Attachment 10 - TVHS Memorandums - 626.pdf

Attachment 16 – TVHS Memorandums

TVHS Memorandum 626-16-11-01 Management of Impaired Practitioner

TVHS Memorandum 626-16-11-25 Credentialing and Privileging Program

TVHS Memorandum 626-16-11M-08 Amended Management of Patient Rights at Risk

TVHS Memorandum 626-16-11M-16 Initial Management of Mental Health Requests

TVHS Memorandum 626-16-136-27 Scanning Policy

TVHS Memorandum 626-17-11-16 Procedure for Reporting Test Results

TVHS Memorandum 626-17-119-16 Medication Reconciliation

TVHS Memorandum 626-18-11M-09 Patient Record Flags – Suicide Risk

TVHS Memorandum 626-18-136-32 Records Management

TVHS Memorandum 626-19-119-07 Medication Use Management

TVHS Memorandum 626-19-119-08 Adverse Drug Events - Reactions

TVHS Memorandum 626-19-119-09 Controlled Substance Management

TVHS Memorandum 626-16-136-09 Rescinded

NOTE: No public access is currently available to view these documents.

Department of Veterans Affairs Memorandum 626-16-11-01 VA Tennessee Valley Healthcare System January 31, 2016

MANAGEMENT OF THE IMPAIRED PRACTITIONER

1. PURPOSE: The purpose of this policy is to provide guidance to Service Chiefs/Care Line Managers and members of the Medical Staff about prevention of physical, psychiatric, or emotional illness; and to facilitate confidential diagnosis, treatment, rehabilitation, or discipline of staff who suffer from a potentially impairing condition.

2. POLICY: The Tennessee Valley Healthcare System (TVHS) has an obligation to protect patients from harm. The medical staff and leadership will be cognizant of the physical and mental health of its Licensed Independent Practitioners (LIPs) and Mid-Level Practitioners (hereinafter referred to as “practitioners”). This policy outlines the process goal of providing assistance and rehabilitation, to aid a practitioner in retaining or regaining optimal professional functioning, consistent with the protection of patients. If at any time during the diagnosis, treatment, or rehabilitation phase of the process it is determined that a practitioner is unable to safely perform the privileges/scope of practice/functional statement he/she has been granted, the matter is forwarded to the Health System Director and the Chief of Staff for review and appropriate corrective action in accordance with Veterans Health Administration (VHA) and health care system policy.

3. DEFINITIONS: (in alphabetical order)

a. Alcohol Abuse: A disorder characterized by repeated excessive drinking which interferes with the individual’s health, interpersonal relations, economic functioning, or professional conduct. A problem drinker is any employee whose use of alcohol frequently affects him/her adversely. An individual does not have an alcohol use disorder for his/her alcohol use to be problematic.

b. Bio-psychosocial problems: A term encompassing an individual’s physical, mental, and social status. For the purpose of this policy, biopsychosocial may include: physical, emotional, financial, marital, family, legal, or vocational problems that are adversely affecting the employee’s job performance and/or conduct.

c. Psychosocial problems: For the purposes of this policy “Psychosocial problems” includes emotional, financial, relationship, family, or minor legal problems that adversely affect the employee’s job performance and or conduct and are not better accounted for by other policies, such as medical illness, psychiatric illness, substance abuse, major legal problems, or criminal activity.

d. Employee Assistance Program (EAP): a service offering 24/7 access to a diverse national clinician network. EAP clinicians provide confidential, face-to-face, and telephonic assessments and short-term counseling services to employees in need of assistance with substance abuse, bio-psychosocial problems, or life stresses. EAP consultants also support managers and employers with on-site trainings, critical incident debriefings, organizational consultation, and expert human resources consultation.

e. Formal referral: A referral of an employee by a supervisor or other staff members, where there is reasonable cause to believe that a practitioner is providing unsafe care and treatment.

