1. society
2. welfare
3. healthcare
4. hospital

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CHRISTUS Santa Rosa HOSPITAL
MEDICAL STAFF
MEMBERSHIP, CREDENTIALING, PRIVILEGING AND DUE PROCESS MANUAL
TABLE OF CONTENTS
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
APPOINTMENT AND REAPPOINTMENT PROCEDURE
PROCEDURES FOR DELINEATING PRIVILEGES
CORRECTION ACTION
PRACTITIONER RIGHTS
FAIR HEARING PLAN
APPELLATE REVIEW
DUE PROCESS PROCEEDING
ADOPTION AND AMMENDMENTS
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Definitions: Please refer to the Bylaws for definitions
I.
APPOINTMENT AND REAPPOINTMENT PROCEDURE
A.
Pre-Application Requirements. Unless specifically authorized by the CEO, each
potential applicant will complete an application request form and submit curriculum
vitae which will be considered a pre-application. This pre-application will be submitted
to the facility Administrator, for the primary practice site as determined by the
applicant or designee, who will determine if the applicant meets the basic qualifications
for staff membership as outlined in the Medical Staff Bylaws. Upon receipt and review of
the request form and curriculum vitae the facility Administrator or his designee will
promptly notify the applicant if an application may be offered. If the applicant does
not meet the basic qualifications to be considered for the requested privileges, the
applicant will be promptly notified. If the applicant meets the minimum requirements, the
facility Administrator, or designee will send the applicant a Texas standardized application.
The Practitioner will also be provided a copy of, or access to, the Medical Staff Bylaws,
Rules and Regulations, Manuals and Policies and Procedures. Practitioners or other
individuals who are not eligible to receive an application shall not be entitled to any
procedural rights of review in connection with such ineligibility.
B.
Application Form
1.
The applicant shall complete the Texas Standardized Credentialing Application
(“TSCA”) and any facility specific addendum as specified, as may be amended
from time to time. Each application shall include an acknowledgment by the
Practitioner of the conditions of appointment as set forth in the Medical Staff
Bylaws and any authorizations and releases necessary to effectuate those
provisions.
2.
In addition to the information submitted on the TSCA every applicant for initial
appointment and reappointment must complete the addendum and provide the
following:
a) health status information:
b) proof of professional liability insurance coverage as required by the Board
and narrative information on malpractice claims history and experience
(suits and/or settlements made, whether concluded or pending) during
the past five (5) years for initial appointment and for reappointment the
past two (2) years covering the appointment period.
c) desired Department (and Section if available) assignment,
d) desired Medical Staff category, active, courtesy, consulting, on-call,
honorary, affiliate
e) a completed core privilege form specifying specific clinical privileges being
requested;
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f) at least two (2) letters of recommendation in the form required from peers
who have substantive knowledge of the Practitioner's professional
competence, ethical character and any other matter requested. Only
one of the references may be from an associate in practice with the
applicant.
g) a Medicare/Medicaid Acknowledgement Statement,
h) a Priority Number Request Form,
i)
the Background Check Authorization
j)
A color photo and a copy of the applicant’s current driver’s license,
3. The applicant for appointment or reappointment shall update the information on
the application form, including all changes in status during the processing of
and/or during the term of appointment, within fifteen (15) days of notice of action
or a status change is given.
C.
Effect of the Application. The Practitioner must sign the application and in so doing
agrees to comply with the obligations of appointment, as well as:
1. attests to the correctness and completeness of all information furnished;
2. signifies his/her willingness to appear for interviews and provide requested
information in connection with his/her application;
3. authorizes and consents to Hospital and Medical Staff representatives consulting
with any third parties who may have information bearing on professional
competence and conduct or other matters under review and to their inspecting
all records and documents pertaining to such information; and
4. releases from any liability all those who, in good faith and without malice, provide,
review or act on information regarding the Practitioner's competence,
professional ethics, character, health status, and other qualifications for
Medical Staff appointment and clinical privileges as provided in the Medical Staff
Bylaws.
D. Review and Approval Process.
1. Submission of Application. The application for appointment shall be submitted to
the facility Physician Services Department which shall issue appropriate
inquiries to third parties and perform primary source verification. An application
shall not be considered complete until all requested information has been
received. If the application remains incomplete six months after receipt, it will
automatically be withdrawn and special notice issued to the applicant.
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2. Department. The facility Physician Services Department shall forward a completed
copy of the application and clinical privileges requested to the facility
Department Chair/Section Chair in which the Practitioner has requested clinical
privileges. The facility Department Chair/Section Chair shall review and
investigate the Practitioner's qualifications and may interview the Practitioner
and request any additional information as necessary. The facility Department
Chair/Section Chair shall, within fourteen (14) days of receipt of the application
and all requested information submit a recommendation to the facility
Credentials & Privileges Committee in writing as to whether the Practitioner
possesses the necessary qualifications and satisfies the Department's criteria to
exercise the clinical privileges requested and whether any conditions should be
imposed on his/her exercise of such privileges. If the facility Department
Chair/Section Chair concludes that he/she cannot recommend the applicant or
recommends restriction, he/she shall, he/she it shall include the reasons in the
recommendation submitted to the facility Credentials & Privileges Committee.
3. Credentials & Privileges Committees/MEC and Medical Board review. The facility
Credentials & Privileges Committee shall review the recommendations of the
Department(s) and investigate the qualifications of the Practitioner and shall,
within sixty (60) days of receipt of the completed application and all requested
information, issue a written recommendation that the application be accepted,
accepted with modifications, or denied. As necessary, the facility Credential
&Privileges Committee may interview the Practitioner or may appoint a
subcommittee to conduct additional investigation. Within sixty (60) days of
receipt of the completed application and all requested information, the facility
Credentials Committee shall forward the application and its written
recommendation that the application be accepted, accepted with modification,
or denied to the next scheduled meeting of the facility MEC.
4. Facility Medical Executive Committee. At its next regular meeting after receipt of
a recommendation from the facility Credentials & Privileges Committee, the
facility MEC shall review the recommendation, investigate further is necessary,
the matter, and issue a favorable or adverse recommendation to the Medical
Board. The facility MEC shall transmit to the Medical Board the completed
application and all other documentation considered in arriving at its
recommendation.
5. Medical Board. At its next regular meeting after receipt of the facility Medical
Executive Committee’s recommendation, the Medical Board shall review the
recommendation. If the recommendation of the Medical Board is in support of
the application the recommendation will be forwarded to the Board of Directors
for action. If the recommendation of the Medical Board is adverse to the
Practitioner, the President/CEO shall provide the Practitioner with a copy of the
Medical Board’s recommendation by Special Notice. The Practitioner shall be
entitled to the Fair Hearing procedures, Section VIII, and all further procedures
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procedures shall be in accord therewith.
6. No Activity. Physicians who are unable to provide the required case activity at
appointment /reappointment or who do not have activity at CHRISTUS Santa Rosa
Health Care may require proctoring in order to gain or renew privileges or may be
subject to denial of privileges without prejudice.
7. Expedited Credentialing and Privileging Process
To expedite initial appointments, reappointments, or renewal or modification of
privileges, the Practitioner may be granted Temporary Privileges by a subcommittee of
the Board, acting with full authority of the Board, as further described in the CSRHC
Region Bylaws.
8. An applicant shall not be eligible for the expedited process if at the time of
appointment or reappointment, any of the following has occurred:
The applicant submits an incomplete application;
The Medical Board makes a final recommendation that is adverse or has limitations;
There is a current challenge or a previous challenge to licensure or registration;
The applicant has received an involuntary termination of Medical Staff membership
at another organization; or
The applicant has received an involuntary limitation, reduction, denial, or loss of
clinical privileges.
E. Reappointment
1. Data Collection. Prior to consideration for reappointment, the facility Physician
Services Department shall assemble current information from the Hospital on the
Practitioner's professional activities, performance and conduct in the Hospital during the
prior term of appointment. Such information shall be available to the Department and
Committees reviewing the reappointment application and should include patterns of
care as demonstrated in the findings of quality assurance/improvement activities;
participation in relevant internal teaching and continuing education activities;
level/amount of clinical activity (patient care contacts at the facility); timely accurate
completion of medical records and compliance with all applicable records policies;
compliance with all Medical Staff Bylaws, Rules and Regulations, Policies and patients
and the Hospital; and cooperativeness in working with other Practitioners, Allied Health
Professionals and Hospital personnel.
2. Submission of Application.
At least one hundred twenty (120) days prior to the expiration of the term of
Medical Staff appointment, each Medical Staff Practitioner shall be mailed an
application for reappointment. Each Practitioner who desires reappointment
shall, at least ninety (90) days prior to such expiration date, send the completed
application for reappointment to the facility Credentials & Privileges Committee.
An application shall not be considered complete until all requested information
has been received. Following receipt of a complete application for
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reappointment, the application shall be processed in accord with the procedures
set out in this Manual.
3. Failure to return a complete application for reappointment within the time periods
required may result in non-consideration of the application and termination of
appointment on the expiration date, without any procedural rights of review.
Thereafter, the Practitioner shall be required to submit an initial application which
shall be processed pursuant to procedures set out in this Manual.
4. Department/Section Review. The facility Department Chair/Section Chair shall review
the reappointment application; primary source verifications, Practitioner profile
information and all requested information and will submit a recommendation to the
facility Credentials & Privileges Committee. If the facility Department Chair/Section
Chair concludes that he/she cannot recommend the applicant for reappointment or
recommends restriction, he/she shall include the reasons in the recommendation
submitted to the facility Credentials & Privileges Committee.
