Lutheran Health Network - Rehabilitation Hospital Credentialing Manual

Rehabilitation Hospital Credentialing Manual

REHABILITATION HOSPITAL

OF FORT WAYNE

CREDENTIALING PROCEDURES MANUAL

TABLE OF CONTENTS

Section Page

1.1 Application Procedures (Active, Courtesy and Consulting Staff) ....................................... 1

1.2 Application Content (Active, Courtesy and Consulting Staff).............................. ............... 1

1.3 References (Active, Courtesy and Consulting Staff)........................................................... 3

1.4 Effect of Application ............................................................................................................ 3

1.5 Processing the Application ................................................................................................. 3

1.6 Temporary Privileges .......................................................................................................... 7

2.1 Information Collection and Verification ............................................................................... 10

2.2 Hospital Evaluation ............................................................................................................. 13

2.3 Credentials Committee Action ............................................................................................ 13

2.4 Medical Executive Committee Action ................................................................................. 13

2.5 Final Processing .................................................................................................................. 14

2.6 Basis for Recommendation and Action ............................................................................... 14

2.7 Time Periods for Processing ............................................................................................... 14

2.8 Requests for Modification of Membership Status or Privileges............................................ 14

3.1 Clinical Privileges ................................................................................................................. 15

3.2 Consultation ......................................................................................................................... 15

3.3 Procedure for Delineating Privileges ................................................................................... 15

4.1 Provisional Period Requirements ........................................................................................ 16

4.2 Procedural Rights ................................................................................................................. 19

5.0 Leave for Extended Illness ................................................................................................... 20

6.1 Exclusivisity Policy ............................................................................................................... 21

6.2 Qualifications ........................................................................................................................ 21

6.3 Effect of Staff Membership Termination .............................................................................. 21

6.4 Effect of Contract Expiration or Termination ....................................................................... 21

7.1 Application and Application Content ................................................................................... 22

7.2 References .......................................................................................................................... 22

7.3 Effect of Application ............................................................................................................. 22

7.4 Processing the Application .................................................................................................. 23

8.1 Amendment ......................................................................................................................... 26

8.2 Responsibilities and Authority ............................................................................................. 26

9.1 Reporting ............................................................................................................................. 27

10.0 Approval .............................................................................................................................. 28

PART I. APPOINTMENT PROCEDURES

1.1 Application Procedures (Active, Courtesy, and Consulting Staff)

1.1.A Pre-Application Procedures

Prior to receipt of an application for Medical Staff membership and privileges, a prospective applicant shall be required to complete a preapplication questionnaire of a form and nature to be determined by resolution of the Advisory Board of the Hospital. The prospective applicant shall submit such information as is requested in this form. Only in the event that the information supplied by the prospective applicant is deemed to be acceptable shall the prospective applicant be provided with an application form.

1.1.B Application (Active, Courtesy, and Consulting Staff)

An application for Staff membership must be submitted by the applicant. The application must be in writing and on such forms as designated by the Medical Executive Committee. Prior to the application being submitted, the applicant will be provided a copy of the Medical Staff Bylaws (hereinafter the "Bylaws") and its accompanying manuals, and the Rules and Regulations of the Staff. The applicant shall acknowledge in writing his responsibility to first review the Bylaws.

1.2 Application Content (Active, Courtesy, and Consulting Staff)

Every applicant must furnish complete information concerning the following:

1.2.A Postgraduate training, including the name of each institution, degrees granted, programs completed, dates attended, and names of practitioners responsible for the applicant's performance;

1.2.B All currently valid medical, dental or other professional licensure or certifications, and Drug Enforcement Administration registration, and Indiana Controlled Substances Certificate, with the date and number of each;

1.2.C Specialty or subspecialty board qualification, certification, and recertification;

1.2.D Any occupationally relevant physical or behavioral impairment that interferes with, or presents a substantial probability of interfering with, the obligations and responsibilities of the practitioner as described in the Bylaws, this manual and all other manuals of the Hospital or the Medical Staff;

1.2.E 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 ten years, including the names of present and past insurance carriers. Such proof shall be evidenced by submitting a certificate of insurance or other evidence of coverage. If an insurance policy covers more than one individual, then the certificate of insurance shall name each individual (not position) who is covered by that particular policy.

