Lutheran Health Network - Rehabilitation Hospital

Rehabilitation Hospital - Allied Health Policies

REHABILITATION HOSPITAL

OF FORT WAYNE

ALLIED HEALTH PROFESSIONALS

PROCEDURES MANUAL

TABLE OF CONTENTS

Section Page

1.1 Definition..................................................................................... ....................................... 1

1.2 Qualifications of Allied Health Professionals...................................................... ............... 1

1.3 Prerogatives of Allied Health Professionals........................................................................ 2

1.4 Limitation of Prerogatives.................................................................................................... 3

1.5 Limitations of Allied Health Professionals............................................................................ 3

1.6 Obligations of Allied Health Professionals........................................................................... 3

1.7 Terms and Conditions of Affiliation...................................................................................... 4

1.8 Scope of Practice................................................................................................................. 5

1.9 Procedure for Specification of Services.............................................................................. 5

1.10 Supervising Practitioner for Physician Assistant................................................................. 5

1.11 Supervising Practitioner's Obligations................................................................................. 5

2.1 Application Procedure for Allied Health Professionals......................................................... 7

2.2 References............. ............................................................................................................. 7

2.3 Effect of Application................ ............................................................................................ 7

2.4 Processing the Application................. ................................................................................. 8

3.1 Disciplinary Action Procedures............................................................................................. 11

3.2 Hearing and Appeals Rights................................................................................................. 11

3.3 Reapplication after Adverse Credentials Decision............................................................... 13

3.4 Hold Harmless Agreement by Allied Health Professionals.................................................. 13

4.1 Reappointment Information Collection and Verification........................................................ 14

4.2 Credentials Committee Action............................................................................................... 16

4.3 Medical Executive Committee Action.................................................................................... 16

4.4 Final Processing.................................................................................................................... 16

4.5 Basis for Recommendation and Action................................................................................. 17

4.6 Notice of Decision................................................................................................................. 17

4.7 Time Periods for Processing................................................................................................ 17

5.1 Provisional Period Requirements......................................................................................... 18

5.2 Procedural Rights................................................................................................................. 20

6.1 Amendment.......... ............................................................................................................... 21

7.0 Approval .............................................................................................................................. 22

PART I. ALLIED HEALTH PROFESSIONALS

1.1 Definition

An Allied Health Professional (AHP) is a non-hospital employed individual who is qualified by academic and clinical training, by prior and continuing experience and current competence in their requested discipline.

1.1.A The categories of allied health professionals are:

(1) Practitioner- Employed/Sponsored (Dependent)

Practitioner-employed/sponsored AHP's may be licensed or certified, as applicable by state law, to perform patient care services under the direction of a practitioner having staff privileges. The practitioner accepts medical responsibility for all patient care services provided by the AHP.

(a) This category of AHP's will consist of the following individuals:

licensed practical nurse, registered nurse, nurse practitioner and physician assistant.

(2) Independent

Independent AHP's are individuals licensed or authorized by the state of Indiana to provide health care services to patients without supervision by a practitioner. Independent AHP's are not allowed to admit patients without a practitioner staff member agreeing to admit the patient and perform the history and physical for the allied health professional.

(a) This category of AHP's will consist of the following individuals:

psychologists, neuropsychologists, orthotists and prosthetists.

1.2 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 is eligible to provide specified services in the Hospital. The Credentials Committee may in consultation with the Chief Executive Officer and the Medical Executive Committee, establish additional qualifications required of members of any particular category of AHP. The qualifications are, but not limited to:

1.2.A Licensure: Current license, registration, or certificate, and if applicable, Drug Enforcement Administration registration and Controlled Substance Registration (CSR) as may be required by Indiana law.

1.2.B Professional Education and Training: As defined on the scope of practice description developed for each specific category.

1.2.C Experience and Professional Performance: Documentation of current experience and results, showing the ability to provide patient care services at an acceptable level of quality and efficiency.

1.2.D Cooperativeness: Ability to work cooperatively with others in the Hospital environment, so as not to adversely affect the quality or efficiency of patient care services.

1.2.E Satisfaction of Obligations: Satisfactory compliance with the obligations outlined in Section 1.6 of these Policies.

1.2.F Professional Ethics and Conduct: To be of high moral character and to adhere to generally recognized standards of professional ethics.

1.2.G Health Status:

(a) Physical or Mental Impairment: Allied health professionals should be free of any mental or physical impairment that could interfere with the performance of all or any of the specified services requested or granted, unless reasonable accommodation can be made for such impairment consistent with the interest of sound patient care. In the event of such a physical or mental impairment, the AHP shall promptly notify the Medical Executive Committee so that a determination can be made as to whether or not there is a reasonable accommodation that can be made for the impairment that will permit the AHP to continue their duties.

