MEDICAL STAFF BYLAWS, POLICIES, AND
RULES AND REGULATIONS
OF
OUR LADY OF LOURDES
MEMORIAL HOSPITAL
CREDENTIALS POLICY
Revised effective May 19, 2017
198158.11
TABLE OF CONTENTS
PAGE
1.GENERAL...... 1
1.A.PREAMBLE...... 1
1.B.TIME LIMITS...... 1
1.C.DELEGATION OF FUNCTIONS...... 1
1.D.CONFIDENTIALITY AND PEER REVIEW PROTECTION...... 1
1.D.1.Confidentiality...... 1
1.D.2.Peer Review Protection...... 2
1.E.INDEMNIFICATION...... 2
2.QUALIFICATIONS, CONDITIONS, AND RESPONSIBILITIES...... 3
2.A.QUALIFICATIONS...... 3
2.A.1.Threshold Eligibility Criteria...... 3
2.A.2.Waiver of Threshold Eligibility Criteria...... 5
2.A.3.Factors for Evaluation...... 5
2.A.4.No Entitlement to Appointment...... 6
2.A.5.Nondiscrimination...... 6
2.A.6.Ethical and Religious Directives...... 7
2.B.GENERAL CONDITIONS OF APPOINTMENT,
REAPPOINTMENT,AND CLINICAL PRIVILEGES...... 7
2.B.1.Basic Responsibilities and Requirements...... 7
2.B.2.Burden of Providing Information...... 9
2.C.APPLICATION...... 10
2.C.1.Information...... 10
2.C.2.Misstatements and Omissions...... 10
2.C.3.Grant of Immunity and Authorization to
Obtain/Release Information...... 10
PAGE
3.PROCEDURE FOR INITIAL APPOINTMENT AND PRIVILEGES...... 13
3.A.PROCEDURE FOR INITIAL APPOINTMENT AND PRIVILEGES...... 13
3.A.1.Application...... 13
3.A.2.Initial Review of Application...... 13
3.A.3.Department Chairperson Procedure...... 14
3.A.4.Credentials Committee Procedure...... 15
3.A.5.Executive Committee Recommendation...... 15
3.A.6.Board Action...... 16
3.A.7.Time Periods for Processing...... 17
3.B.PROVISIONAL PERIOD...... 17
4.CLINICAL PRIVILEGES...... 19
4.A.CLINICAL PRIVILEGES...... 19
4.A.1.General...... 19
4.A.2. Categories of Privileges ...... 20
4.A.3.Privilege Waivers...... 21
4.A.4.Resignation...... 22
4.A.5.Clinical Privileges for New Procedures...... 22
4.A.6.Clinical Privileges That Cross Specialty Lines...... 23
4.A.7.Telemedicine Privileges...... 24
4.A.8.Training...... 25
4.B.TEMPORARY CLINICAL PRIVILEGES...... 25
4.B.1.Temporary Clinical Privileges...... 25
4.C.EMERGENCY SITUATIONS...... 27
4.D.DISASTER PRIVILEGES...... 27
4.E.CONTRACTS FOR SERVICES...... 28
5.PROCEDURE FOR REAPPOINTMENT...... 31
5.A.ELIGIBILITY FOR REAPPOINTMENT...... 31
5.B.FACTORS FOR EVALUATION...... 31
PAGE
5.C.REAPPOINTMENT APPLICATION...... 32
5.D.POTENTIAL ADVERSE RECOMMENDATION AND
CONDITIONAL REAPPOINTMENTS...... 32
6.PEER REVIEW PROCEDURES FOR QUESTIONS
INVOLVING MEMBERS...... 34
6.A.COLLEGIAL INTERVENTION...... 34
6.B.INVESTIGATIONS...... 35
6.B.1.Initial Review...... 35
6.B.2.Initiation of Investigation...... 36
6.B.3.Investigative Procedure...... 36
6.B.4.Recommendation...... 37
6.C.PRECAUTIONARY SUSPENSION OR RESTRICTION
OF CLINICAL PRIVILEGES...... 38
6.C.1.Grounds for Precautionary Suspension or Restriction...... 38
6.C.2.Executive Committee Procedure...... 39
6.D.AUTOMATIC RELINQUISHMENT...... 40
6.D.1.Failure to Complete Medical Records...... 40
6.D.2.Action by Government Agency or Insurer and
Failure to Satisfy Threshold Eligibility Criteria...... 40
6.D.3.Failure to Provide Information...... 42
6.D.4.Failure to Attend Special Conference...... 43
6.E.LEAVES OF ABSENCE...... 43
6.E.1.Initiation...... 43
6.E.2.Duties of Member on Leave...... 44
6.E.3.Reinstatement...... 44
7.CONFLICTS OF INTEREST...... 46
PAGE
8.HOSPITAL EMPLOYEES...... 47
9.ADOPTION...... 48
APPENDIX A: ALLIED HEALTH PROFESSIONALS
APPENDIX B: CONDITIONS OF PRACTICE APPLICABLE TO ALLIED HEALTH PRACTITIONERS
APPENDIX C: APPROVED BOARDS FOR CERTIFICATION OF ALLIED HEALTH STAFF MEMBERS
GLOSSARY
1
198158.11
ARTICLE 1
GENERAL
1.A. PREAMBLE
All Medical Staff and Allied Health Staff members commit to working cooperatively and professionally with each other and Hospital employees and management to promote safe, appropriate patient care. Medical Staff and Hospital leaders will strive to address professional practice issues fairly, reasonably, and collegially in a manner that is consistent with quality care and patient safety.
