36C24819R0007-007.pdf

BYLAWS AND RULES OF THE MEDICAL STAFF

DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER

WEST PALM BEACH, FLORIDA

October 18, 2012

TABLE OF CONTENTS

PREAMBLE

DEFINITIONS

ARTICLE I. NAME

ARTICLE II. PURPOSE

ARTICLE III. MEDICAL STAFF MEMBERSHIP

Section 1. Membership Eligibility Section 2. Qualifications for Medical Staff Membership and Clinical Privileges Section 3. Basic Responsibilities of Medical Staff Membership

ARTICLE IV. APPOINTMENT AND INITIAL CREDENTIALING

Section 1. General Provisions Section 2. Application Procedures Section 3. Process and Terms of Appointment

ARTICLE V. CLINICAL PRIVILEGES

Section 1. General Provisions Section 2. Process and Requirements for Requesting Clinical Privileges Section 3. Credentials Evaluation and Maintenance Section 4. Professional Practice Evaluation Section 5. Recommendations and Approval Section 6. Privilege Decision Notification Section 7. Exceptions – Emergency Care, Expedited, Temporary and Disaster Privileges Section 8. Exceptions – Deployment and/or Activation Privilege Status

ARTICLE VI. FAIR HEARING AND APPELLATE REVIEW PROCEEDINGS ... 33

General Provisions Section 1. Reduction of Privileges Section 2. Revocation of Privileges Section 4. Denial and Non Renewal of Clinical Privileges Section 5. Continuing Education Section 6. Actions Against Clinical Privileges Section 7. Reporting Adverse Actions Section 8. Reporting Malpractice Payments Section 9. Termination of Appointment

ARTICLE VII. ORGANIZATION OF THE MEDICAL STAFF

Section 1. Officers Section 2. Leadership

ARTICLE VIII. COMMITTEES

Section 1. Clinical Executive Board Section 2. Patient Care Review Committee Section 3. Professional Standards Board (PSB) Section 4. Peer Review Committee Section 5. Physical Standards Board Section 6. Executive Committee of Governing Body (ECGB) Section 7. Standing Committees Section 8. Meetings

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Section 9. Attendance and Quorum Section 10. Meeting Minutes

ARTICLE IX. CLINICAL SERVICES

Section 1. Characteristics Section 2. Selection and Appointment of Service Chiefs Section 3. Duties and Responsibilities of Service Chiefs

ARTICLE X. PERFORMANCE IMPROVEMENT PROGRAMS

ARTICLE XI. RULES

ARTICLE XII. AMENDMENTS

ARTICLE XIII. ADOPTION

1. GENERAL

2. PATIENTS’ RIGHTS AND RESPONSIBILITIES

A. Explanation of Patients’ Rights B. Employee Responsibility for Patients’ Rights

3. INFORMED CONSENT

A. Patients’ Right to Informed Consent B. Staff Responsibility regarding Informed Consent

4. GENERAL RESPONSIBILITY FOR CARE

A. Conduct of Care B. Emergency Services C. Admissions D. Inpatient Care E. Special Care Units (Intensive Care Units) F. Transfers G. Consultations H. Discharge I. Autopsy J. Organ Donation K. Submission of Surgical Specimens L. Special Treatment Procedures

5. PATIENT ORDERS

A. Patient Care Orders B. Origination of Orders C. Orders in the Electronic Medical Record D. Electronic Signature of Orders in the EMR E. Orders for Medications F. Verbal and Telephone Orders

6. SUPERVISORY RESPONSIBILITIES OF THE MEDICAL STAFF

7. MEDICAL RECORDS

A. Ownership B. Responsible Staff Unavailable C. Documentation of Supervision D. Basic Administrative Requirements E. Basic Patient Information Requirements for the Medical Record

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F. Inpatient Medical Records G. Outpatient and Emergency Area Medical Record

8. INFECTION CONTROL

A. Policy B. Staff Compliance with Policy C. Screening for Tuberculosis

9. DISASTERS

10. IMPAIRED PROFESSIONAL PROGRAM

11. MEDICAL CENTER MEMORANDA

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BYLAWS OF THE MEDICAL STAFF

DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER

WEST PALM BEACH, FLORIDA

PREAMBLE

Recognizing that the Medical Staff is responsible for the quality of care delivered by its members and accountable to the Governing Body for aspects of that care, the Medical Staff practicing at the West Palm Beach VA Medical Center at West Palm Beach, Florida and any facilities owned or operated by such hereby organize themselves for self governance in conformity with the laws, regulations and policies governing VHA (Veterans Health Administration) and the Bylaws and Rules hereinafter stated. These Bylaws and Rules are consistent with all laws and regulations governing VA (Department of Veterans Affairs), and they do not create any rights or liabilities not otherwise provided for in laws or VA Regulations.

DEFINITIONS

1. Medical Staff

The "Medical Staff" shall mean all physicians, dentists, podiatrists, psychologists, and optometrists who have an active, current, full and unrestricted license to practice the individual’s profession in a state, territory or commonwealth of the U.S. or the District of Columbia and are employed and granted clinical privileges to provide patient care services for West Palm Beach VA Medical Center.