5. Credentials & Privileges Committees. The facility Credentials & Privileges Committee
shall review the recommendations of the Department(s), all requested information and
issue a written recommendation that the reappointment application be accepted,
accepted with modifications, or denied. As necessary, the facility Credential
&Privileges Committee may interview the Practitioner or may appoint a subcommittee
to conduct additional investigation. The facility Credentials & Privileges Committee's
recommendation shall be forwarded to the facility MEC and shall be accompanied by
the completed reappointment application, results of the investigation and all other
documentation considered by the committee.
6. Facility Medical Executive Committee. At its next regular meeting after receipt of a
recommendation from the facility Credentials & Privileges Committee, the facility MEC
shall review the recommendation, investigate further if necessary, the matter, and
issue a favorable or adverse recommendation to the Medical Board. The facility MEC
shall transmit to the Medical Board the completed application and all other
documentation considered in arriving at its recommendation.
7. Medical Board. At its next regular meeting after receipt of the facility Medical
Executive Committee’s recommendation, the Medical Board shall review the
recommendation. If the recommendation of the Medical Board is in support of the
application the recommendation will be forwarded to the Board of Directors for action.
If the recommendation of the Medical Board is adverse to the Practitioner, the
President/CEO shall provide the Practitioner with a copy of the Medical Board’s
recommendation by Special Notice. The Practitioner shall be entitled to the Fair Hearing
procedures, Section VIII, and all further procedures shall be in accord therewith.
8. Status Pending Review. In the event a practitioner, who is seeking reappointment,
is under investigation or is in the fair hearing process, the reappointment will be
processed as per the normal procedure in order to continue privileges and
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membership during the duration of the fair hearing process; provided however that
any emergency corrective action or any other restrictions and conditions that have
been imposed will remain in effect during processing and consideration of the
application for reappointment, pending the outcome of any procedural rights of
review and final action by the Board of Directors.
E. Leave of Absence.
1. Request. A leave of absence may be granted to a Practitioner upon written request to
the facility Chief of Staff, with a copy to his/her Department Chair/Section Chair and
the facility Administrator, and approval by the Medical Board and Board of Directors.
The request must recite the reason and expected duration of the requested leave of
absence.
2. Reinstatement. A Practitioner may request reinstatement following an approved
leave of absence upon submitting documentation of continuing compliance with all
qualifications and obligations of appointment set forth in the Medical Staff Bylaws,
through updating of the reappointment form. The request for reinstatement must
be reviewed and approved by the facility MEC and recommendation sent to the
Medical Board and the Board of Directors in accord with the procedures in this
Manual.
3. Leave of Absence. A Practitioner may not practice at any CHRISTUS Santa
Rosa Health Care facilities during his/her leave of absence.
4. Procedural Rights. Failure to grant reinstatement when the Practitioner has met
all requirements for reinstatement shall entitle the Practitioner to the procedural
rights of review specified herein.
F.
Resignation or Change in Staff Category. A Practitioner may at any time submit to the
President of the Medical Staff, facility Chief of Staff or his/her Department Chair/Section Chair
or the facility Administrator via the Medical Staff Office, a written request to resign on a stated
date any or all clinical privileges and/or Medical Staff appointment or to change Medical Staff
category. If the request is accepted by the Medical Board and Board of Directors, the change
shall be effective on the date requested by the Practitioner and shall not require further action
or review.
G.
Clinical Privileges for a New Procedure or Service
Requests for clinical privileges or services not currently performed at a CHRISTUS Santa
Rosa Hospital facility or for established procedures associated with a new technique or
technology shall be granted as described below. The facility Credentials Committee shall
determine whether the procedure, service or technology is distinctly new and
qualifies for this category of credentialing.
1. The applicant shall make the facility Medical Staff Services Office and/or the facility
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Chief of Staff aware of the request for a new procedure or service and be prepared
to provide the facility Department Chair/Section Chair and the facility
Credentials Committee with information pertaining to the procedure or service
including clinical efficacy, community need, need for additional equipment and
personnel, as well as, cost and potential for reimbursement.
2. After review of the recommendations from the facility Department Chair/Section Chair
The
facility
Credentials
Committee
and
the
facility
MEC
shall determine whether to offer the procedure or service and make their
recommendation known to the Board through the Medical Board.
3. With recommendation from the facility Department Chair/Section Chair the facility
Credentials Committee shall then develop criteria to determine those individuals who
are eligible to request the clinical privileges. The Credentials Committee shall conduct
research and consult with experts to determine:
a. The minimum education, training, and experience necessary to
perform the procedure or service,
b. The extent of proctoring and supervision that should occur if the
privileges are granted, and
c. Monitoring criteria once privileges are granted.
4. Once the credentialing criteria are established, application for the privilege shall
proceed in accordance with the Medical Staff Bylaws and this Manual.
H.
Adding Clinical Privileges
Whenever a Medical Staff appointee requests additional privileges for established
procedures and existing technology, the following process shall be followed:
1. The applicant must request the privilege from the facility Credentials committee in writing.
2. The applicant must provide written evidence of relevant training and/or experience.
3. The facility Department Chair/Section Chair will review and make a recommendation
related to the applicants request for additional privileges.
4. The facility Credentials Committee will review the competency documentation and
recommendations of the facility Department Chair/Section Chair and, as needed, other
practitioners who have supervised and observed the applicant perform the requested
privilege or service.
5.
The facility Credentials Committee shall forward a recommendation to the facility
MEC which shall review the matter and forward a recommendation to the Medical
Board and Board for final action.
6. Following approval by the Board, an appointment letter will be forwarded to the applicant
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by the facility Administrator describing the addition of clinical privileges.
II. PROCEDURE FOR DELINEATING PRIVILEGES
A. Requests. Each application for appointment and reappointment to the Medical Staff must
contain a request for the specific clinical privileges desired by the Practitioner. Specific
requests must also be submitted for temporary privileges.
B. Processing Requests. All requests for clinical privileges will be processed according to the
procedures outlined herein, as applicable. Requests for clinical privileges from dentists and
podiatrists are processed in the same manner as requests from physicians.
C. General Competency Evaluation (GCE)
Applicants and members of the medical staff must satisfactorily exhibit the six (6) general
competencies at the time of appointment and reappointment. The general competencies of the
practitioner can be ascertained in several ways:
1.
Peer references that affirmatively attest to the general competencies of the
practitioner, along with a positive recommendation for appointment or reappointment
to the medical staff.
2.
The decision of the facility Department, Credentials Committee, and the Medical
Executive Committee (MEC) that the practitioner exhibits the general competencies
based on the practitioner’s relevant education, training and experience and known
information about the practitioner’s performance.
3.
Specific information that may arise out of ongoing and/or focused evaluation of a
practitioner that affirmatively or adversely speaks to that practitioner’s general
competencies.
4.
A practitioner who is unable to satisfactorily exhibit the general competencies
outlined in this policy may be subject to the focused evaluation of his or her
professional practice, as described in this policy.
a. Patient Care
Practitioners are expected to provide patient care that is compassionate,
appropriate & effective for promotion of health, prevention of illness,
treatment of disease, & care at end of life.
b. Medical/Clinical Knowledge
Practitioners are expected to demonstrate knowledge of established &
evolving biomedical, clinical &social sciences, and the application of their
knowledge to patient care and the education of others.
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c. Practice-based Learning & Improvement
Practitioners are expected to be able to use scientific evidence and methods
to investigate, evaluate, and improve patient care practices.
d. Interpersonal & Communication Skills
Practitioners are expected to demonstrate interpersonal & communication
skills that enable them to establish & maintain professional relationships
w/patients, families, & other members of health care teams.
e. Professionalism
Practitioners are expected to demonstrate behaviors that reflect commitment
to continuous professional development, ethical practice, understanding and
sensitivity to diversity, & responsible attitude toward their patients, their
profession, & society.
f. Systems Based Practice
Practitioners are expected to demonstrate both an understanding of contexts
& systems in which health care is provided, & ability to apply this knowledge
to improve and optimize health care.
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D. Privilege Determinations. The Practitioner shall be considered and granted clinical privileges
upon demonstration of current competence. Privileges are granted consistent with the
Practitioner's documented training and/or experience in requested categories of treatment
and/or procedures, his/her therapeutic results and the conclusions drawn from quality
assessment. The Practitioner shall have the burden of establishing his/her qualifications and
competence to exercise the clinical privileges being requested. Failure to submit requested
information or adequate documentation shall result in the request not being considered and the
Practitioner shall therefore not be entitled to any procedural rights of review as a result of
such non-consideration. Each Practitioner appointed to the Medical Staff is entitled to exercise
only those clinical privileges specifically granted to him/her by the Board.
E. Telemedicine. For the purpose of this policy, telemedicine is defined as official readings of
images, tracings, or specimens provided by licensed independent practitioners through a
telemedicine link. These clinical services are provided by consultation, contractual
arrangements, or other agreements. Practitioners who provide interpretative or consultative
telemedicine services are credentialed and privileged through the Medical Staff process.
The service site may use credentialing information from the remote site where the
practitioner who provides professional services is located provided that the remote site is an
accredited organization by The Joint Commission.
1. Procedure for Telemedicine privileges
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a. The facility Chief of Staff, Department Chair/Section Chairs, and/or Medical Directors may
recommend to facility administration the need and source of telemedicine services.
