Current Issues in Credentialing and Privileging
Credentialing, Recredentialing, and Privileging: The Basics and BeyondKathy Matzka, CPMSM, CPCSConsultant/Speaker1304 Scott Troy RoadLebanon, IL 62254kathymatzka@website: Phone (618) 624-8124BIOGRAPHICAL SKETCH, KATHY MATZKA, CPMSM, CPCS0000Kathy Matzka, CPMSM, CPCS is a speaker, consultant, and writer with over 25 years of experience in credentialing, privileging, and medical staff services. She holds certification by the National Association Medical Staff Services (NAMSS) in both Medical Staff Management and Provider Credentialing. Ms. Matzka worked for 13 years as a hospital medical staff coordinator before venturing out on her own as a consultant, writer, and speaker.Ms. Matzka has authored a number of books related to medical staff services including Medical Staff Standards Crosswalk: A Quick Reference Guide to The Joint Commission, CMS, HFAP, and DVN Standards, Chapter Leader’s Guide to Medical Staff: Practical Insight on Joint Commission Standards, Compliance Guide to Joint Commission Medical Staff Standards, and The Medical Staff Meeting Companion Tools and Techniques for Effective Presentations. For eight years, she was the contributing editor for The Credentials Verification Desk Reference and its companion website The Credentialing and Privileging Desktop Reference. She is co-author of the HcPro’s publication Verify and Comply: Credentialing and Medical Staff Standards Crosswalk, Sixth Edition.She has performed extensive work with NAMSS’ Library Team developing and editing educational materials related to the field including CPCS and CPMSM Certification Exam Preparatory Courses, CPMSM and CPCS Professional Development Workshops, and NAMSS Core Curriculum. These programs are essential educational tools for both new and seasoned medical services professionals. She also serves as instructor for NAMSS.Ms. Matzka shares her expertise by serving on the editorial advisory boards for two publications - Briefings on Credentialing, and Credentialing & Peer Review Legal Insider.Ms. Matzka is a highly-regarded industry speaker, and in this role has developed and presented hundreds of programs for professional associations, hospitals, and hospital associations on a wide range of topics including provider credentialing and privileging, medical staff meeting management, peer review, negligent credentialing, provider competency, and accreditation standards. In her spare time, Ms. Matzka takes pleasure in spending time with her family, listening to music, traveling, hiking, fishing, and other outdoor activities. Table of Contents TOC \o "1-2" \h \z \u Application Process PAGEREF _Toc410567423 \h 1Exercise: Applying Criteria for Medical Staff Appointment PAGEREF _Toc410567424 \h 3Verification of Application Information PAGEREF _Toc410567425 \h 12Education and Training PAGEREF _Toc410567426 \h 12Sample Letter for Verification of Training PAGEREF _Toc410567427 \h 14Peer Recommendations PAGEREF _Toc410567428 \h 17Work History and Affiliations PAGEREF _Toc410567429 \h 21Sample Letter: Facility Privileges and Competency Validation PAGEREF _Toc410567430 \h 22Licensure PAGEREF _Toc410567431 \h 24Sample Policies and Procedures for Credentialing PAGEREF _Toc410567432 \h 25Verification of Current Licensure and Licensure Sanctions PAGEREF _Toc410567433 \h 26Notification of Internal and External Parties Regarding Practitioner Privileges PAGEREF _Toc410567434 \h 28NPDB Query PAGEREF _Toc410567435 \h 30Identification of Excluded Providers PAGEREF _Toc410567436 \h 31Criminal Background Checks PAGEREF _Toc410567437 \h 32Using The AMA Physician and AAPA Physician Assistant Masterfile Query PAGEREF _Toc410567438 \h 34Liability History/Proof of Insurance PAGEREF _Toc410567439 \h 35Health Status/Ability to Perform PAGEREF _Toc410567440 \h 36Board Certification PAGEREF _Toc410567441 \h 36Verification Of Identity PAGEREF _Toc410567442 \h 38Sample Policy and Procedure for Verification of Identity PAGEREF _Toc410567443 \h 39Privileges Resources PAGEREF _Toc410567444 \h 40“Laundry List” Example PAGEREF _Toc410567445 \h 41AAFP Core Privileges Example PAGEREF _Toc410567446 \h 42HCPro Core Privileges Example PAGEREF _Toc410567447 \h 47Modified Core Example Family Medicine PAGEREF _Toc410567448 \h 57Work Sheet For Consideration of New Privilege PAGEREF _Toc410567449 \h 61Structured Interview Questions PAGEREF _Toc410567450 \h 62Documenting Recommendations PAGEREF _Toc410567451 \h 63Minutes Language PAGEREF _Toc410567452 \h 63Recommendation and Approval Form for Medical Staff Appointment and Clinical Privileges PAGEREF _Toc410567453 \h 64Understanding Negligence in Credentialing PAGEREF _Toc410567454 \h 65 SEQ CHAPTER \h \r 1CREDENTIALING, RECREDENTIALING AND PRIVILEING BASICSApplication ProcessPreapplicationSome organizations use a preapplication form to screen applicants to determine membership eligibility. This form typically contains address, education, training, licensure, board certification, amount of professional liability insurance, distance from home or office to the healthcare facility and any other membership requirements the organization may have. For instance, if a hospital requires the provider to be board certified and he/she is not, this can be evaluated prior to the application process and the provider can be notified that he/she is not eligible for appointment. On the other hand, using a preapplication adds another step and may delay the appointment process.Application Form Content514350014224000Organizations have individualized forms or may use a standardized form developed by the healthcare network or State. The application form typically contains the following information:demographics - name, professional degree, DOB, social security number, UPIN, home and office addresses, phone, fax, pager and cellular phone numbers;education and training information - names and addresses of schools, internship, residency and fellowship programs, type of program and name of program director;ECFMG information if applicant is a foreign medical graduate;current and past licensure and narcotics registrations;board certification information including current status, name of specialty and subspecialty boards;peer references who have personal knowledge of the quality of medicine practiced by the applicant;current and past healthcare organization affiliations; andmilitary service, if applicable.Professional Practice QuestionsAn applicant may have to answer questions regarding the following issues:voluntary or involuntary loss of medical staff membership and voluntary or involuntary limitation reduction, or loss of clinical privileges at another healthcare organization;previous or pending successful challenges to any licensure or narcotics registration or involuntary relinquishment of licensure or registration;past and current professional liability insurance carriers, including policy numbers, amounts and dates of coverage;past or pending professional liability action, including information about final judgments or settlements involving the applicant;misdemeanor or felony convictions;denial of participation, suspended from, denied renewal from the Medicare or Medicaid program, or participation status modified;illegal use of drugs; andability to safely exercise the privileges requested with or without reasonable accommodation.Professional Practice QuestionsBefore granting privileges, the medical staff should evaluate:challenges to any licensure or registration;voluntary and involuntary relinquishment of any license or registration;voluntary and involuntary termination of medical staff membership;voluntary and involuntary limitation, reduction, or loss of clinical privileges; andany evidence of an unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the applicant.Attachments to ApplicationIn addition to the application itself, organization may require attachments to be included. These attachments are considered a part of the application and the application is not considered complete until they are submitted.Sample attachments may include:copies of licensure;professional liability insurance face sheet;curriculum vitae;24003001460500application fee;photograph;CME;application fee; andclinical privileges request.Review for Completeness5029200-37973000The application should contain a chronological history starting with graduate education, and continuing through the date of the application. There should be not be any unaccounted for gaps. The application is not considered complete until all required information has been provided. All questions must be answered, the information provided must be legible, all required attachments are present, and the application is signed and dated. If any information is incomplete or missing, the application should be returned to the applicant for completion.Exercise: Applying Criteria for Medical Staff AppointmentUsing the Sample Medical Staff Bylaws Language for Medical Staff Appointment and Sample application (following pages) determine whether the applicant should be sent an application based on bylaws requirements. Sample Medical Staff Bylaws LanguageCriteria for Medical Staff AppointmentSection 1. General QualificationsEvery practitioner who seeks or enjoys Medical Staff appointment must, at the time of application and initial appointment must demonstrate, to the satisfaction of the appropriate authorities of the Medical Staff and of the Board, the following qualifications:A.Licensure: The following are required:A currently valid M.D., D.O., DDS, DMD, DPM license issued by the State of Louisiana;Current valid Federal DEA Certificate; andCurrent Illinois Controlled Substance LicenseB.Professional Education and Training:Graduate of an approved medical or dental school or school of osteopathy or podiatry, or certified by the Educational Council for Foreign Medical Graduates, or have a Fifth Pathway Certificate and have passed the foreign Medical Graduate Examination in the Medical Sciences; and, if a physician, satisfactory completion of at least three years in an approved postgraduate training program; if a dentist, satisfactory completion of at least two years in an approved postgraduate training program; if a podiatrist, satisfactory completion of at least two years in an approved post graduate training program. An "approved" postgraduate training program is one fully accredited throughout the time of the practitioner's training by the Accreditation Council for Graduate Medical Education, by the Commission on Dental Accreditation, or by the Council on Podiatric Medical Education. C.Board certification by the appropriate specialty Board (American Board of Medical Specialties, American Osteopathic Association, American Dental Association, Council on Podiatric Medical Education, or one of their subspecialty boards); or proof of admissibility for examination for certification by the appropriate specialty Board, and thereafter certified within (5) years of completion of residency training.D.Residence and office location sufficiently close to the hospital to fulfill medical staff responsibilities and to provide timely and continuous care for patients.E.Disability:To be free of or have under adequate control any significant physical or mental health impairment and to be free from abuse of any type of substance or chemical that affects cognitive, motor or communication ability in a manner that interferes with, or presents a reasonable probability of interfering with, the ability to perform privileges requested or carrying out the responsibilities of medical staff membership. F.Verbal and Written Communication Skills:Ability to read and understand the English language, to communicate in writing and verbally in the English language in an intelligible manner, and to prepare medical record entries and other required documentation in a legible manner.G.Professional Liability Insurance:Professional liability insurance of $1 million per occurrence and $5 million annual aggregate.H.Alternate Coverage:Each practitioner must assure timely, adequate professional care for his/her patients in the Hospital by being available or designating a qualified alternate practitioner with whom prior arrangements have been made and who has the requisite clinical privileges at this Hospital to care for the patient. The name of such alternate must be provided on application to the medical staff.I.Hospital and Community Need, and Ability to Accommodate:In acting on new applications for Medical Staff appointment and clinical privileges, and on applications for changes in clinical privileges, in Medical Staff appointment status, or in principal Department affiliation, the Board may also consider any policies, plans and objectives formulated by it concerning:1.the Hospital's current and projected patient care, teaching andresearch needs; and2.the Hospital's ability to provide the physical, personnel and financial resources that will be required if the application is acted upon favorably.SAMPLE APPLICATION FOR APPOINTMENT TO MEDICAL STAFFLAST NAME FIRST NAME MIDDLE NAME DEGREESmith Josiah Thomas MDOther Name Used/Maiden Name __________________________________________________Specialty: General and Vascular SurgeryBOARD CERTIFICATION List the certifying board, the specialty, the date of certification/recertification & expiration.Name of BoardAm Board SurgerySpecialtyGeneral SurgeryCertification/Recertification Date(s) 1/1/83, 6/30/03, 6/30/2013Expiration Date12/31/2020Name of BoardSpecialtyCertification/Recertification Date(s)Expiration Date FORMCHECKBOX Not planning to take boards FORMCHECKBOX Not eligible to take boards FORMCHECKBOX Board certification in process. Date scheduled or taken ___/___/___ Specialty___________GENERAL INFORMATION Citizenship (If foreign national – USA Status)USASocial Security Number 321-897-3876Date of birth12/13/49Medicare UPINA2194PRIMARY OFFICE ADDRESS:Approximate distance from hospital: 30 milesStreet and Suite Number1110 N. 9th StreetCityO’FallonStateILZip62269Telephone Number ( 618) 223-8998FAX ( 618) 223-8990Exchange Number ( ) PendingName of Office ManagerJennifer JohnstonSECONDARY OFFICE ADDRESS:Approximate distance from hospital: Street and Suite NumberCityStateZipTelephone Number ( ) FAX ( ) Name of Office ManagerHOME ADDRESS:Approximate distance from hospital: 40 milesStreet Address43 Green AcresCity GodfreyStateILZip62035Home Phone ( 618) 224-8726Cell Phone Number (618 ) 222-7262LICENSES AND REGISTRATIONStateILLicense Number 036-4598874Date Granted3/30/99Expiration Date6/30/15StateLALicense NumberMD 413679Date Granted7/5/75Expiration Date12/31/99StateIL Cont SubLicense Number031-036-4598874Date Granted3/30/99Expiration Date6/30/15Federal DEA NumberAS 1234567Date Granted7/30/75Expiration Date7/30/15EDUCATION/TRAININGMEDICAL SCHOOL Name U of IllinoisAddress, City, State, ZipChicago, ILDates of Attendance Degree Granted/DateFrom: 5/71 To: 5/75 MDIf Foreign Medical Graduate:ECFMG # Date Issued:RESIDENCY #1NameEarl Long Medical CenterAddress, City, State, ZipShreveport, LADates of Attendance SpecialtyFrom: 7/75 To: 6/77 General SurgeryName of Program DirectorRESIDENCY #2NameLA State UniversityAddress, City, State, Zip Shreveport, LADates of attendance SpecialtyFrom: 7/77 To: 6/81 General SurgeryName of Program DirectorFELLOWSHIPNameAddress, City, State, Zip Dates of attendance SpecialtyFrom: To:Name of Program DirectorALTERNATE(S) - List the name of the Medical Staff appointee(s) who will serve as your alternates and/or proctors.ALTERNATES:Don’t have one at this time. Am discussing with several surgeons on your staff.WORK HISTORY/HOSPITAL AFFILIATIONS, PAST AND PRESENTList work history, starting with the present. Include office practice, teaching appointments, employers, current and past hospital affiliations. If additional space is needed, provide details on separate sheet and attach.Name of Organization, Hospital, or Office PracticeSt. Jude Memorial HospitalAddress, City, State, Zip4501 St. Jude Place, Shreveport, LA From: 7/81 To: 12/98Position Surgeon Name of Organization, Hospital, or Office PracticeSt. Stephen Catholic HospitalAddress, City, State, Zip12 Main Street, Scoville, Il, 63421From: 4/99 To: PresentPosition Surgeon Name of Organization, Hospital, or Office PracticeAddress, City, State, ZipFrom: To:Position Name of Organization, Hospital, or Office PracticeAddress, City, State, ZipFrom: To:PositionName of Organization, Hospital, or Office PracticeAddress, City, State, ZipFrom: To:Position PERSONAL REFERENCESList three peer references - NOT RELATED TO YOU OR A PROSPECTIVE PARTNER - who have personal knowledge of your current clinical ability, ethical character, and ability to work cooperatively with others. These references should have acquired their knowledge through recent observation of your professional performance and, at least one must have had organizational responsibility for supervision of your performance. (e.g. department chair, service chief, training program director).Name Adam West, MD Address11 BrownRelationshipColleagueCity, State, ZipSt. Louis, MO 63108NameTina Graham, M.D. AddressUniversity Hospital Emergency DepartmentRelationshipColleagueCity, State, ZipSt. Louis, MO, 63106NameAddressRelationshipCity, State, ZipPROFESSIONAL LIABILITY INSURANCE INFORMATIONNAME OF CURRENT CARRIER:Lloyds of LondonADDRESS:Lloyd's America Inc.6340 Sugarloaf ParkwaySuite 200DuluthGA 30097POLICY LIMITS_500 K_________ per occurrence _1 mil annual aggregatePOLICY NUMBER:MR 4437DATE UNDERWRITTEN:6/1/13DATE OF EXPIRATION:12/31/15NAME(s), ADDRESS(s), AND POLICY NUMBERS FOR ADDITIONAL PROFESSIONAL LIABILITY INSURANCE CARRIERS YOU HAVE HAD OVER THE PAST FIVE YEARS: PROFESSIONAL BACKGROUNDPlease answer the following questions regarding your professional background. If the answerto any question is "yes", please provide the nature and specific details on a separate sheet and attach. YES NO1.Have you ever voluntarily or involuntarily surrendered, or had any pending or completed action involving the denial, revocation, suspension, reduction, limitation,probation, reprimand, or non-renewal of, a.a license or certificate to practice medicine or any profession in any state FORMCHECKBOX FORMCHECKBOX or countryb.Drug Enforcement Agency or other controlled substance license or registration FORMCHECKBOX FORMCHECKBOX c.membership or fellowship in any local, state, or national professional organization FORMCHECKBOX FORMCHECKBOX d.specialty or subspecialty board certification or eligibility FORMCHECKBOX FORMCHECKBOX e.faculty membership at any medical or other professional school FORMCHECKBOX FORMCHECKBOX f.staff membership or clinical privileges at any