(b) Substance/Chemical Abuse: To be free from abuse of any type of substance or chemical that interferes with, or presents a reasonable probability of interfering with, the allied health professional's ability to perform all of the specified services requested or granted, or to satisfy any of the qualifications required.

1.2.H Communication Skills: Ability to read, write and understand the English language, to communicate in the English language in an intelligible manner, and to prepare any authorized medical record entries and other required documentation in a legible manner.

1.2.I Professional Liability Insurance: Professional liability insurance coverage issued by a recognized company and must have the protection as defined in IC 16-9.5 of the Indiana Malpractice Act and remain a qualified provider under the Act. At time of initial application, a copy of the applicant's certificate of insurance, or that of their employer/sponsor if the applicant is covered thereunder, must be submitted.

1.3 Prerogatives of Allied Health Professionals

The prerogatives of an AHP are to:

1.3.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 1.6 of this manual.

1.3.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 1.9.A, but not beyond the scope of the allied health professional's license, certificate, or other legal credentials.

1.3.C Attend Education Programs

May attend, upon request, Staff, Hospital and clinical service education programs and clinical meetings related to their discipline.

1.3.D Serve on Committees

May serve on Staff, Hospital and clinical service committees (in an Ad Hoc advisory basis) when invited, where special training and knowledge are desirable, and with vote capability, if so specified by the appointing authority.

1.3.E Other Prerogatives

Exercise such other prerogatives as the Medical Executive Committee, with the approval of the Chief Executive Officer may grant allied health professionals in general or certain categories of AHP's.

1.4 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.

1.5 Limitations of Allied Health Professionals

Allied Health professionals are not:

(1) Eligible to become members of the Medical Staff;

(2) Eligible to vote in meetings of, or hold office on the Medical Staff;

(3) Required to pay application fees or dues to the Medical Staff;

(4) Governed by the due process defined by Article VIII of the Medical Staff bylaws; and

(5) Eligible for admitting privileges.

1.6 Obligations of Allied Health Professionals

Each allied health professional shall:

(1) Retain appropriate responsibility within individual area of professional competence for the care and supervision of each patient (for whom services are being provided) in the Hospital;

(2) Provide patients with care or other services at the level of quality and efficiency professionally recognized as the appropriate standard of care by the Medical Staff;

(3) Participate when requested in quality assessment/improvement activities appropriate to discipline;

(4) Abide by any applicable sections of the Medical Staff Bylaws, Rules and Regulations and related manuals, AHP Policies and those appended hereto specific to the particular category of AHP, and all other lawful standards, policies, and rules of the Medical Staff and the Hospital;

(5) Prepare and compile in timely fashion, as appropriate and authorized, those portions of patients' medical records documenting services provided and any other required records;

(6) Immediately notify the Medical Staff Office of:

(a) any criminal charges brought against the allied health professional (other than minor traffic violations not involving a DUI charge);

(b) any change made or formal action initiated that could result in a change in the status of license/certificate to practice or professional liability insurance coverage;

(c) all changes in employment or affiliation relationships involving a termination, disciplinary action or reduction in practice privileges with a physician identified as one who supervised the AHP;

(d) all changes in affiliation with or specified services at other institutional affiliations where specified services are provided;

(e) any change in the status of current or initiation of new malpractice claims involving professional performance; and

(f) any change in health status that would affect the AHP's ability to perform safe and sound patient care.

(7) Refrain from any conduct or acts that are, or could reasonably be interpreted as being beyond, or an attempt to exceed, the scope of practice authorized within the Hospital; and

(8) Provide continuous care to Hospital patients.

Failure to satisfy any of the obligations is grounds, as warranted by the circumstances, for termination or nonrenewal of specified services, or for such other disciplinary action as deemed appropriate under Section 3.2 of these AHP Policies and Procedures.

1.7 Terms and Conditions of Affiliation

An allied health professional's authorized specified scope of practice within any Department is subject to the rules and regulations of that Department. The quality and efficiency of the care provided by AHP's within any such Department shall be monitored and reviewed as part of the regular Medical Staff and/or Hospital mechanisms.

When a supervising practitioner is unable or unavailable to be the principal medical decision maker, another licensed practitioner must be designated to assume temporary supervisory responsibilities with respect to a practitioner-employed/sponsored AHP. For periods of one month or less, the supervising practitioner may designate a temporary replacement; for periods longer than one month, the AHP and supervising practitioner must notify the Medical Staff Office of the need to replace the supervising practitioner. If no temporary supervising practitioner is available, the AHP will be suspended from performing specified services or clinical privileges until such time as a supervising practitioner is named. Reinstatement may then be recommended upon official notice of new supervising practitioner appointment. A permanent supervising practitioner must be designated and officially authorized, by the Medical Executive Committee, in a reasonable period of time but no longer than 90 days.

