DEFINITIONS: The following definitions will apply to this Policy:

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1 CLASSIFICATION: MEDICAL STAFF POLICY NUMBER: MS004 EFFECTIVE DATE: 08/91 SUBJECT: Allied Health Professionals DATE REVIEWED/ REVISED: 03/97, 09/01, 06/03, 12/03, 09/04, 11/08, 2/09, 2/10, 3/12, 2/13, 3/13, 8/14, 12/15, 5/16 CONTACT PERSON: Manager, Medical Staff Services PAGE 1 OF 5 POLICY STATEMENT It is the Policy of Children s Hospital & Medical Center to describe the procedures by which Allied Health Professionals are approved, managed, and evaluated within the organization. DEFINITIONS: The following definitions will apply to this Policy: Allied Health Professional (AHP) - selected individuals other than Medical Staff members who are authorized by law and by the Hospital to provide patient care services within the Hospital.. Sponsoring Physician o o An Active Member of the Children s Hospital & Medical Center Medical Staff who practices in the same specialty as the Advanced Practice Registered Nurse (APRN). If an APRN-NP has less than 2,000 hours of practice, he/she must practice under the supervision of a supervising and sponsoring physician through a transition-to-practice agreement approved by the State of Nebraska to collaboratively provide the delivery of health care services at Children s Hospital & Medical Center. After 2,000 hours of practice, the APRN-NP must continue to be sponsored by a Medical Staff Member. - an Active Member of the Children s Hospital & Medical Center Medical Staff who is responsible for supervision of an Allied Health Professional Licensed Dependent AHP (DAHP) - any AHP who is employed by a Children s Hospital & Medical Center Medical Staff Member, a practice entity of Members, or the Hospital; not licensed or permitted by Children s Hospital & Medical Center to practice independently; under the supervision of a Sponsoring Member or approved Independent AHP. Licensed Independent AHP (IAHP) - an AHP who is licensed and permitted by Children s Hospital & Medical Center to practice independently of supervision by another health care professional; assigned for professional oversight to the Allied Health Professional Subcommittee of the Credentials Committee, and the hospital Administrator of area of primary practice. MEC - Medical Executive Committee of the Medical Staff. Member - a Member of the Children s Hospital & Medical Center Medical Staff. Supervising Physician - an Active Member of Children s Hospital & Medical Center Medical Staff who has a supervisory relationship with a physician assistant, orthoptist or optometrist and must have a written scope of practice agreement that is within the scope of services of the supervising physician at Children s Hospital & Medical Center. Chief Executive Officer or CEO - as used herein shall mean the CEO of Children s Hospital & Medical Center. /

2 MEDICAL STAFF POLICY: Allied Health Professionals Page 2 ALLIED HEALTH PROFESSIONALS SUBCOMMITTEE (AHPSC) - The Allied Health Professionals Subcommittee of the Credentials Committee is the entity responsible for ensuring that the credentialing of AHP s is carried out and for defining scopes of service/privileges, policies and procedures to support this purpose. The AHPSC has the responsibility to review the applications of allied health professionals and to make recommendations to the Credentials Committee. INELIGIBILITY FOR MEDICAL STAFF MEMBERSHIP AHP s are not eligible to be Members and, therefore, shall not be eligible to vote or hold office in the Medical Staff organization nor shall they be entitled to the procedural rights specified in the Medical Staff Documents. Procedural rights of AHPs are those specifically provided in this Policy. AHP staff members may be assigned to serve on committees of the Hospital or of the Medical Staff. QUALIFICATIONS 1. Licensed Fields. AHPs practicing in fields requiring license or registration under Nebraska State Law must have such a license. Other qualifications as outlined in the AHP Scope of Service/Privileges may be required by the Medical Executive Committee (MEC) subject to final determination by the Board of Directors. 2. Sponsor/Supervisor/Collaborating Physician. With the exception of Psychologists and Licensed Independent Mental Health Practitioners, Allied Health Professionals must designate or identify a Member of the Medical Staff who will serve as the Sponsoring Member, Supervising Physician or Collaborating Physician. The physician will be responsible for the patient care and clinical competence of the Allied Health Professional. HOSPITAL CERTIFICATION Areas of Practice. Before the addition of another type of AHPs will be approved, the AHP Subcommittee, Credentials Committee, Medical Executive Committee and Board of Directors, must certify that inclusion of AHPs from that field: a. Is consistent with Hospital long-range plan including human resource plans; b. Is consistent with efficient Hospital operations; c. Will improve the safety, quality and/or cost-effectiveness of Hospital operations; d. Will not materially impair the viability or effectiveness of Hospital services and programs. Limit of Numbers. At any time the Board of Directors may place a limit on the number of persons in a particular field of practice who may be AHPs, provided that such limit may not, unless otherwise decided by the Board of Directors, be applied to require the termination of appointment of existing AHPs. Recognized Types of AHPs. The following are recognized as approved AHP fields of practice subject to the process as outlined in this policy. Advanced Practice Registered Nurse (APRN-NP) ** Advanced Practice Registered Nurse Certified Registered Nurse Anesthetist (APRN-CRNA) Licensed Independent Mental Health Practitioner (LIMHP) Optometrist Physician Assistant (PA-C) Podiatrist (DPM) Psychologist or Provisionally Licensed Psychologist (PsyD or PhD) Registered Nurse First Assistant (RNFA) **Those APRNs that do not have a master s degree and 2000 hours of practice are required to practice under supervision through a transition-to-practice agreement and are considered dependent AHP s. REQUIREMENTS FOR APPROVAL TO PROVIDE SERVICES Applications Allied Health Professionals may only provide patient care at the hospital according to the following:

