipt of a request for a disciplinary review, the President/Chief Executive Officer shall forward the request to the Medical Executive Committee in care of the President of the Medical Staff. Within thirty (30) days of the request for disciplinary review, the Medical Executive Committee shall conduct such review. Prior to such review, the affected Allied Health Professional shall be informed of the evidence supporting the recommendation by the Medical Executive Committee which prompted the request for review. At the disciplinary review, the affected Allied Health Professional shall be invited to discuss, explain, or refute the evidence supporting the recommendation by the Medical Executive Committee. The Allied Health Professional may present evidence to explain or refute the basis for the recommendation. Minutes shall be recorded of the disciplinary review. The Medical Executive Committee may interview other individuals who may have information pertinent to the issues at hand. No attorney representing the Allied Health Professional or the Medical Center may be present at the disciplinary review proceeding or any of the interviews. 46

47 Any member of the Medical Executive Committee who is in direct economic competition with the Allied Health Professional under review shall not participate in the disciplinary review proceeding. 3. Action by Medical Executive Committee The Medical Executive Committee shall make a recommendation to the Board within thirty (30) days of the disciplinary review based on the findings of such review. The recommendation of the Medical Executive Committee and all pertinent information shall be forwarded to the Board for its decision. The President/Chief Executive Officer shall inform the affected Allied Health Professional in writing, delivered by certified mail, return receipt requested, of the recommendation of the Medical Executive Committee. 4. Action by Board The Board shall make the final decision regarding the action taken. The President/Chief Executive Officer shall inform the affected Allied Health Professional and sponsoring Member, as applicable, of the Board s final decision in writing delivered by certified mail return receipt requested, of the Board s decision. No right of appeal shall exist for the affected Allied Health Practitioner or the Medical Executive Committee. 47

48 ARTICLE IV: CLINICAL PRIVILEGES A. EXERCISE OF CLINICAL PRIVILEGES Members and/or Allied Health Professionals providing patient care services at the Medical Center, by virtue of Medical Staff/Allied Health Staff appointment and/or the grant of clinical privileges, shall, in connection with such practice, be entitled to exercise only those clinical privileges specifically granted to him/her by the Board. Such privileges shall be specific to the Medical Center and delineated on an individual basis within the scope of the license, certificate or other credential authorizing the applicant to practice in the State of Kansas and consistent with any restrictions thereon, within the scope of the applicant s education, training and current competence, and subject to the Medical Staff Bylaws, Rules and Regulations, this Policy and Related Documents. Each Member must obtain consultation with another Member who possesses appropriate clinical privileges in any case when the clinical needs of the patient exceed the clinical privileges of the Member(s) currently attending the patient. Additionally, consultation must be obtained as otherwise required by the Medical Staff Bylaws, this Policy, the Rules and Regulations, and Related Documents. B. DELINEATION OF CLINICAL PRIVILEGES 1. Application Clinical privileges may be granted only pursuant to formal request on forms provided by the Medical Center subject to verification of credentials and qualifications, recommendation by the Service Chair, Credentials Committee and Medical Executive Committee and approval by the Board. Each application for appointment and/or reappointment must contain a request for the specific clinical privileges if so desired by the applicant. An application for clinical privileges without a request for Medical Staff membership shall contain the same information as an application for membership. An applicant for clinical privileges shall be subject to the same obligations as are imposed upon an applicant for Medical Staff appointment and/or reappointment. 2. Admitting Privileges The privilege to admit is not automatic and shall be delineated and granted by the Board in accordance with the Medical Staff Bylaws, Rules and Regulations and this Policy. 3. Requests for Additions to Clinical Privileges An application for additional clinical privileges may be submitted at any time, but such requests must be supported by documentation of training, education and current competence as required by the Medical Staff Bylaws, this Policy and Related Documents. At least two (2) peer references shall be obtained. In 48

49 processing such request, the National Practitioner Data Bank, AMA, licensing and/or certifying entities shall be queried and the query responses considered by the Service Chair, Credentials Committee and the Medical Executive Committee before a recommendation is made to the Board for its approval. In addition, the following documentation shall be required before evaluating any request for an increase in clinical privileges: a. verification of education, training and current competence related to the requested clinical privilege(s); b. requested privilege(s) and from peers knowledgeable regarding the applicant s current competence to perform the requested privilege(s); c. verification of malpractice insurance coverage for the requested privilege(s); d. the applicant s response to whether, since submission of his/her last application for appointment, reappointment or clinical privileges, there have occurred any of the following: (1) any final adverse or currently pending challenges to, or voluntary relinquishment of, licensure, registration, certification or other credentials; (2). any voluntary or involuntary reduction or termination of privileges or membership at any other health care facilities at which the applicant holds or has held membership and/or privileges; and (3). any involvement in professional liability actions. C. BASIS FOR PRIVILEGE DETERMINATIONS 1. General Applications and requests for clinical privileges shall be evaluated in accordance with the process described in Articles II and III of this Policy, and on the basis of the applicant s education, training, current competence, the ability to perform the clinical privileges requested, professional references, information from the applicant s current and past facility affiliations, professional liability experience and insurance coverage, and other relevant information, including performance profile information, and an evaluation by the Service Chair of the Service in which the privileges have been sought. Individuals with delineated clinical privileges are required to participate in continuing education as related to their privileges, and the applicant s participation in continuing education shall be considered when renewing or revising such privileges. The criteria for granting clinical privileges shall also include the ability of the Medical Center to provide supportive services for the applicant and his/her patients, the geographic location of the applicant, the patient care need for the requested privilege, and alternate coverage available during the applicant s absence. 49

