Saturday, 12 March 2016
Dr
Dear Dr,
RE: REQUEST FOR CREDENTIALING AT MONTSERRAT DAY HOSPITALS
Thank you for your expression of interest for Clinical Privileges at
Montserrat Day Hospitals.
Please complete and return the accompanying Application for
Credentialing and Defining Scope of Clinical Practice. Please include
with the Application;
a)
b)
c)
d)
e)
CV
Evidence of Medical Registration and Indemnity Insurance,
Contact details of at least 3 referees,
Documentation in relation to ‘false’ answers in Declaration
Any required evidence of competency.
Please return the Application and required documents to:
Montserrat Day Hospitals
Credentialing Officer
Level 2
South Tower
527 Gregory Terrace
Bowen Hills 4006
F: 07 3833 6740
E: nroberts@montserrat.com.au
Thank you for your enquiry and I look forward to reviewing your
application.
Yours sincerely,
Ben Korst
CEO
Montserrat Day Hospitals
Credentialing Application
Applicant Details
Title
Doctor
Professor
Mr
Ms
Mrs
Other
Surname:
Given Name/s:
Previous Name:
Please include your previous (or maiden) name
that appears on birth certificate or APHRA
registration
Place of Birth:
Date of Birth:
Professional
Address:
Intended First List
Date:
Associated Organisation or practice:
(Please provide at least two telephone numbers)
Telephone Numbers:
Business:
Private:
Mobile:
Fax:
Email Address:
Website:
Postal Address
(If different to Professional Address)
Private Address:
Preferred method of correspondence:
Email
Postal Address
Private Address
Emergency Contact - in the event I am unable to be contacted for a clinical emergency
Person nominated must be appropriately qualified, registered (APHRA) and insured.
Name:
Phone:
Nominated Sites:
Please indicate the site/s you are seeking clinical privileges for
Indooroopilly
Gaythorne
North Lakes
Australian Residency status:
Australian citizen
Qualifications/Training:
Qualifications
Permanent resident
University/Organisation
Please refer to CV for supporting information or documentation
Temporary resident
Country
Year Attained
Credentialing Application
Appointments/Education
Previous Clinical Appointments (list chronologically – attach separate list if insufficient space)
Appointment
Organisation
Country
Dates (approx.)
Please refer to CV for supporting information or documentation
Lifetime Registration History (list chronologically – attach separate list if insufficient space)
Registration Authority
Dates Registered
Country
Conditions or sanctions
Are there any current sanctions/restrictions imposed on your Medical Registration? YES
NO
Current Clinical Appointment/s (List appointments that would continue concurrently at other
private or public health care facilities, including time commitments)
Appointment
Scope of Practice
Organisation
Time Commitment
Academic Appointments (attach separate list if insufficient space)
Organisation
Status/Level
Term of Appointment
Continuing Medical Education
College/Organisation
Program
Date Completed/Currently Enrolled
Credentialing Application
Indemnity Insurance
Medical Indemnity Insurance
Do you have current Medical Indemnity Insurance at the appropriate level? YES
Insurance Company _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
NO
_ _ _ _ _ _ _ Expiry Date _ _ _ _ _ _ _ _ _ _ _
Scope of Practice _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Please Note: If you are insured with Avant, please find attached at the back of this application,
Authority for Montserrat Day Hospitals to obtain your insurance information for the next 3 years.
References
Please list the names and contact details of at least 3 professional referees who can comment on
your skills and work ethic in the areas for which you are seeking clinical privileges.
1.
Name:
Current Position:
Associated Organisation:
Business Phone No:
Or Mobile Phone No:
Email Address:
2.
Name:
Current Position:
Associated Organisation:
Business Phone No:
Or Mobile Phone No:
Email Address:
3.
Name:
Current Position:
Associated Organisation:
Business Phone No:
Email Address:
Or Mobile Phone No:
Credentialing Application
Specialist Clinical Privileges
Specialist Clinical Privileges sought in the field/s of:
NB: Must be registered in the indicated speciality with the Australian Health
Practitioner Registration Agency (AHPRA) to complete this section
Anaesthesia
IVF, Obstetrics & Gynaecology
Gastroenterology**
Adults
Gynaecology
Gastroenterology
Paediatric*
Uro-gynaecology
Colonoscopy
*Please attach evidence of
training and currency of
practice.
