Credentialing Manual Table of Contents

Transcription

1 Credentialing Manual Table of Contents 1.0 General Information Preapplication and Application Routine Periodic Recredentialing The Policy for Appointment, Reappointment, and Clinical Privileging Letters of Reference Supervision of Provisional Privileges Temporary Privileges Locum Tenems Emergency Privileges Method of Adoption and Amendment of the Credentials Manual Privileges and Quality Assurance for Health Practitioners other than Medical Staff Members and Employees Allied Health Professionals Application Contents of Application Authorizations and Releases Privileges and Department Termination or Curtailment of Privileges Authorization of Physician s Orders Committees Delineated Privileges for Allied Health Professionals (1) Clinical Psychology (2) Cardiovascular Perfusionist (3) Orthotists and Prosthetists (4) Licensed Master Social Worker (5) Certified Genetics Counselor (6) Registered Nurse First Assistant Certified Registered Nurse Anesthetists Qualifications Initial Application Evaluation and Renewal of Clinical Privileges Mid-Level Practitioners Physician Assistants Nurse Practitioners Specialty Credentialing for Mid-Level Practitioners (1) Emergency Department Resident Physicians Medical Staff Appointment and Reappointment Preapplication Application for Appointment Information Required (1) References (2) Education (3) Licensure (4) Prior Hospital Affiliation (5) Legal Information (6) Health Status (7) Burden on Applicant Authorizations and Releases Agreement To Be Bound By Bylaws Misrepresentations on Application Application Fee Rev

2 4.2-6 Incomplete Application Appointment Process Completed Application Submission of Application Assignment of Application Category (1) Category One (2) Category Two (3) Category Three (4) Application Processing Time Processing Category One Applicants Processing Category Two Applicants Processing Category Three Applicants Privileges Report Deferral Favorable Recommendation Adverse Recommendation Favorable Reconsidered Recommendation Adverse Reconsidered Recommendation Decision by Board More Adverse than Recommendation of Medical Executive Committee Decision of Board after Exhaustion of Hearing and Appeal Rights Board Quality and Operations Committee Final Decision Provisional Appointment Initial, Continued or Reduced Provisional Appointment Report to Credentials Committee Recommendations to Medical Executive Committee Reappointment and Recredentialing Term of Appointment Basis for Reappointment Information Required Release from Liability Preliminary Process Report of Departmental Chairman Report of Credentials Committee Report of Medical Executive Committee Action by Board Adverse Recommendation Continuation of Privileges Favorable Reconsidered Recommendation Adverse Reconsidered Recommendation Decision by Board More Adverse than Recommendation of Medical Executive Committee Decision of Board After Exhaustion of Hearing and Appeal Rights Board Quality and Operations Committee Final Decision Leave of Absence Request for Leave Termination of Leave Delineation of Privileges Delineation of Privileges According to Specialty or Clinical Practice Anesthesiology Emergency Medicine Family Practice Genetics Rev

3 5.1-5 Medicine (1) Allergy & Immunology (2) Dermatology (3) Internal Medicine Neurology Palliative Care Medicine Physical Medicine Psychiatry Obstetrics Gynecology Pathology Pediatrics Pediatric Dentistry Radiology Radiation Oncology Surgery Dentistry General Surgery (1) Laparoscopic Bariatric Surgery (2) Laparoscopic Adjustable Gastric Ban Surgery (LapBand Surgery) (3) Surgical First Assistants Neurological Surgery Ophthalmology Oral and Maxillofacial Surgery Orthopedic Surgery Otolaryngology Pediatric Surgery Peripheral Vascular Surgery Plastic Surgery Podiatry Thoracic Surgery Urology Cardiovascular Surgery Delineation of Privileges According to Procedure or Area of Practice within the Hospital CCU Management ICU Management Locked Psychiatric Ward Pediatric Intensive Care (excludes ventilator management) Attendance at Low Risk Delivery (includes low risk cesarean sections) Intermediate Nursery Care Neonatal Intensive Care Unit (NICU) Addiction Medicine - Recovery Center Anesthesiology Procedures (1)Type I Procedures Requiring Separate Documentation: (2) I.V. Regional Anesthesia (3) Pain Management- Core Privileges (4) Pain Management Procedures (5) Cardiac Anesthesia with Cardiopulmonary Bypass Cardiovascular Procedures (1) EKG Interpretation (2) Holter Monitor Interpretation (3) Stress Testing (4) Echocardiography (5) Interventional Cardiology Procedures (6) Cardiac Catheterization (7) Ventilator Management Rev