Any practitioner-employed/sponsored AHP whose sponsoring practitioner is terminated from the Medical Staff or who terminates employment with a sponsoring practitioner will have their privileges terminated unless the AHP obtains a replacement sponsor, submits a letter from their new sponsor attesting to their acceptance of the sponsorship, and submits a Change of Sponsor Request, which is approved by the Medical Executive Committee.

1.8 Scope of Practice

Limitations may be placed on the allied health professional's authorized scope of practice in the Hospital as deemed necessary either for the efficient and effective operation of the Hospital or its services, or for management of personnel, services and equipment, or for quality or efficient patient care, or as otherwise deemed by the Medical Executive Committee to be in the best interests of patient care in the Hospital.

1.9 Procedure for Specification of Services

1.9.A Position Evaluations and Descriptions

Written guidelines for the performance of specified services by allied health professionals will be developed by the Credentials Committee, in consultation with the Chief Executive Officer and the Medical Executive Committee. For each category of AHP's. such guidelines must include, without limitation:

(1) Specification that services may only be provided for patients of the allied health professional's practitioner-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 AHP in the treating of patients on Hospital premises and any limitations thereon, including the degree of physician supervision required for each service;

(4) A description of the education and training needed to perform the requested services;

(5) If applicable, specific guidelines governing the issuance of prescriptions or medication orders; and

(6) Provisions for managing emergencies.

1.10 Supervising Practitioner for Physician Assistant

Physician supervisor of a physician assistant is a fully licensed practitioner whom the Indiana Health Professions Bureau has approved to supervise the activities of the physician assistant and who is an Active, Courtesy, or Consulting staff member of the Medical Staff of the Hospital.

1.11 Supervising Practitioner's Obligations

Any practitioner supervising a physician-employed/sponsored allied health professional in the care of a specific patient must:

(1) Be an Active, Courtesy, or Consulting staff member of the Medical Staff of the Hospital and accept full responsibility for the AHP's performance;

(2) Accept full responsibility for the proper conduct of the AHP within the Hospital, in accordance with all bylaws, policies and rules of the Hospital and the Medical Staff, and for the correction and resolution of any problems that may arise;

(3) Be available for immediate verbal communication and in such geographic proximity to provide consultation or further guidance when the AHP performs any task or function;

(4) Maintain ultimate responsibility for directing the course of the patient's medical treatment;

(5) Assure that the AHP provides specified services or clinical privileges in accordance with accepted medical standards;

(6) Provide active and continuous overview of the AHP's activities and patient encounters in the Hospital to ensure that directions and advice are being implemented;

(7) Abide by all bylaws, policies, and rules governing the use of AHP's in the Hospital, and the AHP's authorized scope of practice in the Hospital; and

(8) Immediately notify the Medical Executive Committee in the event any of the following occur:

(a) The scope or nature of his professional arrangement with the AHP changes;

(b) His approval to supervise the AHP is revoked, limited, or otherwise altered by action of the applicable state licensing authority;

(c) Notification is given of investigation of the AHP or of his supervision of the AHP by the applicable state licensing authority; and

(d) His professional liability insurance coverage is changed insofar as coverage of the acts of the AHP is concerned or the AHP's professional liability insurance coverage is changed.

II. APPLICATION PROCEDURES

2.1 Application Procedure for Allied Health Professionals

Applications for allied health professionals must be submitted jointly by the applicant and the practitioner-employer/sponsor. Each such application shall contain the information described in Section 2.2 as well as the following:

(1) Medical education including the name of each institution, programs completed, degrees granted and dates attended;

(2) All currently valid medical professional licensure of certifications and if applicable, Drug Enforcement Administration registration;

(3) Professional liability insurance coverage, or other evidence of financial responsibility for professional liability;

(4) Membership in local, state or national professional organization;

(5) Names and addresses of facilities where applicant is/was employed and employment dates;

(6) Hospital, clinic or health care institution or organization where the applicant provides or provided clinical services with the dates of each affiliation;

(7) Evidence of current employment with a physician-employer/sponsor who is a current member of the Medical Staff; and

(8) A description of the services to be provided and procedures to be performed, including any special equipment, procedures or protocols that specific tasks may involve.

2.2 References

The application must include the names of three individuals, in addition to the practitioner-employer/sponsor. The practitioner-employer/sponsor must have personal knowledge of the applicant's current clinical ability, ethical character, and ability to work cooperatively with others and must provide specific written, substantive comments on these matters upon request from Hospital or Medical Staff authorities. The named individuals must have acquired the requisite knowledge through recent observation of the applicant's professional performance over a reasonable period of time, and at least one must have had organizational responsibility for supervision of their performance.