hospital, clinic, or healthcare institution FORMCHECKBOX FORMCHECKBOX 3.Has any hospital, health plan, or government sponsored program ever restricted, FORMCHECKBOX FORMCHECKBOX suspended, invoked probation, or rejected or terminated your contract?4.Have you ever been named as a defendant in a case alleging medical negligence, FORMCHECKBOX FORMCHECKBOX or has a suit for any alleged malpractice ever been brought against you?5.Do you have any physical or mental health condition, treated or untreated, FORMCHECKBOX FORMCHECKBOX which in any way impairs your ability in terms of skill, attitude, or judgmentto practice to the fullest extent of your license and qualifications or in any way poses a risk of harm to your patients?6.Have you ever been convicted of a felony, or currently have felony charges FORMCHECKBOX FORMCHECKBOX pending? APPLICANT'S CONSENT AND RELEASEI hereby apply for appointment to the Medical Staff of State Hospital. In making application for appointment to the Medical Staff of State Hospital, I certify that I have received, read, and agree to be bound by the Medical Staff Bylaws, Rules and Regulations and related manuals, and the current hospital policies that apply to my activities as a Medical Staff appointee and that are consistent with the Medical Staff Bylaws, Rules and Regulations and related manuals. Moreover, I specifically pledge that I will maintain an ethical practice, provide for continuous care of all my patients, refrain from feesplitting or other inducements relating to patient referral, and refrain from providing "ghost" surgical or medical services. I certify that there has not been any unsuccessful or currently pending challenges to licensure or registration, no loss of medical or dental organization membership, nor loss of medical staff membership or privileges at another hospital, except as noted herein. I understand that my competence and general functioning and performance with regard to my patients and my duties and obligations as a Medical Staff appointee of State Hospital, will be reviewed from time to time by my peers working within the structure of the Medical Staff in accordance with the Bylaws thereof. I hereby give my permission for, and in fact request, such review pursuant to my appointment and reappointment to the Medical Staff of State Hospital, that I will not bring legal action to prevent such review or to recover damages from those participating in such review.By applying for Medical Staff appointment, I accept the following conditions below during the processing and consideration of my application and for the duration of my medical staff appointment regardless of whether or not I am granted Medical Staff appointment and clinical privileges:(a)I extend absolute immunity to and release from any and all liability, State Hospital, its authorized representatives, and any third parties, as defined in subsection (c) below, for any acts, communications, reports, statements, documents, recommendations or disclosures involving me, performed, made, requested or received by any third party, including otherwise privileged or confidential information. The foregoing shall be privileged to the fullest extent permitted by law; such privilege shall extend to the hospital and its authorized representatives, and to any third parties.(b)I specifically authorize the hospital and its authorized representatives to consult with any third party who may have information, including otherwise privileged information, bearing on my professional qualifications, credentials, clinical competence, character, mental or emotional stability, physical condition, ethics, behavior or any other matter bearing on my satisfaction of the criteria for Medical Staff appointment as well as to inspect any and all communications, reports, statements, documents, recommendations, or disclosures of said third parties relating to such questions. I also specifically authorize said third parties to release such information, including any and all peer review material from any and all hospitals wherein I have held appointments, to the hospital and its authorized representatives upon request.(c)The term "hospital and its authorized representatives" means State Hospital and any of the following individuals who have any responsibility for acting upon my application for Medical Staff appointment: the members of the hospital's Board and their appointed representatives, the Chief Executive Officer or his designees, other hospital employees, consultants to the hospital, the hospital's attorney(s) and his/her partners, associates or designees, and all appointees to the Medical Staff. The term "third parties" means all individuals, including appointees to the medical staffs of other hospitals or physicians or health practitioners, nurses or other government agencies, organizations, associations, insurance companies, managed care organizations, credentials verification organizations, partnerships and corporations, whether hospitals, health care facilities or not, from whom information has been requested by the hospital or its authorized representatives or who have requested such information from the hospital and its authorized representatives.I also agree to provide any additional information as may be requested by the hospital or its authorized representatives. Failure to produce this information will prevent my application from being evaluated and acted upon. A copy of this consent and release is a binding as the original. In submitting this application for the purpose of securing appointment to the Medical Staff of State Hospital, I hereby voluntarily state that all of the information above is complete and truthful. I also voluntarily state that I have made no effort to evade telling the complete truth regarding my professional career. I understand that any incomplete or false statement will lead to automatic withdrawal of this application for appointment. Should I be appointed to the Medical Staff of State Hospital and it is subsequently found that any statement above is false I understand that my Medical Staff appointment and privileges will be automatically terminated. SIGNATURE______________________________________DATE___________________________PRINTED OR TYPED NAME_______Josiah Smith, M.D.___________________________________Review the application on the previous pages and list any “red flags”.Verification of Application Information The healthcare organization is obligated to assure that only competent practitioners provide treatment and services to its patients. This is accomplished through verification of the information provided by the practitioner and assuring that the practitioner meets the requirements for membership and privileges. Primary SourceA primary source is the original source that can verify the accuracy of a credential, qualification, or other information reported by the practitioner. For instance, when seeking to verify completion of a residency program, the organization contacts the residency program and asks for this verification. Primary source verification can be performed via letter, fax, approved official website, or well-documented telephone call. If verifying by phone, include the name of the organization called, the date, the person contacted, the questions asked, the response, the name of the person receiving the response. Education and TrainingUndergraduate education (school, year of graduation) is not typically verified unless privileges requested correspond with the training received. Hospitals should verify accredited medical school completion. In the managed care setting, the MCO must verify the highest of the following three levels of education and training obtained by the practitioner: (1) graduation from medical or professional school, (2) residency, or (3) board certification. Medical school completion is typically verified through direct contact with the school or by AMA or AOA profile for US graduates and ECFMG for foreign medical graduates.Postgraduate training including internship, residency, and fellowship should be verified. In addition to completion of this training, a hospital will request information about the quality of an applicant’s work and clinical competence from an internship, residency, or fellowship program in order to verify competency and ability to perform privileges. Any specialized training outside the residency or fellowship that reflects on the applicant’s privileges should be verified.Options for Verification of Education and TrainingRelevant training or experience is defined by the specific circumstances of the applicant. This may vary among specialties. The hospital must believe there is sufficient information on which to base a reasoned decision. Verification can come from:the school;American Medical Association (AMA) Physician Masterfile (for physician);A credentials verification organization;Educational Commission for Foreign Medical Graduates (ECFMG) for verification of graduation from a foreign medical school;American Osteopathic Association (AOA) Physician Database for predoctoral education accredited by the AOA Bureau of Professional Education.American Medical Association (AMA) Physician Masterfile; and(AOA) Physician Database for postdoctoral education approved by the AOA Council on Postdoctoral TrainingMedicare CoP Regarding Verification of Education and TrainingThe governing body ensures that the criteria for selection of both new medical staff members and selection of current medical staff members for continued membership must be based on individual character, competence, training, experience, and judgment. Sample Letter for Verification of Training[Date]Re: [Applicant’s full name, Title]Training: [Residency/fellowship]Specialty: [Specialty]Dates: [From/to]Dear [Program Director name]:We have received an application from the above-named provider for medical staff appointment and/or privileges. A copy of the privileges requested is attached. The applicant noted that the above-specified training took place at your institution. In order to process the application we require verification of completion of training and documentation of experience, ability, and current competence on the six areas of “General Competencies” adopted from the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) joint initiative. Our policies require completion of the enclosed form. Failure to receive this form will delay consideration of the applicant’s request for privileges. Also, our policies require the physician to document competency in performing specific procedures by allowing our organization to obtain a copy of his/her procedure list from your program and the outcomes for those procedures (if outcomes are available). The applicant has authorized you to provide this information to our organization via signature on the attached Authorization and Release Form. Enclosed is a copy of a release and immunity statement signed by the applicant consenting to this inquiry and your response. The immunity statement releases from liability any individual who provides the requested information. Thank you for your assistance. We look forward to hearing from you. Sincerely,DirectorEnclosuresResidency Program Director’s Evaluation and RecommendationPage 1Re: [Applicant’s full name]Training: [Residency/fellowship]Specialty: [Specialty]Dates: [From/to]Area of EvaluationPlease use comment section below to provide additional information noting question number for which information is provided. YESNOUnable to Evaluate1Were you the director of the program at the time of this applicant’s training?2Was the applicant at your institution in the above program for the stated period of time?3Was the program fully accredited throughout the applicant’s participation in it?4Did the applicant successfully complete the program?5Did the applicant receive satisfactory ratings for all aspects of his/her training in the program?6Was the applicant ever subject to or considered for disciplinary action?7Did the applicant ever attempt procedures beyond his/her assigned training protocols?8Was the applicant’s status and/or authority to provide services ever revoked, suspended, reduced, restricted, not renewed, or was he/she placed on probationary status or reprimanded at any time or were proceedings ever initiated that could have led to any of the actions?9Did the applicant ever voluntarily terminate his/her status in the program or restrict his/her activities in the program in lieu of formal action or to avoid an investigation?10In reviewing the attached request for privileges, do you feel that the applicant’s training and experience included these procedures?11In reviewing the attached request for privileges, do you feel that the applicant is currently competent to carry out these procedures?12Are you aware of any physical or mental condition that could affect this practitioner’s ability to exercise clinical privileges in his/her specialty area, or would require an accommodation to exercise those privileges safely and competently?Comments:Question Comment_______ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ __________________________________________________________Residency Program Director’s Evaluation and RecommendationPage 2Re: [Applicant’s full name]Training: [Residency/fellowship]Specialty: [Specialty]Dates: [From/to]Please rate the applicant in each of the following areas:ExcellentGoodFairPoorUnable toevaluatePatient careMedical knowledgePractice-based learning and improvement Interpersonal and communication skillsProfessionalismSystems-based practiceThis evaluation is based upon: FORMCHECKBOX Personal knowledge of the applicant. FORMCHECKBOX Review of file. FORMCHECKBOX Other _____________________________________________________________________________Overall Recommendation (check ONE): FORMCHECKBOX I recommend privileges as requested without reservation. FORMCHECKBOX I recommend privileges as requested with the following reservation(s) (use back of form, if necessary__________________________________________________________________________________________________________________________________________________________________________________________ FORMCHECKBOX I do not recommend this applicant for the following reason(s) ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ SignatureDate____________________________________________________________________Name, Position/Title (Please Print) Phone NumberPlease return this form within 2 weeks. Failure to receive the form will delay consideration of the applicant’s request for privileges.Peer RecommendationsA peer recommendation is a statement provided in support of an applicant’s request for appointment/ reappointment and/or privileges by a practitioner in the same professional discipline as the applicant. Peer recommendations are typically obtained from prior training program directors, department chairs, chiefs of staff, or others familiar with the applicant’s professional history and current clinical competence. Friends, neighbors, and relatives are not appropriate sources for peer recommendations. Peer recommendations should include reference to the applicant’s competence and ability to perform the privileges requested. Peer recommendations should address the practitioner’s relevant training and experience, current competence, and any effects of health status on privileges being requested.Sample Peer Recommendation LetterDateFacility NameFacility AddressRegarding applicant: John Doe, M.D.Specialty: General SurgeryDear ______________:We have received an application from the above-named provider for medical staff appointment and privileges. A copy of the privileges requested is attached. The applicant has listed you as a peer who will be willing to provide a recommendation. In order to process the application we require your evaluation of the applicant’s experience, ability, and current competence in the areas of medical/clinical knowledge, technical and clinical skills, clinical judgment, interpersonal skills, communication skills, and professionalism.Our policies require completion of the enclosed form. Failure to receive this form will delay consideration of the applicant’s request for privileges. You may supplement the form with additional information, if you so desire. The applicant has authorized you to provide this information to our organization via signature on the attached Authorization and Release Form. Sincerely,Medical Staff CoordinatorSample Peer Recommendation FormCONFIDENTIAL Professional Peer Reference & Competency ValidationPage 1 of 2Name of Applicant:________________________________________________________________________________Name of Evaluator:____________________________________ Relationship to Applicant:________________________How well do you know the applicant? FORMCHECKBOX not well FORMCHECKBOX casual personal acquaintance FORMCHECKBOX professional acquaintance FORMCHECKBOX very well Do you refer your patients to the applicant? FORMCHECKBOX yes FORMCHECKBOX no. If no, list reason(s) why not ___________________________________ _________________________________________________________________________________________________________PLEASE RATE THE PRACTITIONER IN THE FOLLOWING AREASExcellentGoodFairPoorUnable toevaluateMedical knowledge - Practitioner should have a good knowledge of established and evolving biomedical, clinical, and cognate sciences, and how to apply this knowledge to patient care. This is evidenced by completion of educational and training requirements as well as on-the-job experience, inservice training, and continuing education.Technical and clinical skills - Skill involves the capacity to perform specific privileges/procedures. It is based on both knowledge and the ability to apply the knowledge. Clinical judgment - Clinical judgment refers to the observations, perceptions, impressions, recollections, intuitions, beliefs, feelings, inferences of providers. These clinical judgments are used to reach decisions, individually and/or collectively with other providers, about a patient’s diagnosis and treatment. Communication skills - The provider should create and sustain a therapeutic and ethically sound relationship with other care givers, patients, and their families. He/she should be able to communicate effectively and demonstrates caring, compassionate, and respectful behavior. This also includes effective listening skills, effective nonverbal communication, eliciting/providing information, and good writing skillsInterpersonal skills - Areas of evaluation include how the provider works effectively with other professional associates, including those from other disciplines, to provide