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b. The nature and scope of telemedicine services provided are defined in writing. If the
contracted individuals are credentialed and privileged by a Joint Commission-accredited
organization, the contract will require that only those services are provided by licensed
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independent practitioners are within the scope of his or her privileges at the outside
organization. The individuals under the control of the Joint Commission-accredited
organization are required to complete a medical staff application in accordance with this
Manual. The Joint Commission-accredited organization may provide the Facility with the
primary source verification used to complete the application. The facility may use the provided
primary source verification from the remote accredited site and any additional primary source
verification needed to determine appointment to the Medical Staff.
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c. If the contract is with individuals who are not credentialed and privileged by a Joint Commission
accredited organization all licensed independent practitioners who will be providing
telemedicine services will be required to complete a medical staff application in accordance
with the Medical Staff Bylaws. Medical Staff membership is not required.
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d. The facility Performance Improvement Committee evaluates the contracted telemedicine
service to determine whether it is being provided according to the contract and clinical services
offered are consistent with commonly accepted quality standards. The facility retains overall
authority for services furnished under a telemedicine contract.
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F.
Disaster Privileges
Disaster privileges may be granted only when the Emergency (Disaster) Preparedness
Management Plan has been activated, and the available Medical Staff cannot manage all
immediate patient needs.
1. During disaster(s) in which the Emergency (Disaster) Preparedness Management
Plan has been activated, the facility President/CEO or his or her designee(s),
the facility Chief of Staff or his or her designee(s), as described in the Plan, has
the option to grant disaster privileges to individuals presenting appropriate
identification. Decisions regarding such privileges shall be made on a case-bycase basis. Privileges expire upon termination of the disaster.
2. Appropriate identification presented shall include, at a minimum, one of the
following:
• A current picture facility ID card that clearly identifies professional
designation
• A current license to practice
• Primary source verification of the license
• Identification indicating that the individual is a member of a Disaster
Medical Assistance Team (DMAT), or MRC, ESAR-VHP, or other recognized
state or federal organizations or groups
• Identification indicating that the individual has been granted authority to
render patient care, treatment and services in disaster circumstances; such
authority having been granted by a federal, state or municipal entity
• Identification by current Hospital or Medical Staff member(s) who possess
personal knowledge regarding volunteer’s ability to act as a licensed
independent practitioner during a disaster
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3. The scope of services provided shall be within the individual’s education,
training and experience. Physicians given disaster privileges will be assigned to
a medical staff(s) member who will mentor and oversee the medical care
delivered and who shall report to the Chief of Staff or their designee regarding
issues of questioned competency.
4. A physician granted disaster privileges will be identified through a facility
identification badge.
5. Primary source verification of licensure will begin as soon as the immediate
situation is under control and is completed within 72 hours from the time the
volunteer practitioner presents to the organization. In the extraordinary
circumstances that primary source verification cannot be completed in 72
hours, it is expected that it be done as soon as possible. In this extraordinary
circumstance, there must be documentation of the following: why primary
source verification could not be performed in the required time frame;
evidence of a demonstrated ability to continue to provide adequate care,
treatment and services; and an attempt to rectify the situation as soon as
possible. Primary source verification of licensure would not be required if the
volunteer practitioner has not provided care, treatment and services under the
disaster privileges.
6. Within 72 hours, the facility Administrator and/or the Chief of Staff shall make
a decision based on the information obtained regarding the professional
practice of the volunteer, related to the continuation of the disaster privileges
initially granted.
G.
Temporary Privileges. The facility Administrator, or designee, shall have the authority
to grant, in conjunction with the President of the Medical Staff, facility Department/Section
Chief, or facility Chief of Staff temporary clinical privileges under the following two (2)
circumstances. Once granted, the applicant shall exercise such privileges under the supervision
of the facility Department/Section Chief and for the duration of the temporary privileges only.
An individual is not entitled to any procedural rights of review because his/her request for
temporary privileges is refused or because all or any portion of his/her temporary privileges are
terminated.
1. Fulfillment of an Important Patient Care Need. Temporary privileges may be
granted on a case by case basis when there is an important patient care need
that mandates an immediate authorization to practice, for a limited period of
time, while the full credentials information is verified and approved. Examples
would include, but are not limited to:
a) Locum Tenens coverage for vacation or illness or
b) Care to specific patient by a Practitioner with skill not possessed by a
current facility Medical Staff member.
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c) In these circumstances, temporary privileges may be granted by the CEO, or
designee, upon recommendation of the Department Chair/Section Chair, facility
Chief of Staff or the President of the Medical Staff provided there is verification
of:
i) Current licensure
ii) Current competence
iii) Current malpractice insurance
2. Pendency of Application. When an applicant with a complete, clean application is
awaiting review and recommendation by the MEC, Medical Board and approval by
the Board of Directors temporary privileges may be granted for a limited period of
time, not to exceed ninety (90) days, by the facility Administrator upon
recommendation of the Department Chair/Section Chair, facility Chief of Staff or
the President of the Medical Staff provided that there is verification of the
following:
a. Current Texas licensure
b. Current malpractice insurance
c. Relevant training or experience
d. Current competence
d. Ability to perform the privileges requested
e. The results of National Practitioner Data Bank query have been obtained and
evaluated and
f. The applicant has:
i)
a complete application
ii)
no current or previously successful challenge to licensure or registration
iii)
not been subject to involuntary termination of medical staff
membership at another organization
iv)
not been subject to involuntary limitation, reduction, denial, or loss of
clinical privileges
H. Denial or Termination of Temporary Privileges. Any individual authorized to impose
emergency corrective action as described in the Corrective Action and Fair Hearing Manual may
terminate any or all temporary privileges at any time. The facility Department Chair/Section
Chair shall assist any patient(s) remaining in the facility in the selection of a Practitioner to
provide care until discharge or transfer. Any action involving temporary privileges taken on
behalf of the facility MEC or the Medical Board in the course of their professional review activity
shall not be considered a complete or final professional review action. The Practitioner shall not
be entitled to any procedural rights of review as a result of denial of a request for temporary
privileges, the imposition of any conditions on the exercise of temporary privileges, or
termination of temporary privileges.
I. Out of State License. A physician licensed in another state who has been granted permission
to practice in the State of Texas by the appropriate licensing board such as the Texas State
Board of Medical Examiners may be granted temporary privileges with the approval of the
facility Department Chair/Section Chair and the facility Administrator for a period not to exceed
thirty (30) days to assist staff physicians in learning or performing new procedures or
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treatments.
J. Allied Health Professionals.
1. General. Qualified individuals in the Allied Health Professional categories approved
by the Board of Directors may be granted clinical privileges in accord with the
procedures and requirements set forth in this Manual. Allied Health
Professionals are not eligible for Medical Staff appointment and are not entitled
to any procedural rights of review afforded to Practitioners. Recognizing that
each facility under the Santa Rosa Hospital system may have different patient
needs each facility MEC may determine the categories of AHP which may
practice within the specific facility.
2. Duties. Each Allied Health Professional shall be assigned to a facility Department
and must comply with any Hospital requirements, as well as Medical Staff
requirements, including:
a) providing emergency services and consultation as required by the facility
Department or facility MEC;
b) retaining appropriate responsibility within his/her area of professional
competence for the care and supervision of patients for whom he/she is
providing services, subject to the authority of the patient's attending
Practitioner; and
c) cooperating and participating in performance improvement, quality
assurance, team and committee activities of the facility Department,
Medical Staff and/or Hospital.
d) Fulfilling those responsibilities required by the Rules and Regulations, and if
not so specified, meeting those responsibilities specified in this Manual
as are generally applicable to the more limited practice of the Allied
Health Professional. The decision on whether each applicant will
practice independently or dependently will be determined by the
applicant’s current licensure, registration or certification as well as
facility MEC policy.
3. Pre-Application Requirements. Applications for clinical privileges for Allied Health
Professionals shall be provided only to individuals in disciplines or categories
that have been approved by the Board of Directors and who can document
current licensure, registration or certification, as well as professional liability
insurance if required by the Board. The Allied Health Professional shall be
provided with a copy of or access to the Medical Staff Bylaws and the Rules and
Regulations. Individuals who are not eligible to receive an application shall not
be entitled to any procedural rights of review in connection with such
ineligibility.
4. Criteria for Clinical Privileges. Prior to offering or granting clinical privileges, each
facility Department must recommend, in writing, the minimum or threshold
qualifications and criteria for exercise of the privileges. Qualifications and
criteria may relate to training, experience, specialty or sub-specialty
certification and other pertinent factors. Recommended qualifications and
criteria must be approved by the facility Credentials & Privileges Committee,
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the facility MEC, the Medical Board and by the Board of Directors and shall form
the basis for clinical privileges recommendations.
5. Application Form. The application forms for initial clinical privileges and renewal
shall be approved by the facility Administrator after consultation with the
facility MEC which shall send a recommendation to the Medical Board, and shall
require substantially the same information as Medical Staff applications for
Practitioners.
6. Credentialing. Applications from Allied Health Professionals shall be processed in
accord with the facility credentialing procedures used for Practitioners. The
facility Credentials & Privileges Committee and facility MEC and Medical Board
may delegate the credentialing functions for Allied Health Professionals to
subcommittees. Allied Health Professionals shall be subject to the requirements
of this Manual.