3 MEDICAL STAFF POLICY: Allied Health Professionals Page 3 a. As employees of the hospital, in which case they shall be hired according to the hospital s Human Resources policies, and subject to job descriptions, Human Resources policies and hospital policies in the same manner as other hospital employees; b. As contract AHP s, in which case they shall be entitled to provide only those services specified in individual contracts, and shall be governed by the terms and conditions of such contracts; c. As physician employed AHP s approved to provide services at the hospital, in which case, they shall be subject to the terms of this policy, the appropriate scope of service/privileges or job description for each AHP s discipline and all applicable hospital policies. d. Foreign nationals will need to provide evidence of health care certification issued by the Department of Homeland Security (DHS.) Application Process Allied Health Professionals must apply for approval to provide services and will be evaluated in the following manner: a. Allied Health Professionals must submit a completed Children s Hospital & Medical Center Allied Health Professionals application or Nebraska Credentials Verification Organization initial application, and submit with required documentation as outlined in the Credentialing Policy & Procedure Manual: Non-refundable initial application fee from non-hospital employed AHP s only; Scope of services/privileges requested; Signed statement by Sponsoring/Supervising/Collaborating Physician attesting to qualifications, supervision and responsibility for performance (except psychologists and licensed independent mental health practitioners); Copy of current license to practice in the State of Nebraska; Copy of a transition-to-practice agreement or role delineation approved by the State of Nebraska (if applicable) ; Copy of current DEA registration, if applicable (APRNs, Podiatrists and PAs); Required references; Evidence of professional liability insurance coverage (non-employed AHP s only). Current written evidence of PPD testing or acceptable alternative as outlined in the Medical Staff Policy. Employed APRNs will submit a completed Dependent APRN-NP Protocols form Documentation and maintenance of Basic Life Support (BLS) certification at a minimum (maybe submit documentation of other life support certifications) for Advanced Practice Registered Nurses, Advanced Practice Registered Nurse Nurse Anesthetists, Physician Assistants and Podiatrists. b. Medical Staff Services shall obtain primary source verification as outlined in the Credentialing Policy & Procedure Manual; c. Following primary source verification, the application and supporting documentation/materials shall be reviewed by a member of the Allied Health Subcommittee of the Credentials Committee and then forwarded to the Department Chair who will complete a report containing an appraisal of the individual s qualifications for the privileges requested. d. The Allied Health Professionals Subcommittee of the Credentials Committee will review the application, report its findings and make a written recommendation to the Credentials Committee. e. The Credentials Committee will review the applications and recommendations of the AHP Subcommittee and make recommendation to the Medical Executive Committee f. The Medical Executive Committee shall review the applications and recommendations of the Credentials Committee and make recommendation to the Quality and Patient Safety Committee of the Board of Directors; g. The Quality & Patient Safety Committee of the Board of Directors, after receipt of a verified application and recommendation of the Credentials Committee and/or Medical Executive Committee, shall determine approval of provision of services/privileges at the hospital; h. Temporary and/or an Interim Scope of Service/Privileges may be granted on a case by case basis in two circumstances: To fulfill an important patient care treatment and service need; and/or When a new applicant with a complete application that raises no concerns is awaiting review and approval by the Allied Health Subcommittee, Credentials Committee, Medical Executive Committee and/or the Quality & Patient Safety Committee of the Board of Directors. All temporary Privileges granted pursuant to this Section shall be for a period of not more than 120 days. Scope of Service/Privileges

