Mercy Hospital Medical Staff Credentialing Manual

CREDENTIALING MANUAL APPROVED BY BYLAWS COMMITTEE MAY 22, 2007 Mercy Hospital Medical Staff Credentialing Manual Approved by the Medical Executive Committee: Mercy Hospital Anderson: January 21, 2008 Mercy Hospital Clermont: January 10, 2008 Mercy Hospital Fairfield: January 15, 2008 Mercy Franciscan - Mt. Airy: January 8, 2008 Mercy Franciscan - Western Hills: January 22, 2008 Approved by the Board of Trustees: January 24, 2008 - Cred. i -

Table of Contents 1. DEFINITIONS AND GENERAL PROVISIONS...1 1.1. ADOPTION, AMENDMENT AND APPROVAL...1 2. APPOINTMENT/REAPPOINTMENT TO THE MEDICAL STAFF...1 2.1. FORM AND CONTENT OF APPLICATIONS...1 2.2. PROCESSING APPLICATIONS...5 11 2.3. DISASTER PRIVILEGES. 2.4. MONITORING CONNTINUING ELIGIBILITY...16 2.5. APPLICATIONS FOR RETURN FROM LEAVE OF ABSENCE.15 2.6 TELEMEDICINE.15 3. CLINICAL PRIVILEGES...17 3.1. DEPARTMENT RESPONSIBILITY FOR PRIVILEGES...17 3.2. PROCESSING TEMPORARY PRIVILEGES...18 3.3 LOCUM TENENS.18 3.4 PROCEDURAL SEDATION...18 4. LOW VOLUME/NO VOLUME PRACTITIONER POLICY 18 5. CREDENTIALING PLAN FOR ALLIED HEALTH PROFESSIONALS...19 6. TUBERCULOSIS SCREENING PROGRAM.30 7. NEW TECHNOLOGIES/NEW PROCEDURES..33 ii

CREDENTIALING MANUAL APPROVED BY BYLAWS COMMITTEE MAY 22, 2007 1. DEFINITIONS AND GENERAL PROVISIONS 1.1. Adoption, Amendment and Approval This Credentialing Manual may be adopted or amended by a majority vote of the MEC and is effective upon approval by the Board. 2. APPOINTMENT/REAPPOINTMENT TO THE MEDICAL STAFF 2.1. Form and Content of Applications 2.1.1. Initial Applications: All initial applications to the Medical Staff must be in writing and the attestation signed. In the application, the applicant must provide, at a minimum, the following information or documents: 2.1.1.1.Specific requests for Medical Staff category and Clinical Privileges desired; 2.1.1.2.Residence and office locations; 2.1.1.3.Information reflecting completion of medical school or other professional schools appropriate to the applicant s discipline; 2.1.1.4.Declaration page of current professional liability policy (and attached pages as necessary) showing applicant s name, insurer s name, amount of coverage, policy number and effective and expiration dates; 2.1.1.5.Evidence of satisfactory completion of residency/training programs or other educational curriculum; 2.1.1.6.Evidence of specialty board status, if any; 2.1.1.7.Relevant experience in support of the Privileges sought (to be described on Privileges request form(s)); 2.1.1.8.Other facilities where the applicant has or did have Privileges; 2.1.1.9. The CCO will receive peer references as described in Bylaws 5.4.5 as well as the Credentialing Manual 2.2.5 ; 2.1.1.10.Information about each pending or final disciplinary or licensure action at any other hospital, health maintenance organization, health care entity or academic institution; - Cred. 1 -

2.1.1.11.Information about each voluntary and involuntary withdrawal from a medical staff or a voluntary or involuntary withdrawal of an application for a medical staff appointment or Clinical Privileges; at any other hospital, health maintenance organization, health care entity or academic institution; 2.1.1.12.Information about each pending or final suspension, revocation or restriction, or the voluntary or involuntary relinquishment of an applicant s: 2.1.1.12.1.license to practice in any state; 2.1.1.12.2.specialty board certification; 2.1.1.12.3.state or federal narcotics registration certificate; 2.1.1.12.4.ability to participate in any Federal Health Program; 2.1.1.13.All professional malpractice claim information relative to the applicant within the last ten (10) years 2.1.1.14.Information about health status; 2.1.1.15.Consent to submit to such physical or mental examination as the MEC may require. Taking or passing a physical or mental examination must not be a part of the application process, but the exercise of Clinical Privileges that are otherwise granted may be made subject to the successful completion of such an examination. The identity of the examining physician(s) must be by mutual consent. In the event of a disagreement concerning the need for an examination or the identity of the examining physician(s), the matter must be referred to the Board, whose decision on the matter is final; 2.1.1.16.Consent to release of information from, and releases from liability in favor of, insurance carriers, references, all institutions where applicant has worked, trained or practiced and to which he has applied and all other sources of information required in the application, and consent to appear for an interview, if requested; 2.1.1.17.Statement acknowledging and understanding Mercy Confidentiality policy; 2.1.1.18.A Medicare fraud attestation; 2.1.1.19. The initial applicant shall submit four (4) passport size photographs which will be attached to the release executed by the applicant and distributed to references to confirm the applicant s identity; 2

2.1.1.20.Verification that the applicant has received and reviewed the Bylaws, Rules and Regulations and all policies of the Medical Staff and of the Hospital relating to appointment to the Medical Staff and the delineation of Clinical Privileges and that he agrees to be bound by them; 2.1.1.21.A non-refundable application fee. 2.1.1.22.Statement of Physician Expectations whereby the practitioner attests to having read and agrees to abide by the Expectations. 2.1.1.23. Mercy Health supplemental forms, attestation, release and other related documents. 2.1.2. Applications for Reappointment: At least six months prior to the expiration of a Member s Medical Staff appointment, the CCO will send the Member a written reappointment form. The applicant must provide in his reapplication, at a minimum, the following information or documents: 2.1.2.1. Verification that all information provided on previous applications remains correct, or updated information as necessary. The form must specifically seek, at a minimum, previously undisclosed information relating to: 2.1.2.1.1.previously successful or currently pending challenges to any licensure or registration or the voluntary relinquishment of such licensure or registration; 2.1.2.1.2.voluntary or involuntary termination of medical staff membership or voluntary or involuntary limitation, reduction or loss of clinical privileges at another hospital; 2.1.2.1.3.Any evidence of an unusual pattern of an excessive number of professional liability actions resulting in a final judgment against the applicant; involvement in each professional liability action, including all judgments and settlements within the past ten (10) years. 2.1.2.1.4.relevant practitioner-specific data are compared to aggregate data, when available; Performance Measurement Data including morbidity and mortality data when available; and 2.1.2.2.Information about health status, 2.1.2.3.Specific request for delineated Privileges, 2.1.2.4. Sufficient clinical performance information to grant, limit or deny the requested privileges. 3