4 5.2-10(8) Pericardiocentesis (9) Swan-Ganz Line Insertion and Management (10) Subclavian/Internal Jugular Line Insertion (11) Electrophysiologic Studies Indwelling Vascular Access Port Insertion Intraoperative Transesophageal Echocardiography Diagnostic Transesophageal Echocardiography Interpretation of Noninvasive Vascular Studies Emergency Medicine Procedures (1) Emergency Department Ultrasound Privileges ENT Procedures (1) Endoscopic Nasal/Sinus Surgery (2) ENT Laser Surgery Gastrointestinal Procedures (1) Esophagogastroduodenoscopy (EGD) (2) Endoscopic Retrograde Cholangopancreatography (ERCP) (3) Percutaneous Endoscopic Gastrostomy (PEG) (4) Flexible Sigmoidoscopy (5) Colonoscopy Genito-Urinary Procedures (1) Urologic Procedures (2) Extracorporeal Urinary Lithotripsy - Performance and Interpretation (3) Prostatic Thermotherapy for Treatment of BPH (4) Prostatic Transperineal Radioactive Seed Implantation (5) Prostate Cryotherapy (6) Treatment of Urinary Incontinence using Sacral Neuromodulation Multi-specialty Procedures (1) Breast Cancer Sentinel Lymphadenectomy Criteria (2) Intravenous Moderate Sedation (3) Administration of Botulinum Toxin (4) Use of Ketamine for Procedural Sedation by Non-anesthetist (5) Laparoscopy (6) Operative Laparoscopy (7) Robotic Surgery Privileges* (8) Privileges for Surgical Management of the Breast (9) Percutaneous Kyphoplasty for Nonsurgical Specialties (10) Nuclear Cardiology Procedures for Cardiologists (11) Adult Polysomnography (12) Vascular Stenting - Carotid Artery Stent Placement (13) Use of Propofol for Procedural Sedation by Non-anesthesiologist (14) Advanced Wound Care Management for Non-surgeons (15) Hyperbaric Medicine (16) Cardiac Computed Tomography (CCT) (17) Total Contact Casting Neurological/Neurosurgical Procedures (1) Electroencephalography Interpretation (2) Evoked Potentials (3) Diagnostic Electromyography and Nerve Conduction Studies (EMG/NCV) (4) Chemonucleolysis (5) Neurosurgery Pain Management (6) Artificial Anterior Disc Replacement Obstetrics/Gynecological Procedures (1) Outlet Forceps/Vacuum Extraction (2) Fourth Degree Repair (3) Hysteroscopy (4) Radical Hysterectomy, Pelvic Exeneration, Ileal Conduit Rev

5 5.2-21(5) CO 2 Laser in the Lower Female Genital Tract Ophthalmology Procedures (1) Penetrating Keratoplasty (2) Refractive Corneal Surgery (3) Retinal Detachment Surgery (4) Ophthalmologic Laser Surgery (5) Pars Plana Radical Vitrectomy (6) Seton Placement Orthopedic Procedures Pediatric Procedures (1) Neonatal Circumcision (2) Neonatal Polysomnography (3) Pediatric Polysomnography (4) Pediatric Venous Cutdown (5) Pediatric Abdominal Paracentesis (6) Pediatric Arthrocentesis (7) Umbilical Catheter Insertion Psychiatric Procedures (1) Electroconvulsive Therapy Pulmonary Procedures (1) Chest Tube Placement (2) Flexible Bronchoscopy Radiologic Procedures (1) Nuclear Medicine Procedures (2) Diagnostic Ultrasound I (3) Diagnostic Ultrasound II (4) Computed Tomography I (5) Computed Tomography II (6) Interventional Procedures (7) Magnetic Resonance Imaging Privileges (8) Interpretation of Positron Emission Tomography (PET) Scans Radiation Procedures Plastic Surgery Procedures Urogynecology Procedures (1) Observational Cystoscopy (2) Operative Cystoscopy (3) Endoscopic Retropubic Needle Suspension Procedures (Raz, Pereyra, Stamey, etc.) (4) Periurethral Collagen Injection (Contigen) Rev

6 CREDENTIALING MANUAL 1.0 GENERAL INFORMATION 1.1 Preapplication and Application. See Section 4 of this Credentialing Manual. All initial contacts regarding application for appointment to the Medical Staff of Self Regional Healthcare should be referred to the Medical Staff Coordinator. Department heads, chairmen of committees, individual physicians, or any other individuals who receive requests for information should refer the prospective applicant to the Medical Staff Coordinator without further comment or disclosures. Application for appointment to the Medical Staff and Clinical Privileges will only be sent to individuals who satisfy the minimum criteria set forth in Article III of the Medical Staff Bylaws. 1.2 Routine Periodic Recredentialing. This manual lists eligibility requirements for initial application for clinical privileges. These requirements are not intended to be used for routine periodic recredentialing. Those members of the medical staff who lose any privileges for other reasons, would then be expected to apply for those privileges under the terms of this manual. 1.3 The Policy for Appointment, Reappointment, and Clinical Privileging. This Manual delineates and explains the rules that govern the process by which an individual applies for appointment to the Medical Staff of Self Regional Healthcare and for clinical privileges; by which the medical staff departments and Credentials Committee evaluate the applicant and formulate recommendations; and by which the Board of Trustees grant or deny privileges. All decisions that pertain to this process should be governed by the rules. All communications with applicants or other interested parties should follow the guidelines established in this manual. The Bylaws codify the organization and rules of the Medical Staff. The credentialing of physicians is a function of the hospital, albeit a function which is implemented and supervised by physicians on the medical staff. Removing the Credentialing Procedures from the Bylaws and establishing a separate document emphasizes that in the performance of these functions, physicians are acting as agents of the hospital, and not in the economic interest of those on the medical staff. When a question arises which is not addressed in this manual (e.g., application for a procedure not previously privileged here) the request for application or the application for privileges shall be held in abeyance until the issue can be studied and appropriate policy or rules instituted. Privileges to perform specific procedures or render specific types of care may be denied, regardless of the applicant s training or experience, based on the hospital s inability to provide the necessary facilities, equipment, and support personnel and services. The purpose of such strict adherence to predefined rules is to: 1. ensure that no steps in the process are omitted. 2. reduce the time commitment required from physicians. (Physicians will not have to consider any application until it is complete.) 3. minimize the number of applicants who will have privileges denied. Applicants who meet the eligibility requirements to apply should, if they are practicing sound medicine, be qualified to be granted the requested privileges. 4. minimize the number of individuals exposed to liability should an aggrieved applicant bring suit. 5. minimize the possibility of any successful suit or challenge against any individual or the hospital. 6