Categories of Medical Staff

A. Active Staff - Active staff shall consist of all physicians, dentists, podiatrists, psychologists, optometrists and chiropractors with full or part time appointments who are professionally responsible for specific patient care and/or education and/or research activities of the Medical Center and who assume all the functions and responsibilities of membership of the active staff and who are employed by the VA. Only full time members of the Medical Staff are eligible to vote.

B. Other Categories of Medical Staff – Other Categories of Medical Staff shall consist of practitioners who are responsible for supplementing the members of the active Medical Staff in their roles in patient care, education, and research. These members shall be appointed to a specific service and shall be permitted to serve on committees but shall not be required to attend meetings of the Medical Staff. They are not eligible for active staff membership. These categories include:

1. Consultants

2. On station fee basis, contract or sharing agreement

3. Without compensation

4. Intermittent

5. Administrative

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C. Associate Members of the Medical Staff include Nurse Practitioners, Certified Registered Nurse Anesthetists, and Physician Assistants who are responsible for supplementing members of the active medical staff in their roles in patient care, education, and research. These health care professionals may have input on all medical staff issues but do not have voting privileges as medical staff members.

D. Residents - Residents shall consist of professionals who may or may not be licensed to practice medicine, dentistry, podiatry, psychology and optometry, but who are still engaged in a post graduate training program. Their participation in patient care, education, or research shall be under the appropriate supervision of a Medical Staff member who is licensed to practice medicine, dentistry, podiatry or optometry and who has clinical privileges at the Medical Center. Residents are not eligible for membership on the active Medical Staff. They may be permitted to serve on designated Medical Center committees in a non-voting capacity, but shall not be required to attend meetings of the Medical Staff. Mechanisms for supervision of residents are specified in the facility policy on supervision of postgraduate residents. (548-142-396 Supervision of Medical and Dental Residents and Responsibilities of Staff Practitioners)

E. Students – Students shall consist of physician, dentist, podiatric, optometric or allied health care professionals who may or may not be licensed to practice their profession, but who are still engaged in an accredited training program. Their participation in patient care education or research shall be under the appropriate supervision as outlined by facility policy. Students are not eligible for membership on the Medical Staff. They may be permitted to serve on designated Medical Center committees in a non-voting capacity, but shall not be required to attend meetings of the Medical Staff. Mechanisms for supervision of students are specified in the facility policy on supervision of students. (548-142-395 Supervision of Medical Students).

F. Administrative- There may be practitioners, who by the nature of their position are not involved in patient care (i.e. researchers or administrative physicians). These health care professionals must be credentialed, but may not need to be privileged.

2. Governing Body

The term governing body refers to the Under Secretary for Health, the individual to whom the Secretary of the Department of Veterans Affairs has delegated authority for administration of the Veterans Health Administration; and, for purposes of local facility management and planning, it refers to the VA Medical Center Director.

3. West Palm Beach VA Medical Center Director

The Director (Chief Executive Officer) is appointed by the Governing Body, the Under Secretary of Veterans Administration for Medicine, to act as its agent in the overall management of the West Palm Beach VA Medical Center. The Director is assisted by the Chief of Staff, the Associate

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Medical Center Director, Associate Director for Patient Care Services, and the Chief of Quality Management.

4. Physician

Physician shall refer to all doctors of medicine, osteopathy, podiatry, dentistry, optometry and psychology.

5. Practitioner

Practitioner shall refer to physicians, dentists, podiatrists, psychologists, optometrists, nurse anesthetists and nurse practitioners who are fully licensed or otherwise granted authority to practice in a State, Territory or Commonwealth of the U.S. or District of Columbia. Physician assistants are also practitioners who are nationally certified, and thereby, eligible to practice within the VA.

6. Consultant

This term will be used throughout the Bylaws to define a qualified practitioner with clinical privileges who can be called upon for consultations specifically within his/her own area of expertise.

7. Appointment

As used in this document the term refers to appointment to the Medical Staff. It does not refer to appointment as a VA employee, but is based on having an appropriate personnel appointment action, scarce medical specialty contract or other authority for providing patient care services at the West Palm Beach VA Medical Center. Both VA employees and contractors may receive appointments to the Medical Staff.

8. Rules

Refers to the specific rules set forth in this document, which govern the Medical Staff. It does not refer to formally promulgated VA Regulations.

9. VA Regulations

The term VA Regulations means the regulations set forth by the Department of Veterans Affairs (VHA) and made applicable to its health care facilities in compliance with federal laws.

10. Peer

The term Peer means a counterpart or colleague from the same professional discipline who, in general, performs the same type of care and who is deemed capable of assessing the performance, judgment and clinical skills of a health care giver.

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11. Verification

As used in this document Verification is defined as primary source documentation by letter, telephone call, or computer printout or, in the case of confirmation of board certification, by listing in the specific directories which list board certification or designated equivalent sources as defined by VA and/or TJC (The Joint Commission).

