MEDICAL STAFF BYLAWS, POLICIES, AND RULES …...198832.11 MEDICAL STAFF BYLAWS, POLICIES, AND RULES...
Transcript of MEDICAL STAFF BYLAWS, POLICIES, AND RULES …...198832.11 MEDICAL STAFF BYLAWS, POLICIES, AND RULES...
198832.11
MEDICALSTAFFBYLAWS,POLICIES,ANDRULESANDREGULATIONS
OFEMORYJOHNSCREEKHOSPITAL
POLICYONALLIEDHEALTHPROFESSIONALS
AdoptedbytheMedicalExecutiveCommittee:October14,2017ApprovedbytheBoard:October17,2017
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a 198832.11
TABLEOFCONTENTS
PAGE1. GENERAL ............................................................................................................................ 1
1.A. DEFINITIONS ........................................................................................................... 11.B. TIMELIMITS............................................................................................................ 11.C. DELEGATIONOFFUNCTIONS.................................................................................. 1
2. SCOPEANDOVERVIEWOFPOLICY ................................................................................... 2
2.A. SCOPEOFPOLICY ................................................................................................... 22.B. CATEGORIESOFALLIEDHEALTHPROFESSIONALS ................................................. 22.C. ADDITIONALPOLICIES ............................................................................................ 2
3. GUIDELINESFORDETERMININGTHENEEDFOR NEWCATEGORIESOFALLIEDHEALTHPROFESSIONALS................................................... 3
3.A. DETERMINATIONOFNEED..................................................................................... 33.B. DEVELOPMENTOFPOLICY ..................................................................................... 4
4. QUALIFICATIONS,CONDITIONS,ANDRESPONSIBILITIES ................................................. 5
4.A. QUALIFICATIONS .................................................................................................... 5
4.A.1. EligibilityCriteria......................................................................................... 54.A.2. WaiverofEligibilityCriteria ........................................................................ 64.A.3. FactorsforEvaluation................................................................................. 74.A.4. NoEntitlementtoMedicalStaffAppointment........................................... 84.A.5. Non-DiscriminationPolicy .......................................................................... 8
4.B. GENERALCONDITIONSOFPRACTICE ..................................................................... 8
4.B.1. AssumptionofDutiesandResponsibilities ................................................ 8
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4.B.2. BurdenofProvidingInformation.............................................................. 11
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4.C. APPLICATION ........................................................................................................ 11
4.C.1. Information............................................................................................... 114.C.2. GrantofImmunityandAuthorization toObtain/ReleaseInformation ................................................................ 12
5. CREDENTIALINGPROCEDURE.......................................................................................... 15
5.A. PROCESSINGOFINITIALAPPLICATIONTOPRACTICE ........................................... 15
5.A.1. RequestforApplication............................................................................ 155.A.2. InitialReviewofApplication..................................................................... 155.A.3. DepartmentorDivisionChairProcedure ................................................. 155.A.4. CredentialsCommitteeProcedure ........................................................... 165.A.5. MECProcedure......................................................................................... 175.A.6. BoardAction............................................................................................. 18
5.B. CLINICALPRIVILEGES ............................................................................................ 19
5.B.1. General ..................................................................................................... 195.B.2. FPPEtoConfirmCompetence .................................................................. 19
5.C. TEMPORARYCLINICALPRIVILEGES....................................................................... 20
5.C.1. RequestforTemporaryClinicalPrivileges ................................................ 205.C.2. TerminationofTemporaryClinicalPrivileges........................................... 21
5.D. PROCESSINGAPPLICATIONSFORRENEWALTOPRACTICE .................................. 21
5.D.1. SubmissionofApplication ........................................................................ 215.D.2. RenewalProcessforCategoryIandCategoryIIPractitioners ................. 215.D.3. RenewalProcessforCategoryIIIPractitioners......................................... 22
6. CONDITIONSOFPRACTICEAPPLICABLETO CATEGORYIIANDCATEGORYIIIPRACTITIONERS .......................................................... 23
6.A. STANDARDSOFPRACTICEFORTHEUTILIZATION OFCATEGORYIIPRACTITIONERSINTHE
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INPATIENTHOSPITALSETTING ............................................................................. 236.B. OVERSIGHTBYSUPERVISINGPHYSICIAN ............................................................. 24
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6.C. QUESTIONSREGARDINGAUTHORITYOFACATEGORYII ORCATEGORYIIIPRACTITIONER .......................................................................... 256.D. RESPONSIBILITIESOFSUPERVISINGPHYSICIAN ................................................... 25
7. PEERREVIEWPROCEDURESFORQUESTIONSINVOLVING ALLIEDHEALTHPROFESSIONALS..................................................................................... 27
7.A. COLLEGIALINTERVENTION................................................................................... 277.B. ONGOINGANDFOCUSEDPROFESSIONAL PRACTICEEVALUATIONS ...................................................................................... 277.C. INVESTIGATIONS .................................................................................................. 27
7.C.1. InitiationofInvestigation ......................................................................... 277.C.2. InvestigativeProcedure............................................................................ 287.C.3. Recommendation ..................................................................................... 29
7.D. ADMINISTRATIVESUSPENSION ............................................................................ 297.E. AUTOMATICRELINQUISHMENT/ACTIONS ........................................................... 307.F. ACTIONATANOTHEREMORYHEALTHCAREHOSPITAL ....................................... 317.G. LEAVEOFABSENCE............................................................................................... 31
8. PROCEDURALRIGHTSFORALLIEDHEALTHPROFESSIONALS......................................... 338.A. PROCEDURALRIGHTSFORCATEGORYI ANDCATEGORYIIPRACTITIONERS....................................................................... 33
8.A.1. NoticeofRights ........................................................................................ 338.A.2. HearingCommittee .................................................................................. 338.A.3. HearingProcess ........................................................................................ 348.A.4. HearingCommitteeReport ...................................................................... 35
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8.A.5. AppellateReview...................................................................................... 35
8.B. PROCEDURALRIGHTSFORCATEGORYIIIPRACTITIONERS................................... 36
9. HOSPITALEMPLOYEES..................................................................................................... 37PAGE
10. AMENDMENTS................................................................................................................. 3811. ADOPTION........................................................................................................................ 39APPENDIXA– LICENSEDINDEPENDENTPRACTITIONERS (CATEGORYIPRACTITIONERS)APPENDIXB– ADVANCEDDEPENDENTPRACTITIONERS (CATEGORYIIPRACTITIONERS)APPENDIXC– DEPENDENTPRACTITIONERS (CATEGORYIIIPRACTITIONERS)
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ARTICLE1
GENERAL1.A.DEFINITIONS
ThedefinitionsthatapplytotermsusedinalltheMedicalStaffdocumentsaresetforthintheMedicalStaffCredentialsPolicydocument.
1.B.TIMELIMITS
TimelimitsreferredtointhisPolicyareadvisoryonlyandarenotmandatory,unlessitisexpresslystatedthataparticularrightiswaivedbyfailingtotakeactionwithinaspecifiedperiod.
1.C.DELEGATIONOFFUNCTIONS
(1) WhenafunctionistobecarriedoutbyamemberofHospitalmanagement,byaMedicalStaffmember,orbyaMedicalStaffcommittee,theindividual,orthecommitteethroughitschair,maydelegateperformanceofthefunctiontooneormoredesignees.
(2) WhenaMedicalStaffmemberisunavailableorunabletoperformanecessary
function,oneormoreoftheMedicalStaffLeadersmayperformthefunctionpersonallyordelegateittoanotherappropriateindividual.
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ARTICLE2
SCOPEANDOVERVIEWOFPOLICY2.A.SCOPEOFPOLICY
(1) ThisPolicyaddressesthoseAlliedHealthProfessionalswhoarepermittedtoprovidepatientcareservicesintheHospitalandarelistedintheAppendicestothisPolicy.
(2) ThisPolicysetsforththecredentialingprocessandthegeneralpractice
parametersfortheseindividuals,aswellasguidelinesfordeterminingtheneedforadditionalcategoriesofAlliedHealthProfessionalsattheHospital.
2.B.CATEGORIESOFALLIEDHEALTHPROFESSIONALS
(1) OnlythosespecificcategoriesofAlliedHealthProfessionalsthathavebeenapprovedbytheBoardshallbepermittedtopracticeattheHospital.AllAlliedHealthProfessionalswhoareaddressedinthisPolicyshallbeclassifiedaseitherCategoryI,CategoryII,orCategoryIIIpractitioners.
(2) CurrentlistingsofthespecificcategoriesofAlliedHealthProfessionals
functioningintheHospitalasCategoryI,CategoryII,andCategoryIIIpractitionersareattachedtothisPolicyasAppendicesA,B,andC,respectively.TheAppendicesmaybemodifiedorsupplementedbyactionoftheBoard,afterreceivingtherecommendationoftheMEC,withoutthenecessityoffurtheramendmentofthisPolicy.
2.C.ADDITIONALPOLICIES
TheBoardshalladoptaseparatecredentialingprotocolforeachcategoryofAlliedHealthProfessionalthatitapprovestopracticeintheHospital.TheseseparateprotocolsshallsupplementthisPolicyandshalladdressthespecificmatterssetforthinSection3.BofthisPolicy.
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ARTICLE3
GUIDELINESFORDETERMININGTHENEEDFORNEWCATEGORIESOFALLIEDHEALTHPROFESSIONALS
3.A.DETERMINATIONOFNEED
(1) WheneveranAlliedHealthProfessionalinacategorythathasnotbeenapprovedbytheBoardrequestspermissiontopracticeattheHospital,theMECshallappointanadhoccommitteetoevaluatetheneedforthatparticularcategoryofAlliedHealthProfessionalandtomakearecommendationtotheMECforitsreviewandrecommendationsandthentotheBoardforfinalaction.
(2) Aspartoftheprocessofdeterminingneed,theAlliedHealthProfessionalshall
beinvitedtosubmitinformationaboutthenatureoftheproposedpractice,whyHospitalaccessissought,andthepotentialbenefitstothecommunitybyhavingsuchservicesavailableattheHospital.
(3) Theadhoccommitteemayconsiderthefollowingfactorswhenmakinga
recommendationtotheMECandtheBoardastotheneedfortheservicesofthiscategoryofAlliedHealthProfessionals:
(a) thenatureoftheservicesthatwouldbeoffered;(b) anystatelicenseorregulationwhichoutlinesthescopeofpracticethat
theAlliedHealthProfessionalisauthorizedbylawtoperform;(c) anystate“non-discrimination”or“anywillingprovider”lawsthatwould
applytotheAlliedHealthProfessional;(d) thebusinessandpatientcareobjectivesoftheHospital,includingpatient
convenience;(e) thecommunity’sneedsandwhetherthoseneedsarecurrentlybeingmet
orcouldbebettermetiftheservicesofferedbytheAlliedHealthProfessionalwereprovidedattheHospital;
(f) thetypeoftrainingthatisnecessarytoperformtheservicesthatwould
beofferedandwhetherthereareindividualswithmoretrainingcurrentlyprovidingthoseservices;
(g) theavailabilityofsupplies,equipment,andothernecessaryHospital
resources;
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(h) theneedfor,andavailabilityof,trainedstafftosupporttheservicesthat
wouldbeoffered;and(i) theabilitytoappropriatelysuperviseperformanceandmonitorqualityof
care.