50 Additionally, in considering any request for clinical privileges, the Medical Center, including any Committee of the Medical Staff or the Medical Center, or the Board at its discretion, may obtain assistance with such evaluation, as provided for in Article II, Section A.4 of this Policy. 2. Special Conditions for Dental Privileges Clinical privilege requests received from dentists shall be reviewed in accordance with the Medical Staff Bylaws and this Policy. Patients of dentists must receive a medical evaluation by a Physician Member of the Medical Staff, who shall complete non-dental aspects of the history and physical and shall also be responsible for the medical care of any patient during the patient s hospitalization and shall also advise on the risk and effect of any procedure on the patient s overall health status. The Physician Member and the dentist shall concur on the appropriateness of any recommended procedure if a significant medical condition is present. The dentist shall be responsible for completing the dental history and physical and all appropriate elements of the patient s medical record, and may write orders within the scope of his license and as consistent with the Medical Staff Rules and Regulations. An oral/maxillofacial surgeon who has successfully completed a postgraduate program in oral and maxillofacial surgery accredited by a nationally recognized accrediting body approved by the Board, and who has been determined by the Medical Staff to be currently competent to perform a history and physical examination, may be granted such clinical privilege. 3. Special Conditions for Podiatric Privileges Clinical privilege requests received from podiatrists shall be reviewed in accordance with the Medical Staff Bylaws and this Policy. Patients of podiatrists must receive a medical evaluation by a Physician Member of the Medical Staff, who shall complete the non-podiatric aspects of the history and physical, be responsible for the medical care of any patient during the patient s hospitalization and advise on the risk and effect of any procedure on the patient s overall health status. The Physician Member and the podiatrist shall concur on the appropriateness of any recommended procedure if a significant medical condition is present. The podiatrist shall be responsible for the podiatric history and physical and all appropriate elements of the patient s medical record and may write orders within the scope of his license and as consistent with the Medical Staff Rules and Regulations. 4. Special Conditions for Allied Health Professionals Clinical privilege requests received from Allied Health Professionals shall be processed in the manner specified in Article IV of this Policy. An Allied Health Professional may, subject to any licensure requirements or limitations, exercise independent judgment within the scope of his/her professional competence and license and participate directly in the medical management of patients under the supervision of a Member who has been granted privileges to provide such care. The clinical privileges granted to Allied Health Professionals shall be accordance with 50

51 the Medical Staff Bylaws, Rules and Regulations, this Policy and Related Documents. D. SERVICE RESPONSIBILITIES FOR DEFINING PRIVILEGES Each Service shall assist the Service Chief define, develop and recommend in writing the clinical privileges for that Service and the requisite education, training, experience and other qualifications required to exercise such privileges. The recommendations shall be approved by the Credentials Committee, Medical Executive Committee and the Board, shall be reviewed on an annual basis, and shall form the basis for delineating privileges within the Service. When the delineation of clinical privileges within a Service is revised, by addition, modification or deletion of available clinical privileges, any individual holding clinical privileges within the Service affected by the revision shall submit requests for clinical privileges in accordance with the revision, as appropriate, or adjust his/her practice to comply with any resulting reduction in clinical privileges. E. NEW, EXPERIMENTAL OR MULTI-SPECIALTY PRIVILEGES 1. New or Multi-Specialty Privileges The Credentials Committee shall initially review any request for clinical privileges that are new to the Medical Center, or that overlap more than one Service or medical specialty, and consider the need for and appropriateness of such privilege(s). If such privilege(s) are deemed needed and appropriate to the Medical Center, the Credentials Committee shall facilitate the establishment of hospital-wide credentialing criteria for such new or multi-specialty privileges, soliciting input from all appropriate Services and specialties, utilizing an approach designed to ensure that all individuals with such clinical privileges provide the same level of quality patient care. In establishing the clinical privilege criteria, the Credentials Committee may establish an Ad Hoc Committee to accomplish this task. The development of credentialing criteria may be assisted by the use of outside sources, including experts in the field or information from professional and specialty organizations. The clinical privilege criteria recommended by the Ad Hoc Committee for such new or multi-specialty privilege(s) shall be referred to the Credentials Committee and Medical Executive Committee for recommendation to the Board, and shall be subject to approval by the Board. 2. Experimental Procedures/Services Any individual seeking permission to perform a procedure or provide a service at the Medical Center that is experimental, investigational, or would otherwise require review and evaluation by the Investigational Review Board (IRB) utilized by the Medical Center, shall submit the investigational protocol related to such experimental procedure or service to the IRB, in accordance with that entity s requirements. Following review and evaluation by the IRB, the latter shall provide written authority and direction for the experimental procedure or service to the Research 51

