CREDENTIALS MANUAL
MEDICAL STAFF
AND
ALLIED HEALTH PROFESSIONALS STAFF
HENDRICK MEDICAL CENTER
ABILENE, TEXAS
January 1, 1998
Revised 10/98
Revised 04/03/01
Revised 05/31/02
Revised 09/27/02
Revised 03/28/03
Revised 04/25/03
Revised 12/12/03
Revised 04/30/04
Revised 07/30/04
Revised 09/29/04
Revised 02/03/05
Revised 06/08/06
Revised 08/03/06
Revised 09/05/06
Revised 12/07/06
Revised 10/04/07
Revised 02/07/08
Revised 10/02/08
Revised 12/04/08
Revised 02/05/09
Revised 04/02/09
Revised 04/01/10
Revised 10/07/10
Revised 02/10/11
Revised 04/05/12
Revised 12/06/12
Revised 02/22/13
Revised 12/05/13
Revised 08/06/14
Revised 10/02/14
Revised 12/08/15
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ARTICLE I. QUALIFICATIONS FOR APPLICANTS
1.1
As a general policy, this Hospital permits application to the Medical Staff from licensed medical
and osteopathic physicians, podiatrists, and dentists. Refer to the Credentials Procedure Manual
with respect to Allied Health Professionals.
1.2
In the absence of an exclusive agreement for which the Hospital contracts, it is the policy of the
Board of Trustees of the Hospital that any physician, podiatrist, or dentist meeting the basic criteria
for the granting of an application may apply for Medical Staff membership and clinical privileges,
providing the availability of the requested privileges. None of the documents in the Application
may be altered.
1.3
In keeping with Section 2.2, it is the policy of this Hospital to provide applications for appointment
to the Medical Staff to individuals who:
1.3.1 Have completed, or are in the last six (6) months of, an approved ACGME or AOA
residency/fellowship program, an APMA approved podiatry program, or approved
ADA/GPR program; or who are tenured faculty members of an approved ACGME or AOA
residency/fellowship program, an APMA approved podiatry program, or approved
ADA/GPR program; or who have obtained board certification;
1.3.2 Are residents of an approved ACGME or AOA residency program who will moonlight at
Hospital;
1.3.3 Have actively practiced in a Joint Commission or CMS accredited facility at least two (2) of
the past five (5) years and have no unverifiable gaps in practice greater than twelve (12)
consecutive months (physicians, oral surgeons and podiatrists). Three (3) months of recent
experience in a full-time clinical residency shall be considered equivalent.
A.
B.
Dentists are not required to have hospital experience but must have actively
practiced continuously with no unverifiable gaps in practice greater than twelve (12)
consecutive months. Three (3) months of recent experience in a full-time clinical
training program shall be considered equivalent;
Applicants who do not meet the requirements of Section 1.3.3 and who seek to reenter into practice after a gap lasting more than twelve (12) consecutive months
must provide documentation as required under Section 1.4.
1.3.4 Are in the process of obtaining or can provide evidence of a current Texas physician, dental
or podiatric license without stipulation. Refer to Article II of the Medical Staff Bylaws with
respect to the Military Staff;
1.3.5 Are not excluded from participating in a federally funded health care program;
1.3.6 Are able to complete the requirement for an application as described in the Credentials
Manual and the Credentials Procedure Manual.
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1.4
CRITERIA FOR RE-ENTRY INTO PRACTICE
1.4.1
Applicants who do not meet the requirements of Section 1.3.3 and who seek to re-enter
into practice after a gap lasting more than twelve (12) consecutive months within the past
five (5) years must meet the criteria as required in this Section.
1.4.2
To qualify for an application, an applicant seeking re-entry into practice must submit the
documentation as required in the second column of Table A below:
Table A
Time Frame Away
From Hospital Care
Practice
Between
12 and 24 months
Documentation Required
Co-Admissions and Prospective
Review
1. Case list for last year of
practice;
2. CME completed within last
two (2) years; and
3. Written statement from reentering applicant
summarizing activities during
the past 12 to 48+ months.
First 6 cases
Documented and submitted to the
Performance Improvement
Department within 72 hours of
discharge.
Between
24 and 48 months
1. Case list for last year of
practice;
2. CME completed within last
two (2) years;
3. Specialty-specific formal
retraining; and
4. Written statement from reentering applicant
summarizing activities during
the past 12 to 48+ months.
First 12 cases
Documented and submitted to the
Performance Improvement
Department within 72 hours of
discharge.
49 months or more
1. Case list for last year of
practice;
2. CME completed within last
two (2) years;
3. Specialty-specific formal retraining;
4. Written statement from reentering applicant
summarizing activities during
the past 12 to 48+ months.
First 24 cases
Documented and submitted to the
Performance Improvement
Department within 72 hours of
discharge.
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1.4.3 Applicants for re-entry after twelve (12) months shall have maintained a current medical
license during the time away from practice. For a complete application, applicants must
provide documentation of continuing medical education (CME) completed within the last
two (2) years that satisfies the Texas Medical Board requirements for current licensure.
Documentation shall include the title and date of the course and the number and type of
credits received.
1.4.4 All applicants for re-entry shall undergo a focused professional practice evaluation in
accordance with Article III of this Credentials Manual. As indicated in the third column of
Table A, Applicants will document and submit a specific number of initial cases for review
by the Performance Improvement Department.