VA Tennessee Valley Healthcare System January 31, 2016

f. Impairment: The inability or immediate impending inability of a healthcare professional to practice his or her health profession in a manner that conforms to the standards of acceptable and prevailing practice for that health profession due to the health professional’s substance abuse, chemical dependency, physical or mental illness (or) the presence of the signs of substance use while on duty.

g. Licensed Independent Practitioners (LIP): Refers to any individual permitted by law and by the VA TVHS to provide care and service without direction or supervision, within the scope of the individual’s license and consistent with individually granted privileges. In this organization, this includes physicians, dentists, optometrists, and psychologists. It may also include individuals who can practice independently, who meet this criterion for independent practice.

h. Mandatory referrals: The referral of an employee who has been found to be using illegal drugs, as mandated by the Department of Veterans Affairs Drug Free Workplace Program.

i. Medical Staff: The body of all LIP’s and other practitioners credentialed through the medical staff process who are subject to the medical staff Bylaws. The medical staff includes both members of the organized medical staff and non-members of the organized medical staff who provide healthcare services.

j. Mid-Level Practitioner: Mid-Level Practitioners are those healthcare professionals who are not physicians and dentists and who, most often, function within a Scope of Practice but may practice independently on defined clinical privileges as defined in the Bylaws. Mid-Level Practitioners include: physician assistants (PAs), Pharmacists (PharmDs), and advanced practice nurses (APRN, CRNA, and CRNP).

k. Physical illness: An illness pertaining to the body in which normal or appropriate functioning of the body is impaired in some manner.

l. Physical Standards Board: Responsible board for determining the physical and mental fitness and for recommending action based on examination of findings. A board may recommend acceptance or rejection of a person for physical or mental reasons. The Physical Standards Board may have the same membership as the local physician Professional Standards Board or members may be designated for this purpose by the healthcare facility Director.

m. Self-referral: The employee or provider recognizes that he/she has a physical, psychiatric, or emotional illness and needs assistance in correcting the problem.

n. Substance Abuse: A disorder characterized by the use of a drug in a manner or to a degree which interferes with the individual’s health, interpersonal relations, economic functioning, professional conduct, or social standing.

4. RESPONSIBILITY

a. The Chief of Staff and Clinical Service Chiefs are responsible for ensuring that all members of the Medical Staff and other practitioners receive information addressing prevention

VA Tennessee Valley Healthcare System January 31, 2016 of physical, psychiatric, or emotional illness and options available for the diagnosis, treatment, and rehabilitation of practitioners who suffer potentially impairing conditions.

b. The Professional Standards Board is responsible for promoting the physical, personal, and professional well being of the medical staff and may make appropriate referrals to the Employee Assistance Program (EAP). The EAP mission is to optimize employee wellness and employer productivity by identifying and resolving tomorrow’s problems today. Their philosophy is that most personal and workplace problems can be resolved successfully through the variety of services offered.

c. The Human Resources Management Officer will render advice and assistance on the administrative aspects of the program and work closely with the Occupational Health Physician or Occupational Healthcare Provider in establishing assessments by a Physical Standards Board when requested by the Chief of Staff and/or Health System Director.

5. PROCEDURES

a. Education of the Medical Staff about the illness and impairment recognition issues specific to practitioners:

(1) Practitioners will be issued written information regarding illness and impairment issues at the time of initial appointment and reappointment by their supervisors or Service Chiefs (Attachment A).

(2) Information about the Employee Assistance Program and how to access services of the EAP will be provided to practitioners at the time of initial appointment and reappointment (Attachment B).

b. Referral of the Impaired Practitioner:

(1) Practitioners are encouraged to self-refer to a program for assistance with mental illness, emotional or physical problems; assistance in the self-referral may be obtained from their supervisor, Service Chief, Chief of Staff, Chaplains, or union representatives.

(2) Clinical Service Chiefs are responsible for recognizing signs and symptoms of substance abuse, chemical dependency, physical and/or mental illness adversely affecting employees' job performance and/or conduct and making appropriate referrals.

