TITLE:



TITLE: Overview of the Credentialing and Privileging Procedures for Licensed Independent Practitioners

APPLICABLE STANDARDS: HR.4.10, HR.4.20, HR.4.30, HR.4.40, and HR.4.50

REFERENCES: Joint Commission on Accreditation of Healthcare Organization’s (JCAHO) Comprehensive Accreditation Manual for Ambulatory Care (CAMAC)

OBJECTIVE: To ensure a fair, systematic and standardized procedure for credentialing and privileging CHClicensed independent practitioners

PROCEDURE(S):

All individuals permitted by law and CHC to practice independently (i.e. licensed independent practitioners or LIPs) shall be appointed to the CHC LIP staff in accordance with standards set by relevant accrediting bodies, state and federal law, applicable regulations, and CHC’s own approved process. This procedure is specific to on-staff medical LIPs, including licensed physicians, mid-levels, optometrists and podiatrists. Please see separate policies for behavioral health employees, attending physicians for residency education, and LIPs who serve as volunteers.

Appointment or Employment

Appointment or Employment is the process of bringing a licensed independent practitioner onto the staff of the organization. Nothing stated in this procedure should be construed as replacing the organization’s normal employment procedures. To the contrary, these procedures are intended to augment those procedures to ensure that the organization employs qualified individuals. Appointment to the staff of CHC is the sole responsibility of the Chief Executive Officer, under the oversight and supervision of the Board of Directors. This appointment, depending on the essential functions of the LIP’s position description, may be made conditional upon the successful attainment and maintenance of privileges within CHC and local hospitals in which the LIP is expected to admit and follow patients. If such privileges are not required by the position description then the individual does not need to be processed any further than normal employees or volunteers.

Credentialing

The first step in the privileging of a LIP is a thorough review and verification of their credentials. At the time of initial granting of privileges, will verify by viewing a valid government-issued photo identification issued by a state of federal agency that the individual being granted clinical privileges is the same individual identified in the credentialing documents. A copy of this photo will be kept in the credentialing file. Key elements of the application for appointment (the Licensed Independent Practitioner Credentialing Application) must be verified using exacting standards to ensure that only the most qualified individuals are allowed to provide services to CHC patients. Any properly qualified employee can perform the highly clerical credentialing function. Please note that credentialing information should be maintained using the highest level of confidentiality. All information collected during the credentialing process should be stamped or labeled CONFIDENTIAL.

Credentials of LIPs employed directly by the health center will be verified by internal primary source verification or an outside credentials verification organization or a JCAHO accredited health care organization functioning as a CVO or the Nebraska Credentials Verification Organization. Credentialing of LIPs who are contract employees will be performed by their employer. The health center requires that credential verification procedures performed by other institutions be done in accordance with JCAHO procedures. Letters from each institution certifying compliance with these verification standards will be required every three years. Copies of the current NCVO file documenting primary source verification of documents and NPDB search will be requested and copies will be placed in the privileging file.

Privileging

Privileging is the process by which the organization defines the scope of practice for each LIP. This process must be sensitive to the following factors when determining the criterion for delineation of privileges:

• Skills and knowledge possessed by the LIP (competency)

• Scope of services provided at each delivery site

• Needs of the community

All LIPs (both contract and employees) shall, as part of the application process, complete an application for privileges. Once the credentialing process has been completed satisfactorily, the complete application shall then be reviewed by the Chief Medical Officer (or 2 physician members of the Medical Staff in the case of the Chief Medical Officer’s application) and the application shall be either recommended for approval, approval with revisions, or disapproval.

In order to be eligible for privileges at the health center, a LIP must:

• Be proficient in the English language

• Have graduated from an accredited training program

• Be board eligible if entering practice, or board certified within the usual time period specific to their specialty

• Be licensed to practice in the State of Nebraska

• Have a favorable professional liability history. The Chief Medical Officer will specifically address whether there is any evidence of an unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the applicant.

