36C25518R0214-027.pdf

Department of Veterans Affairs Medical Center Kansas City, Missouri

December 2008

TABLE OF CONTENTS

Preamble & Statement of Purpose

ARTICLE 1: Organization & Governance of the Medical Staff

ARTICLE 2: Medical Staff Membership Section 1: Nature of Medical Staff Membership

Section 2: Qualifications for Membership & Clinical Privileges Section 3: Basic Responsibilities of Staff Membership

ARTICLE 3: Appointment & Initial Credentialing Section 1: Procedures for Appointment Section 2: Process & Terms of Appointment

ARTICLE 4: Clinical Privileges Section 1: Delineation of Clinical Privileges Section 2: Process & Requirements for Requesting Clinical Privileges Section 3: Medical Staff Appointment & Reappraisals Section 4: Exceptions Section 5: Credentials Evaluation & Maintenance Section 6: Recommendations & Approval

ARTICLE 5: Fair Hearing & Appellate Review Section 1: Denial of Medical Staff Appointment Section 2: Actions Against Clinical Privileges Section 3: Reporting Adverse Actions Section 4: Reporting Malpractice Payments Section 5: Termination of Appointment

ARTICLE 6: Immunity from Liability Federal Tort Claims Act

ARTICLE 7: Professional Services Section 1: Professional Services Section 2: Clinical Services Section 3: Organization of Services Section 4: Duties & Responsibilities of Clinical Service Chiefs

ARTICLE 8: Committees Section 1: Appointment Section 2: General Obligations Section 3: Committees & Boards Section 4: Director's Advisory Board…………………………………………………….. 22 ii

ARTICLE 9: Meetings Section 1: Medical Staff Meeting Section 2: Attendance Requirements

ARTICLE 10: Rules & Regulations

ARTICLE 11: Amendments

ARTICLE 12: Adoption

RULES AND REGULATIONS

Section 1: Patient Rights & Responsibilities Section 2: Informed Consent Section 3: General Responsibility for Care A. Conduct of Care B. Emergency Services Section 4: Admission, Discharge & Patient Care A. Admission B History & Physical C. Patient Assignment D. Areas of Restricted Admission E. Transfer of Patients F. Consultations G Physician's Order H. Medication & Other Orders I. Investigational Drugs J. Submission of Surgical Specimens K. Other Special Treatment & Procedures L. Moderate Sedation &/or Anesthesia for Invasive Procedures M Discharge Planning Section 5: Role of Attending Staff Section 6: Medical Records A. Basic Administrative Requirements B. Medical Record Requirements Section 7: Handling of Autopsies Section 8: Professional Education Section 9: Guidelines for Initiating Research, Scientific Authorship, Presentation, & Publication Section 10: Infection Control Section 11: Disaster Plan Section 12: Impaired Professional Program Section 13: Policy Memoranda

APPENDIX 1: Tort Claim Process - KCVA

PREAMBLE AND STATEMENT OF PURPOSE

The Department of Veterans Affairs Medical Center, Kansas City, Missouri, is a public hospital organized under the provisions of the Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) and serves as a key component of an integrated health care delivery system -- the Heartland Veterans Integrated Service Network (VISN 15) -- in providing patient care, education, and research.

The Undersecretary for Health of the Veterans Health Administration (VHA), Department of Veterans Affairs (VA), Washington, D.C., has delegated authority of the Governing Body to the Medical Center Director for local facility management and planning. The Medical Center Director ("Chief Executive Officer"), upon the advice of the Medical Staff and the Director's Advisory Board, acts as the Governing Body for Department of Veterans Affairs Headquarters

Recognizing that the Medical Staff is responsible for the oversight of care, treatment, and services delivered by its members and accountable to the Director for all aspects of that care, the medical staff practicing at this Medical Center hereby organize themselves for self governance in conformity with the laws, regulations and policies governing VHA and the bylaws and rules hereinafter stated. These Bylaws and Rules are consistent with all laws and regulations governing VA, and they do not create any rights or liabilities not otherwise provided for in laws or regulations.

The purpose of the medical staff is to organize the activities of qualified physicians and other clinical practitioners who practice at the Kansas City VA Medical Center in order to carry out the functions delegated to the medical staff by the Governing Body (Medical Director) in conformity with the laws, regulations and policies governing VHA and these bylaws. The members of the medical staff work together as an organized body to promote a uniform standard of quality patient care, treatment, and services and to offer advice, recommendations, and input to the Governing Body.

Responsibilities of the organized medical staff include the following:

1. To develop, amend, and adopt bylaws, policies, and procedures to determine its governance and administrative structures and the processes for carrying out its work, subject to the ultimate authority the Governing Body.