3.B.DEVELOPMENTOFPOLICY
(1) IftheadhoccommitteedeterminesthatthereisaneedfortheparticularcategoryofAlliedHealthProfessionalattheHospital,thecommitteeshallrecommendtotheMECandtheBoardaseparatepolicyforthesepractitionersthataddresses:
(a) anyspecificqualificationsand/ortrainingthattheymustpossessbeyond
thosesetforthinthisPolicy;(b) adetaileddescriptionoftheirauthorizedscopeofpracticeorclinical
privileges;(c) anyspecificconditionsthatapplytotheirfunctioningwithintheHospital
beyondthosesetforthinthisPolicy;and(d) anysupervisionrequirements,ifapplicable.
(2) Indevelopingsuchpolicies,theadhoccommitteeshallconsulttheappropriatedepartmentchair(s)ordivisiondirectorsandconsiderrelevantstatelawandmaycontactapplicableprofessionalsocietiesorassociations.TheadhoccommitteemayalsorecommendtotheBoardthenumberofAlliedHealthProfessionalsthatareneededinaparticularcategory.
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ARTICLE4
QUALIFICATIONS,CONDITIONS,ANDRESPONSIBILITIES4.A.QUALIFICATIONS4.A.1.EligibilityCriteria:
TobeeligibletoapplyforinitialandcontinuedpermissiontopracticeattheHospital,AlliedHealthProfessionalsmust:(a) haveacurrent,unrestrictedlicense,certification,orregistrationtopracticein
Georgia(ifapplicable)andhaveneverhadalicense,certification,orregistrationtopracticerevokedorsuspendedbyanystatelicensingagency;
(b) whereapplicabletotheirpractice,haveacurrent,unrestrictedDEAregistration;(c) beavailableonacontinuousbasis,eitherpersonallyorbyarrangingappropriate
coverage,torespondtotheneedsofinpatientsandEmergencyDepartmentpatientsinaprompt,efficient,andconscientiousmanner.(“Appropriatecoverage”meanscoveragebyanotherpractitionerwithappropriatespecialty-specificprivilegesasdeterminedbytheCredentialsCommittee.)Compliancewiththiseligibilityrequirementmeansthatthepractitionermustdocumentthatheorsheiswillingandableto:
(1) respondwithin30minutes,viaphone,toallinitialpages;and(2) appearinpersontoattendtoapatientwithin60minutesofbeing
requestedtodoso(ormorequicklybasedupon(i)theacutenatureofthepatient’sconditionor(ii)asrequiredforaparticularspecialtyasrecommendedbytheMECandapprovedbytheBoard);
(d) havecurrent,validprofessionalliabilityinsurancecoverageinsuchformandin
amountssatisfactorytotheBoard;(e) haveneverbeenconvictedof,orenteredapleaofguiltyornocontestto,
Medicare,Medicaid,orotherfederalorstategovernmentalorprivatethird-partypayerfraudorprogramabuse,norhavebeenrequiredtopaycivilmonetarypenaltiesforthesame;
(f) haveneverbeen,andarenotcurrently,excluded,precluded,ordebarredfrom
participationinMedicare,Medicaid,orotherfederalorstategovernmentalhealthcareprogram;
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(g) haveneverhadclinicalprivileges,scopeofpractice,orstatusasaparticipating
providerdenied,revoked,orterminatedbyanyhealthcarefacilityorhealthplanforreasonsrelatedtoclinicalcompetenceorprofessionalconduct;
(h) haveneverrelinquishedorresignedaffiliation,clinicalprivileges,orascopeof
practiceduringaninvestigationorinexchangefornotconductingsuchaninvestigation;
(i) haveneverbeenconvictedof,orenteredapleaofguiltyornocontestto,any
felony;ortoanymisdemeanorrelatingtocontrolledsubstances,illegaldrugs,insuranceorhealthcarefraudorabuse,childabuse,elderabuse,orviolence;
(j) havenotresignedpermissiontopracticewithin365daysprecedingthe
application;(k) havenothadanapplicationseekingpermissiontopracticedeemedtohavebeen
withdrawnorineligibleforcontinuedprocessingduetofailureoftheapplicanttorespondtimelytoarequestforinformation;
(l) havenothadpermissiontopractice,clinicalprivileges,orscopeofpractice
automaticallyrelinquishedatthisoranyaffiliatedHospitalastheresultofanomissionormisrepresentationontheapplicationorsupportingmaterials(unlesswaivedbytheCredentialsCommittee,MECandBoardforgoodcausedemonstratedbytheapplicant);
(m) satisfyalladditionaleligibilityqualificationsrelatingtotheirspecificareaof
practicethatmaybeestablishedbytheHospital;(n) documentcompliancewithallapplicabletrainingand/oreducationalprotocols
thatmaybeadoptedbytheMEC,including,butnotlimitedto,thoseinvolvingelectronicmedicalrecords,patientsafety,andinfectioncontrol;and
(o) ifseekingtopracticeasaCategoryIIorCategoryIIIpractitioner,havea
supervisionagreementand/orcollaborativeagreementwithaphysicianwhoisappointedtotheMedicalStaff(the“SupervisingPhysician”).
4.A.2.WaiverofEligibilityCriteria:
(a) Anyindividualwhodoesnotsatisfyoneormoreofthecriteriaoutlinedabovemayrequestawaiver.
(b) ArequestforawaiverwillbesubmittedtotheCredentialsCommitteefor
consideration.Theindividualrequestingthewaiverbearstheburdenof
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demonstratingexceptionalcircumstances,andthathisorherqualificationsareequivalentto,orexceed,thecriterioninquestion.
(c) Inreviewingtherequestforawaiver,theCredentialsCommitteemayconsider
thespecificqualificationsoftheindividualinquestion,inputfromtherelevantdepartmentchair,andthebestinterestsoftheHospitalandthecommunitiesitserves.Additionally,theCredentialsCommitteemay,initsdiscretion,considertheapplicationformandotherinformationsuppliedbytheapplicant.TheCredentialsCommittee’srecommendationwillbeforwardedtotheMEC.Anyrecommendationtograntawaivermustincludethespecificbasisfortherecommendation.
(d) TheMECwillreviewtherecommendationoftheCredentialsCommitteeand
makearecommendationtotheBoardregardingwhethertograntordenytherequestforawaiver.Anyrecommendationtograntawaivermustincludethespecificbasisfortherecommendation.
(e) NoindividualisentitledtoawaiverortoahearingiftheMECrecommends
and/ortheBoarddeterminesnottograntawaiver.(f) Adeterminationthatanindividualisnotentitledtoawaiverisnota“denial”of
permissiontopractice,clinicalprivileges,orscopeofpractice.(g) Thegrantingofawaiverinaparticularcaseisnotintendedtosetaprecedent
foranyotherindividualorgroupofindividuals.(h) Anapplicationformthatdoesnotsatisfyaneligibilitycriterionwillnotbe
processeduntiltheBoardhasdeterminedthatawaivershouldbegranted.
4.A.3.FactorsforEvaluation:
ThesixACGMEgeneralcompetencies(patientcare,medicalknowledge,professionalism,system-basedpractice,practice-basedlearning,andinterpersonalcommunications)willbeevaluatedasapplicable,aspartofarequestforpermissiontopractice,asreflectedinthefollowingfactors:(a) relevanttraining,experience,anddemonstratedcurrentcompetence,including
medical/clinicalknowledge,technicalandclinicalskills,clinicaljudgment,andanunderstandingofthecontextsandsystemswithinwhichcareisprovided;
(b) adherencetotheethicsoftheirprofession,continuousprofessional
development,anunderstandingofandsensitivitytodiversity,andresponsibleattitudetowardpatients,families,andtheirprofession;
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(c) abilitytosafelyandcompetentlyperformtheclinicalprivilegesorscopeofpracticerequested;
(d) goodreputationandcharacter;(e) abilitytoworkharmoniouslywithothers,including,butnotlimitedto,
interpersonalandcommunicationskillssufficienttoenablethemtomaintainprofessionalrelationshipswithpatients,families,andothermembersofhealthcareteams;and
(f) recognitionoftheimportanceof,andwillingnesstosupport,theHospital’sand
MedicalStaff’scommitmenttoqualitycareandarecognitionthatinterpersonalskillsandcollegialityareessentialtotheprovisionofqualitypatientcare.
4.A.4.NoEntitlementtoMedicalStaffAppointment:
AlliedHealthProfessionalsshallnotbeappointedtotheMedicalStafforentitledtotherights,privileges,and/orprerogativesofMedicalStaffappointment.
4.A.5.Non-DiscriminationPolicy:
NoindividualshallbedeniedpermissiontopracticeattheHospitalonthebasisofgender,race,creed,ornationalorigin.