1.B. TIME LIMITS
Time limits referred to in this Policy and related policies and manuals are advisory only and are not mandatory, unless it is expressly stated. Medical Staff and Hospital leaders will strive to be fair under the circumstances.
1.C. DELEGATION OF FUNCTIONS
Functions assigned to an identified individual or committee may be delegated to one or more designees.
1.D. CONFIDENTIALITY AND PEER REVIEW PROTECTION
1.D.1. Confidentiality:
All professional review activity and recommendations will be strictly confidential. No disclosures of any such information (discussions or documentation) may be made outside of the meetings of the peer review committees, except:
(a)to another authorized individual for the purpose of conducting professional review activity;
(b)as authorized by a policy; or
(c)as authorized, in writing, by the Chief Executive Officer or by legal counsel to the Hospital.
Any breach of confidentiality will result in appropriate sanctions.
1.D.2. Peer Review Protection:
(a)All professional review activity will be performed by peer review committees. Peer review committees include, but are not limited to:
(1)all standing and ad hoc committees of the Medical Staff;
(2)all departments;
(3)hearing and appellate review panels;
(4)the Board and its committees; and
(5)any individual acting for or on behalf of any such entity, including, but not limited to,Medical Staff leaders, and experts or consultants retained to assist in professional review activities.
(b)All reports, recommendations, actions, and minutes made or taken by peer review committees are confidential and covered by the provisions of applicable law.
1.E. INDEMNIFICATION
(1)The Hospital will provide a legal defense for, and will indemnify, Medical Staff leaders, peer review committees, members, and authorized representatives when engaged in professional review activity, to the fullest extent permitted by law, in accordance with the Hospital’s Bylaws. The defense of any such suit, claim or proceeding will be conducted by an attorney who is approved by the Hospital.
(2)Individuals seeking indemnification must promptly notify the Hospital, in writing, after receiving notice of such a claim.
ARTICLE 2
QUALIFICATIONS, CONDITIONS, AND RESPONSIBILITIES
2.A. QUALIFICATIONS
2.A.1. Threshold Eligibility Criteria:
To be eligible to apply for initial appointment or reappointment to the Medical Staff or the Allied Health Staff, and for clinical privileges,an individual must, as applicable:
(a)have a current,unrestricted license and registration, which is not subject to any probationary terms or conditions not generally applicable;
(b)have a current, unrestricted DEA registration;
(c)be located (office and residence) within the geographic service area of the Hospital, as defined by the Board, close enough to fulfill their responsibilities and to provide timely and continuous care for their patients in the Hospital (emergency medicine physicians and those practitioners who provide telemedicine services from a remote location are excluded from this requirement);
(d)have current, valid professional liability insurance coverage in the amounts of at least $1 million per claim and $3 million in the aggregate;
(e)have not, within the past five years, been convicted of Medicare, Medicaid, or other federal or state governmental or private third-party payer fraud or program abuse;
(f)have not been, within the past fiveyears, and are not currently, excluded or precluded from participation in Medicare, Medicaid, or other federal or state governmental health care program;
(g)have not had, within the past five years, medical staff or allied health staff appointment, clinical privileges, or status as a participating provider denied, revoked, or terminated by any health care facility or health plan for reasons related to clinical competence or professional conduct;
(h)have not, within the past fiveyears, resigned medical staff or allied health staffappointment or relinquished privileges during an investigation or in exchange for not conducting an investigation;
(i)have not, within the past fiveyears, been convicted of, or entered a plea of guilty or no contest, to any felony, or to any misdemeanor relating to controlled substances, illegal drugs, insurance or health care fraud or abuse, or violence;
(j)agree to fulfill all responsibilities regarding emergency call for their specialty, consistent with the medical staff category requested;
(k)have or agree to make coverage arrangements with other members of the Medical Staff;
(l)demonstrate recent clinical activity in their primary area of practice during at least two of the last four years;
(m)have successfully completed a residency training program approved by the Accreditation Council for Graduate Medical Education or the American Osteopathic Association in the specialty in which the applicant seeks clinical privileges, or an oral and maxillofacial surgery training program accredited by the Commission on Dental Accreditation of the American Dental Association, or a podiatric surgical residency program accredited by the Council on Podiatric Medical Education of the American Podiatric Medical Association(general dentists are excluded from this requirement);
Note: Applicants who have been working for a minimum of three (3) years in the specialty in which they are seeking clinical privileges, and are board certified in the specialty in which they trained are excluded from this requirement.