2.1.3. Applications to Modify Status or Privileges: A Member may apply in writing for a change in his Medical Staff category, Department assignment or Clinical Privileges. Such an application must be in writing. 2.1.4. Effect of Applications (Initial and Reappointment): Each person who signs the consent and release and submits an application under this Article: 2.1.4.1. Warrants that the information submitted with the application and on all prior applications, as amended, is complete and accurate; agrees that he will provide updated information as soon as practicable concerning each change to a response to any question on an application; and agrees that material misstatements, omissions or misleading statements may be grounds for suspension or termination without a hearing under the Fair Hearing Plan; 2.1.4.2. Consents to appear for such interviews and provide such additional information or documents as any Professional Review Body may require; 2.1.4.3. Authorizes each Professional Review Body to consult with persons who may have information bearing on the applicant s qualifications; 2.1.4.4. Consents to the inspection of all documents and the release of all information that any Professional Review Body may determine to be relevant in assessing the applicant s qualifications, including all records and documents pertaining to his or her licensure, specific training, experience, current competence and ability to perform the privileges requested; 2.1.4.5. Agrees to submit any reasonable evidence of current ability to perform the privileges requested and to submit to such physical or mental examination as the MEC may require. Taking or passing a physical or mental examination must not be a part of the application process, but the exercise of Clinical Privileges that are otherwise granted may be made subject to the successful completion of such an examination. The identity of the examining physician(s) must be by mutual consent. In the event of a disagreement concerning the need for an examination or the identity of the examining physician(s), the matter must be referred to the Board, whose decision on the matter is final. 2.1.4.6. Releases all Mercy Representatives, each Professional Review Body and its individual members from liability for acts performed in connection with the evaluation of the applicant s qualifications; 2.1.4.7. Releases all persons from liability who provide information, including information that is otherwise privileged or confidential, in connection with the evaluation of the applicant s qualifications; 4

2.1.4.8. Authorizes Mercy Representatives to release information pertaining to the applicant s qualifications to other hospitals, health care entities and authorized health care licensing, data collection and reporting agencies, to the extent to which consented in writing or permitted or required by law, and releases the Hospital Representatives for so doing; 2.1.4.9. Acknowledges that he has received a copy of the Bylaws, Rules and Regulations and all policies of the Medical Staff and of the Hospital relating to appointment to the Medical Staff and the delineation of Clinical Privileges (and all revisions to those documents), and that he understands them and agrees to be bound by them; 2.1.4.10. Agrees to perform and abide by the obligations set forth under Responsibilities of Medical Staff Membership in the Bylaws, including the obligation to provide continuous care for his or her patients; 2.1.4.11. Agrees to comply with all state and federal laws regarding the practice of medicine, including without limitation, the prohibitions against fee splitting, antireferral and antikickback statutes; 2.1.4.12. Agrees that in the event any Professional Review Body takes, recommends or considers the taking or recommending of a Professional Review Action, he will exhaust all steps provided in these Bylaws, including the provisions of the Resolving Professional Competence, Conduct or Discipline Issues Article and the Fair Hearing Plan as his exclusive remedy. 2.2. Processing Applications 2.2.1. CCO General Function: The CCO will perform the following functions respecting all applications for Medical Staff membership or Clinical Privileges at each Mercy Hospital or affiliate 2.2.1.1.Collect and organize all applications and associated materials; 2.2.1.2.Conduct all necessary primary source and other verifications; 2.2.1.3.Serve as repository of credentialing information; 2.2.1.4.Provide Practitioner-specific credentialing information to each Mercy Hospital or affiliate where a Practitioner applies for or holds Medical Staff membership, Clinical Privileges. 5

2.2.2. Confidentiality Safeguards: The CCO must establish and enforce appropriate safeguards to ensure that credentialing information -- 2.2.2.1.Is protected from disclosure to persons or organizations other than Mercy Hospitals or affiliate, except upon a written, dated release signed by the Practitioner and directed specifically to Mercy Health Partners (MHP) authorizing such disclosure; 2.2.2.2.Is provided only to persons at such Hospitals, affiliates involved in pursuit of a legitimate credentialing function; and 2.2.2.3.Is provided with the express caution that such information is confidential and may not be further disclosed. 2.2.3. Incomplete Applications: The duty to file a complete, signed application, rests exclusively with the applicant. Efforts by the CCO or others to assist in the collection of documents or information do not shift the responsibility from the applicant in any respect. The rules related to timely submission of applications contained in the System-wide Credentialing Services Operations Manual will be strictly enforced: 2.2.3.1.Initial Applicants: Initial applicants who file an incomplete application will receive a letter from the CCO requesting completion within a stated deadline. If the applicant does not comply within the deadline it is deemed voluntarily withdrawn as of that date. The applicant may reapply by submitting a new application and an additional nonrefundable processing fee. 2.2.3.2.Applicants for Reappointment: Applicants who fail to return a completed application for reappointment within timeframes approved in the System-wide Credentialing Services Operations Manual will receive a letter from the CCO requesting completion. If the application is not submitted or remains incomplete the application will be deemed voluntarily withdrawn at the end of the current appointment. 2.2.4. CCO Handling: All applications must be mailed or delivered to the CCO. When an applicant has properly filled in and signed his application, the CCO will do the following: 2.2.4.1.For initial and applicants for reappointment 2.2.4.1.1. Verify the applicant s current licensure, specific training, experience and current competence through primary sources. Action on an initial application may not proceed until all this information has been collected and verified; 6

2.2.4.1.2.Query the National Practitioner Data Bank; 2.2.4.1.3.Obtain professional malpractice claim information; 2.2.4.1.4.Assure the presence of completed references and all other required forms and consents; 2.2.4.1.5.Verify the status of privileges at other health care facilities; 2.2.4.1.6.Check for sanctions through the Office of the Inspector General and the Excluded Provider List System; 2.2.4.2. Collection of statistical data to grant, limit or deny the requested privileges. 2.2.4.2.1.Assure the presence of one peer reference and one hospital verification, if required; (reappointment only) 2.2.5. Peer References: Recommendations from peers are obtained and evaluated for all new applicants for privileges. Upon renewal of privileges (reappointment), when insufficient practitioner-specific data are available, the medical staff obtains and evaluates peer recommendations. A recommendation from peers is defined as an appropriate practitioner in the same professional discipline as the applicant who has personal knowledge of the applicant and the applicant s ability to practice. They reflect a basis for recommending the granting of privileges. Sources for peer recommendation may include the following: 2.2.5.1.An organization performance improvement committee, the majority of whose members are the applicant s peers; 2.2.5.2.A reference letter(s), written documentation or documented telephone conversation(s) about the applicant from a peer(s) who is knowledgeable about the applicant s professional performance and competence; 2.2.5.3.A department or major clinical service chairperson who is a peer; 2.2.5.4.The Medical Executive Committee Peer recommendations include the following: 2.2.5.5.Relevant training and experience 2.2.5.6.Current competence 2.2.5.7.Any effects of health status on privileges being requested 7

