Medical Staff Services Dept.

Policy & Procedure Handbook EXAMPLE * EXAMPLE * EXAMPLE * EXAMPLE * EXAMPLE *

ABC Hospital

POLICY & PROCEDURE HANDBOOK MEDICAL STAFF SERVICES DEPARTMENT

TABLE OF CONTENTS

SECTION I: HOSPITAL INFORMATION - GENERAL

1.1 1.2 1.3 1.5 1.6 Hospital Mission Statement Hospital Organization Chart Hospital Departments / Directors Name & Phone # Frequently Used Phone Numbers Medical Staff / AHP Roster

SECTION 2: MEDICAL STAFF OFFICE GENERAL

2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10

Departmental Mission Statement General Office Orientation Job Descriptions Confidentiality Statement Medical Staff Services Security (Office, Desk, Files, Computer) File Maintenance / Retention Access to Files / Documents Distribution of Information to the Medical Staff Database Management Roster Maintenance

SECTION 3: MEDICAL STAFF POLICIES / ORGANIZATION

3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.10 Medical Staff Organization Chart Officer & Department Chair Phone List Job Descriptions Officers & Department Chairs Leadership Orientation New Physician Orientation Legal Counsel Access & Use Governing Document Review / Revision Medical Staff Annual Meeting Election Process / Ballots Emergency Department Call Rotation

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SECTION 4: CREDENTIALING PROCEDURES INITIAL APPLICATION

4.1 4.2 4.3 4.4 Initial Application / Appointment Process General Instructions Application Procedures Verification Procedures 4.4.1 Verification Elements 4.4.2 Follow up Requests 4.4.3 Red Flags / Discrepancies 4.4.4 Documentation 4.4.5 Database Input Review , Approval and Notification

4.5

SECTION 5: CREDENTIALING PROCEDURES REAPPOINTMENT

5.1 5.2 5.3 Reappointment Process Application Procedures Verification Procedures 5.3.1 Verification Elements 5.3.2 Follow up Requests 5.3.3 Red Flags / Discrepancies 5.3.4 Documentation 5.3.5 Database Input Review, Approval and Notification

5.4

SECTION 6: CLINICAL PRIVILEGES

6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 6.10 Privileging Process Delineation of Privileges Format Delineation of Privileges Specialty Specific Privileging for PAs & APRNs Temporary Privileges Change in Privileges New Procedure Approval Authorization for Students Privileges for Telemedicine Disaster Privileges

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SECTION 7: CREDENTIALING PROCEDURES OTHER

7.1 7.2 7.3 7.4 7.5 7.6 Proctoring Leave of Absence Resignations Continuing Medical Education Ongoing Exirables Verification Credentialing for AHPs

SECTION 8: MEDICAL STAFF MEETING MANAGEMENT

8.1 8.2 8.3 8.4 8.5 8.6 Committee Roster (current year) Monthly Meeting Calendar (current year) Meeting Agenda / Notices / Cancellation Room Arrangements / Food & Room Requests Minutes Content / Format Maintenance & Distribution of Records

SECTION 9: CORRECTIVE ACTION / FAIR HEARING

9.1 9.2 9.3 9.4 9.5 9.6 9.7 Automatic Suspension / Revocation Summary Suspension Fair Hearing Process Reporting Responsibilities BME & NPDB Impaired Practitioner Disruptive Practitioner Sexual Harassment

SECTION 10:

LEGAL REFERENCES
10.1 10.2 Health Care Quality Improvement Act State Statutes

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SUBJECT: POLICY #:
DEPARTMENT: APPLIES TO:

GENERAL OFFICE ORIENTATION MSSD 2.2

Medical Staff Services Personnel in Medical Staff Services Dept. Date Reviewed/Revised:___________________ By:__________________

Date Adopted:_____________

PURPOSE: To ensure that individuals working in the Medical Staff Services Department are aware of general office policies and practices. Office Hours: What hours is the office typically open? Do you stagger schedules so that office is open early / late? Telephone Coverage: Does someone always have to be in office to cover phones? Who do you transfer calls to if youll be out of office? Do you change voice message daily? Dress Code: (if different from hospital policy) Document Locations:
specify where you keep the medical staff roster, copy of bylaws, committee minutes, blank forms, etc.)