2.3 Effect of Application

The allied health professional must sign the application and in so doing:

(1) Attests to the correctness and completeness of all information furnished;

(2) Signifies a willingness to appear for interviews in connection with the application;

(3) Agrees to abide by the terms of the Bylaws, rules, regulations, and policies and procedures manuals of the Medical Staff and those of the Hospital;

(4) Agrees to maintain ethical behavior and to refrain from misrepresenting his position, status, clinical privileges or scope of authorized service to any patient, or any other person affiliated with or coming in contact with the Hospital;

(5) Agrees to notify the Medical Staff Office of any change in any of the information provided on the application, to include status of professional license or permit to practice, DEA or state controlled substance registration, professional liability insurance coverage, membership/employment status or clinical privileges at this or other institutions, and on the status of current or initiation of new malpractice claims;

(6) Authorizes and consents to the Hospital representatives consulting with prior associates or others who may have information bearing on professional or ethical qualifications and competence, and consents to their inspecting all records and documents that may be material to evaluation of said qualifications and competence; and

(7) Releases from any liability all those who, in good faith and without malice, review, act on or provide information regarding the allied health professional's background, experience, clinical competence, professional ethics, character, health status, and other qualifications.

2.4 Processing the Application

2.4.A Applicant's and Practitioner-Employer/Sponsor's Burdens

The practitioner-employer/sponsor and the applicant have the burden of producing adequate information for a proper evaluation of the applicant's experience, training, demonstrated ability, and health status, and of resolving any doubts about these or any of the qualifications required for Staff affiliation or services to be provided. Responsibilities also include satisfying any reasonable requests for information or clarification, including health examinations, as made by appropriate Medical Staff or Advisory Board authorities.

2.4.B Verification of Information

The completed application is submitted to the Medical Staff Office. That office collects or verifies the references, licensure, and other qualifications submitted, and requests information as required from the National Practitioner Data Bank (NPDB), and promptly notifies the applicant and the practitioner-employer/sponsor of any problems in obtaining the information. Upon such notification, it is the applicant's obligation to obtain the required information. When collection and verification are accomplished, the Medical Staff Office transmits the application and all supporting materials to the Credentials Committee. During the initial appointment process, the Hospital shall not routinely perform criminal checks unless circumstances otherwise dictate.

2.4.C Temporary Privileges/Services

Temporary privileges/services may be granted an allied health professional who has submitted an application for privileges which has been determined to be complete and to meet all the criteria for the relevant category. Such privileges may be granted with the concurrence of the Chief Executive Officer and Medical Staff President or his designee.

Temporary privileges/services may also be granted to allied health professionals in postgraduate training performing rotations within the hospital.

Temporary privileges/services shall be granted for a specific period of time, not to exceed ninety (90) days. After that period of time, the AHP may request a renewal of temporary privileges for another specific period of time, not to exceed ninety (90) days.

Under all circumstances, the AHP requesting temporary privileges/services shall agree to abide by the Allied Health Professional Policies, Medical Staff Bylaws and related manuals, and rules and policies of the Staff in all matters relating to the activities at the Hospital.

2.4.D Credentials Committee Action

As stated in Section 1.5.E of the Credentialing Procedures Manual except that the practitioner-employer/sponsor and the allied health professional may be requested to appear before the Credentials Committee prior to the Credentials Committee's recommendations being forwarded to the Medical Executive Committee and the Advisory Board. Any required notifications are sent to the practitioner-employer/sponsor and the allied health professional applicant.

2.4.E Medical Executive Committee Action

The Medical Executive Committee, at its next regular meeting, reviews the application, the supporting documentation, the reports and recommendations from the Credentials Committee, and any relevant information available to it. The Medical Executive Committee then recommends to the Advisory Board that the application either be accepted or denied, as described in Section 7.4.F of the Credentialing Procedures Manual.

2.4.F Advisory Board Action

The Advisory Board may adopt or reject, in whole or in part, a recommendation of the Medical Executive Committee or refer the recommendation back to the Medical Executive Committee, stating the reasons for such referral back and setting a time limit within which subsequent recommendation must be made. Further Advisory Board action is described in Sections 7.4.G(1)(2) and (3).

2.4.G Notice of Decision

A favorable decision by the Advisory Board is deemed to be a final decision. The Chief Executive Officer, through the Medical Staff Office, by written notice, shall promptly inform the practitioner-employer-sponsor and the applicant of that decision.

A decision and notice to appoint includes:

(a) The clinical privileges/services they may exercise; and

(b) Any special conditions attached to the appointment.

2.4.H Time Periods for Processing

All individuals and groups required to act on an application for allied health professional appointment must do so in a timely and good faith manner, and except for good cause, each application should be processed within the following time periods:

Credentials Committee Next regular meeting

Medical Executive Committee Next regular meeting

Advisory Board Next regular meeting

These time periods are to be deemed guidelines and are not directives such as to create any rights for an allied health professional to have an application acted on within such periods.

2.4.I Terms of Appointment

Initial appointment of an allied health professional will be for a one (1) year provisional period. Reappointments at the end of the provisional year are handled in the same manner as any other request for reappointment as specified in Section 4.1.