2. To establish standards of patient care and ensure that every patient admitted to or treated by any provider of this Medical Center shall receive the best possible care our resources can furnish. Quality of health care, treatment and services will be ensured through continuous monitoring and evaluating of care, identifying and resolving problems, identifying and acting on opportunities to improve patient care.

3. To establish criteria for membership, credentialing, and privileging of all licensed independent practitioners authorized to practice in this Medical Center.

4. To ensure a high level of professional performance through establishment and maintenance of an effective mechanism to monitor (performance measurement system), evaluate and improve the quality of patient care and the clinical performance of individuals.

5. To serve in a leadership role in hospital performance improvement activities to improve quality of care, treatment, services and patient safety.

6. To provide an appropriate educational setting which maintains scientific standards, leads to continuous advancement in professional knowledge and skills, and supports education of students and residents.

7. To establish, and assure adherence to, ethical standards of professional practice and conduct.

8. To provide a means whereby issues concerning the Medical Staff and the Hospital may be discussed by the Medical Staff with the Governing Body and Medical Center Management.

9. To provide education and training to healthcare professionals and to perform research that benefits veterans.

ARTICLE 1

ORGANIZATION AND GOVERNANCE OF THE MEDICAL STAFF

SECTION 1: OFFICERS

VHA has no requirement for officers of the Medical Staff.

SECTION 2: CHIEF OF STAFF (COS)

The Chief of Staff functions as the President of the Medical Staff. The Chief of Staff is selected and assigned by the facility Director, VISN Director and VHA Headquarters. Should the Chief of Staff be removed from their position, he/she would no longer serve as the President of the Medical Staff. Procedures for actions against Title 38 employees (including Chiefs of Staff) is contained in VA Manual MP-5, Part II, Chapter 8. The Service Chiefs and the Executive Committee of the Medical Staff (ECMS) assist the Chief of Staff.

The Chief of Staff (President of the Medical Staff) is the medical staff’s advocate and representative in relationship with the Governing Body and the administration. He or she usually serves as the chair of the Executive Committee of the Medical Staff (ECMS) and ex-officio member of all other medical staff committees, participating as invited on hospital committees. The COS must enforce the medical staff bylaws and continually evaluate and report to the governing body, ECMS, and administration on the effectiveness of the credentialing and privileging processes. It is also customary for the COS to appoint committee chairpersons and members.

Job eligibility requirements for the COS include, but are not limited to, the following:

Is an active staff member in good standing with no adverse recommendations concerning medical staff appointments/privileges, no sanctions, and no professional conduct or quality issues

Has previously served in a significant medical staff leadership position or equivalent (e.g., service as a department or committee chair or as a member of the executive committee)

Has received training in medical staff leadership, or demonstrates a willingness to attend such training during the term of office

Has demonstrated an ability to work well with others and in compliance with the professional conduct policies of the medical center

Fully discloses all conflicts of interest or interest in competing healthcare entities

Demonstrates the ability to work positively and communicates well with colleagues, hospital;

administration, and the governing body.

Recognizes and agrees to the commitment of time needed to perform medical staff duties, and assumes responsibility for participation in continuing leadership education http://www1.va.gov/ohrm/HRLibrary/Archives/MP5_Chapters/Part_2/chap08.pdf

ARTICLE 2

MEDICAL STAFF MEMBERSHIP

SECTION 1: NATURE OF MEDICAL STAFF MEMBERSHIP

A. Membership of the Medical Staff of the Kansas City VA Medical Center is a privilege, which shall be extended only to professionally competent physicians, optometrists, podiatrists, dentists, doctors of chiropractic, Ph.D./Psy.D. Psychologists, Ph.D. audiologists, and Ph.D. speech pathologists, who continuously meet the qualifications, standards, and requirements set forth in these Bylaws and by the Department of Veterans Affairs’ rules, regulations, and policies.

B. Membership on the staff of this Medical Center will include the following categories: Full-time, temporary full-time, part-time, and intermittent staff physicians, dentists, optometrists, podiatrists, doctors of chiropractic, Ph.D./Psy.D. Psychologists, Ph.D. audiologists, and Ph.D. speech pathologists. All members of the Medical Staff are considered to have active membership. VA employees, consultants, Without Compensation (WOC) appointees and contractors may receive appointments to the medical staff.

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

SECTION 2: QUALIFICATIONS FOR MEDICAL STAFF MEMBERSHIP AND CLINICAL

PRIVILEGES

It is the policy of the Kansas City VA Medical Center to grant and maintain medical staff membership and clinical privileges only to those practitioners who continuously meet the following criteria:

1. Possess appropriate education degrees (Doctor of Medicine, Osteopathy, Dentistry, Optometry, Podiatry, Chiropractic, or a Ph.D. in Psychology [Ph.D. or Psy.D.], Audiology or Speech Pathology from an approved college or university) and demonstrate the relevant training and/or experience, current competence, knowledge, judgment, ability to perform, and technique in his or her specialty for all privileges requested. Exceptions require approval from the Chief of Staff, Director, and possibly VA Headquarters.