1.2.F 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, or other controlled substances registration;

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

(4) Specialty or subspecialty board certification or qualification;

(5) Faculty membership at any medical or other professional school;

(6) Staff membership status and clinical privileges at any other hospital, clinic, or health care institution at which privileges have been or are currently held, including information on voluntary or involuntary reduction, limitation, or loss of privileges at these institutions; and

(7) Professional liability insurance.

1.2.G Location of offices; names and addresses of other practitioners with whom the applicant is or was associated and inclusive dates of such association; names and location of any other hospital, clinic, or health care institution or organization where the applicant provides or provided clinical services with the inclusive dates of each affiliation;

1.2.H Staff category, and specific clinical privileges requested;

1.2.I Any current felony criminal charges pending against the applicant and any past charges including their resolution;

1.2.J References as required by Section 1.3 below;

1.2.K Notification of the applicant of the scope and extent of the authorization, confidentiality, immunity, and release provisions of the Bylaws and the Credentialing Procedures Manual, shall be considered met with mailing of or other method of delivery of the documents referred to in this manual; and

1.2.L The applicant shall, when requested, provide a recent picture with his application.

1.2.M Each applicant for Affiliate and House Staff membership must include only the following:

(1) Documentation of professional liability insurance as described in Section 3.2.E of the Bylaws;

(2) A true and accurate copy of the practitioner's license to practice in the State of Indiana as a medical doctor, doctor of osteopathy or doctor of dentistry; and

(3) For House Staff only, a current Drug Enforcement Administration Registration , Indiana Controlled Substances Certificate with the date and number of each, and a letter from the Ft. Wayne Medical Education Program Director verifying enrollment in their residency program.

1.3 References (Active, Courtesy, and Consulting Staff)

The application must include the names of three medical professionals who have personal knowledge of the applicant's current clinical ability, ethical character, and ability to work cooperatively with others, who will 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 his performance, e.g., clinical service chairman, section chief, training program director. This information should include a statement on the applicant's current competence based upon quality assurance studies which would clearly document the applicant's experience, results of treatment, etc.

1.4 Effect of Application

The applicant must sign the application, and in so doing:

1.4.A Attests to the correctness and completeness of all information furnished;

1.4.B Signifies a willingness to appear for interviews in connection with the application;

1.4.C Agrees to abide by the terms of the Bylaws, Rules and Regulations, policies, and procedure manuals of the Medical Staff and those of the Hospital if granted membership and/or clinical privileges, and to abide by the terms thereof in all matters relating to consideration of the application without regard to whether or not membership and/or privileges are granted;

1.4.D Agrees to maintain an ethical practice and to provide continuous care to his patients;

1.4.E Authorizes and consents to the Hospital's consultation 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

1.4.F Releases from any liability all those who, in good faith and without malice, review, act on, or provide information regarding the applicant's competence, professional ethics, character, health status, and other qualifications for Staff appointment and clinical privileges.

1.5 Processing the Application

1.5.A Applicant's Burden

The applicant has the burden of producing adequate information for a proper evaluation of this experience, training, current competence, demonstrated ability, and health status, and of resolving any doubts about these or any of the quali- fications required for Staff membership or the requested Staff category assignment, or clinical privileges, and of satisfying any reasonable requests for information or clarification, including health examinations, made by the Executive Committee or other appropriate Staff or Board authorities. If the applicant fails to provide all information requested, the application will be treated as void, and the applicant will have no due process rights.

1.5.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, and promptly notifies the applicant 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.

1.5.C Credentials Committee Action

The Credentials Committee reviews the application, the supporting documentation, and any other relevant information available to it. The chairman may interview the applicant if he deems it necessary to obtain further information. The Credentials Committee then transmits to the Medical Executive Committee its written report and recommendations as to approval or denial of, any special limitations of Staff appointment, category of Staff membership and prerogatives, requested clinical service, and scope of clinical privileges. If the Credentials Committee requires further information about an applicant, it may request the applicant to appear before the committee. Notification by the Chief Executive Officer, through the Medical Staff Office, shall be promptly given to the applicant if the Credentials Committee requires further information about the applicant or if the committee's report to the Medical Executive Committee is considered adverse; provided, that no such adverse recommendation by the Credentials Committee shall entitle the applicant to the due process rights described in Article VIII of the Bylaws. A Credentials Committee deferral shall not exceed thirty days and in all cases would require notification of the Medical Staff President, the Chief Executive Officer, and the applicant, stating in writing the reasons for the deferral.