(3) Any individual within the organization has the responsibility to report concerns regarding unsafe treatment by practitioners. These reports are to be made directly to the practitioner’s Service Chief or Chief of Staff. Reports may also be made directly to the Health System Director. Informant confidentiality will be maintained to the extent allowed by law.

(4) All complaints, allegations, or concerns regarding the potential impairment of a practitioner will be thoroughly investigated.

(5) The affected practitioner will be referred to the appropriate professional internal or external resources for diagnosis and treatment of the condition or concern.

VA Tennessee Valley Healthcare System January 31, 2016

c. The confidentiality of the individual will be strictly maintained, with the following exceptions:

(1) State and Federal law

(2) State and Federal regulatory limitations (as applicable)

(3) Ethical obligations

(4) When maintaining confidentiality threatens the safety of a patient or patients.

d. An evaluation of the credibility of a complaint, allegation, or concern will be made by the Chief of Staff, and the appropriate service chief, with the assistance of the Human Resources Management Officer. In cases of known or suspected impairment due to physical, mental illness, or chemical dependence, the Chief of Staff may request an assessment by the Physical Standards Board and the Occupational Health Physician.

e. In cases of known or suspected impairment due to physical and/or mental illness, the Chief of Staff may request the Health System Director to authorize a physical examination. Such examination will be requested customarily after a practitioner has undergone surgery or sustained illnesses or injuries, which have a reasonable risk of impairing professional functioning.

Examples are intracranial surgery, cardiopulmonary bypass, severe physical trauma, hospitalization requiring intensive care, psychiatric hospitalization, and use of neuroleptic medication or chemical dependency rehabilitation. This list is not meant to be comprehensive and is intended only to clarify the types of conditions around which a reasonable and good faith concern of impairment may be raised.

f. The occurrence of hospitalization or treatment is a basis for inquiry only and is not conclusive of impairment. The fitness for duty examination will be tailored to the clinical circumstances and may involve a physical examination, imaging studies, neuropsychological testing, or other indicated measures.

g. If credible evidence of impairment is found after appropriate investigation, the appropriate credentialing and privileging actions will be taken. As part of any privileging rehabilitation intervention, the practitioner may be referred to an appropriate treatment facility and the practitioner’s progress may be monitored.

h. All allegations, concerns, or complaints brought before the Physical Standards Board will be investigated and evaluated by the committee as a whole. Any practitioner under investigation may provide information to the Board which he/she feels may clarify any allegation, concern, or issue brought before the Board.

i. The Physical Standards Board will submit its report to the Chief of Staff and the Health System Director for necessary action. If the Board determines a person to be physically and/or mentally incapable of performing the duties of the assignment, the appropriate course of action shall be taken, in accordance with VHA regulations.

VA Tennessee Valley Healthcare System January 31, 2016

j. While the goal of this process is to provide assistance rather than disciplinary action, in some instances, the Physical Standards Board may recommend to the Health System Director discipline of the practitioner as a necessary action to improve or resolve quality of patient care issues. Any requests for disciplinary action will be forwarded to the Chief of Staff and the Health System Director for approval and in accordance with VHA regulations.

k. A practitioner’s return to work will be based on the health and well-being of the practitioner, the safety of patients, and the practitioner’s competency. Therefore, each case must be assessed independently and the return to work will be structured accordingly. If the Physical Standards Board determines a person to be physically and/or mentally capable of performing the duties of the assignment, a written plan submitted by the Physical Standards Board that has been subsequently approved by the Professional Standards Board should be conveyed to the Service Chief. The following courses of action may be taken:

(1) If the nature of the physical condition is one that may be corrected by remedial treatment, sick leave, annual leave, or leave without pay may be granted as appropriate.

(2) A successful program assists the employee in overcoming a personal problem so that performance and/or conduct improves and corrective action, such as disciplinary, adverse, or other performance-based actions, becomes unnecessary.