1.4.5 To complete an application, an applicant who has not provided acute inpatient care within
the past two (2) years who requests clinical privileges at the Hospital shall arrange
proctoring with a current Member in good standing of the Medical Staff who practices in the
same or like specialty, subject to approval by the Credentials Committee. The applicant shall
assume responsibility for any financial costs required to fulfill the requirements. The
proctoring physician provided by the applicant and approved by the Credentials Committee
shall be required to review all cases required in the third column of Table A in accordance
with Article III of this Credentials Manual and the Performance Improvement, Performance
Review Policy and Procedure Manual. If the applicant is unable to obtain a proctoring
physician who is approved by the Credentials Committee, the applicant’s application to the
Medical Staff shall remain incomplete.
1.4.6
1.5
The criteria for re-entry into practice do not apply to Practitioners who timely seek a return
from a leave of absence. Rather, the Medical Staff Bylaws govern Practitioners returning
from a leave of absence. If the Practitioner is deemed to have voluntarily resigned after a
leave of absence, however, the criteria for re-entry may apply.
Upon receipt of a completed application, the Medical Staff Office shall verify its contents and shall,
if the requirements herein are met, process the application as set forth in Article II. In the event the
requirements are not met, the applicant shall be notified and the application shall not be processed.
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ARTICLE II. INITIAL APPOINTMENT
2.1
Application for staff appointment is to be submitted by the applicant. The Application must be
submitted on such form as designated by the Credentials Committee and approved by the Board of
Trustees. The applicant shall have access to a copy of the Medical Staff Bylaws. The applicant
must sign the Application, thereby:
2.1.1
Signifying his/her willingness to appear for interviews in regard to his/her application;
2.1.2
Authorizing Hospital representatives to consult with others who have been associated with
the applicant and/or have information bearing on his/her competence and qualifications;
2.1.3
Consenting to Hospital representatives' inspection of all records and documents that may be
material to an evaluation of his/her professional qualifications and competence to carry out
the clinical privileges he/she requests, of the applicant's physical and mental health status,
the applicant's professional and ethical qualifications, and the applicant's criminal history;
2.1.4
Releasing from any liability all Hospital representatives for their acts performed in
connection with evaluation of the applicant's credentials;
2.1.5
Releasing from any liability all individuals and organizations that provide information,
including otherwise privileged or confidential information to Hospital's representatives
concerning the applicant's competence, professional ethics, character, physical and mental
health, emotional stability, and other qualifications for Medical Staff appointment and
clinical privileges;
2.1.6 Consenting to Hospital representatives providing other hospitals, medical associations,
licensing Boards, and other organizations concerned with provider performance and the
quality and efficiency of patient care with any information relevant to such matters that
Hospital may have concerning the applicant, and release Hospital representatives from
liability for so doing;
2.1.7 Agreeing to be bound by the terms of the Medical Staff Bylaws if granted membership
and/or clinical privileges and be bound by the terms thereof without regard to whether
granted membership and/or clinical privileges in all matters relating to consideration of the
application;
2.1.8 Under the Health Insurance Portability and Accountability Act of 1996 and its
implementing regulations, a clinically integrated setting such as a hospital and its Medical
Staff and Allied Health Professionals Staff is an organized health care arrangement.
Medical Staff Members agree as a condition of their Medical Staff membership to
participate in the organized health care arrangement and to comply with the Hospital’s
privacy policies and procedures with regard to all patients admitted or treated by the
Medical Staff Member in the Hospital. All patients admitted to the Hospital or treated in a
Hospital owned facility shall receive the Hospital’s Notice of Privacy Practices, which shall
be considered the joint notice of privacy practices of the Medical Staff and the Hospital. All
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Medical Staff Members are required to participate in privacy education including such
education as related to the Hospital's privacy policies, procedures and practices, during
orientation, as necessary and appropriate as determined by the Hospital, and within a
reasonable period of time after any material change relative to such privacy policies,
procedures, and practices becomes effective as requested by the Hospital.
2.1.9 Agreeing to provide and update the information requested on the original application and
subsequent re-applications or privilege request forms (specifically, hospital appointments,
voluntary relinquishment of Medical Staff membership, clinical privileges, or licensure
status; voluntary or involuntary limitation, reduction or loss of clinical privileges at another
hospital, any special supervision, proctoring or co-admission requirements to which the
applicant has been subject in any other hospital in which the applicant has previously been
granted staff privileges);
2.1.10 Agreeing to provide any information relating to any action or investigation involving the
applicant's license or practice rights by the Texas Medical Board or the professional
licensing agency of this or any other state, and of any action or investigation relating to
suspension or limitation of the applicant's narcotics license or prescription rights or
involvement in liability claims (including both current and pending investigations and
challenges).
2.2
Receipt of an Application shall not be interpreted as an indication that the applicant meets the
qualifications for, or shall be granted, Medical Staff membership and clinical privileges.
