Lutheran Hospital - Health Professional's Manual
Lutheran Hospital of Indiana
Fort Wayne, Indiana
LIMITED PRIVILEGE
HEALTH PROFESSIONALS MANUAL
ADOPTED BY EXECUTIVE COMMITTEE
JUNE 28, 1993
ADVISORY BOARD APPROVAL
JULY 27, 1993
JULY 25, 1995
JUNE 10, 1997
JUNE 8, 1999
JUNE 12, 2001
JUNE 10, 2003
JUNE 14, 2005
JUNE 12, 2007
REVISED
OCTOBER 14, 1997
MAY 10, 2005
TABLE OF CONTENTS
Section Page
1.0 Specified Professional Personnel .............................................................. 1
2.0 Allied Health Professionals .........................................................................................5
3.0 Amendment ..........................................................................................................9
4.0 Amendment ..........................................................................................................10
SPECIFIED PROFESSIONAL PERSONNEL
1.1
Definition
Specified Professional Personnel (or "Specified Professionals") are certain
nonpractitioners who provide independent professional medical services to patients at the
Hospital. These individuals must be licensed by the appropriate state licensing
authorities. At present, Specified Professional Personnel include only podiatrists and
psychologists who otherwise satisfy the requirements of this section. Privileges for
Specified Professional Personnel shall be based upon the individual's professional
training, experience, and demonstrated competency.
1.2
Eligibility Criteria
Eligibility in general shall be determined on the basis of the following criteria:
A.
Specified Professional Personnel shall exercise independent judgment within their
areas of competence; provided, however, that a member of the Medical Staff
shall have ultimate responsibility for patient care and shall supervise and direct
the general medical management of each patient under the care of a Specified
Professional;
B.
Specified Professional Personnel shall record reports and progress notes on
patients' records and write orders to the extent established by the Medical Staff;
C.
The Medical Staff shall delineate in its rules and regulations the clinical duties and
responsibilities of such Specified Professional Personnel.
1.3
Qualifications of Specified Professional Personnel
Only those Specified Professionals who hold a license, certificate, or other credentials
required by applicable state law and satisfy the same basic qualifications required for
those eligible for Medical Staff membership are eligible to provide specified professional
services in the Hospital. The Credentials Committee may, in consultation with the Chief
Executive Officer and the Medical Executive Committee, establish such additional
qualifications required of Specified Professional Personnel as are deemed appropriate for
patient care purposes.
1.4
Procedure for Specification of Services
1.4.A
Position Evaluation and Description
Written guidelines for the performance of specified services by Specified
Professional Personnel will be developed by the
Chief Executive
Officer and the Medical Executive Committee with input, when
applicable, from the practitioner chairman of the clinical service
involved. For each category of Specified Professional Personnel, such
guidelines must include, without limitation:
(1)
Specification of classes of patients who may be seen;
(2)
Description of the services to be provided, procedures to be
performed, and responsibility for medical record completion and
ordering of drugs;
(3)
Definition of the degree of assistance that may be provided to
Specified Professional Personnel in the treating of patients on
Hospital premises and any limitation thereof, including the degree
of Specified Professional Personnel or physician supervision
required for each service;
(4)
Procedure for admission and discharge of patients for whom
Specified Professional Personnel are to provide services.
1.5
Prerogatives of Specified Professional Personnel
Specified Professional Personnel have the following prerogatives:
1.5.A
Provide Specifically Designated Patient Care Services
Provide specifically designated patient care services under the overall
supervision or direction of the chairman of the Surgery Service or other
clinical service chairman as deemed appropriate by the Chief Executive
Officer and the Medical Executive Committee; however, the
responsibility of the practitioner providing supervision or direction is
limited to that set forth in Section 1.8 of this manual.
1.5.B
Write Orders to Extent Specified
Write orders only to the extent specified in the Medical Staff Rules and
Regulations or the position description required under Section 1.4.A(2)
of this Section, but not beyond the scope of the Specified Professional's
license, certificate, or other legal credential.