1.5.D 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 other relevant information available to it. The Medical Executive Committee defers action on the application or prepares a written report with recommendations as to approval or denial of, or any special limitations on Staff appointment, category of Staff membership and prerogatives, requested clinical service, and scope of clinical privileges.

1.5.E Effect of Medical Executive Committee Action

(1) Deferral

Action by the Medical Executive Committee to defer the application for further consideration must be followed up in a timely manner with subsequent recommendations as to approval or denials of, or any special limitations on Staff appointment, category of Staff membership and prerogatives, requested clinical service, and scope of clinical privileges. The Chief Executive Officer, through the Medical Staff Office, promptly sends the applicant written notice of an action to defer.

(2) Favorable Recommendation

When the Medical Executive Committee's recommendation is favorable to the applicant in all respects, the Medical Executive Committee promptly forwards it, together with supporting documentation, to the Advisory Board.

(3) Adverse Recommendation

When the Medical Executive Committee's recommendation to the Advisory Board is adverse to the applicant, the Chief Executive Officer, through the Medical Staff Office, immediately informs the applicant by special notice, and the applicant is then entitled to the procedural rights as provided in Article VIII of the Bylaws. An "adverse recommendation" by the Medical Executive Committee is defined as a recommendation to deny appointment, requested staff category, requested clinical service, or to deny or restrict requested clinical privileges.

In the case of an adverse recommendation, the Advisory Board takes final action in the matter as provided in Article VIII of the Bylaws.

1.5.F Advisory Board's Action

(1) Recommendations and Actions

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.

(2) Favorable Action

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

Notice of the Board's final decision is also given by the Chief Executive Officer, through the Medical Staff Office, to the Medical Executive Committee, and to all appropriate departments.

A decision and notice to appoint includes:

(a) The Staff category to which the applicant is appointed;

(b) The requested clinical service;

(d) Any special conditions attached to the appointment.

(3) Adverse Action

If the Advisory Board's decision is adverse to the applicant, the Chief Executive Officer, through the Medical Staff Office, immediately informs the applicant by special notice, and the applicant is then entitled to the procedural rights as provided in Article VIII of the Bylaws.

"Adverse action" by the Advisory Board is defined as an action to deny, in full or in part, appointment, requested Staff category, requested clinical service or to deny or restrict requested clinical privileges. (Such action could be based on previous revocation or suspension of Staff membership, denial of appointment or reappointment, termination or significant reduction of clinical privileges, or resignation resulting from disciplinary action).

Report of adverse Board action shall be given by the Chief Executive Officer, through the Medical Staff Office, to the Indiana Medical Licensing Board, as required by Indiana Statute IC 16-10-1-6.5(b), and to the National Practitioner Data Bank.

1.5.G Time Periods for Processing

All individuals and groups required to act on an application for Staff 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 30 daysMedical Executive Committee Next regular meetingAdvisory Board Next regular meeting

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

1.5.H Waiting List for Denials Based on Need for Ability to Accommodate

When a final adverse decision has been made on an application for Staff membership, requested clinical service, or particular clinical privileges on the basis of what is reasonably projected to be a temporary lack of Hospital or community need or inability of the Hospital to provide adequate patient load, the application shall, upon written request by the applicant to the Credentials Committee, be kept in a pending status for the next succeeding year.

If, during this period, the Hospital finds it possible to accept Staff applications for which the applicant is eligible, and there is no obligation to applicants with prior pending status, the Credentials Committee promptly so informs him by special notice. Within 90 days of receipt of such notice, the applicant must provide, in writing on the prescribed form, such supplemental information as is required to update all elements of his original application. Thereafter, the procedure provided in Section 1.5 of this manual applies.

1.5.I Reapplication After Adverse Appointment Decision

An applicant who has received a final adverse decision regarding appointment, Staff category, requested clinical service, or clinical privileges is not eligible to reapply to the Medical Staff or for the denied category, clinical service, or clinical privileges for a period of three years. Any such reapplication is processed as an initial application, and the applicant must submit such additional information as the Staff or the Advisory Board may require in demonstration that the basis for the earlier adverse action no longer exists.