2.2.1
By applying for appointment/reappointment to the Medical Staff, each applicant:
A. Agrees that any misstatements in or omissions from the Application for appointment or
request for clinical privileges may constitute cause for denial of appointment and/or
termination from the Medical Staff;
B. Agrees to notify the Credentials Committee in writing within fifteen (15) Days of
receipt of notice, written or oral, of any of the following:
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(1)
Voluntary review or investigation or involuntary termination, denial, suspension,
limitation or refusal to renew Medical Staff membership at any hospital;
(2)
Voluntary or involuntary relinquishment, limitation, reduction, denial or
revocation of any delineated privileges at any hospital;
(3)
A leave of absence request at any hospital;
(4)
Being placed on leave of absence by any hospital when such leave of absence was
not requested by the applicant;
(5)
Being placed on probation at any hospital for any reason other than delinquent
medical records or lack of meeting attendance;
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(6)
Denial, suspension, revocation, limitation (including sanctions and probation),
refusal to renew or the surrender of any license to practice or DEA or DPS
permits to prescribe; or currently pending proceedings which could result in any
of these;
(7)
Commencement of an investigation regarding any matter affecting his/her
professional practice by any State or federal regulatory agency, except for an
investigation by the Texas Medical Board , which only has to be reported upon
receipt of notice of an Informal Settlement Meeting;
(8)
Filing of criminal charges, including DWI by any law enforcement or regulatory
agency, or filing of civil suit(s) by or on behalf of any patient or former patient,
(including medical malpractice lawsuits;
(9)
Sanctions by the Texas Medical Foundation (TMF);
(10) Any final judgments or settlements alleging professional negligence or
incompetence;
(11) Any changes in physical or mental health that might affect the ability to practice
the privileges granted or on-call responsibilities and agrees to submit to an
examination; or
(12) Any voluntary or involuntary changes, terminations, denials, or exclusions in
professional liability insurance coverage.
C. The applicant acknowledges that failure to notify the Credentials Committee of any of
these situations within the prescribed time may be grounds for disciplinary action, up to
and including termination of Medical Staff membership and clinical privileges.
However, it is not necessary to notify the Credentials Committee of:
2.3
(1)
Traffic offenses except those involving allegations of driving under the influence;
(2)
Suspension of privileges for less than thirty (30) Days based upon failure to
complete medical records or lack of meeting attendance;
(3)
Filing of civil lawsuits which do not allege professional negligence or improper
professional conduct; and
(4)
Inquiry letters received from the TMF or other peer review organizations (TMF
sanctions are reportable).
POLICY
Applications shall be categorized by the complexity of the information received. Application
categories and the procedures for processing applications are described in the Credentials
Procedure Manual.
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2.4
2.5
EFFECT OF DEPARTMENT CHAIRPERSON'S REPORT
2.4.1
Deferral: Department Chairpersons may not defer consideration of an application. A report
must be forwarded to the Credentials Committee within thirty (30) Days. In the event a
Chair is unable to formulate a report for any reason, the Chairpersons must so inform the
Credentials Committee.
2.4.2
Favorable findings: Department Chairpersons must document their findings pertaining to
adequacy of education, training, and experience for all privileges requested. Reference to
any criteria for privileges review must be documented. Specific reference to the credentials
file should be made in support of all findings.
2.4.3
Unfavorable findings: Department Chairpersons must document the rationale for all
unfavorable findings. Reference to any criteria for clinical privileges that is not met should
be documented.
EFFECT OF CREDENTIALS COMMITTEE ACTION
2.5.1
Deferral: Action by the Credentials Committee to defer the application for further
consideration must be followed up at the next meeting to discuss approval or denial of, or
any special limitations to, staff appointment, category of staff and prerogatives, department
affiliations, and scope of clinical privileges. The Chair of the Credentials Committee shall
promptly send the applicant written notice of an action to defer.
2.5.2
Favorable recommendation: When the recommendation of the Credentials Committee or
the Credentials Committee Chair acting on behalf of the Credentials Committee is
favorable to the applicant in all respects, it shall be promptly forwarded, together with all
supporting documentation, to the MEC or the Chief of Staff acting on behalf of the MEC.
All supporting documentation includes the application form and its accompanying
information, the reports and recommendations of the Department Chair and comment by
the Credentials Committee, if any, as well as all dissenting views
2.5.3
Adverse recommendation: When the Credentials Committee's recommendation is adverse
to the applicant, notice shall be sent to the Medical Executive Committee. An adverse
recommendation by the Credentials Committee is defined as a recommendation to deny
appointment, or to deny or restrict requested clinical privileges.
2.5.4
Within sixty (60) Days after the receipt of the completed application for membership, the
Credentials Committee shall make a written report of its recommendation to the MEC,
provided, however, that this time period may be extended, if necessary but not to exceed
one hundred twenty (120) Days total, in order for the Committee to obtain and review
information concerning the applicant's qualifications. In any case, where such extension is
for more than an additional sixty (60) Days, the Credentials Committee shall file a written
report with the MEC indicating the reason(s) why the Credentials Committee has been
unable to approve its investigation during such period.
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2.6
2.7
2.8
MEDICAL EXECUTIVE COMMITTEE ACTION
2.6.1
After receipt of a recommendation from the Credentials Committee or the Credentials
Committee Chair acting on behalf of the Credentials Committee, the MEC, at its next
regular meeting, shall consider such actions and recommend to the Board of Trustees that
the applicant shall be appointed to the staff or deferred or rejected. The recommendation of
the MEC should be communicated within the time frame established by Texas law
following notice from the Medical Staff Office that the application is completed and
verified.