6. REFERENCES

a. VA Directive 5383, VA Drug-Free Workplace Program

b. VA Handbook 5019, Part III, Physical Standards Board

c. The Joint Commission

d. “Physician Well-Being Program” http://www.mc.vanderbilt.edu

7. RESCISSION: TVHS Memorandum 626-11-11-01 dated January 31, 2012.

http://www.mc.vanderbilt.edu/

VA Tennessee Valley Healthcare System January 31, 2016

8. RESPONSIBILITY AND REVIEW DATE: The Office of the Chief of Staff will review annually and revised no later than January 31, 2019.

/s/Suzanne L Jene' 3/31/2016

Suzanne L. Jene, MBA, VHA-CM Interim Health System Director

Attachments:

A. Common Warning Signs of the Impaired Practitioner B. Acknowledgement of Receipt of Information Statement

VA Tennessee Valley Healthcare System January 31, 2016

ATTACHMENT A

COMMON WARNING SIGNS OF THE IMPAIRED PRACTITIONER

1. Attitude/Behavior Changes:

a. Rapidly turns from compassionate and caring to abrupt, caustic

b. Withdraws from friends and activities

c. Becomes mistrusting, anxious, depressed, irritable

2. Physical Changes:

a. Loss of appetite or reduced level of exercise

b. Looks tried; admits to insomnia

c. Personal hygiene deteriorates

d. Physical problems are self-treated

3. Performance Changes:

a. Misses appointments

b. Makes rounds at unusual hour

c. Can’t be reached when on call

d. Sloppy charting

e. Smell of alcohol on breath during the day

4. Relationship Changes:

a. Family communication deteriorates

b. Frequent arguments, spouse blamed

c. Occurrence of spouse/child abuse

d. Children may exhibit poor school performance

e. Jealousy, infidelity leading to separation/divorce

VA Tennessee Valley Healthcare System January 31, 2016

ATTACHMENT B

ACKNOWLEDGEMENT OF RECEIPT OF INFORMATION STATEMENT

It is the intent of this facility to provide the Medical Staff with information regarding the impaired practitioner program policy at the time of initial privileging and/or re-privileging (or scope of practice/functional statement). An impaired practitioner is one with a chemical dependency, mental illness, physical illness, or aging problems who may be unable to care for his or her patients with reasonable skill, attention, or safety. Many physicians and health care personnel are uninformed about chemical dependence and mental illness. These are treatable diseases that can be managed.

TVHS has provided you with a copy of the Management of the Impaired Practitioner policy and a review of common signs of impairment. Should you have any questions or concerns, please do not hesitate to contact the Chief of Staff or your Service Chief.

For information about the Employee Assistance Program (EAP) or to request services, call 800- 869-0276, contact your Human Resources representative or you may securely request services from the Member Access Section of EAP’s website, www.eapconsultants.com.

I have received a copy of the policy, “Management of the Impaired Practitioner”, including Attachments.

Print Name: ______________________________________ Date: ____________________

Signature:______________________________________________

Service or Care Line: _____________________________________

Department of Veterans Affairs Memorandum 626-16-11-25

VA Tennessee Valley Healthcare System April 1, 2016

CREDENTIALING AND PRIVILEGING PROGRAM

1. PURPOSE: To state the policy, procedures, and responsibilities for the credentialed, privileged, and appointed membership of the Medical Staff of Department of Veterans Affairs

Tennessee Valley Healthcare System (VA TVHS) and all other licensed, registered, or certified healthcare workers under a scope of practice.

NOTE: This policy does not reflect the process utilized for the credentialing of Dependent

Providers. See TVHS Memorandum 626-13-05-24, “Credentialing of Dependent Health Care

Providers”.

2. POLICY: VA TVHS shall maintain a credentialing and privileging program whereby healthcare professionals are appointed to and maintained on the Medical Staff according to rules and regulations established by the Veterans Health Administration (VHA) and in accordance with regulatory agencies to ensure that only the highest quality applicants are appointed to ensure the highest quality patient care. This policy has no inconsistencies with the Medical Staff

Bylaws, Rules and Regulations and is consistent with the law, Department of Veterans Affairs

(VA) regulations, Veterans Integrated Service Network (VISN) 9 Directives, or other TVHS policies.