• In good health sufficient to perform clinical duties

• Not have a history of professional sanctions relevant to current practice of medicine. Specifically the Chief Medical Officer will review any challenges to any licensure or registration voluntary or involuntary relinquishment of any license or registration, voluntary or involuntary termination of medical staff membership at another organization, voluntary and involuntary limitation, reduction or loss of clinical privileges.

• Not have any felony, criminal or misdemeanor charges or convictions against them considered relevant to current practice of medicine or to the LIP’s standing in the community as a representative of the health center

• Not currently engaged in the illegal use of drugs or the abuse of prescribed mediations

• Have favorable professional references

• Have hospital privileges in good standing (as applicable to practice)

• Current ACLS certification for all staff physician providers and BCLS certification for all other staff medical providers

The Chief Medical Officer will make decisions according to the LIP’s current credentials and competence as well as the population served and the types of care, treatment and services provided by OneWorld.

ALL PRIVILEGING RECOMMENDATIONS ARE SENT TO THE BOARD OF DIRECTORS FOR FINAL APPROVAL.

In order to facilitate review of privilege applications, the Chief Medical Officer will complete a summary sheet for board members to review (see attached “Licensed Independent Practitioners Credentialing and Privileging Board Review Form”). After this information is reviewed, a motion is brought before the full Board during a regular meeting. English and Spanish examples of Board motions appear near the end of this policy document. Once the Board has made a decision, a congratulatory letter will be sent to the provider along with clarification of their approved privileges (see attached). The provider being privileged has opportunity to request from the Chief Medical Officer any additional information regarding the privileging decision.

Temporary Privileges

Temporary privileges may be granted to a LIP in order to facilitate timely commencement of clinical services before official approval by the board of directors. Temporary privileges may only be granted after the credentialing process has been completed and the privilege request form has been favorably reviewed by the Chief Medical Officer. To meet the important needs of patients, verification of current licensure and current competence may be done by telephone. The same criteria will be used for providers considered for temporary privilege as for permanent privileges (see list above). Because hospital privileges often take longer to obtain, temporary privileges for outpatient services can be granted while hospital privileges are pending. To grant privileges for new applicants, the applicant must have the following:

• A complete privilege request form

• A complete NCVO application (or equivalent if verification not being performed by NCVO)

• No current of previously successful challenge to licensure or registration

• Not been the subject to involuntary termination of professional or medical staff membership or privileges at another organization

Temporary privileges may be granted for up to 120 days with approval of the Chief Medical Officer. This process is only to be used until a regularly scheduled Board of Directors meeting can be scheduled to formally grant privileges.

Emergency Privileges

In the event of adverse weather, illness, etc. that may disrupt regularly scheduled board meetings, temporary privileges and existing privileges will automatically be extended for thirty days until the next regularly scheduled meeting, unless grounds exist to suspend such privileges.

In the event of a natural disaster or mass casualty the Chief Medical Officer (or Chief Executive Officer if the Chief Medical Officer is unable) may grant temporary privileges to providers for a period of up to 120 days.

Re-privileging

At least every two years, but more often if necessary, each LIP who has been accorded privileges shall undergo an abbreviated privileging process. Reprivileging shall be undertaken more frequently than every two years as information regarding each practitioners’ scope of privileges is updated and changes in clinical privileges are made. Each LIP will be required to complete a re-appointment application. In sharp contrast with initial privileging, only those credentials that would expire or would be prone to change would need to be verified again (i.e. licensure, board certification, NPDB status, etc.) prior to undergoing the privileging process again. Once the verification process has been completed, the entire application shall then be reviewed by the Chief Medical Officer (or at least two physician members of the Medical Staff for the Chief Medical Officer’s application) and the application shall be recommended as approved, approved with revisions, or disapproved.

Additional data used in determining a provider’s competency will be kept in each privileging folder. This will include evidence of any CPR certification, laboratory or procedure competency reviews, chart reviews and quality assurance activities, PECS reports and CME activities. NCVO will also provide updated references and verification of current credentials. To be eligible for re-privileging, the LIP must:

• Maintain board certification.