Mail Procedures:
Describe where to pick up incoming mail (or if delivered, approx. time of day), instructions on date-stamping all incoming mail, where to put outgoing mail (and if picked up, approx. time of day)

Frequently Used Phone Numbers:

Attach a list of frequently used phone numbers, such as to IS support, CEO, nursing director, OR scheduler, catering, security, mail room, etc.)

Office Supplies:
Describe where supplies are kept, and who is responsible for ordering supplies. If there is a requisition form utilized for ordering supplies, attach copy and describe ordering process.

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SUBJECT:
POLICY #: DEPARTMENT: APPLIES TO:

MAINTENANCE / RETENTION OF CREDENTIALING & PEER REVIEW FILES

MSSD 2.6 Medical Staff Services All individuals included in credentialing process Date Reviewed / Revised:_______________ BY:_____________________

Date Adopted:________________

PURPOSE: To ensure that all medical staff records maintained by or on behalf of the Medical Staff will be handled and preserved according to the procedures outlined in this policy, and that confidentiality be maintained for the protection of the practitioner and the facility. POLICY: It is the policy of this department to maintain two separate files for each practitioner that is credentialed through the medical staff/privileging process. The Credentials File will contain practitioner-specific information related to the initial credentialing process and the reappointment process. The Peer Review File (red file) will contain documents deemed confidential by law, including reports from the National Practitioners Data Bank, results of quality assessment reviews, disciplinary reviews or actions, complaints, and any such other documentation as may be deemed confidential. All information contained in the practitioners Peer Review File is privileged, confidential, and protected from disclosure to the fullest extent permitted by state and federal law. Files will be appropriately identified as confidential, and access to all files will be limited pursuant to MSSD 2.7. PROCEDURE: 1. CREATING THE FILES When an application for medical staff membership and/or clinical privileges is received by the MSSD, the credentialing staff will create two folders for the practitioner. The Credentials File will be a 6-part file with appropriate tabs. A label will be made listing LAST NAME, First Name, Middle Initial and degree on the first line. The second line will list the individuals Specialty. Files will be assembled utilizing the prescribed file format (see attached). The Peer Review File will be a red folder with appropriate tabs. A label identical to the Credentials File label will be made, and the folder will be stamped with the appropriate Confidential Peer Review Documents stamp maintained in the Medical Staff Services Department. Files will be assembled utilizing the prescribed file format (see attached). Files and are maintained in the Medical Staff Services Department. They are kept in locked, fireproof file cabinets. Access is limited pursuant to MSSD 2.7.

2.

CONTENTS OF CREDENTIALS FILE A. The completed and verified application for Medical Staff membership and/or clinical privileges, including information on training, experience, references, work history, malpractice history.

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B. C. D. E. F. G.

H. 3.

Evidence of verification of education, training, licensure and other information as determined by the facility. Peer recommendations. Continuously updated information on licensure, DEA registration, malpractice insurance, other expirables. Specific and current clinical privileges requested by the applicant, recommended by the Medical Staff, and approved by the Board of Directors. Data pertinent to reappraisal and reappointment/renewal of privileges, including reappointment application, continuing medical education, attendance at required meetings (if applicable). Evidence that the Medical Staff critically evaluated the above information and assessed the current clinical competence for privileges requested, as well as evidence that appropriate action was taken on appointment and reappointment, and on granting and renewal of clinical privileges. Evidence that the practitioner was duly notified of final decisions related to medical staff appointment, reappointment, staff status, clinical privileges.