2.2.5.8.Patient Care 2.2.5.9.Medical/clinical Knowledge 2.2.5.10.Technical and clinical skills 2.2.5.11.Clinical judgment 2.2.5.12.Practice-Based Learning and Improvement 2.2.5.13.Interpersonal and Communication Skills 2.2.5.14.Professionalism 2.2.5.15.Systems-Based Practice 2.2.6. Forwarding the Application File: When all information has been collected and sources have been verified as necessary, the CCO will forward credentialing information to the Hospital(s) to which the applicant has applied for Membership and Privileges. 2.2.7. Each Hospital to which the applicant has applied for Membership and Privileges will assure the assembly of the following information: performance data (i.e., clinical activity data), information and comparative physician profiles to include at a minimum, the following information: 2.2.7.1.review of operative and other clinical procedure(s) performed and their outcomes 2.2.7.2. pattern of blood and pharmaceutical usage 2.2.7.3.requests for tests and procedures 2.2.7.4.length of stay patterns 2.2.7.5.morbidity and mortality data 2.2.7.6.practitioner s use of consultants 2.2.7.7.other relevant criteria as determined by the individual MHP organized medical staffs. 2.2.8. Department Recommendations: The Chairperson of the Department (or his designee) in which the applicant seeks Privileges must review the Application File. He may conduct an interview and must document the interview if he conducts one. The Chairperson may make such additional inquiries, as he deems appropriate in assessing the applicant s qualifications. He should also coordinate his review with that of other chairpersons in whose Departments the applicant also seeks Privileges. Upon completion 8

of the review, interview and inquiry, the Chairperson must make a written recommendation to the Credentials Committee relating to the requested status and Clinical Privileges. The interview, if one is conducted, is not a hearing, and neither the interview nor the recommendation entitles the applicant to any rights under the Fair Hearing Plan. Where the applicant is a Department Chairperson, the report will be prepared by the Credentials Committee. 2.2.9. Credentials Committee Action: The Credentials Committee must review the Application File, Department and peer recommendation(s). The Credentials Committee must collect and consider available information concerning the applicant s professional conduct, performance and conduct both in the Hospital and at other health care entities. The Credentials Committee may conduct an interview and must make a record of the interview and include the record in the Application File. At the conclusion of its review, the Credentials Committee must make a recommendation to the MEC pertaining to the requested Medical Staff status, staff category, Department assignment and Clinical Privileges, with suggested special conditions or limitations, if any. 2.2.10 MEC Action: At its next regular meeting after receipt of the Credentials Committee report and recommendation, or as soon thereafter as is practical, the MEC shall consider the Credentials Committee report and any other relevant information. The MEC may request additional information, return the matter to the Credentials Committee for further investigation, and/or elect to interview the applicant. The MEC shall then prepare and forward to the Chief of Staff, for prompt transmittal to the Board, a recommendation as to Medical Staff appointment and, if appointment is recommended, as to membership category, Clinical Privileges to be granted and any special conditions to be attached to the appointment. 2.2.11 If the recommendation Affects Adversely the applicant s membership or Clinical Privileges, the MEC must give Notice to the applicant of his right to a hearing in accordance with the Fair Hearing Plan. 2.2.12 Board Action: The Board must review each favorable recommendation of the MEC requesting Medical Staff appointment and Clinical Privileges. SUBCOMMITTEE OF THE BOARD: In lieu of review by the full Board, the Board may, pursuant to authority in the Board s bylaws, direct that initial and reappointment applications which meet the criteria for expedited credentialing and privileging process, and have received approval by the Department Chair, Credentials Committee and Medical Executive Committee may be reviewed by a Board subcommittee of at least two voting members of the governing body Only those applicants that qualify under Medical Staff Standard 4.35 of the Comprehensive Accreditation Manual for Hospitals published by the Joint Commission may be reviewed. Approval of such applicants is effective as of the date of approval by the designated subcommittee. An application which has been deemed complete and has received approval by the Department Chair, Credentials Committee and the Medical Executive Committee shall be forwarded to the Board Committee of two or more persons. The Medical staff uses criteria developed for the expedited process when recommending privileges. The following situations are evaluated on a case by case basis and usually are ineligible for Board Subcommittee approval if any of the following has occurred: 9

2.2.12.1. Submission of an incomplete application; 2.2.12.2 Recommendation from the Credentials or Medical Executive Committee that is adverse or with limitation. 2.2.12.3 A current challenge or a previous successful challenge to licensure or registration 2.2.12.4. Involuntary termination of medical staff membership at another organization. 2.2.12.5. Involuntary limitation, reduction, denial or loss of clinical privileges; or, 2.2.12.6. The hospital determines that there has been either an unusual pattern of, or an excessive number of, professional liability actions resulting in a final judgment against the applicant. FULL BOARD: The actions of the Governing Board Subcommittee will be reported to the full Board at their next regular scheduled meeting. 2.2.12.7. If the Board (or designated subcommittee) accepts the recommendation, its decision is final. The applicant will be promptly notified of his department assignment, staff category, clinical privileges and any special conditions. 2.2.12.8. If the full Board rejects a recommendation, and its decision Affects Adversely the applicant s membership or Clinical Privileges, it must direct the Chief Executive Officer to give prompt Notice to the applicant of his right to a hearing in accordance with the Fair Hearing Plan. 2.2.12.9. If a designated committee of the board rejects the recommendation, the committee must refer it back to the MEC for further consideration. 2,2.13 Time for Processing of Applications: 2.2.13.1 Initial Applications: The application process must be completed within a reasonable time. The CCO should collect and verify information within 41 days of the applicant s delivery of the application. The Department Chairperson should prepare and deliver his or her report to the Credentials Committee at its next regular meeting. The Credentials Committee, MEC (except as may be necessary for JRC review) and the Board, in turn, should each act on an application at the next regular meeting following receipt of the preceding recommendation. Complete applications (as defined in the Credentialing Manual) should normally be processed within 90 days, 10

2.3 DISASTER PRIVLEGES: unless the gathering of additional information or additional deliberation in specific cases is necessary to ensure a fully informed review. These time limits are guidelines only and do not create any right to have an application processed within a particular time. 2.2.13.2. Reappointment applications: Will be mailed out to the applicants six months prior to the earliest entity expiration date. Reappointment applications will be processed by the CCO within 41 days and submitted to the sites where they will be processed based upon the earliest entity expiration date. 2.2.14. Records: A separate record is maintained for each individual requesting Medical Staff Membership or Clinical Privileges. These records are confidential peer review information subject to the protection of Ohio law and these Bylaws, and must be stored under appropriate security measures. The organization may grant disaster privileges to volunteers eligible to be licensed independent practitioners when the Chief Executive Officer or his designee has implemented the Hospital s Emergency Management Plan, and has determined that additional medical personnel are needed in order to address the emergency. Medical Personnel who are not currently members of the Medical Staff request or are requested by the Hospital to provide patient care during the emergency; 2.3.1 The Medical Personnel requesting these privileges present to the Chief Executive Officer, or the Chief of Staff or their designees, a valid government-issued photo identification issued by a state or federal agency (e.g., drivers license or passport) and at least one of the following: 2.3.1.1 A current picture hospital ID card from their primary hospital that clearly identifies professional designation; 2.3.1.2. A current license to practice medicine. Primary source verification of the license. Primary Source verification begins as soon as the immediate situation is under control, and is completed within 72 hours from the time the volunteer practitioner presents to the organization. In the extraordinary circumstance that primary source verification cannot be completed in 72 hours (e.g., no means of communication or a lack of resources), it is expected that it be done as soon as possible. In this extraordinary circumstance, there must be documentation of the following: Why primary source verification could not be performed in the required time frame, evidence of a demonstrated ability to continue to provide adequate care, treatment and services: and an attempt to rectify the situation as soon as possible. Primary source verification of licensure would not be required if the volunteer practitioner has not provided care, treatment and services under the disaster privileges. 2.3.1.3. Identification indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT); or Medical Reserve 11