(n)obtain board certification in their primary area of practice at the Hospital within five years from the date of completion of their training (general dentists are excluded from this requirement);
(o)for members appointed after November 16, 2012,have evidence of recertification or maintenance of certification to the extent required by the applicable specialty/subspecialty board; members who have recertified twice and have been on the Medical Staff or Allied Health Stafffor at least ten years will be exempt from this criterion; and
(p)if seeking to practice as an allied health professional, have a written agreement with a member of the Medical Staff to provide the requisite supervision or collaboration.
(q)Certification as a Nurse Practitioner by one of the national certifying organizations accepted by the New York State Office of Professions or within six months of initial appointment. Current certification must be maintained.
2.A.2. Waiver of Threshold Eligibility Criteria:
(a)Waivers of threshold eligibility criteria will not be granted routinely. No one is entitled to a waiver. An application from an applicant who does not meet the threshold criteria for appointment, reappointment or clinical privileges will not be processed unless the Board has granted the requested waiver.
(b)A request for a waiver will only be considered if the applicant provides information sufficient to demonstrate that his or her qualifications are equivalent to, or exceed, the criterion in question and that there are exceptional circumstances that warrant a waiver.
(c)The Credentials Committee may consider supporting documentation submitted by the applicant, any relevant information from third parties, input from the relevant department chairperson, and the best interests of the Hospital and the communities it serves. The Credentials Committee will forward its recommendation, including the basis for such, to the Executive Committee.
(d)The Executive Committee will review the recommendation of the Credentials Committee and make a recommendation to the Board regarding whether to grant or deny the request for a waiver and the basis for its recommendation.
(e)The Board’s determination regarding whether to grant a waiver is final. A determination not to grant a waiver is not a “denial” of appointment or clinical privileges and the applicant who requested the waiver is not entitled to a hearing. A determination to grant a waiver in a particular case is not intended to set a precedent. A determination to grant a waiver does not mean that appointment will be granted, only that processing of the application can begin.
2.A.3. Factors for Evaluation:
The following factors will be evaluated as part of the appointment and reappointment processes:
(a)relevant training, experience, and demonstrated current competence, including medical/clinical knowledge, technical and clinical skills, clinical judgment and an understanding of the contexts and systems within which care is provided;
(b)adherence to the ethics of the profession, continuous professional development, an understanding of and sensitivity to diversity, and responsible attitude toward patients and the profession;
(c)good reputation and character;
(d)ability to safely and competently perform the clinical privileges requested;
(e)ability to work harmoniously with others, including, but not limited to, interpersonal and communication skills sufficient to enable them to maintain professional relationships with patients, families, and other members of health care teams; and
(f)recognition of the importance of, and willingness to support, a commitment to quality care and a recognition that interpersonal skills and collegiality are essential to the provision of quality patient care.
2.A.4. No Entitlement to Appointment:
No one is entitled to receive an application for appointment to the Medical Staff or Allied Health Staff, or be granted particular clinical privileges merely because he or she:
(a)is employed by the Hospital or its subsidiaries or has a contract with the Hospital;
(b)is or is not a member or employee of any particular physician group;
(c)is licensed to practice a profession in this or any other state;
(d)is a member of any particular professional organization;
(e)has had in the past, or currently has, medical staff or allied health staff appointment or privileges at any hospital or health care facility;
(f)resides in the geographic service area of the Hospital; or
(g)is affiliated with, or under contract to, any managed care plan, insurance plan, health maintenance organization, preferred provider organization, or other entity.
2.A.5. Nondiscrimination:
No one will be denied appointment or clinical privileges on the basis of gender, race, creed, sexual orientation, or national origin.
2.A.6. Ethical and Religious Directives:
All members will abide by the terms of the Ethical and Religious Directives for Catholic Health Care Services promulgated by the National Conference of Catholic Bishops with respect to their practice at the Hospital. No member will engage in activity prohibited by the Directives at the Hospital.