7 1.4 Letters of Reference. Many of the privileges and procedures which an applicant may seek have a stated requirement of a letter from the director of his residency program, or the chiefs of departments or medical staffs at former hospitals. When more than one of these privileges or procedures is requested, a single letter from each reference will suffice, but each of the privileges and procedures requested must be specifically addressed in that letter. 1.5 Supervision of Provisional Privileges. Shall be carried out in accordance to of the Credentials Manual. Many of the privileges and procedures available in this hospital require a period of supervision before unrestricted privileges are granted. In some cases, a specified number of specific procedures must be supervised. It is not intended that inability to obtain supervision be used to exclude otherwise qualified practitioners. 1.6 Temporary Privileges A. Temporary privileges may be used in the following specific situations: 1. for physician or allied health practitioners not interested in medical staff membership but who: a. are needed for care of specific patients, or b. participate in or provide advanced education training 2. for medical staff or allied health applicants with complete, clean applications who are awaiting review and approval of the Credentials Committee, Medical Executive Committee, and Hospital Board. B. Temporary privileges are granted by the CEO, upon recommendation of the Medical Director, the department chairman, Chairman of the Credentials Committee or the President of the Staff, for periods not to exceed 120 days. C. The procedures for granting temporary privileges for care of specific patients and for advanced education training (1a and 1b above) are defined by Medical Staff policy D. Temporary privileges and Category 1 medical staff applications: An applicant for medical staff membership designated Category 1 in accordance with section of the Credentials Manual may be granted temporary privileges by the CEO, upon recommendation of the Medical Director, the department chairman, Credentials Chairman or the President of the Staff, subject to any conditions imposed by the recommending party. The temporary privileges will be for not more than 120 days. E. Temporary privileges and Category 2 medical staff applications: An applicant for medical staff membership designated Category 2 in accordance with section of the Credentials Manual may be granted temporary privileges by the CEO, upon recommendation of the Credentials Committee, subject to any conditions imposed by the Credentials Chairman. The temporary privileges will be for not more than 120 days. F. Termination of Temporary Privileges: Temporary privileges are granted only as a courtesy and may be denied, limited, conditioned or terminated at any time for any reason by the CEO or his designee or by the President of the Staff and no such action shall entitle the affected individual to any of the procedural rights provided in the Fair Hearing Plan. 7

8 1.7 Locum Tenems The chief executive officer may permit a physician serving as a locum tenens for a member of the medical staff to attend patients without applying for membership on the medical staff for a period not to exceed ninety (90) days, providing all of his credentials have first been approved by the departmental chairman concerned and by the chairman of the medical executive committee. 1.8 Emergency Privileges. In the case of emergency, any member of the medical staff, to the degree permitted by his license and regardless of service or privileges, shall be permitted and assisted to do everything possible to save the life of a patient using every facility of the hospital necessary, including the calling for any consultation necessary or desirable. When an emergency situation no longer exists, such physician, dentist, or podiatrist must request the privileges necessary to the patient. In the event such privileges are denied, or he does not desire to request privileges, the patient shall be assigned to an appropriate member of the medical staff. For the purpose of this section, an emergency is defined as a condition in which serious 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. 2.0 METHOD OF ADOPTION AND AMENDMENT OF THE CREDENTIALS MANUAL All proposed amendments, whether originated by the MEC, another standing committee, or by a member of the active category of the Medical Staff, must be reviewed and discussed by the Medical Executive Committee prior to an MEC vote. Such amendments may be recommended to the Board: A. By the MEC after a majority vote, provided that the proposed amendment(s) was first distributed to the members of the active category, including senior active, at least 21 days prior to an MEC vote. The Medical Executive Committee s recommendation may be acted upon by the board unless more than 10% of the active staff members object. If more than 10% of the active staff members object to a proposed amendment, the chief of staff or the MEC will schedule and hold a general staff meeting at which the proposed amendment will be presented, discussed, and acted upon. The affirmative vote of two thirds of those active staff members present and voting is required for passage. (Absentee ballots will not be permitted.) B. The Executive Committee shall have the power to adopt such amendments to the Credentials Manual as are, in the committee s judgment, technical or legal modifications or clarifications; reorganization or renumbering; or amendments needed because of punctuation, spelling, or other errors of grammar or expression. C. Credentialing criteria using technology no longer available at Self Regional Healthcare shall become null and void and will be deleted from the Credentialing Manual upon approval of the Medical Executive Committee. Clinical privileges granted by these criteria shall automatically expire upon deletion of the credentialing criteria. D. Such amendment(s) shall be approved by the Board or its authorized agent prior to becoming effective. 8