7. Corrective Action. Allied Health Professionals shall be subject to the corrective
action procedures used for Practitioners. In the event of an adverse
recommendation, the professional shall not be entitled to the procedural rights
of review afforded to Practitioners, but shall be afforded the right to an
interview as set forth herein.
8. Procedural Rights of Review. Notwithstanding any provisions in the Medical Staff
Bylaws or this Manual to the contrary, Allied Health Professionals shall not be
entitled to the procedural rights of review afforded to Practitioners. In the
event of an adverse recommendation pertaining to an Allied Health Professional,
the professional shall be informed of the recommendation by Special Notice and
shall have thirty (30) days to submit a written request for an interview with the
facility MEC, Medical Board or the Board, whichever issued the adverse
recommendation.
a) The interview shall be scheduled within thirty (30) days of receipt of a timely
request and shall be held by the facility MEC or a subcommittee. The Allied
Health Professional may submit any information prior to or during the
interview pertaining to his/her qualifications to exercise the clinical
privileges being requested. The professional may not be accompanied by an
attorney.
b) The facility MEC, Medical Board or Board may change their recommendation
as a result of the interview and, if so, shall give the Allied Health
Professional Special Notice of the decision. The decision of the Board is final
III. CORRECTIVE ACTION
Automatic Action. Occurrence of any of the following events shall operate as an
automatic limitation, suspension or termination of the Practitioner's clinical privileges
and/or Medical Staff appointment as specified below. Automatic action shall not
preclude other corrective action on the same or similar grounds. Failure of a
Practitioner to report the occurrence of any of the events shall be grounds for
corrective action, in addition to any automatic action.
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A. Grounds
1) License: If a Practitioner's license is revoked, his/her Medical Staff
appointment and all clinical privileges are immediately terminated. If
the Practitioner's license is suspended, his/her Medical Staff
appointment and all clinical privileges are suspended for the term of
the license suspension. If the Practitioner's license is limited or
restricted, any affected clinical privileges are similarly limited or
restricted for the term of the license limitation or restriction. If a
Practitioner is placed on probation by his/her Texas licensing board,
his/her voting and office-holding privileges are automatically
suspended for the term of the probation. If a practitioner fails to
provide proof of current licensure, his/her appointment and clinical
privileges are immediately suspended; however once the Practitioner
shows proof of a current licensure his/her appointment and clinical
privileges will be immediately reinstated.
.
2) Controlled Substances Registration: Whenever a Practitioner's state or
federal authority to prescribe controlled substances is revoked,
suspended or limited for cause, his/her clinical privileges to prescribe
controlled substances shall be similarly revoked, suspended, or limited.
If a practitioner’s fails to provide proof of current DEA and/or DPS due
to an administrative delay , such as failure to timely pay the fee,
his/her appointment and clinical privileges to prescribe are immediately
suspended.
3) Professional Liability Insurance: Whenever a Practitioner fails to maintain
professional liability insurance as required by the Board, all clinical
privileges are immediately suspended pending receipt of documentation
acceptable to the facility Administrator that insurance has been
reinstated and the required insurance coverage has been secured for
any period during which insurance had lapsed. Failure to provide such
documentation within thirty (30) days shall automatically terminate
his/her Medical Staff appointment and privilege.
4) Medical Records Completion: Failure to complete medical records within the
time limits established by the Medical Staff Rules and Regulations and
Hospital policies, shall automatically suspend (except with respect to his
ability to care for patients already in the Hospital and those previous to
suspension who were scheduled for admission or procedures)the
Practitioner’s right to admit patients and to provide any other
professional services and shall remain so suspended until all delinquent
medical records are completed.
B. Procedural Rights of Review. Except as otherwise described in this Manual and
Medical Staff Bylaws, the Practitioner shall not be entitled to any procedural rights
of review for any automatic action.
C. Reinstatement following an Automatic Action
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1) License: A Practitioner whose license is reinstated after revocation or
suspension must seek initial appointment in accord with the Medical Staff
Bylaws. Where licensure restrictions are terminated, before full clinical
privileges are restored the facility MEC shall review the matter pursuant to
the corrective action procedures and may file a request for routine
corrective action. Clinical privileges shall not be restored until resolution of
the request for corrective action.
2) Controlled Substances Registration: When a controlled substances
registration is restored following revocation, suspension, or limitation,
before full clinical privileges to prescribe are restored, the facility MEC
shall review the matter pursuant to the corrective action procedures
and may file a request for routine corrective action. Clinical privileges
shall then not be restored until resolution of the request for corrective
action. Where controlled substances registration is restored following
revocation, suspension, or limitation due to an administrative oversight,
as described above, the privileges will be restored once proof of current
registration is provided.
3) Professional Liability Insurance: Upon presentation of a certificate of
insurance as required by the Medical Staff Bylaws to the facility
Administrator within thirty (30) days (including coverage for any periods
during which insurance lapsed), the automatic suspension shall
terminate. If the suspension exceeds thirty (30) days, it shall
automatically become a termination of Staff appointment and the
Practitioner shall be required to seek initial appointment in accord with
the Medical Staff Bylaws.
4) Medical Records Completion: Upon completion of medical records as
required in the Rules and Regulations, the automatic suspension of
admitting and consulting privileges shall terminate. A Practitioner who
involuntarily resigns Medical Staff appointment and clinical privileges
for failure to comply with medical records completion requirements
shall be required to seek initial appointment in accord with the Bylaws.
D. Notice. The facility Administrator shall notify the Practitioner, the facility MEC, the
Medical Board and Department Chair/Section Chair of termination or an
automatic action.
Emergency Corrective Action
A. Grounds. Whenever a Practitioner's conduct requires that immediate action be
taken to protect the life or to reduce the substantial likelihood of injury or damage
to the health or safety of a patient, a Practitioner , associate , or other person
present in the Hospital:
1) the President of the Medical Staff, the facility Chief of Staff or a facility
Department Chair/Section Chair may, with the concurrence of the
facility Administrator, immediately suspend all or any portion of the
clinical privileges of the Practitioner, or
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2) The facility Administrator, in consultation with the President of the Medical
Staff and the facility Chief of Staff, may immediately suspend all or any
portion of a Practitioner's clinical privileges
B. Imposition of emergency corrective action is an initial step in the professional
review activity, but is not a complete or final professional review action in and
of itself.
C. Investigation. The facility Administrator shall give the Practitioner Special Notice of
the imposition of emergency corrective action. Within fifteen (15) days of the
emergency corrective action being imposed, the facility MEC shall appoint a
committee to investigate the grounds for the action, which shall include an
interview with the Practitioner, and issue a recommendation to the facility MEC
and the Medical Board to (a) continue the emergency corrective action; (b)
terminate the emergency corrective action and initiate routine corrective
action; or (c) terminate the emergency corrective action and take no further
action.
D. Facility MEC. At its next regular meeting, of if necessary at a special called
meeting, after receipt of the investigating committee’s report and
recommendation, the facility MEC shall make a recommendation to the Medical
Board of Directors regarding the imposition of corrective action. The Medical
Board may, but is not required to, afford the Practitioner an interview and may
conduct additional investigation before issuing its recommendation. The
recommendation may include, without limitation:
1) rejecting the request for corrective action;
2) issuing a warning letter of admonition, or letter of reprimand;
3) imposing a term of probation which is defined as mandatory chart review;
4) imposing continuing medical education requirements;
5) reducing, limiting, suspending, or revoking clinical privileges; or
6) suspending or revoking staff appointment
E. When the recommendation of the Medical Board is not adverse to the Practitioner,
the Medical Board shall inform the facility Administrator of its recommendation
and the facility Administrator shall forward the recommendation to the
Practitioner.
F. When the recommendation of the Medical Board is adverse to the Practitioner, the
Medical Board shall inform facility Administrator and the facility Administrator
shall notify the Practitioner by Special Notice and provide the Practitioner with
a copy of the Medical Board's recommendation. The Practitioner shall be
entitled to the procedures provided for herein, and all further procedures shall
be in accord therewith.
G. The individual or medical staff committee who impose an emergency corrective
action may, at any time, terminate the emergency corrective action, and
convert the recommendation to one for routine corrective action, in which case
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the procedures herein shall apply.
Routine Corrective Action
A. Grounds. When a Medical Staff Member engages in conduct , whether within or
outside of the Hospital, that:
1) is reasonably likely to be detrimental to patient safety
2) violate Medical Staff Bylaws, Rules or Regulations, Policies and Procedures,
or accepted professional standards of practice or conduct; or
3) violate any medical staff policies relative to Professional Conduct and/or
Physician Health, then
corrective action against the Practitioner may be imposed.
B. Interview. Before corrective action is formally requested against a Practitioner, the
individual or Committee authorized to request corrective action may afford the
Practitioner an interview, at which the circumstances prompting consideration
of corrective action are discussed and the Practitioner is permitted to present
relevant information in his/her own behalf. This interview is not a hearing or
procedural right of the Practitioner and need not be conducted according to the
procedural rules provided.
C. Request.
1) Corrective action must be requested in writing by an officer of the Medical
Staff, a Medical Staff Committee, a Department Chair/Section Chair, or
the facility Administrator.
2) A request for routine corrective action shall be submitted in writing to the
facility MEC, signed by the requesting party and include the specific
reason or basis for the request, as well as a description of the conduct
or events prompting the request.
D. Investigation. Upon receipt of a request for routine corrective action, the facility
MEC shall review the request and initiate an investigation, to be performed by
the facility MEC itself, a subcommittee, a special committee or a Department
("investigating committee").