12. Executive Committee of the Governing Body

The Executive Committee of the Governing Body is a top management level committee that will provide continuity, oversight and review, and integrate activities of the medical center including all boards, committees, services and interdisciplinary key functions. The permanent members of this committee are the Medical Center Director who shall act as Chairman, the Associate Medical Center Director, the Chief of Staff, the Chief of Fiscal Service, the Chief of Nursing Service, the Assistant to the Medical Center Director and the Quality Manager.

13. VETPRO

VetPro is the electronic credentialing program of the Veterans Health Administration (VHA).

ARTICLE I. NAME

The name of this organization shall be the Medical Staff of the Department of Veterans Affairs Medical Center, West Palm Beach, Florida (WPBVAMC).

ARTICLE II. PURPOSE

The purpose of the Medical Staff shall be to:

A. Ensure that all patients treated at the West Palm Beach VA Medical Center will receive efficient, timely, and appropriate care that is responsive to continuous quality improvement practices. Timeliness for evaluation, care and treatment is defined in current hospital policies.

B. Ensure all patients being treated for the same health problems or with the same methods/procedures receive the same level of care.

C. Establish, and assure adherence to, an ethical standard of professional practice and conduct.

D. Develop and adhere to facility specific mechanisms for appointment to the Medical Staff and delineation of clinical privileges.

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E. Provide educational activities that relate to: care provided, findings of quality of care review activities, and expressed need of caregivers.

F. Ensure a high level of professional performance of practitioners authorized to practice in the facility through continuous performance improvement practices and appropriate delineation of clinical privileges.

G. Assist the Governing Body in developing and maintaining rules for Medical Staff governance and oversight.

H. Provide leadership, development, & implementation on the continuous performance improvement activities in collaboration with the staff of the West Palm Beach VA Medical Center.

I. Stimulate research activities and assure that research programs are conducted in keeping with the standards established by the Research and Development committee.

J. Ensure that all patients, their families, visitors, and staff will be treated with courtesy, compassion and respect.

K. Ensure that there shall be medical staff participation and representation in any hospital deliberation affecting the discharge of medical staff responsibilities.

ARTICLE III. MEDICAL STAFF MEMBERSHIP

Section 1. Membership Eligibility

A. Membership on the Medical Staff is a privilege extended only to, and continued for, professionally competent physicians, dentists, podiatrists, psychologists, and optometrists, who continuously meet the qualifications, standards and requirements of VHA, this VA medical center, and these Bylaws and Rules & Regulations. Membership may be considered for other licensed practitioners who are permitted by law to provide patient care services independently and who meet the qualifications, standards and requirements of VHA, this Medical Center and these Bylaws.

B. Categories of Staff Membership include: Active Staff, Consulting Staff, On-station Fee Basis, Contract (Scarce Medical Specialties), or Sharing Agreement, Without Compensation, Associate Members, Intermittent, Residents/Students and Administrative. These categories may further be subdivided into full time and part time.

C. Decisions regarding Medical Staff membership are made without discrimination for reasons such as race, color, religion, national origin, gender, sexual orientation, lawful partisan political affiliation, marital status, physical or mental handicap when the individual is qualified to do the work, age, membership or non-membership in a labor organization, or on the basis of any other criteria unrelated to professional qualifications.

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Section 2. Qualifications for Medical Staff Membership and Clinical Privileges

To qualify for Medical Staff membership and clinical privileges, individuals who meet the eligibility requirements identified in Section 1 must submit satisfactory evidence as listed below.

Applicants not meeting these requirements will not be considered. This determination of ineligibility is not considered a denial.

A. Active, current, full and unrestricted license to practice the individual's profession in a state, territory or commonwealth of the United States or the District of Columbia as required by VA employment and utilization policies and procedures. Physician assistants need not be licensed but must be nationally certified by the National Commission on Certification of Physician Assistants (NCCPA). Nurse Practitioners must be certified by the American Nurse Credentialing Center (ANCC) or other VA-recognized certification program.

B. Education applicable to individual Medical Staff members as defined by regulation.

C. Relevant training and/or experience, consistent with the individual's professional assignment and privileges for which he/she is applying. This includes any internship, residencies, fellowships, board certification and other specialty training.

D. Current competence, consistent with the individual's assignment and the privileges for which he/she is applying.

E. Health status consistent with physical and mental capability of satisfactorily performing the duties of the Medical Staff assignment within clinical privileges assigned.

F. Complete information consistent with requirements for application and clinical privileges as defined in Articles IV or V of these Bylaws for a position for which the Medical Center has the patient care need, adequate facilities, support services and staff.

G. Satisfactory findings relative to peer recommendation, previous professional competence and professional conduct.

H. English language proficiency as defined in VA Human Resource regulations.

I. Compliance with the criteria for response time from residence for the applicable service. Reasonable time criteria and the definition of response time shall be determined for each service by the Professional Standards Board after recommendation by the Chief of each service.

Section 3. Basic Responsibilities of Medical Staff Membership

Medical Staff members are accountable for and have responsibility to:

A. Provide for continuous care of patients.

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B. Respect patients' rights.