2.6.2
If the recommendation of the MEC is for appointment to the staff, the Chief of Staff shall
forward the recommendation, including privileges granted, to the Board of Trustees.
2.6.3
If the applicant is deferred for further investigation it must be followed up at the next
regular meeting of the MEC. This action is to be followed within thirty (30) Days by
recommendation to the Board of Trustees for appointment to the staff with privileges
granted or rejected for staff appointment.
2.6.4
If rejected by the MEC, either in respect to appointment or clinical privileges, the Chief of
Staff shall promptly notify the applicant by certified mail (return receipt requested) stating
the reasons for such action and informing the applicant of all procedural rights as provided
in the Medical Staff Bylaws. No such adverse recommendation need be forwarded to the
Board of Trustees until after the applicant has exercised or has been deemed to have waived
his/her right to a hearing as provided in other articles of the Medical Staff Bylaws.
ACTION OF THE BOARD OF TRUSTEES
2.7.1
The Board of Trustees may accept the recommendation of the MEC for further
consideration, stating the purpose for such referral and setting a reasonable time limit for
making a subsequent recommendation. The following procedure shall apply with respect to
action of the application: If the MEC issues a favorable recommendation and the Board of
Trustees concurs in that recommendation, the Board of Trustees shall act in the matter.
2.7.2
When the recommendation of the MEC is to defer the application for further consideration,
it must be followed within thirty (30) Days with a subsequent recommendation of
appointment with specified clinical privileges or for rejection for staff membership.
2.7.3
When the final action of the Board of Trustees is unfavorable, the CEO shall promptly give
the applicant written notice of the final adverse recommendation by certified mail (return
receipt requested) and the applicant shall be entitled to the procedural rights set forth in the
Medical Staff Bylaws. Such adverse decision shall be held in abeyance until the applicant
has exercised appeal rights.
BOARD OF TRUSTEES ACTION IN CONTESTED CASE
2.8.1
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At its first regular meeting after all of the applicant's rights under the Medical Staff Bylaws
have been exhausted or waived, the Board of Trustees, or its duly authorized committee,
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shall act in the matter. The Board of Trustees' decision shall be conclusive, except that the
Board of Trustees may defer final determination by referring the matter back for further
reconsideration. Any such referral back shall state the reasons therefore, shall set a time
limit within which a subsequent recommendation to the Board of Trustees shall be made,
and may include a directive that an additional hearing be conducted to clarify issues which
are in doubt. At its next regular meeting after receipt of such subsequent recommendation
and new evidence in the matter, if any, the Board of Trustees shall make a decision either to
appoint the applicant to the staff or to reject him/her for staff membership. All decisions to
appoint shall include a delineation of the clinical privileges which the applicant may
exercise.
2.8.2
2.9
When the decision of the Board of Trustees shall be contrary to the recommendations of the
MEC, the Board of Trustees shall submit the matter to the Joint Conference Committee for
review and recommendation and shall consider such recommendation before making its
decision final.
NOTICE OF FINAL DECISION
2.9.1
When the decision of the Board of Trustees is final, notice of such decision shall be sent
through the CEO to the Chair of the MEC, and by certified mail (return receipt requested)
to the applicant.
2.9.2
A decision and notice of appointment includes:
A. The staff category to which the applicant is appointed;
B. The department to which he/she is assigned;
C. The clinical privileges he/she may exercise;
D. Any special conditions attached to the appointment and/or clinical privileges;
2.9.3
2.10
Medical Staff membership and clinical privileges for initial appointees to the Medical Staff
shall be contingent upon completion of an orientation scheduled by the Medical Staff
Office during normal business hours.
TIME PERIODS FOR PROCESSING
All individuals and groups required to act on an application for staff appointment must do so in a
timely and good faith manner and, except for good cause, each application should be processed
within the time periods established by state and federal law. If the provisions of the Medical Staff
Hearing Plan are activated, the time requirements provided therein govern the continued processing
of the application.
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ARTICLE III. PROFESSIONAL PRACTICE EVALUATION
3.1
FOCUSED PROFESSIONAL PRACTICE EVALUATION
All initially requested privileges and privileges requested for re-entering practice shall be subject to
focused professional practice evaluation (FPPE). FPPE shall occur (i) in all requests for new
privileges, (ii) in all requests for re-entering practice, and (iii) when there are concerns regarding
the provision of safe, high quality care by a current Medical Staff Member. The Department Chair
shall be responsible for overseeing the evaluation process for all applicants or Medical Staff
Members assigned to their department.
3.1.1 Information for this evaluation may be derived from the following:
A.
Discussion with other individuals involved in the care of each patient (e.g.,
consulting physician, assistants in surgery, nursing or administrative personnel);
B.
Chart review;
C.
Monitoring clinical practice patterns;
D.
Proctoring;
E.
Simulation;
F.
External peer review.
3.1.2 The Credentials Committee shall be responsible for: (i) monitoring compliance with FPPE;
and (ii) establishing the duration for such FPPE as well as the triggers that indicate the need
for performance monitoring.