Corp. (MRC), Emergency System for Advance Registration of Volunteer Health Care Personnel( ESAR-VHP), or other recognized state or federal organizations or groups; 2.3.1.4. Identification indicating that the individual has been granted authority to render patient care in emergency circumstances, with such authority having been granted by a federal, state or municipal governmental entity; 2.3.1.5. Present Identification by a current hospital or medical staff member with personal knowledge regarding practitioner s identity volunteer s ability to act as a licensed independent practitioner during a disaster; 2.3.1.6. The medical staff oversees the professional practice of volunteer licensed independent practitioners. 2.3.1.7. The organization makes a decision (based o information obtained regarding the professional practice of the volunteer) within 72 hours related to the continuation of the disaster privileges initially granted. 2.3.2 The verification of information in accordance with the Medical Staff Bylaws for membership continues as a high priority during the implementation of the Emergency Management Plan. 2.3.3 The physicians who are granted Disaster Privileges will report to the Disaster Control Center Chief Medical Officer for direction and management. Upon presentation of any of the information in 2.3.1 above, the Chief Executive Officer, or the Chief of Staff or their designees may grant disaster privileges on a case by case basis at his or her discretion. Unless membership is granted pursuant to the Expedited Credentialing Policy, said privileges shall terminate when the Emergency Management Plan implementation is terminated, the immediate situation is under control and the practitioner to whom disaster privileges have been granted has transferred care of patients treated during the emergency to a member of the Medical Staff. Furthermore, the Chief of Staff may terminate these privileges at any time and for any reason during the implementation of the Emergency Management Plan. Said termination shall not be considered a reportable event with the National Practitioner Data Bank. 12

MERCY HEALTH PARTNERS DISASTER INFORMATION & RELEASE AUTHORIZATION FORM (WHEN THE EMERGENCY SITUATION NO LONGER EXISTS, THE DISASTER PRIVILEGES WILL BE TERMINATED) APPLICANT S NAME: SPECIALTY: BOARD STATUS: GROUP PRACTICE NAME: OFFICE ADDRESS: Street City State Zip TELEPHONE: ( ) FAX: ( ) RESIDENCE ADDRESS: Street City State Zip TELEPHONE: ( ) FAX: ( ) PRIMARY HOSPITAL NAME: HOSPITAL ADDRESS: Street City State Zip DATE OF BIRTH: SS # MEDICAL LICENSURE #: EXPIRATION: STATE DEA #: EXPIRATION: MALPRACTICE INSURANCE CARRIER: LIABILITY COVERAGE LIMITS EQUAL TO $1M/$3M YES NO Expiration * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 13

ADMINISTRATIVE COMPLETION Credentials Presented : Government Issued ID (driver s license or passport) and Hospital ID Badge Government Issued ID (driver s license or passport) and Medical License Government Issued ID (driver s license or passport) and DMAT Identification Government Issued ID (drivers license or passport) and Identification indicating that the individual has been granted authority to render patient care in emergency circumstances, with such authority having been granted by a federal, state or municipal governmental entity Government Issued ID (drivers license or passport) and presents identification by a current hospital or medical staff member with personal knowledge regarding practitioner s identity volunteer s ability to act as a licensed independent practitioner during a disaster; Disaster Privileges Authorized by: Title Mercy Member Assigned to: Location Assigned: Time: * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * MEDICAL STAFF PERSONNEL Credentials Verified by: Title If unable to verify credentials within 72 hours of disaster, please indicate reason below: 14

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2.4 Monitoring Continuing Eligibility The CCO will continuously monitor, verify and maintain current information on each Medical Staff Member respecting licensure, narcotics permits, TB Testing documentation as required by the Ohio Department of Health, and professional liability insurance. 2.5 Applications for Return From Leave of Absence 2.5.2 A Member whose appointment has not expired and who seeks return from a leave of absence must file a written request to return. At a minimum, the request must contain: 2.5.2.1 A summary of his or her activities during the period of leave; and 2.5.2.2 Details of all medical training and experience and other circumstances during the period of leave demonstrating the maintenance of skills; and 2.5.2.3 Evidence of current licensure, current professional liability insurance, current competence and current ability to perform the privileges requested. 2.5.3 The MEC may request any additional information it may require to assure that the Member is qualified for Medical Staff membership and possesses current competence to exercise the Clinical Privileges to which he seeks to return. 2.5.4 The Medical Staff Offices at each entity must conduct a National Practitioner Data Bank query and primary source verification of licensure 2.5.5 The MEC must process the request for return from leave, with the assistance and recommendation of the Credentials Committee if desired, applying the same standards as an applicant for reappointment. 2.5.6 Reinstatement is not effective until approved by the Board. 2.5.7 Where a Member s appointment expires during the leave of absence, the MEC in its discretion may require a full initial application 2.6 Telemedicine Telemedicine is the use of medical information exchanged from one site to another via electronic communications. The medical staff recommends which clinical services are appropriately delivered by licensed independent practitioners through this medium. The clinical services offered are consistent with commonly accepted quality standards. Mercy facilities are defined as the originating site, where the patient is located at the time the service is provided. 16

All licensed independent practitioners who are responsible for the patient s care, treatment and services via telemedicine links are credentialed and privileged to do so at the originating site through one of the following mechanisms: 2.6.2 The originating site fully privileges and credentials the practitioner, according to The JC standards 2.6.3 The originating site privileges practitioners using credentialing information from the distant site if the distant site is a The JC accredited organization; or 2.6.4 The originating site uses the credentialing and privileging decisions from the distant site to make a final privileging decision if all the following requirements are met: 2.6.4.1. The distant site is a The JC accredited hospital or ambulatory care organization; 2.6.4.2 The practitioner is privileged at the distant site for those services to be provided at the originating site; 2.6.4.3 The originating site has evidence of an internal review of the practitioner s performance of these privileges and sends to the distant site information that is useful to assess the practitioner s quality of care, treatment, and services for use in privileging and performance improvement. 3 CLINICAL PRIVILEGES 3.1 Department Responsibility for Privileges Each Department must have a system for the development of delineation criteria, the adjustment of criteria to meet developing community needs and the state of medical knowledge, and the monitoring of delineated Privileges. At a minimum, this system must: 3.1.1 Make quality of patient care its main design objective; 3.1.2 Establish and revise criteria that include, at a minimum, evidence of current licensure, relevant training or experience, current competence, and ability to perform the Privileges requested; 3.1.3 Ensure that quality of care among those with the same Privileges is uniform within Departments and, working with other Department chairpersons and Medical Staff leadership, uniform between Departments and among Medical Staff Members and non-members; 3.1.4 Ensure that where categories are used, they are clear and well-defined; 17