How many lists performed in
the past 12 months:
Dental
General Dental
IVF
Other (please detail)
** Must have Conjoint
Committee Certification –
Please attach
Other (Please detail)
ENT
Adult
Urology
Adult
Paediatric
Paediatric
Pathology
General Surgery
Clinical Haematology
(please detail)
Orthopaedics
Adult
Adult
Paediatric
Paediatric
Other (please detail)
Plastic and Reconstructive*
Surgery
Dermatology
Cosmetic Surgery*
Adult
Adults
*Please specify level of procedures and
attach evidence of competency
Adult
Paediatric
Paediatric
Other
* Please specify level of
procedures and attach
evidence of competency
(Please specify)
*NB: Clinical Privileges are granted for
a period of 6 months
Categories:
Specialist Practitioner
Dentist
Other
Privileges:
Consulting
Assist
Anaesthetic
Surgical
Other
Credentialing Application
Applicant Declaration
I declare that all the following statements are TRUE or FALSE as indicated in the tick
boxes. Please tick ( )
I have never been subject to an adverse finding or had conditions or undertakings
attached to my registration and I am not currently under investigation. This may include
breach of insurance / medical laws, professional misconduct, sexual assaults or assault by
the Health Insurance Commission, a Medical Board, a Health Care Complaints
Commission/Body, a Coroner, a Court
or any other professional disciplinary or similar body.
TRUE
FALSE
My right to practise and/or scope of clinical practice is not under investigation and/or
has never been denied, restricted, suspended, terminated or otherwise modified in or
by any other health care organisation (including overseas organisations, health
facilities, learned colleges or other official bodies
I am not and have never been the subject of investigation by the Health Rights
Commission (HRC), Health Quality Complaints Commission (HQCC) or other similar
body interstate or overseas.
A Medical Defence Union or Fund has never refused to renew my membership.
I have not been subject to criminal investigation or conviction
My clinical work is assessed by quality assurance mechanisms including clinical audit
and peer review processes. I am not aware of any data from patient
records, clinical audit, peer review processes or quality activities which reflects
adversely on the outcomes of my clinical practice.
I participate in the continuing medical education program, maintenance of
professional standards program, or similar, of my College or Society and I am current
with the requirements of that program.
I agree to abide by the Policies and Standards of Montserrat Day Hospitals in regards
to Privacy, Informed Consent (Financial and Clinical) and Open Disclosure.
I have no physical or other conditions or substance abuse that may limit my ability
to exercise the scope of practice which has been granted/requested
I do not have any criminal charges pending against me.
I have not been convicted of a criminal offence.
I have never been convicted of a drug or alcohol related offence.
Please comment below if you are unable to answer “True” to any of the above questions, and attach any
relevant documentation.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Credentialing Application
Statement of Acceptance
I, .............................................................................. authorise
Montserrat
Day Hospitals
to obtain
information on an annual basis form the registration body as nominated in this application,
regarding currency of my registration with that body or organisation. I will ensure that Montserrat Day
Hospitals is provided with current and valid evidence of membership with an Indemnity insurance
organisation.
I authorise Montserrat Day Hospitals to contact my medical defence organisation/insurer to verify that I
maintain appropriate medical indemnity coverage for privileges sought.
I authorise, if applicable, Montserrat Day Hospitals to request a criminal history check be carried out
on me.
I declare that the statements contained in this application are correct. In applying for appointment
I agree to abide by Montserrat Day Hospital’s policies and regulations and any terms or conditions
which are attached to my appointment by the credentialing committee.
I undertake to immediately notify the Chair of Credentialing Committee of any material changes to
the information provided by me in connection with this application, as soon as possible after the
change, and particularly if my clinical Privileges are retracted, withdrawn or altered at any other
hospital or day procedure facility.
I authorise Montserrat Day Hospitals, its officers and agents to seek information as to my past
experience, performance and current fitness and the validity of my responses to the above questions.
I understand that I will be granted Interim Clinical Privileges until I receive notification of Full Privileges
following the next Credentialing Committee Meeting.
I am aware that I will have to complete a renewal of Clinical Privileges form when notified of the expiry
of my privileges at Montserrat Day Hospitals.