1.5.J Special Appointment Issues

(1) Appointment to the Affiliate Staff shall be based upon information provided by a practitioner's primary practice institution concerning the practitioner's Staff membership, licensing and malpractice insurance. Applicants for appointment/reappointment to the Affiliate Staff shall be exempted from the requirements of Part I of this Manual so long as the information provided by the practitioner's primary practice institution is, in the judgment of the Credentials Committee, sufficient to permit evaluation of the practitioner's credentials. Should an Affiliate Staff member seek appointment to the Active or Courtesy Staff, the full credentialing process, including the requirements of Part I of this Manual shall apply.

(2) House Staff shall be comprised of resident practitioners-in-training and medical students who have provided proper credentials to the Medical Education Committee. These credentials shall be presented to the Medical Staff Office, who in turn, will present such documentation to the Credentials Committee. Appointment to the House Staff shall be pursuant to Article IV, Section 4.7.A of the Bylaws.

(3) Active and Courtesy Staff members who have attained age 65 shall be granted Senior Status. Such practitioners shall enjoy all clinical privileges granted to them and all other prerogatives enjoyed by Active and Courtesy Staff members. The credentials of each such Staff members shall be reviewed on an annual basis by the Credentials Committee upon the receipt of information:

(a) Submitted by the Hospital's Medical Director attesting to the practitioner's professional and collegial activities, performance and compliance with the Bylaws after a review of the practitioner's peer review file.

(b) If the Medical Director is unable to evaluate the practitioner's credentials and performance because of low practice activity at the Hospital, a reference from a peer attesting to the practitioner's clinical performance will be requested.

1.6 Temporary Privileges

1.6.A Conditions

Temporary privileges may be granted only in the circumstances described in 1.6.B to an appropriate licensed practitioner.

Prior to temporary privileges being granted, a practitioner must demonstrate that he has appropriate professional qualifications, a valid State license, a current DEA and applicable State drug registration, professional liability insurance coverage, and a query must be submitted as required by federal law to the National Practitioner Data Bank. Special requirements for consulting and reporting may be imposed by the Medical Staff President. When applying for temporary privileges, the practitioner has agreed, in writing, to be bound by the Medical Staff Bylaws, Rules and Regulations, and applicable Hospital policies. If written agreement is not obtained, the Medical Staff Bylaws, Rules and Regulations, and Hospital policies control all matters relating the exercise of temporary privileges.

1.6.B Authority to Grant Temporary Privileges

The Chief Executive Officer or his designee, with the concurrence of the Medical Staff President or his designee may grant temporary privileges under the circumstances noted below. In all cases, unless otherwise specified, temporary privileges shall be granted for a specific period of time, not to exceed ninety (90) days. After that period of time, the practitioner may request a renewal of temporary privileges for another specific period of time, not to exceed ninety (90) days. Temporary privileges shall terminate automatically at the end of the specific period for which they were granted without the hearing and appeal rights set forth in Article VIII of the Bylaws. Special requirements of supervision and consultation may be imposed upon the granting of temporary privileges.

(1) Care of a Specific Patient

Temporary privileges may be granted to a practitioner, upon receipt of a written request, who is not an applicant for membership but is required for the care of a specific patient. Such privileges are restricted to the treatment of no more than five (5) patients by any one practitioner, after which he shall be required to apply for staff membership before being permitted to attend additional patients.

Also upon receipt of a written request, temporary privileges may be granted for educational purposes which would enhance patient care, or for cases in which the necessary expertise is not currently available at this institution.

(2) Practitioners in Postgraduate Training

Temporary privileges may be granted to practitioners in postgraduate training performing occasional or temporary rotations within the hospital.

(3) Pending Appointment to the Medical Staff

After receipt of an application for Medical Staff Membership and/or Clinical Privileges, and pending the application verification process by the Medical Staff Office, an appropriately licensed practitioner may be granted temporary privileges.

1.6.C Verification of Credentials

Prior to granting temporary privileges, the Medical Staff Office shall verify, at a minimum, the professional qualifications, ability and judgment to exercise the temporary privileges requested, the applicant's state medical license and applicable drug registration and professional liability insurance.