9 3.0 PRIVILEGES AND QUALITY ASSURANCE FOR HEALTH PRACTITIONERS OTHER THAN MEDICAL STAFF MEMBERS AND EMPLOYEES The Medical Staff of Self Regional Healthcare has been delegated the required authority by the board of trustees to implement systems designed to provide credentialing to assure for high quality health care services Allied Health Professionals. Allied Health Professionals are limited license practitioners who, by reason of degree and licensure, do not qualify for Medical Staff membership, but who, by degree and state law, are qualified and allowed to render specific aspects of patient care, either dependently or independently Application. An application as an Allied Health Professional will be provided to such individuals as described above, who are not employed by or contracted for in lieu of employment by the Hospital, and who meet the following qualifications: The service to be provided is recommended by the Medical Executive Committee and approved by the Board as one which is needed by the Hospital and in keeping with its mission. The applicant is either employed by Self Memorial, self-employed, employed by a member of the Medical Staff or a group thereof, or employed by a contractual group which provides services to the Hospital. The applicant is recommended by a member of the Active Medical Staff. The applicant has no physical or mental health problem preventing him or her from exercising the privileges requested Contents of Application. The completed application must include the following information: A. Educational background, certification, and licensure. B. Three references, two from peers and one from a physician, preferably in a related field. C. Evidence of professional liability insurance as required by the Medical Executive Committee. D. A detailed description of the privileges requested, and documentation of experience in these areas Authorizations and Releases By applying for privileges, an Allied Health Professional grants all the authorizations, consents and releases as set forth in Section of the Credentials Manual Privileges and Department Privileges will be recommended and granted through regular Medical Staff and Board processes as required by these Bylaws. The individual so privileged will be assigned to a specific Medical Staff department, and must be recommended by the chairman of that department for reappointment at two year intervals. Allied Health Professionals will attend departmental meetings only upon invitation, and will not have departmental voting privileges. 9

10 3.1-5 Termination or Curtailment of Privileges The Board, upon recommendation of the Medical Executive Committee, may for reasons it deems appropriate, terminate or curtail the privileges of an Allied Health professional. The Allied Health Professional shall be notified in writing of such termination or curtailment and the reasons therefor. The only right to appeal from such a decision shall be to the Medical Executive Committee. In order to quality for such an appeal, the Allied Health Professional shall deliver to the Medical Executive Committee, within twenty (20) days after receipt of such notice of termination or curtailment, a written request for a hearing. At such hearing the Allied Health Professional shall be entitled to be present, to testify, and to present evidence. The decision of the Medical Executive Committee, when approved by the Board, shall be final. If the Allied Health Professional is an employee of a member of the Medical Staff or a contracting group, termination of staff membership of the employing physician for any reason, or termination of the contract shall automatically terminate all privileges of the Allied Health Professional without any right of appeal Authorization of Physician s Orders Allied Health Professionals may render patient care services only when authorized or requested by a physician member of the Medical Staff, who is accountable for the care so rendered. An Allied Health Professional may admit and discharge a patient as long as the attending physician signs orders within 24 hours and writes or dictates an admission note within that time period. Admission history and physical and discharge summary must reference discussion with the attending. Allied Health Professionals may not issue verbal orders, write for Do Not Resuscitate, or issue restraint orders unless a certified Psychiatric Nurse Practitioner. Telephone or written orders may be given only when specific privileges to do so have been granted, and such orders must be countersigned by a physician within twenty-four (24) hours Committees Allied Health Professionals may serve with vote on departmental, Hospital, or Medical Staff committees when requested to do so Delineated Privileges for Allied Health Professionals 3.1-8(1) Clinical Psychology A. Successful completion of a doctoral program at a regionally accredited training program and licensed to practice as a psychologist at the independent level in South Carolina B. Three reference letters from practitioners who have known the applicant for at least two years. C. Demonstrate that the applicant has provided inpatient, outpatient, or consultative service to 30 patients over the past 12 months (2) Cardiovascular Perfusionist A. BA or BS from an accredited college or university. This requirement may be waived by the MEC if the applicant meets all of the following requirements. 10

11 B. Successful completion of an accredited cardiovascular perfusion education program and certification by the American Board of Cardiovascular Perfusion (ABCP) within 24 months of program completion. A candidate will be ineligible to be reappointed if not certified. C. Letter of reference from the director of the school of perfusion or from a supervising cardiac surgeon, attesting to current competency For reappointment, the applicant must have a satisfactory competency assessment by a peer or cardiovascular surgeon, maintain current certification, and meet continuing medical education requirements set by the ABCP (3) Orthotists and Prosthetists A. Letter of recommendation from current employer or physician able to assess work quality B. Proof of state licensure, if applicable C. Proof of certification by the American Board for Certification in Orthotics and/or Prosthetics 3.1-8(4) Licensed Master Social Worker To be eligible to apply, applicant must have A, B, C, and D: A. Successful completion of a master s degree in social work from a school accredited by the Council of Social Work Education B. Two reference letters from peers who have known the applicant for at least 2 years. C. State license for the licensed master social worker D. Two years of full time (or 3,000 hours equivalent part time) paid social work experience in an agency or organized setting (5) Certified Genetics Counselor In order to be eligible to apply, candidate must have A, B, C, and D: A. Masters degree in genetics counseling B. Certified by the American Board of Genetic Counseling or active candidate to complete the Board Exam C. Three letters of recommendation attesting to adherence and commitment to professional and ethical principles. D. Letter of recommendation from training program director E. Reappointment will require Certification by the American Board of Genetic Counseling 3.1-8(6) Registered Nurse First Assistant Basic Education: RNFA Training: Certified nurse operating room (CNOR), bachelors or master's degree in nursing and successful completion of a Certification Board of Perioperative Nursing (CBPN) - approved Registered Nurse First Assistant program. This requirement may be waived by the MEC if the applicant meets all of the remainder requirements. 11