I understand that if I have provided misleading or deceptive information of information which is likely
to mislead or deceive, that the Montserrat Board may (at its absolute discretion) consider that I do not
have ‘current fitness’ under the Hospital By-Laws.
I acknowledge that I have been provided with, and read a copy of the Hospital By-Laws. If appointed I
agree to abide by the polices, procedures of the Hospital By-Laws
Signed:....................................................................................................................................................
Date: .......................................................................................................................................................
Witness Signature: .................................................................................................................................
Witness Name: ......................................................................................................................................
(Please use block letters)
Credentialing Application
Applicant Checklist
Please ensure that all items are included in/with your application
Curriculum Vitae
Required evidence of competency (as indicated in privileges sought)
Documentation in relation to “FALSE” answers in the ‘Applicant’s Declaration’
(Pages 4 & 5)
Evidence of current Indemnity Insurance membership
Contact details of at least 3 referees
Applicants Declaration
Signed and Witnessed Statement of Acceptance
OFFICE USE ONLY
Applicant Name: .......................................................................................................................................
Discipline: ................................................................. Scope of Practice: ................................................
Checked ( )
1. Contact details provided
2. CV
3. Qualifications
4. Training and experience
5. Clinical appointments
6. Continuing medical education/professional development
7. Medical Indemnity Insurance (Evidence provided)
8. Documentation in relation to “FALSE” answers in the Declaration.
9. Provider Number (if applicable)
10. Specialist status
11. Referees
12. Peer review
13. Google search completed; Surname, First name, Disciplinary action
14. Declaration signed
15. Statement of Acceptance signed
16. Other comments
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
Credentialing Application
OFFICE USE ONLY
Applicant’s details checked by (name) ......................................................................................................
Signature ............................................................... Date:...........................................................................
Reference Checked by (name) ....................................................................................................................
Signature .................................................................. Date:........................................................................
Please note: the Chair of the Credentialing Committee or CEO only may confirm granted Interim
Privileges
Peer Review Conducted by (name): ...................................... Specialty: ................................................
Signature .................................................................. Date:......................................................................
Peer Review Recommendation:
Approved
Rejected
Comments: ...................................................................................................................................................
........................................................................................................................................................................
Recommendation of Credentialing Committee at its meeting on (date) .............................................
Application:
Endorsed
NOT Endorsed
If Application rejected, detail reasons:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
Endorsement/Approval of Credentialing by Board at its meeting on (date)………………………….. Letter to
applicant advising outcome of application
YES
Copy provided in electronic file
YES
SharePoint updated with Doctor credentialing, insurance and registration details
YES
Credentialing By Laws
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BY-LAWS FOR CREDENTIALLING AND ACCREDITATION FOR HEALTH CARE PROFESSIONALS
1. The Purpose of these By-Laws.
Montserrat Day Hospitals aims to provide and maintain a high standard of medical care in
day patient procedures. The responsibility for delivery of care is between the patient and
the medical practitioner. The Montserrat Day Hospital aims to share with the professionals
the responsibility for maintenance of high standards. Montserrat Day Hospitals will ensure
professionally competent nursing staff as provided. It will provide equipment and ensure
that such equipment is maintained in good working order, checked at regular intervals and
operated by trained and approved staff. Montserrat Day Hospitals will provide for
preventative and corrective maintenance and regular checking of all emergency
equipment.
2. Authority to make and amend by-laws.
The Board is required to make and amend by-laws as it may deem necessary from time to
time. The Board will review these by-laws at least every three years.
3. The Board.
The governing body of Montserrat Day Hospitals is the Board. It delegates responsibility and
authority to credential practitioners to the credentialing committee who may recommend
accreditation for clinical privileges within the scope of practice determined by the
credentialing committee. The Board will consider all recommendations and it will, at its
discretion accredit the credentialed health care professional.
4. Period of accreditation.
The maximum period of accreditation will be three years.
5. Laps of accreditation.
The accreditation will be deemed to have elapsed:
(i)
If the period of accreditation has elapsed and the health care practitioner has not
renewed application despite three communications with them notifying them of the
lapse and opportunity to re-apply all performed in the three months prior to the time
of the accreditation lapse.
(ii)
If the practitioner is no longer registered with APHRA.
(iii)
The practitioner fails to provide evidence of current medical indemnity despite three
verbal requests and one written request to do so within two weeks.