1.6.D Denial, Termination or Restriction of Temporary Privileges

Temporary privileges, unless acted upon pursuant to other provisions of these Bylaws, shall terminate automatically at the end of the specified period for which they were granted, without the hearing and appeal rights under these Bylaws. The Chief Executive Officer or Medical Staff President or their designees may terminate or restrict temporary privileges for any reason at any time. A practitioner is entitled to the procedural rights as provided in Article VIII of the Bylaws for a denial, non-renewal, restriction or termination of temporary privileges based on the practitioner's professional conduct or competence. In the event a practitioner's temporary privileges are terminated or restricted, the practitioner's patients then in the Hospital shall be assigned to another practitioner by the Medical Director or Medical Staff President. The wishes of the patient shall be considered, when feasible, in choosing a substitute practitioner.

PART II. REAPPOINTMENT PROCEDURES

2.1 Information Collection and Verification

2.1.A From Staff Member

At least 90 days prior to the date of expiration of current privileges, the member (except for Affiliate and House Staff members, who shall update the documentation required under 1.2.L of this Manual) shall furnish in writing:

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

(a) Forty hours of Category I continuing education activities during the past two years as they specifically apply to the privileges requested by the member.

(b) Current valid medical, dental, or other professional licensure or certifications as applicable, and Drug Enforcement Administration Registration and Indiana Controlled Substances Certificate with the expiration date and number of each;

(c) Specialty or subspecialty Board qualification, certification and/or recertification, including documented evidence of any change in certification;

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

(e) 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;

(f) 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) Specialty or subspecialty board certification or eligibility;

(5) Faculty membership at any medical or other professional school;

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

(g) Members who do not have an active practice at Rehabilitation Hospital of Ft. Wayne of sufficiency to judge their current competence, ability, and quality assurance activities, etc., should provide information from the hospital at which the majority of their practice is performed. This should include statements from the Chief Executive Officer and/or the department chief as to information from their quality assurance department which would provide adequate information as to their ability, current competence, etc;

(h) Location of offices (if changed since last credentialing); names and addresses of other practitioners with whom the applicant is or was associated and the inclusive dates of such associations (if changed since last credentialing); names and locations of any other hospital, clinic, or health care institution or any organization where the member provides or provided clinical services with the inclusive dates of each affiliation (if changed since last credentialing);

(i) Clinical service, Staff category, and specific clinical privileges requested;

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

(k) Notification of the member of the scope and extent of the authorization, confidentiality, immunity, and release provisions of the Bylaws and the Credentialing Procedures Manual, which are contained in the above, shall be considered met with mailing of or other methods of delivery of the documents referred to in this manual.

(2) Continuing training and education external to the Hospital during the preceding period;

(3) Requests for changes in Staff category, clinical service, or clinical privileges.

(a) Documentation is required for any requested change in clinical privileges;

(4) Statement of reference (from at least one colleague practicing same specialty) 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 Staff and results in automatic termination of membership at the expiration of the current term. A practitioner whose membership is so terminated is entitled to the procedural rights provided in Article VIII of the Bylaws for the sole purpose of determining the issue of good cause.

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

Should an Active Staff applicant have fewer than five (5) discharges, consultations, procedures, or any combination of these during his biennial reappointment period, he may remain on Active Staff pending approval of Medical Executive Committee and Advisory Board.

2.1.B From Internal Sources

The Medical Staff Assistance Office collects for each Staff member's credentials and peer review file all relevant information regarding the individual's professional and collegial activities, 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 Medical Staff and clinical service meetings;

(4) Service on Medical Staff and Hospital committees;

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

(6) Compliance with all applicable Bylaws, Rules and Regulations, and Hospital policies.

This information should also include a document from the Credentials Committee Chairman and Medical Director which should include a statement as to the applicant's level of current competence, as well as to the individual's clinical judgment and performance at the Hospital.

2.1.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 applicant. During the reappointment process, the hospital shall not routinely perform criminal checks unless circumstances otherwise dictate.

2.1.D Effect of Application

The applicant must sign the application, and in so doing:

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

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

(3) Agrees to abide by the terms of the Bylaws, Rules and Regulations, policies, and procedure manuals of the Medical Staff and those of the Hospital if granted membership and/or clinical privileges, and to abide by the terms thereof in all matters relating to consideration of the application without regard to whether or not membership and/or privileges are granted;

(4) Agrees to maintain an ethical practice and to provide continuous care to his patients;

(5) 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 applicant's competence, professional ethics, character, health status, and other qualifications for Staff appointment and clinical privileges.