3.1.3 FPPE for applicants seeking to re-enter practice will include a case review by the
Performance Improvement Department as required under Section 1.4. The Performance
Improvement Department shall review all required cases within seventy-two (72) hours of
any patient care activity by the applicant.
3.1.4 A re-entering applicant who has not provided acute inpatient care within the past two (2)
years who requests clinical privileges at the Hospital shall arrange proctoring with a current
Member in good standing of the Medical Staff who practices in the same or like specialty,
subject to approval by the Credentials Committee. The applicant shall assume responsibility
for any financial costs required to fulfill the requirements. The Performance Improvement,
Performance Review Policy and Procedure Manual shall apply to the FPPE by the proctor.
3.1.5 A proctoring physician selected pursuant to Section 3.1.4 shall be required to review all
cases, as required in Section 1.4, Table A. The Performance Improvement Department shall
notify the proctoring physician when it identifies any patient concerns. The proctoring
physician shall immediately notify the Chair of Department or his/her designee in the event
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the proctoring physician observes or identifies patient care that adversely affects or could
adversely affect the patient. Patient care activity as defined in the Medical Staff Bylaws does
not include referrals for outpatient diagnostic procedures.
3.1.6 The scope and intensity of proctoring activities required under Sections 3.1.4 and 3.1.5, and
the requirement for submission of a written report from the proctor to the Department Chair
for the Credentials Committee prior to termination of the proctored period, shall assess, at a
minimum, the applicant’s demonstrated clinical competence related to the privileges
requested, ability to get along with others, the quality and timeliness of medical records
documentation, professional ethics and conduct. The proctor’s written report shall be
reviewed by the Department Chair and the Credentials Committee and approved by the
Medical Executive Committee before the re-entering applicant is approved to practice
independently.
3.2
ONGOING PROFESSIONAL PRACTICE EVALUATION
The Medical Staff shall also engage in ongoing professional practice evaluation (OPPE) to identify
professional practice trends that affect quality of care and patient safety. Information from this
evaluation process will be factored into the decision to allow Practitioners to maintain existing
privileges, revise existing privileges, or revoke existing privileges prior to or at the time of
reappointment.
OPPE shall be undertaken as part of the Medical Staff's evaluation, measurement and improvement
of Practitioners' current clinical competency. In addition, each Practitioner may be subject to FPPE
when issues affecting the provision of safe, high quality patient care are identified during the OPPE
process. Decisions to assign a period of performance monitoring or evaluation to further assess
current competence must be based on the evaluation of an individual's current clinical competence,
practice behavior and ability to perform a specific privilege.
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ARTICLE IV. REAPPOINTMENT
4.1
INFORMATION COLLECTION AND VERIFICATION
4.1.1 Each Member of the Medical Staff becomes eligible for reappointment every two (2) years.
Members of the Medical Staff shall be reappointed in groups and on a schedule determined
by the Credentials Committee and approved by the MEC. The usual reappointment period
shall be for two (2) years. Any Practitioner may, based upon concerns regarding physical or
mental health or impairment or other concerns which, in the judgment of the Credentials
Committee and MEC justify such action, be appointed or reappointed for a period less than
two (2) full years. Any such appointment or reappointment shall be processed for review at
the appropriate time. A reappointment for a period of less than the full period of time for
which the Practitioner is otherwise eligible, does not entitle the Practitioner to the
procedural rights provided in the Medical Staff Hearing Plan.
4.1.2 A notification of reappointment shall be mailed by the Medical Staff Office to the
Practitioner whose appointment is expiring. The Application must be returned to the
Medical Staff Office within ninety (90) Days of mailing. If the Application for
reappointment is not received in the Medical Staff Office within thirty (30) Days of
mailing, the Medical Staff Office shall promptly send written notice to the Practitioner
advising that an Application has not been received. If the Application for reappointment is
not received in the Medical Staff Office within sixty (60) Days of mailing, the Medical
Staff Office shall promptly send a second written notice to the Practitioner. Failure to
submit an Application within ninety (90) Days of mailing without good cause shall result in
expiration of the Member's Appointment. Upon receipt, the information shall be processed
as set forth in Article II of this manual.
4.1.3 All returned documents shall be reviewed, processed and verified as described in the
Credentials Procedure Manual.
4.1.4 The Medical Staff Coordinator or appropriate administrative representative shall compile a
summary of clinical activity for each appointee due for reappointment.
4.2
PROCEDURE FOR PROCESSING APPLICATIONS FOR STAFF REAPPOINTMENT
4.2.1 Refer to Article II of the Credentials Manual for the procedure for processing.
4.2.2
Request for Modification of Appointment Status or Privileges
A staff appointee, either in connection with reappointment or at any other time, may request
modification of his/her staff category, department assignment, or clinical privileges by
submitting a written application to the Medical Staff Office. A modified application is
processed in the same manner as a reappointment. All requests for increased privileges
must be accompanied by information demonstrating current clinical competence in the
specific privilege requested. Such a request may not be filed within six (6) months of the
time that a similar request has been denied.
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4.2.3
4.3
Effect of application: Unless otherwise modified, suspended, or revoked under the
Medical Staff Bylaws, the existing membership and privileges shall remain effective until
the anniversary date of the Practitioner's membership and privileges.