1.5.C
Attend Clinical Service, Hospital, Staff Education Programs
Attend, upon request and without vote, Staff, Hospital, and clinical
service education programs and clinical meetings related to their
disciplines or where their special training and knowledge are desirable.
1.5.D
Other Prerogatives
Exercise such other prerogatives as the Credentials Committee, with the
approval of the Medical Executive Committee, may accord them in
general or as a specific category of Specified Professional Personnel.
1.6
Obligations of Specified Professional Personnel
1.6.A
Basic Responsibilities
Specified Professional Personnel must meet the same basic qualifications
and obligations as required for Medical Staff members, or as applicable to
the Specified Professional Personnel personnel's field of practice
1.6.B
Appropriate Responsibility
Retain appropriate responsibility within their area of professional
competence for the continuous care and supervision of each patient in the
Hospital for whom they are providing services, or arrange a suitable
alternate for such are and supervision.
1.6.C
Quality Management Program
Participate as appropriate in the quality management program activities,
supervise new appointees of the same profession during the provisional
period, and discharge such other functions as may be requested by the
MedicalExecutive Committee.
1.6.D
Malpractice Insurance
Specified Professional Personnel shall carry in force malpractice
insurance equal to that required of Medical Staff members or as deemed
appropriate by the Medical Staff Executive Committee, and, if permitted
by law, meet the requirements of I.C. 16-9.5, et seq, to be qualified health
care providers.
1.7
Applications
Applications and credentials concerning specified professional privileges shall be
submitted and processed in the same manner as that prescribed for Medical Staff
members in the Credentials Committee Procedure Manual.
1.8
Special Conditions for Specified Professional Personnel Status Privileges
Requests for clinical privileges from Specified Professional Personnel are processed in the
same manner specified in Article III. Surgical procedures performed by Specified
Professional Personnel shall be under the overall supervision of the chairman of surgery.
All Specified Professional Personnel patients shall receive a basic medical appraisal by a
physician member of the Medical Staff. A physician member of the Medical Staff shall
also be responsible for the care of any medical problems that may be present at admission
or that may arise during hospitalization and shall advise on the risk and effect of any
proposed surgical or special procedure on the total health status of the patient. If such
physician believes that the risk of the proposed procedures is not medically indicated,
then the chairman of surgery will decide the issue in case of dispute. The Medical Staff
member is not responsible for the care rendered by the Specified Professional, but only
for the medical care and supervision.
1.9
Limitation of Prerogatives
The prerogatives set forth under each membership category are general in nature and
may be subject to limitation by special conditions attached to a particular membership, by
other sections of the Medical Staff Bylaws (the "Bylaws") and by the Medical Staff Rules
and Regulations.
1.10
Appellate Rights of Limited Privilege Health Professionals
1.10.A
Limited Privilege Health Professionals, including both Allied Health
Professionals and Specified Professional Personnel shall have no
appellate rights
relating to the denial of privileges. Appellate rights, as
more fully set forth
herein, shall be limited only to the suspension or
termination of privileges or
prerogatives.
1.10.B
A Limited Privilege Health Professional may appeal the suspension or
termination of privileges or prerogatives pursuant to the
following procedure:
(1)
The Limited Privilege Health Professional must submit a written
appeal
of a suspension or termination of privileges or
prerogatives to the Chief
Executive Officer of the Hospital
within 10 days of the Limited Privilege
Health Professional's
receipt of notice of such suspension or termination.
Failure to provide
a written appeal as herein described shall result in a
waiver of
the Limited Privilege Health Professional's appeal rights.
(2)
The written appeal shall contain a concise statement of the
Limited
Privilege Health Professional's reasons for
appealing the suspension or
termination, and shall describe all
material facts which support the
Limited Privilege Health
Professional's appeal.
(3)
The Limited Privilege Health Professional may retain an attorney
or any
other counsel to prepare or to assist in the preparation of
the written
appeal.