52 Initiative Committee at the Medical Center. Following its review and acceptance of the recommendations of the IRB, the Research Initiative Committee shall consult with the Credentials Committee to determine if the experimental/investigational procedure/service is within the scope of the requesting individual s clinical privileges. The Credentials Committee shall consult with the individual seeking to perform the experimental/investigational procedure, Medical Staff Members, Medical Center representatives, and others, including outside consultants/experts as indicated, to make this determination. If determined by the Credentials Committee that the experimental/investigational procedure is within the scope of the requesting individual s previously granted privileges, it shall seek the concurrence of the Medical Executive Committee, which in turn shall inform the Research Committee and the Board. The Board shall have ultimate authority for approving all experimental/investigational protocols. If, after appropriate evaluation and consultation, it is determined by the Credentials Committee that the experimental/investigational procedure is outside the scope of the requesting individual s previously granted privileges, the individual shall be required to apply for the privilege applicable to the experimental/investigational protocol in accordance with the Medical Staff Bylaws and this Policy. If the applicable privilege is new to the Medical Center, the process described in Article IV.E.1 of this Policy shall apply. In such instance, the requesting individual and the Research Initiative Committee shall be so informed and advised that unless and until the privilege is available at the Medical Center and privilege criteria established, the privilege is granted to the requesting individual and the Board approves implementation of the experimental/investigational protocol, such protocol shall not be implemented. F. REQUEST FOR UNAVAILABLE PRIVILEGES Notwithstanding any other provisions of the Medical Staff Bylaws, Rules and Regulations, this Policy or Related Documents, if an application is made for a clinical privilege not available at the Medical Center, such application shall not be processed and the individual submitting the application so notified. Because the basis for declining to process the application is unrelated to the requesting individual s qualifications or clinical competence, the individual shall not be entitled to the procedural rights described in the Fair Hearing Plan. G. TEMPORARY PRIVILEGES 1. General Temporary privileges may be granted in two limited circumstances, each with different criteria for granting such privileges: a. to fulfill an important patient care, treatment and service need; or b. when a new applicant has submitted a complete application that raises no 52

53 concerns, temporary privileges are recommended by the Credentials and Medical Executive Committees, and the applicant is awaiting review and approval by the Board. 2. Conditions and Authority for Granting Temporary Privileges Upon recommendation of the Credentials and Medical Executive Committees and the written concurrence of the Service Chief (or his/her designee) of the Service where the temporary privileges shall be exercised, the Medical Staff President (or his/her designee) and the President/Chief Executive Officer (or his designee) may agree to approve the temporary privilege(s) request in the following circumstances: a. Important Patient Care Need (1) Specific Patient Care Need (a) Upon receipt of a written request, on forms provided by the Medical Staff Office, an appropriately licensed and individual currently competent to perform the requested privilege(s) who is not an applicant for appointment and clinical privileges as specified in Article II of this Policy, may be granted temporary privileges for the care of one or more identifiable patients under the following conditions: (i) (ii) (iii) when the requested privilege(s) is one recognized and granted by the Board; when the President/Chief Executive Officer (or designee) concurs with the grant of such temporary privilege(s); and when no one else has been granted such requested privilege(s) or, if such requested privilege(s) are held by another Member, such Member is unavailable to exercise the privilege(s). (b) The grant of such temporary privilege(s) shall be based upon a complete review of the application, credentials and licensure of the requesting individual to include, but not be limited to the following: (i) (ii) (iii) evidence of a current, unencumbered professional license to practice in the applicant s specialty in the state of Kansas; evidence of current, unrestricted federal and state prescribing authority for controlled substances if related to the temporary privileges requested; documentation of professional liability insurance as 53

54 required by the Board; (iv) (v) (vi) (vii) (viii) (ix) (x) satisfactory findings from query of the National Practitioner Data Bank and AMA; evidence of current competence related to the temporary privileges requested, including competence verification from other health care entities at which the applicant holds the requested privileges; verification from hospitals at which the applicant holds or has held appointment and/or clinical privileges; at least four acceptable peer references (two, if the individual is an Allied Health Professional); evidence of relevant training and experience; verification of the OIG Sanction Report and GSA List to confirm that the individual is not an Ineligible Person; and criminal background check. (c) (d) Qualifications for temporary privileges in this circumstance shall be verified from a primary source and documented. When applying for temporary privileges, each applicant shall agree to be bound by the Medical Staff Bylaws, Rules/Regulations, Related Documents and Medical Center policies and procedures. Temporary privileges granted in this circumstance shall be restricted to the term of confinement of the patient/patients being treated and shall not be granted to any one applicant more than three (3) times in any one (1) calendar year. An applicant requesting temporary privileges exceeding this limit shall be required to apply for appointment and/or clinical privileges under the processes described in Article II of this Policy. (2) Locum Tenens (a) In very rare circumstances and on a case-by case basis, after receipt of a written request for privileges on forms provided by the Medical Staff Office, an appropriately licensed individual who is not an applicant for appointment and clinical privileges as specified in Article II of this Policy may be granted temporary privileges to fulfill an important patient care need created by the absence of a Member of the Medical 54