patient-focused care as a member of a healthcare team.Professionalism - Professionalism is demonstrated by respect, compassion, and integrity. It means being responsive and accountable to the needs of the patient, society, and the profession. It means being committed to providing high-quality patient care and continuous professional development as well as being ethical in issues related to clinical care, patient confidentiality, informed consent, and business practices.CONFIDENTIAL Professional Peer Reference & Competency ValidationPage 2 of 2Name of Applicant:__________________________________________________________________________Name of Evaluator:________________________________________________________________________________ Relevant training and experience – In reviewing the attached request for privileges, do you feel that the applicant’s training and experience are adequate to carry out these procedures? FORMCHECKBOX No - If no, please provide an explanation_______________________________________________________________ FORMCHECKBOX Yes FORMCHECKBOX Unable to evaluate Current competence – In reviewing the attached request for privileges, do you feel that the applicant is currently competent to carry out these procedures? FORMCHECKBOX No - If no, please provide an explanation_______________________________________________________________ FORMCHECKBOX Yes FORMCHECKBOX Unable to evaluateHealth Status - Are you aware of any physical or mental condition that could affect this practitioner’s ability to exercise clinical privileges in his/her specialty area, or would require an accommodation to exercise those privileges safely and competently? FORMCHECKBOX No FORMCHECKBOX Yes - If yes, please provide an explanation_______________________________________________________________ FORMCHECKBOX Unable to evaluate_________________________________________________________________________________________________Overall Recommendation (check ONE): FORMCHECKBOX I recommend privileges as requested without reservation. FORMCHECKBOX I recommend privileges as requested with the following reservation(s) (use back of form, if necessary________________________________________________________________________________________________________________________________________________________________________________________________ FORMCHECKBOX I do not recommend this applicant for the following reason(s) _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ SignatureDate____________________________________________________________________Name, Position/Title (Please Print)Phone NumberPlease return this form within 2 weeks. Failure to receive the form will delay consideration of the applicant’s request for privileges.Work History and Affiliations Some organizations verify all current and past hospital affiliations, while some verify only the past 5 -10 years. There are several reasons for performing this verification. One reason is to make sure there are no unexplained gaps. Many hospitals feel it is important to document the provider’s whereabouts and clinical activity for the period from medical school to the date of application. This is done to make sure that there are no unaccounted for periods of time. For example, a provider who spent time in prison or in a drug/alcohol rehabilitation facility may attempt to hide this by stating he/she was on staff at a hospital during this time. Verification of the dates on staff may turn up the discrepancy.Another reason work history and affiliations are verified is to ascertain current clinical competence. This is particularly important in the hospital. Typically, such requests will include dates on staff, current staff status or category, disciplinary actions, and whether the privileges requested are consistent with those held at the facility being queried. Some managed care plans require a provider to have medical staff appointment at a hospital that contracts with the managed care plan. The MCO will verify this appointment. Some MCOs will ask the hospital to provide a list of providers on a routine basis in lieu of individual verification letters. Sample Letter: Facility Privileges and Competency ValidationDateFacility NameFacility AddressRegarding applicant: John Doe, M.D.Specialty: General SurgeryDear Medical Services Professional:We have received an application from the above-named provider for medical staff appointment and privileges. A copy of the privileges requested is attached. The applicant noted that s/he currently, or has in the past, held privileges at your facility. In order to process the application we require documentation experience, ability, and current competence on the six areas of “General Competencies” adopted from the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) joint initiative. These competencies include assessment of patient care, interpersonal and communication skills, professionalism, medical knowledge, practice-based learning and improvement, and systems-based practice. Our policies require completion of the enclosed form. Failure to receive this form will delay consideration of the applicant’s request for privileges. Also, our policies require the physician to document competency in performing specific procedures by allowing our organization to obtain a copy of his/her privilege form from your hospital as well as a list of the actual procedures performed in the past 12 months and the outcomes for those procedures. The applicant has authorized you to provide this information to our organization via signature on the attached Authorization and Release Form. Sincerely,Medical Staff CoordinatorCONFIDENTIAL Evaluation of Privileges and Competency ValidationName of Facility Providing Information:___________________________________________________________Name of Practitioner for which Information is Provided:_______________________________________________Dates on Staff: From ________________________________ To ____________________________________Has the practitioner been subject to any disciplinary action, restrictions, modifications, or loss of FORMCHECKBOX Yes FORMCHECKBOX Noprivileges or medical staff appointment either voluntary or involuntary at your facility? Are you aware of any restrictions, modifications, or loss of privileges or medical staff appointment, FORMCHECKBOX Yes FORMCHECKBOX Noeither voluntary or involuntary, at any another facility? Are you aware of any physical or mental condition that could affect this practitioner’s FORMCHECKBOX Yes FORMCHECKBOX Noability to exercise clinical privileges as requested, or would require accommodation to perform privileges safely and competently? If the answer to any of the above questions is “YES”, please explain: __________________________________________________________________________________________________________________________________________________Evaluation: Please rate the practitioner in the following areas. Patient Care is compassionate, appropriate, and effective for the treatment of health problems and promotion of health Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient careInterpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.ExcellentGoodFairPoorUnable toevaluatePatient careMedical knowledgePractice-based learning and improvement Interpersonal and communication skillsProfessionalismSystems-based practice____________________________________________________________________ Signature Date____________________________________________________________________Name, Position/Title (Please Print)Phone NumberPlease return this form within 2 weeks along with a copy of the applicant’s privilege list for your hospital and a list of the actual procedures performed in the past 12 months and the outcomes for those procedures.Licensure A license is the authority a government agency grants an individual to practice a profession. Regulation of medical and other professional practice is a state function. States exercise the regulation of medical practice through licensing laws. Some states issue a controlled substance license in addition to the license to practice medicine. If so, this license should also be verified.State licensing boards also take disciplinary action against professional licenses. This may include revocation, suspension, probation or reprimand. Although basic information is available via the Internet or telephone, many state licensing boards will not provide specific information on disciplinary actions unless requested in writing. The extent of the information provided differs depending on the laws of the state.It is essential to verify licensure status for all licensed providers in the state the practitioner will be practicing. It is up to the individual facility or MCO whether or not to check licensure in each state the applicant is or was ever licensed. Some states use reciprocity, which refers to agreements between jurisdictions in which states are willing to recognize each other's licensees based on comparable requirements for licensure. In many cases, not only do they accept the licensure of that state, they also accept disciplinary action from the other state.Definitions of Licensure/Certification/RegistrationSome professions are not licensed, but rather are regulated through registration or certification. Although individual states may have their own definitions, below are general definitions:Licensure: The most restrictive form of professional and occupational regulation. Under licensure laws, it is illegal for a person to practice a profession without first meeting state or provincial standards. Certification: Under certification, the state grants title protection (right-to-title) to persons meeting predetermined standards. Those without certification may perform the duties of the occupation, but may not use the title. Registration: The least restrictive form of regulation. Usually takes the form of requiring individuals to file their names, addresses and qualifications with a government agency before practicing the occupation. This may include posting a bond or filing a fee.Medicare CoPs Requirements for Verification of LicensureThe hospital must assure that personnel are licensed or meet other applicable standards that are required by State or local laws. All staff required by the State to be licensed must possess a current license. The hospital must assure that these personnel are in compliance with the State’s licensure laws. The laws requiring licensure vary from state to state. Examples of healthcare professionals that a state may require to be licensed could include: nurses, MD/DOs, physician assistants, dieticians, x-ray technologists, dentists, physical therapists, occupational therapists, respiratory therapists, and hospital administrators. Sample Policies and Procedures for CredentialingVerification of Current Licensure and Licensure SanctionsPOLICY AND PROCEDURES[Facility Name]Policy:It is the policy of the Facility and Medical Staff to require verification of all relevant information provided on applications for Medical Staff appointment and/or clinical privileges. The verification of current licensure informs the facility that the applicant is appropriately licensed to practice as a health care provider as required by state and/or federal law. Practitioners currently licensed in the state of [add state name] are eligible to request Medical Staff Appointment and clinical privileges. AHPs holding a license, certificate or other official credential as provided under state law, are eligible to provide specified services in the Facility as delineated by the Medical Staff Executive Committee and Governing Body. In addition, Applications must include information as to previously successful or currently pending challenges to, or the voluntary relinquishment of a license to practice any profession in any jurisdiction. It is the policy of the facility to verify current licensure in the state in which the facility provides services with the state licensure board or that board’s designated agent at the time of appointment and initial granting of privileges, at reappointment, renewal, or revision of clinical privileges, and at the time of expiration by a letter or computer printout obtained from the appropriate licensing board, through the primary source internet site, or by telephone. It is the policy of this Facility to verify whether or not the applicant has been subject to licensure sanctions in each state in which the practitioner currently or has ever held a license or certificate. This is accomplished by either (1) querying the medical board of each state in which the provider has held or currently holds licensure, or (2) querying the Federation of State Medical Boards (FSMB).Note: Each facility should customize the paragraph above to reflect current practices.Note: If the Facility contracts with a Credentials Verification Organization (CVO), these licensure and sanction verifications may be provided by the CVO. ProcedureProcedure for verification of current licensure and licensure disciplinary actions via internet site:Access the state licensure board web page for each state in which the license is held or has been held in the past. Each licensure board maintains a data base that can be used to verify licensure. Some states include all licensed and certified providers in one database, and some maintain separate data bases for nursing and other non-physician providers.Note: The website of the Administrators in Medicine (AIM) Association of State Medical Board Executive Directors has a page with links to each licensure board’s web site. You can access this site at . The data in the AIM DocFinder database is intended for public use, not for commercial verification, and it requires a contractual agreement for the facility to use the database for verification of licensure. There are some state licensure boards that use AIM as their only source of internet verification and when you attempt verify licensure at the State’s website, it opens a link to AIM DocFinder. In this case, the AIM website is considered a primary source for the licensure board data for that state and you do not have to pay for this verification.Using the search mechanism on the state licensure board’s website, enter the required provider information and search. If you are searching on name only, the search results may contain more than one name. Examine each resulting name to determine the correct provider. In some cases, the search results may only provide a summary and you may have to click on an additional link(s) to bring up detailed information. Print all available information.If the results of the verification show that there was disciplinary action taken against the license, but this information is not available on the website, write to the licensing board and request the additional information. You can find the address on the licensing board’s website. Include a copy of the Applicant’s consent and release form with the request. Place a copy of the letter in the applicant’s credentials file. Note:A listing of names and mailing addresses for all state licensure boards is also available at the printed document(s) to make sure the current date is printed. If the verification does not have the date on it, write the date on the verification using permanent ink.Place the verification in the credentials file. Include the verification date in the [software name] credentialing software database.Notification of Internal and External Parties Regarding Practitioner PrivilegesPolicy:Key external and internal persons and organizations must be notified whenever a change occurs in a practitioner’s privileges or when a new practitioner is granted privileges or appointment. Some internal sources require information regarding clinical privileges granted, while others require only a general notification.Procedure:Internal Sources:General Notification of New Practitioner:When a new practitioner is granted medical staff appointment or clinical privileges, a general notification should be distributed via email or memo to all hospital departments. The following information should be included:Full name, credential, address, phone, fax, pager/paging service number, partners, alternates, effective date, picture, sponsoring physician (if AHP).General Notification Practitioner Leaving Staff:When a practitioner leaves the staff, a general notification should be distributed via email or memo to all hospital departments. The following information should be included:Full name, credential, forwarding address (if applicable), and effective date.Notification of PrivilegesWhen new privileges are granted either to a new applicant or an existing medical staff member or allied health professional; or when there is a modification (addition, deletion, termination, proctorship, etc.) to current privileges; the following internal personnel should be notified via email or memo and a copy of the privileges (or modification to privileges) should be included with the notification. (Note: Will need to modify this language to reference privileges that are posted via intranet or other electronic means).