2. Possess active, current, full, and unrestricted license to practice in one of the States, Territories or Commonwealth of the United States or the District of Columbia. Those not licensed to practice in any State, Territories or Commonwealth of the United States or the District of Columbia may be appointed members under the provisions of 38 USC 4114 (d). The Undersecretary for Health or his/her designee may waive the licensure requirements of a physician or dentist if he/she is to be solely involved in research or academic activities or in other positions where there is no direct responsibility for patient care.

3. Maintain appropriate personal qualifications, including applicant’s consistent observance of ethical and professional standards by consistently acting in a professional, appropriate, and collegial manner with others in clinical and professional settings.

4. Demonstrate proficiency in the use of the computer and VA computer systems to support patient care.

5. Upon request, provide evidence of both physical and mental health that does not impair the fulfillment of his or her responsibilities of his or her medical staff membership and the specific privileges requested by and granted to the practitioner.

6. Possess appropriate written and verbal communication skills and demonstrate proficiency of the English Language.

7. Evidence of current professional liability insurance as required by Federal and VA acquisition regulations.

SECTION 3: BASIC RESPONSIBILITIES OF STAFF MEMBERSHIP

A. Provide for continuous high quality care of patients and arrange transfer of care when appropriate.

B. Participate in performance improvement, patient safety, peer review, and medical staff monitoring and evaluation.

C. Maintain standard of ethics and ethical relationships that include:

1. Abide by the Medical Staff Bylaws, Rules and Regulations and all other lawful standards, policies and rules of the Kansas City VA Medical Center, VISN 15, and VHA. Comply with facility, VISN 15 and VHA policies regarding ethical practice of medicine and ethical conduct to include professional courtesy and functioning in a manner to educate and support other employees. Abide by federal law and VA rules and regulations regarding outside professional activities for remuneration (MP-5, Part II, Ch 13 and its supplements, Ethics Reform Act). Medical staff members are especially admonished to refrain from activities, which might have the appearance of a conflict of interest. Additionally, full time staff members must not engage in any outside activity, which would limit their availability to care for VA patients. Title 5 employees will follow the guidelines as outlined in the FPM Manual, Chapters 531 and 61O. All members of the Medical Staff are expected to comply with VHA Handbook 5011, Official Time and Attendance.

2. Practicing within the scope of privileges granted by the Medical Center Director and advise the Medical Center Director/Chief of Staff of any change in his/her ability to meet fully the criteria for Medical Staff membership or to carry out clinical privileges that are held. On-call requirements include the ability to be contacted readily and respond in a matter of minutes. When on-call, the practitioner must be within a 30 -60 minute drive of the Medical Center or as clinically appropriate.

3. Advise the Medical Center Director/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 outcomes.

4. Ethical practices as outlined by the national bodies such as, the American Medical Association, the American Dental Association, the American Osteopathic Association, the American Podiatry Association, the American Chiropractic Association, the American Psychological Association, the American Optometric Association, the American Society for Microbiology, and the American Speech, Language and Hearing Association, whichever is applicable, will be strictly followed. Members of the Medical Staff may opt to not participate in procedures to which they object on an ethical, cultural or religious basis, without fear of reprisal or other action, providing care of the patient is properly transferred and documented. Additional information can be found in the related hospital policy memoranda.

D. Actively participate in student and resident education, as required, and comply with GMEC/RRC/ACGME requirements as required.

E. Participate on hospital committees, task forces, boards, attend meetings, etc. as requested.

F. Maintain licensure requirements, CME, and other privileging requirements (e.g. ACLS, etc.)

http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1044 http://www.warms.vba.va.gov/admin20/directve/va/5011_2.doc

ARTICLE 3

APPOINTMENT AND INITIAL CREDENTIALING (PER VACO POLICY)

SECTION 1: PROCEDURES FOR APPOINTMENT

A. Authority

1. All members of the Medical Staff shall be appointed under the provisions of Title 38 United States Code, (VA manual DM&S Supplement MP-5, Part II, Chapter 2), or Title 5 (DM&S Supplement MP-5, Part I, Chapter 338). Procedures for appointment of Doctor of Chiropractic Medicine are published in VA Handbook 5005, Part II, Appendix H10.

2. Scarce medical specialty contracts are executed under the provisions of federal and VA acquisition requirements. (VAR, FAAR) Medical Staff members performing under these contracts will meet requirements for appointment as stated in this Article (VHA Handbook 1100.19)

B. Regularly appointed United States citizen staff members shall be granted an initial two-year probationary appointment with career appointment to follow subject to annual review.

C. For licensed non-citizen individuals with permanent (immigrant) visas, appointments will be three years, temporary renewable and subject to annual review (DM&S Supplement, MP-5, Part II, Chapter 2, paragraph 2.O8).