CONTENTS OF PEER REVIEW FILES A. Any report(s) from National Practitioner Data Bank (NPDB). B. Specific information related to malpractice suits. C. Patterns of care as demonstrated in findings of quality assessment activities, such as surgical case review, blood usage evaluation, etc. D. Completed peer review forms showing evaluation of specific cases. E. Peer Review Profile / Activity Summary (summary of peer review, usually used at time of reappointment). F. Letters to and from a practitioner related to quality assessment, peer review, complaints, or risk management activities. G. Documentation related to practitioner-related patient care problems or alleged improper behavior or conduct. H. Documentation related to investigations, disciplinary actions (including but not limited to letters of admonition, automatic suspensions and suspensions for medical record delinquency). RETENTION OF FILE CONTENTS A. Credentials files of current practitioners may be purged of old copies of license, insurance and/or DEA certificates, CME activity and meeting attendance periodically (documents older than 4 years). A log of purged documents must be maintained in the credentials file. (NOTE: If the practitioner has a malpractice case pending which may include a suit against the hospital related to credentialing, no documents should be purged.) B. Documents of current practitioners related to previous (more than 4 years) reappointments / privilege delineations / peer review / disciplinary actions may be removed periodically from the active files and placed in a secured area in (Central Storage; scanned onto CD, etc.????). However, a log of these archived documents must be maintained in the current credentials and/or peer review file. Files of inactive practitioners may be placed in a secured area in (Central Storage; scanned onto CD, etc.????). Files may be destroyed after 5 years, but a log of appointment/reappointment/staff status must be maintained. (Exception: files of individuals with disciplinary actions or with OB/GYN privileges check with legal counsel should be kept for ___ years.)

4.

C.

FORMS ATTACHED: Develop your log sheets and attach to this P&P

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Credentials File Organization - Format

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**Most current information will always be on top in each section; **Blue sheets will be used to separate past from current; **Do not keep unverified copies of certificates, etc. (Exception: state license, DEA cert.; insurance face sheet

SECTION 1: TAB: INITIAL / REAPPOINTMENT Board Approval Letter Department Eval / Approval Form Worksheet Correspondence re: additional information Application, questionnaire, release/attest CME Summary Sheet only CV Pre-Application SECTION 3: TAB: LICENSURE / DEA / Other Verification of State License Copy of State License (if required) Verification of other state licenses Copy of DEA Certificate Copy of other certificates as applicable (ex: ACLS, BLS, etc.)

SECTION 2: TAB: Privileges Privilege Delineation Proctoring Reports (as applicable) Correspondence requesting changes in priv. Temporary Privileges

SECTION 4: TAB: References Reference Letters

TAB: AFFILIATIONS
Hospital Affiliation Verifications Other Affiliations (group practice, etc. as may be required)

TAB: INSURANCE / MALPRACTICE HISTORY

Copy of Insurance Face Sheet Verification of Malpractice History SECTION 5: SECTION 6: TAB: OTHER TB Test Results Medicare/Medicaid Signature Sheet Pharmacy Signature Sheet Misc. information related to practitioner

TAB: EDUC / TRAINING / BOARD

Verification of Board Certification Verification of Training (Fellowship, Residency, Internship) Verification of Education (Med. School) ECFMG Verification (if applicable)

RED FOLDER **Folder and contents are stamped as Confidential Peer Review Documents
**Most current information on top, with blue sheet to separate past from current under each tab

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TAB: NPDB
Copies of NPDB Reports

TAB: QUALITY PROFILES

Profiles and related attachments assembled for reappointment review

TAB: INVESTIGATIONS / DISC. ACTION

Any formal investigations and/or disciplinary actions Documents related to Medical Record suspensions, automatic suspensions, letters of reprimand, complaints, etc.