12 Experience: 12 months of clinical practice within the RFNA's area of specialization and RFNA and Surgeon Collaboration Agreement (Supervising physician should be currently appointed to the medical staff of the hospital, and has appropriate privileges) and meet requirements of statutes, regulations, and institutional policies relevant to the RNFA. Certification: Certified Registered Nurse First Assistant (CRNFA) or Certified Nurse Operating Room (CNOR). Core Assess and monitor immediate postoperative status Assessment, focused nursing based on planned surgical intervention Assessment, intraoperatively for prevention or early detection of perioperative complications Collects data from appropriate multiple sources Dressing change, performs initial postoperatively Electrocardiogram, performs (as directed by surgeon) Handling tissue Health assessment data, synthesizes and interprets to identify and prioritize Hemostasis, provides and maintains Implements and manages perioperative plan of care consistent with RNFA practice Operative site exposure Sterile field, creates and monitors Surgical instruments, use of Suturing techniques Venipuncture, performs (as directed by surgeon) Wound healing, monitoring of 3.2 Certified Registered Nurse Anesthetists. Clinical privileging is the process through which individuals are credentialed at Self Regional Healthcare to provide specific patient care services. Credentialing may be defined as the recognition of professional and technical competence and involves establishing mechanisms to verify information and evaluate the applicant requesting privileges. The credentialing and privileging process will provide an objective mechanism for initial application and renewal of clinical privileges based on education, legal qualifications and a practitioner s competence and ability to render quality care. All CRNAs will be credentialed as Allied Health Professionals as established in 3.1 of the Credentials Manual. The responsibility for their credentialing will be the Medical Staff Credentials Committee. The Department of Anesthesiology will be responsible to reviewing each application and making recommendations to the Credentials Committee who will then make their recommendation to the Medical Executive Committee who will then make their recommendation to the Board of Trustees for final action. The Chairman of the Department of Anesthesiology or his designated representative will be responsible for the initial review of each application and will provide recommendations to the Credentials Committee. Privileges will be appropriate to the scope and complexity of care provided by CRNAs. Clinical privileging will be defined as to permit the CRNA to provide selected procedures under specific conditions with supervision by an anesthesiologist. The clinical privileging process will include: (1) the qualifications of the CRNA; (2) the actual practice privileges requested and granted; (3) the conditions or limits of practice; and, (4) the process for evaluation and renewal of privileges. All applicants must be employed by and work under the direct supervision of an anesthesiologist to be eligible for clinical privileges. 12

13 3.2-1 Qualifications Applicants for clinical privileges for the practice of anesthesiology as CRNAs must meet the following requirements: 1. Qualified CRNAs must be able to provide general and regional anesthesia. They must be able to perform all of the services usually required in the practice scope of anesthesiology by CRNAs to render the patient insensible to pain for the performance of surgical and obstetrical procedures, or other necessary but pain producing clinical maneuvers. 2. Support life functions during the period of anesthesia. 3. Recognize and take appropriate corrective action for abnormal patient responses to anesthesia or to any adjunctive medication or other form of therapy. 4. Provide professional observation and resuscitative care until the patient has regained control of his/her vital functions and reflexes. In order to be eligible to apply, applicants must have A, B, and C. A. State licensure as a registered professional nurse. Compliance with state regulatory requirements regulating advanced practice for nurse anesthesia. Graduation from a program of nurse anesthesia education accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs or its predecessor. Certification by the Council on Certification or recertification by the Council on Recertification or their respective predecessors or, if pending initial certification, evidence of graduation from an approved nurse anesthesia educational program. Any applicant must attain certification status within 14 months of finishing their training program. B. Letter or recommendation from the Director of their CRNA training program or the Chief of Anesthesiology (or Surgery if there is no Chief of Anesthesiology) at the last hospital where they were employed. C. Active practice of anesthesiology during the preceding twelve months. If paragraph C above can not be satisfied by an otherwise eligible applicant, then privileges may be granted conditional to the applicant with the understanding that all the applicant s work performed at Self Regional Healthcare must be reviewed by the Chairman of the Department of Anesthesiology for a period of six months. After this period of intensive review, the Chairman of Anesthesiology will determine the applicant s competency in the practice of privileges applied for and will submit a report and recommendation to the Credentials Committee Initial Application The CRNA requesting privileges shall complete an application form. The CRNA will be required to submit the following: 1. Provide detailed information regarding qualifications as specified above; 2. Make a specific request for the anesthesia service and anesthesia clinical privileges for which the applicant wishes to be considered; 3. Provide references of persons who have worked with and who can comment on the ability and character of the applicant; 4. Provide information as to whether certification, licensure or clinical privileges have ever been denied, revoked, suspended or reduced; and 5. Provide proof of malpractice coverage of which the minimum amount will be one million dollars. 6. When all required information is completed and submitted, the application will be forwarded to the Credentials Committee for action. The Chairman of the Department of Anesthesiology will be asked to review the application and furnish to the Credentials Committee a recommendation concerning the applicant. After review by the Credentials Committee, their recommendation will be forward to the Medical Executive Committee and the Board of Trustee for action. 13