C. Participate and provide leadership in continuing education, peer review, Medical Staff monitoring, performance improvement activities, patient safety, and oversight in the process of analyzing and improving patient satisfaction.

D. Maintain highest standards of ethics and ethical relationships including a commitment to:

(1) Abide by Federal law and VA rules and regulations regarding financial conflict of interest and outside professional activities for remuneration.

(2) Provide care to patients within the scope of privileges and advise the West Palm Beach VA Medical Center Director through the Chief of Staff of any change in ability to meet fully the criteria for Medical Staff membership or to carry out clinical privileges, which are held.

(3) Advise the Medical Center Director, through the Chief of Staff, of any challenges or claims against professional credentials, professional competence or professional conduct within 15 calendar days of notification of such occurrences and their outcome consistent with requirements under Article IV of these Bylaws.

(4) Physicians, dentists, podiatrists, and optometrists employed full time by VHA may engage in non-VA health care related professional activities outside their scheduled tour of duty as long as those activities do not interfere with call back provisions.

E. Abide by the Medical Staff Bylaws, Rules and Regulations and all other lawful standards and policies of the West Palm Beach VA Medical Center and Veterans Health Administration.

Section 4. Code of Conduct

A. Acceptable Behavior: The West Palm Beach VA Medical Center expects that members of the medical staff will serve diligently, loyally, and cooperatively. They must avoid misconduct and other activities that conflict with their duties; exercise courtesy and dignity; and otherwise conduct themselves, both on and off duty, in a manner that reflects positively upon themselves and the Medical Center. Acceptable behavior includes the following (1) being on duty as scheduled. (2) being impartial in carrying out official duties and avoiding any action that might result in, or look as though, a medical staff member is giving preferential treatment to any person, group or organization, (3) not discriminating on the basis of race, age, color, sex, religion, national origin, politics, marital status, or disability in any employment matter or in providing benefits under any law administered by the West Palm Beach VA Medical Center, (4) not making a governmental decision outside of official channels, (5) not taking any action that impedes government efficiency and economy, affects one’s impartiality, or otherwise lowers public confidence in the Federal Government, and (6) with certain exceptions in accordance with

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5 C.F.R. 2635, not asking for or accepting any gift, tip, entertainment, loan, or favor, or anything of monetary value for oneself or any member of one’s family from any person or organization that is seeking or has a business or financial relationship with the West Palm Beach VA Medical Center to avoid the appearance that one’s official actions might be influenced by such gifts.

B. Behavior or Behaviors That Undermine a Culture of Safety: The West Palm Beach VA Medical Center recognizes that the manner in which its Practitioners interact with others can significantly impact patient care. The West Palm Beach Medical Center strongly urges its providers to fulfill their obligations to maximize the safety of patient care by behaving in a manner that promotes both professional practice and a work environment that ensures high standards of care. The Accreditation Council for Graduate Medical Education highlights the importance of interpersonal/communication skills and professionalism as two of the six core competencies required for graduation from residency. Providers should consider it their ethical duty to foster respect among all health care professionals as a means of ensuring good patient care. Conduct that could intimidate others to the extent that could affect or potentially may affect quality and safety will not be tolerated. These behaviors, as determined by the organization, may be verbal or non-verbal, may involve the use of rude and/or disrespectful language, may be threatening, or may involve physical contact.

Section 5. Conflict Management

A. In the event that conflicts arise between the medical staff and the Clinical Executive Board (CEB) on issues including, but not limited to, proposals to adopt a rule, regulation, or policy or an amendment thereto, the provisions of these Bylaws shall apply. In the event, that the provisions of these Bylaws are insufficient to resolve or successfully manage the conflict, the West Palm Beach VA Medical Center’s policy on managing conflict shall apply, as outlined in MCM 548-00E-292 “Alternative Dispute Resolution (ADR) Program”. Nothing in the foregoing is intended to prevent members of the medical staff from communicating with the governing body on a rule, regulation, or policy adopted by the Medical Staff of the West Palm Beach VA Medical Center or the CEB. The governing body shall determine acceptable methods for such communication.

B. If conflicts regarding the medical staff Bylaws, Rules and Regulations, or policies arise between the governing body and the organized medical staff, the organization will follow a conflict management processes that assures the health care safety and quality of care of the patients. The governing body, represented at the West Palm Beach VA Medical Center by the Medical Center Director, will identify an individual with conflict management skills who will meet with two representatives of the medical staff who are not service chiefs, and the involved parties as early as possible to gather information, work with the parties, and if possible, resolve the conflict, protecting the safety and quality of care and practicing a patient centered culture thru the whole process. Care, treatment, and services are provided based on patient needs, regardless of compensation or financial risk-sharing with those who work in the hospital. The

[12] governing body and medical staff operate, create policies and procedures, and secure resources and services that support patient safety and quality care, treatment, and services.

ARTICLE IV. APPOINTMENT AND INITIAL CREDENTIALING

Section 1. General Provisions

A. All members of the Medical Staff as defined in Article III, Section 1.b., will be subjected to full credentials review at the time of initial appointment and as outlined in this Article.