3. BACKGROUND

a. All VA TVHS healthcare professionals who are permitted by law and this healthcare system to provide patient care services independently will be credentialed and privileged as defined in this policy. The requirements of The Joint Commission (TJC) standards and VHA policies have been used to define the credentialing, privileging, reappraisal and reprivileging processes.

b. Active and Associate Medical Staff members are classified under one of the following:

(1) Full Time

(2) Part Time

(3) Contract

(4) Sharing Agreement

(5) On-Station Fee-Basis

(6) Off-Station Fee-Basis

(7) Telemedicine

(8) Without Compensation (WOC)

(9) Intermittent

(10) Consultant

c. The credentialing and privileging requirements of this policy apply to professionally licensed physicians, osteopaths, dentists, optometrists, podiatrists, physician assistants, advance practice nurses, clinical nurse specialists, clinical psychologists and clinical pharmacy specialists. Research or administrative positions not involved in patient care are credentialed but may not always request clinical privileges. The credentialing portion of this policy is also applicable to allied health professionals, including Advanced Practice Registered Nurses

(APRN) and Physician Assistants (PA) even though these practitioners may not practice as licensed independent practitioners (see Definitions).

d. Policy and procedures related to the denial, failure to renew, reduction, and revocation of clinical privileges, where based on professional competence, professional misconduct, or substandard care, apply to all health care professionals who are granted privileged within the scope of this policy.

e. VetPro, VHA’s electronic credentialing system, must be used for credentialing all providers who are credentialed, privileged, or have a scope of practice. One component of

VHA’s Patient Safety Program is quality credentialing and the use of VetPro is necessary to reduce the potential for human error in the credentialing process. In addition, documentation other than in Vet Pro that is required by this policy must be maintained in a paper or electronic medium. The requirements of this policy are the same whether carried out on paper or electronically. For example, if a signature is required and the mechanism in use is electronic, then that modality must provide for an electronic signature.

f. Credentialing and privileging must be completed prior to initial appointment or reappointment and before transfer from another medical facility. If the primary source verification(s) of the practitioner’s credentials are on file (paper or electronic), those credentials that were verified at the time of initial appointment and are not time-limited or specifically required by this policy or TJC to be updated or re-verified can be considered verified.

g. All credentialing procedures described in this policy are applicable to the Chief of Staff

(COS) and Health System Director. The Chief of Staff is the individual appointed by the

Governing Body whose responsibilities are both administrative and clinical in nature. Clinical responsibilities are defined as those involving professional capability as a practitioner such as to require the exercise of clinical judgment with respect to patient care. The Chief of Staff is

President of the Medical Staff.

h. This policy does not apply to residents unless they function outside the scope of their training program (e.g., act as Medical Officers of the Day (MOD), perform Compensation and

Pension exams, or have been boarded, credentialed, and/or received privileges in another specialty.)

4. DEFINITIONS

a. Allied Health Professional. Allied health professional refers to advanced practice nurses, audiologists, physician assistants (PA), dental hygienists, dietitians, kinesiotherapists, medical technologist, occupational therapists, pharmacists, clinical pharmacy specialists, physical therapists, recreational therapists, registered nurses (RN), respiratory therapists, clinical social workers, speech pathologists, licensed practical nurses (LPN), diagnostic radiologic technologists, corrective therapists, creative arts therapists, medical technicians, orthotists, prosthetists, and other qualified members of the health profession (i.e., Hybrid Title 38).

b. Appointment. Appointment refers to appointment to the Medical Staff. It does not refer to appointment as a VA employee unless specified as such, but is based on having an appropriate personnel appointment action, scarce medical specialty contract or other authority for providing patient care services in the healthcare system. Both VA employees and contractors may receive appointments to the Medical Staff.

c. Authenticated Copy. An authenticated or certified copy means that each page of the document is a true copy of the original document and each page is stamped “authenticated copy of original” and dated and signed by the person doing the authentication. Facsimile copies of verification documents may not be used for final verification.

d. Clinical Privileging or Privileging. Clinical privileging is the process by which a practitioner, licensed for independent practice (e.g., without supervision, direction, required sponsor, preceptor, mandatory collaboration), is permitted by law and the healthcare system to practice independently to provide specified medical or other patient care services within the scope of the individual's license based on the individual's clinical competence as determined by peer references, professional experience, health status, education, training, and licensure.