• Be licensed to practice in the State of Nebraska

• Have a favorable professional liability history

• Not have a history of professional sanctions relevant to current practice of medicine

• Not have any felony, criminal or misdemeanor charges or convictions against them considered relevant to current practice of medicine or to the LIP’s standing in the community as a representative of the health center

• Not currently engaged in the illegal use of drugs or the abuse of prescribed mediations.

• Have favorable professional references

• In good health sufficient to perform clinical duties

• Maintain hospital privileges in good standing (as applicable)

• Demonstrate favorable competency as evidenced by laboratory or procedure competency reviews, chart reviews and quality assurance activities, PECS reports and yearly peer review.

• Provide evidence of sufficient CME credits to maintain hospital privileging, board certification and licensure.

• Current ACLS certification for all staff physician providers and BCLS certification for all other staff medical providers

Peer Review

Peer Review is the process of retrospective review of the clinical competency of each LIP. Peer review on a LIP can only be done by another similarly privileged or credentialed LIP. Peer review is primarily done through medical record reviews and focuses on the following elements:

• Evaluation of the completeness and accuracy of the assessment of a randomly chosen set of patients,

• Evaluation of the appropriateness of care or treatment plan for the correlating assessments of the selected patients,

• Evaluation of the appropriateness and effectiveness of the education provided to the selected patients, and

• Evaluation of the appropriateness of the continuum of services utilized by the providers in assessing and treating the selected patients.

This process has elements of quality control and performance improvement. Its ultimate purpose is to maintain minimum levels of performance among all LIPs and to identify opportunities to improve the performance of CHC LIPs overall as well as individually. Additionally, because of the impact on reimbursement and continuum of care, medical record completeness and other performance based reviews will also be factored into the peer review process (see “Licensed Clinical Practitioner Peer Review and Other Performance Based Assessment Procedures”).

ALL RE-PRIVILEGING RECOMMENDATIONS ARE SENT TO THE BOARD OF DIRECTORS FOR FINAL APPROVAL.

Discontinuing Appointment or Curtailing of Clinical Privileges

Occasionally, it may become clear to the Chief Medical Officer or Medical Staff that the clinical delineation of privileges to an individual provider or even a group of providers must be curtailed or discontinued. The most persuasive argument for such an action would be a concern for patient safety generated either as a part of the peer review process or through some adverse occurrence or Sentinel Event. Such a process would be handled in the same manner as a typical privileging determination and would be forwarded to the Board of Directors for final resolution.

ALL RECOMMENDATIONS TO DISCONTINUE OR CURTAIL PRIVILEGING ARE SENT TO THE BOARD OF DIRECTORS FOR FINAL APPROVAL.

Reconsideration Process

Applicants may request reconsideration of decisions to deny, discontinue or curtail privileges. Hearings will be held by the Board Chair and Personnel Committee of the Board of Directors. The Chief Medical Officer shall attend the hearing, but shall not vote. The hearings shall be recorded or stenographically reported. LIPs who wish to seek reconsideration of privileging decisions should contact the Board Chair in writing. The Board Chair will respond by setting up a meeting with the Personnel Committee within two weeks of the receipt of the letter requesting reconsideration. The applicant may be accompanied by one representative, for example a lawyer. The applicant will have twenty minutes to present additional evidence supporting their application for privileges. The Chief Medical Officer shall, upon request of the Committee, have twenty minutes to provide any additional evidence regarding the privileging decision. The Personnel Committee and the Board Chair will then meet in a closed door session without the applicant to discuss the matter. The committee may request additional information from the Chief Medical Officer or the applicant before making its final recommendation. The committee shall make a decision by a simple majority vote of the members present, including the Board Chair, and its recommendation shall be presented to the full Board of Directors for final action at the next board meeting. The applicant will be informed in writing of Board’s decision by the Chief Executive Officer.

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