55 Staff who is unable to provide services at the Medical Center. Such temporary privileges shall be based upon a complete review of the application, credentials and licensure of the requesting individual to include, but not be limited to the following: (i) (ii) (iii) (iv) (v) (vi) (vii) (viii) evidence of a current, unencumbered professional license to practice in the applicant s specialty in the state of Kansas; evidence of current, unrestricted federal and state prescribing authority for controlled substances if related to the temporary privileges requested; documentation of professional liability insurance as required by the Board; satisfactory findings from query of the National Practitioner Data Bank; evidence of current competence related to the temporary privileges requested; evidence of relevant training and experience; verification of the OIG Sanction Report and GSA List to confirm that the individual is not an Ineligible Person; and criminal background check. (b) (c) Qualifications for temporary privileges in this circumstance shall be verified from a primary source and documented. When applying for temporary privileges, the locum tenens applicant shall agree to be bound by the Medical Staff Bylaws, Rules/Regulations, Related Documents and Medical Center policies and procedures. Temporary privileges granted in this circumstance shall be restricted to the term of absence of the Medical Staff Member being replaced but shall not exceed one hundred twenty (120) calendar days. The locum tenens physician shall not be granted temporary privileges in excess of those granted to the Medical Staff Member being replaced. An applicant requesting temporary privileges exceeding this limit shall be required to apply for appointment and/or clinical privileges under the processes described in Article II of this Policy. 55

56 b. Pending Processing of Appointment, Reappointment or Privilege Application Upon receipt of a complete application for Medical Staff appointment and/or clinical privileges, as defined by the Medical Staff Bylaws and this Policy, which application also includes a specific request for temporary privileges, such applicant may be granted temporary privileges by the President/Chief Executive Officer (or his designee) for a term of up to one hundred twenty (120) days (but not to exceed the pendency of the application), if such privileges are recommended by the Service Chief (or his/her designee) and the Medical Staff President (or his/her designee) and it is determined that no obvious concerns are raised in the application documents after a complete review and approval of the application documents by the Service Chief, the Credentials Committee, and the Medical Executive Committee. The temporary privileges granted may not exceed the scope of the privileges requested in the regular application for privileges. In exercising such privileges, the applicant shall act under the supervision of the Service Chief (or his/her designee) of the Service to which the applicant is pending appointment and/or privileges. 3. Termination of Temporary Privileges Temporary privileges constitute temporary authorization to attend patients at the Medical Center. The grant of temporary privileges does not acknowledge that the applicant has met the qualifications for medical staff appointment and an applicant who is unable to obtain temporary privileges shall not be entitled to the procedural rights afforded under the Fair Hearing Plan. Temporary privileges may be granted only for a specific period of time, not to exceed one hundred twenty (120) days or as otherwise specified in this Section, and shall automatically expire at the end of the specified period. Temporary privileges may be revoked or withdrawn at any time, with or without cause, and such revocation or withdrawal does not entitle the individual to the procedural rights afforded under the Fair Hearing Plan. 4. Rights of the Individual with Temporary Privileges The individual holding temporary privileges does not have the rights of a Medical Staff Member or other individual holding clinical privileges and will not participate in Medical Staff or Medical Center Committees except as requested, may not vote, and is not expected to assume Emergency Department call responsibilities. Special conditions of monitoring and evaluation may be imposed on the individual granted temporary privileges and the imposition of same or termination of temporary privileges does not entitle the individual to any procedural rights afforded under the Fair Hearing Plan. H. DISASTER PRIVILEGES Upon activation of the Medical Center s Emergency Management Plan and the determination that the immediate needs of patients cannot be met by current Medical Staff members and Medical Center staff, temporary disaster privileges may be granted by the President/Chief Executive Officer (or designee) or Medical Staff President (or designee) to 56