(4)
Neither the Limited Privilege Health Professional nor his/her
counsel, if
any, shall have the unconditional right to make an
oral presentation in
support of the written appeal to the Chief
Executive Officer of the
Hospital. At his/her sole
discretion, the Chief Executive Officer may
agree to hear an
oral presentation in support of the written appeal. In
addition to,
and in his/her sole discretion, the Chief Executive Officer
may agree to hear an oral presentation in opposition to the written appeal
by a member of the Credentials Committee or that Committee's designee.
(5)
The Chief Executive Officer shall render a decision on the written
appeal within 30 days of the later of his receipt of the
written appeal or
oral arguments in support thereof, if any.
(6)
The Chief Executive Officer's decision shall be final.
PART II. ALLIED HEALTH PROFESSIONALS
2.1
Definition
An Allied Health Professional is an individual who is employed/sponsored by a Medical
Staffmember and who has been approved to provide specific services under the direct
supervision and control of his employer/ sponsor.
2.2
Qualifications of Allied Health Professionals
Only an Allied Health Professional holding a license, certificate, or such other credentials
as may be required by applicable state law and who is employed/sponsored by a
practitioner having Staff privileges is eligible to provide specific services in the Hospital.
The Credentials Committee may, in consultation with the Chief Executive Officer and the
MedicalExecutive Committee, establish additional qualifications required of members of
any particular category of Allied Health Professionals.
2.3
Procedure for Specification of Services and Evaluation of Application
2.3.A
Position Evaluations and Descriptions
Written guidelines for the performance of specified services by Allied
Health Professionals will be developed by the Chief Executive Officer
and the Medical Executive Committee with input, where applicable, from
the practitioner- chairman of the clinical service involved. For each
category of Allied Health Professionals, such guidelines must include,
without limitation:
(1)
Specification that services may only be provided for patients of
the Allied Health Professional's employer/sponsor;
(2)
A description of the services to be provided, procedures to be
performed, equipment or special procedures or protocols that
specific tasks may involve, and responsibility for charting services
provided in the patient's medical record;
(3)
Definition of the degree of assistance that may be provided to an
Allied Health Professional in the treating of patients on Hospital
premises and any limitations thereon, including the degree of
practitioner supervision required for each service;
(4)
Each Allied Health Professional must be certified and qualified at
all times as a health care provider under the Indiana Medical
Malpractice Act (Indiana Code 16-9.5 et seq.). At the time of
initial application, a copy of the applicant's certificate of
insurance, or that of his employer/sponsor if the applicant is
covered thereunder, must be submitted.
2.3.B
Evaluation of Individual Allied Health Professional Applications
Evaluation of individual Allied Health Professionals' application is
detailed in the Credentials Committee Procedure Manual. The steps to be
followed are as follows:
(1)
An application for specified services for an Allied Health
Professional is completed by the practitioner-employer/sponsor
and the Allied Health Professional.
(2)
The completed application is submitted to the Credentials
Committee for review. The practitioner-employer/sponsor and
the Allied Health Professional may be requested to appear before
the Credentials Committee before the Committee's
recommendations are forwarded to the Medical Executive
Committee.
(3)
An individual Allied Health Professional may render only those
services for which he is specifically approved.
2.4
Prerogatives of Allied Health Professionals
An Allied Health Professional has the following prerogatives:
2.4.A
Provide Specifically Designated Services
Provide specifically designated patient care services under the supervision
or direction of a practitioner member of the Medical Staff and consistent
with the limitations stated in Section 2.3.A of this manual.
2.4.B
Write Orders to Extent Specified
Write orders to the extent specified in the Medical Staff Rules and
Regulations or the position description required under Section 2.3.A of
this Manual, but not beyond the scope of the Allied Health Professional's
license, certificate, or other legal credentials.
2.4.C
Attend Education Programs
May attend, upon request, Staff, Hospital and clinical service education
programs and clinical meetings related to his discipline.
