Allied Health Care Provider: Appointment and Re-appointment

Allied Health Care Provider: Appointment and Re-appointment Document Owner: Lawson, Louise Version: 8 Effective Date: 10/23/2013 Revision Date: 4/26/2015 Approvers: Calkins, Paul; Del Boccio, Suzanne; Goble, Jonathan, Keene, Jack; Leland, James Department: Medical Staff Office I. PURPOSE The purpose of this policy is to ensure that the provision of health care services to all patients within Indiana University Health North Hospital is in compliance with regulatory statutes and rules governing the practice of Allied Health Practitioners. This policy also outlines the credentialing process required to ensure the competency and appropriate supervision of all Allied Health Practitioners. II. III. SCOPE This policy applies to Allied Health Practitioners who are credentialed and request privileges or reappointment to care for patients within IU Health North Hospital. These individuals include but are not limited to psychologists, podiatrists, certified registered nurse anesthetists, physician s assistants, nurse practitioners, optometrists, and private surgical technologists. DEFINITIONS A. ALLIED HEALTH PRACTITIONERS (AHPs) are individuals other than Medical Staff members who are deemed eligible through appropriate education, training and demonstrated competency to provide health care services within IU Health North Hospital. Allied Health Practitioners are granted privileges at a level dependent on their training to perform certain evaluations, examinations and treatments that would traditionally fall within the practice of a physician member of the medical staff. B. SUPERVISED ALLIED HEALTH PRACTITIONERS are health care professionals who are employed by a physician or dentist member of the Indiana University Health North Hospital Medical Staff and provide patient care services within IU Health North under direct supervision of the physician or dentist. Supervised Allied Health Practitioners may include registered nurses, licensed practical nurses, dental assistants or technologists. A Supervised Allied Health Practitioner may perform an act, duty or function for which the practitioner is trained, and which is performed under the direct supervision of a physician/dentist member of the supervising group within whose area of practice the act, duty, or function falls and within the Allied Health Care Provider: Appointment and Reappointment Page 1

practitioner s scope of practice. A Supervised Allied Health Practitioner may not make a diagnosis or prescribe a treatment and must report the results of any examination of a patient to the supervising physician or a physician member of the group under whose supervision the practitioner is working. C. LICENSED INDEPENDENT PRACTITIONERS (LIPs) are those Allied Health Practitioners who are licensed or certified under state law, authorized to function independently in the Hospital, and granted clinical privileges. These individuals require no formal or direct supervision by a physician. (Psychologists, Podiatrists) D. COLLABORATIVE OR SUPERVISORY AGREEMENT: a formal description of the manner in which an advanced practice nurse, physician assistant or other Allied Health Practitioner will cooperate, coordinate and consult with a licensed practitioner in the provision of health care to patients. IV. POLICY STATEMENTS A. QUALIFICATIONS In general, each Allied Health Practitioner shall at the time of credentialing and continuously thereafter demonstrate to the satisfaction of the Medical Staff and the Board of Managers the following qualifications: 1. A valid and unrestricted license, certificate or other such credentials as may be required by applicable state laws and regulations to practice the advanced nursing or specific allied health profession; 2. Maintain a practice within a reasonable distance of the Hospital; so as to provide continuity and quality care, which distance may vary depending upon the specialty of the member and nature of the privileges; 3. Professional education, training, experience, ethical conduct and any record of clinical results which the monitoring section may reasonably require to assure competency to provide quality patient care; 4. Willingness and capability to work with and relate to patients, Medical Staff members, students, hospital employees and other health disciplines in a cooperative, professional manner to maintain a hospital environment appropriate to quality patient care; 5. Qualification as a health care provider and professional liability insurance in the amounts required by the Indiana Medical Malpractice Statute; 6. Annual evaluation of competency if applicable; 7. Initial application fee will be assessed at time of application; 8. Subject to Indiana University Health North Hospital annual dues as outlined in Medical Staff Bylaws. B. No Entitlement to Appointment and Reappointment Allied Health Care Provider: Appointment and Reappointment Page 2