2.4.J Orientation of Allied Health Professionals

Approval of an allied health professional's application for specified services shall be conditional upon satisfactory completion of an orientation program within 30 days of approval, including:

(a) Completion of orientation manual;

(b) Corporate Compliance Program

1. Confidentiality

2. Sexual Harassment;

(c) Orientation to nursing activities specific to any of the units/services of the Hospital where the AHP will function; and

(e) Orientation to medical records.

2.4.K Identification

At all times while on Hospital premises, the allied health professional shall wear a name tag clearly identifying their name and professional designation.

III. DISCIPLINARY ACTION PROCEDURES

3.1 Disciplinary Action Procedures

The following process will be employed to resolve issues of unacceptable practice by all allied health professionals:

(1) The Director of Patient Care Services or designee will discuss the need for improved practice with the allied health professional. Written documentation of this discussion is to be signed by both the AHP and the Director of Patient Services or designee with a copy forwarded to the practitioner-employer/sponsor (along with any related documentation) and to the Medical Staff Office for inclusion in the credentials file of the AHP.

(2) If unacceptable practice continues, the Director of Patient Care Services or designee will forward a copy of documentation of such unacceptable behavior to the Medical Staff Office for review by the Medical Executive Committee. A copy of this report will be sent by certified mail to the supervising practitioner indicating that this information will be placed in the credentials file of the allied health professional. Any further incidents will result in summary suspension of privileges at the discretion of the Medical Executive Committee and the Chief Executive Officer. The supervising physician and AHP will have the opportunity to respond to the allegations in accordance with the Hearing and Appeal Rights set forth in Section 3.2 hereunder.

(3) When an AHP's employment by or affiliation with the supervising practitioner is terminated by either party for other than clinical incompetence, their specified services or clinical privileges will be suspended until such time as a new supervising practitioner is identified. This period may last no longer than ninety (90) days. If a new supervising physician, who is a member of the Medical Staff is identified, the AHP will be reevaluated following procedures outlined in Section 1.7.

(4) If the AHP's employment or affiliation is terminated for reasons of clinical incompetence, the AHP's specified services/clinical privileges shall be automatically terminated. A process of the evaluation of the circumstances will take place by the Medical Executive Committee to determine whether or not the AHP will be reevaluated.

In both instances, the allied health professional and the supervising practitioner must notify the Medical Staff Office of the change and provide the reason for the termination.

3.2 Hearing and Appeals Rights

Whenever the activities or conduct of an independent or practitioner-employed/sponsored allied health professional is considered by the Director of Patient Care Services, Credentials Committee Chairman, Medical Executive Chairman, or Chief Executive Officer, or his designee, to be below the standards in criteria established for an independent AHP or a practitioner-employed/sponsored AHP, any of the persons named above may summarily suspend the privileges of an allied health professional.

3.2.A Practitioner-Employed/Sponsored Allied Health Professional

(1) The practitioner-employed/sponsored allied health professional and their supervising practitioner shall be given notice in writing of effective time and date of any suspension and the reasons for such suspension. The practitioner-employed/sponsored AHP must submit a written appeal of a suspension or termination of privileges to the Medical Executive Committee within ten (10) days after receipt of such notice. Failure to provide a written appeal as herein described shall result in a waiver of the AHP's appeal rights.

The written appeal shall contain a concise statement of the AHP's reasons for appealing the suspension or termination, and shall describe all material facts which support the AHP.

The allied health professional may retain an attorney or any other counsel to prepare or to assist in the preparation of the written appeal.

The AHP may request a hearing on the matter before the Medical Executive Committee, but the summary suspension shall remain in effect pending such hearing and a decision by the Committee. The practitioner-employed/sponsored AHP shall be given five (5) days written notice of the time and place of the hearing. The hearing shall be conducted informally by the Medical Executive Chairman. The Medical Executive Committee may modify, terminate, or affirm the action of the staff member or Chief Executive Officer imposing the summary suspension. The practitioner-employed/sponsored AHP and their supervising practitioner shall be given written notice of the determination of the Medical Executive Committee. The practitioner-employed/sponsored AHP may appeal the decision of the Medical Executive Committee to the Advisory Board within ten (10) days after the decision of the Medical Executive Committee.

(2) The appeal to the Advisory Board by the practitioner-employed/sponsored AHP shall be confined to a review of the matter which was before the Medical Executive Committee, but may also include evidence at the discretion of the members of the Advisory Board. If the Advisory Board believes that the decision made by the Medical Executive Committee was in good faith and was made upon a reasonable review of sufficient evidence, the Advisory Board shall affirm the action of the Medical Executive Committee. If the Advisory Board feels that the action taken by the Medical Executive Committee should be modified, the Advisory Board may impose, modify or reject the actions taken by the Medical Executive Committee.

