medical staff bylaws, policies, and rules …...198832.11 medical staff bylaws, policies, and rules...
TRANSCRIPT
198832.11
MEDICALSTAFFBYLAWS,POLICIES,ANDRULESANDREGULATIONS
OFEMORYJOHNSCREEKHOSPITAL
POLICYONALLIEDHEALTHPROFESSIONALS
AdoptedbytheMedicalExecutiveCommittee:October14,2017ApprovedbytheBoard:October17,2017
198832.11
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
b 198832.11
4.B.2. BurdenofProvidingInformation.............................................................. 11
PAGE
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
c 198832.11
INPATIENTHOSPITALSETTING ............................................................................. 236.B. OVERSIGHTBYSUPERVISINGPHYSICIAN ............................................................. 24
PAGE
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
d 198832.11
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)
198832.111
ARTICLE1
GENERAL1.A.DEFINITIONS
ThedefinitionsthatapplytotermsusedinalltheMedicalStaffdocumentsaresetforthintheMedicalStaffCredentialsPolicydocument.
1.B.TIMELIMITS
TimelimitsreferredtointhisPolicyareadvisoryonlyandarenotmandatory,unlessitisexpresslystatedthataparticularrightiswaivedbyfailingtotakeactionwithinaspecifiedperiod.
1.C.DELEGATIONOFFUNCTIONS
(1) WhenafunctionistobecarriedoutbyamemberofHospitalmanagement,byaMedicalStaffmember,orbyaMedicalStaffcommittee,theindividual,orthecommitteethroughitschair,maydelegateperformanceofthefunctiontooneormoredesignees.
(2) WhenaMedicalStaffmemberisunavailableorunabletoperformanecessary
function,oneormoreoftheMedicalStaffLeadersmayperformthefunctionpersonallyordelegateittoanotherappropriateindividual.
198832.112
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.
198832.113
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.
198832.115
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.);
198832.1110
(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;
198832.1111
(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.
198832.1112
(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.
198832.1113
(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
198832.1114
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