CREDENTIALS PROCEDURE MANUAL - stjosephhospital.com

1 CREDENTIALS PROCEDURE . MANUAL . Approved by Board of Directors JANUARY 29, 2002. Last revisions 12/18/2018. St. Joseph Hospital CREDENTIALS PROCEDURE MANUAL 12/18/2018. Table of Contents PART ONE: QUALIFICATIONS FOR MEMBERSHIP. Section A Qualifications .. 1. Section B Physicians/Oral Surgeons/Podiatrists/All .. 1. PART TWO: INITIAL APPOINTMENT PROCESS AND PROCEDURES. Section A Nature of Medical Staff Membership .. 3. Section B 3. Section C No Entitlement to Appointment .. 3. Section D Conditions of Appointment .. 3. Section E Hospital Need and Ability to Accommodate .. 4. Section F Term of Appointment .. 4. Section G Request for Application and Application Packet .. 4. Section H Application for Initial Appointment and Clinical Privileges .. 5. (1) Information .. 5. Section I Basic Responsibilities and Requirements for Applicants and Appointees.

2 7. Section J Burden of Providing Information .. 9. Section K PROCEDURE for Initial Appointment .. 10. (1) Submission of Application .. 10. (2) Verification of Information .. 10. (3) Applicant Interview Policy .. 12. Section L Department Chair Action .. 12. (1) Deferral .. 12. (2) Favorable Report .. 12. (3) Adverse 12. Section M Effect of CREDENTIALS Committee Action .. 13. (1) Deferral .. 13. (2) Favorable Recommendation .. 13. (3) Adverse Recommendation .. 13. (4) Recommendation for Imposition of Specific Conditions .. 13. Section N Effect of Medical Executive Committee Action .. 14. (1) Deferral .. 14. (2) Favorable Recommendation .. 14. (3) Adverse Recommendation .. 14. (4) Contrary 14. Section O Board of Directors Action .. 15. (1) Favorable Recommendation .. 15. (2) Adverse Recommendation.

3 15. (3) After Procedural Rights .. 15. Section P Basis for Recommendation and 15. Section Q Conflict 15. Section R Notice of Final Decision .. 16. Section S Time Periods for Processing .. 16. i St. Joseph Hospital CREDENTIALS PROCEDURE MANUAL 12/18/2018. PART THREE: PROVISIONAL PERIOD. Provisional Period .. 16. PART FOUR: REAPPOINTMENT PROCESS AND PROCEDURES. Section A Information Collection and Verification .. 17. (1) From Staff Appointees .. 17. (2) Internal and/or External Sources .. 19. Section B PROCEDURE for Processing Applications .. 20. Section C CREDENTIALS Committee Action .. 21. (1) Meeting with Affected Individual .. 21. Section D Medical Executive Committee Action .. 21. Section E Final Processing and Board of Directors 21. PART FIVE: CLINICAL PRIVILEGES. Section A Exercise of 21.

4 Section B Privileges in General .. 21. (1) Requests.. 21. (2) Basis for Privileges Determination .. 22. Section C Clinical Privileges for Experimental Procedures .. 22. Section D Clinical Privileges for New Procedures/Treatments .. 23. Section E Clinical Privileges that Cross Specialty Lines .. 23. Section F Special Conditions for Dental 24. Section G Special Conditions for Podiatric 24. Section H Requests for Additional Privileges or Modification to Existing Privileges or Appointment Status .. 24. Section I Temporary Privileges .. 25. (1) 25. (2) Circumstances .. 25. (a) Pendency of Complete, Clean Application .. 25. (b) Care of Specific Patient/ PROCEDURE .. 25. (c) Locum Tenens .. 26. (3) Termination of Temporary Privileges .. 26. (4) Rights of the Practitioner with Temporary Privileges.

5 26. (5) Emergency 26. Section J Telemedicine Privileges .. 27. Section K Ambulatory Privileges .. 28. (1) Definition .. 28. (2) Education, Training and Experience .. 28. (3) Additional Minimum Requirements .. 28. (4) Privileges .. 28. (5) Determination of Current Competence .. 29. Section L Consulting Privileges .. 29. (1) Definition .. 29. (2) Privileges .. 29. Section M Milford Medical Center/St. Joseph Hospital Setting Specific 30. ii St. Joseph Hospital CREDENTIALS PROCEDURE MANUAL 12/18/2018. PART SIX: QUESTIONS INVOLVING MEDICAL STAFF MEMBERS. Section A Collegial Intervention .. 30. Section B Investigation Initial Review .. 30. Section C Initiation of Investigation .. 31. Section D Investigative PROCEDURE .. 31. Section E Recommendation .. 32. Section F Precautionary Suspension of Clinical Privileges.