(3) The Advisory Board decision shall be final.

3.2.B Independent Allied Health Professionals

(1) The independent AHP shall be given notice in writing of effective time and date of any suspension and the reasons for such suspension. The independent AHP must submit a written appeal of a suspension or termination of privileges to the Medical Executive Committee within ten (10) days after receipt of such notice. Failure to provide a written appeal as herein described shall result in a waiver of the AHP's appeal rights.

The written appeal shall contain a concise statement of the AHP's reasons for appealing the suspension or termination, and shall describe all material facts which support the AHP.

The allied health professional may retain an attorney or any other counsel to prepare or to assist in the preparation of the written appeal.

The AHP may request a hearing on the matter before the Medical Executive Committee, but the summary suspension shall remain in effect pending such hearing and a decision by the Committee. The independent AHP shall be given five (5) days written notice of the time and place of the hearing. The hearing shall be conducted informally by the Medical Executive Chairman. The Medical Executive Committee may modify, terminate, or affirm the action of the staff member of Chief Executive Officer imposing the summary suspension. The independent AHP shall be given written notice of the determination of the Medical Executive Committee. The AHP may appeal the decision of the Medical Executive Committee to the Advisory Board within ten (10) days after the decision of the Medical Executive Committee.

(2) The appeal to the Advisory Board by the independent AHP shall be confined to a review of the matter which was before the Medical Executive Committee, but may also include evidence at the discretion of the members of the Advisory Board. If the Advisory Board believes that the decision made by the Medical Executive Committee was in good faith and was made upon a reasonable review of sufficient evidence, the Advisory Board shall affirm the action of the Medical Executive Committee. If the Advisory Board feels that the action taken by the Medical Executive Committee should be modified, the Advisory Board may impose, modify or reject the actions taken by the Medical Executive Committee.

(3) The Advisory Board decision shall be final.

3.3 Reapplication after Adverse Credentials Decision

All allied health professionals who have received a final adverse decision, or who have voluntarily resigned or withdrawn an application for specified services or clinical privileges to avoid further disciplinary action are not eligible to reapply for a period of one (1) year from the date of the notice of the final adverse decision or the effective date of the resignation or application withdrawal. Any such reapplication must include the information as required under Section 2.1, must be processed as an initial application, and must include such additional information that the Credentials Committee, Medical Executive Committee, and the Advisory Board may reasonably require in demonstration that the basis for the earlier adverse action no longer exists. If such information is not provided, the reapplication will be considered incomplete and will not be further processed.

3.4 Hold Harmless Agreement by Allied Health Professionals

The independent and practitioner-employed/sponsored allied health professional shall, in applying for privileges hereunder, be deemed to have agreed to the provision herein for discipline and suspension and also to have agreed that it is in the best interest of good patient care that such disciplinary measures be taken without risk of professional liability on the part of any members of the Medical Staff, the members of its committees, the Hospital, or the officers or employees of the Hospital. Therefore, the application for privileges for an allied health professional shall contain a statement that all persons acting in granting or withholding privileges or in disciplinary actions shall be absolutely immune from civil liability arising from any acts, reports, communications, or recommendations made thereunder in good faith.

IV. REAPPOINTMENT APPLICATION PROCEDURES

4.1 Reappointment Information Collection and Verification

4.1.A From Allied Health Professional

At least 90 days prior to the date of expiration of current privileges, the allied health professional shall furnish in writing:

(1) Complete information to update his file on the items listed in Section 1.2 of this manual;

(a) Continuing education activities during the past two years as they specifically apply to the privileges requested by the AHP;

(b) Current valid medical professional licensure or certifications and if applicable, Drug Enforcement Administration registration and Controlled Substance Registration (CSR);

(c) Health impairments, if any, affecting the member's ability in terms of skill, attitude, or judgment to perform professional and Medical Staff duties fully;

(d) Professional liability insurance coverage, or other evidence of financial responsibility for professional liability, and information on malpractice claims history and experience (suits and settlements made, concluded, and pending) during the past two years, including the names of present and past insurance carriers;

(e) The nature and specifics of any pending or completed action involving denial, revocation, suspension, reduction, limitation, probation, nonrenewal or voluntary relinquishment, by resignation or expiration, of:

(1) License or certificate to practice any profession in any state or country;

(2) Drug Enforcement Administration (DEA), Indiana Controlled Substances Registration Certificate (CSR), or other controlled substances registration;

(3) Membership or fellowship in local, state, or national professional organization;

(4) Staff membership status and clinical privileges at any other hospital, clinic, or health care institution at which privileges have been or are currently held.

(f) Clinical service and specific clinical privileges requested; and

(g) Any current felony criminal charges pending against the member and any past charges including their resolution.

(2) Statement of reference from two colleagues (other than their practitioner-employer/sponsor) attesting that the member has adequate health status and current clinical competence to perform the privileges requested.