(iv)
Fails to observe the clinical services capability framework as set out by Queensland
Health without in the view of the credentialing committee adequate explanation.
All failures to comply are to be referred to the Board for consideration and the Board
has the final determination for continuing credentialing.
6. Clinical privileges.
Montserrat Day Hospitals entitles only those health care professionals accredited with
clinical privileges to engage in care and treatment of patients at their hospitals.
Accreditation shall only be extended to competent medical health professionals, legally
registered to practice by APHRA, who can document experience and background
training. Applications for clinical privileges must be made on the prescribed form
attached.
Further documentation required is:
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Documentation of registration with APHRA
Documentation of current medical indemnity
Conjoint committee accreditation for endoscopy if endoscopy privileges are
applied for.
7. Appeals process.
Health care professionals may appeal in writing against any matters relevant to the
granting of clinical privileges. Neither Montserrat nor the health care professional may be
legally represented during any proceedings directly or indirectly related to the appeals
process.
8. Interim privileges.
The credentialing committee will meet every four months.
Should it be deemed necessary to give clinical privileges to a new or re-applying health
care professional before the next meeting then interim privileges may be given –
A] For a single list to go ahead by the credentialing committee Chairman over the phone.
B]Interim privileges until the next credentialing meeting provided proper application has
been made in writing and the credentialing committee Chairman has checked two
referee reports (of the three provided) documented these and deemed these reports to
be satisfactory.
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The credentialing committee Chairman must be satisfied:
(a) That the health care professional has APHRA registration, be aware of any
conditions on that registration and
(b) Satisfied that the candidate has current medical indemnity.
(c) Any other documentation usually required for that particular accreditation has
been supplied.
That any interim privileges would be within the guidelines set down by the Medical
Board.
Such interim privileges would not be considered controversial.
Interim privileges will lapse on the evening of the Board meeting following the next
credentialing committee meeting after the granting of interim clinical privileges.
9. Scope of Practices
The credentialing committee at its credentialing meeting will determine the scope of
practice allowed for a candidate health care professional at Montserrat Day Hospitals.
10. Change in scope of practice.
The health care professional contemplating a change in scope of practice will apply in
writing to the Secretary of the Credentialing Committee. Where the change involves a new
procedure, written application within any supporting documentation will also be sent to the
Secretary of the MAC. The committee will assess the application to make
recommendations to the Board.
11. Research.
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Any proposal for research will be submitted to the Secretary of the MAC in writing with
support documentation including ethics committee approval.
MAC will make recommendation to the Board.
12. Re-Accreditation, Re-Credentialing and Re-Defining Scope of Practice.
All accredited Health Care Professionals are to be notified no less than three months before
expiry of their Accreditation and invited to reapply, with a reapplication form.
The process for initial accreditation including re-defining scope of practice will apply,
except where the Health Care Professional has provided services for at least 12 lists, in
which case referee reports will only be required at the Chairman of The Credentialing
Committee’s discretion.
13. Complains against a Health Care Professional.
Any complaints of a nature which might suggest impairment of a health care professional
whether it is by way of physical, medical, psychiatric impairment or substance abuse will be
reported to the Secretary of the Credentialing Committee and the Chairman of the Board.
The Chairman of the Board will instruct the Chairman of the Credentialing Committee to set
up the “Council of three wise people” as outlined in the Credentialing Committee minutes
to investigate speedily the complaint and determine if:
 The privileges of the health care professional should be immediately suspended
 Suspended pending further enquiry or
 Where the complain was seen to have validity and hence be immediately referred
to APHRA
 The complaint is seen to have no validity and is dismissed.
 Any other course of action should be taken.
The “council of three wise people” will notify the Chairman of the Board or his deputy in his
absence for immediate action.
The Chairman of the Board or his Deputy will institute the recommendations immediately,
unless he determines that there are such issues requiring an extraordinary meeting of the
Board to determine if there should be consideration of any other outcome. In the latter
case he will arrange this to occur within two weeks. The health care professional under
review will have clinical privileges suspended until such time.
14. Professional capabilities for health care professionals.
(a) Interpersonal
The health care professional will act with dignity honesty and respect for –
 Staff
 Other health care professionals.