2.2 Hospital Evaluation

The Credentials Committee Chairman and Medical Director complete a statement as to whether or not they know of, have observed, or been informed of any conduct which indicates significant present or potential physical or behavioral problems affecting the practitioner's ability to perform professional and Medical Staff duties appropriately and with recommendations for reappointment or nonreappointment and for Staff category, requested clinical service, and clinical privileges.

2.3 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 Staff category, requested clinical service, and clinical privileges.

2.4 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 Staff category, requested clinical service, and clinical privileges.

2.5 Final Processing

Final processing of reappointments follows the procedure set forth in Part I. 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;

(2) To deny a requested change in Staff category or requested clinical service;

(3) To change without the Staff member's consent his Staff category or clinical service; or

(4) To deny or restrict requested clinical privileges.

The terms "applicant" and "appointment" as used in those sections shall be read respectively as "Staff member" and "reappointment".

2.6 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 Staff member'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.

2.7 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 2.1.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 Staff membership of the member whose reappointment is being processed.

If reappointment processing has not been completed by an appointment expiration date, through no fault of the Staff member, the member maintains his current membership status and clinical privi- leges 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 practitioner's failure to provide information required by Section 2.1.A, his Staff membership terminates on the expiration date as provided in Section 2.1.A unless explicitly extended by the 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 2.1.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.

2.8 Requests for Modification of Membership Status or Privileges

A Staff member may, either in connection with reappointment or at any other time, request modification of his Staff category, requested clinical service, or clinical privileges by submitting a written application or letter to the Chairman of the Credentials Committee on the prescribed form. Such applications shall be processed in the same manner as an application for reappointment.

PART III. SYSTEMS AND PROCEDURES FOR

DELINEATING CLINICAL PRIVILEGES

3.1 Clinical Privileges

Clinical privileges at this Hospital will be granted to practitioners demonstrating the proper level of training and qualifications for the exercise of those privileges. Definitions of the clinical privileges must be approved by the Credentials Committee, the Medical Executive Committee and by the Advisory Board. These privileges must be periodically reviewed and revised, must form the basis for clinical service, and be defined as being hospital specific.

3.2 Consultation

Special requirements for consultation as a condition to the exercise of particular privileges may be attached to those privileges, in addition to requirements for consultation in specified circumstances provided for in the Bylaws, Rules and Regulations, and Hospital policies.

3.3 Procedure for Delineating Privileges

3.3.A Requests

Each application for appointment and reappointment to the Medical Staff must contain a request for the specific clinical privileges desired by the applicant or Staff member. Specific requests must also be submitted for temporary privileges and for modifications of privileges, including reductions, in the interim between reappraisals.

3.3.B Processing Requests

All requests for clinical privileges will be processed according to the procedures outlined in Part I and Part II of this manual, as applicable.

PART IV. PROVISIONAL PERIOD PROCESS

4.1 Provisional Period Requirements

4.1.A Information Collection and Verification

Prior to one year after a practitioner's appointment to the Staff, the Medical Staff Office will provide the practitioner with an application for reappointment to the Medical Staff following the end of the provisional period. 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 as they specifically apply to the privileges requested by the applicant and as established by the Medical Staff;

(c) Specialty or subspecialty Board qualification, certification and/or recertification, including documented evidence of any change in certification;

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

(e) 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;

(4) Specialty or subspecialty board certification or eligibility;

(5) Faculty membership at any medical or other professional school;

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

(h) Location of offices (if changed since last credentialing); names and addresses of other practitioners with whom the member is or was associated and the inclusive dates of such associations (if changed since last credentialing); names and locations of any other hospital, clinic, or health care institution or any organization where the member provides or provided clinical services with the inclusive dates of each affiliation (if changed since last credentialing);

(i) Clinical service, Staff category, and specific clinical privileges requested;

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

(k) Two peer references (at least one colleague in the same specialty) to attest to the member's current clinical competence and health status;

(l) Notification of the member of the scope and extent of the authorization, confidentiality, immunity, and release provisions of the Bylaws and the Credentialing Procedures Manual, which are contained in the above, shall be considered met with mailing of or other methods of delivery of the documents referred to in this manual.

Should an Active Staff applicant have fewer than five (5) discharges, consultations, procedures, or any combination of these during his provisional period, he may remain on Active Staff pending approval of the Executive Committee and Advisory Board.