4 MEDICAL STAFF POLICY: Allied Health Professionals Page 4 Scopes of Service/Privileges and qualifications of each field of service will be developed by the AHPSC and recommended by the Credentials Committee and Medical Executive Committee and approved by the Quality & Patient Safety Committee of the Board of Directors. For those categories of AHPs for whom a Scope of Service/Privilege list has been developed, applicants will be asked to indicate which services from that list the applicant wishes to perform. If the applicant wishes to perform services not on the list, the applicant s request will be considered individually by the Allied Health Professionals Subcommittee, Credentials Committee, Medical Executive Committee and the Quality & Patient Safety Committee of the Board of Directors. For those categories for which a scope of service/privileges has not been approved, the applicant will be asked to complete the Request for Additional Privileges form indicating, in detail, what they wish to do as part of the applicant s field of service and duties in the Hospital and that service will be considered for delineation as an approved service by the Quality & Patient Safety Committee of the Board of Directors. The Sponsoring Member, Collaborating Physician or Supervising Physician will be required to review and approve the scope of service/privileges requested initially and at reappointment. Applicants will be required to submit the appropriate documentation regarding competency with performing the privileges requested as outlined on the scope of service/privileges form. The documentation can be submitted from past employers or hospital affiliations. Application Approval Process The AHP Subcommittee will make a recommendation regarding approval or denial of an applicant s request for scope of service/privileges to the Credentials Committee, and the recommendation of both bodies shall be forwarded to the Medical Executive Committee and to the Quality and Patient Safety Committee of the Board. The CEO, on behalf of the Board of Directors, will communicate a decision to the AHP, and in the case of an employee, to the relevant Administrator and/or their designee. Additionally the AHP will be scheduled for orientation (in person or a self-study) as part of the credentialing process. Renewal of Approved Services Allied Health Professional status will not exceed a period of twenty-four (24) months. Terms of each AHP s appointment and renewal of services will be based upon each applicant s: Clinical competence and judgment in the treatment of patients; Job competencies, service and behavioral expectations; Satisfactory completion of assigned responsibilities; Compliance with all policies, rules and regulations of the Hospital and of the Medical Staff; Satisfactory completion of continuing education requirements as may be imposed by the State of Nebraska, Hospital or applicable accreditation agencies; Continued medical staff membership of the sponsoring/collaborating/supervising physician (if applicable); Peer recommendations regarding medical/clinical knowledge, technical and clinical skills, clinical judgment, interpersonal skills and professionalism; Willingness of sponsoring/collaborating/supervising physician to agree to supervising the AHP and being responsible for conduct and care of the AHP (if applicable); Any other factors bearing upon the AHP s credentials. Hospital employed AHPs will be subject to the Human Resources annual review process. The documents from this process will be utilized for the biennial renewal/reappointment of approved services for employed AHPs. Those AHPs who are not hospital employed will have an annual competency evaluation completed by their sponsoring, supervising or collaborating physician and reviewed by Medical Staff Services. Evaluations which contain derogatory information will be forwarded to the AHPSC for review. Recommendations regarding renewal/reappointment of Allied Health Professional status will be forwarded to the Allied Health Professional Subcommittee and the Credentials Committee. Renewals/Reappointments will be forwarded to the Medical Executive Committee and the final determination will be made by the Quality & Patient Safety Committee of the Board of Directors. Monitoring When an AHP is allowed to provide services according to a Scope of Service/Privileges, competency evaluation by the hospital medical staff services personnel may include, but not be limited to variance reports, patient satisfaction data, focused professional practice evaluations, ongoing professional practice evaluations, medical record completion data and/or direct observation by others. Deficits in competency will be addressed through an individual performance improvement plan. All allied health practitioners will be subject to the focused and ongoing professional practice evaluation as outlined in the Medical Staff Policy. Change of Sponsoring/Supervising/Collaborating Physician

5 MEDICAL STAFF POLICY: Allied Health Professionals Page 5 AHP s undergoing a change of Sponsoring/Supervising/Collaborating or employing physician(s) must complete the following: a. For APRNs - Submit copy of a transition-to-care agreement between the nurse practitioner and the collaborating physician or from the State of Nebraska. b. For PAs - Submit a copy of the letter of agreement or supervision agreement letter between supervising physician and physician assistant. c. Submit a complete new scope of service/privilege list including the signature of the Sponsoring/Supervising/Collaborating Physician. d. Submit malpractice insurance coverage certificate if there is a change in the policy or certificate. The request for change in sponsoring/supervising/collaborating physician will be submitted to the AHP Subcommittee, Credentials Committee and Medical Executive Committee with final determination by the Quality & Patient Safety Committee of the Board. APRN Change from Protocols Required to Protocols Exempt When an advanced practice registered nurse has reached exempt status by obtaining a master s degree and two thousand hours of supervised practice, the practitioner may apply for exempt status privilege by completing the following: a. Submit a new scope of service/privilege list requesting protocols exempt including the signature of the Collaborating Physician. b. Submit a copy of the letter