TAB: MALPRACTICE HISTORY

Information related to malpractice claims, such as copy of suit, other legal affidavits, statement from practitioner, etc. which has specific information about the lawsuit, claim or settlement

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SUBJECT: POLICY #:
DEPARTMENT: APPLIES TO:

VERIFICATION PROCESS MSSD 4.4

Medical Staff Services All practitioners applying for appointment and/or privileges Date Reviewed/Revised:________________________________

Date Adopted:_____________

PURPOSE: To ensure that information contained on the application is correct and valid. POLICY: Medical Staff Policy: For an applicant for initial appointment to the medical staff and/or for initial granting of clinical privileges, the hospital verifies information about the applicants licensure, specific training, experience and current competence provided by the applicant with information from the primary source(s) whenever feasible. (MS Credentialing Manual X.X.X) MSSD Policy: It is the goal of the MSSD to complete the verification process within 90 days of receipt of a complete application, utilizing industry standard verification sources which are approved by the JCAHO and within the means of the hospital. The MSSD will utilize industry standards regarding the scope of verified history (at a minimum, 5 years history). Nothing in these policies prevents the MSSD or the medical staff from obtaining additional information than may be minimally required, especially in circumstances where additional information would be beneficial in making an informed decision regarding the applicants qualifications and competence. PROCEDURE: 4.4.1 Verification Elements Once a complete application has been determined complete by the MSSD, processing of the application will begin within 3 working days. All verifications will be filed in the applicants Credentials File (or Peer Review File, as indicated) under the appropriate tabs. All verification request dates and subsequent receipt dates will be entered into the database on a daily basis. At a minimum, the following verifications will be performed: 1. Colorado State Licensure / Sanction Information: Verification of current Colorado license will be obtained directly from the Colorado State Board of Medical Examiners via internet. The verification will be printed and placed under the appropriate tab in the Credentials file. The verification should be reviewed, checking that the license is current (check to see when it will expire if its within the next 90-120 days, be sure to add a tickler on your Checklist to verify it again before it goes for review/approval). Also check the appropriate space on the verification form to

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3.1 FUNCTION Request for Application

Initial Application Procedure - CVS PROCEDURE Initial Application (CVS) 1. CVS staff will obtain info from applicant (or designee) to include: name, mailing address, phone, email, practicing specialty, anticipated start date, group practice, facilities to which he/she will be applying for privileges. 2. If request made by designee, obtain name, title, phone and email address of designee. 3. If applicants specialty is covered by an exclusive contract at any of the facilities to which he/she is applying, determine if applicant is part of the contracted group. If not, application/privilege form will not be sent for that facility. 1. CVS staff will enter available information into database and list as applicant, and indicate date requested and date mailed. Pre-populate cover letter, application and signature forms and email (or mail) the following: cover letter and application; appropriate facility-specific forms (Bylaws, R&R, etc); and appropriate facilityspecific privilege forms. 2. Email copy of cover letter to appropriate MSO, and to designee (if applicable) so they know an application has been sent out. 3. If application has not been returned within 21 days, send follow up email to applicant with copy to MSO (and designee, if applicable) 1. CVS receives application. Review for completeness. If all blanks are filled in and all required documents are attached, stamp date received and send email to applicant indicating application received/complete. (copy MSO and designee) 2. If incomplete, send email to applicant indicating the missing items needed (copy MSO and designee) 3. If applicaiton complete, input all data into database, including date of receipt. 4. Scan application and accompanying documents 5. Notify applicable MSOs that privilege forms and any supporting documentation is available in Cactus 6. Create applicant-specific file folder and worksheet 1. Create applicable verification letters and email or fax to primary source. 2. Obtain on-line verifications (see Table __ Credentialing Verification Elements). 3. If a potential flag is identified, notify appropriate MSOs for follow up, with copy to CVS Manager 4. If verification not received, follow up at 14-day and 21-day intervals (email can set automatic reminder to CVS to resend and create new date stamp). 5. Notify applicant, designee and MSO at 30 days if information still not received. 1. Once all verifications have been received, scan in remaining information to Cactus 2. File will then go to a second CVS credentialer for quality review discrepancies or missing information will be identified and obtained. 3. Following quality review, file will be deemed complete and that date will be entered into Cactus. A profile will be created and an email will be sent to appropriate MSOs that the file is ready.