D. Application information.

1. Burden of Proof. The applicant has the burden of obtaining and producing all necessary, adequate, verifiable, and complete information for a proper evaluation of his/her 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 his/her qualifications. If information provided by the applicant varies substantially from information obtained through the VA credentials verification process, the applicant will be notified by the Credential Office staff, in collaboration with the Chief of Staff. The applicant has the right to provide written information that he/she believes will correct any discrepancy or error. Failure to provide necessary information within 30 days may serve as a basis for denial of employment consideration.

2. Complete Application. To complete applications for appointment they must be submitted by the applicant on forms approved by the VA and/or the Medical Center (VHS&RA Supplement, MP-5, Part II, Ch.1, para.2.44 a.), submitted through Vet Pro, and include information regarding:

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

Active, current, full and unrestricted License Education Relevant Training and/or Experience Current competence Physical and Mental Health Status Residence Geographic Location Professional Liability Insurance (contractors) English Language Proficiency Absence from OIG Sanction List

(b) U.S. Citizenship. Must be a citizen of the United States. Practitioners who are not citizens will be eligible for consideration for appointment, with proof of VISA status, when it is not possible to recruit qualified citizens, pursuant to qualifications as outlined in VA regulations (MP-5, Part II, ch. 2 and its VHS&RA Supplement) and provided by 38 U.S.C. 4114 or Title 5.

(c) References. Names and addresses of three (3) individuals who are qualified as peers or supervisors to provide authoritative information regarding training/experience, competence, health status and/or fulfillment of obligations as medical staff member within privileges requested;

http://www1.va.gov/ohrm/HRLibrary/Archives/MP5_Chapters/Part_2/chap02VHA.pdf http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1039 http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1039 http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=357 http://www1.va.gov/ohrm/HRLibrary/Archives/MP5_Chapters/Part_2/chap02VHA.pdf http://www1.va.gov/ohrm/HRLibrary/Archives/MP5_Chapters/Part_2/chap01.pdf http://www1.va.gov/ohrm/HRLibrary/Archives/MP5_Chapters/Part_2/chap01.pdf http://www1.va.gov/ohrm/HRLibrary/Archives/MP5_Chapters/Part_2/chap02VHA.pdf http://www1.va.gov/ohrm/HRLibrary/Archives/MP5_Chapters/Part_2/chap02VHA.pdf

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

Name of health care institution or practice Term of appointment or employment Privileges held and any disciplinary actions taken against the privileges, including suspension, revocation, limitations, or voluntary surrender.

(e) DEA Registration:

For those who have DEA certificates, (list any) previously successful or currently pending challenges to DEA registration or the voluntary relinquishment of such registration..

(f) Challenges to License 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.

(g) Status of any claims made against the practitioner in the practice of any health occupation and the status of the claim.

(h) Voluntary or involuntary termination of medical staff membership or voluntary or involuntary limitation, reduction, or loss of clinical privileges at another health care facility.

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

(j) 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 and to appear for an interview if required or requested.

3. Documents required in addition to those listed above include:

(a) Pre-employment References from the current or most recent employer and two other references who can provide authoritative information regarding training/experience, professional competence and conduct and health status.

(b) Documentation of Current or Most Recent Clinical Privileges held, if available.

(c) Verification of Licenses for all States in which the applicant has ever held a license.

(d) Educational Commission for Foreign Medical Graduates (ECFMG) verification, for foreign medical graduates.

(e) Evidence and verification of Board Certification, if claimed.

(f) Verification of Education Credentials used to qualify for appointment (and privileges).

(g) Reports of queries from National Practitioner Data Bank (NPDB) and OIG Sanction list for all practitioners.

(h) Review of Bylaws, Rules, Regulations, and policies with signature certifying their review and compliance.

SECTION 2: PROCESS AND TERMS OF APPOINTMENT

A. The Service Chief of the program to which the applicant is to be assigned is responsible for recommending appointment, based upon background checks, interviews, and pre-employment recommendations and evaluation of the applicant's credentials and determination that the program’s criteria for clinical privileges are met.

B. The Executive Committee of the Medical Staff - Professional Standards Session, will examine all application materials before making a recommendation regarding appointments to the Medical Center Director.

Included in this are pending or settled malpractice claims; prior work records; challenges to and/or voluntary relinquishment of any licensure or registration; voluntary or involuntary termination of medical staff membership;

limited, revoked or suspended privileges (voluntary or involuntary) at other institutions; and qualifications for clinical privileges that meet the needs of this Medical Center.

C. Appointments shall be approved by the Medical Center Director within three (3) weeks of receipt of a fully complete application including recommendations from the appropriate service chief, Professional Standards Board (PSB), and when applicable, the Chairman of the department at the university (ies) in which the individual holds an academic appointment.