4.B.GENERALCONDITIONSOFPRACTICE4.B.1.AssumptionofDutiesandResponsibilities:
AsaconditionofpermissiontopracticeattheHospital,allAlliedHealthProfessionals(andtheirSupervisingPhysicians,asapplicable)shallspecificallyagreetothefollowing:(a) toattendandparticipateinanappropriateorientationprogramattheHospital
beforeactivelyseeingortreatingpatients;(b) toprovidecontinuousandtimelyqualitycaretoallpatientsintheHospitalfor
whomtheindividualhasresponsibility;(c) toabidebyallbylaws,rulesandregulations,andpoliciesoftheMedicalStaffand
Hospital;(d) toacceptcommitteeassignmentsandsuchotherreasonabledutiesand
responsibilitiesasmaybeassigned;
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(e) tomaintainacurrente-mailaddresswiththeMedicalStaffOffice,whichwillbetheofficialmechanismusedtocommunicateallinformationtothepractitionerotherthanpeerreviewinformationpertainingtothepractitionerand/orprotectedhealthinformationofpatients(thise-mailaddresswillnotbesharedoutsideofEmoryHealthcare;also,thisprovision(e)shallnotbeinterpretedtolimittheabilityofMedicalStaffLeaderstoutilizeconfidentiale-mailtocommunicateaboutongoingpeerreviewmattersamongandbetweenthemselves);
(f) tonotifytheMedicalStaffOffice,inwriting,ofanychangeinthepractitioner’s
statusoranychangeintheinformationprovidedonthepractitioner’sapplicationform.Thisinformationwillbeprovidedwithorwithoutrequest,atthetimethechangeoccurs,andwillinclude,butnotbelimitedto:
• changesinlicensureorcertificationstatus,DEAcontrolledsubstance
authorization,orprofessionalliabilityinsurancecoverage;• thefilingofaprofessionalliabilitylawsuitagainstthepractitioner;• changesinthepractitioner’sstatusatanyotherhospitalorhealthcare
entityasaresultofpeerreviewactivitiesorinordertoavoidinitiationofpeerreviewactivities;
• knowledgeofacriminalinvestigationinvolvingthepractitioner,arrest,
charge,indictment,conviction,orapleaofguiltyornocontestinanycriminalmatterotherthanamisdemeanortrafficcitation;
• exclusionorpreclusionfromparticipationinMedicare/Medicaidorany
sanctionsimposed;• anychangesinthepractitioner’sabilitytosafelyandcompetently
exerciseclinicalprivileges,orscopeofpractice,ortoperformthedutiesandresponsibilitiesofpermissiontopracticebecauseofhealthstatusissues,including,butnotlimitedto,impairmentduetoaddiction,alcoholuse,orothersimilarissue(allofwhichshallbereferredforreviewunderthepractitionerhealthpolicy);and
• anychargeof,orarrestfor,drivingundertheinfluence(“DUI”)(AnyDUI
incidentwillbereviewedbytheChiefofStaffandtheCMOsothattheymayunderstandthecircumstancessurroundingit.Iftheyhaveanyconcernsafterdoingso,theywillforwardthematterforfurtherreviewunderthepractitionerhealthpolicyorthisAHPPolicy.);
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(g) toimmediatelysubmittoanappropriateevaluationwhichmayincludediagnostictesting(suchasbloodand/orurinetest)ortoacompletephysical,mental,and/orbehavioralevaluation,ifatleasttwoMedicalStaffLeaders(oroneMedicalStaffLeaderandonememberoftheAdministrativeteam)areconcernedwiththeindividual’sabilitytosafelyandcompetentlycareforpatientsandrequestsuchtestingand/orevaluation.Thehealthcareprofessional(s)toperformthetestingand/orevaluationswillbedeterminedbytheMedicalStaffLeaders,andtheAlliedHealthProfessionalwillexecuteallappropriatereleasestopermitthesharingofinformationwiththeMedicalStaffLeaders;
(h) toappearforpersonalorphoneinterviewsinregardtoanapplicationfor
permissiontopracticeasmayberequested;(i) torefrainfromillegalfeesplittingorotherillegalinducementsrelatingtopatient
referral;(j) torefrainfromassumingresponsibilityfordiagnosisorcareofhospitalized
patientsforwhichheorsheisnotqualifiedorwithoutadequatesupervision;(k) torefrainfromdeceivingpatientsastotheindividual’sstatusasanAlliedHealth
ProfessionalandtoalwayswearproperHospitalidentificationoftheirnameandstatus;
(l) toseekconsultationwhenappropriate;(m) toparticipateintheperformanceimprovementandqualitymonitoringactivities
oftheHospital;(n) tocomplete,inatimelyandlegiblemanner,themedicalandotherrequired
records,containingallinformationrequiredbytheHospital;(o) tocooperatewithallutilizationoversightactivities;(p) toperformallservicesandconducthimself/herselfatalltimesinacooperative
andprofessionalmanner;(q) tosatisfyapplicablecontinuingeducationrequirements(e.g.,statelicensure;
certification;privilegeeligibilitycriteria);(r) topayanyapplicableapplicationfees,assessments,and/orfines;
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(s) tostrictlycomplywiththestandardsofpracticeapplicabletothefunctioningofCategoryIIpractitionersintheinpatienthospitalsetting,assetforthinSection6.AofthisPolicy;
(t) toconstructivelyparticipateinthedevelopment,review,andrevisionofclinical
practiceandevidence-basedmedicineprotocolsandpathwayspertinenttohisorherspecialty(includingthoserelatedtonationalpatientsafetyinitiativesandcoremeasures),andtocomplywithallsuchprotocolsandpathways;
(u) tocomplywithallapplicabletrainingand/oreducationalprotocolsthatmaybe
adoptedbytheMEC,including,butnotlimitedto,thoseinvolvingelectronicmedicalrecords,patientsafety,andinfectioncontrol;and
(v) that,ifthereisanymisstatementin,oromissionfrom,theapplication,the
Hospitalmaystopprocessingtheapplication(or,ifpermissiontopracticehasbeengrantedpriortothediscoveryofamisstatementoromission,thepermissionmaybedeemedtobeautomaticallyrelinquished).Ineithersituation,thereshallbenoentitlementtotheproceduralrightsprovidedinthisPolicy.TheindividualwillbeinformedinwritingofthenatureofthemisstatementoromissionandpermittedtoprovideawrittenresponsefortheCredentialsCommittee’sconsideration.
4.B.2.BurdenofProvidingInformation:
(a) AlliedHealthProfessionalsseekingpermissiontopracticeorrenewalofpermissiontopracticeshallhavetheburdenofproducinginformationdeemedadequatebytheHospitalforaproperevaluationofcurrentcompetence,character,ethics,andotherqualifications,andforresolvinganydoubtsaboutsuchqualifications.
(b) AlliedHealthProfessionalsseekingpermissionorrenewalofpermissionto
practicehavetheburdenofprovidingevidencethatallthestatementsmadeandinformationgivenontheapplicationareaccurate.
(c) Anapplicationshallbecompletewhenallquestionsontheapplicationform
havebeenanswered,allsupportingdocumentationhasbeensupplied,andallinformationhasbeenverifiedfromprimarysources.Anapplicationshallbecomeincompleteiftheneedarisesfornew,additional,orclarifyinginformationatanytimeduringthecredentialingprocess.Anyapplicationthatcontinuestobeincomplete30daysaftertheindividualhasbeennotifiedoftheadditionalinformationrequiredshallbedeemedtobewithdrawn.
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(d) Itistheresponsibilityoftheindividualseekingpermissiontopracticeorrenewalofpermissiontopracticetoprovideacompleteapplication,includingadequateresponsesfromreferences.Anincompleteapplicationwillnotbeprocessed.
4.C.APPLICATION4.C.1.Information:
(a) TheapplicationformsforbothinitialandrenewedpermissiontopracticeasanAlliedHealthProfessionalshallrequiredetailedinformationconcerningtheapplicant’sprofessionalqualifications.TheAlliedHealthProfessionalapplicationformsexistingnowandasmayberevisedareincorporatedbyreferenceandmadeapartofthisPolicy.
(b) Inadditiontootherinformation,theapplicationsshallseekthefollowing:
(1) informationastowhethertheapplicant’sclinicalprivileges,scopeofpractice,permissiontopractice,and/oraffiliationhaseverbeenvoluntarilyorinvoluntarilyrelinquished,withdrawn,denied,revoked,suspended,reduced,subjectedtoprobationaryorotherconditions,limited,terminated,ornotrenewedatanyhospital,healthcarefacility,orotherorganization,oriscurrentlybeinginvestigatedorchallenged;
(2) informationastowhethertheapplicant’slicenseorcertificationto
practiceanyprofessioninanystate,DEAregistration,oranystatecontrolledsubstancelicense(ifapplicable)isorhaseverbeenvoluntarilyorinvoluntarilyrelinquished,suspended,modified,terminated,restricted,oriscurrentlybeinginvestigatedorchallenged;
(3) informationconcerningtheapplicant’sprofessionalliabilitylitigation
experienceand/oranyprofessionalmisconductproceedingsinvolvingtheapplicant,inthisstateoranyotherstate,whethersuchproceedingsareclosedorstillpending,includingthesubstanceoftheallegationsofsuchproceedingsoractions,thesubstanceofthefindingsofsuchproceedingsoractions,theultimatedispositionofanysuchproceedingsoractionsthathavebeenclosed,andanyadditionalinformationconcerningsuchproceedingsoractionsastheCredentialsCommittee,MECorBoardmaydeemappropriate;
(4) currentinformationregardingtheapplicant’sabilitytoperform,safely
andcompetently,theclinicalprivilegesorscopeofpracticerequestedandthedutiesofAlliedHealthProfessionals;and
(5) acopyofgovernment-issuedphotoidentification.
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(c) Theapplicantshallsigntheapplicationandcertifythatheorsheisableto
performtheclinicalprivilegesorscopeofpracticerequestedandtheresponsibilitiesofAlliedHealthProfessionals.
4.C.2.GrantofImmunityandAuthorizationtoObtain/ReleaseInformation:
Byrequestinganapplicationand/orapplyingforpermissiontopractice,theindividualexpresslyacceptsthefollowingconditions:(a) Immunity:
Tothefullestextentpermittedbylaw,theindividualreleasesfromanyandallliability,extendsimmunityto,andagreesnottosuetheHospitalortheBoard,anymemberoftheMedicalStaffortheBoard,theirauthorizedrepresentatives,andthirdpartiesforanymatterrelatingtopermissiontopractice,clinicalprivileges,scopeofpractice,ortheindividual’squalificationsforthesame.Thisimmunitycoversanyactions,recommendations,reports,statements,communications,and/ordisclosuresinvolvingtheindividualthataremade,taken,orreceivedbytheHospital,itsauthorizedagents,orthirdpartiesinthecourseofcredentialingandpeerreviewactivities.
(b) AuthorizationtoObtainInformationfromThirdParties:
TheindividualspecificallyauthorizestheHospital,MedicalStaffLeaders,andtheirauthorizedrepresentatives(1)toconsultwithanythirdpartywhomayhaveinformationbearingontheindividual’sprofessionalqualifications,credentials,clinicalcompetence,character,abilitytoperformsafelyandcompetently,ethics,behavior,oranyothermatterreasonablyhavingabearingonhisorherqualificationsforinitialandcontinuedpermissiontopracticeattheHospital,and(2)toobtainanyandallcommunications,reports,records,statements,documents,recommendations,ordisclosuresofthirdpartiesthatmayberelevanttosuchquestions.TheindividualalsospecificallyauthorizesthirdpartiestoreleasethisinformationtotheHospitalanditsauthorizedrepresentativesuponrequest.Further,theindividualagreestosignnecessaryconsentformstopermitaconsumerreportingagencytoconductacriminalbackgroundcheckontheindividualandreporttheresultstotheHospital.
(c) AuthorizationtoReleaseInformationtoThirdParties:
TheindividualalsoauthorizesHospitalrepresentativestoreleaseinformationtootherhospitals,healthcarefacilities,managedcareorganizations,governmentregulatoryandlicensureboardsoragencies,andtheiragentswheninformationisrequestedinordertoevaluatehisorherprofessionalqualificationsfor
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permissiontopractice,clinicalprivileges,scopeofpractice,and/orparticipationattherequestingorganization/facility,andanylicensureorregulatorymatter.
(d) AuthorizationtoShareInformationWithinEmoryHealthcare:
TheindividualspecificallyauthorizesalloftheHospitalswithinEmoryHealthcaretosharecredentialingandpeerreviewinformationpertainingtotheindividual’sclinicalcompetenceand/orprofessionalconduct.Thisinformationmaybesharedatinitialappointment,reappointment,and/oranyothertimeduringtheindividual’sappointment.
(e) ProceduralRights:
TheAlliedHealthProfessionalagreesthattheproceduralrightssetforthinthisPolicyarethesoleandexclusiveremedywithrespecttoanyprofessionalreviewactiontakenbytheHospital.