3.1.5 Include mechanisms for ensuring that those who hold Clinical Privileges remain within their respective delineations; 3.1.6 Employ appropriate means of surveillance, including the results of Hospital quality monitoring, to assess the exercise of delineated Privileges; 3.1.7 Where new Privileges are sought, privilege criteria are developed by the Department, reviewed by the Credentials Committee and the MEC and approved by the Board before Privileges are granted to particular Practitioners. 3.2 Processing Temporary Privileges 3.2.1 Temporary privilege requests will be processed as promptly as possible in a manner consistent with the Bylaws. 3.2.2 Initial Applicants Awaiting Credentials Committee, MEC or Board Action 3.2.2.1 An applicant is considered for temporary privileges when all primary source verifications have been completed, including, but not limited to, A complete application Current licensure; Relevant training and experience; Current competence and ability to perform the privileges requested; Results of the National Practitioner Data Bank query have been obtained and evaluated; The applicant has in force professional liability insurance as specified by the Board, covering the exercise of the privileges requested; No current or previously successful challenge to licensure or registration No voluntary or involuntary limitation, reduction, loss or suspension of membership or clinical privileges at another organization. 3.2.2.2 Once the preceding requirements are met, temporary privileges may be granted for a limited period of time, not to exceed 120 days, by the Chief Executive Officer (or designee) upon recommendation of either the applicable clinical department 18

chairperson or the chief of the medical staff (or their respective designees) when the applicant s file is awaiting review and approval of the Credentials Committee, Medical Executive Committee or the Board of Directors. 3.2.3 Temporary Privileges to Fulfill an Important Patient Care Need 3.3 Locum Tenens 3.2.3.1 Temporary privileges may be granted on a case-by-case basis when there is an important patient care need. 3.2.3.2 Under these circumstances, the Chief Executive Officer (or designee) applicable clinical department chairperson or the chief of the medical staff (or their respective designees) provided there is verification of current licensure and current competence. In addition, a query to the National Practitioner Data Bank is required. A documented Internet or telephone verification of licensure is sufficient. A documented telephone call to a Physician with firsthand knowledge of the applicant s current competence suffices for verification of competence. Verification of professional liability insurance must occur as soon as possible, and not later than the next business day. Applications for Locum Tenens practitioners are processed in the same manner as an initial applicant. 3.4 Procedural Sedation 3.4.1 For the following specialties procedural sedation is included in the core privileging for those invasive procedures that normally utilize such sedation: Anesthesiology, Cardiology, Emergency Medicine, ENT, Gastroenterology, General Surgery, Oral Surgery, Orthopedics, Plastic Surgery, Pulmonary Medicine, Radiology, Thoracic Surgery and Vascular Surgery In order to perform procedural sedation, physicians must: Complete the MHP Procedural Sedation Competency Test and supply required documentation to support the request. Monitoring for continued competency is performed at the individual sites, with outcomes provided for review at the time of request for privileges. 4.0 LOW VOLUME/NO VOLUME PRACTITIONER POLICY FOR REAPPOINTMENT APPLICANTS: LOW VOLUME PRACTITIONERS - The Practitioner that treats a majority or all of his or her patients at another facility. 19

Those practitioners who have not had 24 patient encounters throughout Mercy Health Partners during a two-year period shall be required to have the department chair at his or her primary facility complete a reference form which will include the following elements: volume or clinical activity at that facility confirmation of medical staff status, in good standing with no disciplinary actions, no contemplated investigations and no ongoing investigations or quality/review adverse action, confirmation that the physician is clinically competent in all areas covered by his or her requested privileges. NO VOLUME PRACTITIONERS - The physician is not clinically active at another institution but is active within the community: Will be required to provide the names of two peers, to whom they refer patients for inpatient services (only one of which the practitioner may be affiliated with), to validate competency. These practitioners will be moved to Supplemental Staff. Those practitioners who have had no clinical activity at any facility within the previous two-year review period and who still request clinical privileges will be required to submit evidence of competency via a report card from a Managed Care Organization or other documentation required by the Credentials Committee, Medical Executive Committee or Governing Body. 4.1 ALLIED HEALTH PROFESSIONAL CREDENTIALING PLAN SCOPE Mercy Health Partners has identified categories of healthcare professionals (hereinafter referred to as Allied Health Professionals or AHPs) that may be needed to provide patient care services within the Mercy Health Partners system. These healthcare professionals are not eligible to be members of the medical staff organizations. They are, however, given permission to practice at Mercy Health Partners sites pursuant to this policy. The purpose of this policy is to establish minimum standards and procedures. This policy applies to the following AHPs: 1. Licensed mid-level practitioners supervised by or in collaborative practice with members of the medical staff, specifically Physician Assistants (PAs) and Advanced Practice Nurses(APNs). These individuals may be employed by Mercy Health Partners or employed/sponsored by a member of the medical staff (Category 1); and 1). 2. AHPs who are employed/sponsored by a member of the medical staff (Category 20

This policy does not apply to AHPs whose discipline is listed in Category 2 but who are employed by Mercy Health Partners or who have a contractual arrangement with Mercy Health Partners (by individual, group or staff agency contract or lease). The Governing Board, with recommendations from Administration and the Medical Executive Committee, shall approve categories of AHPs who may practice at its site as well as grant clinical privileges or authorization to practice to each AHP. If AHP services are already provided by Mercy Health Partners associates, the Governing Board may choose to disapprove that category. Governing Board, Medical Staffs and management staff are involved in the credentialing or authorization process for AHPs. PURPOSE The purpose of this Credentialing Plan ( Plan ) is: 1. To establish the procedures to assess, evaluate and review the qualifications, professional conduct, quality and appropriateness of care provided by AHPs in approved categories; and 2. To establish the procedures and guidelines for consideration of new categories of AHPs to practice at Mercy Health Partners facilities and sites, based upon the available medical resources, equipment, supplies and staff, patient convenience, community need, quality of care, efficiency of operations, provider qualifications, and other business and patient care objectives of Mercy Health Partners. III. CATEGORIES Category 1 - Physician Assistants (PAs) -Advanced Practice Nurses (APNs) including Certified Registered Nurse Anesthetist, Certified Nurse Midwife, Advanced Practice Nurse, Certified Clinical Nurse Specialist PAs must be: 1) credentialed through medical staff processes, 2) granted delineated clinical privileges, 3) afforded rights of hearing as set forth in this Plan but not a Medical Staff Fair Hearing Plan, 4) monitored through the hospital s performance improvement activities, 5) subject to reappointment and evaluation at least every two years through medical staff processes and, 6) subject to all The JC standards relevant to practitioners with delineated clinical privileges. APNs are subject to all of the above except with regard to the credentialing process, which may be the same as, or equivalent to the Medical Staff process in one of the following ways: a) same as PAs, b) same as PAs with the additional participation of a Nurse Management Reviewer, or 21