Clinical privileges are facility specific and provider specific, as well as, setting specific.

e. Competency. Competency is documented demonstration of an individual having the requisite or adequate abilities or qualities capable to perform up to a defined expectation.

f. Credentialing. The term “credentialing” refers to the systematic process of screening and evaluating qualifications and other credentials, including licensure, required education, relevant training and experience, current competence, and health status.

g. Current. The term “current” applies to the timeliness of the verification and use for the credentialing and privileging process. No credential is current and no query of the Federation of

State Licensing Boards (FSMB) or the National Practitioner Data Bank (NPDB)-Health Integrity and Protection Data Bank (HIPDB) is current if performed prior to submission of a complete application by the practitioner to include submission of VetPro. At the time of initial appointment, all credentials must be current within 180 days of submission of a complete application. For reappointment, all time-limited credentials must be current within 180 days of submission of the application for reappointment including peer appraisals, confirmation of

National Practitioner Data Bank (NPDB) - Health Integrity and Protection Data Bank (HIPDB), Proactive Disclosure Service (PDS) annual registration, and other credentials with expirations.

h. Fifth Pathway Program. This program is available to U.S. Citizens and/or legal residents who matriculate at a foreign medical school (outside the United States, Puerto Rico or

Canada) that is listed in the World Directory of Medical Schools published by the World Health

Organization. This program was created as a substitute for internship and/or social service requirements, allowing students to complete 6 years of requirements in 5 years.

i. Focused Professional Practice Evaluation (FPPE). An FPPE is a prospectively planned and timed-limited evaluation process that allows the medical staff to focus evaluation on a specific aspect of a practitioner’s performance, when data from the Ongoing Professional

Practice Evaluation indicates a potential problem, or meets triggers outlined in the Bylaws. The practitioner’s service chief (or appropriate peer, if a different specialty) plans and implements the

FPPE. Results are submitted to the Professional Standards Board (PSB) for considering in its recommendations to the Health System Director to maintain, revise, or reduce a practitioner’s privileges. The FPPE is maintained in the service-level provider 6-part competency folder, part

VI.

j. Independent Practitioner. The term “independent practitioner: is any individual permitted by law (the statute which defines the terms and conditions of the practitioner’s license) and the facility to provide patient care services independently (i.e., without supervision or direction), within the scope of the individual’s license and in accordance with individually-granted clinical privileges. This is also referred to as a licensed independent practitioner (LIP).

k. Licensed Independent Practitioner. Licensed independent practitioners include physicians, dentists, clinical psychologists, podiatrists, and optometrists. These individuals are permitted by law and by TVHS to provide patient care services without direction or supervision, within the scope of the practitioner’s license and in accordance with any individually granted clinical privileges. Only LIPs may be granted clinical privileges.

l. Licensure. Licensure refers to the official or legal permission to practice in an occupation, as evidenced by documentation issued by a state, territory, commonwealth or the

District of Columbia (hereinafter referred to as “state”) in the form of a license, registration, or certification.

m. Medical Executive Board. The Medical Executive Board (MEB) is the Executive

Committee of the Medical Staff, chaired by the Chief of Staff, and empowered to act on behalf of the medical staff. It carries out its work within the medical staff functions of governance, leadership, and performance improvement activities.

n. Medical Staff. All fully licensed and appointed physicians, dentists, podiatrists, optometrists, and clinical psychologists.

o. Mentoring. Mentoring is a process for the informal transmission of knowledge, social capital, and the psychosocial support perceived by the recipient as relevant to work, career, or professional development; mentoring entails informal communication, usually face-to-face and during a sustained period of time, between a person who is perceived to have greater relevant knowledge, wisdom, or experience (the mentor) and a person who is perceived to have less (the protégé).