(f) LegalActions:
If,despitethisSection,anindividualinstituteslegalactionchallenginganycredentialing,privileging,peerreview,orotheractionaffectingthepermissiontopracticeanddoesnotprevail,heorshewillreimbursetheHospitalandanymemberoftheMedicalStafforBoardinvolvedintheactionforallcostsincurredindefendingsuchlegalaction,includingreasonableattorney’sfeesandlostrevenues.
(g) ScopeofSection:
AlloftheprovisionsinthisSectionareapplicableinthefollowingsituations:(1) whetherornotpermissiontopractice,clinicalprivileges,orscopeof
practiceisgranted;(2) throughoutthetermofanyaffiliationwiththeHospitalandthereafter;(3) shouldpermissiontopractice,clinicalprivileges,orscopeofpracticebe
denied,revoked,reduced,restricted,suspended,and/orotherwiseaffectedaspartoftheHospital’sprofessionalreviewactivities;and
(4) asapplicable,toanythird-partyinquiriesreceivedaftertheindividual
leavestheHospitalabouthisorhertenureasamemberoftheAlliedHealthProfessionalStaff.
198832.1115
198832.1116
ARTICLE5
CREDENTIALINGPROCEDURE5.A.PROCESSINGOFINITIALAPPLICATIONTOPRACTICE5.A.1.RequestforApplication:
(a) AnyindividualrequestinganapplicationforpermissiontopracticeattheHospitalshallbesent(i)aletterthatoutlinestheeligibilitycriteriaforpermissiontopracticeasoutlinedinthisPolicy,(ii)anyeligibilityrequirementsthatrelatetotheAlliedHealthProfessional’sspecificareaofpractice,and(iii)theapplicationform.
(b) AnAlliedHealthProfessionalwhoisinacategoryofpractitionersthathasnot
beenapprovedbytheBoardtopracticeattheHospitalshallbeineligibletoreceiveanapplication.AdeterminationofineligibilitydoesnotentitleanAlliedHealthProfessionaltotheproceduralrightsoutlinedinArticle8ofthisPolicy.
5.A.2.InitialReviewofApplication:
(a) Acompletedapplication,withcopiesofallrequireddocuments,mustbesubmittedtotheMedicalStaffOfficewithin30daysafterreceiptoftheapplicationiftheAlliedHealthProfessionaldesiresfurtherconsideration.Theapplicationmustbeaccompaniedbytheapplicationprocessingfee,ifapplicable.
(b) Asapreliminarystep,theapplicationwillbereviewedbytheMedicalStaffOffice
(andCMO,ifnecessary)todeterminethatallquestionshavebeenansweredandthattheindividualsatisfiesallthresholdcriteria.IndividualswhofailtoreturncompletedapplicationsorfailtomeettheeligibilitycriteriasetforthinSection4.A.1ofthisPolicywillbenotifiedthattheyarenoteligibleforpermissiontopracticeattheHospitalandthattheirapplicationwillnotbeprocessed.AdeterminationofineligibilitydoesnotentitleanAlliedHealthProfessionaltotheproceduralrightsoutlinedinArticle8ofthisPolicy.
(c) TheMedicalStaffOfficeshalloverseetheprocessofgatheringandverifying
relevantinformationandconfirmingthatallreferencesandotherinformationormaterialsdeemedpertinenthavebeenreceived.IfanapplicationiscompleteinaccordancewithSection4.B.2(c),itshallbeprovided,alongwithallsupportingdocumentation,totheapplicabledepartmentchair.
198832.1117
5.A.3.DepartmentorDivisionChairProcedure:
(a) TheMedicalStaffOfficeshallprovidethecompleteapplicationandallsupportingmaterialstotheappropriatedepartmentordivisionchairortheindividualtowhomthedepartmentordivisionchairhasassignedthisresponsibility.Eachchairshallprepareareport(onaformprovidedbytheMedicalStaffOffice)regardingwhethertheapplicanthassatisfiedallofthequalificationsforpermissiontopracticeandtheclinicalprivilegesorscopeofpracticerequested.
(b) Aspartoftheprocessofmakingthisreport,thedepartmentordivisionchairhas
therighttomeetwiththeapplicantandtheSupervisingPhysician(ifapplicable)todiscussanyaspectoftheapplication,qualifications,andrequestedclinicalprivilegesorscopeofpractice.Thedepartmentordivisionchairmayalsoconferwithexpertswithinthedepartmentandoutsideofthedepartmentinpreparingthereport(e.g.,otherphysicians,relevantHospitaldepartmentheads,nursemanagers).
(c) Intheeventthatthedepartmentordivisionchairisunavailableorunwillingto
prepareawrittenreport,theChairoftheCredentialsCommitteeortheChiefofStaffshallappointanindividualtopreparethereport.
(d) Thedepartmentordivisionchairshallbeavailabletoansweranyquestionsthat
mayberaisedwithrespecttothatchair’sreportandfindings.
5.A.4.CredentialsCommitteeProcedure:
(a) TheCredentialsCommitteeshallreviewthereportfromtheappropriatedepartmentordivisionchairandtheinformationcontainedinreferencesgivenbytheapplicantandfromotheravailablesources.TheCredentialsCommitteeshallexamineevidenceoftheapplicant’scharacter,professionalcompetence,qualifications,priorbehavior,andethicalstandingandshalldeterminewhethertheapplicanthasestablishedandsatisfiedallofthenecessaryqualificationsfortheclinicalprivilegesorscopeofpracticerequested.
(b) TheCredentialsCommitteemayusetheexpertiseofanyindividualonthe
MedicalStafforintheHospital,oranoutsideconsultant,ifadditionalinformationisrequiredregardingtheapplicant’squalifications.TheCredentialsCommitteemayalsomeetwiththeapplicantand,whenapplicable,theSupervisingPhysician.Theappropriatedepartmentchairmayparticipateinthisinterview.
(c) Afterdeterminingthatanapplicantisotherwisequalifiedforpermissionto
practiceandtheclinicalprivilegesorscopeofpracticerequested,theCredentials
198832.1118
Committeeshallreviewtheapplicant’sHealthStatusConfirmationFormtodetermineifthereisanyquestionabouttheapplicant’sabilitytoperformtheprivilegesorscopeofpracticerequestedandtheresponsibilitiesofpermissiontopractice.Ifso,theCredentialsCommitteemayrequiretheapplicanttoundergoaphysical,mental,and/orbehavioralexaminationbyaphysician(s)satisfactorytotheCredentialsCommittee.TheresultsofthisexaminationshallbemadeavailabletotheCommitteeforitsconsideration.FailureofanapplicanttoundergoanexaminationwithinareasonabletimeafterbeingrequestedtodosoinwritingbytheCredentialsCommitteeshallbeconsideredanincompleteapplicationandallprocessingoftheapplicationshallcease.Thecostofthehealthassessmentwillbebornebytheapplicant.
(d) TheCredentialsCommitteemayrecommendtheimpositionofspecific
conditions.Theseconditionsmayrelatetobehavior(e.g.,personalcodeofconduct)ortoclinicalissues(e.g.,generalconsultationrequirements,appropriatedocumentationrequirements,proctoring,completionofeducationrequirements).TheCredentialsCommitteemayalsorecommendthatpermissiontopracticebegrantedforaperiodoflessthantwoyearsinordertopermitclosermonitoringofanindividual’scompliancewithanyconditions.
(e) TheCredentialsCommittee’srecommendationwillbeforwardedtotheMEC.
5.A.5.MECProcedure:
(a) Atitsnextmeeting,afterreceiptofthewrittenfindingsandrecommendationoftheCredentialsCommittee,theMECshall:
(1) adoptthefindingsandrecommendationsoftheCredentialsCommittee
asitsown;or(2) referthematterbacktotheCredentialsCommitteeforfurther
considerationandresponsestospecificquestionsraisedbytheMEC;or(3) setforthinitsreportandrecommendationclearandconvincingreasons,
alongwithsupportinginformation,foritsdisagreementwiththeCredentialsCommittee’srecommendation.
(b) IftheMEC’srecommendationisfavorabletotheapplicant,theCommitteeshall
forwarditsrecommendationtotheBoard,throughtheCEO,includingthefindingsandrecommendationofthedepartmentchairandtheCredentialsCommittee.TheMEC’srecommendationmustspecificallyaddresstheclinicalprivilegesorscopeofpracticerequestedbytheapplicant,whichmaybequalifiedbyanyprobationaryorotherconditionsorrestrictionsrelatingtosuchclinicalprivilegesorscopeofpractice.
198832.1119
(c) IftheMEC’srecommendationisunfavorableandwouldentitletheapplicantto
theproceduralrightssetforthinthisPolicy,theMECshallforwarditsrecommendationtotheCEO,whoshallnotifytheapplicantoftherecommendationandhisorherproceduralrights.TheCEOshallthenholdtheMEC’srecommendationuntilaftertheindividualhascompletedorwaivedtheproceduralrightsoutlinedinthisPolicy.
5.A.6.BoardAction:
(a) TheBoardmaydelegatetoacommittee,consistingofatleasttwoBoardmembers,actiononapplicationsiftherehasbeenafavorablerecommendationfromtheCredentialsCommitteeandtheMEC(ortheirdesignees)andthereisnoevidenceofanyofthefollowing:
(1) acurrentorpreviouslysuccessfulchallengetoanylicense,certification,
orregistration;(2) aninvoluntarytermination,limitation,reduction,denial,orlossof
permissiontopractice,clinicalprivileges,orscopeofpracticeatanyotherhospitalorotherentity;or
(3) anunusualpatternof,oranexcessivenumberof,professionalliability
actionsresultinginafinaljudgmentagainsttheapplicant.AnydecisionreachedbytheBoardcommitteetoappointandgranttheclinicalprivilegesorscopeofpracticerequestedshallbeeffectiveimmediatelyandshallbeforwardedtotheBoardforratificationatitsnextmeeting.
(b) WhentherehasbeennodelegationtoaBoardcommittee,uponreceiptofarecommendationthattheapplicantbegrantedpermissiontopracticeandclinicalprivilegesorscopeofpracticerequested,theBoardmay:
(1) granttheapplicantpermissiontopracticeandclinicalprivilegesorscope
ofpracticeasrecommended;or(2) referthematterbacktotheCredentialsCommitteeorMECortoanother
sourceinsideoroutsidetheHospitalforadditionalresearchorinformation;or
(3) rejectormodifytherecommendation.
(c) IftheBoarddeterminestorejectafavorablerecommendation,itshouldfirstdiscussthematterwiththeChairoftheCredentialsCommitteeandtheChiefof
198832.1120
Staff.IftheBoard’sdeterminationremainsunfavorabletotheapplicant,theCEOshallpromptlysendspecialnoticetotheapplicantthattheapplicantisentitledtorequesttheproceduralrightsasoutlinedinthisPolicy.
(d) AnyfinaldecisionbytheBoardtogrant,deny,revise,orrevokepermissionto
practiceand/orclinicalprivilegesorscopeofpracticewillbedisseminatedtoappropriateindividualsand,asrequired,reportedtoappropriateentities.