2.4.D
Other Prerogatives
Exercise such other prerogatives as the Medical Executive Committee,
with the approval of the Chief Executive Officer may accord Allied
Health Professionals in general or a specific category of Allied Health
Professionals.
2.5
Limitation of Prerogatives
The prerogatives set forth under this category are general in nature and may be subject to
limitation by special conditions attached to an Allied Health Professional's association
with the Staff, by other sections of these bylaws and related manuals, and by other
policies of the Hospital. The prerogatives of the Allied Health Professionals are limited to
those for which they have demonstrated the requisite level of education, training,
experience, and ability.
2.6
Special Conditions for Allied Health Professional Services
The employing/sponsoring practitioner is responsible for the care rendered by the Allied
Health Professional.
2.7
Temporary Permission to Provide Specific Services
Upon receipt by the Medical Staff of a completed application, temporary privileges may
be granted the Allied Health Professional by the chairman of the Credentials Committee,
the President of the Medical Staff, or by the Hospital's Medical Director.
2.8
Appellate Rights of Limited Privilege Health Professionals
2.8.A
Limited Privilege Health Professionals, including both Allied Health
Professionals and Specified Professional Personnel shall have no
appellate rights
relating to the denial of privileges. Appellate rights, as
more fully set forth
herein, shall be limited only to the suspension or
termination of privileges or
prerogatives.
2.8.B
A Limited Privilege Health Professional may appeal the suspension or
termination of privileges or prerogatives pursuant to the
following procedure:
(1)
The Limited Privilege Health Professional must submit a written
appeal
of a suspension or termination of privileges or
prerogatives to the Chief
Executive Officer of the Hospital
within 10 days of the Limited Privilege
Health Professional's
receipt of notice of such suspension or termination.
Failure to provide
a written appeal as herein described shall result in a
waiver of
the Limited Privilege Health Professional's appeal rights.
(2)
The written appeal shall contain a concise statement of the
Limited
Privilege Health Professional's reasons for
appealing the suspension or
termination, and shall describe all
material facts which support the
Limited Privilege Health
Professional's appeal.
(3)
The Limited Privilege Health Professional may retain an attorney
or any
other counsel to prepare or to assist in the preparation of
the written
appeal.
(4)
Neither the Limited Privilege Health Professional nor his/her
counsel, if
any, shall have the unconditional right to make an
oral presentation in
support of the written appeal to the Chief
Executive Officer of the
Hospital. At his/her sole
discretion, the Chief Executive Officer may
agree to hear an
oral presentation in support of the written appeal. In
addition to,
and in his/her sole discretion, the Chief Executive Officer
may agree to hear an oral presentation in opposition to the written appeal
by a member of the Credentials Committee or that Committee's designee.
(5)
The Chief Executive Officer shall render a decision on the written
appeal within 30 days of the later of his receipt of the
written appeal or
oral arguments in support thereof, if any.
(6)
The Chief Executive Officer's decision shall be final.
PART III. AMENDMENT
3.1
Amendment
This Limited Privilege Health Professionals Manual may be amended or repealed, in
whole or in part, by one of the following mechanisms:
3.1.A
A resolution of the Medical Executive Committee recommendation to and
adopted by the Advisory Board; or,
3.1.B
A resolution of the Medical Staff and confirmed by the Executive
Committee, and approved by the Advisory Board.
3.2
Responsibilities and Authority
The procedures outlined in the Bylaws and Hospital Corporate Bylaws regarding Medical
Staffresponsibility and authority to formulate, adopt, and recommend the Bylaws and
amendments thereto, and the circumstances under which the Advisory Board may resort
to its own initiative in accomplishing those functions apply as well to the formulation,
adoption, and amendment to this Limited Privilege Health Professionals Manual.
PART IV. APPROVAL
Approved by Executive Committee on _______________________________________,
___________
___________________________________________________
Chairman, Medical Executive Committee
Approved by Advisory Board on ___________________________________________,
___________
___________________________________________________
Secretary
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