1) In determining whether adequate grounds for corrective action exist, the
investigating committee shall consider all available evidence and shall not
be limited to the examination of any particular incident or event, or to
incidents or events occurring within the Hospital or the System.
2) The Practitioner for whom corrective action has been requested shall be
advised of the request by the facility MEC by Special Notice and shall
have an opportunity to appear before the investigating committee in the
course of its investigation. At such appearance, the Practitioner shall
be invited to provide information about any matter(s) being considered
by the investigating committee. This appearance shall not constitute a
hearing, shall be preliminary in nature, and none of the procedural
rights of review shall apply. The Practitioner may not be accompanied
by an attorney. The Practitioner shall not be entitled to be present
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be present during interviews with any witnesses, or committee
deliberations or voting, nor may he/she tape record his/her
appearance.
3) Within thirty (30) days of initiation of the investigation, the investigating
committee shall make a written report to the facility MEC regarding the
investigation and describing grounds for or against corrective action.
E. Facility MEC. At its next regular, or if necessary at a special called, meeting after
receipt of the investigating committee’s report and recommendation, the
facility MEC shall make a recommendation to the Medical Board regarding the
imposition of corrective action. The Medical Board may, but is not required to,
afford the Practitioner an interview and may conduct additional investigation
before issuing its recommendation. The recommendation may include, without
limitation:
1) rejecting the request for corrective action;
2) issuing a warning letter of admonition, or letter of reprimand;
3) imposing a term of probation which is defined as mandatory chart review;
4) imposing continuing medical education requirements;
5) reducing, limiting, suspending, or revoking clinical privileges; or
6) suspending or revoking staff appointment
F. When the recommendation of the Medical Board is not adverse to the Practitioner,
the Medical Board shall inform the facility Administrator who shall inform the
Practitioner.
G. When the recommendation of the Medical Board is adverse to the Practitioner, the
Medical Board shall inform the facility Administrator and the Administrator shall
notify the Practitioner by Special Notice and provide the Practitioner with a
copy of the Medical Board's recommendation. The Practitioner shall be entitled
to the procedures provided for herein, and all further procedures shall be in
accord therewith.
Impairment. As per the Physician Health Policy the facility MEC or facility Administrator may
require a Practitioner to undergo a physical or mental examination or testing if there is reason
to suspect that the Practitioner's ability to exercise clinical privileges may be impaired.
Privileges at other Facilities. Any corrective action taken against a Practitioner or Allied
Health Professional at a Facility within the System shall apply to all facilities of the System
where the Practitioner or Allied Health Professional has clinical privileges.
IV. PRACTITIONER RIGHTS
A. General
1. In the event a Practitioner is unable to resolve with his/her facility Department
Chair/Section Chair a particular situation, issue or concern, that Practitioner may
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request through Special Notice to meet with the facility MEC to discuss the matter
and shall be given an opportunity to do so.
2. Any Practitioner may question a Rule, Regulation, Policy or Procedure approved by
the Medical Board by submitting a petition signed by ten (10) percent of the
members of the Active Medical Staff. When such a petition has been received
by the Medical Board, it may provide the petitioners with information clarifying
the intent of such Rule, Regulation Policy or Procedure or schedule a meeting
with the petitioners to discuss the issue.
B. Procedural Rights of Review. When a Practitioner receives notice of a recommendation of
or action by the facility MEC, the Medical Board, or the Board of Directors where no
prior procedural rights of review are provided and the recommendation or action is
adverse to the Practitioner (see Section V C, 1), the Practitioner shall be entitled to the
procedures set forth herein. Notwithstanding any other provisions in the Bylaws of the
Medical Staff or this Manual, the Practitioner shall not be entitled to any review of a
recommendation or action which is not defined below as adverse.
C. Definitions
1. Adverse Recommendation/Action: Except as qualified herein and otherwise
specified by the Bylaws of Medical Staff , and provided no prior right to a
hearing existed, only the following recommendations and actions are "adverse":
a) denial of appointment or reappointment;
b) suspension or termination of appointment;
c) denial of requested clinical privileges;
d) restriction, reduction, suspension, or revocation of clinical privileges;
e) mandatory consultation requirement.
2. Recommendations that are Not Adverse: The following recommendations and
actions, and any others specifically so qualified in the Medical Staff Bylaws, are not
adverse and shall not entitle a Practitioner to any procedural rights of review:
a) refusal to furnish an application as provided in this Manual and the Medical
Staff Bylaws or failure to process an application for clinical privileges as
provided this Manual and the Medical Staff Bylaws;
b) refusal to process an application for appointment, reappointment or request
for clinical privileges because the application is incomplete or the
Practitioner has not provided requested information;
c) termination of appointment upon expiration of the term for failure to
reapply timely or submit a completed application for reappointment or
requested information;
d) failure to accept or consider an application for clinical privileges because the
Practitioner has not satisfied the facility Department's minimum or
threshold criteria for such privileges as provided in this Manual and the
Medical Staff Bylaws;
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e) imposition of conditions during the provisional period that are imposed on all
Practitioners granted those privileges during the provisional period,
extension of the provisional period (or failure to grant an extension), or
termination of appointment upon expiration of the provisional period
because of lack of use of the Hospital;
f) imposition of probation during which the Practitioner is subject to a
specific, time-limited, period of testing and trial to ascertain
competency, which may include, but is not limited to, oversight,
education and counseling.
g) termination of appointment in accord with the terms of the Practitioner's
contract with the System, Hospital or facility;
h) termination of emergency privileges;
i) denial or termination of any temporary privileges granted or imposition of
any conditions on the exercise of temporary privileges;
j) automatic placement on Courtesy Medical Staff as provided in the Medical
Staff Bylaws or ineligibility for Active or Courtesy Medical Staff as
provided the Medical Staff Bylaws;
k) automatic action as provided herein and
l) Failure to provide an application as described in the Medical Staff Bylaws.
3. Procedures. The procedures and specific rights of the Practitioner and Hospital are
as set forth herein. In no event shall a Practitioner be entitled to more than one
hearing or appellate review on a matter subject to recommendation or action by the
Medical Board or Board.
4. Authorization and Conditions. By submitting an application for Medical Staff
appointment or reappointment or by applying for or exercising clinical
privileges, a Practitioner:
a) authorizes representatives of the Hospital and Medical Staff to solicit,
provide and act upon information bearing on the Practitioner's
competence and conduct;
b) agrees to be bound by the provisions herein and to waive all legal claims
against any representative who acts in accordance with the provisions of
this Section; and
c) acknowledges that the provisions of this Section are express conditions to the
Practitioner's application and acceptance of Medical Staff appointment,
the continuation of such appointment, and the exercise of clinical
privileges.
D. Confidentiality
1. Confidentiality of Information. Information with respect to any Practitioner that is
submitted collected or prepared by any representative of the Hospital or Medical
Staff or any other health care entity or organization or by any third party for the
purpose of professional review activity and peer review shall, to the fullest extent
permitted by law, be confidential.
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a) Unless authorized or required by law, disclosure of any information
generated by or at the direction of a Medical Staff Committee or
Department to any person other than within the Hospital for authorized
purposes shall require execution of a written waiver by the committee's
or Department's chairperson and approval of the facility Administrator
or CEO.
b) All Committee and Department documents shall be maintained by the facility
on behalf of the Committee or Department and the facility in accord
with facility policy. Access to Committee or Department documents
shall be in accord with facility policy and applicable legal requirements
to maintain any available privileges of confidentiality.
2. Practitioner Responsibility. By accepting appointment to the Medical Staff and/or
clinical privileges, each Practitioner agrees to respect and maintain the
confidentiality of all discussions, deliberations, proceedings and activities of the
Medical Staff and all Committees and Departments engaging in professional
review activity and peer review, except as directed by the facility MEC, the
Medical Board or the Board of Directors or as required by law. Any questions
regarding whether information is confidential shall be resolved by the President
of the Medical Staff, facility administrator or the CEO. Any violation or
threatened violation of this provision may subject the Practitioner to corrective
action as provided herein.
E. Releases. Each Practitioner shall, upon request of the CEO, execute general and specific
releases in accordance with the provisions of this Section. Execution of releases is not a
prerequisite to the effectiveness of this Section.
F. Cumulative Effect. Provisions in the Bylaws of the Medical Staff and this Manuel and in
application forms relating to authorizations, confidentiality of information and
immunities from liabilities are in addition to, not in limitation of, any other protections
provided by law.
G. Termination of Privileges. Physicians, whose privileges are terminated for any reason
consistent with the Bylaws and this Manual, may re-apply for privileges at the discretion
of the Medical Board.
V. FAIR HEARING PLAN
A. Time Periods for Processing. Any time periods within which action by a committee is to be
taken are intended as guidelines and not to create a right of a Practitioner to have an action
taken within the time period. Time periods may be extended by the Committee, facility
Chief of Staff, the President of the Staff, or facility Administrator for good cause. A
Practitioner who objects to an extension may file a written request with the facility Medical
Executive Committee which shall verify the existence of good cause.
B.
Entitlement to Mediation.