p. One Standard of Care. The term “one standard of care” means that one standard of care must be guaranteed for any given treatment or procedure regardless of the practitioner, service, or location within the facility. In the context of credentialing and privileging, the requirements or standards must be the same for granting privileges to perform any given procedure, if performed by more than one service.

q. Ongoing Professional Practice Evaluation (OPPE). An OPPE is an ongoing process of continual monitoring and assessment of the clinical competence of all Medical Staff with privileges based on objective, measurable criteria of performance. The process allows for any potential problems with a practitioner’s performance to be identified and resolved as soon as possible, and supports the evidence-based privileges renewal process. The OPPE is maintained in the service 6-part competency folder.

r. Primary Source Verification. Primary source verification is documentation from the original source of a specific credential that verifies the accuracy of a qualification reported by an individual practitioner. This can be documented in the form of a letter, report of telephone contact, or secure electronic communication with the original source.

s. Proctoring. Proctoring is the activity by which a practitioner is assigned to observe the practice of another practitioner performing specified activities and to provide required reports on those observations. The proctor must have clinical privileges for the activity being performed, but must not be directly involved in the care observed practitioner is delivering. Proctoring that requires a proctor to do more than just observe, (i.e., exercise control or impart knowledge, skill, or attitude to another practitioner to ensure appropriate, timely, and effective patient care), constitutes supervision. Such supervision may be a reduction of privileges.

t. Professional Standards Board. The Professional Standards Board (PSB) acts for the

Medical Executive Board in matters concerning appointments, disciplinary matters, and probationary reviews of physicians, dentists, podiatrists, psychologists, optometrist, advanced practice nurses, and physician assistants. Membership may include the Chief of Staff, Deputy

Chief of Staff, designated Clinical Service Chiefs or Care Line Managers (Extended Care, Anesthesia, Dental, Medicine, MHCL, Neurology, Pathology and Laboratory, Primary Care, Medical Imaging Services, Surgery, Transplant, Compensation and Pension, Physical Medicine

& Rehabilitation), a representative from Credentialing and Privileging, a representative from

Human Resource Management Service, a physician assistant, a nurse practitioner, and the

Service or Section Chief representing the specialty of the individual whose credentials are under review. A quorum of 51 percent of voting members must be present to make recommendations to the VA TVHS Director. The activities and functions of this board are defined by VA regulations. The Chief of Staff or designee is Chairman of the PSB.

u. Reappraisal. The mandatory two-year review and evaluation of the credentials, clinical competence, and health status of all professionals requiring credentialing.

v. Recredentialing: Recredentialing is an evaluation process of the professional credentials and clinical competence of the medical staff that have been granted clinical privileges. The process is conducted not more than 2 years.

w. Reduction of Privileges. A process of restricting performance of specific procedures or prescribing and/or dispensing controlled substances. The reduction may be time limited and/or have restoration contingent upon some condition, such as demonstration of recovery from a medically disabling condition or further training in a particular area.

x. Registration or Certification. Official documentation by a professional organization that one has fulfilled the requirements or met the standard or skill to practice the profession.

y. Relinquishment of Privilege(s). A provider can voluntarily relinquish a privilege or privileges at the time of reprivileging or any time during the 2-year cycle for a specified period of time or permanently. This request is reviewed by the Service Chief and documented at the

Professional Standards Board.

z. Reprivileging. The process of reviewing and granting privileges to practitioners who currently have clinical privileges at VA TVHS.

aa. Revocation of Privileges. The permanent loss of all clinical privileges at TVHS.

bb. Teleconsulting. Teleconsulting is the provision of advice on a diagnosis, prognosis, and/or therapy from a licensed independent provider to another licensed independent provider using electronic communications and information technology to support the care provided when distance separates the participants and where hands-on care is delivered at the site of the patient by a licensed independent healthcare provider.

cc. Telemedicine. Telemedicine is the provision of care by a licensed independent healthcare provider that directs, diagnoses, or otherwise provides clinical treatment delivered using electronic communications and information technology when distance separates the provider and the patient.