Failure, without good cause, to provide this requested information is deemed a voluntary resignation from the Allied Health Professional Staff and results in automatic termination of membership at the expiration of the current term.

The Medical Staff Office verifies this additional information, and notifies the AHP and their practitioner-employer/sponsor of any information inadequacies or verification problems. The AHP and their practitioner-employer/sponsor then has the burden of producing adequate information and resolving any doubts about the data.

4.1.B From Internal Sources

The Medical Staff Office collects for each allied health professional information regarding the individual's clinical skills and competence, overall performance, and conduct in this Hospital. Such information shall include, without limitation:

(1) Patterns of care as demonstrated in the findings of quality assurance activities;

(2) Participation in relevant internal teaching and continuing education activities;

(3) Attendance at clinical service meetings;

(4) Service on Hospital committees;

(5) Timely and accurate completion of medical records; and

(6) Compliance with all applicable AHP Policies, Medical Staff Bylaws, Rules and Regulations, and Hospital policies.

4.1.C From External Sources

As required by the Health Care Quality Improvement Act of 1986, the National Practitioner Data Bank will be queried at each reappointment time for information pertaining to the AHP. During the reappointment process, the hospital shall not routinely perform criminal checks unless circumstances otherwise dictate.

4.1.D Effect of Application

The allied health professional must sign the application, and in so doing:

(1) Attests to the correctness and completeness of all information furnished;

(2) Signifies a willingness to appear for interviews in connection with the application;

(3) Agrees to abide by the terms of the Policies, the Bylaws and related manuals, rules, regulations, policies and procedures manuals of the Medical Staff and those of the Hospital;

(6) Authorizes and consents to Hospital representatives' consulting with prior associates or others who may have information bearing on professional or ethical qualifications and competence, and consents to their inspecting all records and documents that may be material to evaluation of said qualifications and competence; and

(6) Releases from any liability all those who, in good faith and without malice, review, act on, or provide information regarding the allied health professional's background, experience, clinical competence, professional ethics, character, health status, and other qualifications.

4.2 Credentials Committee Action

The Credentials Committee reviews the report from the Credentials Committee Chairman and Medical Director and any other information it deems necessary, and forwards to the Medical Executive Committee a written report with recommendations for reappointment or nonreappointment and for requested clinical privileges/services.

4.3 Medical Executive Committee Action

The Medical Executive Committee reviews the Credentials Committee's recommendations and defers action on the reappointment or prepares a written report to the Advisory Board with recommendations for reappointment or nonreappointment and for requested clinical privileges/services.

4.4 Final Processing

Final processing of reappointments follows the procedure set forth in Sections 7.4.D-7.4.G of the Credentialing Procedures Manual. For purposes of reappointment, an "adverse action" by the Advisory Board or as used in those sections means a recommendation or action:

(1) To deny reappointment; or

(2) To deny or restrict requested clinical privileges/services.

The terms "applicant" and "appointment" as used in those sections shall be read respectively as "Allied Health Professional" and "reappointment".

4.5 Basis for Recommendation and Action

The report of each individual or group required to act on a reappointment shall state the reasons for each recommendation made or action taken, with specific reference to the AHP's credentials file and all other documentation considered. Any dissenting views at any point in the process must also be reduced to writing, supported by reasons and references, and transmitted with the majority report.

4.6 Notice of Decision

A decision and notice to appoint includes:

(a) The clinical privileges/services they may exercise; and

(b) Any special conditions attached to the reappointment.

4.7 Time Periods for Processing

Transmittal of the notice to an allied health professional and their providing updated information is to be carried out in accordance with Section 4.1.A of this manual. Thereafter and except for good cause, all persons and groups required to act must complete such action so that all reappointment reports and recommendations are transmitted to the Medical Executive Committee and in turn to the Advisory Board prior to the expiration date of the AHP whose reappointment is being processed.

Failure to satisfy the requirements of Section 4.1.A shall result in an automatic suspension of AHP membership and shall be considered a voluntary relinquishment of any and all clinical privileges/services.

V. PROVISIONAL PERIOD APPLICATION PROCEDURES

5.1 Provisional Period Requirements

5.1.A Information Collection and Verification

Prior to one year after an allied health professional's appointment, the Medical Staff Office will provide the AHP with an application for reappointment to the Allied Health Professional Staff. Reappointments at the end of the provisional year are handled in the same manner as any other request for reappointment to the Medical Staff. The member shall furnish in writing:

(1) Complete information to update his file on the items listed in Section 1.2 of this manual;

(a) Continuing education activities during the past year, if applicable as they specifically apply to the privileges requested by the AHP

(b) Current valid medical professional licensure or certifications and if applicable, Drug Enforcement Administration registration and Controlled Substance Registration (CSR);

(c) Health impairments, if any, affecting the member's ability in terms of skill, attitude, or judgment to perform professional and Medical Staff duties fully;

(d) Professional liability insurance coverage, or other evidence of financial responsibility for professional liability, and information on malpractice claims history and experience (suits and settlements made, concluded, and pending) during the past year, including the names of present and past insurance carriers;

(1) License or certificate to practice any profession in any state or country;

(2) Drug Enforcement Administration (DEA), Indiana Controlled Substances Registration Certificate (CSR), or other controlled substances registration;

(3) Membership or fellowship in local, state, or national professional organization; and

(4) Staff membership status and clinical privileges at any other hospital, clinic, or health care institution at which privileges have been or are currently held.