57 an individual(s) who otherwise does not hold privileges at the Medical Center upon presentation of a valid government-issued photo identification card issued by a state or federal agency (e.g., driver s license or passport) and at least one of the following: 1. a current picture hospital ID card that clearly identifies the individual s professional designation; 2. a current Kansas license, certification or registration as required to practice the individual s profession (primary source verification shall be undertaken as soon as the immediate situation is under control and such verification shall be completed within seventy-two (72) hours of the request for disaster privileges or as soon as possible given the disaster situation); 3. identification indicating the individual is a member of a Disaster Medical Assistance Team (DMAT), Medical Reserve Corps (MRC), Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP), or other state or federal organization or group; 4. identification indicating the individual 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); or 5. identification by a current Medical Staff Member or Medical Center staff member/employee who possesses personal knowledge regarding the individual s ability to act as a licensed independent practitioner during a disaster. Prior to the grant of disaster privileges, the individual so requesting them shall, to the extent possible under the circumstances, complete forms provided by Medical Staff Services in accordance with the applicable Medical Staff policy. The individual granted disaster privileges shall be assigned to a Medical Staff Member who shall assume responsibility for monitoring and evaluating the care and treatment provided by such individual in accordance with Medical Staff and Medical Center policies and procedures. Disaster privileges initially shall be granted for no longer than seventy-two (72) hours, at which time the President/Chief Executive Officer (or designee) or the Medical Staff President (or designee) shall recommend continuation of such disaster privileges based on information obtained regarding the individual s professional practice during the disaster or through primary source verification. In the event information regarding the individual s professional performance/licensure results in adverse or unsubstantiated information about the qualifications of the individual, disaster privileges shall be immediately terminated by the Medical Staff President (or designee) or President/Chief Executive Officer (or designee). Disaster privileges otherwise expire when the disaster situation no longer exists or when care and treatment may be adequately provided by Medical Staff Members and/or Medical Center staff. If primary source verification of the individual s licensure cannot be completed within seventy-two (72) hours, there shall be documentation reflecting why such verification could not be completed, evidence of the individual s demonstrated ability to continue to provide 57

58 care, treatment and services, and the attempts made to rectify the lack of verification. If the need for disaster privileges extends beyond the immediate disaster response period, the individual shall apply for and be considered for temporary privileges in accordance with the process described in Article IV, Section G.2 of this Policy. Notwithstanding any provision in the Medical Staff Bylaws, this Policy or Related Documents to the contrary, during a mass disaster, any individual granted clinical privileges is authorized to intervene to provide patient care, treatment and services to the extent necessary as a life-saving measure or to prevent serious harm in accordance with the circumstances and conditions described in Article IV, Section I of this Policy regarding emergency privileges. I. EFFECT OF EMERGENCY In a valid emergency as defined below, any individual granted clinical privileges, to the extent and scope authorized by his/her license, certification or registration, and regardless of Medical Staff membership status, staff category or clinical privileges, shall be permitted to intervene to the extent necessary and to provide any type of patient care, treatment, and services necessary as a life-saving measure or to prevent serious harm. When the emergency no longer exists, care of the patient shall be assigned to a Member with the appropriate clinical privileges to provide the care required by the patient, if such assignment has not previously been made. An emergency, as referenced in this Section, is a situation in which serious or permanent harm would result to a patient or in which the life of a patient is in immediate danger and any delay in administering treatment would add to that danger. J. TELEMEDICINE PRIVILEGES An appropriately licensed individual who provides only interpretive services (official readings of images, tracings and specimens) through a telemedicine link from a distant location and is not otherwise providing services on site at the Medical Center is not required to be appointed to the Medical Staff or credentialed through the processes described in the Medical Staff Bylaws and this Policy. Instead, the Medical Center may delegate to the individual s distant site health care entity the responsibility for credentialing and privileging such individual, pursuant to an agreement between the Medical Center and the healthcare entity at the distant site, if the following conditions are met: 1. the nature and scope of the interpretive services to be provided are defined in writing; 2. the Board approves the provider of services specified in the agreement; 3. such services meet applicable Joint Commission standards and state and federal laws and regulations, as applicable; 4. the health care entity at the distant site is Joint Commission accredited and has 58

59 complied with applicable Joint Commission standards in its processes for credentialing and privileging the individual at the distant site; and 5. the individual providing such interpretive services executes an attestation agreeing to comply with the Medical Staff Bylaws, Rules/Regulations and Related Documents and Medical Center policies and procedures. Following receipt of satisfactory evidence that these conditions have been met, and upon recommendation and advice of the Medical Executive Committee, the Board may approve that the individual provide interpretive services at the Medical Center relying on the credentialing and privileging decision of the health care provider at the distant site. Once approved to perform such services, the individual shall be subject to and cooperate with the Medical Center s processes for monitoring and evaluating the services provided under the agreement. In this circumstance, the individual performing interpretive services by agreement shall not hold appointment to the Medical Staff and shall not be entitled to the rights and prerogatives such membership avails. The Medical Center may terminate the individual s services in accordance with the agreement and the individual is not entitled to any of the procedural rights afforded under the Medical Staff Bylaws and Fair Hearing Plan. When evidence of compliance with the conditions stated above cannot be demonstrated, the individual seeking to provide only interpretive services through a telemedicine link from a distant site shall be credentialed and privileged through the processes described in the Medical Staff Bylaws and this Policy. Likewise, applicants seeking Medical Staff appointment or clinical privileges in addition to the privilege to perform interpretive services by telemedicine link shall be appointed and/or privileged through the processes described in the Medical Staff Bylaws and this Policy. K. ANCILLARY SERVICES ORDERED BY NON-PRIVILEGED PHYSICIANS A physician who is not a Medical Staff Member or who does not hold clinical privileges at the Medical Center, including physicians (M.D./D.O.) and podiatrists (D.P.M.), who are not licensed to practice in Kansas, and chiropractors (D.C.) who are licensed to practice in Kansas, may order diagnostic and/or therapeutic services, as defined below, in accordance with applicable state and federal laws/regulations, applicable accrediting body standards and the following requirements: 1. the Medical Center verifies that the ordering physician s medical license is current and not subject to any of the following restrictions: a. prior revocation; or b. present suspension or other discipline preventing the physician from making such order; 2. the order may lawfully be given by a physician or podiatrist with a current license to practice medicine or chiropractor licensed to practice in Kansas; and 59