from the State of Nebraska indicating receipt of the required documentation to practice protocols exempt. The request for change in protocols privileges will be submitted to the AHP Subcommittee, Credentials Committee and Medical Executive Committee with final determination by the Quality & Patient Safety Committee of the Board. Termination of Services In the event an AHP is no longer employed by or affiliated with the Hospital or by the AHP s Sponsoring /Supervising/Collaborating Physician, or the Dependent AHP s Sponsoring/Supervising/Collaborating Physician no longer holds privileges, all functions outlined in the AHP s Scope of Service/Privileges shall cease. Further activity in the Hospital, thereafter, shall be conditioned upon the AHP either arranging another Member to be approved as their Sponsoring/Supervising/Collaborating Physician or meeting other criteria established by the Board on a general or case-by-case basis. A Hospital employee, who is terminated for cause, will be ineligible to reapply as an AHP. Responsibilities Each AHP providing services within the Hospital must: a. Provide patients with care at the level of quality and efficiency recognized as appropriate and required by the Hospital; b. Abide by Hospital policies, including any rules and policies, specifically applicable to AHPs, and Medical Staff documents as they apply to AHPs; c. Prepare and complete in a timely fashion appropriate portions of all required records for patients to whom the AHP provides services to in the Hospital; d. Abide by generally recognized standards of professional ethics and Hospital s compliance plan; e. Refrain from any conduct or acts that are or could be reasonably interpreted as being beyond or attempting to exceed the scope of practice/privileges authorized for the AHP in the hospital; f. Be subject to and participate in Performance Improvement and peer review activities and in discharging such other functions as may be required from time to time by the MEC or the Board; g. Attend professional continuing education programs applicable to areas of scope of service/privileges to maintain level of skill and knowledge as requested by the Hospital, or required for licensure or certification; h. Immediately notify in writing to Medical Staff Services, the Sponsoring/Supervising/Collaborating Physician and the CEO of any investigative, disciplinary, or limiting action by any state licensing board, regulatory agency or health care facility;

6 MEDICAL STAFF POLICY: Allied Health Professionals Page 6 i. Immediately report in writing to Medical Staff Services any change in professional liability. Additional Responsibilities of Licensed AHPs Licensed Allied Health Professionals shall: a. Exercise autonomous judgment in their areas of competence and appropriate scope of service/privileges; a privileged member of the Medical Staff shall have the ultimate responsibility for inpatient care; b. Participate directly in the management and care of inpatients under the direction of or collaboration with the privileged Medical Staff member responsible for inpatient care, as defined in the approved scope of service/privileges; c. Record reports and progress notes on the patients records and write orders for treatment, within the scope of the AHP s license and approved scope of service/privileges, d. Licensed Allied Health Professionals do not have admitting privileges. Corrective Action Corrective Action for Employees of the Hospital. AHPs who are employees of the hospital are subject to corrective action as outlined in the Human Resources Policy, Behavioral Improvement/Corrective Action. The employee s Administrator will initiate the corrective action with the assistance of the Human Resources Department and the collaboration of the Sponsoring/Supervising/Collaborating Physician. Corrective Action for Non-Employees of the Hospital. AHPs who are not employees of the hospital are subject to corrective action as outlined in the Human Resources Policy, Behavioral Improvement/Corrective Action. The Administrator of the affected area in collaboration with the Sponsoring/Supervising/Collaborating Physician will initiate corrective action with the assistance of Medical Staff Service with advisement and/or consultation with the Human Resources Department and the Senior Vice President Medical Affairs/Chief Medical Officer (SVPMA/CMO). Grievance Process. An AHP may file a grievance against the application of a policy, but not against the policy itself. In order to file a grievance the AHP should notify the Sponsoring/Supervising/Collaborating Physician, Administrator or the SVPMA/CMO. The SVPMA/CMO and President/CEO will appoint a qualified person or persons to conduct a review. The Vice President of Human Resources or designee may serve in this role. Action. Following the review, the qualified person will confer with the President/CEO or designee to make the final determination of action, providing a written notice of the final determination to the affected AHP and Sponsoring/Supervising/Collaborating Physician. GENERAL PROVISIONS FOR ALLIED HEALTH PROFESSIONALS Professional Liability Insurance Each AHP providing approved services in the Hospital shall have, and maintain in-force, professional liability insurance in the minimum amount of $1million per occurrence/$3million annual aggregate or $500,000 per occurrence/$1 million annual aggregate if the sponsoring/supervising/collaborating physician is a member of the Nebraska Medical Liability Act, or amounts not less than the minimum as determined and approved by the Board. The professional liability company/carrier shall be approved or licensed by the State Insurance Department.