[Name]Admitting Department[Name]Operating Room[Name]Nursing Administration (for distribution to all nursing units)[Name]Administration[Name]Emergency Department[Name]Outpatient/Ambulatory Clinic(s)[Name]Quality Management[Name](Include others, as appropriate)External SourcesNational Practitioner Data Bank and State Licensing BoardsThe Health Care Quality Improvement Act of 1986 includes a requirement for reporting of certain adverse actions to the National Practitioner Data Bank.Hospitals must report: (1)a professional review action which adversely affects a physician’s or dentist’s clinical privileges for more than 30 days and is based upon the physician’s or dentist’s professional competence or professional conduct; and (2)the voluntary surrender of clinical privileges by a physician or dentist who is under investigation relating to questions of professional competence or conduct, or in return for no investigation or professional review action being conducted.A professional review action includes denying, reducing, restricting, revoking and suspending privileges, and also includes a decision not to renew clinical privileges if that action is based on the physician’s or dentist’s professional competence or conduct. Hospitals must submit adverse action reports to the appropriate state licensing board within 15 days of final Board action in the case of an adverse action or within 15 days of the date the physician surrenders his or her clinical privileges. These reports must be submitted electronically to the National Practitioner Data Bank as an Adverse Action Report. Within 15 days, a printed copy of the electronic report must be forwarded to the state medical licensing board.Revisions to previously reported adverse actions must also be reported. For example, if a physician’s clinical privileges are reinstated after a 45 day suspension, both the suspension and the reinstatement must be reported.Note: All reports to state licensing boards and the NPDB should be coordinated with the Legal Department.NPDB Query POLICY AND PROCEDURES[Facility Name]PolicyIt is the facility’s policy to comply with the requirements of the Healthcare Quality Improvement Act by performing a query of the National Practitioner Data Bank (NPDB) at each of the following times:A physician, dentist, or other health care practitioner applies for medical staff appointment or for clinical privileges at the facilityAt least every 2?years (biennially) on all physicians, dentists, and other health care practitioners who are on the medical staff or have clinical privileges. When a practitioner wishes to add to or expand existing privilegesWhen a practitioner submits an application for temporary privilegesIn addition, the facility may, in its discretion, query the NPDB as necessary for professional review activities.Procedure:The following information is required to perform a query:Entity Data Bank Identification Number: [insert DBID Number]User ID Number: [insert ID number]Password: [insert password]Note: Each facility should add information here regarding the password and entity ID number.If the facility uses the Data Bank’s Querying and Reporting XML Service (QRXS) to store and manage their subject and report data within their own information or credentialing systems, this process should be included on this procedure.For more information, see npdb-hipdb..Identification of Excluded ProvidersPOLICY AND PROCEDURE[Facility Name]Policy:It is the policy of the facility to verify that providers are not currently excluded from participation in Medicare, Medicaid, or other Federal health care programs.The Office of Inspector General's (OIG) List of Excluded Individuals/Entities (LEIE) database provides information regarding individuals and entities currently excluded from participation in Medicare, Medicaid and all Federal health care programs.System for Award Management (SAM) identifies those parties excluded throughout the U.S. Government (unless otherwise noted) from receiving Federal contracts or certain subcontracts and from certain types of Federal financial and nonfinancial assistance and benefits. The System for Award Management (SAM) includes the following systems:Central Contractor Registry (CCR)Federal Agency Registration (Fedreg)Online Representations and Certifications ApplicationExcluded Parties List System (EPLS)Procedure for accessing the OIG’s LEIE:1.Access the exclusion database at the last name and first name of the provider.3a.If no results are found, print the search results. 3b.If results are found, click on the name field and this will bring up a page in a printable format along with a place to enter the social security number. Enter the social security number and click Verify. 4.Print out the page5.Place report in the credentials file.6.If results show that an action was taken, notify [include appropriate name].Procedure for accessing the System for Award Management:1.Access database at and click Search Records tab.2.Enter name of the provider and click the Search button (a new page will open with results)3.Click on the Printer Friendly link. A new page will open. Print the search results. 4.If no records, print out the page and place report in the credentials file.5.If results show that an action was taken, click on View Details button, print the page and place report in the credentials file. Notify [include appropriate name].Criminal Background ChecksPOLICY AND PROCEDURES[Facility Name]Policy:It is the policy of the facility and Medical Staff to require verification of all relevant information provided on applications for Medical Staff appointment and/or clinical privileges (“Application(s)”. Criminal background checks are provided for in the Medical Staff Bylaws and by the Facility’s policy on employee criminal history background checks for employed physicians or other employed privilege-holders. Medical Staff Bylaws require applicants to include with their application, any current criminal charges pending against the applicant and any past convictions or pleas. In addition, Bylaws require that a practitioner shall notify the CEO and the Chief of Staff within seven (7) days of receiving notice of the initiation of any criminal charges, and shall acknowledge the Facility’s right to perform a background check at appointment, reappointment and any interim time when reasonable suspicion has been shown.Procedure:Each applicant for clinical privileges or appointment to the Medical Staff (“Applicants”) shall be required to sign an authorization to allow the Facility to conduct a criminal background check on the Applicant (“Authorization”) as part of his/her Application. Failure to sign the Authorization or withdrawal of the Authorization by the professional shall constitute a material omission from the Application which shall result in the Application being incomplete, and the Facility may decline to process the Application further. A material omission shall also be grounds for automatic and immediate rejection of the Application resulting in denial of appointment and/or privileges. With respect to Facility employees (or prospective employees) who are also Applicants, such individuals shall also be required to comply with the Employee Background Checks policy of the Facility. The Human Resources Department may share results of Employee Background Checks of such individual with the Medical Staff Office and the others involved in the credentialing process in the same manner as if it were a Medical Staff Background Check. The Medical Staff Office may share reports on employee Applicants with the Facility’s HR Department.Denial of appointment and/or privileges based solely on failure to provide or revocation of the Authorization shall not entitle the Applicant to the procedural rights of hearing and appellate review provided in the Medical Staff Bylaws, and it shall not be deemed to be an adverse action or professional review action for purposes of reporting to the National Practitioner Data Bank.The Medical Staff Office shall include the results of the Background Check in the Applicant’s credentialing file. If an Applicant makes a misrepresentation or omission on his/her Application concerning his/her criminal history which is revealed as a result of further investigation, including, but not limited to, the Medical Staff Background Check (or the Employee Background Check, if applicable), such action shall be grounds for automatic and immediate rejection of the Application, resulting in denial of appointment and/or clinical privileges. Denial of appointment and/or privileges based solely on such misrepresentation or omission shall not entitle the Applicant to the procedural rights of hearing and appellate review provided in the Medical Staff Bylaws, and it shall not be deemed to be an adverse action or professional review action for purposes of reporting to the National Practitioner Data Bank.The Applicant may refute the information in the report with the CRA pursuant to the requirements of the CRA.If the report (or Employee Background Check, if applicable) reveals that the Applicant has a criminal history, the Medical Staff Office shall and share the reports with the Chief of Staff (COS), the Chief Executive Officer (CEO), and the applicable Department Chair or Service Chief.The Facility shall investigate any adverse information in such report(s) by inquiring with the Applicant to provide clarification or more information, among other means. In all cases, the Applicant should be given an opportunity to explain the circumstances of the arrest through a written submission or through a meeting with the COS and CEO. The facility may also request additional information including, contacting the arresting officer and/or obtaining a copy of the arrest record.The COS and CEO shall consider the criminal history information and make recommendations to the Credentialing Committee.The Credentialing Committee shall consider criminal history information in light of how the conduct relates to the Applicant’s qualification for appointment to the medical staff including, but not limited to, the applicant’s practice, maintaining patient safety and protecting the reputation of the Facility and Medical Staff. The committee should take into consideration whether the crime has a relationship to the treatment of patients, and whether or not it may be a reflection of poor moral conduct or unethical character.A disqualifying offense may be a felony conviction, guilty plea or plea of no contest to a felony possession or sale of narcotics or controlled substances, murder, manslaughter, armed robbery, rape, sexual battery, sex offenses listed in state codes, child abuse, arson, grand larceny, burglary, gratification of lust, or aggravated assault, or felonious abuse and/or battery of a vulnerable adult which has not been reversed on appeal or for which a pardon has not been granted.Mitigating circumstances which may be considered include, but are not limited to, age at which the crime was committed; nature and gravity of the crime; circumstances surrounding the crime; length of time since the arrest, conviction or prison time; criminal history since the conviction; work history; current membership and character references; and other evidence demonstrating the individual’s ability to perform their privileges competently and that the person poses no threat to the health and safety of patients. In any such instance, documentation will be produced and maintained outlining any mitigating circumstances and recommendations as to whether or not the Applicant’s membership and/or privileges shall be granted.Using The AMA Physician and AAPA Physician Assistant Masterfile QueryPOLICY AND PROCEDURE[Facility Name]Policy:It is the policy of [Facility Name] to require verification of all relevant information provided on applications for Medical Staff appointment and/or clinical privileges.The American Medical Association’s Physician Masterfile and the American Academy of Physician Assistants Masterfiles contains primary source verification of a number of credentialing elements. It is the policy of [Facility Name] to use the AMA Physician Masterfile for verification of the following elements for physicians who hold an M.D:U.S. or Puerto Rican medical school graduation Residency completionBoard certificationNote: While completion of residency can be verified with the AMA Masterfile, the residency program should also be contacted to verify that the physician has been trained to perform the privileges requested. (See policy and procedure on Verification of Postgraduate Training.)It is the policy of [Facility Name] to use the AMA Physician Assistant Masterfile for verification of the following elements for physician’s assistants:Education of physician assistant’s medical schoolCertification by the National Commission for the Certification of Physician AssistantsNote: If the Facility contracts with a Credentials Verification Organization (CVO), as the hospital’s agent, the Masterfiles may be requested by the CVO, or the CVO may query directly to the primary source in lieu of using the AMA/AAPA Masterfiles. . Liability History/Proof of InsuranceMalpractice insurance is provided by per occurrence and by an aggregate value. For instance, the policy may provide $1 million per each occurrence with a maximum yearly aggregate amount of $3 million. Most hospitals require proof of liability insurance with a specified minimum face value. Most hospitals and MCOs require the applicant to provide, at minimum, information concerning current professional liability coverage and any final judgments and settlements. The applicant may be required to provide information regarding current past insurers, whether insurance has ever been canceled by carrier and reasons why, and claims filed and disposition. Often, a letter, such as the one below, is included in the application packet.It is important for the organization to understand that just because a provider has a malpractice suit, it does not necessarily mean that the provider is incompetent or is a problem provider. The organization must evaluate the liability history of each individual provider to determine whether or not it is significant in relation to the privileges requested. In some physician specialties, for instance orthopedics and neurosurgery, there is a higher rate of malpractice suits filed. In addition, liability insurance providers may settle some lawsuits just because it's cheaper to do so then to go through the litigation. Oftentimes, the provider has no control over these settlements. Date][Insurance Company name and address]RE: [Practitioner name][Policy number]Dear Sir or Madam:I have applied for Medical Staff membership at [hospital name]. As a requirement for this membership, proof of ongoing liability insurance is required. Please add [hospital name] as a certificate holder to my policy and provide a copy of my certificate of coverage to [hospital name] including the limits of the insurance coverage and any additional insured.Additionally, please provide ongoing notice of cancellation, nonrenewal, or any material limitations in coverage within 30 days in advance for any statutorily permitted reason including nonpayment of premium.Please also provide [hospital name] with a record of my claims history/loss run including date of the loss, date the claim was reported, name of the claimant, synopsis of what happened, amount paid to date, and whether the claim is closed or open.Sincerely,[practitioner name]Health Status/Ability to Perform Applicants should be asked to document their ability to safely exercise the privileges requested with or without reasonable accommodation. The Americans with Disabilities Act (ADA) is a federal civil rights law that prohibits discrimination based on disability and bars discrimination against a qualified individual due to the disability. State and local court opinions vary regarding whether ADA applies only to employees only or includes medical staff members. It is up to individual hospitals to determine how the ADA applies to its privileging and credentialing processes. When discussing the issue of the aging provider, it is essential to maintain compliance with state and federal law related to age discrimination. Joint Commission standards require that the hospital evaluate the health status of physicians who exercise, or seek to exercise clinical privileges or other health care services. When the organization employs the physician the ADA applies. If not employed, most hospital medical staffs do not abide by the ADA. The question that needs to be addressed is whether the physician is currently competent and qualified to safely exercise the privileges granted. Some believe that age is irrelevant. Bylaws and policies should be designed to effectively monitor, review, audit and evaluate how providers perform. This is essential in making a determination as to whether they are meeting expected standards. Of course, there may come a time when the skills of a provider begin to diminish. If so, steps need to be taken in order to assure that the interests of patient care are seen to while also respecting the rights and privileges of physicians. This may involve a process to review and investigate possible causes. The review should be accomplished in a supportive, collegial manner consistent with bylaws, rules and regulations and applicable policies. Some medical staffs set a certain age, for instance age 65, at which physicians are required to submit to an annual physical exam.Board Certification The ABMS coordinates the activities of its 24 Member Boards in the United States and provides information to the public, government, medical profession and its Members concerning issues involving specialization and certification in medicine. According to the ABMS, the fundamental objective of its member boards is to act in the public interest by contributing to the improvement of medical care by establishing qualifications for candidates and by evaluating those who apply for certification.The 24 ABMS member boards offer general and sub-specialty certificates. Each specialty board acts as an independent body determining its own requirements and policies for certification. The board accepts candidates for certification from persons who fulfill its requirements, administers certification exams, and issues certificates to those who pass. All member boards require a written exam and most also require an oral exam. Obstetrics and gynecology, neurological surgery orthopedic surgery, pathology, physical medicine & rehab, radiology, and urology boards have an additional requirement for one to two years of clinical experience. At one time, boards issued lifetime certificates meaning once you were certified, you were certified for life. All ABMS member boards now have time-limited certificates and require recertification. Most boards now require recertification after 10 years with the exception of Family Practice (7 years), OB/GYN (7 years), and Pediatrics (7 years). If you query an ABMS member board and ask about “board eligibility”, it will respond by stating an individual's precise position in the certifying process. The American Osteopathic Association does continue use the term “board eligible”. AOA Board eligibility status terminates on December 31 of the sixth year after completing the training program. AOA has 18 certifying boards.Hospital requirements for board certification vary, often based on physician availability. Those hospitals located in a geographic area with an abundance of physicians often require board certification, while those in underserved areas often do not. It is not unusual for each medical staff department to set its own criteria for privileges which may include board certification. Some managed care organizations require board certification to participate in provider panels. If certification is required, it is necessary to keep track of all certifications and expiration dates. Bylaws should define any requirements for board certification/eligibility and a process should be in place to verify board certification. If the medical staff requires board certification on appointment or