D. 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 that appointment is not approved, reasons will be provided.

E. Probationary Period. Initial appointments made under authority of Title 38 USC 4104 are probationary.

During this time the appointee's professional competence, performance and professional conduct will be evaluated by the appropriate Service Chief, and reviewed by the Chief of Staff, and the appropriate. Professional Standards Board (PSB). At the end of two years, if the applicant has demonstrated an acceptable level of performance and conduct, probationary status will be lifted. Individuals, appointed under Title 5, must serve a one-year probationary period during the first year of Title 5 appointment. Supervisors and managers will 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.

F. Temporary Appointment. When there is an emergent or urgent patient care need, a temporary appointment may be made by the Kansas City VA Medical Center Director. Prior to receipt of references or verification of other information and action by the ECMS, evidence of current licensure verification, conformation of possession of comparable clinical privileges and a reference will be made prior to making such an appointment.

National Physicians Data Bank (NPDB) query will also be initiated at the time of the temporary appointment.

G. Salary Determination. Determination of salary will be in accordance with Department of Veterans Affairs Handbook 5007. Pay is based upon longevity in the VA, and market pay. Performance pay will also be available based on yearly goal achievements. Recruitment and retention incentives are also available.

http://www1.va.gov/ohrm/Directives-Handbooks/Documents/5007.doc

ARTICLE 4

CLINICAL PRIVILEGES

SECTION 1: DELINEATION OF CLINICAL PRIVILEGES

A. Medical Center specific privileges are granted for a period not to exceed two years and considered for renewal every two years.

B. Granting, renewing, or revising setting-specific clinical privileges will be handled in accordance with policies outlined in this document. Any physician or non-physician health care provider who is permitted to initiate, alter or terminate a treatment regimen must have appropriate clinical privileges/scope of practice statement. Credentials that are subject to change during leaves of absence will be subject to review at the time the individual returns to duty.

C. Service Chiefs will establish written criteria for recommending clinical privileges for their staff members and will certify annually that the criteria have been reviewed and modified as necessary. The Service Chief will be responsible for the recommendation for granting, renewing, limiting, expanding, denying, or withdrawing clinical privileges (to include setting specific) and will be responsible for the annual performance evaluation or proficiency rating of each professional staff member. If the Service Chief is not a physician he/she must defer evaluation of clinical competency of clinical staff to the Clinical Leader, Section Chief or Chief of Staff. The clinical competence component as outlined in the Proficiency Report includes categories 1, 2, and 3 (clinical competence, educational competence, and research and development) as well as overall rating. The Physician Performance Appraisal at KCVAMC has been standardized and includes the definitions and criteria.

D. Every initial application for appointment must be accompanied by a separate request for the specific clinical privileges desired by the applicant. The evaluation of such requests shall be based upon the applicant's education, training, experience, demonstrated competence, peer recommendations, and other relevant information, including an appraisal by the clinical discipline and program in which such privileges are sought. The applicant shall have the burden of establishing his/her qualifications and competency in the clinical privileges he/she requests.

Initial clinical privileges for new employees will be provisional for a period of six months and a period of focused professional practice evaluation will be implemented. During this period a proctor assigned by the Service Chief must directly observe the performance and clinical competence of the practitioner, at least periodically and that individual must submit a formal written evaluation of the practitioner's performance to the Service Chief and Chief of Staff. The appropriate professional standards board will consider the evaluation and recommend action.

E. Granting of clinical privileges will be based on clinical criteria, will be governed by applicable VA regulations, the scope of their licenses, applicable statutes and consistent with the Medical Staff's regulations. At the time of application for clinical privileges, they shall agree to comply with all applicable Medical Staff Bylaws, Rules and Regulations. House Officers will function within the clinical privileges as determined by the attending staff responsible for the resident. Applications from residents for privileges are not required except when functioning outside of their training capacity (such as AOD's, chief residents and fellows functioning as attendings).

F. Privileges granted to dentists shall be based on their training, experience, and demonstrated competence and judgment. The scope and extent of surgical procedures that each dentist may perform shall be specifically delineated and granted in the same manner as all other surgical privileges. Surgical procedures performed by dentists in the operating rooms of the Surgery Service, shall be under the overall supervision of the Chief of Surgery.

G. Qualified, licensed physicians, dentists, podiatrists, optometrists, and chiropractors are granted Medical Center privileges by the Medical Center Director, based on the recommendation of the ECMS - Professional Standards Board.

H. Temporary Privileges in Emergency Situations Licensed physicians and dentists with expertise not available to the Medical Center by existing staff appointments can be authorized privileges by the facility Director on a temporary basis. Temporary privileges in emergency situations may be granted at the time of a temporary appointment. Such privileges will be based on documentation of a current state license, other reasonable, reliable information concerning training and current competence. The recommendation for temporary privileges will be made by the Service Chief to the Chief of Staff and approved by the facility Director. Temporary privileges should not exceed 60 days. Termination of a practitioner’s temporary privileges is not subject to appeal. The facility Director may at any time, on recommendation of the Chief of Staff, terminate a practitioner’s temporary privileges. Such action is not subject to appeal.