4.1.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 Medical Staff and clinical service meetings;

(4) Service on Medical Staff and Hospital committees;

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

(6) Compliance with all applicable Bylaws, Rules and Regulations, and Hospital policies.

This information should also include a document from the Credentials Committee Chairman and Medical Director which should include a statement as to the member's level of current competence, as well as to the individual's clinical judgment and performance at the Hospital.

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 applicant. During the reappointment process, the hospital shall not routinely perform criminal checks unless circumstances otherwise dictate.

4.1.D Effect of Application

The member must sign the application, and in so doing agrees to abide by Sections 1.4.A through 1.4.F of this manual.

4.1.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 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 Staff membership of the member whose reappointment is being processed.

If reappointment processing has not been completed by an appointment expiration date, through no fault of the Staff member, the member maintains his current membership status and clinical privileges 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 practitioner's failure to provide information required by Section 4.1.A, his Staff membership terminates on the expiration date as provided in Section 4.1.A unless explicitly extended by the 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 4.1.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.

4.1.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 1.5 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, without the Staff member's consent, his clinical service;

(2) To reduce Staff category assignment without his consent; or

(3) To deny or restrict requested clinical privileges.

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

4.2 Procedural Rights

Whenever a provisional period including any period of extension expires without favorable conclusion for the practitioner, or whenever an extension is denied, the practitioner's provisional status and staff appointment shall automatically terminate. The Chief Executive Officer, through the Medical Staff Office, will provide the practitioner with special notice of the adverse result and of his entitlement to the procedural rights provided in Article VIII of the Bylaws.

PART V. LEAVE FOR EXTENDED ILLNESS

Any Staff member experiencing an illness of such severity that requires his/her absence from clinical practice for over sixty (60) days, must present evidence in the form of a statement by his/her attending physician that he/she is physically able to perform all clinical privileges previously granted or the exceptions thereof.

PART VI. PRACTITIONERS PROVIDING CONTRACTUAL

PROFESSIONAL SERVICES

6.1 Exclusivity Policy

In recognition of the Hospital's policy that certain Hospital facilities will be used on an exclusive basis in accordance with contracts between the Hospital and qualified practitioners, such that other Staff members must, except in emergency or life-threatening circumstances, adhere to this exclusivity policy in arranging for the care of their patients, applications for initial appointment or for clinical privileges related to those Hospital facilities and services designated as subject to the Hospital's exclusivity policy will not be accepted for processing unless submitted in accordance with an existing or proposed contract with the Hospital.

6.2 Qualifications

A practitioner who is or who will be providing specified professional services pursuant to a contract with the Hospital must meet the same membership qualifications, must be processed for appointment, reappointment, and clinical privileges in the same manner, and must fulfill all of the obligations of his membership category as any other applicant or Staff member.

6.3 Effect of Staff Membership Termination

Because practice at the Hospital is always contingent upon continued Staff membership and is also constrained by the extent of clinical privileges enjoyed, a practitioner's right to use Hospital facilities is automatically terminated when Staff membership expires or is terminated. Similarly, the extent of his clinical privileges is automatically limited to the extent that pertinent clinical privileges are diminished.

6.4 Effect of Contract Expiration or Termination

6.4.A The effect of expiration or other termination of a contract upon a practitioner's Staff membership status and clinical privileges will be governed solely by the terms of the practitioner's contract with the Hospital.

6.4.B If the contract is silent on the matter or if there is no written contract, then contract expiration or other termination alone will not affect the practitioner's Staff member- ship status or clinical privileges, except that the practitioner may not thereafter exercise any clinical privileges for which exclusive contractual arrangements have been made.

PART VII. APPOINTMENT PROCEDURE FOR

ALLIED HEALTH PROFESSIONALS

7.1 Application and Application Content

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 7.2, 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 or 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 practitioner-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.

7.2 References

The application must include the names of three individuals, one of whom must be the practitioner-employer. 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 his performance.

7.3 Effect of Application

The practitioner-employer/sponsor and the applicant must sign the application, and in so doing agree to abide by Sections 1.4.A through 1.4.F of this manual.

7.4 Processing the Application

7.4.A Applicant's and Practitioner-Employer's/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, and of satisfying any reasonable requests for information or clarification, including health examinations, as made by appropriate Staff or Board authorities.

7.4.B Verification of Information

As set out in Section 1.5.B, except that the practitioner- employer/sponsor will also be notified by the Medical Staff Office of any problems in obtaining information.