AUTHORITY TO APPOINT, ELEVATE, AND REAPPOINT
There shall be no “reinstatement” of terminated, lapsed, or relinquished membership except in the
case of a return from an approved leave of absence or in the event that the termination or lapse was
occasioned by an error on the part of the Hospital. In the event of terminated, lapsed, or
relinquished membership, the affected Practitioner must reapply and qualify for Staff membership.
Such applicant cannot be granted temporary privileges; therefore, he/she cannot treat or attend
patients in the Hospital until membership and clinical privileges have been approved by the Board
of Trustees. Whether, and to what extent, proctoring of such an individual shall be required shall be
determined by the Board of Trustees upon recommendation of the Credentials and Medical
Executive Committees and shall be based upon the amount of time the applicant has been away
from the Hospital and any concerns regarding the applicant’s previous record with the Hospital.
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ARTICLE V. CLINICAL PRIVILEGES
5.1
EXERCISE OF PRIVILEGES
A Practitioner providing clinical services at Hospital may exercise only those privileges granted to
him/her by the Board of Trustees or emergency privileges as described herein.
5.2
PRIVILEGES IN GENERAL
5.2.1 Exercise of Privileges: Except as otherwise provided in the Medical Staff Bylaws, said
privileges and services must be Hospital specific; within the scope of any license,
certificate, or other legal credential authorizing practice in the State of Texas and consistent
with any restrictions thereon; and shall be subject to the Medical Staff Policies of the
clinical department and the authority of the Department Chair and the Medical Staff.
5.2.2 Basis for Privileges Determination: Requests for clinical privileges shall be considered
only when accompanied by supporting documentation of education, training, experience,
judgment, independent character and demonstrated competence as specified by Hospital. In
the event a request is submitted for which no criteria have been created, the request shall be
tabled for a reasonable period of time during which the Board of Trustees shall, after
consultation with the Credentials and Medical Executive Committees, formulate the
necessary criteria with input from the Medical Staff. Once objective criteria have been
established, the original request shall be processed as described herein.
Valid requests for clinical privileges shall be evaluated on the basis of education, training,
experience, demonstrated competence, ability, judgment and peer recommendations that
provide written information regarding the applicant's current medical/clinical knowledge,
technical/clinical skills, clinical judgment, interpersonal skills, communication skills and
professionalism. The basis for privileges determination to be made in connection with
periodic reappointment or a requested change in privileges must include observed clinical
performance and documented results of the staff's quality improvement program activities.
Privilege determinations shall also be based on pertinent information from other sources,
especially other institutions and health care settings where a professional exercises clinical
privileges, including the information specified in Section 2.1.9 herein. The information
shall be added to and maintained in the Medical Staff file established for the staff
appointee.
5.2.3 The procedure by which requests for clinical privileges are processed and the specific
qualifications for the exercise of privileges are found elsewhere in this Manual.
5.2.4 Dentists and Podiatrists: Privileges granted to dentists or podiatrists shall be based on
their training, experience, and demonstrated competence and judgment. The scope and
extent of surgical privileges that each dentist and podiatrist may perform shall be
specifically delineated and granted in the same manner as all other surgical privileges. All
podiatric and dental patients (except patients of oral surgeons) shall be co-admitted by a
physician member of the Active Medical Staff and shall receive the same basic medical
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appraisal as patients admitted for other surgical services. A physician member of the
Active Medical Staff shall be responsible for the care of any medical problem that may be
presented at the time of admission or that may arise during hospitalization.
5.2.5 Emergency Medicine Physicians: Privileges granted to Emergency Medicine physicians
may include time-limited admission orders. The Medical Staff policies and procedures will
dictate the purpose and application of such orders.
5.3
REVIEW OF CLINICAL PRIVILEGES
5.3.1 Biannual or annual determination of privileges and the increase or curtailment of same shall
be based upon the applicant's training, experience, and demonstrated competence, which
shall be evaluated by review of the applicant's credentials, direct observation by the active
staff, review of the records, or any portion thereof, of patients treated in this or other
hospitals, and/or other institutions and health care settings.
5.3.2 In order to obtain additional clinical privileges, any Member of the Medical Staff shall
make written application stating the type of privileges desired and furnish evidence to
establish competency and qualifications for such privileges. Such application shall be
presented to the Department Chair.
5.3.3 A Medical Staff Member may voluntarily relinquish specific clinical privileges without
penalty at any time, providing no disciplinary action is pending.
5.3.4 Any Medical Staff Member whose practice has been interrupted for a period of one hundred
twenty (120) Days or more by reason of disability may be interviewed by the Credentials
Committee for reevaluation of privileges.
5.3.5 Termination of a Medical Staff Member from an administrative position within Hospital
shall not result in a reduction in clinical privileges without due process.
5.4
TEMPORARY PRIVILEGES
5.4.1. Circumstances: Temporary privileges may be granted to fulfill an important patient care,
treatment and/or service need and when a Category one initial applicant is awaiting review
and approval by the MEC and Board of Trustees.
A.
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Pending Application: Temporary privileges may be granted when an applicant for
new privileges with a complete application that raises no concerns is awaiting
review and approval by the MEC and the Board of Trustees. Applicants for new
privileges include an individual applying for clinical privileges at the hospital for
the first time; an individual currently holding clinical privileges who is requesting
one or more additional privileges; and an individual who is in the reappointment/reprivileging process and is requesting one or more additional privileges.