I. In case of emergency, any physician, dentist or osteopathic physician member of the organized Medical Staff, to the degree permitted by his/her licenses and regardless of program or staff status, shall be permitted and assisted in doing everything possible to save the life of a patient.

J. Other licensed individuals (allied health professionals) who are presently permitted by law to provide patient care services independently, may be granted clinical privileges based on their assignments and responsibilities.

When this is done, the responsibilities of physicians/dentists in relation to these professionals must be specified.

K. Requirements for requesting and granting privileges are the same for all practitioners who hold privileges.

L. Individuals with clinical privileges are assigned to and have clinical privileges in one clinical discipline/program, but may be granted clinical privileges in other clinical disciplines/programs.

M. Service Chiefs will establish and maintain a mechanism to assure that all individuals with clinical privileges function within the scope of privileges granted. A written procedure outlining this mechanism will be approved by the ECMS PSB and the facility Director. Copies of clinical privileges will be available to hospital staff on a need to know basis in order to assure providers are operating within the scope of their clinical privileges.

N. When granting of clinical privileges is contingent on appointment to the faculty of the medical or other health professional school affiliate, loss of faculty status will result in termination of existing clinical privileges.

O. Additional specific information is available in Medical Center Policy Memorandum 11-44, "Appointment, Privileging and Reprivileging, Promotion."

P. Focused review of Practitioner’s Performance: A “peer” is defined as an individual practicing in the same profession. The level of subject matter expertise required to provide a meaningful evaluation of care will determine what “practicing in the same profession” means on a case-by-case basis. For all peer review or focused reviews performed by the medical staff, the COS will determine the degree of subject matter expertise required for a provider to be considered a peer. (Focused review is an intensive review to determine whether a practitioner’s performance may require further action to improve that practitioner’s performance). The method for selection of a focused review panel or “peer” will be the decision of the Chief of Staff, and based upon the situation requiring review, the expertise required and the need to assure objectivity and confidentiality. The focused review will be conducted in a timely manner with the goal to complete this review within 45 days of identification of need.

Participation in this review process by the provider whose performance is being reviewed would be accomplished by requesting his/her input regarding the issue or performance under review. Feedback and request for response would be, at a minimum, solicited upon PRB’s review of findings of the focused review. Determination of action would incorporate the feedback from the provider.

Focused review will be conducted when an unusual clinical pattern of care or other major adverse issues are identified or abnormal trends in quality of care/performance improvement data. Circumstances requiring external peer review will be utilized for case(s) of: litigation, ambiguity, lack of internal expertise, new technology, and/or other miscellaneous issue such as benchmarking, expert witness for a fair hearing, evaluation of a credentialing file.

The ECMS is involved in: (1) evaluation of individuals with clinical privileges whose performance is questioned as a result of the measurement and assessment activities; (2) communication to the appropriate parties of the findings, conclusions, recommendations, and actions taken to improve practitioner performance; and (3) implementation of changes to improve performance. Timeframes in which peer reviews activities are to be conducted and the results reported is so noted in the Hospital’s Performance Improvement Plan.

SECTION 2: PROCESS AND REQUIREMENTS FOR REQUESTING CLINICAL

PRIVILEGES

A. Burden of Proof. The individual requesting clinical privileges, initial or renewal, has the burden of obtaining and producing all necessary, adequate, verifiable, and complete information for a proper evaluation of his/her professional competence, professional conduct, ethics and other qualifications requested and for resolving any doubts concerning such qualifications. Failure to provide necessary information in a timely manner of 60 days may http://vaww.kansas-city.med.va.gov/policies/hospitalwide/npm/chiefofstaff/npm11-44.doc serve as a basis for denying initial privileges or renewal of privileges.

B. Practitioner Requests for Clinical Privileges, initial and renewal, must be made in writing and include privileges requested within well-defined limits utilizing the format approved by the Medical Staff. Practitioners may submit a request for modification of clinical privileges at any time. The facility queries the NPDB at the time of initial medical staff appointments to membership and initial granting of clinical privileges, and at the time of expanding privileges or requesting to add new privileges as well as at least every two years thereafter for information on physicians, dentists, and other health care practitioners granted clinical privileges. Requests will be accompanied by the appropriate documentation, which supports the practitioner's assertion of competence. An explanatory statement should accompany requests for changes, which should be submitted through the service chief.