5.B.CLINICALPRIVILEGES5.B.1.General:
TheclinicalprivilegesrecommendedtotheBoardforCategoryIandCategoryIIpractitionerswillbebaseduponconsiderationofthefollowingfactors:(a) education,relevanttraining,experience,anddemonstratedcurrentcompetence,
includingmedical/clinicalknowledge,technicalandclinicalskills,clinicaljudgment,interpersonalandcommunicationskills,andprofessionalismwithpatients,familiesandothermembersofthehealthcareteamandpeerevaluationsrelatingtothesame;
(b) abilitytoperformtheprivilegesrequestedcompetentlyandsafely;(c) informationresultingfromongoingandfocusedprofessionalpracticeevaluation
andperformanceimprovementactivities,asapplicable;(d) adequateprofessionalliabilityinsurancecoveragefortheclinicalprivileges
requested;(e) theHospital’savailableresourcesandpersonnel;(f) anypreviouslysuccessfulorcurrentlypendingchallengestoanylicensureor
registration,orthevoluntaryorinvoluntaryrelinquishmentofsuchlicensureorregistration;
(g) anyinformationconcerningprofessionalreviewactionsorvoluntaryor
involuntarytermination,limitation,reduction,orlossofappointmentorclinicalprivilegesatanotherhospital;
(h) practitioner-specificdataascomparedtoaggregatedata,whenavailable;(i) morbidityandmortalitydata,whenavailable;and
198832.1121
(j) professionalliabilityactions,especiallyanysuchactionsthatreflectanunusualpatternorexcessivenumberofactions.
5.B.2.FPPEtoConfirmCompetence:
AllnewclinicalprivilegesforCategoryIandCategoryIIpractitioners,regardlessofwhentheyaregranted(initialpermissiontopractice,renewalofpermissiontopractice,oratanytimeinbetween),willbesubjecttofocusedprofessionalpracticeevaluation(“FPPE”)inordertoconfirmcompetence.TheFPPEprocessforthesesituationsisoutlinedinthePolicyRegardingFPPEtoConfirmPractitionerCompetence.
5.C.TEMPORARYCLINICALPRIVILEGES5.C.1.RequestforTemporaryClinicalPrivileges:
(a) Applicants:TemporaryprivilegesforanapplicantforinitialpermissiontopracticemaybegrantedbytheCEO,uponrecommendationoftheChiefofStaffandthedepartmentchair,whenaCategoryIorCategoryIIpractitionerhassubmittedacompletedapplicationandtheapplicationispendingreviewbytheCredentialsCommittee,theMEC,andtheBoard.Priortotemporaryprivilegesbeinggrantedinthissituation,thecredentialingprocessmustbecomplete,including,whereapplicable,verificationofcurrentlicensure,relevanttrainingorexperience,currentcompetence,abilitytoexercisetheprivilegesrequested,andcompliancewithcriteria,andconsiderationofinformationfromtheNationalPractitionerDataBankandfromacriminalbackgroundcheck.Inordertobeeligiblefortemporaryprivileges,anindividualmustdemonstratethattherearenocurrentorpreviouslysuccessfulchallengestohisorherlicensureorregistrationandthatheorshehasnotbeensubjecttoinvoluntaryterminationofmembership,orinvoluntarylimitation,reduction,denial,orlossofclinicalprivilegesatanotherhealthcarefacility.
(b) LocumTenens:TheCEO,uponrecommendationoftheChiefofStaffandthe
applicabledepartmentchair,maygranttemporaryprivilegestoaCategoryIorCategoryIIpractitionerservingasalocumtenensforanindividualwhoisonvacation,attendinganeducationalseminar,orill,and/orotherwiseneedscoverageassistanceforaperiodoftime.Priortotemporaryprivilegesbeinggrantedinthissituation,theverificationprocessmustbecomplete,including,whereapplicable,verificationofcurrentlicensure,relevanttrainingorexperience,currentcompetence,abilitytoexercisetheprivilegesrequested,andcompliancewithcriteria,andconsiderationofinformationfromtheNationalPractitionerDataBankandfromacriminalbackgroundcheck.Inordertobeeligiblefortemporaryprivileges,anindividualmustdemonstratethattherearenocurrentorpreviouslysuccessfulchallengestohisorherlicensureorregistrationandthatheorshehasnotbeensubjecttoinvoluntarytermination
198832.1122
ofmembership,orinvoluntarylimitation,reduction,denial,orlossofclinicalprivilegesatanotherhealthcarefacility.
(c) Priortotemporaryprivilegesbeinggranted,theindividualmustagreeinwriting
tobeboundbyallapplicablebylaws,rulesandregulations,andpolicies,procedures,andprotocols.
(d) Temporaryprivilegeswillbegrantedforaspecificperiodoftime,nottoexceed
120days,andwillexpireattheendofthetimeperiodforwhichtheyaregranted.
5.C.2.TerminationofTemporaryClinicalPrivileges:
(a) TheCEOmay,atanytimeafterconsultingwiththeChiefofStaff,theChairoftheCredentialsCommittee,thedepartmentchair,ortheCMO,terminatetemporaryprivilegesforanyreason.
(b) Thegrantingoftemporaryprivilegesisacourtesy.Neitherthedenialnor
terminationoftemporaryprivilegeswillentitletheindividualtotheproceduralrightssetforthinArticle8.
5.D.PROCESSINGAPPLICATIONSFORRENEWALTOPRACTICE5.D.1.SubmissionofApplication:
(a) Thegrantofpermissiontopracticewillbeforaperiodnottoexceedtwoyears.Arequesttorenewclinicalprivilegesorscopeofpracticewillbeconsideredonlyuponsubmissionofacompletedrenewalapplication.
(b) AtleastfourmonthspriortothedateofexpirationofanAlliedHealth
Professional’sclinicalprivilegesorscopeofpractice,theMedicalStaffOfficewillnotifytheindividualofthedateofexpirationandprovidetheindividualwitharenewalapplication.AcompletedrenewalapplicationmustbereturnedtotheMedicalStaffOfficewithin30days.
(c) Failuretosubmitacompleteapplicationatleasttwomonthspriortothe
expirationoftheindividual’scurrenttermwillresultinautomaticexpirationofclinicalprivilegesorscopeofpracticeattheendofthethencurrentterm,unlesstheapplicationcanstillbeprocessedinthenormalcourse,withoutextraordinaryeffortonthepartoftheMedicalStaffOfficeandtheMedicalStaffLeaders.
198832.1123
(d) Onceanapplicationforrenewalofclinicalprivilegesorscopeofpracticehasbeencompletedandsubmitted,itwillbeevaluatedfollowingthesameproceduresoutlinedinthisPolicyregardinginitialapplications.
5.D.2.RenewalProcessforCategoryIandCategoryIIPractitioners:
(a) Theprocedurespertainingtoaninitialrequestforclinicalprivileges,includingeligibilitycriteriaandfactorsforevaluation,willbeapplicableinprocessingrequestsforrenewalforthesepractitioners.
(b) Aspartoftheprocessforrenewalofclinicalprivileges,thefollowingfactorswill
beconsidered:
(1) anassessmentpreparedbytheapplicabledepartmentchair;(2) anassessmentpreparedbyapeer,ifpossible;(3) resultsoftheHospital’sperformanceimprovementandongoingand
focusedprofessionalpracticeevaluationactivities,takingintoconsideration,whenapplicable,practitioner-specificinformationcomparedtoaggregateinformationconcerningotherindividualsinthesameorsimilarspecialty(providedthat,otherpractitionerswillnotbeidentified);
(4) resolutionofanyverifiedcomplaintsreceivedfrompatientsorstaff;and(5) anyfocusedprofessionalpracticeevaluations.
(c) ForCategoryIIpractitioners,thefollowinginformationmayalsobeconsidered:
(1) anassessmentpreparedbytheSupervisingPhysician(s);or(2) anassessmentpreparedbytheapplicableHospitalsupervisor(i.e.,OR
Supervisor,NursingSupervisor).
5.D.3.RenewalProcessforCategoryIIIPractitioners:
(a) Theprocedurespertainingtoaninitialrequestforascopeofpractice,includingeligibilitycriteriaandfactorsforevaluation,willbeapplicableinprocessingrequestsforrenewalforthesepractitioners.
(b) Aspartoftheprocessforrenewalofscopeofpractice,thefollowingfactorswill
beconsidered:
198832.1124
(1) acompetencyassessmentoftheindividualperformedbytheSupervisingPhysician(s)and/ortheapplicableHospitaldepartmentheads(i.e.,ORSupervisor,NursingSupervisor);and
(2) resolutionofanyvalidatedcomplaintsreceivedfrompatientsorstaff.
198832.1125
ARTICLE6
CONDITIONSOFPRACTICEAPPLICABLETOCATEGORYIIANDCATEGORYIIIPRACTITIONERS
6.A.STANDARDSOFPRACTICEFORTHEUTILIZATIONOFCATEGORYII PRACTITIONERSINTHEINPATIENTHOSPITALSETTING
(1) CategoryIIpractitionersarenotpermittedtofunctionindependentlyintheinpatientHospitalsetting.AsaconditionofbeinggrantedpermissiontopracticeattheHospital,allCategoryIIpractitionersspecificallyagreetoabidebythestandardsofpracticesetforthinthisSection.Inaddition,asaconditionofbeingpermittedtoutilizetheservicesofCategoryIIpractitionersintheHospital,allMedicalStaffmemberswhoserveasSupervisingPhysicianstosuchindividualsalsospecificallyagreetoabidebythestandardssetforthinthisSection.
(2) ThefollowingstandardsofpracticeapplytothefunctioningofCategoryII
practitionersintheinpatientHospitalsetting:
(a) AdmittingPrivileges.CategoryIIpractitionersarenotgrantedinpatientadmittingprivilegesandthereforemaynotadmitpatientsindependentoftheSupervisingPhysician.
(b) Consultations.CategoryIIpractitionersmaynotindependentlyprovide
patientconsultationsinlieuofthepractitioners’SupervisingPhysicians.ACategoryIIpractitionermaygatherdataandordertests;however,theSupervisingPhysicianmustpersonallyperformtherequestedconsultationwithin24hours(ormoretimelyinthecaseofanyemergencyconsultationrequest)unlessthephysicianrequestingtheconsultationagreesthattheCategoryIIpractitionermayprovidetheconsultation.IfitisagreedthattheCategoryIIpractitionermayprovidetheconsultation,theSupervisingPhysicianshallreviewandcountersigntheconsultationreportwithin24hoursofitscompletion.
(c) EmergencyOn-CallCoverage.CategoryIIpractitionersmaynot
independentlyparticipateintheemergencyon-callroster(formally,orinformallybyagreementwiththeirSupervisingPhysicians),inlieuoftheSupervisingPhysician.ItshallbewithinthediscretionoftheEmergencyDepartmentpersonnelrequestingassistancewhetheritisappropriatetocontactaCategoryIIpractitionerpriortotheSupervisingPhysician.However,whencontactedbytheEmergencyDepartment,theSupervisingPhysician(orhisorhercoveringphysician)mustpersonallyrespondtoallcallsinatimelymanner,inaccordancewithrequirements
198832.1126
setforthintheMedicalStaffCredentialsPolicy.FollowingdiscussionwiththeEmergencyDepartment,theSupervisingPhysicianmaydirectaCategoryIIpractitionertoseethepatient,gatherdata,andordertestsforfurtherreviewbytheSupervisingPhysician.However,theSupervisingPhysicianmustpersonallyseethepatientwhenrequestedbytheEmergencyDepartmentphysician.