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Upon review of a completed application for Medical Staff membership from an
appropriately licensed applicant, the CEO, upon the written concurrence of the
Chief of Staff, Chairman of the Credentials Committee and Chairman of the
appropriate Department, may grant temporary privileges to the applicant after
review and positive recommendation from the Credentials Committee or the MEC.
Temporary privileges for Category one applicants may be granted initially for a
limited period of time, not to exceed one hundred twenty (120) Days, provided the
applicant has met the requirements for membership and clinical privileges set forth
in Articles I and II of this Manual.
Temporary privileges may be granted by the CEO acting on behalf of the Board of
Trustees, upon written concurrence of the Chief of Staff on behalf of the MEC, by
the Credentials Chair on behalf of the Credentials Committee for a period not to
exceed one hundred twenty (120) Days to an appropriately licensed applicant only
when verified information as described elsewhere and a recommendation of the
Department Chair reasonably supports a favorable determination regarding the
requesting applicant’s qualifications, ability, and judgment to exercise the privileges
requested.
Special requirements of consultation and reporting may be imposed by the Chair
responsible for supervision. Except in unusual circumstances, temporary privileges
shall not be granted unless the applicant has agreed in writing to abide by the
Medical Staff Bylaws and the policies, procedures, and protocols of Hospital, and
the policies of the Board of Trustees in all matters relating to his/her temporary
privileges. Whether such written agreement is obtained, the Medical Staff Bylaws
control all matters relating to the exercise of clinical privileges.
B.
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Important Patient Care Need:
(1)
A circumstance in which one or more individual patients will experience
care that does not adequately meet their clinical needs if the temporary
privileges under consideration are not granted (i.e., a patient scheduled for
urgent surgery who would not be able to undergo surgery in a timely
manner);
(2)
A circumstance in which the institution will be placed at risk of not
adequately meeting the needs of patients who seek care from the institution
if the temporary privileges under consideration are not granted (i.e., the
institution will not be able to provide adequate emergency room coverage in
the provider's specialty, or the Board of Trustees has granted privileges
involving new technology to a physician on staff provided the physician is
precepted for a specific number of initial cases and the precepting physician,
who is not seeking Medical Staff membership, requires temporary
privileges to serve as preceptor;
(3)
A circumstance in which a group of patients in the community will be
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placed at risk of not receiving patient care that meets their clinical needs if
the temporary privileges under consideration are not granted (i.e., a
physician who has a large practice in the community for which adequate
coverage of hospital care for those patients cannot be arranged).
C.
Specific Patient: At the request of the attending physician, temporary clinical
privileges may be granted for the care of a specific patient to a physician, dentist, or
podiatrist who is not a member of the Medical Staff. The applicant must be a
member in good standing of the active staff of another Joint Commission or state
(DSHS) accredited hospital, and be exercising the privileges he/she requests at such
other hospital. Such temporary privileges shall be restricted to the treatment of not
more than four (4) patients in any one (1) calendar year by any applicant, at the
discretion of the CEO with the concurrence of the Chief of Staff. The attending
physician must co-sign all orders.
D.
Visiting Instructors and Students: Upon receipt of an application for temporary
privileges from an appropriately licensed applicant and verification of such
applicant's qualifications and credentials to teach or learn specific clinical
procedures, the CEO, upon the written concurrence of the Chief of Staff, may grant
temporary clinical privileges to an applicant for the purpose of teaching or learning
specific clinical procedures.
E.
Emergency Privileges: In case of an emergency, any Practitioner, to the degree
permitted by his/her license, is required to do everything he/she deems reasonably
necessary and appropriate to save the life or limb of a patient. A Practitioner
exercising emergency privileges is obligated to summon all consultative assistance
deemed necessary. As soon as practical, the patient shall be assigned to a Member
of the Medical Staff with appropriate privileges.
For the purposes of this section, an emergency shall be defined as a condition in
which serious harm would result to a patient or in which the life or limb of a patient
is in immediate danger and any delay in administering treatment would add to that
danger.
F.
Disaster Privileges: Disaster privileges may be granted on a case by case basis to
those applicants considered eligible to act as licensed independent practitioners and
who volunteer their services at Hospital when the Emergency Management Plan has
been activated, and the organization is unable to handle the immediate patient
needs. Disaster privileges may be granted to an appropriately licensed applicant by
the CEO.
(1)
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Prior to granting such privileges, Hospital shall attempt to verify the
applicant’s state licensure and obtain an AMA Masterfile, and a report from
the National Practitioner Databank. At a minimum, the applicant must
present a valid government-issued photo identification issued by a state or
federal agency (e.g., driver's license, passport) and at least one of the
following:
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(a)
(b)
(c)
(d)
(e)
(f)
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A current picture identification card from a health care organization
that clearly identifies professional designation;
A current license to practice;
Primary source verification of licensure;
Identification indicating that the individual is a member of a
Disaster Medical Assistance Team (DMAT), the Medical Reserve
Corp (MRC), the Emergency System for Advance Registration of
Volunteer Health Professionals (ESAR-VHP) or other recognized
state or federal response organization or group;
Identification indicating that the individual has been granted
authority by a federal, state or municipal entity to render patient
care, treatment and services in disaster circumstances;
Confirmation by a current hospital or Medical Staff Member who
possesses personal knowledge regarding the volunteer's ability to act
as a licensed independent practitioner during a disaster.