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

1. Complete appointment information as outlined in Article IV.

2. Application for clinical privileges as outlined in this Article.

3. Curriculum Vitae

D. The practitioner applying for renewal of clinical privileges will provide the following information for use in reappraisal of credentials, professional performance and competence and renewal of clinical privileges:

1. Application for clinical privileges as outlined in this Article. (Since practice and techniques change over time, it is expected that modifications, additions or deletions to existing clinical privileges will occur.)

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

3. Physical and mental health status as it relates to his/her ability to function within privileges requested.

4. Documentation of continuing medical education, consistent with area and scope of clinical privileges, (specify any minimum requirements, e.g. consistent with minimum state licensure requirements, etc.) not previously submitted.

5. Status of all licenses, certifications held.

6. Additional information, i.e., names of other hospitals or other health care institutions in which the individual holds medical staff membership and/or clinical privileges held.

7. Any sanction(s) by a hospital, state licensing agency or any other professional health care organization; voluntary or involuntary relinquishment of licensure or registration; any malpractice claims, suits, settlements and/or final judgments; reduction or loss of privileges at any other hospital such disclosure must be made no later than the time of the request for reprivileging.

E. Bylaws Receipt and Pledge. Prior to the granting of clinical privileges, initial or renewal, Medical Staff members or applicants will pledge to provide for continuous care of their patients and arrange transfer of care. The applicant will receive a copy of the Bylaws, Rules and Regulations and agree 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 this Article.

2. The credentialing process includes a mechanism to ensure that the individual requesting approval is the same individual identified in the credentialing documents. The Credentials Coordinator or Human Resources will personally review and examine a photo ID – driver’s license, school ID, or military ID - to verify the individual requesting privileges is in fact the same individual who is identified in the credentialing documents.

3. For renewal or revision of clinical privileges, Kansas City VA Medical Center C&P office and the responsible Service Chiefs, will assure that the following reappraisal and credentials information is on file and verified with primary sources as appropriate:

Current licenses in all states Current DEA license and/or registration National Practitioner Data Bank query Physical and mental health status information from applicant, clinical chief, peer Continuing education to meet requirements for privileges requested VISA and naturalization status Board certification(s) Quality of care information Absence from OIG Sanction List

G. For employees employed under Title 38, at the time of their annual proficiency evaluation, the proficiency form will be initiated by Human Resources, Network Business Office, and routed through the service chief, Patient Care and Performance Improvement (PPCI) for the determination of the requirement for clinical privileges. If clinical privileges are to be renewed, the Application for Renewal of Clinical Privileges, the Quality of Care Appraisal form and Reappraisal Assessment will be completed. When privileges are due for renewal, PPCI will provide the Service Chief with a Quality of Care Appraisal form and the annual performance appraisal form.

H. However, the Service Chief is responsible for ensuring the verification of current licensure, professional performance, technical skills and health status. Additionally, information will be provided regarding adverse actions, previous, successful or current pending challenges to licensure or registration, or the voluntary relinquishment of such licensure or registration, voluntary or involuntary termination of medical staff membership or voluntary or involuntary limitation, reduction, or loss of clinical privileges at another hospital, and involvement in liability actions, with final judgments and settlements and other reasonable indicators or continuing qualifications. Peer recommendations are also part of the basis of development of recommendations for continued membership on the medical staff and/or the delineation of individual clinical privileges.

I. The proficiency form, request for renewal of privileges and all other information obtained will be forwarded to the ECMS - Professional Standards Session, for consideration.

SECTION 3: MEDICAL STAFF APPOINTMENTS AND REAPPRAISALS

A. Every Medical Staff member is required to have on file a current license, record of formal medical training and a record of any board certification.

B. Every Medical Staff member’s proficiency will be appraised annually in accordance with VHA and KCVAMC regulations. The service chief will request medical staff members to conduct a self-assessment, prior to the completion of the appraisal. The completed appraisal will be sent to the Chief of Staff for review and signature. The Service Chief will then meet with the medical staff member to review and discuss their proficiency. Key components include the categories of direct patient care, administration, education, research, and personal qualities.

C. Practitioners and allied health professionals whose patient care activities require delineation of clinical privileges may render clinical services to Medical Center patients under the following conditions:

1. Each individual in this category will present his/her request for clinical privileges and qualifications for review by the appropriate Service Chief and Professional Standard Board. If approved, the Governing Body may grant such individuals privileges.

2. They may not admit patients nor write orders for patient care except under certain circumstances as outlined under admitting procedures in Rules and Regulations.

3. Services will be performed under the supervision of a member of the Medical Staff who will be responsible for the patient and their records in all respects.

SECTION 4: EXCEPTIONS

A. Temporary clinical privileges for emergent or urgent patient care needs may be granted for a limited period of time (not to exceed 45 workdays) by the Medical Center Director or the Acting Medical Center Director, in the absence of the Director, on the recommendation of the Chief of Staff. Temporary privileges will be based on evidence of a current State license and other reasonably reliable information concerning training and current competence.