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1. Who is Eligible to Request Mediation
a) A Practitioner on the Medical Staff or a Practitioner applying for membership
on the Medical Staff may request mediation if the facility Credentials &
Privileges Committee has failed to make a recommendation on
appointment to the facility MEC on or before the 90th day after receiving
the applicant’s completed application. The 90-day period does not
begin to run until the facility Credentials Committee has received all
documents necessary for review of the application, including documents
that are requested from other entities, such as medical schools and
other hospitals or practice locations.
b) Medical Staff Practitioner who is subject to an adverse professional review
action that may adversely affect his medical staff membership or
privileges may request mediation.
2. How to Request Mediation
a) A practitioner must submit the request for mediation in writing to the facility
Administrator.
b) The Practitioner has the right to one mediation during the application
process or professional review action.
c) The Practitioner must submit the written request for mediation within the
following timeframes:
d) If the facility Credentials & Privileges Committee has failed to make a
recommendation on appointment within the required timeframe, the
applying Practitioner must submit the written request for mediation
within 30 days from the 90th day after the facility Credentials &
Privileges Committee received the applicant’s completed application.
e) If the Practitioner is subject to an adverse action, the Practitioner must
request mediation before requesting a hearing as specified in herein.
The Practitioner must notify the facility Administrator within thirty (30)
days following the date of receipt of a notice as described herein. The
Practitioner is not entitled to a second mediation.
3. Who Represents the Facility in the Mediation
a) The facility Administrator represents the Facility/Hospital in the mediation.
The facility Administrator may appoint another individual to serve as the
Facility and/or Hospital’s representative during mediation.
b) The facility Administrator may also request that an attorney representing the
Hospital and/or any Medical Staff Committee assist the facility
Administrator during the mediation.
c) The facility Administrator or designee is responsible for making arrangements
for the mediation, including selecting the location for the mediation.
4. Time Frame for Mediation
a) The mediation must occur within a reasonable period of time after the
facility Administrator receives the Practitioner’s written request for
mediation.
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5. Selection of Mediator and Responsibility for Fees
a) The facility Administrator will choose a mediator and the mediator must
meet the qualifications set forth below.
b) The facility Administrator has the discretion to make the following options
available for selection of a mediator:
(i) If the Practitioner requesting mediation wishes to choose the
mediator, the Practitioner must agree to pay the fees and
expenses of the mediator selected.
(ii) If the facility Administrator chooses the mediator without approval
of the Practitioner requesting mediation, the Facility pays the
fees and expenses of the mediator.
(iii) If the Practitioner and the facility Administrator select a mediator
that is acceptable to both parties, the Practitioner and the
Facility shall each pay half of the fees and expenses charged by
the mediator.
(iv) If the Practitioner requesting the mediator does not make a decision
regarding a mediator within a reasonable period of time, the
facility Administrator may choose the mediator, and the Facility
would bear the costs.
6. Qualifications of Mediator.
a) Individuals with the following qualifications may serve as mediators:
(i) A person who has completed forty (40) classroom hours of training in
dispute resolution techniques in a course conducted by a dispute
resolution organization approved by the facility Administrator
(ii) A person who has other legal or professional training related to
health care issues or dispute resolution;
(iii) An attorney registered with the American Health Lawyers
Association Alternate Dispute Resolution Service;
(iv) An attorney who specializes in Health Law; or
(v) A person registered as a mediator with the American Arbitration
association.
(vi) A person who can prove that s/he has been appointed by any Texas
district court as a Mediator or Arbitrator.
b) If the Practitioner participates in mediation with a mediator chosen by the
Practitioner or selected by mutual agreement, the Practitioner may not
assert that the mediator did not meet the qualifications set forth above.
7. Time of Mediation
a) Once the mediator has been selected and has proposed dates when the
mediation can occur; the facility Administrator will provide the
Practitioner with an option of three dates. Failure to accept one of the
three dates will result in waiver of the mediation by the Practitioner.
8. Waiver of Mediation
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a) If the Practitioner fails to appear for a scheduled mediation, the Practitioner
waives the right to mediation. The Facility is not required to reschedule
the mediation or to respond to another request for mediation for the
same adverse action.
9. Effect of Mediation
a) If the Facility and Practitioner reach an agreement resolving the dispute,
within 30 days following the mediation, the facility Administrator will
have the agreement reduced to writing and submit it to the Medical
Board for approval and referral to the Board of Directors at the next
scheduled meeting of the Medical Board. If the Medical Board approves
an agreement, the action is concluded, and the Practitioner will have no
further rights of appeal on that action. If the Medical Board or the
Board of Directors does not approve an agreement, the Practitioner will
still have any rights of due process or appeal that are otherwise granted
to the Practitioner in these Medical Staff Bylaws.
10. If the Facility and Practitioner do not reach an agreement resolving the dispute,
within 30 days following the mediation, the Practitioner shall notify the facility
Administrator of his/her request for a hearing as described herein. Failure to
request such a hearing within this time period waives the Practitioner’s right to
a hearing and appellate review, resulting in the adverse recommendation
becoming a final decision of the Board of Directors.
C. Entitlement to Hearing.
1. Right to a Hearing
a) When a Practitioner receives notice of a recommendation by the facility
MEC, the Medical Board or the Board of Directors that is adverse as
defined herein, he/she shall be entitled to a hearing as provided in this
Section, provided that he/she requests such hearing within thirty (30)
days after receipt of the notice. If the final recommendation following
such hearing is still adverse to the Practitioner, he/she shall then be
entitled to an appellate review before a final decision is rendered by
the Board of Directors.
b) When a Practitioner receives notice of a recommendation by the Board of
Directors on their own initiative that is adverse as defined herein, and
such decision is not based on a prior adverse recommendation by the
Facility Medical Executive Committee or the Medical Board with respect
to which he/she would be entitled to a hearing, the Practitioner shall
be entitled to a hearing as provided in this Section. If following the
hearing the recommendation is still adverse, the Practitioner is then
entitled to an appellate review before a final decision is made by the
Board of Directors.
2. All hearings and appellate review shall be in accordance with the procedural
safeguards set forth herein.
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3. Notice of Decision and Right to Hearing
a) The facility Administrator shall be responsible for giving Special Notice of any
adverse recommendation to the Practitioner. In the written notice, the
facility Administrator shall advise the Practitioner that:
(i) a professional review action has been recommended against him,
the name of the specific entity or individual recommending the
action and the reasons for the action;
(ii) the Practitioner is entitled to request a hearing pursuant herein;
(iii) the Practitioner has thirty (30) days following the date of receipt of
this notice within which to request a hearing by submitting a
written request to the facility Administrator;
(iv) in the request for a hearing, the Practitioner must state whether
he/she will be represented by an attorney in the hearing;
(v) failure to request a hearing within the specific time period waives
the Practitioner's right to a hearing and appellate review,
resulting in the adverse recommendation becoming a final
decision of the Board;
(vi) upon the facility Administrator’s receipt of the Practitioner's timely
request for a hearing, the Practitioner will be provided with
Special Notice of the date, time and place of the hearing, which
shall be at least thirty (30) days from the date of the notice;
and
(vii) in the hearing, the Practitioner (and the Medical Executive
Committee, the Medical Board or Board of Directors, whichever
initiated the right to the hearing) will have the right to:
(a) be accompanied by an attorney, Medical Staff Practitioner
in good standing or, by an appointee of his/her local
medical, dental, or podiatry association;
(b) have a record made of the proceedings, copies of which may
be obtained by the Practitioner upon payment of
reasonable charges associated with the preparation
thereof;
(c) call, examine, and cross-examine witnesses;
(d) present evidence determined to be relevant by the
arbitrator, hearing officer or committee chairperson
regardless of its admissibility in a court of law;
(e) submit a written statement at the close of the hearing; and
(f) receive the written recommendation of the Hearing
Committee, including a statement of the basis of the
recommendation, and the written decision following
consideration of the Hearing Committee report,
including a statement of the basis for that decision.
4. Waiver. Failure of a Practitioner to request a hearing to which he/she is entitled
herein within the time and in the manner herein provided shall be deemed a
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waiver of the Practitioner's right to such a hearing and a waiver of any appellate
review to which the Practitioner might otherwise have been entitled. When the
waived hearing relates to an adverse recommendation of the facility Medical
Executive Committee, or the Medical Board the recommendation shall become
effective immediately against the Practitioner pending the Board' of Director’s
final decision. When the waived hearing relates to a recommendation by the
Board of Directors, the recommendation shall become final and immediately
effective. The facility Administrator shall notify the Practitioner of the decision
by Special Notice.
D. Notice of Hearing and Composition of Hearing Committee
1. Notice. Within thirty (30) days after the receipt of a timely request for hearing
from the Practitioner, the facility Administrator shall schedule such a hearing
and shall notify the Practitioner of the time, place, and date by Special Notice.
The hearing shall be at least thirty (30) days from the date of the notice of the
time, place and date of the hearing, except for a Practitioner who is under
emergency corrective action, in which case the hearing may be held as soon as
mutually agreeable arrangements may reasonably be made.
2. Witnesses. The notice provided herein shall include a list of witnesses expected to
testify in support of the adverse recommendation. This notice shall also advise
the Practitioner that, at least fifteen (15) days before the hearing, the
Practitioner shall be required to forward to the facility Administrator a written
list of witnesses the Practitioner expects to present to testify against the
adverse recommendation or in his/her behalf. Each party is responsible for
arranging for the attendance of the party's own witnesses.