(2)
The Hospital determines through direct observation by Hospital personnel
and/or Medical Staff Members whether privileges granted during a disaster
situation should continue. The Medical Staff oversees the performance of
each volunteer licensed independent practitioner as follows:
(a)
All physicians working in the Emergency Department will be
subject to oversight by the Emergency Medicine physicians;
(b)
All physicians working in surgical areas will be subject to oversight
by the Department of Surgery Chair or designee;
(c)
All physicians working in other areas will be subject to oversight by
the Department of Medicine Chair or designee or as assigned by the
Chief of Staff.
(3)
Based on such oversight, the Hospital determines within seventy-two (72)
hours of the volunteer's arrival if disaster privileges granted to the volunteer
should continue. If the privileges continue for more than seventy-two (72)
hours, retrospective review of ten percent (10%) of cases involving the
volunteer licensed independent practitioner shall be attempted in an effort to
review the treatment being provided.
(4)
Volunteer licensed independent practitioners will be distinguished by their
badges which will clearly state they are volunteers.
(5)
If not accomplished prior to granting disaster privileges, primary source
verification of licensure will begin as soon as possible. An attempt will be
made to complete verification within seventy-two (72) hours. If Hospital is
unable to do so within seventy-two (72) hours, the following documentation
will be required:
(a)
The reason primary source verification cannot be performed within
the time frame;
(b)
Evidence of a demonstrated ability to continue to provide adequate
care, treatment and services;
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(c)
(6)
Evidence of the Hospital's attempt to perform primary source
verification as soon as possible.
Disaster privileges will automatically terminate when the disaster situation
is resolved. Special requirements of direct observation, mentoring, or
clinical record review may be imposed by the Department Chair or other
Medical Staff Member responsible for supervision. Termination of disaster
privileges and rights of individuals with disaster privileges shall be
addressed as with temporary privileges described elsewhere in this Section.
5.4.2 Termination of Temporary Privileges: The CEO, acting on behalf of the Board of
Trustees and after consultation with the Chief of Staff, may terminate any or all of a
Practitioner's temporary privileges based upon the discovery of any information or the
occurrence of any event of a nature which raises questions about a Practitioner's privileges.
Where the life or well being of a patient is determined to be endangered, the termination
may be affected by any person entitled to impose Summary Suspension under the Medical
Staff Bylaws. In the event of any such termination, the Member’s patients in Hospital shall
be assigned to another Member by the Chair responsible for supervision. The wishes of the
patient shall be considered, when feasible, in choosing a substitute Member.
5.4.3 Rights of the Practitioner with Temporary Privileges: A Practitioner is not entitled to
the procedural rights afforded by the Medical Staff Hearing Plan of the Medical Staff
Bylaws because his/her request for temporary privileges is refused or because all or any part
of his/her temporary privileges are terminated or suspended unless based on a determination
of clinical incompetence or unprofessional conduct.
5.4.4 Reappointment: Temporary privileges are not to be used at reappointment for
administrative purposes such as failure of the Practitioner to provide all information
necessary for the processing of his/her reappointment in a timely manner.
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ARTICLE VI. PRACTITIONER PROVIDING CONTRACTUAL SERVICES
6.1
EXCLUSIVE POLICY: Whenever hospital policy specifies that certain hospital facilities or
services may be used on the exclusive basis in accordance with the contracts or letters of agreement
between Hospital and qualified Practitioners, then other staff appointees must, except in an
emergency or life-threatening situation, adhere to this exclusivity policy in arranging care for their
patients. Application for initial appointment or for clinical privileges related to hospital facilities or
services covered by exclusivity agreements shall not be accepted or processed unless submitted in
accordance with the existing contract or agreement with Hospital.
6.2
QUALIFICATIONS: A Practitioner who is or shall be providing specified professional services
pursuant to a contract or letter of agreement with Hospital must meet the same qualifications, must
be processed in the same manner, and must fulfill all the obligations of his/her appointment
category as any other applicant or staff appointee.
6.2.1 When a Practitioner is a resident of an approved residency program at another institution
and wishes to moonlight at Hospital, the Medical Staff Office shall process the application
and maintain all files;
6.2.2 When a practitioner is a medical student, an affiliation agreement between the educational
institution and Hospital must exist and the Department of Education shall process the
paperwork and maintain all files.
6.3
EFFECT OF STAFF APPOINTMENT TERMINATION: Because practice at Hospital is
always contingent upon continued staff appointment and is also constrained by the extent of clinical
privileges enjoyed, a Practitioner's right to use hospital facilities is automatically terminated when
his/her staff appointment expires or is terminated. Similarly, the extent of his/her clinical privileges
is automatically limited to the extent the pertinent clinical privileges are diminished.
6.4
EFFECT OF CONTRACT EXPIRATION OR TERMINATION: The effect of expiration or
other termination of a contract upon a Practitioner's staff appointment and clinical privileges shall
be governed solely by the terms of the Practitioner's contract with Hospital. If the contract is silent
on the matter, then contract expiration or other termination alone shall not affect the Practitioner's
staff appointment status or clinical privileges.
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