14 3.2-3 Evaluation and Renewal of Clinical Privileges Requests for renewal of clinical privileges will be evaluated every two years from the date of approval of the CRNA for permanent clinical privileges. The basis for renewal of privilege determinations will include quality assessment activities to the extent applicable. Both CME and recertification will be as required by the American Association of Nurse Anesthetists. Changes in privileges will be based on the CRNA s education, training, proctoring, experience, demonstrated abilities and judgment. Clinical Privileges for which CRNAS may apply CRNA privileges and responsibilities must be consistent with the law and may include the following: 1. Preanesthetic Preparation and Evaluation 2. Obtaining an appropriate health history. 3. Conducting an appropriate physical screening assessment. 4. Recommending or requesting and evaluating pertinent diagnostic studies. 5. Selecting, obtaining, ordering, and administering preanesthetic medications. 6. Documenting the preanesthetic evaluation and obtaining informed consent for anesthesia, anesthesia induction, maintenance and emergence. 7. Intraoperative Care a. Obtaining, preparing, and using all equipment, monitors, supplies and drugs used for the administration of anesthesia, performing and ordering safety checks as needed. b. Selecting, obtaining or administering the anesthetics, adjuvant drugs, accessory drugs, fluids and blood products necessary to manage the anesthetic. c. Performing all aspects of airway management. d. Performing and managing regional anesthetic techniques including subarachnoid, epidural and caudal blocks; plexus, major and peripheral nerve blocks; intravenous regional anesthesia; transtracheal, topical and local infiltration blocks; and peribulbar and retrobulbar blocks e. Providing appropriate invasive and non-invasive monitoring modalities utilizing current standards and techniques. f. Recognizing abnormal patient responses during anesthesia, selecting and implementing corrective action and requesting consultation whenever necessary. g. Evaluating patient response during emergence from anesthesia and instituting pharmacological or supportive treatment to insure patient stability during transfer. 8. Postoperative Care a. Providing postanesthesia follow-up and evaluation of the patient s response to anesthesia and surgical experience, taking appropriate corrective actions and requesting consultation when indicated. b. Initialing and administering respiratory support to insure adequate ventilation and oxygenation in the postanesthesia period. c. Initialing and administering pharmacological or fluid support of the cardiovascular system during the postanesthesia period to prevent morbidity and mortality. d. Discharging patients from a postanesthesia care area. Since all CRNAs must be employed by anesthesiologists, all the above must have been discussed with the anesthesiologist and approved by the anesthesiologist. All orders are to be counter signed by the anesthesiologist. Clinical Support Functions CRNAs may apply for privileges for the following: 14

15 1. Inserting peripheral and central intravenous catheters. 2. Inserting pulmonary artery catheters. 3. Inserting arterial catheters and performing arterial puncture to obtain arterial blood samples. 4. Managing emergency situations, including initiating or participating in cardiopulmonary resuscitation. 5. Providing consultation and implementation of respiratory and ventilatory care. 6. Initiating management of pain therapy utilizing drugs, regional techniques or other accepted pain relief modalities. All of the above procedures are to be performed under the direct supervision of the employing anesthesiologist. Clinical Privileges by Proctoring A CRNA may obtain new privileges for which he/she previously did not qualify through proctoring. The CRNA shall submit the request for the privilege desired and the anesthesiologist(s) who will do the proctoring to the Credentials Committee for approval for the proctoring. The CRNA must demonstrate successful completion of ten procedures along with written documentation of the proctoring process and patient data to the Chairman of the Department of Anesthesiology who will review the information and make a recommendation to the Credentials Committee who will then act on the request for permanent privileges for that procedure unless otherwise stipulated in Credentials Manual of the Medical Staff Rules and Regulations. 3.3 Mid-Level Practitioners Mid-Level Practitioners (MLP) are Allied Health Professionals who function as physician extenders. They are assigned to an active or senior active medical staff member and function under that physician s supervision, although may have variable levels of autonomy as defined by the applicant s privileges request. A MLP will generally be a Nurse Practitioner or Physician Assistant, although categories of MLP may be expanded if applicable Physician Assistants In order for a Physician Assistant to be eligible to apply, applicant must have A-F: A Baccalaureate degree from an accredited college or university. This requirement may be waived by the MEC if the applicant meets all of the following requirements. B. Graduation from a Committee on Allied Health, Education, and Accreditation (CAHEA) approved program. C. Current state registration or licensure. D. Completion of the national certifying examination given by the National Commission on Certification of Physician Assistants (NCCPA) within 24 months of graduation from a CAHEA approved program for Physician Assistants or be ineligible for reappointment. E. No physical or mental health problem preventing him or her from exercising the privileges granted. F. Written agreement with a physician currently appointed to the medical staff of the hospital who agrees to provide: 1. Supervision and monitoring of the PA s practice. 2. Availability, either personally or via an alternate, for consultation on a continuous basis. 3. Total responsibility for the care of any patient when requested by the MLP or in the interest of patient care or when requested by the patient. 4. Co-signature for all orders written by the PA. 15