Allied Health and medical staff membership and clinical privileges are a privilege, not a right. No one is entitled to receive an application or be appointed or reappointed to the Allied Health staff or to be granted particular clinical privileges merely because he or she: 1. is licensed to practice a profession in this or any other state; 2. is a member of any particular professional organization; 3. has had in the past, or currently has, medical staff appointment or privileges at any hospital or health care facility; 4. resides in the geographic service area of the hospital; 5. is affiliated with, or under contract to, any managed care plan, insurance plan, HMO, PPO, or other entity. C. Gender, color, race, creed, and national origin are not used in making decisions regarding the granting or denying of Allied Health membership and/or privileges. D. Any decision not to tender an application to an Allied Health Practitioner will be made by the Credentials Committee. E. Basic Responsibilities and Requirements: Every individual seeking to practice as an Allied Health Practitioner and his or her respective Supervising Physician specifically agree that: 1. any privileges granted by the Board to any Allied Health Practitioner who is not a LIP will be performed in the Hospital only under the supervision of a Supervising Physician; 2. the number of Allied Health Practitioners employed by or under the supervision of a Member of the Medical Staff will be consistent with state law and the rules and regulations of the Medical Staff; and 3. an Allied Health Practitioner will give notice, within three business days, to the Medical Staff Office of any revisions or modifications that are made to the supervision agreement. The Medical Staff Office will submit the documentation to the appropriate Allied Health reviewer, Chief Nursing Officer and Section Chair. V. PROCEDURE(s) A. MECHANISM FOR APPOINTMENT Upon the recommendation of the physician sponsor/supervisor and a section chair with whom they wish to affiliate, applicants will complete an Application and Request for Clinical Privileges form specific to the Allied Health Practitioner category for which they qualify. The application and request must include evidence of the following: 1. education and training, including appropriate evidence of certification(s); Allied Health Care Provider: Appointment and Reappointment Page 3

2. affiliations with health care facilities, past and current; 3. references; 4. Copy of current and adequate liability insurance as established in the State of Indiana (copy of policy or letter from carrier describing effective date, termination date and limitations of coverage). (declarations page) 5. copy of TB skin test or other TB surveillance documentation (questionnaire, results of chest x-ray) no more than twelve (12) months old. 6. documentation of current flu vaccination when applicable per INDIANA UNIVERSITY HEALTH influenza vaccination policy. 7. practitioner s agreement to abide by the Medical Staff and Hospital Rules and Regulations. 8. collaborative practice or supervisory agreement, if applicable. Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs) and Physician Assistants-C (PA-Cs) will provide a copy of their current Agreement signed by the AHP and the sponsoring physician with whom the practitioner will be working. A current list of other practitioners in the office with whom the AHP may work at IUH North Hospital will be provided along with the agreement. 9. Verification of current licensure in the State of Indiana and verification of current State of Indiana Controlled Substance Registration (CSR), if applicable. 10. Copy of current Federal Drug Enforcement Administration Certificate (DEA) or copy of verification from the U.S. Department of Commerce National Technical Information Service (NTIS) database, if applicable. 11. Delineation of Clinical Privileges form for clinical section in which privileges are requested. 12. Statement of current health status and ability to provide patient care in the area in which privileges are requested. 13. Circumstances concerning voluntary or involuntary termination of Allied Health membership or voluntary or involuntary limitation, reduction, or loss of clinical privileges at any hospital or healthcare organization. 14. Circumstances concerning previously successful or currently pending challenges to any licensure or registration (state or district Drug Enforcement Administration) or the voluntary or involuntary relinquishment of such licensure or registration. 15. Documentation of current CPR certification. 16. Query of National Practitioner Data Bank (NPDB) if applicable. 17. Each applicant shall sign a consent form, Authorization, Consent and Release, consenting to the inspection/review of records and Allied Health Care Provider: Appointment and Reappointment Page 4