 Structure of the organisation and its change of authority and responsibility
 Quality and risk management initiatives at Montserrat Day Hospitals
(b) Patient relationship
It is expected that the health care professional will –
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Establish an empathetic relationship based on helpfulness, high quality clinical
services, and appropriate level of service relative to the clinical problem.
It is expected that patients will be continued to be treated at Montserrat Day
Hospitals unless requiring hospital admission, after which their treatment will
continue at Montserrat Day Hospitals.
15. Open disclosure
It is a policy of Montserrat Day Hospitals to adhere to the National Open Disclosure
Standard. “The open disclosure standard promotes a clear and consistent approach by
Australian hospitals to open communications with patients and their nominated support
person following an adverse event. It includes guidelines for discussion about what has
happened, why it happened, what is being done to prevent it happening again, reference
the Australian Standard for Safety and Quality in Healthcare Open Disclosure Standard
2004”.
16. Evidence based practice.
The health care professional should have expertise in accessing Cochrane library and
undertaking evidence based practice. The practitioner should have the ability to do
clinical research on the internet.
17. Personal behaviour.
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Health care professionals will maintain his/her relevant registrations and
accreditations.
Health care professionals will maintain his/her relevant “maintenance and
professional standards” and documentation of ongoing education through their
relevant college.
Health care professionals will practice with strong focus on “evidence based”
medical principles.
Health care professionals will adhere to the Queensland Government legislation and
registration.
Health care professionals will adhere specifically to the provisions of the current
Queensland Government Health Department Clinical Services capability framework.
18. General.
It is expected that the practitioner will:
 Report all incidents, hazards, complaints, and maintenance requirements using the
“Make a Commitment” process. These will include incidents becoming apparent
after discharge e.g. admission to hospital with post polypectomy bleed or aspiration
within one day of the practitioner becoming aware of the incident.
 Abide by the relevant polices and procedures of MDH including the management
of patients in the absence of the Principle Medical Officer
 Practise principle of privacy legislation.
 Keep confidential all knowledge of strategies and goals as well as commercial
factors of Montserrat Day Hospital and Digestive Health Clinics and associated
health entities.
 Keep confidential all private information of personnel within Digestive Health Clinics
and Montserrat Day Hospitals.
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Use the IT system to streamline processes within Montserrat Day Hospitals.
Practice in a manner which is cost sensitive and avoids unnecessary waste of
materials services and staff.
Maintain appropriate follow up register where appropriate.
Be aware of “key performance indicators” in the facilities and practices and use
best endeavours to achieve these.
Work as a team player in non clinical areas.
Be participative in formal ongoing education to clinical and other staff.
19. Contracted providers.
If a contract provides for the delivery of clinical services such as microbiology for validation
sterilisation by a third party contractor the contract may
(a) Only medical practitioners who have been accredited at the facility may provide the
service and
(b) Require the contractor to ensure the credentials and professional indemnity insurance
status of the medical practitioners who provide the contracted services are strictly
verified.
DEFINITIONS
Health professionals means:


Medical practitioner or dentist
Any other category approved by the Board, of persons who provide health services
Credentialing means:
The formal process used to verity the qualifications, experience, professional standing and other
relevant professional attributes of health care professionals for the purpose of forming a view as to
their competence, performance and professional suitability to provide safe, high quality health
care services in accordance with the needs and capabilities of the facility
Accreditation means:
The authorisation in writing by the Board or its representative for a Health Care Professional
to treat patients at the Montserrat Day Hospitals facilities within the Scope of Practice and in
accordance with any conditions specified in that authorisation .
Chairman of a Committee
The Chairman of the Committee will either be an appointed or elected Chairman and in their
absence a nominated deputy, a person nominated by the Board.
Quorum/Meetings
Where these by-laws refer to a meeting the following quorum requirements shall apply:
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DN:MDOC-16-961
Where there are an odd number of members of the committee or group the majority of the
members or where there is an even number of the members of the committee of group one half
the numbers of the members plus one.
Voting
Where voting on an issue is performed pursuant to these by-laws the vote of a simple majority of
those present will determine the issue.
Unless otherwise provided by these by-laws if there is an equality of votes the Chairperson shall
have a casting vote in addition to a deliberative vote.
Proxy voting is not permitted.
Definitions:
Principle Medical Officer
The medical practitioner primarily responsible for the patient.