(d) CallsRegardingSupervisingPhysician’sHospitalizedInpatients.Itshallbe
withinthediscretionoftheHospitalpersonnelrequestingassistancewhetheritisappropriatetocontactaCategoryIIpractitionerpriortotheSupervisingPhysician.However,theSupervisingPhysicianmustpersonallyrespondtoallcallsdirectedtohimorherinatimelymanner.CategoryIIpractitionersmaynotindependentlyrespondtocallsfromthefloororspecialcareunitsregardinghospitalizedinpatientsthatwerespecificallydirectedtotheSupervisingPhysician.
(e) DailyInpatientRounds.ACategoryIIpractitioner(specificallyaNurse
Practitioner,PhysicianAssistant,orCertifiedNurseMidwife)ispermittedtoperformdailyinpatientrounds;however,allinpatientsmustalsobevisitedbytheSupervisingPhysician(oradesignatedphysician)whenrequested.
6.B.OVERSIGHTBYSUPERVISINGPHYSICIAN
(1) AnyactivitiespermittedtobeperformedattheHospitalbyaCategoryIIorCategoryIIIpractitionershallbeperformedonlyunderthesupervisionordirectionofaSupervisingPhysician.
(2) CategoryIIorCategoryIIIpractitionersmayfunctionintheHospitalonlysolong
as(i)theyaresupervisedbyaSupervisingPhysicianwhoiscurrentlyappointedtotheMedicalStaff,and(ii)theyhaveacurrent,writtensupervisionagreementwiththeSupervisingPhysician.Inaddition,shouldtheMedicalStaffappointmentorclinicalprivilegesoftheSupervisingPhysicianberevokedorterminated,theCategoryIIorCategoryIIIpractitioner’spermissiontopracticeattheHospitalandclinicalprivilegesorscopeofpracticeshallbeautomaticallyrelinquished(unlesstheindividualwillbesupervisedbyanotherapprovedphysicianontheMedicalStaff).
(3) Asaconditionofclinicalprivilegesorascopeofpractice,aCategoryIIor
CategoryIIIpractitionerandtheSupervisingPhysicianmustprovidetheHospitalwithacopyoftheirwrittensupervisionagreementaswellasnoticeofanyrevisionsormodificationsthataremadetosuchagreementsbetweenthem.ThisnoticemustbeprovidedtotheMedicalStaffOfficewithinthreedaysofanysuchchange.
198832.1127
6.C.QUESTIONSREGARDINGAUTHORITYOFACATEGORYII ORCATEGORYIIIPRACTITIONER
(1) ShouldanyMedicalStaffmemberorHospitalemployeewhoislicensedorcertifiedbythestatehaveanyquestionregardingtheclinicalcompetenceorauthorityofaCategoryIIorCategoryIIIpractitioner,eithertoactortoissueinstructionsoutsidethephysicalpresenceoftheSupervisingPhysicianinaparticularinstance,theMedicalStaffmemberorHospitalemployeeshallhavetherighttorequirethattheCategoryIIorCategoryIIIpractitioner’sSupervisingPhysicianvalidate,eitheratthetimeorlater,theinstructionsoftheCategoryIIorCategoryIIIpractitioner.AnyactorinstructionoftheCategoryIIorCategoryIIIpractitionershallbedelayeduntilsuchtimeasthestaffmemberorHospitalemployeecanbecertainthattheactisclearlywithinthescopeoftheCategoryIIorCategoryIIIpractitioner’sactivitiesaspermittedbytheBoard.Inthesesituations,theMedicalStaffmemberorHospitalemployeeshallfirstdiscussthematterwiththeSupervisingPhysician.Ifthatdoesnotresolvethematter,theChiefofStaffortheCMOwillbecontacted.
(2) Anyquestionregardingtheclinicalpracticeorprofessionalconductofa
CategoryIIorCategoryIIIpractitionershallbeimmediatelyreportedtotheChiefofStaff,theChairoftheCredentialsCommittee,therelevantdepartmentchair,theCMO,ortheCEO,whoshallundertakesuchactionasmaybeappropriateunderthecircumstances.TheindividualtowhomtheconcernhasbeenreportedwillalsodiscussthematterwiththeSupervisingPhysician.
6.D.RESPONSIBILITIESOFSUPERVISINGPHYSICIAN
(1) PhysicianswhowishtoutilizetheservicesofaCategoryIIorCategoryIIIpractitionerintheirclinicalpracticeattheHospitalmustnotifytheMedicalStaffOfficeofthisfactinadvanceandmustensurethattheindividualhasbeenappropriatelycredentialedinaccordancewiththisPolicyorwithHumanResourcespoliciesandproceduresbeforetheCategoryIIorCategoryIIIpractitionerparticipatesinanyclinicalordirectpatientcareofanykindintheHospital.
(2) TheSupervisingPhysicianwillremainresponsibleforallcareprovidedbythe
CategoryIIorCategoryIIIpractitionerintheHospital.(3) SupervisingPhysicianswhowishtoutilizetheservicesofCategoryIIpractitioners
intheinpatientsettingspecificallyagreetoabidebythestandardsofpracticesetforthinSection6.Aabove.
198832.1128
(4) ThenumberofCategoryIIorCategoryIIIpractitionersactingunderthesupervisionofoneSupervisingPhysician,aswellasthecaretheymayprovide,willbeconsistentwithapplicablestatestatutesandregulationsandanyotherpoliciesadoptedbytheHospital.TheSupervisingPhysicianwillmakeallappropriatefilingswiththeStateBoardofMedicineregardingthesupervisionandresponsibilitiesoftheCategoryIIorCategoryIIIpractitioner,totheextentthatsuchfilingsarerequiredandshallprovideacopyofthesametotheMedicalStaffOffice.
(5) ItwillbetheresponsibilityoftheSupervisingPhysiciantoensurethatthe
CategoryIIorCategoryIIIpractitionermaintainsprofessionalliabilityinsurancecoverageinamountsrequiredbytheBoard.TheinsurancemustcoveranyandallactivitiesoftheCategoryIIorCategoryIIIpractitionerintheHospital.TheSupervisingPhysicianwillfurnishevidenceofsuchcoveragetotheHospital.TheCategoryIIorCategoryIIIpractitionerwillactintheHospitalonlywhilesuchcoverageisineffect.
198832.1129
ARTICLE7
PEERREVIEWPROCEDURESFORQUESTIONSINVOLVINGALLIEDHEALTHPROFESSIONALS
7.A.COLLEGIALINTERVENTION
(1) AspartoftheHospital’sperformanceimprovementandprofessionalpracticeevaluationactivities,thisPolicyencouragestheuseofcollegialeffortsandprogressivestepswithAlliedHealthProfessionals(andtheirSupervisingPhysicians,asapplicable)byMedicalStaffLeadersandHospitalmanagementinordertoarriveatvoluntary,responsiveactionsbyindividualstoresolvequestionsthathavebeenraised.CollegialinterventioneffortsarenotmandatoryandshallbewithinthediscretionoftheappropriateMedicalStaffLeaders.
(2) Collegialinterventioneffortsmayinclude,butarenotlimitedto,counseling,
sharingofcomparativedata,monitoring,andadditionaltrainingoreducation.Allsucheffortsshallbedocumentedinanindividual’sconfidentialfile.
(3) CollegialinterventioneffortsareapartoftheHospital’songoingandfocused
professionalpracticeevaluationactivities.(4) TheChiefofStaff,inconjunctionwiththeCEOortheCMO,shalldetermine
whethertodirectthatamatterbehandledinaccordancewithanotherpolicy(e.g.,codeofconductpolicy;practitionerhealthpolicy;professionalpracticeevaluationpolicy)ortodirectthemattertotheMECforfurtherreviewand/orinvestigation.
7.B.ONGOINGANDFOCUSEDPROFESSIONALPRACTICEEVALUATIONS
AllongoingandfocusedprofessionalpracticeevaluationsshallbeconductedinaccordancewiththeProfessionalPracticeEvaluationPolicy.MattersthatarenotsatisfactorilyresolvedthroughcollegialinterventionorthroughtheProfessionalPracticeEvaluationPolicyshallbereferredtotheMECforitsreviewinaccordancewithSection7.Cbelow.Suchinterventionsandevaluations,however,arenotmandatoryprerequisitestoMECreview.
7.C.INVESTIGATIONS7.C.1.InitiationofInvestigation:
198832.1130
WhenaquestioninvolvingclinicalcompetenceorprofessionalconductofanAlliedHealthProfessionalisreferredto,orraisedby,theMEC,theMECwillreviewthematteranddeterminewhethertoconductaninvestigation,todirectthemattertobehandledpursuanttoanotherpolicy,ortoproceedinanothermanner.
7.C.2.InvestigativeProcedure:
(a) TheMECwilleitherinvestigatethematteritself,requestthattheCredentialsCommitteeconducttheinvestigation,orappointanadhoccommitteetoconducttheinvestigation(“investigatingcommittee”).TheinvestigatingcommitteewillnotincluderelativesorfinancialpartnersoftheAlliedHealthProfessionalor,whereapplicable,theAlliedHealthProfessional’sSupervisingPhysician.
(b) Theinvestigatingcommitteewillhavetheauthoritytoreviewrelevant
documentsandinterviewindividuals.ItwillalsohaveavailabletoitthefullresourcesoftheMedicalStaffandtheHospital.
(c) Theinvestigatingcommitteewillalsohavetheauthoritytouseoutside
consultants,ifneeded.(d) Theinvestigatingcommitteemayrequireaphysical,mental,and/orbehavioral
examinationoftheindividualbyahealthcareprofessional(s)acceptabletoit.Theindividualbeinginvestigatedshallexecutearelease(inaformapprovedorprovidedbytheinvestigatingcommittee)allowing(i)theinvestigatingcommittee(oritsrepresentative)todiscusswiththehealthcareprofessional(s)conductingtheexaminationthereasonsfortheexamination;and(ii)thehealthcareprofessional(s)conductingtheexaminationtodiscussandprovidedocumentationoftheresultsofsuchexaminationdirectlytotheinvestigatingcommittee.Thecostofsuchhealthexaminationshallbebornebytheindividual.
(e) Theindividualwillhaveanopportunitytomeetwiththeinvestigatingcommittee
beforeitmakesitsreport.Priortothismeeting,theindividualwillbeinformedofthegeneralquestionsbeinginvestigated.Atthemeeting,theindividualwillbeinvitedtodiscuss,explain,orrefutethequestionsthatgaverisetotheinvestigation.Norecording(audioorvideo)ortranscriptofthemeetingshallbepermittedormade.Asummaryoftheinterviewwillbeprepared.Thismeetingisnotahearing,andnoneoftheproceduralrulesforhearingswillapply.Theindividualbeinginvestigatedwillnothavetherighttoberepresentedbylegalcounselatthismeeting.