c) the same as PAs but with a hospital Nurse Management Review taking the place of the MS Credentials Committee in the credentials review process. Category 2 Dental Assistant Intraoperative Monitoring Technician Orthopedic Technician Perfusionist Registered Nurse Scribes Scrub Nurse Social Worker Surgical Assistant Surgical Technician The scope of practice is set forth in the approved AHP Category Description. These practitioners have no right to review of an action negatively affecting their ability to practice. AHP 2s (sponsored by members of any Mercy Health Partners Medical Staff) will be credentialed using The JC Human Resources Standards. Mercy Employed Clinician who supervises the area/unit in which the AHP most frequently provides services (for example, the Surgery Supervisor for Surgical Assistants) Department Chair, and Credentials Committee Chair are to review applications, and if approved, the latter shall report approvals to the Credentials Committee, Medical Executive Committee and Governing Board. Ongoing monitoring of clinical competence and performance evaluation will be performed by Mercy Employed Clinician who supervises the area/unit in which the AHP most frequently provides services (for example, the Surgery Supervisor for Surgical Assistants) and sponsoring physician (if applicable) using data provided by performance improvement department. CREDENTIALING CRITERIA Credentialing criteria for each type of Allied Health Professional shall include, at least, the following: a. Education 22

b. Training c. Licensure/Certification d. Experience e. Current Competence f. Collaborative Agreement (Advanced Practice Nurses), Physician Supervisory Plan (Physician Assistant) g. Continuing Education h. Requirements for Supervision i. Professional References j. Ability to Perform k. Identification of medical staff member(s) providing supervision/sponsorship l. Evidence of continuing comprehensive professional liability insurance coverage in the amount of $1,000,000/ $3,000,000. (If an AHP is covered under the employing physician s policy, the AHP must submit documentation from the professional liability insurer which acknowledges coverage for the physician s employment or supervision of AHPs and, if the physician group employs the AHP, indicates that the specific AHP, by name, is covered by the policy in the amounts required in this Plan.) APPLICATION PROCESS A. Release of Application An AHP shall be provided an application only where an Mercy Health Partners Hospital Governing Board has approved the AHP category/profession and an appropriate category description. B. Application and Fee AHPs shall be credentialed in accordance with this Plan and shall bear the actual costs of the credentialing process. AHPs must complete the State of Ohio application form in its entirety along with Mercy Health Partners supplemental forms, attestation, release and other related documents, and submit the application fee. C. Burden of Providing Information AHPs shall have the burden of producing information deemed adequate by Mercy Health Partners for a proper evaluation of current competence, character, ethics and other qualifications and for resolving any doubts about such qualifications. An application is not complete unless the application form is completed, all items required to be verified are completed, and any additional information necessary to evaluate the applicant s qualifications has been provided. If, after 30 days (from the date of signature), the application is incomplete due to outstanding information, documents, verification/references, the application shall be automatically withdrawn, and the applicant shall be notified that the application will not be considered. 23

The provision of information by an applicant which contains material misrepresentations, misstatements, omissions or inaccuracies, whether intentional or not, and /or failure of an applicant to sustain the burden of providing adequate information for the evaluation of the applicant s qualifications, shall result in denial of the application. If such misrepresentations, misstatements, omission or inaccuracies are discovered after the applicant has been authorized for clinical duties, the ability to practice shall be immediately terminated. D. Verification The following shall be verified with the primary source for all AHPs: 1. Licensure, certification and/or registration, as applicable to the AHP category. 2. Professional education and training. 3. Employers for the past five years, as applicable (dates and services provided and/or job classification). If previously employed by Mercy Health Partners, check with HR associate database to verify affirmative rehire status. 4. Competence questionnaires completed by health care professionals who have worked with the AHP in the last 2 years. (Number of references and type of health care professionals completing questionnaire to be defined in the AHP Category Description.) 5. Medicare/Medicaid Sanctions. 6. National Practitioner Data Bank. Additional items may be verified, depending upon the AHP Category Description. E. Screenings (cost to be the responsibility of the AHP and/or sponsoring physician) All screenings must be complete, documented and in the credentialing file prior to the AHP providing any services. All AHPs must: 1. meet the minimum screening requirements as outlined in the Human Resources Department. 2. authorize a Criminal Background check by Mercy Health Partners Central Credentialing Office 3. submit a drug screening report that meets the requirements of Mercy Health Partners and has been performed at the time of application. 24

Evaluation of Applications The following guidelines shall be used to evaluate completed applications by the responsible parties as set forth in Section III: 1. The applicant meets the applicable criteria and qualifications for all requested clinical duties. 2. The applicant submits signed Supervisory or Collaborative Agreement/Physician Supervisory Plan (if applicable) which meets criteria set forth in this Plan. 3. The applicant has received positive references with respect to the applicant s competence and ability to work cooperatively with others in the hospital and ambulatory settings. 4. The applicant has not had any restrictions, suspensions, probations, or revocations of the applicant s clinical services at a health care facility or managed care plan or of the applicant s professional license or certification, and if previously employed by Mercy Health Partners, has rehire status. 5. The applicant has not had any disciplinary actions or investigations by any licensing or certifying authority, health care facility or health care plan including Medicare/Medicaid. 6. The Hospital has determined that there has been either an unusual pattern of, or an excessive number of, professional liability actions resulting in a final judgment against the applicant. 7. There are no other indications that the applicant does not meet the qualifications for clinical duties. POST APPROVAL A. Orientation AHPs must receive a general orientation to Mercy Health Partners and to the facility(s) area(s) in which each AHP will be providing services. 1. General Orientation - A general orientation program for AHPs will be provided by Mercy Employed Clinician who supervises the area/unit in which the AHP most frequently provides services (for example, the Surgery Supervisor for Surgical Assistants) but not limited to training on HIPAA confidentiality, Corporate Compliance and other pertinent hospital policies. 2. Orientation to Specific Patient Care Areas - AHPs shall also be oriented to the specific patient care areas in which the AHP will provide services. Responsibility for provision 25

of the department-specific orientation will be the responsibility of the Mercy Employed Clinician who supervises the area/unit in which the AHP most frequently provides services (for example, the Surgery Supervisor for Surgical Assistants). B. Responsibilities of all AHPs As a condition of the ability to practice within Mercy Health Partners, each AHP shall: 1. Abide by all applicable state and federal laws regulating health care providers. 2. Abide by and comply with all applicable bylaws, policies, rules, regulations and requirements in force during the time the individual is granted permission to practice at Mercy Health Partners including Mercy Health Partners Mission, Values and Philosophy. 3. Maintain all qualifications to perform as an AHP. 4. Submit to such physical and/or mental examinations(s) or provide documentation of current health status as may be required to verify the AHPs ability to fully meet his/her responsibilities and/or to perform the requested clinical duties. 5. Document in patient medical records in a complete and timely fashion only to the extent authorized in the AHP scope of practice. 6. At all times observe and promote the confidentiality of patient health information. 7. Disclose to patients the individual s status as an Allied Health Professional and wear an Mercy Health Partners approved name tag identifying themselves at all times while at a facility which is part of Mercy Health Partners. The name tag will be different from those worn by Mercy Health Partners employees. 8. Provide continuous and timely care to all patients for whom the individual has responsibility. 9. Cooperate in performance improvement and quality monitoring activities of Mercy Health Partners. 10. Work cooperatively and professionally with medical staff and Mercy Health Partners associates. 11. Provide to the Credentialing Staff, updates and modifications to his/her credentials data as follows: a. revocation, suspension, restriction or probation of State professional license or other certification; Medicare or Medicaid sanctions; revocation or restriction of privileges or permission to practice at any health care institutions; any lapse in professional liability insurance coverage required by Mercy Health Partners; a conviction of a felony, drug/alcohol related misdemeanors or other crimes bearing on risk to patient safety; 26