documents pertinent to his or her licensure, specific training, medical/clinical knowledge, clinical judgment, interpersonal skills, communication skills, experience, current competency, and health status. If requested, the applicant will agree to appear for an interview. 18. Applicant shall sign an agreement acknowledging that the bylaws, rules and regulations, and policies have been made available to him or her and agrees in writing that his or her activities as an Allied Health Practitioner will be bound by the bylaws. The completed application and request for clinical privileges will be reviewed and approved by the physician sponsor/supervisor and the section chair, and submitted to the Credentials Committee for consideration; recommendations will be made to the Medical Staff Executive Committee. Final action will rest with the Board of Managers. The applicant and Section Chair shall be advised in writing when approved, limited or denied. The Medical Staff Services Office will maintain files on all Allied Health Practitioners. Appointments shall be granted for not more than two (2) year period following presentation to and approval of the governing body. A period of focused professional practice evaluation (FPPE) is required for every new practitioner. Specific parameters are developed by each section to accomplish this review. The Allied Health Practitioner and section chair will be advised in writing when their reappointment is granted, limited or denied or when privileges are granted, limited or revoked. External agencies are notified as defined by applicable law. B. MECHANISM FOR REAPPOINTMENT The reappointment process at IU Health North Hospital requires Allied Health Practitioners to complete a reappointment process every two (2) years. An Application for Reappointment to the Allied Health Practitioner Staff must be complete and include the following documents/information in addition to the requirements outlined for appointment. 1. A completed application for reappointment must be submitted within forty-five (45) days following the date stipulated in the Reappointment Cover Memo. During the forty-five (45) days, the following steps will be taken by the Medical Staff Office or Central Verification Organization: Allied Health Care Provider: Appointment and Reappointment Page 5

a. On the due date stipulated in the cover memo, the Allied Health Practitioner shall be faxed, emailed or mailed a reminder notice to the address on file in the Medical Staff Office. The Allied Health Practitioner shall receive an additional two (2) weeks to complete the application. b. Six (6) weeks past the due date, the Medical Staff Office or Central Verification Organization will fax, email or mail (certified, return receipt requested) a Non Compliance Letter, to the office address on file in the Medical Staff Office, stating that their privileges will expire on the last day of the month prior to their reappointment date due to non-compliance with the Medical Staff Bylaws and the Reappointment Policy. c. Allied Health Practitioners desiring to maintain privileges once the Non Compliance Letter is received must: 1.) Deliver, email or fax the Reappointment Application, Request for Clinical Privileges (if applicable), and current copies of licensure, State of Indiana Controlled Substance Registration (CSR if applicable, Federal DEA (if applicable), current professional liability insurance, TB surveillance testing documentation, and flu vaccine documentation (if applicable) to the Medical Staff Office. 2.) Pay a reinstatement fee of $100 if requested. Checks should be made payable to IU Health North Hospital Medical Staff. 3.) The Medical Staff Office will not accept reappointment applications if any items mentioned above are not attached or already on file when delivered to the Medical Staff Office. 4.) The Allied Health Practitioner must cease providing care in IU Health North Hospital until such time as the reappointment process is completed. If failure to allow the practitioner to continue to provide care would result in a problem meeting an important patient care need, temporary privileges could be granted. Temporary privileges must be requested by the physician supervisor and section chair on the recommendation of the President of the Medical Staff or authorized designee and granted by the Chief Executive Officer (CEO) or designee. Temporary privileges are granted for no more than 120 days. 2. Circumstances concerning professional liability actions since initial or last appointment. 3. Final settlements or judgments of professional liability actions since initial or last appointment. Allied Health Care Provider: Appointment and Reappointment Page 6

4. Circumstances concerning voluntary or involuntary termination of Allied Health membership or voluntary or involuntary limitation, reduction, or loss of clinical privileges at any hospital or health care organization. 5. Circumstances concerning previously successful or currently pending challenges to any licensure or registration (state or district Drug Enforcement Administration) or the voluntary or involuntary relinquishment of such licensure or registration. 6. Disciplinary actions since initial or last appointment. 7. Documentation of current TB skin test or other TB surveillance documentation (questionnaire or results of chest x-ray) and documentation of current flu vaccination when applicable per INDIANA UNIVERSITY HEALTH influenza vaccination policy. 8. Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs) and Physician Assistants-C (PA-Cs) will provide a copy of their current Supervisory or Collaborative Practice Agreement signed by AHP and the sponsoring physician with whom the practitioner will be working. A current list of other practitioners in the office with whom the AHP may work at IUH North Hospital will be provided along with the agreement. 9. Documentation of current CPR certification. 10 Documentation of current certification in their specialty when applicable. 11. Documentation of completion of Continuing Education (CE) since the last reappointment must be submitted. The number of credits required is determined by the specialty and the requirements of IUH North Hospital. An applicant is responsible for documenting credit earned and for providing such documentation as the Medical Staff Office may require. EXCEPTION: Applicants going through the reappointment process early due to the birthdate schedule, will not be required to meet the CE requirement until their next scheduled reappointment date. 12. Applicant shall have satisfied all Allied Health Staff responsibilities including payment of any dues or fees. The completed reappointment application and request for clinical privileges, as well as findings from quality assessment and ongoing professional practice evaluation (OPPE), will be reviewed and approved by the physician sponsor/supervisor, Chief Nursing Officer (CNO) and the section chair, and submitted to the Credentials Committee for consideration; recommendations will be made to the Medical Staff Executive Committee. Final action will rest with the Board of Managers. Allied Health Care Provider: Appointment and Reappointment Page 7