Mailing Application

Application Received

Application Processing

Processing Complete

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SUBJECT: POLICY #: DEPARTMENT:

APPLIES TO:

DEA VERIFICATION MSSD 4.4.1 - D Medical Staff Services

Credentialing Verification Process (Medical Staff) Date Reviewed / Revised:______________ BY:______________________

Date Adopted:______________

PURPOSE: To verify applicant has a valid, unrestricted certificate to prescribe controlled substances. Required by: JCAHO AOA - NCQA - URAC PROCEDURE: 1. Copy of Certificate: A copy of the applicants DEA certificate should have been attached to the initial application. Make sure it is date stamped. NOTE: Not all applicants will have a DEA certificate. Medical specialties that do not generally require DEA are: Radiologists, Pathologists. AHPs do not have DEA certificates. If applicant indicated N/A, so note on database & worksheet.
2. Expiration date: DEA must be current at the time of the approval process. (Check to see

if it will expire within the next 120 days. You may have to get another copy before the file can be taken to committee.)
3. Address: Certificate should have a local address that corresponds with the address of the applicants practice. NOTE: If the address is not local, and/or does not correspond to the

applicants practice address, notify the applicant by phone or by letter that a corrected certificate must be provided.
4. Schedules: Check for schedules: 2, 2N, 3, 3N, 4, 5. NOTE: If the certificate does not

have all schedules, notify the applicant by phone or by letter that a corrected certificate or a written explanation must be provided. 5. Database: Enter into database the following: DEA # Comments (as applicable) * * Expiration Date Schedules

6. Worksheet: Note on worksheet date verified, and any comments (as applicable) 7. Acceptable source of verification: Copy of DEA Certificate, provided by applicant.

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4.1.3

Process for Temporary Privileges (Pendency of Application)

Application Received / Complete

Primary Source Verification

Department Chair review and recommendation

Credentials Committee review and recommendation

(if applicable, per bylaws)

Temp privileges for new applicant if clean file; Limited to 120 days still has to go to MEC

Medical Executive Comm. review and recommendation

Expedited Board approval (initial, reappt, new priv) if meets criteria

Governing Body approval (send FYI, if expedited)

Board letter / notifications

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SUBJECT: POLICY #: DEPARTMENT:

APPLIES TO:

MEETING ROOM ARRANGEMENTS MSSD 8.3 Medical Staff Services

Medical Staff General, Department & Committee Meetings Date Reviewed / Revised:_____________ BY:______________________

Date Adopted:______________

PURPOSE: To ensure that medical staff meetings are arranged in advance, and that the location, setup and amenities are conducive to an efficient meeting atmosphere. PROCEDURE: 1. 2. Locations: Meeting rooms are available in the following locations: (list here) Scheduling: To schedule a meeting room, contact ______ at ext. ___. Whenever possible, meeting rooms should be scheduled 30 days in advance. For standing meetings listed on the Master Calendar, meeting rooms should be scheduled for the entire year by submitting a written request to (who? What info? What format?) Room Set-up: Do you have a Work Order that you submit to maintenance or another department? How far in advance should you submit the work order, and who do you submit it to? The work order should include information such as how you want the room set (ie: classroom, theater, hollow square, etc.), approximate number of chairs required, extra table for buffet or handouts, etc. Food Requests: Which meetings routinely require food? Who do you contact? Do you fill out a Food Request form? How far in advance do you have to request catering? Are there any limitations on price or catering service? Audio/Visual Equipment: Are there specific meetings that routinely require AV equipment? Who do you contact? Whats available? Do you fill out an AV Request Form? How far in advance do you have to request equipment?

3.

4.

5.

FORMS REQUIRED: If there are facility request forms for any services, attach here. You may want to develop a checklist to use for each meeting to ensure you havent forgotten something.

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