receipt of notice of any formal charges or the commencement of a formal investigation by any professional regulatory or licensing agency; the filing of charges by the Department of Health and Human Services; Peer Review Organization, or any law enforcement agency or health regulatory agency of the United States or the State of Ohio, initiation, settlement or entry of a final judgment against the AHP for professional liability b. any other change in the information from the date the AHP knew of the change. SUPERVISORY AND COLLABORATIVE RELATIONSHIPS A. Physician Supervisory Plans for Physician Assistants and Collaborative Agreements for Advanced Practice Nurses Physician Assistants are required to obtain Physician Supervisory Plans which have been signed by the AHP and each supervising physician. Advanced Practice Nurses (APNs) (excluding CRNAs) are required to obtain Collaborative Agreements which have been signed by the AHP and the appropriate physician. A copy of the agreement will be maintained in the AHP s credentialing files. The Agreement shall describe the arrangements for personal and responsible supervision or collaboration which have been made between the AHP and the physician. It is also the responsibility of the AHP and the physician to provide the Hospital(s), in a timely manner, with any revisions or modifications that are made to the agreement. The Agreement must meet all requirements of applicable laws and regulations, as well as all criteria set forth in this Plan and the applicable AHP Position Description. It is the AHP s responsibility to obtain the Agreement and to adhere to the requirements of the Agreement. Failure to do so may result in termination of the AHP s authorization to practice. B. Supervising Physicians Each supervising physician must annually sign an acknowledgment for each AHP, accepting responsibility for the actions of the AHP and agreeing to provide appropriate supervision of their services. The number of Dependent Practitioners acting under the supervision of one physician, as well as the acts they may undertake, shall be consistent with applicable State statutes and regulations, the rules and regulations of the Medical Staff and policies of Mercy Health Partners. An AHP may have multiple physician supervisors, as permitted by law (for example: a physician assistant may work for more than one physician). In the event the Medical Staff appointment or clinical privileges of the supervising physician cease for any reason (including suspension for incomplete medical records), permission for the AHP to practice at the Hospital and scope of practice shall automatically cease unless or until the 27

Medical Staff Office is notified of a replacement supervisor and has received and approved all appropriate documents required under this policy. CREDENTIALS FILES Each AHP will have a credentials file which is maintained by the Medical Staff Office. IPERFORMANCE AND CLINICAL COMPETENCE EVALUATIONS OF AHPs A. AHP Category 1s will be evaluated as part of the bi-annual medical staff reappointment process. B. AHP Category 2s 1. Annual Performance Review AHP Category 2s shall have an annual performance review and a clinical competence evaluation by the appropriate Supervising Physician and an Administrative Review by the Mercy Employed Clinician who supervises the area/unit in which the AHP most frequently provides services. Completed performance evaluations shall be forwarded to the Medical Staff Office prior to the AHP s anniversary date. 2. Clinical Competence The clinical competence of AHP Category 2s will be evaluated according to Human Resources policies and procedures and The JC standards through review by peers. Competency reviews shall be forwarded to the Medical Staff Office at least 60 days prior to the AHP s anniversary date and shall be evaluated as part of the annual performance evaluation process. 3. Quality Review The quality management/performance improvement department shall screen and review any case(s) in which a quality issue has been identified. A report shall be prepared of all screened/reviewed cases. Cases in which problems are identified shall be referred to the Advisory Committee. CATEGORY DESIGNATION AND APPROVAL OF ADDITIONAL AHP TYPES 28

Proposals for additional AHP professions to be considered for inclusion in this policy may be submitted to the Board for approval. Such proposals should include: 1) the profession, 2) the need that is not currently being fulfilled with current professionals, 3) the proposed category (Section II Categories), 4) the proposed Category Description (Section III), 5) any other specific information which would be helpful in considering the profession for credentialing. REVIEW OF PROFESSIONAL REVIEW ACTION In the event an AHP Category 1 is the subject of a Professional Review action, the AHP is entitled to have the action reviewed. A Professional Review action is defined as a non-renewal, reduction, limitation, suspension or revocation of clinical privileges on other than a voluntary basis and not in lieu of an investigation or corrective action. The AHP shall not practice between the time of the professional review action being first taken and the final decision of the committee. After receiving written notice of a professional review action, the AHP may request a review in writing, with the reasons therefore, to Chairman of the Credentials Committee at the appropriate facility within 5 days. The decision shall be issued in writing within 30 days. There is no appeals process for Allied Health Practitioners. ATTACHMENT A SUGGESTED MINIMUM EDUCATION/ TRAINING/ LICENSURE/ CERTIFICATION REQUIREMENTS CATEGORY 1 Certified Registered Nurse Anesthetist - Current Ohio licensure as an Advanced Practice Nurse - Certified Registered Nurse Anesthetist (CRNA) - Certification (and maintenance thereof) by the Council on Certification of the American Association of Nurse Anesthetists; or Council on Recertification of the American Association of Nurse Anesthetists Certified Nurse Midwife - Current Ohio licensure as an Advanced Practice Nurse - Certified Nurse Midwife - Certification (and maintenance, thereof) by the American College of Nurse Midwives (ACNM) or American College of Nurse Midwives Certification Council (ACC) Advanced Practice Nurse - Current Ohio licensure as an Advanced Practice Nurse - Advanced Practice Nurse 29

- Certification (and maintenance thereof) by certification organizations approved by IDPR (listed on the IDPR web site www.idpr.com/who/ar/apn.asp); or Certification Board for Urologic Nurses and Associates as a Urologic Nurse Practitioner Certified Clinical Nurse Specialist - Current Ohio licensure as an Advanced Practice Nurse - Clinical Nurse Specialist - Certification (and maintenance thereof) by the certification organizations approved by IDPR (listed on the IDPR web site www.idpr.com/who/ar/apn.asp) Physician Assistant - Completion of an ARC-PA accredited program (masters degree preferred) in Physician Assistant Practice, consistent with Ohio Law. - Current certification (and maintenance thereof) by NCCPA - Current Ohio licensure as a Physician Assistant CATEGORY 2 Audiologist - Evidence of a Master s Degree in speech-language pathology or audiology from a program approved by the Ohio Department of Professional Regulation - Current Ohio licensure as a Speech Language Pathologist or Audiologist Dental Assistant - Graduation from a program accredited by the American Dental Association s Commission on Dental Accreditation Interoperative Monitoring Technician - MA, MS, Ph.D. or Au.D from a graduate program in Audiology accredited by the American Speech-Language Hearing Association; or Foreign Trained MD Degree, or B.A., B.S. degree in related science field. - Requires board certification ABNM (American Board of Neurophysiological Monitoring) or ABRET (American Board of Registration of Electroencephalographic and Evoked Potential Technologists), D.ABNM (Diplomat of the American Board of Neurophysiological Monitoring), or a Certified Neurophysiological Intraoperative Monitoring (CNIM) Orthopedic Technician - Completion of an Orthopedic Technician Training Program - Certification (and maintenance thereof) by the National Association of Orthopedic Technologists (NAOT) Perfusionist - Graduation from a school accredited by the Commission on the Accreditation of Allied Health Education Programs (CAAHEP) - Certification (and maintenance thereof) by the American Board of Cardiovascular Perfusion (ABCP) Registered Nurse 30