C. CATEGORIES OF ALLIED HEALTH PRACTITIONERS Individuals meeting requirements defined in the following categories, may be considered for appointment as Allied Health Practitioners at IU Health North Hospital. SUPERVISED ALLIED HEALTH PRACTITIONERS Supervised Allied Health Practitioners are health care professionals who are employed by a physician or dentist member of the Indiana University Health North Hospital Medical Staff and provide patient care services within IU Health North under direct supervision of the physician or dentist. Supervised Allied Health Practitioners may include registered nurses, licensed practical nurses or technologists. PODIATRISTS Podiatrists are Allied Health Practitioners who have a valid, current and unsuspended license to practice their profession, and meet the applicable requirements for allied health practitioners who are eligible to perform health care services in the hospital as LIPs. They are assigned to the Surgery section of the IU Health North Hospital Medical Staff, which shall monitor such services as provided by the podiatrist in the hospital setting. 1. Podiatrists shall adhere to the rules and regulations of the Surgery section. 2. Privileges granted shall be commensurate with the training, competence judgment, character and current capability of the candidate. 3. Privileges granted to perform surgery in the operating rooms of IU Health North Hospital shall be limited to those individuals who are graduates of an accredited college of Podiatric Medicine; have completed a PSR 12 one year or greater American Podiatric Association approved residency program; and are Board eligible pursuant to the requirements of the American Board of Foot Surgery. Upon completion of the third year of membership of the Podiatric staff at IU Health North Hospital, individuals are required to be Board Certified by the American Board of Foot Surgery. 4. Training and experience to perform privileges requested must be confirmed in writing by the clinical training supervisor of the approved residency program, or in the case of a new procedure and/or technique, proof of successful completion of a training Allied Health Care Provider: Appointment and Reappointment Page 8

course(s) in the requested procedure or technique. The burden of submitting this information is the responsibility of the applicant. 5. Patients undergoing inpatient or outpatient procedures must have a history and physical done by an IU Health North Hospital Medical Staff physician according to preoperative preparation of patients. 6. Applicants shall complete and sign an Allied Health Practitioner Request for Clinical Privileges form for Podiatrists indicating the privileges being requested. The Section chair of the Surgery section shall review and sign all requests for clinical privileges. PSYCHOLOGISTS Psychologists are Allied Health Practitioners who have a valid, current and unsuspended license to practice their profession; who hold the Health Service Provider in Psychology credential in the state of Indiana; and, who meet the applicable requirements to perform health care services in the hospital as LIPs. Psychologists may be assigned to the Medicine section of the IU Health North Hospital Medical Staff, which shall monitor such services as provided by psychologists in the hospital setting. Psychologists are trained and experienced in the evaluation and treatment by psychological methods of a number of mental, emotional, behavioral, interpersonal, cognitive, intellectual and learning problems of patients. 1. Psychologists shall adhere to the rules and regulations of the Medicine section. 2. Privileges granted shall be commensurate with the training, competence, judgment, character, and current capability of the candidate to evaluate and treat by psychological methods a number of emotional, behavioral, and interpersonal problems of patients. 3. Physical care and treatment of patients must be provided at the direction of a physician with hospital privileges. 4. Applicants shall complete and sign an Allied Health Practitioner Request for Clinical Privileges form indicating the privileges being requested. 5. The Section chair of the Medicine section shall review and sign all requests for clinical privileges. PHYSICIAN ASSISTANTS Physician Assistants are licensed healthcare providers working under the direction of a supervising physician to provide patient care, in both inpatient and outpatient settings. The Physician Assistant performs delegated activities which are traditionally associated with the physician role, and designated as clinical privileges. The Physician Assistant Allied Health Care Provider: Appointment and Reappointment Page 9