60 3. the order is lawfully within the scope of the ordering physician s, chiropractor s or podiatrist s license to practice. If any of the above requirements cannot be verified, the order shall not be implemented and the patient advised to contact/return to the ordering physician or given the option of being evaluated in the Emergency Department. If the order for diagnostic and/or therapeutic services insufficiently supports the medical appropriateness/necessity of the ordered service, an attempt shall be made to contact the ordering physician to obtain the required information. If, after reasonable attempts, no contact is made with the ordering physician, the order shall not be implemented and the patient advised to contact/return to the ordering physician or given the option of being evaluated in the Emergency Department. A diagnostic service is defined by Kansas regulation as the testing of a person for the detection or evaluation of a disease, ailment, deformity or injury... Kansas regulations define therapeutic service to mean any treatment for the cure, relief, palliation, adjustment or correction of any human disease, ailment, deformity, or injury. In the event a patient requires medical care during the implementation of an order for a diagnostic or therapeutic service by a physician who does not hold appointment or privileges at the Medical Center, the patient shall be attended by the physician implementing the order, if such order requires physician implementation, or referred to the Emergency Department. Non-physicians are not entitled to order diagnostic and/or therapeutic services unless they have been granted such ordering privileges by the Medical Center. 60

61 ARTICLE V: CORRECTIVE ACTION A. CRITERIA FOR INITIATION Any person or Committee may report information about the conduct, performance, or competence of its Members or other individuals with clinical privileges. Such information shall be reported to the Medical Staff President, appropriate Service Chief (or designee), Credentials Committee Chairperson, President/Chief Executive Officer, or to any other appropriate individual as specified by the Medical Staff Bylaws or Medical Center policy. Corrective Action may be initiated when reliable information, including the results of performance improvement, peer review and/or risk management activities, indicates that an individual may have exhibited acts, demeanor, conduct or professional performance reasonably likely to be: 1. detrimental to patient safety or to the delivery of quality of patient care within the Hospital; 2. unethical; 3. disruptive or harassing (as defined in these Bylaws, Rules/Regulations, Related Documents and/or by Medical Center policies and procedures, including its Corporate Compliance Plan); 4. contrary to the requirements of the Medical Staff Bylaws, Rules/Regulations, Related Documents and/or Medical Center policies, procedures (including its Corporate Compliance Plan) or Rules and Regulations; 5. below applicable professional standards of care; or 6. subject to discipline by the applicable licensing entity. The President of the Medical Staff, appropriate Service Chief, Credentials Committee Chairperson, or President/Chief Executive Officer or designee, as appropriate, shall make sufficient inquiry to satisfy him/her that the concern or question raised is credible. A determination will be made as to whether to refer the matter to the Medical Executive Committee or to deal with the matter in accordance with the relevant Medical Staff or Medical Center policy. If it is determined to direct the matter to the Medical Executive Committee, a written request for investigation shall be prepared, making specific reference to the performance information activity or conduct that gave rise to the request. The investigation shall be conducted pursuant to the provisions described in this Article. B. ALTERNATIVES TO A PROFESSIONAL REVIEW RECOMMENDATION/ ACTION As appropriate, Corrective Action may include initial collegial efforts made with the affected individual prior to resorting to a formal Professional Review Recommendation or Action. Such collegial interventions on the part of Medical Staff and/or Medical Center leaders in addressing the conduct or performance of an individual shall not afford the individual 61

62 subject to such efforts to the right to a Hearing and Appeal, and shall not require reporting to any state licensure board or the NPDB, except as otherwise provided by law or in these Bylaws including this Policy and the Fair Hearing Plan, Medical Staff Rules/Regulations, and other Related Documents and/or Medical Center policy. Such interventions may include: 1. informal discussions or formal meetings with the affected individual, with appropriate documentation of same; 2. written letters of guidance, reprimand or warning regarding the concerns about conduct or performance; 3. notification that future conduct or performance shall be closely monitored with stated expectations for improvement; 4. suggestions or requirements that the individual seek continuing education, concurrent monitoring, or other assistance in improving performance; 5. warnings regarding the potential consequences of failure to improve conduct or performance; 6. requirements to seek evaluation for impairment, as provided in this Policy, the Medical Staff Bylaws, and Related Documents; and/or 7. conditional appointment, reappointment and/or grant of clinical privileges, as described in Article II, Section A.6 of this Policy. C. SUMMARY (PRECAUTIONARY) SUSPENSION OR RESTRICTION 1. Whenever a Member's conduct or the conduct of an individual with clinical privileges appears to require that immediate action be taken to protect the life or well-being of a patient or to reduce a substantial and imminent likelihood of significant impairment of the health and safety of any patient, prospective patient or other person, the Medical Staff President, appropriate Service Chief, or President/Chief Executive Officer may impose a summary (precautionary) suspension or restriction on the clinical privileges of the individual. 2. Unless otherwise stated, such suspension or restriction shall become effective immediately upon imposition, and the person responsible for imposing the suspension or restriction shall promptly give written notice to the President/Chief Executive Officer (or designee) and the Medical Executive Committee. In addition, the affected individual shall be provided with a written notice of the action within twenty-four (24) hours of imposition. 3. The initial notice shall include a summary of facts and issues regarding the individual's conduct that led to the suspension or restriction, and shall not substitute for the notice as detailed in the Fair Hearing Plan. When the individual being suspended or restricted is a Medical Staff Member, the President of the Medical 62