within a certain timeframe, follow-up should occur to assure these requirements are met. Reminder letters should be sent to physicians prior to the expiration of their boards or eligibility. Include in this letter the bylaws language that requires board certification. Whatever your requirements, make sure that they are consistently applied.Board certification is usually verified by obtaining confirmation from the board. Board certification for ABMS boards can be verified via the ABMS CertiFacts online, the ABMS Certifax service, ABMS products administered through Choice Point Services, Inc. and the online subscription service, . AOA certification can be verified via the AOA Official Osteopathic Physician Profile Report or AOA Physician Master File. The American Board of Medical Specialties (ABMS) has replaced its recertification program with a Maintenance of Certification (MOC) program that reflects the concept of physician practice assessment based on performance rather than solely on success on a written exam. This includes assessment of six “general competencies” - patient care, interpersonal and communication skills, professionalism, medical knowledge, practice-based learning and improvement, and systems-based practice. The MOC has four basic components requiring evidence of professional training, lifelong learning with involvement in a periodic self-assessment process, cognitive expertise, and evaluation of performance in practice. What About Those “Other Boards”There are many self-designated medical boards in the U.S. that are not members of the ABMS or the AOA. While hospitals and medical staffs set their own criteria for appointment, careful consideration should be given to specifying which certifying boards are considered acceptable. Medicare CoPs Regarding Board Certification§482.12(a)(7) [The governing body must] Ensure that under no circumstances is the accordance of staff membership or professional privileges in the hospital dependent solely upon certification, fellowship or membership in a specialty body or society. “A hospital is not prohibited from requiring board certification when considering a MD/DO for medical staff membership. Rather, the regulation provides that a hospital may not rely solely on the fact that a MD/DO is or is not board certified in making a judgment on medical staff membership. In addition to matters of board certification, a hospital must also consider other criteria such as training, character, competence and judgment. After analysis of all of the criteria, if all criteria are met except for board certification, the hospital has the discretion to decide not to select that individual to the medical staff.” (Source: CMS Interpretive Guidelines)Verification Of IdentityJoint Commission standards require the organization to verify the identity of the practitioner requesting by viewing a current picture hospital ID card or a valid picture ID issued by a state or federal agency (e.g., driver's license or passport). It is expected that this be done prior to the practitioner providing patient care, treatment, or services.Sample Policy and Procedure for Verification of IdentityPolicy: It is the policy of ___________ Hospital to verify the identity of all licensed independent practitioners (LIPs) who apply for medical staff appointment and privileges prior to the practitioner providing any patient care, treatment, or services. This is done to determine that these practitioners are the same practitioners identified in the credentialing documents.Verification of identity can be accomplished by viewing any of the following:Military ID, State ID, Customs Passport, State Drivers LicenseProcedure:Verification can be done during any of the following processes:During provider orientationDuring the process of obtaining hospital picture IDAny time the practitioner presents in person to the Medical Staff OfficeAfter presentation of a valid Military ID, state drivers license/ID, or customs passport that includes a picture, the person verifying completes the Verification of Identity Documentation Form (Attachment A). The completed form is forwarded to the Medical Staff Office for inclusion in the practitioner’s credentials file.Reference: Joint Commission Hospital Standard MS.06.01.03-9144008826500Attachment AVerification of Identity Documentation FormPractitioner Name: ____________________________________________________I have reviewed the following identification for the above-named practitioner: FORMCHECKBOX Military ID FORMCHECKBOX Passport FORMCHECKBOX State Driver’s license or ID ______________________________________ [list issuing state]___________________________________________________Signature of person verifying Date_______________________________Printed name of person verifyingPrivileges Resources “Laundry List” ExampleFamily Practice Privilegesamniocentesisandroscopyanoscopyarterial puncturearthrocentesisaspiration of bladder: suprapubicbartholin’s cyst: drainagebiopsy skin and subcutaneousbiopsy: vulva or vaginabladder catheterizationbreast: needle aspiration of cystburns: partial; full thicknesscasting, splinting, and bracingcervix: biopsy and polypectomycervix: cryosurgerychemotherapy, adult and childcolonoscopy w /biopsycolonoscopy w/o biopsycolposcopy and biopsyculdocentesisdilatation and curettagedilatation and curettagedislocations: simple/closed reductionECG interpretationectopic pregnancy: medical managementEGD w/ biopsyEGD w/o biopsyendometrial bx/aspiration curettageendoscopy: w/ foreign body removalepistaxis: anteriorextensor tendon repair: simple/primaryfine needle biopsy: superficial lymph node or thyroid800100438150Signature___________________________________________Date________________________________________________00Signature___________________________________________Date________________________________________________foreign body removal, eye, ear, nose, throat fracture care closed reductionfracture care non-operative/non-displacedfrenulum release ganglion: aspiration/drainagehemorrhoidectomy: banding or infraredhemorrhoidectomy: external surgicalhistory and physical examholter monitoringhymenotomyhysterosalpingogramI & D abscessinjection: joint, tendon, or bursaintrauterine demis managementIU insertion/removallaceration: simple repairlaceration: intermediate repairlaryngoscopy: directlaryngoscopy: indirectLEEP biopsy or conelumbar puncturelymph node superficial biopsy or excisionlymph node excision or biopsymeatotomymorton’s neurom injectionnail matrix destructionnail plate removalnasal fractur undisplacedneoplasia of skin: thermal or surgical treatmentNG tube placementnon-stress testingoral lesions: biopsy and excision; simpleosteopathic manipulative therapyparacervical blockpilonidal cyst I & D or excisionproctosigmoidoscopy: flexible w/ biopsyproctosigmoidoscopy: flexible w/o biopsyproctosigmoidoscopy: rigid w/ biopsyproctosigmoidoscopy: rigid w/o biopsypudendal blockpulmonary function testingremoval of cerumen impactionrhinolaryngoscopy: fiberopticsebaceous cyst excisionskin biopsy: shave, punch, incisional or excisionalslit lamp examstress testin exercise treadmillsub-cutaneous contraceptive devic insertion/removalthoracentesis: needle/catheter thoracentesis: needle/cathetertonometryultrasoundurethra dilation of femaleurethra dilation of malevacuum curette incomplete abortionvasectomyvenereal warts: treatmentvenereal warts: treatmentvenipunctureAAFP Core Privileges ExampleClinical Privilege RequestFor Family Medicine WITH MATERNITY CARE Source: American Academy of Family PhysiciansClinical Privilege RequestFor Family Medicine WITH MATERNITY CAREName:Effective from __/__/__ to __/__/__INTRODUCTION OF CORE PRIVILEGESFamily medicine is the medical specialty which provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ system and every disease entity.Core privileges within the department of family medicine should reflect the core curriculum and training offered in accredited family medicine residency programs. The categories and core privileges listed are based on the “Program Requirements for Graduate Medical Education in Family Medicine,” a publication by The Accreditation Council for Graduate Medical Education (ACGME) (), and the “Recommended Curriculum Guidelines for Family Medicine Residents” endorsed by the American Academy of Family Physicians (). Resources for family physicians and hospitals for special non-core privileges can be found at the AAFP website at , including the AAFP position paper on colonoscopy found at be eligible to apply for core privileges in family medicine, the applicant must meet the following criteria:Current certification or active participation in the examination process leading to certification in family medicine by the American Board of Family Medicine or the American Osteopathic Board of Family PhysiciansAnd/orSuccessful completion of an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) accredited post-graduate training program in family medicine.family medicine Core Privileges?RequestedAdmission, evaluation, diagnosis, treatment and management of infants and children, adolescents and adults for most illnesses, disorders and injuries. Core privileges include but are not limited to:The care of neonates and infants, including both well-baby and ill newborns. Illnesses, disorders and injuries of childhood, such as pneumonia, asthma, gastrointestinal infections, dehydration and urinary tract infections.Illnesses, disorders and injuries of adolescence.Illnesses, disorders and injuries of the adult, including but not limited to conditions of the heart, kidney, lung, musculoskeletal system, skin, eye, and nervous system, and including multi-system diseases such as diabetes mellitus, HIV/AIDS and cancer, and including the care of patients requiring admission to intensive care.Women’s health, including illnesses, disorders and injuries of the female reproductive and genitourinary systems.Pre- and post-operative evaluation and care.Acute and chronic diseases of the elderly, including dementias, as well as functional assessment, physiologic and psychologic aspects of senescence and end-of-life care.Psychiatric disorders in children and adults, emotional aspects of non-psychiatric disorders, psychopharmacology, alcoholism and other substance abuse.The care for patients of all ages with acute illnesses, disorders and injuries in an emergency care munity issues, such as child abuse and neglect, domestic violence, elder abuse and neglect, disease prevention and disaster preparedness.Procedures such as suturing lacerations, removal of non-penetrating corneal foreign bodies, simple skin biopsies or excisions, incision and drainage of abscesses, burn care, the management of uncomplicated minor closed fractures and uncomplicated dislocations, and such other procedures that are extensions of the same techniques and skills. Exclusions: Though considered core privileges for Family Medicine, the following privileges will be excluded for this applicant at their request.____________________________________________________________________________________________________________________________________________________________________________________MATERNITY Core Privileges?RequestedAdmit, evaluate and manage pregnancy, labor and delivery, post-partum care, and other procedures related to maternity care, including medical diseases that are complicating factors in pregnancy (with consultation as appropriate). Applicant must provide documentation of at least 2 months obstetrical rotation during family practice residency with 40 patients delivered. Special NON-Core PrivilegesTo be eligible to apply for special non-core privileges, the applicant must have documented training and/or experience and current competence in performing the requested procedure(s) consistent with criteria set forth in medical staff policies governing the exercise of specific privileges. This may be accomplished by providing documentation of acceptable supervised training and experience during residency and/or fellowship training, or successful completion of an approved, recognized course when such exists.C-section?RequestedApplication Criteria: Successful completion of an ACGME or AOA accredited residency training program in family medicine or obstetrics and gynecology.Required Previous Experience: A minimum of 30 Cesarean births as primary operator.Acknowledgement of PractitionerI acknowledge that I have requested only those privileges for which by current competence, training and/or experience, I am qualified to perform and for which I wish to exercise at the Hospital. I understand that I am bound by the applicable bylaws or policies of the Hospital.Signed:Date:Typed or printed name: Department Chair’s RecommendationI have reviewed the requested clinical privileges and supporting documentation for the above-named applicant and make the following recommendation(s):?Recommend all requested privileges?Recommend privileges with the following conditions/modifications:?Do not recommend the following requested privileges:PrivilegeCondition/Modification/Explanation1.2.3.4.Notes:Department Chair Signature:Date:FAMILY MEDICINE CORE: APPENDIX ACore ProcedureSThe following are a few examples of procedures from the Family Medicine CORE, illustrating the depth of Family Medicine training. As with other specialties, not every applicant for privileges will choose to do all procedures within the core, and may elect to exclude those procedures from their privilege request. It remains the responsibility of the Family Medicine department chair to forward credentialing/privileging applications to the credentials committee that have been appropriately vetted at the department level.GeneralArthrocentesisIncision and drainage (I & D) abscessIncision and drainage (I & D) hemorrhoidsBreast cyst aspirationBurn careExcision of skin and subcutaneous lesionsExcision of cutaneous and subcutaneous tumors and nodulesLocal anesthetic techniquesLumbar punctureManagement of uncomplicated closed fractures and dislocationsNeedle biopsiesPlacement of anterior and posterior nasal hemostatic packingPerform skin biopsy or excision Peripheral nerve blocksInterpretation of electrocardiogramsManagement of non-penetrating corneal foreign body, nasal foreign bodyRepair of lacerations, including those requiring layer closureSuprapubic bladder aspirationExercise Treadmill testingVascular access and intubation of newbornsManagement of abnormal Pap, including colposcopy, cryotherapy and LEEPInsertion and removal of intrauterine devicesTracheal IntubationCircumcisionCentral venous line placementParacentesis/ThoracentesisMaternity CareAmniotomyNormal spontaneous vaginal delivery of a term vertex presentation, including ante- and postpartum careDilation and curettage (D&C), including suction and postpartumExcision of vulvar lesions at deliveryExternal and internal fetal monitoring Augmentation of labor Induction of laborManagement of uncomplicated laborManual removal of placenta, post deliveryOperative or assisted vaginal deliveryOxytocin challenge testPost partum hemorrhage (PPH)Post partum endometritisPudendal anesthesiaRepair of episiotomy, including lacerations/extensionsRepair of vaginal and cervical lacerationsDilation and Curettage for Incomplete AbortionNote: Appendix A is NOT incorporated by reference into the Core document but instead is to be used by an applicant when seeking privileges when they determine it would be to their benefit. There is no expectation that every physician graduating from a Family Medicine program will have been trained/be competent in all listed procedures. It is the responsibility of the Family Medicine department chair to forward only those requests for privileges that have been appropriately reviewed and vetted at the department level. Alternatively, Appendix A does not represent the entire scope of family medicine. Utilizing Appendix A as a mechanism to restrict privileges for family physicians by interpreting the appendix as a comprehensive delineation of services offered by family physicians would be incorrect.HCPro Core Privileges Example?Initial appointment?ReappointmentAll new applicants must meet the following requirements as approved by the governing body effective ____/____/______.If any privileges are covered by an exclusive contract or an employment contract, practitioners who are not a party to the contract are not eligible to request the privilege(s), regardless of education, training, and experience. Exclusive or employment contracts are indicated by [EC].Applicant: Check off the “Requested” box for each privilege requested. Applicants have the burden of producing information deemed adequate by the Hospital for a proper evaluation of current competence, current clinical activity, and other qualifications and for resolving any doubts related to qualifications for requested privileges. [Department Chair/Chief]: Check the appropriate box for recommendation on the last page of this form. If recommended with conditions or not recommended, provide condition or explanation on the last page of this form.Other RequirementsNote that privileges granted may only be exercised at the site(s) and setting(s) that have the appropriate equipment, license, beds, staff, and other support required to provide the services defined in this document. Site-specific services may be defined in hospital or department policy.This document is focused on defining qualifications related to competency to exercise clinical privileges. The applicant must also adhere to any additional organizational, regulatory, or accreditation requirements that the organization is obligated to meet. Qualifications for Family MedicineTo be eligible to apply for core privileges in family medicine, the initial applicant must meet the following criteria:Successful completion of an Accreditation Council for Graduate Medical Education (ACGME)– or American Osteopathic Association (AOA)–accredited residency in family medicine.AND/ORCurrent certification or active participation in the examination process [with achievement of certification within [n] years] leading to certification in family medicine by the American Board of Family Medicine or the American Osteopathic Board of Family Physicians.Required previous experience: Applicants for initial appointment must be able to demonstrate provision of care, reflective of the scope of privileges requested, for at least 24 inpatients as the attending physician during the past 12 months or demonstrate successful completion of an ACGME- or AOA-accredited residency, clinical fellowship, or research in a clinical setting within the past 12 months.Reappointment requirements: To be eligible to renew core privileges in family medicine, the applicant must meet the following maintenance of privilege criteria:Current demonstrated competence and an adequate volume of experience ([n] inpatients) with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current ability to perform privileges requested is required of all applicants for renewal of privileges.Core PrivilegesFamily Medicine Core Privileges?RequestedAdmit, evaluate, diagnose, treat, and provide consultation to adolescent and adult patients with illnesses, diseases, and functional disorders of the circulatory, respiratory, endocrine, metabolic, musculoskeletal, hematopoietic, gastroenteric, and genitourinary systems. [May provide care to patients in the intensive care setting in conformance with unit policies.] Assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the procedures on the attached procedure list and such other procedures that are extensions of the same techniques and skills.refer and follow Privileges Criteria: Education and training as for family medicine core privileges. ?RequestedPerform outpatient preadmission and history and physical, order noninvasive outpatient diagnostic tests and services, visit patient in hospital, review medical records, consult with attending physician, and observe diagnostic or surgical procedures with the approval of the attending physician or surgeon. Pediatric Core PrivilegesCriteria: As for family medicine core plus: Required previous experience: Demonstrated current competence and evidence of the provision of care, reflective of the scope of privileges requested, to at least 10 pediatric inpatients in the past 12 months. Maintenance of privilege: Demonstrated current competence and evidence of the provision of care to at least [n] pediatric inpatients in the past 24 months based on results of ongoing professional practice evaluation and outcomes.?RequestedAdmit, evaluate, diagnose, and treat pediatric patients up to the age of 18 with common illnesses, injuries, or disorders. This includes the care of the normal newborn as well as the uncomplicated premature infant equal to or greater than 36 weeks gestation. Assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the procedures on the attached procedure list and such other procedures that are extensions of the same techniques and skills.Gynecology Core PrivilegesCriteria: Must qualify for and be granted privileges in family medicine plus: Required previous experience: Demonstrated current competence and evidence of provision of care, reflective of the scope of privileges requested, to at least 10 gynecologic inpatients in the past 12 months. Maintenance of privilege: Demonstrated current competence and evidence of provision of care to at least [n] gynecologic inpatients in the past 24 months based on results of ongoing professional practice evaluation and outcomes.?RequestedAdmit, evaluate, diagnose, treat, and provide consultation to postpubescent female patients with injuries and disorders of the female reproductive system and the genitourinary system. [May provide care to patients in the intensive care setting in conformance with unit policies.] Assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the procedures on the attached procedure list and such other procedures that are extensions of the same techniques and skills.Obstetrical Core PrivilegesCriteria: Must qualify for and be granted privileges in family medicine. Plus, applicant must provide documentation of three to four months’ obstetrical rotation during family medicine residency with [n] patients delivered. Current NALS certification. Required previous experience: Demonstrated current competence and evidence of the performance of at least 10 deliveries in the past 12 months. Maintenance of privilege: Demonstrated current competence and evidence of the performance of at least [n] deliveries in the past 24 months based on ongoing professional practice evaluation and outcomes.?RequestedAdmit, evaluate, and manage female patients with normal term pregnancy with an expectation of uncomplicated vaginal delivery, management of labor and delivery, and procedures related to normal delivery, including medical diseases that are complicating factors in pregnancy (with consultation). [May provide care to patients in the intensive care setting in conformance with unit policies.] Assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the procedures on the attached procedure list and such other procedures that are extensions of the same techniques and skills.Qualifications for Geriatric Medicine (Applicable when a family medicine physician treats geriatric patients only, has completed a fellowship and/or holds subspecialty certification.)To be eligible to apply for core privileges in geriatric medicine, the initial applicant must meet the following criteria:Successful completion of an Accreditation Council for Graduate Medical Education (ACGME)– or American Osteopathic Association (AOA)–accredited residency in either family medicine or internal medicine followed by an ACGME- or AOA-accredited fellowship in geriatric medicine.AND/ORCurrent subspecialty certification or active participation in the examination process [with achievement of certification within [n] years] leading to subspecialty certification in geriatric medicine by the American Board of Internal Medicine, or the American Board of Family Medicine, or a Certificate of Added Qualifications in Geriatric Medicine by the American Osteopathic Board of Family Physicians.Required previous experience: Applicants for initial appointment must be able to demonstrate provision of inpatient care, reflective of the scope of privileges requested, for at least 24 patients as the attending practitioner during the past 12 months or demonstrate successful completion of an ACGME- or AOA-accredited residency, clinical fellowship, or research in a clinical setting within the past 12 months.Reappointment requirements: To be eligible to renew core privileges in geriatric medicine, the applicant must meet the following maintenance of privilege criteria:Current demonstrated competence and an adequate volume of experience ([n] inpatients) with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current ability to perform privileges requested is required of all applicants for renewal of privileges.Core PrivilegesGeriatric Medicine Core Privileges?RequestedAdmit, evaluate, diagnose, treat, and provide consultation to older adult patients with illnesses and disorders that are especially prominent in the elderly or have different characteristics in the elderly, including neoplastic, cardiovascular, neurologic, musculoskeletal, metabolic, and infectious disorders. [May provide care to patients in the intensive care setting in conformance with unit policies.] Assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the procedures on the attached procedure list and such other procedures that are extensions of the same techniques and skills.Special Noncore Privileges (See Specific Criteria)If desired, noncore privileges are requested individually in addition to requesting the core. Each individual requesting noncore privileges must meet the specific threshold criteria governing the exercise of the privilege requested including training, required previous experience, and maintenance of clinical competence.CESAREAN SectionCriteria: Must qualify for and receive family medicine obstetrics privileges. Required previous experience: Demonstrated current competence and the successful completion of an accredited one- to two-year family medicine obstetric fellowship in the past 12 months or [n] cesarean births as primary operator during the past 12 months. Maintenance of privilege: Demonstrated current competence and evidence of [n] cesarean births as the primary operator in the past 24 months.?RequestedAttendance at delivery to assume care of normal newborns Criteria: Successful completion of an accredited residency which included training in this procedure, or the applicant must have completed hands-on training in this procedure under the supervision of a qualified physician preceptor. Current NALS certification. Required previous experience: Demonstrated current competence and evidence of attendance at [n] deliveries in the past 12 months. Maintenance of privilege: Demonstrated current competence and evidence of attendance at [n] deliveries in the past 24 months based on results of quality assessment/improvement activities and outcomes.?RequestedCircumcisionCriteria: Successful completion of formal training in this procedure or the applicant must have completed hands-on training in this procedure under the supervision of a qualified physician preceptor. Evidence of having performed [n] proctored procedures during training. Required previous experience: Demonstrated current competence and evidence of the performance of at least [n] procedures in the past 12 months. Maintenance of privilege: Demonstrated current competence and evidence of the performance of at least [n] procedures in the past 24 months based on results of quality assessment/improvement activities and outcomes.?RequestedFlexible SigmoidoscopyCriteria: Successful completion of an ACGME- or AOA-accredited residency in family medicine that included training in flexible sigmoidoscopy or evidence of prior training and experience. Required previous experience: Demonstrated current competence and evidence of at least 30 procedures in the past 12 months. Maintenance of privilege: Demonstrated current competence and evidence of the performance of at least [n] procedures in the past 24 months based on results of ongoing professional practice evaluation and outcomes.?RequestedLumbar PunctureCriteria: Successful completion of an ACGME- or AOA-accredited residency in family medicine that included training in lumbar puncture, or evidence of active clinical practice in the procedure. Required previous experience: Demonstrated current competence and evidence of the performance of at least [n] lumbar punctures in the past 12 months. Maintenance of privilege: Demonstrated current competence and evidence of the performance of at least [n] lumbar punctures in the past 24 months based on results of ongoing professional practice evaluation and outcomes.?RequestedVentilator ManagementCriteria: For ventilator cases not categorized as complex (up to 36 hours), successful completion of an ACGME- or AOA-accredited postgraduate training program that provided the necessary cognitive and technical skills for ventilator management not categorized as complex. For complex ventilation cases, the applicant must demonstrate successful completion of an accredited fellowship that provided the necessary cognitive and technical skills for complex ventilator management. Required previous experience: Demonstrated current competence and evidence of the management of at least [n] mechanical ventilator cases in the past 12 months. Maintenance of privilege: Demonstrated current competence and evidence of the management of at least [n] mechanical ventilator cases in the past 24 months based on results of ongoing professional practice evaluation and outcomes.Source: California Thoracic Society Position Paper—Clinical Privileges for Mechanical Ventilator Management 05/25/06?RequestedVentilator Management (not complex including CPAP—up to 36 hours)?Requested Complex, including BiPAP. *More than 36–48 hours, or for patients defined as those having any of the following ongoing characteristics or any other of similar complexity: PEEP requirement 10 cm of water; FI02 requirement 0.6; static plateau pressure 30 cm of water; presence of significant preexisting pulmonary disease; multisystem organ failure; chronic ventilator dependence; patient not meeting previous criteria, but clinical condition deteriorating. Administration of Sedation and Analgesia?RequestedSee Hospital Policy for Sedation and Analgesia by Non-AnesthesiologistsCore Procedure ListThis list is a sampling of procedures included in the core. This is not intended to be an all-encompassing list but rather reflective of the categories/types of procedures included in the core.To the applicant: If you wish to exclude any procedures, please strike through those procedures that you do not wish to request, initial, and date.GeneralArthrocentesis and joint injectionBurns, superficial and partial thicknessChronic ventilator managementI & D abscess Local anesthetic techniquesManage uncomplicated minor closed fractures and uncomplicated dislocationsPerform history and physical examPerform simple skin biopsy or excision Peripheral nerve blocksPlacement of anterior and posterior nasal hemostatic packingRemove nonpenetrating foreign body from the eye, nose, or ear Suture uncomplicated lacerationsPediatricsI & D abscessManage uncomplicated minor closed fractures and uncomplicated dislocationsPerform history and physical examPerform simple skin biopsy or excisionRemove nonpenetrating corneal foreign body Suture uncomplicated lacerationsGynecologyBiopsy of cervix, endometrium ColposcopyCryosurgery/cautery for benign diseaseDiagnostic cervical dilation and uterine curettage Excision/biopsy of vulvar lesionsIncision and drainage of Bartholin duct cyst or marsupializationInsertion of intrauterine devicesPerform history and physical examRemoval of foreign body from vaginaSuturing of uncomplicated lacerationsUterine curettage following incomplete abortionObstetricsAmniotomyAugmentation of labor D&C including suction and postpartumExcision of vulvar lesions at deliveryExternal and internal fetal monitoringInduction of labor with consultation and pitocin management Initial management of post partum hemorrhage (PPH)Investigative OB ultrasound for presentation onlyManagement of prenatal and postpartum careManagement of uncomplicated labor including normal spontaneous vaginal delivery or a term vertex presentation Manual removal of placenta, post deliveryNormal spontaneous vaginal delivery Oxytocin challenge testPerform history and physical examPost partum endometritisPudendal anesthesiaRepair of episiotomy—first, second, and third degreeRepair of vaginal lacerationsVacuum assisted deliveryGeriatric Medicine Apply the general principles of geriatric rehabilitation, including those applicable to patients with orthopedic, rheumatologic, cardiac, and neurologic impairmentsAssess patient to includes medical, affective, cognitive, functional status, social support, economic, and environmental aspects related to healthManage areas of special concern such as falls and incontinenceManage aspects of preventive medicine, including nutrition, oral health, exercise, screening, immunization, and chemoprophylaxis against diseaseManage the appropriate interdisciplinary coordination of the actions of multiple health professionals, including physicians, nurses, social workers, dieticians, and rehabilitation experts, in the assessment and implementation of treatmentPerform history and physical examRecognize and evaluate cognitive impairmentTreat and prevent iatrogenic disordersAcknowledgement of PractitionerI have requested only those privileges for which by education, training, current experience, and demonstrated performance I am qualified to perform and that I wish to exercise at Hospital, and I understand that:a.In exercising any clinical privileges granted, I am constrained by Hospital and Medical Staff policies and rules applicable generally and any applicable to the particular situation.b.Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such situation my actions are governed by the applicable section of the Medical Staff Bylaws or related documents.Signature: Date: [Department Chair/Chief]'s RecommendationI have reviewed the requested clinical privileges and supporting documentation for the above-named applicant and make the following recommendation(s):Recommend all requested privileges.Recommend privileges with the following conditions/modifications:Do not recommend the following requested privileges:PrivilegeCondition/Modification/Explanation1.2.3.4.Notes[Department Chair/Chief] Signature: Date: FOR MEDICAL STAFF OFFICE USE ONLYCredentials Committee actionDate: Medical Executive Committee actionDate: Board of Trustee actionDate: Modified Core Example Family MedicineQualificationsTo be eligible to apply for privileges in family medicine, the applicant must meet the following criteria:Training:MD or DO with successful completion of an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) accredited residency in family medicine. (Does not apply to current medical staff appointees.)Board CertificationOne of the following requirements must be met:1.Current certification in family medicine by the American Board of Family Medicine or the American Osteopathic Board of Family Physicians; or2.Actively seeking Board certification with achievement of certification within 1 year of appointment.Board certification requirements do not apply to any practitioner already a member of the Medical Staff as of _____________________.Required previous experienceApplicants for initial appointment or initial privileges must be able to demonstrate adequate experience reflective of the scope of privileges requested in order for the medical staff to make a reasoned decision regarding the competency of the practitioner. Reappointment requirementsTo be eligible to renew privileges in family medicine, the applicant must demonstrate current demonstrated competence and an adequate volume of experience with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation, monitoring through the Medical Staff Quality Improvement Program, and patient care outcomes.Privileges RequestedApplicant Instructions: Check off the “Requested” box for each privilege requested. Applicants have the burden of producing information deemed adequate by the Hospital for a proper evaluation of current competence, current clinical activity, and other qualifications and for resolving any doubts related to qualifications for requested privileges. Your ability to perform each procedure/privilege will be assessed. Requests for privileges not included on this form should be made in writing and include documentation of training and experience. Please check only the boxes reflective of your practice specific to this hospital. The procedures and privileges listed on this form reflect what most physicians with specified training and experience can request & the hospital can support. FORMCHECKBOX Referring Staff Category Privileges - Refer patients to the Hospital for outpatient testing and/or procedures and refer patients to Active Staff members or Hospitalists