Credentials that are subject to change during leaves of absence will be subject to review at the time the individual returns to duty.

B. Appointments to the Medical Staff occur in conjunction with VA employment regulations or utilization under a VA contract or sharing agreement. The authority for these actions is based upon:

(1) Provisions of 38 U.S.C. in accordance with Department of Veterans Affairs Manual MP-5, part II, chapter 2, and its supplements; 38 U.S.C. sections 7402(b)(8), and applicable Agreement(s) of Affiliation in force at the time of appointment.

(2) Federal law authorizing VA to contract for health care services.

C. Probationary Period. Initial and certain other appointments made under U.S.C.

7401(1), 7401(3), 5 U.S.C. 3301, are probationary. During the two (2) year probationary period, professional competence, performance and conduct will be closely evaluated under applicable VA policies and procedures. If, during this period, the employee demonstrates an acceptable level of performance and conduct, the employee will successfully complete the probationary period.

Supervisors and managers apply similar processes to the evaluation of individuals employed under provisions of 38 U.S.C. 7405 and those utilized under contracts and sharing agreements. At the end of the probationary period, if the individual has demonstrated an acceptable level of performance, the probationary status will be converted to a career appointment. Appointment of properly licensed non-citizen individuals with a permanent immigration visa will be considered temporary and subject to annual review of performance.

Section 2. Application Procedures

A. Applicants for appointment to the Medical Staff must submit a complete application.

The applicant must submit credentialing information through VetPro as required by VHA Handbook 1100.19. To be complete, applications for appointment must be submitted by the applicant on forms approved by the VA and/or the facility and include authorization for release of information pertinent to the applicant and information as listed below:

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(1) Items specified in Article III, Section 2, Qualifications for Medical Staff Membership:

(a) Active, current, full and unrestricted license to practice the individual’s profession in a state, territory or commonwealth of the U.S. or the District of Columbia or national certification by NCCPA for physician assistants and national certification by ANCC or VA-recognized certification program for nurse practitioners.

(b) Relevant education,

(c) Relevant training and/or experience,

(d) Current clinical competence and conduct as evidenced by performance information that bears on the applicant’s credentials.

(e) Physical and mental health status,

(f) Response time from residence as defined in Article III, Section 2, paragraph (i).

(g) English language proficiency, as defined in VA Human Resource regulations.

(h) Professional Liability Insurance history. When a non-VA practitioner applies for Medical Staff appointment and/or clinical privileges professional liability insurers will be contacted. Applicants must supply any present or past involvement in administrative, professional or judicial proceedings in which professional malpractice is or was alleged. The details will include name of action or proceeding, date filed, court or reviewing agency, status or disposition of case concerning allegation together with an explanation by applicant of the circumstances involved.

(2) U.S. Citizenship. Applicant must be a citizen of the United States.

However, when it is not possible to recruit qualified citizens, practitioners otherwise eligible for Medical Staff appointment who are not citizens will be eligible for consideration for appointment. Proof of current VISA status and documentation from Immigration and Naturalization Service of employment authorization, pursuant to qualifications as outlined in 38 U.S.C. 7405 and VA Handbook 5005, Part II, Chapter 3 will be required

(3) References. Where possible, names and addresses of a minimum of three (3) individuals one of which is from the most recent supervisor or Program Director who are qualified to provide authoritative information regarding training/experience, competence, health status and/or fulfillment of obligations as a Medical Staff member within the privileges requested. One of the references must be provided by a peer. Peer recommendations include written information

[14] regarding the practitioner’s current Medical / Clinical Knowledge, Technical and Clinical Skills, Clinical Judgment, Interpersonal Skills, Communication Skills, and Professionalism.

(4) Previous Employment. List of all health care institutions where the practitioner is/has been appointed, utilized or employed, including:

(a) Name of health care institution or practice,

(b) Term of appointment or employment, and

(c) Privileges held and any disciplinary actions taken or pending against the privileges, including suspension, revocation, limitations, or voluntary or involuntary surrender.

(5) DEA (Drug Enforcement Administration)/ CDS (Controlled Dangerous Substances) registration.

(a) Of those who have, or have had, DEA registration.

(b) Previously successful or currently pending challenges to DEA/CDS registration or the voluntary or involuntary relinquishment of such registration.

(6) Current pending challenges to license or registration, including whether a license or registration ever held to practice a health occupation by the practitioner has been suspended, revoked, voluntarily surrendered or not renewed.

(7) Status of any claims made against the practitioner in the practice of any health occupation. (NOTE: Final judgments or settlements of professional liability actions are minimum requirements.)

(8) Voluntary or involuntary termination of Medical Staff membership or voluntary or involuntary limitation, reduction, or loss of clinical privileges at other health care facilities.

(9) Current pending challenges against the practitioner by any hospital, licensing board, law enforcement agency, professional group or society.

(10) Authorization for release of information, including written consent to the inspection of records and documents pertinent to applicant's licensure, training, experience, current competence, and health status.