16 For all requested procedures, PA must document the number he or she has done in the preceding 2 years. Procedures that are specifically delineated in the Medical Staff Rules and Regulations shall apply to the PA. For reappointment both CME and recertification will be as required by the National Commission on Certification of Physician Assistants. Categories of clinical privileges: Category 1: Category 2: Category 3: May be initiated and carried out independently by the allied health professional. May be done by the allied health professional when ordered by the supervising member of the medical staff who is available, but not necessarily present. May be done by the allied health professional when ordered by the supervising member of the medical staff when the supervisor is present in the room. Core Privileges for PA: Initial and ongoing assessment of patients medical, physical, and psychological status, including: conduct histories and physicals, develop treatment plans, perform rounds, record progress notes, and, write discharge summaries. Implement physician-directed treatment plans that permit PAs to: provide first, second, or third assist in general surgery and surgical subspecialties; write orders for medications, treatments, tests, IV fluids, etc. (Countersigned by the supervising physician); take calls; provide advanced cardiac life support; and provide pre- and post-operative surgical care Nurse Practitioners In order for a Nurse Practitioner to be eligible to apply, applicant must have A-F: A. An active RN license in the United States or its territories. B. A masters degree in nursing from an accredited college or university or evidence of successful completion of a postgraduate track or program in the applicant s specialty within a school of nursing granting graduate level academic credit. C. Certification in the Nurse Practitioner s area of specialization by any of the Advanced Practice Certification Organizations approved by the South Carolina Board of Nursing within 24 months of graduation from the graduate level nursing program. A candidate will be ineligible for reappointment if not certified. D. Current licensure or registration in South Carolina. E. No physical or mental health problems preventing him or her from exercising the privileges granted. F. A written agreement with a physician currently appointed to the medical staff of the hospital who agrees to provide: 1. Supervision and monitoring of the NP s practice. 2. Availability, either personally or via an alternate, for consultation on a continuous basis. 3. Total responsibility for the care of any patient when requested by the MLP or in the interest of patient care or when requested by the patient. 4. Co-signature for all orders written by the NP. 16

17 For all requested procedures, NP must indicate the number he or she has done in the preceding two years. Procedures that are specifically delineated in the Medical Staff Rules and Regulations shall apply to the Nurse Practitioner. Both CME and recertification will be as required by the candidate s Advance Practice Certification Organization as long as that organization is approved by the South Carolina Board of Nursing. Categories of clinical privileges: Category 1: May be initiated and carried out independently by the allied health professional. Category 2: May be done by the allied health professional when ordered by the supervising member of the medical staff who is available, but not necessarily present. Category 3: May be done by the allied health professional when ordered by the supervising member of the medical staff when the supervisor is present in the room. Core Privileges for NP: A. Initial and ongoing assessment of patients medical, physical, and psychological status, including: conduct histories and physicals, develop treatment plans, perform rounds, record progress notes, and, Write discharge summaries. B. Implement physician-directed treatment plans that permit NPs to: provide first, second, or third assist in general surgery and surgical subspecialties; write orders for medications, treatments, tests, IV fluids, etc. (Countersigned by the supervising physician); take calls; provide advanced cardiac life support; and Provide pre- and post-operative surgical care Specialty Credentialing for Mid-Level Practitioners 3.3-3(1) Emergency Department A. Minimal requirements for application same as for Nurse Practitioners and Physician Assistants given above, whichever is applicable. B. Additional requirements: 1. ACLS certification within 6 months of assuming emergency department Duties. 2. MLP will be expected to practice under the guidelines of the ED policies And procedures as well as approved written protocols or other standards of care guidelines in effect in the ED. Scope of practice will be delineated by the Emergency Department Medical Director but will not exceed those privileges recommended by the Credentials Committee and approved by the Medical Executive Committee and Hospital Board. The ED Medical Director will supervise the applicant s performance. 17

18 3.4 Resident Physicians A. Those physicians formally enrolled in the Self Regional Healthcare Family Practice Residency Program shall be considered members of the Resident Staff. In certain instances other resident physicians may be eligible for such membership on approval of the departmental chairman and the credentials committee. B. Residents will be assigned to the department in which they are receiving their formal training and will be subject to the rules of that department. Family practice residents will be subject to the rules of each department in which they are receiving assigned education and training. C. Residents shall have patient care privileges only as are assigned to them by the residency faculty members who are members of the active medical staff. For each patient they attend, they shall be associated with, supervised by, and responsible to a designated member of the active medical staff. D. First year residents will perform duties in the emergency room only as part of their education and training and shall at such times be supervised by qualified emergency room physicians, consultants, or faculty members of the residency program. D. Residents in the family practice training program are employees of Self Regional Healthcare and are subject to hospital personnel policies as well as to medical staff bylaws and rules and regulations. F. Professional liability insurance for residents in the family practice training program is furnished by Self Regional Healthcare, covering all their professional activities within the training program, and is at least commensurate with the level of coverage set by the Medical Executive Committee for the general medical staff. G. Supervising physicians must sign or countersign the front sheet, the history and physical examination, the operative note, and the discharge summary. H. Specifics of care and patient management provided by Resident Physicians will be delineated in appropriate policies and procedures developed by the Family Practice Residency Program. 18