63 I Staff or the appropriate Service Chief shall arrange for coverage of patient care that may be affected by the suspension or restriction. The wishes of the patient shall be considered in the selection of an alternative health care provider. When the individual being suspended or restricted is a sponsored Allied Health Staff Member, the sponsoring physician shall be responsible for arranging alternative coverage for the care normally provided by the individual. 4. An investigation shall be conducted, in accordance with Section D of this Article to determine whether there is a reasonable basis for continuing the summary (precautionary) suspension or termination. Attempts shall be made, to the extent reasonably possible under the circumstances, to complete the investigation within twenty-one (21) calendar days. The Medical Executive Committee shall determine whether such continuation is warranted, based on the investigation findings. A summary suspension extending longer than thirty (30) days shall be reported to the National Practitioner Data Bank as required by law. D. INVESTIGATION 1. Peer review may be initiated in response to the circumstances in a single case, or to investigate a pattern or trend in performance. The Medical Executive Committee or the Board of Trustees may request an investigation. The Medical Executive Committee may conduct such an investigation, or may assign such investigation to a standing or ad hoc Medical Staff Committee, Medical Staff Officer, or Service Chief. External third parties may be utilized to assist in the investigation process. 2. The investigation shall include an interview with the affected individual and/or an interview of other individuals or groups deemed appropriate by the investigating body. If the investigation is conducted by a group or individual other than the Medical Executive Committee, that group or individual shall forward a written report of the investigation to the Medical Executive Committee as soon as practical after the assignment to investigate has been made. The Medical Executive Committee may at any time within its discretion, and shall at the request of the Board, terminate the investigation process and proceed with action as provided below. The investigation procedures do not constitute a Fair Hearing and need not be conducted in accordance with the formal procedures outline in the Fair Hearing Plan. In addition, the investigation shall include: a. conformance to the peer review procedures described in the Medical Staff Bylaws and Medical Center policy and procedures; b. as deemed necessary by the investigating body, a review of the medical record for specific cases, a review of aggregate performance data, a review of comparative data when available, a review of any verbal or written reports regarding any specific incidents, conduct or behavior, or any other information material to the matter being investigated; c. a written report of the investigation, detailing all material evidence, and a 63

64 47 recommendation to the Medical Staff Executive Committee; and d. as deemed indicated by the investigating body, the affected individual may be required to procure a physical or mental evaluation by a professional named by the investigating body. E. ACTION ON THE INVESTIGATION REPORT As soon as practicable after the conclusion of an investigation, the Medical Executive Committee or the Board may: 1. determine that no type of corrective action is warranted and dismiss the matter; 2. defer action for a reasonable time when circumstances warrant; 3. determine that corrective action is warranted but other than a recommendation for a professional review action, and initiate one of the alternatives to same, as describe in Article V, Section B. of this Policy; 4. determine that a recommendation for professional review action is warranted, and recommend such, which shall entitle the individual subject to such action and qualified for such entitlement to the procedural rights described in the Fair Hearing Plan; or 5. take other actions deemed appropriate to the circumstances. F. STATUTORY RISK MANAGEMENT PROCESS No provision in this Section shall preclude the Medical Staff or Medical Center from meeting its compliance obligations under the Kansas Risk Management statutes. Each Member of the Medical Staff and individual granted clinical privileges shall incur internal reporting obligations as detailed in the Medical Center s Risk Management Plan whenever such Member or individual possesses direct knowledge that another Member, individual with clinical privileges, or employee of the Medical Center has committed an act that is or may be a deviation from the applicable standard of care creating a reasonable probability of patient harm or that may be grounds for possible discipline by the applicable licensing agency. All such reports shall be referred for investigation and evaluation pursuant to the Medical Center s Risk Management Plan. In addition to fulfilling its statutory risk management compliance obligations, such investigation and evaluation may also be utilized by the Medical Executive Committee or the Board, as appropriate, as a basis for corrective action. However, any statutory reporting obligation necessitated by the Kansas Risk Management statutes shall proceed automatically at such time a reporting obligation is triggered and shall not entitle the affected individual to the procedural rights afforded in the Fair Hearing Plan regarding such reporting. 64