B. Documents required in addition to those listed include:

(1) Documentation of current or most recent clinical privileges held, if applicable or available.

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(2) Verification of status of licenses for all states in which the applicant has ever held a license.

(3) For foreign medical graduates, evidence and verification of the ECFMG (Educational Commission for Foreign Medical Graduates) certificate and/or a fifth pathway route of training.

(4) Evidence and verification of current board certification in an area relevant to the privileges requested, by a VA recognized physician board.

(5) Verification of education credentials used to qualify for appointment (and privileges) including all postgraduate training.

(6) Evidence of registration with the NPDB (National Practitioner Data Bank) and PDS (Proactive Disclosure Service) for all members of the Medical Staff and those practitioners with clinical privileges.

(7) For all physicians screening will be accomplished through the Federation of State Medical Boards (FSMB) Physician Data Center. This screening will report all licenses known to FSMB ever held by the physician. If the screen results in a disciplinary alert, primary source information from the State licensing board for all actions related to the disciplinary alert as well as a statement from the practitioner must be obtained.

(8) Testimony, by the applicant, of their physical and mental ability to perform the privileges, which they seek.

(9) Agreement to abide by the Medical Staff Bylaws, Rules and Regulations and to provide continuous care of applicant's patients.

C. Burden of Proof. The applicant has the burden of obtaining and producing all needed information for a proper processing and evaluation of applicant’s professional competence, character, ethics, and other qualifications. The information must be complete and verifiable. The applicant has the responsibility for furnishing information that will help resolve any doubts concerning such qualifications. Failure to provide necessary information within 30 days may serve as a basis for denial of employment consideration.

NOTE: Verification is defined as primary source documentation by letter, telephone call, computer printout or, in the case of confirmation of board certification, by listing in specific directories, as outlined in VHA policies on Credentialing and Privileging and VHA Handbook 1100.19.

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Section 3. Process and Terms of Appointment

A. The appropriate service chief is responsible for recommending appointment to the Medical Staff. The Chief of Staff is responsible for recommending appointment of Service Chiefs.

The Chief of the appropriate clinical service recommends appointment of the Chief of Staff. This recommendation is based on evaluation of the applicant's credentials and determination that service criteria for clinical privileges are met.

B. In order to ensure an appropriate review is completed in the credentialing process the applicant’s file must be submitted to the VISN 8 Chief Medical Officer (CMO) for review and recommendation as to whether to continue the appointment and privileging process prior to presentation to the Professional Standards Board (PSB) if the response from the NPDB-HIPDB query indicates that any of the following criteria is met: There have been, for or on behalf of the applicant, (a) three or more medical malpractice payments, (b) a single medical malpractice payment of $550,000 or more, or (c) two medical malpractice payments totaling $1,000,000 or more. The higher level review by the VISN 8 CMO is to assure that all circumstances, including the individual’s explanation of the specific circumstances in each case, are weighed against the primary source verification and that the appointment is still appropriate. The VISN 8 CMO may consult with Regional Counsel as needed to determine the appropriate documents for primary source verification of the basis for medical malpractice payments. The VISN 8 CMO review will be documented on the Service Chief’s Approval screen in VetPro as an additional entry.

Review by the CMO is also required for applicants for initial appointment who have had any licensure actions or may have any pending licensure actions.

C. The Professional Standards Board (PSB) recommends a Medical Staff appointment based on evaluation of credentials of each applicant and a determination that Medical Staff criteria for clinical privileges are met. This recommendation is forwarded to the CEB for final recommendation. The recommendation of the CEB is subject to final approval by the Medical Center Director.

D. Appointments to the Medical Staff should be acted upon by the Medical Center Director within 30 days of receipt of a fully complete application including all required verifications, references and recommendations from the appropriate Service Chief, PSB and CEB.

Applicants shall enter on duty (EOD) within ninety (90) days of approval by the Professional Standards Board. Appointees who do not meet this requirement must be re-presented to the Professional Standards Board for consideration of adverse occurrences between the time of initial Board approval and EOD date. The term of appointment is for a period not to exceed two (2) years.

NOTE: In conformity with VA Rules and Regulations, appointments of certain clinically privileged employees are based on recommendations of "Standards Boards" which differs from the West Palm Beach VA Medical Center Professional Standards Board. In all cases where recommendations are made by any Standards Board, whether it is the West Palm Beach VA Medical Center Professional Standards Board or other "Standards Boards", in

[17] order to conform to VA Rules and Regulations, these recommendations are forwarded to the CEB for their approval and for final approval by the Medical Center Director.

E. Candidates for appointment who have submitted complete applications as defined by these Bylaws will receive written notice of appointment or non-appointment. In the case where appointment is not approved, reasons will be provided.