functions under a supervisory agreement with the physician, and according to privileges granted by the Board of Managers. 1. Qualifications: a. Successful completion of an educational program for Physician Assistants accredited by the Committee on Allied Health Education and Accreditation of the American Medical Association (CAHEA); b. Physician Assistant National Examination Certification indicating successful completion by the National Commission on the Certification of Physician Assistants (NCCPA) or equivalent certification approved by the Committee; c. Registered as a physician assistant with the Medical Licensing Board; d. Evidence of training in the area of medical specialty (if applicable). 2. Scope: clinical sections planning to engage a physician assistant are required to: a. adhere to the overall program description outlined in the medical Staff Rules and Regulations; b. develop a service specific job description including the following: objective of the program (service); objectives of the physician assistant role (this should be service-specific and indicate primary setting, e.g., inpatient, outpatient or both). c. define clinical privileges (specific medical care activities to be delegated requiring credentialing); d. establish procedure protocols as deemed necessary and appropriate; e. provide a copy of the supervisory agreement. 3. Supervision: a. The physician assistant is accountable to the medical staff member for all aspects of delegated medical management of patients and is supervised by the attending physician. Delegated medical management functions are performed according to a supervisory agreement and/or protocols defined by the specific clinical service, and approved by the medical staff. b. Specific levels of supervision for delegated medical management activities are required as follows: Allied Health Care Provider: Appointment and Reappointment Page 10

1) The supervising physician must be physically present or immediately available for supervision and/or consultation at all times that the services are rendered by the physician assistant. 2) The physician assistant may perform only such procedures and other tasks that are within the normal scope or practice of the supervising physician. 4. Practice: a. A physician assistant working under the supervision of an attending physician, may be granted privileges to: 1) obtain history and perform physical exam; 2) propose a differential medical diagnosis; 3) order and evaluate diagnostic studies; 4) evaluate and manage follow-up plans based on patient/family response; 5) document health appraisal data, including history, physical findings, diagnosis and treatment; 6) following approval of an attending physician, communicate results of evaluation and treatment to referring practitioner; 7) perform procedures as appropriate; and 8) administer non-scheduled drugs as prescribed by the attending physician. 5. Prescriptive Authority for Physician Assistant-C A PA-C may be authorized to prescribe drugs, including controlled substances, if the following requirements have been met: a. proof of an active, unrestricted Indiana PA-C license; b. proof of collaboration with licensed practitioner in the form of a written supervisory agreement that includes prescriptive authority; c. current Indiana Controlled Substance Registration; and d. current Federal DEA Registration. Without both the CSR and DEA, the PA-C cannot prescribe controlled substances. ADVANCED PRACTICE NURSES Allied Health Care Provider: Appointment and Reappointment Page 11

Advanced Practice Nurses are registered nurses who hold a current license in the state of Indiana and who have obtained additional knowledge and skill through a formal, organized didactic program and clinical experience or equivalent training as determined by the Board of Nursing. These qualified individuals function in an expanded role of nursing at a specialized level through the application of advanced knowledge and skill to provide health care to individuals, families or groups in a variety of settings. Such settings include, but are not limited to homes, institutions, offices, industries, schools, community agencies, private practice, hospital outpatient clinics and health maintenance organizations. Advanced Practice Nurses make independent decisions about the nursing needs of patients. An advanced practice nurse may perform independently all functions that fall within the scope of nursing practice. An advanced practice nurse who performs special evaluations, examinations or treatments that would traditionally fall within the practice of a Medical Staff member shall operate in collaboration with an independent licensed physician. This would be evidenced in a practice agreement with the physician and by privileges granted by the Board of Managers. Privileges granted shall be commensurate with the training, competence judgment, character and current capability of the candidate. It will be the responsibility of the section to identify individuals who may be eligible to be credentialed for delegated activities traditionally associated with the physician role and to develop practice agreements, protocols and a delineation of clinical privilege form for these roles. Practice agreements must describe specific activities, define the required credentials, identify the appropriate medical supervision, and provide an indication of the amount of time devoted to these activities. An Application and Request for Clinical Privileges form must be submitted to the Credentials Committee for consideration. Recommendations will be made to the Executive Committee with final action by the Board of Managers. NURSE PRACTITIONERS AND CLINICAL NURSE SPECIALISTS 1. Qualifications: a. RN currently licensed in Indiana; b. Master s degree in nursing from an accredited program; c. Nurse practitioner or clinical nurse specialist certification; d. Evidence of training in the area of medical specialty (if applicable) Allied Health Care Provider: Appointment and Reappointment Page 12