3. Hearing Committee Selection and Composition
a) The hearing shall be held before a Hearing Committee consisting of one of
the following:
(i) an arbitrator mutually acceptable to the Practitioner and the
facility Administrator
(ii) a hearing officer who is appointed by the facility Administrator who
is not in direct competition with the Practitioner involved;
(iii) a panel of at least three (3) Medical Staff Practitioners appointed by
the facility Chief of Staff following consultation with the facility
Medical Executive Committee; or
(iv) a hearing officer and a panel of Medical Staff Practitioners are
appointed as described herein.
b) The facility Administrator, in consultation with the facility Chief of Staff,
shall select the type of Hearing Committee to be used.
c) If an arbitrator is used, he/she shall have experience in medical staff
privileges disputes.
d) If a hearing officer is used who is an attorney, he/she shall be an attorney
with expertise in medical staff privileges disputes who has not advised
the Hospital on the adverse recommendation.
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e) Panel members may not be in direct economic competition with the
Practitioner and may not have participated in initiating the complaint or
investigating the complaint or in any committee consideration of the
matters at issue. One member shall be designated by the facility
Administrator as the presiding officer. Panel members shall be selected
from the Active or Courtesy Medical Staff. Practitioners who are not
members of the Medical Staff may be used if particular expertise is
needed or the panel cannot be appointed from the Active or Courtesy
Medical Staff.
f) If a hearing officer is used in conjunction with a panel, the hearing officer
shall serve as the presiding officer and may participate in deliberations,
but may not vote.
g) Unless a hearing officer is being used, the facility Administrator may appoint
an attorney to assist the Hearing Committee during the hearing and in
deliberations and issuance of a recommendation. The attorney may not
have advised the Hospital on the adverse recommendation.
4. The Practitioner shall be furnished with the names of the arbitrator, hearing officer
or panel members at least thirty (30) days prior to the hearing. The Practitioner
shall be requested to raise any objections to the qualifications of these
individuals at least fifteen (15) days before commencement of the hearing in
writing to the facility Administrator. If the facility Administrator determines
that the objections have merit, other individual(s) shall be selected to serve on
the Hearing Committee.
E. Conduct of Hearing
1. Purpose of Hearing. The hearing provided for in this Section is for the purpose of
resolving, on an intraprofessional basis, matters bearing on professional
competence and conduct in accord with this Section and applicable law.
2. Presence of Members and Vote. There shall be at least a majority of the members
of the Hearing Committee present when the hearing takes place and no person
may vote by proxy. If a member is absent from any part of the proceedings,
he/she shall not be permitted to participate in the deliberations or the
recommendation unless he/she certifies in writing that he/she has read the
transcript of all proceedings that occurred in his/her absence prior to the
deliberations.
3. Failure to Appear. The personal presence of the Practitioner at the hearing shall be
required. A Practitioner who fails without good cause to appear and proceed at
such hearing shall be deemed to have forfeited his/her right to a hearing
hereunder, to have waived his/her rights in the same manner as provided herein
and to have accepted the adverse recommendation or decision involved, which
shall become and remain in effect as provided herein.
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4. Presiding Officer. The presiding officer shall determine the order and procedures
during the hearing, to assure that all participants in the hearing have a
reasonable opportunity to present relevant oral and documentary evidence and
to maintain decorum. The presiding officer may require that the parties attend
a pre-hearing conference to resolve procedural objections or issues that have
arisen or may arise during the hearing and to submit all documentary evidence
they plan to use during the hearing. The presiding officer shall have the
authority and discretion to make all rulings on questions that arise during the
hearing, and may exclude any evidence unrelated to the reasons for the adverse
recommendation or the Practitioner's qualifications or competence.
5. Representative of facility Medical Executive Committee, the Medical Board or
Board. The Medical Executive Committee, the Medical Board or Board of
Directors, whichever initiated the adverse recommendation, shall appoint one
of its members or some other individual to represent it at the hearing to present
the facts in support of the adverse recommendation and to examine witnesses.
If Practitioner has elected to be represented by an attorney in the hearing, the
facility Administrator shall entitled to appoint an attorney to represent and
assist the facility Medical Executive Committee, the Medical Board or Board the
Board of Directors in the hearing.
6. Burden of Proof. The facility Medical Executive Committee, the Medical Board or
the Board of Directors shall present the evidence supporting the adverse
recommendation, followed by the Practitioner's presentation. The burden of
proof shall be on the Practitioner to show he/she is qualified and competent for
Medical Staff appointment and/or the requested clinical privileges.
7. Record. An accurate record of the hearing shall be kept by a certified court
reporter retained by the Facility. The cost of attendance of the reporter shall
be borne by the Facility, but the cost of obtaining a copy of the transcript shall
be borne by the requesting party.
8. Postponement. Postponement of the hearing beyond the times set forth in this Plan
shall be only with the written approval of the presiding officer for good cause
shown and in the sole discretion of the presiding officer.
9. Recess of the Hearing. The Hearing Committee may, without Special Notice, recess
the hearing and reconvene the same for the convenience of the participants or
to obtain new or additional evidence or consultation.
10. Authority and Evidence. The hearing need not be conducted strictly according to
rules of law relating to the examination of witnesses or presentation of
evidence. Any relevant matter upon which responsible persons customarily rely
in the conduct of serious affairs shall be considered, regardless of the existence
of any common law or statutory rule that might make evidence inadmissible
over objection in civil or criminal actions. The Practitioner for whom the
hearing is being held and the Medical Executive Committee's, the Medical Board
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or Board of Director’s representative shall, prior to or during the hearing, be
entitled to submit memoranda concerning any fact issue or procedure, which
shall become a part of the hearing record. Written statements may also be
submitted at the end of the hearing
or, at the option of the presiding
officer, within a designated number of days following the hearing.
11. Deliberation and Recommendation. Upon conclusion of the presentation of oral and
written evidence, including submission of any written statements, the hearing
shall be closed. The Hearing Committee may, at a convenient time, conduct its
deliberations outside the presence of the parties and court reporter. Within
fifteen (15) days after closing the hearing, the Hearing Committee shall make a
written report and recommendation, including a statement of the findings and
basis for the recommendation, and shall forward the same together with the
hearing record and all other documentation to the facility Medical Executive
Committee, the Medical Board or the Board of Directors, whichever initiated the
adverse recommendation. The Hearing Committee's report may recommend
confirmation, modification, or rejection of the original adverse
recommendation. A copy of the Hearing Committee's written report and
recommendation, including a statement of the basis for the recommendation,
shall also be forwarded to the Practitioner.
12. Notice and Further Action.
a) Within thirty (30) days after receipt of the Hearing Committee's report, the
Medical Executive Committee, the Medical or Board the Board of
Directors, whichever initiated the adverse recommendation shall affirm,
modify or reverse its prior recommendation.
b) If the final reconsidered recommendation is still adverse to the Practitioner,
the facility Administrator shall provide Special Notice to the Practitioner
of the adverse recommendation and advise the Practitioner of the right
to request appellate review as set out herein.
c) If the reconsidered recommendation is not adverse to the Practitioner, it
shall be forwarded to the Board of Directors for a final decision. If the
Board of Directors decision is adverse, the Practitioner shall be entitled
to appellate review as set out herein and the facility Administrator shall
provide Special Notice to the Practitioner of the decision.
d) If the reconsidered recommendation of the Board of Directors is not adverse
to the Practitioner, then the recommendation shall become the final
decision of the Board of Directors and the facility Administrator shall
provide Special Notice to the Practitioner of the decision.
VI. APPELLATE REVIEW
A. Scope of Appellate Review. Request for an Appellate review shall be limited to a review as
to:
1. Whether the procedures set forth in the Medical Staff Bylaws regarding the adverse
recommendation, hearing and any subsequent review were substantially
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complied with; and
2. Whether, based on the evidence in the record, the adverse recommendation is
unreasonable, arbitrary, capricious, discriminatory or without basis.
B. Notices to the Practitioner. Within fifteen (15) days after receipt of notice of an adverse
recommendation pursuant herein the Practitioner may request appellate review by
giving Special Notice to the facility Administrator. Such notice may request that the
appellate review be held only on the record on which the adverse recommendation is
based, as supported by written statements as provided below, or may request that oral
argument also be permitted as part of the appellate review.
C. Waiver. If appellate review is not timely requested, the Practitioner shall be deemed to
have waived his/her right to any appeal and to have accepted the adverse
recommendation, which shall become effective immediately.
D. Notice of Appellate Review. Within thirty (30) days after receipt of a timely request for
appellate review, the facility Administrator shall schedule a date for such review,
including a time and place for oral argument if such has been requested. The facility
Administrator shall notify the Practitioner by Special Notice of the date of the appellate
review, which shall be at least fifteen (15) days from the date of that Special Notice,
except that when the Practitioner is under emergency corrective action, such review
shall be scheduled as soon as mutually agreeable arrangements may reasonably be
made.
E. Composition of Appellate Review Panel. The appellate review shall be conducted by the
Board of Directors or by a subcommittee of the Board of Directors of at least three (3
appointed by the President/Chairman of the Board of Directors.
F. Written Statements. The Practitioner shall have access to the report and record of the
Hearing Committee and all the materials, favorable or unfavorable, that were
considered by the Medical Board or Board in reconsideration after the hearing. The
Practitioner may submit a written statement in his/her behalf specifying those factors
and procedural matters with which the practitioner disagrees, and his/her reasons for
such disagreement, to the appellate review panel, through the facility Administrator, at
least ten (10) days prior to the appellate review. The facility Administrator shall deliver
a copy of the Practitioner's statement to the facility MEC, or the Medical Board's or the
Board of Director’s representative, who may submit a written statement in response at
least five (5) days prior to the appellate review. If submitted, the facility Administrator
shall send a copy of the facility MEC’s, or the Medical Board's or the Board of Director's
written statement to the Practitioner at least two (2) days prior to the appellate
review.