F. Temporary Appointment. When there is an emergent or urgent patient care need, a temporary VA employment appointment, under provisions of 38 U.S.C. 7405(a)(1) and VHA Supplement MP-5, part II, chapter 2, temporary Medical Staff appointment, may be approved by the West Palm Beach VA Medical Center Director, upon recommendation of the Chief of Staff, prior to receipt of all references or verification of other information and action by the Professional Standards Board and CEB. Verification of current licensure, confirmation of possession of clinical privileges comparable to those to be granted and a reference will be obtained prior to making such an appointment. National Practitioner Data Bank – Healthcare Integrity and Protection Data Bank (NPDB-HIPDB) report will be obtained on the applicant to be considered with the application.

Section 4. Credentialing for Telehealth and Teleconsultation

When the staff of a facility determines that telemedicine and/or teleconsultation is in the best interest of quality patient care, appropriate credentialing and privileging is required between the Providing Facility and the Receiving Facility.

A. Telehealth providers will be credentialed and privileged to practice at the Providing Facility. Telehealth providers do not need to be credentialed and privileged at the Receiving Facilities so as long as the provider’s practice is limited to the privileges granted by the Providing Facility and accepted by the Receiving Facility as noted in the Memorandum of Understanding and the Telehealth Service Agreement.

1. The practitioner providing the telemedicine and/or teleconsultation services must be credentialed and privileged in accordance to VHA Handbook 1100.19.

2. Competency reviews will be performed at every center where the telehealth provider is privileged.

3. The Providing Facility will be responsible and accountable for ensuring that the telehealth providers are credentialed and privileged in compliance with the Joint Commision standards for the telehealth providers.

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ARTICLE V. CLINICAL PRIVILEGES

Section 1. General Provisions

A. Medical Center specific privileges are granted for a period not to exceed two (2) years.

B. Biennial reappraisal of each Medical Staff member and any other practitioner who holds clinical privileges is required. This reappraisal is instituted by the practitioner’s Service Chief at the time of a request by the practitioner for new or renewed clinical privileges. Reappraisal includes a review of performance by someone with comparable privilege, an evaluation of the individual's physical and mental status, and an assessment of the individual's current privileges. It also requires verification of satisfactory completion of sufficient continuing education to satisfy a minimum requirement of 40 hours of continuing education every two years. The amount of continuing education relevant to current privileges is determined by the Service Chief.

C. A practitioner's request for modification/enhancement of existing clinical privileges is made by the practitioner through submission of a formal request for desired changes with full documentation to support the change.

D. Certain other practitioners which include but are not limited to nurse practitioners, physician assistants, Certified Registered Nurse Anesthetists (CRNAs), and clinical nurse specialists who are presently permitted by law and the West Palm Beach VA Medical Center to provide patient care services may be granted clinical scope of practice based on their assignments, responsibilities and demonstrated competence.

E. Requirements and processes for requesting and granting privileges are the same for all practitioners who hold privileges regardless of their appointment type, utilization authority, or their professional discipline. Although the reappraisal process occurs biennially, Ongoing Professional Practice Evaluation is designed to continuously evaluate a practitioner’s performance.

F. Practitioners with clinical privileges are assigned to and have clinical privileges in one clinical department/service, but may be granted clinical privileges in other clinical departments/services. If new privileges are requested, a proctorship may be initiated requiring the provider to perform a specified number of procedures within an allotted time period to validate competence.

G. Exercise of clinical privileges within any service is subject to the rules of that service and by the authority of that Service Chief. Practitioners practice only within the scope of their privileges that have been granted.

H. Admitting Privileges - Only members of the active Medical Staff are eligible to be granted the privilege to admit patients to the acute, critical, or Community Living Center of the facility. Physicians and oral-maxillofacial surgeons with admitting privileges have the

[19] responsibility for taking the medical history and conducting a comprehensive physical examination and required updates on patients admitted for inpatient care. The process of taking the medical history and conducting a comprehensive physical examination and required updates may be delegated to physician assistants or nurse practitioners. However, in all cases, the attending physician of record bears the responsibility for the accuracy and completeness of the history and physical and required updates. When an oral-maxillofacial surgeon admits to inpatient services, the provision is made for the prompt medical evaluation of these patients by a qualified physician, if a risk or condition requiring such evaluation is discovered by the oral-maxillofacial surgeon during the admitting history and examination. Dentists are responsible for that part of the patient's history and physical examination related to oral pathology. Some dentists, because of their training and experience, may be privileged to perform the admitting history and physical and required updates.

Dentists possessing such credentials must request and be granted these privileges. A patient's general medical condition will be the responsibility of a qualified designated physician irrespective of the illness, management, or reason for admission.

I. Special Conditions for Dental Privileges - Requests for clinical privileges from dentists shall be processed, evaluated and granted in the same manner as physicians. Surgical procedures performed in the operating suite shall be under the overall supervision of the Chief of Surgical Service. Patients admitted to the Medical Center for dental care or any type of oral pathology shall receive the same basic medical appraisal as patients admitted for any other reason.

A designated physician member of the Medical Staff shall be responsible for the care of any medical problem that may be present at the time of admission or that may arise during hospitalization. The admitting dentist shall determine the risk and effect of the proposed surgical procedures through performance of the admitting H&P and will consult with a physician member of the Medical Staff on the total health status of the patient, as necessary.