2. Scope: clinical sections planning to engage a nurse practitioner or clinical nurse specialist are required to: a. Coordinate the nursing related service specific job description and the hiring process with the nursing department. b. Develop a service specific job description including the following: objective of the program (service); objectives for the advanced practice nurse role (this should be service-specific and indicate primary setting, e.g., inpatient, outpatient or both). c. define clinical privileges (specific medical care activities to be delegated requiring credentialing); d. establish procedure protocols as deemed necessary and appropriate; e. provide a copy of collaborative practice agreement. 3. Practice: a. A nurse practitioner or clinical nurse specialist working under the supervision of an attending physician may be granted the following privileges: 1) obtain a history and perform physical exam; 2) propose a differential medical diagnosis; 3) order and evaluate diagnostic studies; 4) order and adjust medications; 5) evaluate and manage follow-up plans based on patient/family response; 6) document health appraisal data, including history, physical findings, diagnosis and treatment, following approval of an attending physician, and communicate results of evaluation and treatment to referring practitioner; 7) perform procedures as appropriate. 4. Prescriptive Authority for Advanced Practice Nurse a. An Advanced Practice Nurse may be authorized to prescribe drugs, including controlled substances, if the following requirements have been met: 1) application made to the Indiana State Board of Nursing with the required fee; 2) proof of an active, unrestricted Indiana registered nurse license; Allied Health Care Provider: Appointment and Reappointment Page 13

3) proof of having met the requirements of all applicable laws for practice as an advanced practice nurse in the State of Indiana; 4) proof of successfully completing all educational requirements to qualify for prescriptive authority; 5) proof of collaboration with licensed practitioner in the form of a written practice agreement; 6) current Indiana Controlled Substance Registration; 7) current Federal DEA Registration. b. Clinical sections utilizing an advanced practice nurse who has been granted prescriptive authority by the Indiana State Board of Nursing will be responsible for developing the practice agreement outlining the collaboration between the physician(s) and the advanced practice nurse. D. Termination of Privileges for any Allied Health Practitioner (AHP) functioning under an agreement with a member of the medical staff When the following occurs, any AHP employed by a member of the Medical Staff will have his/her privileges automatically terminated: 1. the Medical Staff membership of the physician supervisor is terminated, whether such termination is voluntary or involuntary; 2. the physician supervisor terminates the supervising relationship with the AHP regardless of the reason; or 3. the certification or license of the AHP expires, is revoked or is suspended. An Allied Health Practitioner within the definition of I.C. 34-4-12.6-1 is entitled to the rights and obligations of Medical Staff members under Article IX of the Medical Staff Bylaws in the event that charges are brought that if sustained by the Board of Managers could result in action required to be reported to or result in disciplinary action by the allied health care provider's state licensing board. VI. VII. REFERENCES IUH North Hospital Medical Staff Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) Policy RESPONSIBILITY Medical Executive Committee Medical Staff Office Allied Health Care Provider: Appointment and Reappointment Page 14

VIII. APPROVAL BODY Medical Executive Committee Board of Managers IX. APPROVAL SIGNATURES James Leland, MD, Chair Credentials Committee Date Suzanne Del Boccio, CNO and VP of Patient Care Services Date Jack Keene, MD President Medical Staff Chair, Medical Executive Committee Date Paul Calkins, MD Chief Medical Officer Date Jonathan R. Goble, MHA, MBO, FACHE President and CEO Date Allied Health Care Provider: Appointment and Reappointment Page 15