B. Emergency care may be provided by any individual who is a member of the Medical Staff or who has been granted clinical privileges, within the scope of his/her license, to save a patient's life or save the patient from serious harm. Properly supervised members of the house staff may also provide emergency care.

C. Expedited Medical Staff Appointment Process: To expedite appointment, reappointment, or renewal or modification of clinical privileges, the governing body may delegate the authority to render those decisions to a committee consisting of at least two governing body members. Following a positive recommendation from the Executive Committee of the Medical Staff (ECMS) on an application, the committee of the governing body (Director) reviews and evaluates the qualifications and competence of the practitioner applying for appointment, reappointment, or renewal or modification of clinical privileges and renders its decision. A positive decision by the committee results in the status or privileges requested. The full governing body considers and, if appropriate, ratifies all positive committee decisions at its next regularly scheduled meeting. If the committee's decision is adverse to an applicant, the matter is referred back to the Medical Staff Executive Committee for further evaluation. The committee shall meet as often as necessary as determined by its chairperson.

An applicant is usually ineligible for the expedited process if at the time of appointment, or if since the time of reappointment, any of the following has occurred:

1. The applicant submits an incomplete application;

2. The Medical Staff Executive Committee makes a final recommendation that is adverse or with limitation;

3. There is a current challenge or a previously successful challenge to licensure or registration;

4. The applicant has received an involuntary termination of medical staff membership at another organization;

5. The applicant has received involuntary limitation, reduction, denial, or loss of clinical privileges;

or

6. There has been a final judgment adverse to the applicant in a professional liability action.”

The KCVAMC incorporates by reference the following process into the Medical Staff Bylaws, Credentialing and Privileging policy (Policy Memorandum 11-44) procedures for an expedited appointment process for medical staff appointments not to exceed 30 workdays during which time full credentialing must be completed. This process will assist in expediting the medical staff appointment process.

1. Critical to the implementation of the Expedited Appointment is the commitment of the KCVAMC service chiefs to assuring the timely completion and submission of the credentials information package through VetPro, with the necessary local facility supplements. The credentialing process cannot begin until the licensed independent provider completes the credentials package. Joint Commission requires that there be a complete application for an expedited appointment, therefore the provider must submit this information through VetPro and documentation of credentials must also be retained in VetPro.

2. Credentialing requirements for this process includes confirmation of:

(a) The practitioner's education and training (which, if necessary, can be accomplished in 24 hours through the purchase of the American Medical Association’s Practitioners Profile);

(b) One active, current, unrestricted license verified by the primary source State, Territory, or Commonwealth of the United States or in the District of Columbia;

http://vaww.kansas-city.med.va.gov/policies/hospitalwide/npm/chiefofstaff/npm11-44.doc

NOTE: To be eligible for appointment to a position listed in Title 38 United States Code (U.S.C.), Section 7402(b), an applicant or employee must meet its statutory licensure requirements for the position. In addition, a person may not be employed in any position under Title 38 U.S.C., Section 7402(b) (other than as a Director of a hospital, domiciliary, center or outpatient clinic), if the person is or has been licensed, registered, or certified in more than one State, and either (1) any of those States has terminated such license, registration or certification for cause, or (2) the person has voluntarily relinquished such license, registration, or certification in any of those States after being notified in writing by that State of potential termination for cause. See Title 38 U.S.C., Section 7402(f).

(c) Confirmation on the declaration of health, by a practitioner designated by or acceptable to the facility, of the applicant’s physical and mental capability to fulfill the requirement of the clinical privileges being sought;

(d) Query of licensure history through the Federation of State Medical Boards Action Data Center;

(e) Confirmation from two peer references who are knowledgeable of and confirm the practitioner’s competence, including at least one from the current or most recent employer(s) or institution(s) where the applicant holds or held privileges or who would have reason to know the individual's professional qualifications;

(f) Current comparable privileges held in another institution; and

(g) National Practitioner Data Bank query.

3. If all credentialing elements are reviewed and no current or previously successful challenges to any of the credentials are noted, and there is no history of malpractice payment, a delegated subcommittee of the ECMS, consisting of at least two members of the full committee, may recommend appointment to the medical staff. Full credentialing will be completed within 30 workdays and presented to the Executive Committee of the Medical Staff for ratification.

NOTE: The expedited appointment process may only be used for what are considered to be “clean” applications. The expedited appointment process can not be used if the application is not complete (including answers to Supplemental Questions, Declaration of Health, and Bylaws Attestation); there are any current or previously successful challenges to licensure; ANY history of involuntary termination of medical staff membership at another organization, received involuntary limitation, reduction, denial, or loss of clinical privileges; or there has been a final judgment adverse to the applicant in a professional liability action.

4. This recommendation by the delegated…