2.B. GENERAL CONDITIONS OF APPOINTMENT, REAPPOINTMENT,
AND CLINICAL PRIVILEGES
2.B.1. Basic Responsibilities and Requirements:
(a)As a condition of appointment, reappointment, and the grant of privileges, every applicant and memberof the Medical Staff and Allied Health Staffspecifically agree to the following, as applicable:
(1)to provide continuous and timely care;
(2)to abide by the bylaws, policies, and rules and regulations of the Medical Staff and the Hospital and any revisions or amendments thereto;
(3)to participate in Medical Staff affairs through committee service and participation in performance improvement and peer review activities, and to perform such other reasonable duties and responsibilities as may be assigned;
(4)to provide emergency call coverage, consultations, and care for unassigned patients;
(5)to comply with applicable clinical practice protocols and guidelines, as adopted by the Executive Committee, or document the clinical reasons for variance;
(6)to participate, as requested, in risk management and quality assurance activities designed to increase patient safety and prevent medical malpractice claims;
(7)to immediately submit to a blood, hair or urine test, or to a complete physical or mental evaluation, if at least two Medical Staff leaders (or one Medical Staff leader and the Vice President for Medical Affairs) are concerned about the individual’s ability to safely and competently care for patients. The health care professional(s) to perform the testing or evaluations will be determined by the Medical Staff leaders;
(8)to participate in interviews in regard to an application for initial appointment, reappointment, or clinical privileges,if requested;
(9)to use the Hospital,as appropriate to the individual’s medical specialty,sufficiently to allow continuing assessment of current competence;
(10)to seek consultation whenever necessary;
(11)to complete in a timely manner all medical and other required records;
(12)to perform all services and to act in a cooperative and professional manner. Deviations in appropriate behavior will be addressed as warranted by the situation, pending full investigation of the incident. Refer to the Administrative Policy-ADM-23-001- Disruptive Behavior;
(13)to promptly pay any applicable dues, assessments, or fines;
(14)to obtain 50 Category I or II continuing education credits every two years; and
(15)to maintain a current e-mail address with the Medical StaffOffice, which will be the preferredmeans of communicating information other than peer review information or patient protected health information.
(16)to complete on-site or on-line orientation to the Medical Staff, which includes training in the Lourdes electronic health record systems prior to their start date.
(b)The Board may, in its discretion, upon review by the Executive Committee, waive any of the conditions, responsibilities and requirements set forth above.
(c)In addition to the above, as a condition of appointment and privileges, every individual seeking appointment to the Allied Health Staffwill specifically agree, as applicable, to the following:
(1)any privileges granted by the Board will be performed in the Hospital under the supervision of, or in collaboration with,a Supervising/Collaborating Physician;
(2)the number of allied health professionalsemployed by or under the supervision of,or working in collaboration with,a member of the Medical Staff will be consistent with New York law and the rules and regulations of the Medical Staff; and
(3)to give notice, within three days, to the Vice President for Medical Affairs of any revisions or modifications that are made to the supervision/collaboration agreement.
(d)Additional collaboration and supervision requirements for members of the Allied Health Staffare included in Appendix B.
2.B.2. Burden of Providing Information:
(a)Applicants and members have the burden of producing information deemed adequate by the Hospital for a proper evaluation of current competence, character, ethics, and other qualifications and for resolving any doubts.
(b)Applicants must provide a sworn statement that all the statements made and information given on the application are accurate, complete, and true.
(c)An application will be complete when all questions on the application form have been answered, all supporting documentation has been received, and all information has been verified from primary sources. An application will become incomplete if the need arises for new, additional, or clarifying information. Any application that continues to be incomplete 30 days after the applicant has been notified of the additional information required will be deemed to be withdrawn.
(d)Applicants are responsible for providing a complete application, including adequate responses from references. An incomplete application will not be processed.
(e)Notification of any change in status or any change in the information provided on the application form will be given to the President of the MedicalStaff or the Vice President for Medical Affairs. This information must be provided, with or without request, at the time the change occurs.
(f)Failure to provide this information will render the individual ineligible for staff membership or clinical privileges and may result in automatic relinquishment of appointment and privileges.
(g)With the exception of references, recommendations or other peer review information, applicants will have the right to review information submitted in support of their application.
2.C. APPLICATION
2.C.1. Information:
Applications for appointment and reappointment will contain a request for specific clinical privileges and will require detailed information concerning the applicant’s professional qualifications. The applications for initial appointment and reappointment existing now and as may be revised are incorporated by reference and made a part of this Policy. The applicant will sign the application and certify that he or she is able to perform the privileges requested and to fulfill the responsibilities of appointment.
2.C.2. Misstatements and Omissions:
(a)Any misstatement in, or omission from, the application is grounds to stop processing the application. The applicant will be informed in writing of the nature of the misstatement or omission and permitted to provide a written response. The President of the MedicalStaff and Vice President for Medical Affairswill review the response and determine whether the application should be processed further.