G. Conduct of the Appellate Review.
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1. The appellate review panel shall review the record created in the proceedings and
consider any written statements submitted pursuant herein to make its
determination.
2. If oral argument is requested as part of the review procedure, the Practitioner shall
be present at the appellate review, shall be permitted to speak against the
adverse recommendation and shall answer questions put to him by the appellate
review panel. The representative of the Medical Board or Board shall also be
permitted to speak in favor of the adverse recommendation and shall answer
questions put to him/her by the appellate review panel. Neither party may be
accompanied by counsel during oral argument.
3. New or additional matters not raised during the hearing and not otherwise reflected
in the record may be introduced at the appellate review only on a showing that
the matter was not available at the time of the hearing and only at the sole
discretion of the appellate review panel.
H. Decision
1. If the appellate review is conducted by the Board of Directors, it may affirm, modify
or reverse the adverse recommendation, which shall become the Board' of
Directors final decision. The Board of Director’s may also return the matter to
the facility MEC, or the Medical Board or Hearing Committee for further review
and recommendation within a designated time period. Such referral may
include a request to obtain an outside expert review or conduct an additional
hearing to correct possible procedural errors.
2. If the appellate review is conducted by a subcommittee of the Board of Directors,
the committee shall, within fifteen (15) days after completion of the appellate
review, make a written report either recommending that the Board of Directors
affirm, modify or reverse the adverse recommendation or returning the matter
further review and recommendation within a designated time period. Such
referral may include a request to obtain an outside expert review or conduct an
additional hearing to correct possible procedural errors.
I.
Final Decision by the Board of Directors. At its next regular meeting following conclusion
of the appellate review, or return of the matter following additional review or
procedures as set forth herein, the Board of Directors shall make its final decision. The
facility Administrator shall send notice of the Board of Director’s final decision to the
facility MEC, the Medical Board and to the Practitioner by Special Notice. Notice to the
Practitioner shall include the written decision of the Board, including a statement of the
basis for the decision.
J. Limitations. Notwithstanding any other provision of the Medical Staff Bylaws, a Practitioner
shall not be entitled to more than one hearing and appellate review on any matter that
has been the subject of action by the Medical Staff or the Board of Director’s. Once the
Board of Directors has issued a final decision, there shall be no further right to any
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further right to any review or reconsideration of the decision, pursuant to the Bylaws,
this Plan or otherwise
K. Dispute Resolution. Whenever appropriate, as determined by the President of the Staff,
following consultation with the facility Administrator, or by the facility Administrator,
following consultation with the facility Medical Executive Committee, a matter involving
one or more Practitioners or the Medical Staff may be submitted to dispute resolution
prior to resorting to other methods or procedures in the Bylaws or elsewhere for
addressing the matter. Dispute resolution shall not be binding on the parties involved
and is intended to promote prompt resolution and avoid the use of more costly or time
consuming procedures. Unless otherwise provided by the facility Administrator prior to
initiation of dispute resolution or agreed to by the parties, any costs of dispute
resolution shall be borne by the Facility.
VII
DUE PROCESS PROCEEDING
A. Other than the actions described above, any professional review action is considered
adverse as defined in these documents will proceed as described by the Due Process
Procedure outlined below:
1. The professional review action must be taken:
a) In the reasonable belief that the action was in the furtherance of quality
health care,
b) After a reasonable effort to obtain the facts of the matter,
c) After adequate notice and hearing procedures are afforded to the physician
involved or after such other procedures as are fair to the physician
under the circumstances, and
d) In the reasonable belief that the action was warranted by the facts known
after such.
B. Adequate Notice and Hearing
1. If a an adverse recommendation has been approved, other than the
cooling off period as described above, the facility Administrator shall
send notice to the physician stating:
a) that a professional review action has been proposed to be taken
against the Physician;
b) reasons for the proposed action;
c) that the physician has the right to request a hearing before a
Review Committee on the proposed action, and that failure
to request such a review shall constitute an acquiesce in the
recommendation and a waiver of any rights or any hearing to
which the Staff Member might otherwise have been entitled;
d) that the physician has 30 days within which to request such a
hearing; and
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e) a summary of the rights in the hearing which are as follows, these
rights to be specifically delineated in the notice letter to the
physician:
2. In the Review Committee hearing physician involved has the right:
a) To representation by an attorney or other person of the physician’s choice;
b) To have a record made of the proceedings, copies of which may be obtained
by the physician upon payment of any reasonable charges associated
with the preparation thereof;
c) To call, examine, and cross-examine witnesses. The practitioner may
present testimony by a colleague of the same discipline;
d) To present evidence determined to be relevant by he hearing officer,
regardless of its admissibility in a court of law; and
e) To submit a written statement at the close of the hearing.
3. Notice of hearing. If a hearing is requested on a timely basis the Administrator
will give notice to the physician involved, such notice to include:
a) The place, time, and date, of the hearing, which date shall not be less than
30 days after the date of the notice, and
b) A list of the witnesses (if any) expected to testify at the hearing on behalf of
the individual(s) or committee which has made the recommendation.
The requesting Staff Member shall be notified at least ten (10) days in
advance of the time and place of such review, which review shall be
conducted no less than thirty (30) days after the original notice of
adverse action and no more than forty-five (45) days following the
receipt of the request for a hearing.
C. Conduct of the Review Committee hearing and notice. If a hearing is requested on a timely
basis the hearing shall be conducted in one of the three following ways: (as determined
by the health care entity);
1. Before a panel of no less than 5 individuals, the panel to include at least one
member of the Facility or Hospital Senior administrative team and/or a member
of the Board who are appointed by the Chairperson of the Board in consultation
with the President of the Medical Staff. All other members of the Panel to be
physicians members of the Medical staff that are not in direct economic
competition with the physician. The Board Chair in consultation with the
President of the Medical staff will decide whether or not the Panel will be
chaired by;
a) An arbitrator who is not in direct economic competition with the Physician
involved; or
b) A hearing officer who is not in direct economic competition with the
physician involved; or
c) The Panel may elect their own chair from among their members. If due to
the size of the medical staff it is impossible to appoint sufficient
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physician members who are not in direct economic competition with the
physician the Chair of the Board in consultation with the President of
the Medical Staff may appoint other Physicians from the nearby region
or community who are on the staff at a CHRISTUS facility.
D. Quorum. Three (3) members of the Review Committee shall constitute a quorum. The
arbitrator, presiding officer or the Panel chair shall count as a member for purposes of
constituting a quorum.
E. The arbitrator, presiding officer or the Chair, as the case may be, shall have the following
authority and responsibility:
1. To rule on request for postponements of the hearing beyond the time set forth
herein.
2. To ensure that all parties have a reasonable opportunity to present relevant
evidence and that decorum is maintained at all times.
3. To participate in the deliberations of, and act as an advisor to the review
committee, but shall not vote except when there is a tie vote among the
members of the Review Committee.
4. To recess the hearing and reconvene the same from time to time without special
notice for the convenience of the participants or for the purpose of obtaining
new or additional evidence or consultation.
F. Upon conclusion of the evidence the hearing shall be closed. The Review
Committee may thereupon, at a time convenient to itself, conduct its
deliberations outside the presence of the Staff Member and the individual or
committee representative bringing forth the recommendation for adverse
action. Upon conclusion of deliberations of the Review Committee, the hearing
shall be declared adjourned.
G. Report. Within seven (7) days after adjournment of the hearing, the Review
Committee shall prepare a written report of its findings and recommendation
and shall forward the same together with the hearing record, to the facility
MEC, via the Administrator.
H. At the next regularly scheduled facility MEC, or pursuant to the Bylaws, at a
specially called meeting of the facility MEC, the facility MEC shall render a final
recommendation. The final written recommendation, together with the report
of the Review Committee shall be forwarded to the facility Administrator who
shall forward same to the Medical Board and the Board of Directors.
I.
The physician involved has the right:
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1. To receive the written recommendation of the arbitrator, officer, or panel, and the
final recommendation of the facility MEC and, the Medical Board prior to the
recommendation being forwarded to the Board of Directors for final disposition; and
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2. To receive the final written decision of the Board of Directors, (or Board of Directors
committee acting with the full authority of the Board) including a statement of the
basis for the decision.
J. The decision of the Board is final. There is no further right to appeal
VIII.
AMENDMENTS
1) Any proposed amendment to the Membership/Privileging /Credentialing and Due
Process Manual or recommendation for adoption of provisions may be proposed by the:
a) Medical Staff;
b) Facility MEC;
c) Medical Board; or
d) Board of Directors on its own initiative; and
e) Submitted directly to the Bylaws Committee for review and recommendation to
the facility MEC and the Medical Board.
2) The Membership/Privileging/Credentialing and Due Process Manual may be amended or
new provisions adopted;
a) Upon recommendation of the facility MEC to the Medical Board; and
b) Only if the Medical Board, at any regular meeting in which a quorum has
been established, approves amendment or adoption by a majority vote of
seventy-five (75) per cent of the Medical Board members who are present
and eligible to vote.
c) The revisions become effective upon approval by the Hospital Board of
Directors.
REVIEW AND APPROVAL
Board of Directors:
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