for inpatient treatment. (Referring Staff may visit their referred patients in the Hospital, review patients’ medical records and receive information concerning patients’ medical condition and treatment, but may not participate in any inpatient treatment or make any entries in the medical record.)Applicants for Refer and Follow category are not eligible to request additional privileges. Stop here and review and sign the Acknowledgment section of this form. FORMCHECKBOX Active Staff Privileges - > 2 patient admissions per month or > 24 per year FORMCHECKBOX Courtesy Staff Privileges - < 2 patient admissions per month or < 24 per year FORMCHECKBOX Consulting Staff Privileges - Evaluate, diagnose, treat, and provide consultation to adolescent and adult patients on request of an Active or Courtesy Staff member.Adult Medicine Privileges/Procedures - The privileges below include the specific procedure requested and such other procedures that are extensions of the same techniques and skills. FORMCHECKBOX Admit, evaluate, diagnose, treat, and provide consultation to adolescent and adult patients; assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services; provide care to patients in the intensive care setting; performance of history and physical exam; care of the normal newborn and uncomplicated premature infant equal to or greater than 36 weeks gestation. FORMCHECKBOX Arthrocentesis and joint injection FORMCHECKBOX Bone marrow aspiration/biopsy FORMCHECKBOX Burns, superficial and partial thickness FORMCHECKBOX I & D abscess FORMCHECKBOX Local anesthetic techniques FORMCHECKBOX Lumbar puncture FORMCHECKBOX Manage uncomplicated minor closed fractures and uncomplicated dislocations FORMCHECKBOX Osteopathic manipulative treatment using isotonic, isometric forces FORMCHECKBOX Perform simple skin biopsy or excision FORMCHECKBOX Peripheral nerve blocks FORMCHECKBOX Placement of anterior and posterior nasal hemostatic packing FORMCHECKBOX Remove nonpenetrating foreign body from the eye, nose, or ear FORMCHECKBOX Suture uncomplicated lacerations FORMCHECKBOX Vasectomy FORMCHECKBOX Administration of Conscious Sedation and Analgesia Additional Qualifications for Conscious Sedation and Analgesia: Initial applicants must complete Qualifying Examination for Sedation/Analgesia For recredentialing, must have performed a minimum of ten (10) cases per year within the two (2) year reappointment period (total of 20 cases) OR must retake and successfully pass the Qualifying Examination for Sedation/Anesthesia.Pediatric Privileges/Procedures - The privileges below include the specific procedure requested and such other procedures that are extensions of the same techniques and skills. FORMCHECKBOX Newborn Circumcision FORMCHECKBOX I & D abscess FORMCHECKBOX Lumbar puncture FORMCHECKBOX Manage uncomplicated minor closed fractures and uncomplicated dislocations FORMCHECKBOX Perform simple skin biopsy or excision FORMCHECKBOX Remove nonpenetrating corneal foreign body FORMCHECKBOX Suture uncomplicated lacerations FORMCHECKBOX Administration of Conscious Sedation and Analgesia Additional Qualifications for Conscious Sedation and Analgesia: Initial applicants must complete Qualifying Examination for Sedation/Analgesia For recredentialing, must have performed a minimum of ten (10) cases per year within the two (2) year reappointment period (total of 20 cases) OR must retake and successfully past the Qualifying Examination for Sedation/Anesthesia.Gynecology Privileges/Procedures - The privileges below include the specific procedure requested and such other procedures that are extensions of the same techniques and skills. FORMCHECKBOX Biopsy of cervix, endometrium FORMCHECKBOX Colposcopy FORMCHECKBOX Cryosurgery/cautery for benign disease FORMCHECKBOX Diagnostic cervical dilation and uterine curettage FORMCHECKBOX Excision/biopsy of vulvar lesions FORMCHECKBOX Incision and drainage of Bartholin duct cyst or marsupialization FORMCHECKBOX Insertion and removal of intrauterine devices FORMCHECKBOX Removal of foreign body from vagina FORMCHECKBOX Suturing of uncomplicated lacerations FORMCHECKBOX Uterine curettage following incomplete abortionObstetrical Privileges/Procedures- The privileges below include the specific procedure requested and such other procedures that are extensions of the same techniques and skills. FORMCHECKBOX Amniotomy FORMCHECKBOX Attendance at delivery to assume care of normal newborns FORMCHECKBOX Augmentation of labor FORMCHECKBOX Cesarean section FORMCHECKBOX D&C including suction and postpartum FORMCHECKBOX Excision of vulvar lesions at delivery FORMCHECKBOX External and internal fetal monitoring FORMCHECKBOX Induction of labor, medical FORMCHECKBOX Induction of labor, rupture of membranes FORMCHECKBOX Initial management of post partum hemorrhage (PPH) FORMCHECKBOX Investigative OB ultrasound for presentation only FORMCHECKBOX Management of prenatal and postpartum care FORMCHECKBOX Management of uncomplicated labor including normal spontaneous vaginal delivery or a term vertex presentation FORMCHECKBOX Manual removal of placenta, post delivery FORMCHECKBOX Normal spontaneous vaginal delivery FORMCHECKBOX Oxytocin challenge test FORMCHECKBOX Post partum endometritis FORMCHECKBOX Pudendal anesthesia FORMCHECKBOX Repair of episiotomy—first, second, and third degree FORMCHECKBOX Repair of vaginal lacerations FORMCHECKBOX Vacuum assisted deliveryAcknowledgement of PractitionerI have requested only those privileges for which by education, training, current experience, and demonstrated performance I am qualified to perform, for which my professional liability insurance will cover, and that I wish to exercise at [Hospital Name]. I understand that:a.In exercising any clinical privileges granted, I am constrained by Hospital and Medical Staff policies and rules applicable generally and any applicable to the particular situation.b.Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such situation my actions are governed by the applicable section of the Medical Staff Bylaws or related documents.c.If any privileges are covered by an exclusive contract or an employment contract, practitioners who are not a party to the contract are not eligible to request the privilege(s), regardless of education, training, and experience.Signature: _______________________________ Date: _________________02857400Department Chair's RecommendationI have reviewed the requested clinical privileges and supporting documentation for the above-named applicant and make the following recommendation(s): FORMCHECKBOX I recommend all requested privileges. FORMCHECKBOX I recommend privileges with the following conditions/modifications (include explanation):PrivilegeCondition(s)/Modification(s)/Explanation FORMCHECKBOX I do not recommend the following requested privileges (include explanation):PrivilegeCondition(s)/Modification(s)/Explanation_______________________________________ ___________________ Department Chair Signature DateWork Sheet For Consideration of New PrivilegeName of procedure/privilege_________________________________________Education required to request privilege (check all that apply) FORMCHECKBOX MD - Medical Doctor FORMCHECKBOX DO - Osteopathic Physician) FORMCHECKBOX DDS - Oral and Maxillofacial Surgeon FORMCHECKBOX DMD - Dentist FORMCHECKBOX DPM - Podiatrist FORMCHECKBOX APN – Advance Practice Nurse (specify specialty)______________________________ FORMCHECKBOX PA – Physician Assistant (specify specialty) ___________________________________ FORMCHECKBOX DC – Chiropractic FORMCHECKBOX Other (specify) __________________________________________________________Training Required:Experience requiredAdditional Requirements: FORMCHECKBOX CME FORMCHECKBOX Board Certification FORMCHECKBOX Manufacturer’s Training Course/Certificate FORMCHECKBOX Peer RecommendationsIs monitoring or proctoring required? FORMCHECKBOX No FORMCHECKBOX Yes. If yes, specify the following: FORMCHECKBOX Number of procedures ___________ FORMCHECKBOX Length of time __________________ FORMCHECKBOX In order to complete proctorship/monitoring requirements, the applicant must perform _______ (number) procedures within _____________(time frame). What type of review or follow up will be conducted?Structured Interview QuestionsEducation, Training, Experience, and Current Work Practice and ExperienceBriefly explain your educational background and training.Do you have any specific areas of interest or expertise? If so, explain.Are there any areas of your practice for which you anticipate the hospital would need to purchase additional equipment or would require additional training of staff should the hospital choose to provide these services?Systems-Based Practice1.Please describe the various health care delivery settings and systems in which you will be participating. (i.e. outpatient surgical centers, other hospitals, etc.). 2.Describe how membership on the medical staff of [Hospital name] will develop or build your practice.3.What percentage of your patient practice do you anticipate will be performed at [Hospital name]?4.Describe your anticipated use of consultants.5.Would you be available to provide patient education by participating in educational presentations, development of educational materials, etc?Understanding of Bylaws Requirements(List key issues the medical staff or hospital feel need to be reinforced.)1.Do you understand that the bylaws require you to provide for alternate coverage? Please describe the arrangements you have made for alternate coverage.2.Do you understand that the bylaws require continuous professional liability coverage of at least $1 million per claim and $3 million annual aggregate and if claims made insurance is purchased, you must provide for the purchase of "tail coverage" or "nose coverage"? 3.Do you understand your responsibility for participating in the call rotation for providing care to unassigned patients who present through the emergency department?4.Do you understand the requirements for completion of medical records including automatic suspension provision for incomplete records over ___ days old?Follow-up of Information Received in Application Process (List any issues identified in the application process that require clarification or discussion.)1.Please discuss the details of any malpractice claims that have been filed against you.2.A letter received from one of the hospitals you practiced at it the past documents that you experienced a chronic problem with timely completion of medical records. Please describe the steps you are taking to assure this does not happen at [Hospital name].3.You noted in your application that you are not board certified. Have you applied to take the exam? Have you taken the exam and failed?4.You seem to have changed practice locations a number of times; can you explain the reason for these movesDocumenting RecommendationsMinutes LanguageSample language for medical staff minutes:“Committee members reviewed the applications, the supporting documentation, the Department Chairmen’s recommendations, and information received during the credentialing and privileging processes [or insert OPPE/FPPE etc., as appropriate]. Based on this review, it is the committee’s opinion that the following applicants meet the requirements for Medical Staff appointment and have documented appropriate education, training, experience, current competency, clinical judgment, professionalism, and health status to perform the privileges requested. It was moved, seconded, and carried to recommend to the [fill in Credentials Committee or MEC as appropriate] approval of the following appointments and clinical privileges [or insert cessation of FPPE, etc]:”Sample language for Board minutes: “Board members reviewed the applications, the supporting documentation, the Department Chairmen’s recommendations, Medical Executive Committee’s recommendations, and information received during the credentialing and privileging processes [insert OPPE/FPPE etc., as appropriate]. Based on this review, it is the Board’s opinion that the following applicants meet the requirements for Medical Staff appointment and clinical privileges [insert cessation of FPPE etc., as appropriate] as recommended and it was moved, seconded, and carried to approve of the following appointments and clinical privileges [insert cessation of FPPE, etc]:”Recommendation and Approval Form for Medical Staff Appointment and Clinical PrivilegesPractitioner Name:____________________________________________________________________Staff Status:__________________ Department:_____________________ Specialty:_________________________Departmental RecommendationBased on the evaluation of the education, training, current competence, health status, skill, character, and judgment of the applicant the following recommendations are made: Privileges be granted/renewed Medical staff membership be granted/renewed Additional privileges requested be granted Privileges be modified as follows: _________________________________________________________________________ _____________________________________________________________________________________________________ Privileges not be granted/renewed Medical staff membership not be granted/renewed (comment below) Additional privileges requested be denied (comment below)Comments: Department Chairman Date-1143006731000Credentials Committee RecommendationBased on the evaluation of the education, training, current competence, health status, skill, character, and judgment of the applicant and on the evaluations and recommendations of the Department Chairman the following recommendations are made: Concur with recommendation(s) of the Department Chairman and forward these recommendations to the Medical Executive Committee Do not concur with the recommendations of the Department Chairman, and instead make the following recommendations: ___________________________________________________________________________________________________________ Credentials Committee Representative Date01714500Medical Staff Executive Committee RecommendationBased on the evaluation of the education, training, current competence, health status, skill, character, and judgment of the applicant, and on the evaluations and recommendations of the Department Chairman and Credentials Committee, the following recommendations are made: Concur with recommendation(s) of the Department Chairman and Credentials Committee and forward these recommendations to the governing body for consideration. Do not agree with the recommendations of the Department Chairman, and Credentials Committee and instead make the following recommendations: _________________________________________________________________________ Medical Staff Executive Committee Representative Date06477000Governing Body Approvals/Action TakenBased on the evaluation of the education, training, current competence, health status, skill, character, and judgment data and information, and on the recommendations of the Medical Staff, the following action is taken: Concur with and approve the recommendation(s) of the Medical Staff. Do not concur with the recommendations of the Medical Staff. Action taken is documented in Board minutes of ________________. (date) Board of Trustees Representative DateUnderstanding Negligence in CredentialingWhat is Negligence?Negligence is defined as conduct that is culpable because it falls short of what a reasonable person would do to protect another individual from a foreseeable risk of harm.If the organization knew or should have known that a practitioner is not qualified and the practitioner injures a patient through an act of negligence, the organization can be found separately liable for the negligent credentialing of this practitioner.Healthcare organizations have legal responsibility under a number of theories. Some have been held liable for “negligent credentialing” or, the failure to adequately screen a practitioner through the credentialing and privileging processes. There are at least 28 states which recognize the claim of negligent credentialing.But there are some other theories under which Health Care organizations are held liable.Theories of Liability In some states, negligent credentialing falls under the corporate liability or corporate negligence doctrine. The premise of this theory is that a patient who enters a hospital does so with the reasonable expectation that the hospital will attempt to cure him. The hospital has the duty to make a reasonable effort to monitor and oversee the care and treatment prescribed and administered by the physicians practicing in its property. A hospital’s responsibility also includes extending privileges only to competent practitioners.The governing body is given authority to make final decisions in credentialing matters. Although the board may delegate an activity, such as oversight of those with independent privileges to the medical staff, it maintains the ultimate responsibility for these decisions. Respondeat Superior is a common-law doctrine that makes an employer liable for the actions of an employee when those actions take place within the scope of employment. This doctrine is often applied to contracted or employed practitioners.Apparent or Ostensible Agency is a legal doctrine that is used to hold someone liable for the acts of a third party because the third party looks like the agent of that person. This theory is frequently applied to facility-based providers such as anesthesiologists and emergency physicians. The basis of this theory is, the patient has no choice in choosing these practitioners therefore, they are felt to be an agent of the hospital.Elements of NegligenceThe fact that someone did not credential someone adequately, in itself, does not mean that the organization was negligent. For example, if an organization fails to verify a medical license for a qualified and competent practitioner within the prescribed requirements of the accreditation standards, this in itself is not negligence.Specific elements need to be present in order to establish negligence. There has to be a duty to exercise due care, and that duty has to be breached. There has to be an injury, and the breach of duty has to be the reason or “proximate cause” of the injury. Finally, the person bringing the charges must establish that the injury resulted in compensable damages. An easy way to remember elements of negligence are by remembering the “4 D’s”:Deviation from Duty Directly causes Damages Using the earlier example, suppose a Physician injured a patient, and it was found that this injury was a result of negligence on the Physicians behalf. If it was found