- Current Ohio licensure as a Registered Nurse Scribes (Emergency Department) - High School Diploma. A strong interest and/or involvement in a medical field, premedical students, nursing students, EMT and EMT students. Scrub Nurse - Current Ohio licensure as a Registered Nurse Social Worker - Current State of Ohio licensure as a Clinical Social Worker - Two years of full-time experience in psychiatric social work with prior experience in a hospital or partial hospital setting - Social workers with child psychology practices must have training with children/families. Surgical Assistant - Graduation from a program accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP) - Current (and maintenance, thereof) certification by the National Surgical Assistant Association (CSA) Surgical Technician - Graduation from a program accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP) - Current certification (and maintenance thereof) as a Certified Surgical Technologist (CST) Section 6. HEALTH ASSESSMENT/TUBERCULOSIS SCREENING PROGRAM FOR MEDICAL/ALLIED HEALTH PROFESSIONALS INVOLVED WITH MATERNITY UNIT, CARDIAC CATH LAB AND RADIATION ONCOLOGY DEPARTMENTS PURPOSE: The purpose of this policy is to provide direction and guidelines for monitoring and complying with the Ohio Department of Health Administrative Code regarding TB Testing for those practitioners utilizing the following services within the hospital: Maternity Units, Cardiac Cath Labs and Radiation Oncology Departments. This requirement will be incorporated in the core privilege forms as a necessary requirement for all Medical Staff Members and Allied Health Practitioners who may utilize these services within Mercy. This policy reflects the Ohio Department of Health Administrative Code Section 3701-84 as it pertains to hospital maternity units and maternity homes, Cardiac Cath lab and Radiation Oncology Department which requires all persons involved with patients and activities in the maternity unit, Cardiac Cath lab and Radiation Oncology Department to have a health evaluation and a tuberculin test on an annual basis. 31

Medical/Allied Health Professional Staff Members (practitioners and specified health personnel) are required to undergo PPD Testing or show evidence of testing as outlined in the surveillance guidelines. A letter notifying them of the need for health exam and PPD testing will be sent by the Central Credentialing Office on a yearly basis. The charge for the annual PPD testing will be incurred by Medical Health Partners if Mercy Employee Health is utilized. Further follow-up testing/treatment will be the responsibility of the Medical/Allied Health Professional Staff Member. Follow-up of positive PPD testing will be coordinated through the Medical Director of Employee Health Services and the Chief of Staff. TUBERCULOSIS SURVEILLANCE PROGRAM FOR HEALTH CARE WORKERS I. GENERAL GUIDELINES A. BASELINE TESTING 1) All Medical Staff/Allied Health Personnel in the Maternity Unit, Cardiac Cath Labs and Radiation Oncology Departments will be skin tested annually for TB using the Mantoux Method of intradermal injection of PPD (purified protein derivative). 2) All Medical Staff/Allied Health Personnel who receive BCG vaccine will be included in the screening process to establish a baseline. They will be given the option to receive a PPD skin test or have a chest x- ray. 3) A Medical Staff/Allied Health Professional staff Member who presents as a known positive TB reactor will be exempt from PPD testing. All Medical Staff/Allied Health members with a history of a Positive PPD reaction will have a chest x-ray as part of the baseline TB Surveillance Program and will be assessed for signs and symptoms of active TB. A repeat chest x-ray will be necessary only if signs and symptoms of TB Occur. 4) When a skin test conversion, abnormal chest x-ray or signs/symptoms of TB occur, directions on how to proceed can be found in the employee health departments. 5) Evidence of no active TB will be based on one of the following: a. Negative PPD skin test b. Known positive PPD Skin Test and absence of clinical signs and symptoms of active TB c. Newly converted positive PPD skin test with radiologist s verification of normal chest x-ray. B. ANNUAL PPD SKIN TESTING Evidence of annual PPD skin testing will be required of all practitioners who have privileges in the maternity units, cardiac cath laboratories and Radiation Oncology Departments. All PPD skin testing must be administered and read by a Health Care Professional who has been 32

trained to administer and interpret PPD test results. Test results must be viewed within 48 to 72 hours (SELF READING OF RESULTS IS NOT ACCEPTABLE). PPD testing will be available by appointment with the Employee Health Department at each Mercy Facility. C. TB TESTING AT 3 MONTH INTERVALS Any time a cluster of PPD test conversions occurs, practitioners must comply with further evaluation according to CDC guidelines. If any medical staff/allied health professional staff member is considered to have had a significant exposure to tuberculosis in any area of that hospital, then he/she will be required to undergo PPD testing at that time and repeated after a three month period. II. MANAGEMENT OF NEWLY CONVERTED +PPD SKIN TESTS: The practitioner with a newly converted +PPD skin test conversion will be evaluated for ACTIVE TB. This will include: Chest x-ray, Evaluation for signs and symptoms of TB (by employee health services); referral to appropriate follow-up. III. MANAGEMENT OF INACTIVE OR LATENT TB INFECTION (The practitioner who is at increased risk of developing active TB when latent TB (Positive PPD without actual disease exists). It is recommended that the Practitioner seek medical evaluation if signs and symptoms of TB Develop. IV. MANAGEMENT OF ACTIVE TB (active laryngeal or pulmonary TB): Will be required to take a medical leave of absence effective immediately, until they are deemed non-infectious by a treating physician and approved by the Medical Director of Employee Health. Documentation by the treating physician should include the following information: treatment plan, compliance with therapy and response to therapy. A. THE MEDICAL/ALIED HEALTH PROFESSIONAL STAFF MEMBER WILL BE RESPONSIBLE FOR: 1) Seeking medical evaluation if signs/symptoms of TB develop and notification of the Medical Director of Employee Health Services confirms the diagnosis of Active TB. V. RECORD KEEPING AND TB SKIN TEST DATA: 1) The CCO staff will maintain a listing of TB Expiration dates in their data base and notify practitioners of their need to renew the TB Test one month prior to expiration of their current TB Testing Information. A second reminder will be submitted 15 days prior to the expiration date. 33

2) Physicians who fail to provide documentation of current TB Testing information shall be forwarded to the Medical Staff Offices for assistance in obtaining documentation. Failure to provide upon request will result in loss of privileges until documentation of current TB test information is provided. SECTION 7. NEW TECHNOLOGIES/NEW PROCEDURES (see following pages): 34

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ADOPTED by the Medical Executive Committee on the dates indicated below: Mercy Hospital Anderson: January 21, 2008 Mercy Hospital Clermont: January 10, 2008 Mercy Hospital Fairfield: January 15, 2008 Mercy Franciscan - Mt. Airy: January 8, 2008 Mercy Franciscan - Western Hills: January 22, 2008 Approved by the Board of Trustees: January 24, 2008 45