(f) Clinical service and specific clinical privileges requested;and

(g) Any current felony criminal charges pending against the member and any past charges including their resolution;

(k) Two peer references (other than their practitioner-employer/sponsor) to attest to the member's current clinical competence, health status, and competence to perform the privileges requested.

5.1.B From Internal Sources

(1) Patterns of care as demonstrated in the findings of quality assurance activities;

(2) Participation in relevant internal teaching and continuing education activities;

(3) Attendance at clinical service meetings;

(4) Service on Hospital committees;

(5) Timely and accurate completion of medical records; and

(6) Compliance with all applicable AHP Policies, Medical Staff Bylaws, Rules and Regulations, and Hospital policies.

5.1.C From External Sources

As required by the Health Care quality Improvement Act of 1986, the National Practitioner Data Bank will be queried at each reappointment time for information pertaining to the AHP. During the reappointment process, the hospital shall not routinely perform criminal checks unless circumstances otherwise dictate.

5.1.D Effect of Application

The member must sign the application, and in so doing agrees to abide by Section 2.3

5.1.E Time Periods for Processing

Transmittal of the notice to a Staff member and his providing updated information is to be carried out in accordance with Section 5.1.A of this manual. Thereafter and except for good cause, all persons and groups required to act must complete such action so that all reappointment reports and recommendations are transmitted to the Medical Executive Committee and in turn to the Advisory Board prior to the AHP's expiration date.

If processing has not been completed by the provisional year expiration date, through no fault of the Allied Health Professional Staff member, the member maintains their clinical privileges/services until the time that processing is completed, unless corrective action is taken with respect to all or any part thereof. If the delay is attributable to the AHP's failure to provide information required by Section 5.1.A, the Staff membership terminates on the expiration date as provided in Section 5.1.A unless explicitly extended by the Advisory Board. An appointment extension does not create a right of automatic reappointment for the coming term. Only one extension is permissible.

Failure to receive an extension, or failure to satisfy the requirements of Section 5.1.A at the completion of an extension, shall result in an automatic suspension of membership and shall be considered a voluntary relinquishment of any and all clinical privileges/services.

5.1.F Action Required

The Credentials Committee considers the requests and statements furnished to it and either defers action on the request for no more than 30 days, or prepares a written report with recommendations and supporting documentation for transmittal to the Medical Executive Committee. Final processing follows the same procedures set forth in Section 2.4 of this manual. For purposes of concluding the provisional period, an "adverse recommendation" by the Medical Executive Committee or the Advisory Board as used in the appointment process means a recommendation or action:

(1) To change, deny, or restrict requested clinical privileges/services.

The terms "applicant and "appointment" as used in those sections shall be read respectively as "Allied Health Professional" and "reappointment" at the conclusion of the provisional period.

5.2 Procedural Rights

Whenever a provisional period, including any period of extension, expires without favorable conclusion for the allied health professional, the AHP's provisional status and staff appointment shall automatically terminate. The Chief Executive Officer, through the Medical Staff Office, will provide the AHP and their practitioner-employer/sponsor with special notice of the adverse result and of their entitlement to Hearing and Appeals Rights as described in Section 3.2.

PART VI. AMENDMENT

6.1 Amendment

This Allied Health Professional Policies and Procedures may be amended or repealed, in whole or in part, by one of the following mechanisms:

6.1.A A resolution of the Medical Executive Committee recommended to and adopted by the Advisory Board; or,

6.1.B A resolution of the Medical Staff and confirmed by the Executive Committee, and approved by the Advisory Board.

6.2 Responsibilities and Authority

The procedures outlined in the Bylaws and Hospital policies regarding Medical Staff responsibility 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 Allied Health Professional Policies and Procedures.

PART VII. APPROVAL

Approved by the Credentials Committee on ___ ________ ___, 2000

_______________________________________

Chairman, Credentials Committee

Approved by the Chief Executive Officer on ___ _________ __, 2000

_______________________________________

Chief Executive Officer

Approved by the Executive Committee on , 2000

______________________________________

Chairman, Medical Executive Committee

Approved by the Advisory Board on __________________________, 2000

______________________________________

Chairman, Advisory Board