that the organization failed to verify the license on initial appointment, and if it had done so, it would have found that the license was suspended, then it can be reasonably assumed that, had the organization credentialed the Physician appropriately, it would not have granted the Physician privileges. In this case it’s pretty easy to connect the dots and see that the breach of the hospital’s duty to appropriately credential the Physician could have resulted in the injury to the patient.Duty to Exercise Due CareWithin the healthcare organization, the duty to exercise due care is defined in a number of ways.State licensing regulations may include requirements for adopting criteria and for granting medical staff appointment and privileges.Accreditation standards specify what kind of primary-source verification must be completed and specify requirements for credentialing and privileging policies and proceduresMedical staff and facility bylaws, R&R, policies may include additional requirements above and beyond regulations and accreditation standards.Finally, case law may address due care in credentialing and privileging. Examples of Breach of DutyIn many cases in which organizations are found to be negligent in credentialing, the facility has the appropriate bylaws, policies and procedures, but fails to consistently apply the requirements. This emphasizes the importance of knowing the requirements of your facility’s bylaws, rules and regulations and policies. Another potential for breach of duty is the failure to address concerns identified in the credentialing/recredentialing process. Documentation in the credentials file should address all issues or concerns identified in the credentialing or recredentialing process. For example, if a verification letter comes back with a response that is different than the information provided on the application, such as different affiliation dates, there should be documentation in the credentials file of how you resolved this issue. In addition, medical staff and governing body minutes should document how these bodies addressed concerns. For example, suppose you are recredentialing an applicant a find that he was named in three medical malpractice suits since his last application. When your medical staff reviews this, they determine that none of these cases have settled or been tried, so they feel that there is no reason to not grant medical staff appointment and privileges based on outstanding cases. There should be some documentation that this issue was discussed and addressed by the medical staff.Finally, adopting credentialing policies and procedures or privileging criteria that do not reflect what a reasonable hospital would do to protect a patient from a foreseeable risk of harm may also be considered a breach of duty. For example, most hospitals verify all past medical staff appointments for all initial applicants. This is not required by Joint Commission accreditation standards. The fact that it is something that most hospitals do, means that it is the standard of care that all hospitals will be held to. It’s essential that your policies meet the requirements of your organization’s accreditation standards as well as state and federal regulations. If there is a difference between accreditation standards and a state and Federal requirements, you always have to follow the strictest requirement. When developing privileging criteria, the organization should take into consideration any guidelines that have been published by professional organizations.Setting a PrecedentA precedent-setting case is one which establishes a new legal principle. This principle is based on the court coming to a certain conclusion based on a certain set of facts. This finding is thereafter authoritative, meaning it is to be followed from that point on when similar or identical facts are before a court.Let’s take a look at some precedent-setting cases as well as some recent negligent credentialing cases. These will give you a better idea of how the courts apply the duty to exercise due care in the credentialing process.Darling v. Charleston Community Memorial HospitalThis 1965 case is the very first case in which a hospital was found to be negligent in allowing a doctor to practice at the hospital. Prior to this case, hospitals were looked upon as charitable organizations and were immune from being sued under the Charitable Immunity Doctrine. This case set aside this doctrine.Darling was a football player who broke his leg during a game. He had his leg placed in a cast by the on-call doctor, subsequently developed gangrene, and had to have his leg amputated below the knee. The plaintiff claimed—and the court agreed—that the hospital was negligent for two reasons: it failed to properly review the work of an independent doctor, and its nurses failed to administer necessary tests. Darling held that the hospital bylaws, licensing regulations, and standards for hospital accreditation were sufficient evidence to establish the standard of care. Therefore, a lay jury was able to conclude from the evidence that the hospital had breached its duty to act as a reasonably careful hospital.Johnson v. MisericordiaIn another negligent credentialing case – Johnson v. Misericordia Community Hospital, the hospital was found to be liable to a patient injured by physician who had failed to disclose pending malpractice cases and who lied about his privileges at other hospitals. This action arose out of a surgical procedure performed at Misericordia by a Dr. Salinsky. Salinsky unsuccessfully attempted to remove a pin fragment from Johnson’s right hip, and during surgery, damaged the common femoral nerve and artery. This caused permanent paralysis of Johnson’s right thigh muscles, atrophy, weakness, and loss of function. Johnson settled his claim against Salinsky for medical malpractice, and then sued the hospital alleging negligence in hospital’s appointment of Salinsky to its medical staff and in granting him orthopedic surgical privileges. When completing his application, Salinsky stated that his privileges at other hospitals had never “been suspended, diminished, revoked, or not renewed.” He also failed to answer any of the questions pertaining to his malpractice insurance and stated that he had requested privileges only for those surgical procedures in which he was qualified by certification.The hospital did not verify the information on the application. Had they done so, they would have found that Salinsky had experienced denial and restriction of his privileges, as well as never having been granted privileges at the hospitals he listed in his application. This information was readily available to Misericordia and if the hospital had credentialed Salinsky appropriately, it would have been revealed that these hospitals had a concern regarding his competency. In addition, if the hospital would have verified medical malpractice information, they would have found that seven malpractice suits had been filed against Salinsky prior to his appointment date.The court in this case instructed the jury that “a hospital is under a duty to exercise reasonable care to permit only competent medical doctors the privilege of using their facilities”. The court also stated that reasonable care “meant that degree of care, skill, and judgment usually exercised under like or similar circumstances by the average hospital”. Evidence in this case supported a finding that, had the hospital exercised ordinary care, it would not have appointed Salinsky to its medical staff.Recent cases Now that we’ve discussed some precedent-setting cases let’s look at some recent cases.Frigo v. Silver Cross Hospital This in an Illinois case from 2007. In this case, the patient alleged that podiatrist Dr. Kirchner’s negligence in performing a bunionectomy on an ulcerated foot resulted in osteomyelitis and subsequent amputation of the foot.When Dr. Kirchner applied for membership and Level II surgical privileges at the Hospital in 1992, a podiatrist was required to have either completion of an approved surgical residency training program or board eligibility or certification by the American Board of Podiatric Surgery. Dr. Kirchner did not meet these criteria.To complicate matters, in 1993, the hospital’s credentialing criteria was changed to require successful completion of a 12-month podiatric surgical residency training program, passage of at least the written portion of the board certification exam, and documentation of having performed a specific number of procedures. For Level II surgical privileges, which included bunionectomies, a podiatrist needed to document performing at least 30 procedures. For every reappointment thereafter and at the time Dr. Kirchner performed the bunionectomy on Jean Frigo, he had not satisfied these requirements. He had only performed six Level II procedures, none of them at Silver Cross. Based on these facts, Frigo argued that Dr. Kirchner never should have been given Level II privileges in the first place and certainly not in 1998, when he performed her surgery. Additionally, she maintained that the granting of privileges to an unqualified practitioner who was never appropriately grandfathered was a violation of the Hospital’s duty to ensure that only those podiatrists who met the required criteria were granted Level II privileges. Frigo claimed that the Hospital's breach of this duty caused her amputation because of Dr. Kirchner’s negligence. The jury agreed and awarded her almost eight million dollars.Larson v. WasemillerIn August 2007, the Minnesota Supreme Court recognized, for the first time, that a cause of action exists against a hospital for the manner in which a hospital credentials a physician to see patients within that facility. The Larson case stemmed from a medical malpractice claim initially asserted against two physicians who performed a gastric bypass surgery on the plaintiff, Mary Larson. Larson experienced a number of complications and remained hospitalized for approximately three months.After initially suing only the physicians, the Larsons amended their Complaint to include a claim that St. Francis was negligent in credentialing Dr. James Wasemiller to perform surgery or see patients at the hospital. They base this upon the fact that Dr. James Wasemiller had been the subject of ten prior malpractice claims or lawsuits and had struggled to find malpractice insurance. He also had been disciplined by the Minnesota Board of Medical Practice and had failed his board certification examination three times before passing. Interestingly, they also claimed that the Physician should not have been credentialed for reasons apart from his professional experience – namely, that he was behind in his child support and income taxes. After a series of findings and appeals, the case eventually made it to the Minnesota supreme court. The supreme court compared the tort of negligent credentialing to one of negligent hiring and it concluded that negligent credentialing is “more directly related” to the negligent selection of an independent contractor. The supreme court concluded in favor of recognizing a negligent credentialing claim because “negligence could be shown on the basis of what was actually known or what should have been known at the time of the credentialing decision”.Other Related IssuesThere are couple other things that need to be considered when credentialing providers and those are being sure not to give wrong information when answering verification requests and omitting key information when answering verification requests.One way this can be avoided it is by maintaining all information in the credentials file. If there is important information that is not included in the credentials file, there should be some kind of cross reference in the credentials file so that the people who respond to verification requests will know where to find information. For example, I know of a case in which a Medical Services professional provided information to another hospital that said that a Physician had resigned in lieu of termination. Unknown to the Medical Services professional, the hospital had worked out a written agreement with the Physician which stated that the hospital would reply to any verification letters with a statement that the Physician had resigned in good standing. Unfortunately this information was not included in the credentials file. When the Medical Services professional researched medical staff minutes to find out what happened with the Physician, she only found reference to a recommendation for termination. The case of Kadlec Medical Center v. Lakeview Anesthesia Associates also is an example of what can happen when wrong information is provided or pertinent information is omitted.Kadlec v. Lakeview Anesthesia Assoc. and Lakeview Medical CenterAccording to court documents, Dr. Lee Berry was fired by Lakeview Anesthesia Associates for reporting to work in an “impaired” condition in March of 2001. Here is a copy of the termination letter which was signed four physicians, including Drs. Mark Dennis and William Preau, III. The termination letter stated that Berry was being terminated “with cause” due to having “reported to work in an impaired physical, mental, and emotional state” that prevented Berry from properly performing his duties and put patients “at significant risk”. After Berry was terminated by Lakeview Anesthesia Associates, he sought work as a locum tenens physician which eventually landed him at Kadlec Medical Center in Richland, WA.Kadlec had credentialed Dr. Berry, but the letters they received failed to disclose his impairments. The letter from Dr. Dennis stated, “I have worked closely with Dr. Berry for the past four years. He is an excellent clinician with a pleasant personality. I am sure he will be an asset to your anesthesia service.” The letter from Dr. William Preau stated, “This is a letter of recommendation for Dr. Lee Berry. I have worked with him here at Lakeview Regional Medical Center for four years. He is an excellent anesthesiologist. He is capable and all fields of the anesthesia including obstetrics, pediatrics, cardiovascular, and all regional blocks. I recommend him highly.”The Kadlec hospital had also written to Lakeview medical center to confirm Dr. Berry’s appointment there. They received a letter back that just gave the dates on staff. It was one of those letters that said “due to the volume of requests that we receive, we are responding with this form letter.”Dr. Berry was granted privileges at Kadlec Medical Center where, after a routine tubal ligation procedure, he removed a patient’s breathing tube too early and she suffered a heart attack and massive brain damage. This resulted in a multimillion-dollar lawsuit against the hospital. During the course of discovery, these letters that you’ve seen here were provided to the plaintiff on order of the court. Kadlec first learned that Dr. Berry had been terminated by his anesthesia group during discovery for this case. Kadlec sued Lakeview Anesthesia Associates and Lakeview Medical Center for failing to disclose Berry’s known impairments. The hospital won its cases against both, but the appeals court reversed the decision against Lakeview Medical Center.Although the court found that the reference letters from Berry’s former partners were false and patently misleading, it felt that Lakeview Medical Center’s letter was not materially misleading. The court also found that, because Lakeview hospital did not have a legal duty to disclose its investigation of Dr. Berry and its knowledge of his drug problems, the judgment against Lakeview Medical must be reversed.Decreasing the ChanceMaking sure that Medical Services professionals and medical staff leaders are adequately trained is very important. It is helpful for Medical Services professionals to be involved in their state and local NAMSS chapters or to attend the NAMSS National conference. Medical staff leaders need to know what they’re getting themselves into when they say yes to taking on a job as a department chair, credentials committee member, or medical executive committee member. They need to be trained in their responsibilities in reviewing the qualifications of their peers. This can be something as simple as sitting down with a department chairman and going over how to read a credentials file to something more complicated, and costly, such as, bringing someone into the hospital to train medical staff leaders or sending them to educational programs where they can receive intensive training about their roles and responsibilities.Be sure to get the Medical Staff involved in all phases of credentialing and privileging. It is essential that your medical staff leaders review all information in the credentials file and, that they have sufficient information on which to base a reasoned decision regarding the competency of the practitioner.Follow all policies, procedures, and bylaws. Many times, bylaws and procedures mirror language contained in accreditation standards. Over time the accreditation standards change, and so we change our practices to reflect the new accreditation standards. Sometimes, we neglect to make appropriate changes to our bylaws and policies to reflect the changes resulting in a failure to follow our own policies.It is a good idea to audit bylaws, rules and regulations and policies to make sure they comply with state regulations and accreditation standards. If you find that, in practice, you are doing something that is not in compliance with bylaws, determine the basis for this bylaws requirement. If it is not required by a corporate policy, accreditation standards, or state or Federal regulations, confer with your legal counsel as to whether to change the bylaws to reflect your current practice. A good example of this is many hospitals have a requirement for all physicians to be board certified or actively participating in the board certification process. This is not required by state or Federal regulations, or accreditation standards. But if the hospital has such a bylaws requirement, it must follow and apply this requirement. If it finds it is making exceptions to this rule then it should consider changing the requirement.When making an effort to see that that only qualified, competent practitioners are providing patient care services, the first line of defense is a thorough credentialing and privileging process that is consistently applied. If the process is circumvented, the very safeguards which are put in place to assure patient safety can be comprised. ................
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