7.4.C Clinical Service

(1) It is the responsibility of the Medical Executive Committee with input, where applicable, to develop the written guideline for the performance of specified services by allied health professionals. For each category of allied health professionals, such guidelines must include, without limitation:

(a) Specification that services may only be provided for patients of the allied health professional's employer/sponsor;

(b) A description of the services to be provided and procedures to be performed, including the equipment or special procedures or protocols that specific tasks may involve; responsibility for charting services provided in the patient's medical record; and,

(c) 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.

7.4.D Credentials Committee Action

As stated in Section 1.5.E, 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 Board. Any required notifications are sent to the practitioner-employer/sponsor and the allied health professional applicant.

7.4.E Medical Executive Committee Action

7.4.F Effect of Medical Executive Committee Action

(1) Deferral

Action by the Medical Executive Committee to defer the application for further consideration must be followed up in a timely manner with subsequent recommendations as to approval or denials of, or any special limitations on appointment or clinical privileges. The Chief Executive Officer, through the Medical Staff Office, promptly sends the practitioner-employer/sponsor and the applicant written notice of an action to defer.

(2) Favorable Recommendation

(3) Adverse Recommendation

When the Medical Executive Committee's recommendation to the Advisory Board is adverse to the applicant, the Chief Executive Officer, through the Medical Staff Office, shall provide written notice to the practitioner-employer/ sponsor and the applicant. An "adverse recommendation" by the Medical Executive Committee is defined as a recommendation to deny appointment, or to deny or restrict requested clinical privileges. An Allied Health Professional is not entitled to the procedural rights provided in Article VIII of the Bylaws.

7.4.G Effect of Advisory Board Action

(1) Recommendations and Actions

(2) Favorable Action

A favorable decision by the 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 he may exercise; and

(b) Any special conditions attached to the appointment.

(3) Adverse Action

If the Advisory Board's decision is adverse to the applicant, the Chief Executive Officer, through the Medical Staff Office, immediately informs the practitioner-employer/sponsor and the applicant. The applicant must submit a written appeal of the adverse action to the Advisory Board within ten (10) days of the applicant's receipt of adverse action as specified in Section 2.3.B(3) of the Allied Health Professionals Manual.

"Adverse action" by the Advisory Board is defined as an action to deny appointment, or deny or restrict requested clinical privileges.

7.4.H Terms of Appointment

Initial appointment of an Allied Health Professional will be for a one 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 2.1 of the Allied Health Professionals Manual.

PART VIII. AMENDMENT

8.1 Amendment

This Credentialing Procedures Manual may be amended or repealed, in whole or in part, by one of the following mechanisms:

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

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

8.2 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 Credentialing Procedures Manual.

PART IX. REPORTING TO INDIANA MEDICAL LICENSING BOARD AND

NATIONAL PRACTITIONER DATA BANK

9.1 Reporting

9.1.A Indiana Medical Licensing Board

The Chief Executive Officer shall report, in writing, to the Indiana Medical Licensing Board the results and circumstances of any final, substantive, and adverse disciplinary action taken by the Advisory Board regarding a practitioner on the Medical Staff, or an applicant for the Medical Staff, if the action results in voluntary or involuntary resignation, termination, nonappointment, revocation or significant reduction of clinical privileges or Staff membership. Such a report shall not be made for nondisciplinary resignations nor for minor disciplinary action taken regarding practitioners. The Advisory Board and its employees, agents, consultants, and attorneys have absolute immunity from civil liability for communications, discussions, actions taken, and reports made concerning disciplinary action or investigation taken or contemplated, if such reports or actions are made in good faith and without malice.

9.1.B National Practitioner Data Bank

Information as required by the Health Care Quality Improvement Act of 1986 is reported by the Chief Executive Officer, as prescribed by law, to the National Practitioner Data Bank.

PART X. APPROVAL

Approved by the Credentials Committee on ___October 22___________, 1999

_______________________________________

Chairman, Credentials Committee

Approved by the Chief Executive Officer on ___October 26___________, 1999

_______________________________________

Chief Executive Officer

Approved by the Executive Committee on ___October 26____________, 1999

______________________________________

Chairman, Medical Executive Committee

Approved by the Advisory Board on ____________________________, 1999

______________________________________

Chairman, Advisory Board