J. Clinical Direction of Specialty Care Units - Overall clinical direction of Specialty Care Units is vested in multidisciplinary committees of the Medical Staff; namely Critical (Intensive) Care and End stage Renal Disease Committees. The Chairman of the Critical Care Committee and the End Stage Renal Disease Committee shall be a physician member of the Medical Staff. Upon recommendation of the Chief of Staff, the Medical Center Director shall appoint the Chairman of the Critical Care Committee and the Chairman of the End stage Renal Disease Committee. Responsibilities of the Chief of Critical Care Units and Renal Dialysis Unit will be in accordance with the respective Medical Center Policy Memorandum.

K. Determination of Organization Resource Availability – The Clinical Service Chief makes an assessment to determine whether sufficient space, equipment, staffing, and financial resources are in place or available within 90 days to support each requested privilege.

Section 2. Process and Requirements for Requesting Clinical Privileges

A. Burden of Proof. The practitioner requesting clinical privileges must furnish all information needed for a proper evaluation of professional competence, conduct, ethics, and other qualifications. The information must be complete and verifiable. The practitioner is responsible for

[20] furnishing information that will help resolve any doubts concerning such qualifications. Failure to provide necessary information within 30 days may serve as a basis for denying the processing of the request for clinical privileges.

B. All practitioner requests for clinical privileges must be made in writing and include privileges requested "within well defined limits" as defined by each Service, in a format approved by the CEB upon recommendation of the Professional Standards Board. Each application for clinical privileges will be accompanied by signed consents to the inspection of records and documents, pertinent to the applicant’s licensure, specific training, experience, current competence, and ability to perform the privileges requested. If requested, the applicant will appear for an interview.

C. The practitioner applying for reappraisal of clinical privileges must submit a complete application for privileges, which will include:

(1) Complete appointment information as outlined in Section 2 of Article IV.

(2) Application for clinical privileges as outlined in Section 2b of this Article.

(3) Documentation of current Basic Life Support (BLS) for all Healthcare Providers.

Exceptions to the BLS requirement may only be made by the PSB. Staff members with physical restrictions are still responsible for completing didactic portion of BLS training.

(4) Documentation of current Advanced Cardiac Life Support (ACLS) if the staff member is an emergency, critical care, or hospitalist provider; is in code blue or rapid response team, or has moderate sedation or anesthesia privileges.

D. A practitioner’s request for modification to clinical privileges subsequent to those granted initially will initiate the recredentialing process and the practitioner must provide the following information:

(1) An application for clinical privileges as outlined in Section 2b of this Article.

(Since practice, techniques, and facility missions change over time, it is expected that modifications, additions or deletions to existing clinical privileges will occur. Practitioners are urged to consider carefully and discuss appropriateness of specific privileges with the appropriate Service Chief prior to formal submission of the request.)

(2) Supporting documentation of professional training and/or experience not previously submitted.

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(3) Physical and mental health status as it relates to practitioner's ability to perform privileges requested including such reasonable evidence of health status that may be required by either the Professional Standards Board or the Physical Standards Board.

(4) Documentation of continuing medical education related to area and scope of clinical privileges not previously submitted. Continuing educational requirements will be determined by the Professional Standards Board after recommendations by the Continuing Medical Education (CME) Committee.

(5) Status of all licenses, certifications held.

(6) Any sanction(s) by a hospital, state licensing agency or any other professional health care organization; voluntary or involuntary relinquishment or current pending challenges of appointment, privileges, licensure or registration; any malpractice claims, suits or settlements (e.g., final judgments or settlements); or voluntary or involuntary termination of medical staff membership or voluntary or involuntary limitation, reduction or loss of privileges at any other hospital within 15 days of an adverse action.

(7) Response time from residence to facility.

(8) Names of other hospitals at which privileges are held, copies of the privileges held and provider profile data for privileges requested. When possible, the copies of the privileges will be obtained from primary source verification and not from the applicant.

(9) Information from the practitioner’s professional practice evaluation data that are collected and assessed on an ongoing basis, if available.

E. Bylaws Receipt and Pledge. Prior to the granting of clinical privileges, Medical Staff members or applicants will pledge to provide for continuous care of their patients and will receive a copy of the Bylaws and Rules and agree in writing to abide by the professional obligations therein.

F. Verification

(1) Verification of credentials prior to granting of initial privileges will be accomplished as described in Article IV, Section 2, "Appointment and Initial Credentialing".

(2) Before granting subsequent clinical privileges, the Chief of Staff will assure that the following information is on file and verified with the primary sources, as applicable:

(a) Current and former licenses in all states.

(b) Current and former DEA license and/or registration.

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(c) National Practitioner Data Bank query.

(d) Physical and mental health status information from applicant indicating their ability to practice in the area in which they are requesting privileges. In instances where there is doubt about an applicant’s ability to perform privileges requested, an evaluation by an external or internal source may be required as prescribed by VHA Human Resource Policy.

(e) Physical and mental health confirmation and confirmation of applicant’s…