19 4.0 MEDICAL STAFF APPOINTMENT AND REAPPOINTMENT 4.1 Preapplication Any person who wishes to apply for Medical Staff membership shall complete a preapplication form specified by the Medical Staff which shall be submitted to the Medical Staff Office for a determination of eligibility to receive an application. The completed preapplication form shall contain basic information as to the person s education, degrees, training experience, state licensure, and professional liability insurance. 4.2 Application for Appointment All applications for initial appointment to the Medical Staff shall be in writing, shall be signed by the Applicant, and shall be submitted on the original of the form developed by the Medical Staff, approved by the Board and delivered to the applicant by the Medical Staff Coordinator after approval of the applicant s preapplication form Information Required The application shall require the applicant to furnish detailed information concerning his professional qualifications, including the following information: 4.2-1(1) References Names and addresses of at least three (3) references who have detailed and personal knowledge of the professional competence, training, experience, ethics and character of the applicant. One reference shall be the residency program director if applicant has completed residency within the past three years. One reference shall be the chairman of the department of which applicant is or was a member if applicant has been on the staff of another hospital subsequent to completion of residency. At least one reference shall be of the same specialty as the applicant. Additional references may be requested at the discretion of the Credentials Committee. The Credentials Committee, may, at its discretion, contact any other potential sources of information concerning the applicant, including medical staff members or administrative officers of other hospitals with which the applicant has been associated, who may have information bearing on the applicant s competence, training, experience, ethics, health status, or character (2) Education Name and location of college(s), medical school(s), residencies, and/or fellowships, with times of attendance, to include month and year; names and addresses of clinical directors of residencies and fellowships; copies of diplomas and board certification certificates. This information is verified by primary source verification or the equivalent as outlined by the JCAHO (3) Licensure Copies of any state licenses held by applicant, as well as copies of Federal and state DEA certificates. Statement as to whether any state license or DEA certificate has ever been denied, limited restricted, suspended, revoked, voluntarily or involuntarily relinquished, or not renewed. South Carolina State Licensure is verified by primary source verification (4) Prior Hospital Affiliation Names and addresses of all hospitals with which applicant has been affiliated in the past, with dates, to include month and year, of affiliation. Statement as to whether applicant has ever been subjected to any disciplinary action at any hospital, and whether staff membership or hospital privileges have ever been voluntarily or involuntarily denied, revoked, suspended, restricted, surrendered or application therefor withdrawn at any hospital or other health care facility. 19

20 4.2-1(5) Legal Information Name and address of liability insurer and copy of face sheet of current professional liability insurance policy. Statement describing each malpractice suit in which applicant has been named as a defendant and disposition of same. Statement as to whether applicant has ever been charged with a crime (6) Health Status Statement by applicant as to the presence of any physical or mental health condition, including alcohol or drug dependence, that affects or is reasonably likely to affect his ability to perform clinical privileges requested (7) Burden on Applicant The applicant shall have the burden of producing adequate information for a proper evaluation of his competence, character, ethics and other qualifications, and for resolving any reasonable doubts about such qualifications Authorizations and Releases By applying for appointment to the Medical Staff, each applicant: 1. signifies his willingness to appear for interviews in regard to his application; 2. authorizes the Hospital to consult with members of Medical Staffs of other hospitals with which the applicant has been associated and with others who may have information bearing on his competence, character and ethical qualifications; 3. consents to the Hospital s inspection of all records and documents that may be material to an evaluation of his professional qualifications and competence to carry out the clinical privileges he requests as well as of his moral and ethical qualifications for staff membership; 4. releases from any liability the Hospital, the Medical Staff and all representatives of either for their acts performed without malice in connection with evaluating the applicant and his credentials; 5. releases from any liability all individuals and organizations who provide information to the Hospital or the Medical Staff without malice concerning the applicant s competence, ethics, character and other qualifications for staff appointment and clinical privileges, including otherwise privileged or confidential information; and 6. releases from any liability the Hospital, the Medical Staff and all representatives of either for their acts performed without malice in connection with peer review, quality assessment or other Medical Staff functions Agreement To Be Bound By Bylaws By applying for appointment to the Medical Staff each applicant represents that he has received and read the Bylaws, rules and regulations of the Medical Staff and agrees to be bound by the terms thereof if he is granted membership and/or clinical privileges and agrees to be bound by the terms thereof in all matters relating to consideration of his application even if he is not granted membership and/or clinical privileges Misrepresentations on Application Untruthful statements or misrepresentation of facts will constitute grounds for denial of staff membership and/or clinical privileges Application Fee A non-refundable application fee of not less than $100.00, as established by the Board, and payable to the Hospital must accompany the completed application. This fee will be waived for referral staff categories, but otherwise no application will be processed until such fee has been paid. 20