6 33. (1) Grounds for Precautionary Suspension .. 33. (2) Medical Staff Executive Committee PROCEDURE .. 34. PART SEVEN: OTHER ACTIONS CONCERNING PERSONS HOLDING CURRENT. APPOINTMENTS TO THE MEDICAL STAFF. Section A Failure to Complete Medical Records .. 34. Section B Action by Federal or State Licensing 35. Section C Failure to be Adequately Insured .. 35. Section D Criminal 35. Section E Exclusion from any Federally Funded Payor Program .. 35. Section F Failure to Provide Requested Information .. 35. Section G Failure to Attend Special Conference .. 35. Section H Confidentiality and 36. (1) Reports Regarding Privileges .. 36. (2) Confidentiality .. 36. Section I Peer Review Protection .. 36. PART EIGHT: REAPPLICATION ADMINISTRATIVE REVOCATION. Section A Reapplication after Administrative Revocation.

7 36. PART NINE: MODIFICATION OF STAFF STATUS. Section A Leave of Absence .. 37. Section B Modification of Staff or Department Status .. 38. Section C Resignation .. 38. Section D Reapplication after 38. PART TEN: PHYSICIAN HEALTH. Section A Physician Health Function .. 38. Section B Known or Suspected Physical/Mental Health Impairments or Suspected Substance Abuse .. 39. PART ELEVEN: PRACTITIONER PROVIDING CONTRACTUAL SERVICES. Section A Exclusivity Policy .. 40. iii St. Joseph Hospital CREDENTIALS PROCEDURE MANUAL 12/18/2018. PART TWELVE: MEDICO-ADMINISTRATIVE OFFICERS. Section A Definition of Medico-Administrative Officer .. 40. Section B Effect of Removal from Office or Adverse Change in App. Status or Clinical Privileges .. 40. PART THIRTEEN: PERIOD REVIEW, ADOPTION AND AMENDMENT. Section A Review 41.

8 Section B Amendment .. 41. Section C 41. Section D Responsibilities and Authority .. 41. PART FOURTEEN: ALLIED HEALTH PROFESSIONALS. Allied Health Professionals Policy .. 41. PART FIFTEEN: ANCILLARY SERVICES. Ancillary Services 45. PART SIXTEEN: EMAIL CREDENTIALING AND PEER REVIEW MATTERS. Email Credentialing and Peer Review Matters Policy .. 46. PART SEVENTEEN: EMERGENCY CREDENTIALING AT TIME OF DISASTER. Emergency Credentialing At Time of Disaster Policy .. 47. PART EIGHTEEN: HOSPITAL-AFFILIATED PHYSICIAN EMPLOYEES. Hospital-Affiliated Physician Employees .. 48. PART NINETEEN: USE OF TERMS. Use of Terms .. 49. iv St. Joseph Hospital CREDENTIALS PROCEDURE MANUAL 12/18/2018. PART ONE: QUALIFICATIONS FOR MEMBERSHIP. SECTION A: QUALIFICATIONS. St. Joseph Hospital accepts applications to the Medical Staff from licensed medical and osteopathic physicians, oral surgeons and podiatrists.

9 Other licensed independent practitioners will be permitted to apply for specific clinical privileges as defined in the Allied Health Professionals Policy. Only the Board of Directors may make exceptions to this policy. SECTION B: It is St. Joseph Hospital's policy to process applications for appointment to the Medical Staff and requests for privileges only for individuals who meet the following criteria: PHYSICIANS (MD/DO): (1) Demonstrate successful graduation from an approved school of medicine or osteopathy; or (2) Demonstrate certification by the Educational Commission for Foreign Medical Graduates or Fifth Pathway certification; and (3) Demonstrate successful completion of an ACGME or acceptable equivalent accredited residency training program; and (4) Current ABMS or AOA certification or an equivalent certification deemed acceptable by the CREDENTIALS Committee and Medical Executive Committee, or active participation in the examination process leading to certification or recertification in their primary specialty (board qualified) within the time period of board qualification as specified by each respective specialty board.

10 The burden of proof of board equivalency rests with the potential applicant. In cases where a specialty board does not specify an eligibility time period, the applicant must become certified within five (5) years of completion of training and within three (3) years after lapse of certification in the instance of recertification. Medical Staff members who were appointed and/or privileged as of February 27, 1996, are exempt from the above stated requirement. (Rev 8/10; 12/14). ORAL SURGEONS (DMD/DDS): (1) Demonstrate successful graduation from an approved school of dentistry;. (2) Demonstrate successful completion of at least one year in a postgraduate training program accredited by the Commission on Dental Accreditation or by an equivalent professionally recognized accrediting body;. (3) Current ADA certification or an equivalent certification deemed acceptable by the CREDENTIALS Committee and Medical Executive Committee, or active participation in the examination process leading to certification within the time period of board qualification as specified by each respective specialty board.