(f) Theinvestigatingcommitteewillmakeareasonableefforttocompletethe
investigationandissueitsreportwithin30daysofthecommencementofthe
198832.1131
investigation,providedthatanoutsidereviewisnotnecessary.Whenanoutsidereviewisnecessary,theinvestigatingcommitteewillmakeareasonableefforttocompletetheinvestigationandissueitsreportwithin30daysofreceivingtheresultsoftheoutsidereview.Thesetimeframesareintendedtoserveonlyasguidelines.
(g) Attheconclusionoftheinvestigation,theinvestigatingcommitteewillpreparea
reportwithitsfindings,conclusions,andrecommendations.
7.C.3.Recommendation:
(a) TheMECmayaccept,modify,orrejectanyrecommendationitreceivesfromaninvestigatingcommittee.Specifically,theMECmay:
(1) determinethatnoactionisjustified;(2) issuealetterofguidance,counsel,warning,orreprimand;(3) imposeconditionsforcontinuedpermissiontopractice;(4) imposearequirementformonitoring,proctoring,orconsultation;(5) imposearequirementforadditionaltrainingoreducation;(6) recommendreductionofclinicalprivilegesorscopeofpractice;(7) recommendsuspensionofclinicalprivilegesorscopeofpracticefora
term;(8) recommendrevocationofclinicalprivilegesorscopeofpractice;or(9) makeanyotherrecommendationthatitdeemsnecessaryorappropriate.
(b) ArecommendationbytheMECthatwouldentitletheindividualtorequestahearingwillbeforwardedtotheCEO,whowillpromptlyinformtheindividualbyspecialnotice.TheCEOwillholdtherecommendationuntilaftertheindividualhascompletedorwaivedahearingandappeal.
(c) IftheMECmakesarecommendationthatdoesnotentitletheindividualto
requestahearing,itwilltakeeffectimmediatelyandwillremainineffectunlessmodifiedbytheBoard.
7.D.ADMINISTRATIVESUSPENSION
198832.1132
(1) TheChiefofStaff,therelevantdepartmentchair,theCMO,theCEO,andtheMECwilleachhavetheauthoritytoimposeanadministrativesuspensionofalloranyportionoftheclinicalprivilegesofanyAlliedHealthProfessionalwheneveraquestionhasbeenraisedaboutsuchindividual’sclinicalcareorprofessionalconduct.
(2) Anadministrativesuspensionwillbecomeeffectiveimmediatelyupon
imposition,willimmediatelybereportedtotheCEOandtheChiefofStaff,andwillremainineffectunlessoruntilmodifiedbytheCEOortheMEC.TheimpositionofanadministrativesuspensiondoesnotentitleanAlliedHealthProfessionaltotheproceduralrightssetforthinArticle8ofthisPolicy.
(3) Uponreceiptofnoticeoftheimpositionofanadministrativesuspension,the
CEOandChiefofStaffwillforwardthemattertotheMEC,whichwillreviewandconsiderthequestion(s)raisedandthereaftermakearecommendationtotheBoard.
7.E.AUTOMATICRELINQUISHMENT/ACTIONS
(1) AnAlliedHealthProfessional’sclinicalprivilegesorscopeofpracticeshallbeautomaticallyrelinquished,withoutentitlementtotheproceduralrightsoutlinedinthisPolicy,inthefollowingcircumstances:
(a) theAlliedHealthProfessionalnolongersatisfiesanyofthethreshold
eligibilitycriteriasetforthinSection4.A.1oranyadditionalthresholdcredentialingqualificationssetforthinthespecificHospitalpolicyrelatingtohisorherdiscipline;
(b) theAlliedHealthProfessionalisarrested,charged,indicted,convicted,or
entersapleaofguiltyornocontesttoanyfelony;ortoanymisdemeanorinvolving(i)controlledsubstances;(ii)illegaldrugs;(iii)Medicare,Medicaid,orinsuranceorhealthcarefraudorabuse;(iv)childabuse;(v)elderabuse;or(vi)violenceagainstanother(DUIswillbeaddressedinthemanneroutlinedinSection4.B.1(f)ofthisPolicy);
(c) theAlliedHealthProfessionalfailstoprovideinformationpertainingto
hisorherqualificationsforclinicalprivilegesinresponsetoawrittenrequestfromtheCredentialsCommittee,theMEC,theCMO,theCEO,oranyothercommitteeauthorizedtorequestsuchinformation;
(d) theAlliedHealthProfessionalfailstocompleteorcomplywithrequired
trainingoreducationalrequirements;
198832.1133
(e) adeterminationismadethatthereisnolongeraneedfortheservicesofaparticulardisciplineorcategoryofAlliedHealthProfessional;
(f) aCategoryIIorCategoryIIIpractitionerfails,foranyreason,tomaintain
anappropriaterelationshipwithaSupervisingPhysicianasdefinedinthisPolicy;or
(g) anyAlliedHealthProfessionalemployedbytheHospitalhashisorher
employmentterminated.
(2) RequestsforReinstatement.
(a) Requestsforreinstatementfollowingtheexpirationofalicense/certification/registration,controlledsubstanceauthorization,and/orinsurancecoveragewillbeprocessedbytheMedicalStaffOffice.Ifanyquestionsorconcernsarenoted,theMedicalStaffOfficewillreferthematterforfurtherreviewinaccordancewith(b)below.
(b) AllotherrequestsforreinstatementwillbereviewedbytheChiefof
Staff,theCMO,andtheCEO.Ifeachoftheseindividualsmakesafavorablerecommendationonreinstatement,theAlliedHealthProfessionalmayimmediatelyresumeclinicalpracticeattheHospital.ThisdeterminationwillthenbeforwardedtotheCredentialsCommittee,theMEC,andtheBoardforratification.If,however,anyoftheseindividualsreviewingtherequesthasanyquestionsorconcerns,thosequestionswillbenotedandthereinstatementrequestwillbeforwardedtothefullCredentialsCommittee,MEC,andBoardforreviewandrecommendation.
7.F.ACTIONATANOTHEREMORYHEALTHCAREHOSPITAL
Anydisciplinaryaction,involuntarychangeinappointment,clinicalprivileges,and/orscopeofpracticestatus,orthedevelopmentofaPerformanceImprovementPlan(collectively“action”)thatoccursatanotherHospitalwithinEmoryHealthcare(exceptthoserelatingtomedicalrecordcompletioninfractions)shallautomaticallyandimmediatelybeeffectiveatthisHospital,withouttheindividual’srecoursetoanyadditionalreview,investigation,hearing,orappeal(asmaybeapplicable).ThisautomaticactionmaybewaivedbytheMECandtheBoardinexceptionalcircumstances,afterafullreviewofthespecificcircumstancesandanyrelevantpeerreviewdocuments(e.g.,professionalpracticeevaluation,investigation,andhearingdocuments)fromtheEmoryfacilitywheretheactionfirstoccurred.
198832.1134
7.G.LEAVEOFABSENCE
(1) AnAlliedHealthProfessionalmayrequestaleaveofabsence,foraperiodnottoexceedayear,bysubmittingawrittenrequesttotheMedicalStaffOffice.TheCEOwillthendeterminewhetherarequestforaleaveofabsenceshallbegranted.Requestsforreinstatementmustbemadeatleast30dayspriortotheconclusionoftheleaveofabsence.
(2) AlliedHealthProfessionalsmustreporttotheMedicalStaffOfficeanytimethey
areawayfrompatientcareresponsibilitiesforlongerthan30daysandthereasonforsuchabsenceisrelatedtotheirphysicalormentalhealthorotherwisetotheirabilitytocareforpatientssafelyandcompetently.Undersuchcircumstances,theCEO,inconsultationwiththeChiefofStaff,maytriggeranautomaticmedicalleaveofabsence.
(3) Individualsrequestingreinstatementwillsubmitawrittensummaryoftheir
professionalactivitiesduringtheleave,andanyotherinformationthatmayberequestedbytheHospital.RequestsforreinstatementwillthenbereviewedbytheChiefofStaff,theservicechief,theCMO,andtheCEO.Ifeachoftheseindividualsmakesafavorablerecommendationonreinstatement,theAlliedHealthProfessionalmayimmediatelyresumepractice.ThisdeterminationwillthenbeforwardedtotheCredentialsCommittee,theMEC,andtheBoardforratification.If,however,anyoftheindividualsreviewingtherequesthasanyquestionsorconcerns,thosequestionswillbenotedandthereinstatementrequestwillbeforwardedtothefullCredentialsCommittee,MEC,andBoardforreviewandrecommendation.IntheeventtheMECdeterminestotakeactionthatwouldentitletheindividualtotheproceduralrightssetforthinArticle8,theindividualwillbegivenspecialnotice.
(4) Iftheleaveofabsencewasforhealthreasons(exceptformaternityleaves),the
requestforreinstatementmustbeaccompaniedbyareportfromtheindividual’sphysicianindicatingthattheindividualisphysicallyand/ormentallycapableofresumingahospitalpracticeandsafelyexercisingtheclinicalprivilegesrequested.
198832.1135
ARTICLE8
PROCEDURALRIGHTSFORALLIEDHEALTHPROFESSIONALS
AlliedHealthProfessionalsshallnotbeentitledtothehearingandappealsproceduressetforthintheMedicalStaffCredentialsPolicy.AnyandallproceduralrightstowhichtheseindividualsareentitledaresetforthinthisArticle.
8.A.PROCEDURALRIGHTSFORCATEGORYIANDCATEGORYIIPRACTITIONERS
8.A.1.NoticeofRights:
(a) IntheeventarecommendationismadebytheMECthataCategoryIorCategoryIIpractitionernotbegrantedclinicalprivilegesorthattheprivilegespreviouslygrantedberestrictedforaperiodofmorethan30days,terminated,ornotrenewed,theindividualwillreceivespecialnoticeoftherecommendation.Thespecialnoticewillincludeageneralstatementofthereasonsfortherecommendationandwilladvisetheindividualthatheorshemayrequestahearing.
(b) TherightsandproceduresinthisSectionwillalsoapplyiftheBoard,withouta
prioradverserecommendationfromtheMEC,makesarecommendationnottograntclinicalprivilegesorthattheprivilegespreviouslygrantedberestricted,terminated,ornotrenewed.Inthisinstance,allreferencesinthisArticletotheMECwillbeinterpretedasareferencetotheBoard.
(c) IftheCategoryIorCategoryIIpractitionerwantstorequestahearing,the
requestmustbeinwriting,directedtotheCEO,within30daysafterreceiptofwrittennoticeoftheadverserecommendation.
(d) Thehearingwillbeconvenedassoonasispractical,butnosoonerthan30days
afterthenoticeofthehearing,unlessanearlierhearingdatehasbeenspecificallyagreedtobytheparties.