65 G. AUTOMATIC SUSPENSION OR TERMINATION The following circumstances shall constitute conditions for automatic suspension, and if indicated, automatic termination of Medical or Allied Health Staff membership/clinical privileges. Unless specifically provided in this Section, an individual subject to an automatic suspension or termination shall not be afforded the procedural rights detailed in the Fair Hearing Plan. 1. Licensure: If an individual's license or other required credential/qualification to practice is revoked or suspended by a state licensing authority, or if an individual fails to maintain a current license, credential or other qualification for practice, he/she shall be automatically suspended from practicing in the Medical Center and his/her Medical Staff or Allied Health Staff membership, as appropriate, shall be automatically terminated. 2. Controlled Substance Registration: If an applicant's DEA or Kansas DEA registration is revoked, suspended, or restricted, or if an individual fails to maintain a current unrestricted registration, s/he may be automatically suspended from practicing in the Medical Center and his/her Medical Staff or Allied Health Staff membership, as appropriate, shall be automatically terminated. 3. Liability Insurance: If an individual's professional liability insurance is revoked or the individual fails to maintain ongoing coverage as required by the Medical Staff Bylaws and this Policy, s/he shall be automatically suspended from practicing in the Medical Center until such time that sufficient professional liability coverage is confirmed. 4. Eligibility to Participate in Federal Programs: If an individual is designated as an Ineligible Person, such designation shall result in automatic suspension from practicing in the Medical Center. 5. Medical Records: A medical record is considered to be delinquent when it is deemed incomplete for any reason within thirty-one (31) calendar days following a patient's discharge. When a Medical Staff member or individual with clinical privileges has failed to complete a medical record and the record becomes delinquent, following notification and the process described in the Rules/Regulations, his/her clinical privileges shall be automatically suspended. The suspension shall continue until all of the individual's delinquent records are completed. 6. Misrepresentation: When it appears at any stage of the reappointment process that an applicant seeking reappointment and/or clinical privileges may have intentionally misrepresented material information on the application or during the interview process, either by omission or commission, the application for reappointment to the Medical Staff and/or request for clinical privileges shall be deemed voluntarily withdrawn, subject to the provisions of Article II, Section A.3 of this Policy regarding intentional misrepresentations. The individual may not reapply until thirty six (36) months have elapsed from such voluntary withdrawal. 65

66 If an intentional misrepresentation of material information on the application for appointment and/or clinical privileges is discovered after the applicant has been granted appointment, reappointment and/or clinical privileges, the individual s membership and clinical privileges shall automatically terminate, subject to the process described in Article II, Section A.3 of this Policy regarding intentional misrepresentations. The individual may not re-apply until thirty six (36) months have elapsed from such automatic termination. 7. Criminal Conviction or Plea of Nolo Contendere: Whenever it is discovered that an individual has been convicted of or entered a plea of nolo contendere to any felony under state or federal law, or has been convicted of or entered a plea of nolo contendere to any health-related misdemeanor under state or federal law, the individual s membership and clinical privileges shall be automatically terminated. H. AUTOMATIC RESIGNATION A term of Medical Staff membership or the grant of clinical privileges shall be for a period of no more than two years (24 months). A term of Allied Health membership or the grant of clinical privileges shall be for a period of no more than one (1) year. In the event that reappointment or renewal of clinical privileges has not occurred for whatever reason prior to the expiration of the current term of appointment, the membership and clinical privileges of the individual shall be terminated. The individual shall be notified of the termination and the need to submit a new application if continued membership or clinical privileges are desired. I. ACTIONS INVOLVING AN INDIVIDUAL WITH AN IMPAIRMENT The Medical Staff and Medical Center leaders have a process to provide education about health issues related to Members and other individuals with clinical privileges, as described in the Medical Staff Policy titled Practitioner Health Policy. The process addresses physical, psychiatric or emotional illness, and facilitates confidential diagnosis, treatment, and rehabilitation of individuals who suffer from a potentially impairing condition. It is the policy of the Medical Staff and the Medical Center to properly investigate and act upon concerns that a Member or other individual with clinical privileges in suffering from impairment. The investigation shall be conducted in accordance with the referenced policy and with pertinent state and federal laws, including but not limited to, the Americans with Disabilities Act (ADA). J. ACTIONS INVOLVING AN INDIVIDUAL RESPONSIBLE FOR DISRUPTIVE CONDUCT It is the policy of the Medical Staff and the Medical Center for all individuals working in the Medical Center to treat others with respect, courtesy, and dignity and to conduct themselves in a professional and cooperative manner. In dealing with incidents of disruptive conduct, the protection of patients, employees, physicians, and others in the Medical Center and the orderly operation of the Medical Center are paramount concerns. The Medical Staff shall properly investigate and act upon concerns that a Member or other individual with clinical 66

67 privileges has displayed or is responsible for disruptive conduct in accordance with the Medical Staff policy titled Medical and Allied Health Staff Code of Conduct Policy. 67