8.A.2.HearingCommittee:
(a) Ifarequestforahearingismadeinatimelymanner,theCEO,inconjunctionwiththeChiefofStaff,shallappointaHearingCommitteecomposedofuptothreeindividuals(including,butnotlimitedto,individualsappointedtotheMedicalStaff,AlliedHealthProfessionals,Hospitalmanagement,individualsnotconnectedtotheHospital,oranycombinationoftheseindividuals)andaPresidingOfficer,whomaybelegalcounseltotheHospital.TheHearing
198832.1136
Committeeshallnotincludeanyonewhopreviouslyparticipatedintherecommendation,anyrelativesorpracticepartnersoftheCategoryIorCategoryIIpractitioner,oranycompetitorsoftheaffectedindividual.
(b) AsanalternativetotheHearingCommitteedescribedinparagraph(a)ofthis
Section,theCEO,inconjunctionwiththeChiefofStaff,mayinsteadappointaHearingOfficertoperformthefunctionsthatwouldotherwisebecarriedoutbytheHearingCommittee.TheHearingOfficershallpreferablybeanattorneyatlaw.TheHearingOfficermaynotbeindirecteconomiccompetitionwiththeindividualrequestingthehearingandshallnotactasaprosecutingofficerorasanadvocatetoeithersideatthehearing.IftheHearingOfficerisanattorney,heorsheshallnotrepresentclientswhoareindirecteconomiccompetitionwiththeaffectedindividual.IntheeventaHearingOfficerisappointedinsteadofaHearingCommittee,allreferencesinthisArticletotheHearingCommitteeshallbedeemedtoreferinsteadtotheHearingOfficer,unlessthecontextwouldclearlyotherwiserequire.
(c) Thehearingshallbeconvenedassoonasispractical,butnosoonerthan30days
afterthenoticeofthehearing,unlessanearlierhearingdatehasbeenspecificallyagreedtobytheparties.
8.A.3.HearingProcess:
(a) Arecordofthehearingwillbemaintainedbyastenographicreporterorbyarecordingoftheproceedings.Copiesofthetranscriptwillbeavailableattheindividual’sexpense.
(b) Thehearingwilllastnomorethansixhours,witheachsidebeingafforded
approximatelythreehourstopresentitscase,intermsofbothdirectandcross-examinationofwitnesses.
(c) Atthehearing,arepresentativeoftheMECwillfirstpresentthereasonsforthe
recommendation.TheCategoryIorCategoryIIpractitionerwillbeinvitedtopresentinformationtorefutethereasonsfortherecommendation.
(d) Bothpartieswillhavetherighttopresentwitnesses.ThePresidingOfficerwill
permitreasonablequestioningofsuchwitnesses.(e) TheCategoryIorCategoryIIpractitionerandtheMECmayberepresentedat
thehearingbylegalcounsel.However,whilecounselmaybepresentatthehearing,counselwillnotcall,examine,orcross-examinewitnessesorpresentthecase.
198832.1137
(f) TheCategoryIorCategoryIIpractitionerwillhavetheburdenofdemonstrating,byclearandconvincingevidence,thattherecommendationoftheMECwasarbitrary,capricious,ornotsupportedbysubstantialevidence.ThequalityofcareprovidedtopatientsandthesmoothoperationoftheHospitalwillbetheparamountconsiderations.
(g) TheCategoryIorCategoryIIpractitionerandtheMECwillhavetherightto
prepareapost-hearingmemorandumforconsiderationbytheHearingCommittee.ThePresidingOfficerwillestablishareasonablescheduleforthesubmissionofsuchmemoranda.
8.A.4.HearingCommitteeReport:
(a) Within20daysaftertheconclusionoftheproceedingorsubmissionofthepost-hearingmemoranda,whicheverdateislater,theHearingCommitteewillprepareawrittenreportandrecommendation.TheHearingCommitteewillforwardthereportandrecommendation,alongwithallsupportinginformation,totheCEO.TheCEOwillsendacopyofthewrittenreportandrecommendationbyspecialnoticetotheCategoryIorCategoryIIpractitionerandtotheMEC.
(b) Withintendaysafternoticeofsuchrecommendation,theCategoryIor
CategoryIIpractitionerand/ortheMECmaymakeawrittenrequestforanappeal.Therequestmustincludeastatementofthereasons,includingspecificfacts,whichjustifyanappeal.
(c) Thegroundsforappealwillbelimitedtoanassertionthattherewassubstantial
failuretocomplywiththisPolicyduringthehearing,soastodenyafairhearing,and/orthattherecommendationoftheHearingCommitteewasarbitrary,capricious,ornotsupportedbysubstantialevidence.
(d) TherequestforanappealwillbedeliveredtotheCEObyspecialnotice.(e) Ifawrittenrequestforappealisnotsubmittedtimely,theappealisdeemedto
bewaivedandtherecommendationandsupportinginformationwillbeforwardedtotheBoardforfinalaction.Ifatimelyrequestforappealissubmitted,theCEOwillforwardthereportandrecommendation,thesupportinginformationandtherequestforappealtotheBoard.TheChairoftheBoardwillarrangeforanappeal.
8.A.5.AppellateReview:
(a) AnAppellateReviewCommitteeappointedbytheChairoftheBoardwill
considertherecorduponwhichtheadverserecommendationwasmade.Neworadditionalwritteninformationthatisrelevantandcouldnothavebeenmade
198832.1138
availabletotheHearingCommitteemaybeconsideredatthediscretionoftheAppellateReviewCommittee.Thisreviewwillbeconductedwithin30daysafterreceivingtherequestforappeal.
(b) TheCategoryIorCategoryIIpractitionerandtheMECwilleachhavetherightto
presentawrittenstatementonappeal.(c) AtthesolediscretionoftheAppellateReviewCommittee,theCategoryIor
CategoryIIpractitionerandarepresentativeoftheMECmayalsoappearpersonallytodiscusstheirposition.
(d) Uponcompletionofthereview,theAppellateReviewCommitteewillprovidea
reportandrecommendationtothefullBoardforaction.TheBoardwillthenmakeitsfinaldecisionbasedupontheBoard’sultimatelegalresponsibilitytograntprivilegesandtoauthorizetheperformanceofclinicalactivitiesattheHospital.
(e) TheCategoryIorCategoryIIpractitionerwillreceivespecialnoticeofthe
Board’saction.AcopyoftheBoard’sfinalactionwillalsobesenttotheMECforinformation.
8.B.PROCEDURALRIGHTSFORCATEGORYIIIPRACTITIONERS
(1) IntheeventthatarecommendationismadebytheMECthataCategoryIIIpractitionernotbegrantedthescopeofpracticerequestedorthatascopeofpracticepreviouslygrantedberestrictedorterminated,theindividualshallbenotifiedoftherecommendation.ThenoticeshallincludeaspecificstatementofthereasonsfortherecommendationandshalladvisetheindividualthatheorshemayrequestameetingwiththeMECbeforetherecommendationisforwardedtotheBoardforfinalaction.
(2) IftheCategoryIIIpractitionerdesirestorequestameeting,heorshemustmake
suchrequestinwritinganddirectittotheHospitalPresidentwithin30daysafterreceiptofthewrittennoticeoftheadverserecommendation.
(3) Ifameetingisrequestedinatimelymanner,itshallbescheduledtotakeplace
withinareasonabletimeframe.Themeetingshallbeinformalandshallnotbeconsideredahearing.TheCategoryIIIpractitionerandhisorherSupervisingPhysicianshallbothbepermittedtoattendandparticipateinthemeeting.However,nocounselforeithertheCategoryIIIpractitionerortheMECshallbepresent.
(4) Followingthismeeting,theMECshallmakeafinalrecommendationtothe
HospitalBoard.
198832.1139
198832.1140
ARTICLE9
HOSPITALEMPLOYEES
A. Exceptasprovidedbelow,theemploymentofanAlliedHealthProfessionalbytheHospitalshallbegovernedbytheHospital’sorEmoryHealthcare’semploymentpoliciesandmanualsandthetermsoftheindividual’semploymentrelationshipand/orwrittencontract.TotheextentthattheHospital’sorEmoryHealthcare’semploymentpoliciesormanuals,orthetermsofanyapplicableemploymentcontract,conflictwiththisPolicy,theemploymentpolicies,manualsanddescriptionsandtermsoftheindividual’semploymentrelationshipand/orwrittencontractshallapply.
B. ExceptasnotedinA,Hospital-employedAlliedHealthProfessionalsarebound
byallofthesameconditionsandrequirementsinthisPolicythatapplytonon-HospitalemployedAlliedHealthProfessionals.
C. Arequestforclinicalprivileges,onaninitialbasisorforrenewal,submittedbya
CategoryIorCategoryIIpractitionerwhoisseekingemploymentorwhoisemployedbytheHospitalshallbeprocessedinaccordancewiththetermsofthisPolicy.Areportregardingeachpractitioner’squalificationsshallthenbemadetoHospitalmanagementorHumanResources(asappropriate)toassisttheHospitalinmakingemploymentdecisions.
D. IfaconcernaboutanemployedAlliedHealthProfessional’sclinicalcompetence
orprofessionalconductoriginateswiththeMedicalStaff,theconcernwillbereviewedandaddressedinaccordancewithArticles7and8ofthisPolicy,afterwhichareportwillbeprovidedtoHospitalmanagementorHumanResources(asappropriate).
198832.1141
ARTICLE10
AMENDMENTS
ThisPolicymaybeamendedbyamajorityvoteofthemembersoftheMEC,providedthatthewrittenrecommendationsoftheCredentialsCommitteeconcerningtheproposedamendmentsshallhavefirstbeenreceivedandreviewedbytheMEC.NoticeofallproposedamendmentsshallalsobeprovidedtoeachvotingmemberoftheMedicalStaffatleast14dayspriortotheMECmeeting.AnyvotingmemberoftheMedicalStaffmaysubmitwrittencommentstotheMEC.NoamendmentshallbeeffectiveunlessanduntilithasbeenapprovedbytheBoard.
198832.1142
ARTICLE11
ADOPTION
ThisPolicyisadoptedandmadeeffectiveuponapprovaloftheBoard,supersedingandreplacinganyandallotherMedicalStaffbylawsorrulesandregulationsorHospitalpoliciespertainingtothesubjectmatterthereof.OriginallyadoptedbytheMedicalStaffonNovember15,2012andapprovedbytheBoardonNovember20,2012.RevisionsadoptedbytheMEC: October14,2017RevisionsapprovedbytheBoard: October17,2017
198832.11
APPENDIXA
ThoseindividualscurrentlypracticingasCategoryIpractitionersattheHospitalareasfollows:
ClinicalPsychologists
198832.11
APPENDIXB
ThoseindividualscurrentlypracticingasCategoryIIpractitionersattheHospitalareasfollows:
AnesthesiaAssistantsCertifiedNurseMidwivesCertifiedRegisteredNurseAnesthetistsNursePractitionersPhysicianAssistantsSurgicalAssistants,CertifiedSurgicalAssistants,CertifiedSurgicalFirstAssistants,OrthopedicTech–SurgeryCertified,RNFirstAssistants
198832.11
APPENDIXC
ThoseindividualscurrentlypracticingasCategoryIIIpractitionersattheHospitalareasfollows:
OrthopedicTechnicianCertifiedRegisteredNurses