NOTE: A crucial consideration in making a distinction between consultation and care is that teleconsultation occurs when the consultant involved recommends diagnoses, treatments, etc., to the consulting provider requesting the consult, but does not actually write orders, or assume the care of the patient. If the consultant diagnoses, writes orders, or assumes care in any way, this constitutes “care” and requires privileges. A Medical Staff appointment is required if the provider is entering documentation into the medical record, (e.g., via teleradiology.)

dd. VetPro. VetPro is an Internet-enabled databank for the credentialing of VHA healthcare providers that facilitates completion of a uniform, accurate and complete credentials file.

5. RESPONSIBILITIES

a. The VISN Chief Medical Officer. The VISN Chief Medical Officer (CMO) is responsible for oversight of the credentialing and/or privileging process of the facilities within the VISN. The VISN 9 CMO may be credentialed and privileged through the TVHS

Professional Standards Board. The process for requesting clinical privileges follows the procedures in this policy, as outlined for other practitioners. The process for forwarding a credentials file to the CMO for review prior to appointment is outlined in Attachment B, along with the review form.

b. The Health System Director. The ultimate responsibility for credentialing and privileging resides with the Health System Director. The Health System Director is responsible for ensuring that:

(1) The labor-management obligations are met prior to implementing this credentialing and privileging program for Title 5 independent practitioners who are represented by a professional bargaining unit.

(2) Medical Staff Leadership and all staff with responsibility for the credentialing and privileging process complete the one time training determined by the VHA Office of Quality, Safety & Value, Medical Staff Affairs within 3 months of assuming their position. This training is accessed through the VA Learning Management System. It also includes the Chief of Staff, System Director, Credentialing staff, and Quality Management professionals, including the Risk

Manager.

c. Chief of Staff. The Chief of Staff (COS) is responsible for maintenance of the credentialing and privileging program for the healthcare professionals designated in this policy.

The COS is responsible for ensuring all credentialing and privileging functions and the Medical

Staff Bylaws are consistent with VHA Handbook 1100.19, Credentialing and Privileging, and any other VHA policy related to the Medical Staff Bylaws.

d. Service Chiefs and Care Line Managers: Service Chiefs and Care Line Managers are responsible for:

(1) Recommending the criteria for clinical privileges that are relevant to the care provided in the service;

(2) Reviewing all credentials and requested clinical privileges and making recommendations regarding appointment and privileging action; and

(3) Continuous surveillance of the professional performance of those who provide patient care services with delineated clinical privileges (ongoing professional practice evaluations).

e. Applicants and Practitioners. Applicants and practitioners must provide evidence of licensure, registration, certification, or other relevant credentials for verification prior to appointment and throughout the employment process, as requested. They must agree to accept the professional obligations delineated in the Medical Staff Bylaws provided to them. They are responsible for keeping the healthcare system appraised of anything that would adversely affect or otherwise limit their clinical privileges. All applicants and practitioners are required to be credentialed through VetPro.

f. Credentialing Staff. The Credentialing staff is responsible for the implementation of policies and procedures in accordance with VHA Directives, Handbooks, and The Joint

Commission standards. They ensure that individuals requiring credentialing are processed through VetPro; prepare and maintain credentialing folders; provide pertinent information to the

Professional Standards Board; and, ensure that all required signatures have been obtained. The

Credentialing Staff is also responsible for providing the facility Privacy Officer with the number of disclosures each year for the Annual Freedom of Information Act (FOIA) Report. Disclosures include releasing any patient or employee data, including physicians and allied health professionals, to third parties.

6. PROCEDURES: Credentialing

NOTE: This section describes requirements for credentialing for initial appointments, reappointments and reappointments after a break in service.

a. Healthcare professionals. Healthcare professionals (licensed independent practitioners and allied health professionals) must be fully credentialed prior to initial appointment or reappointment except for expedited appointments to the Medical Staff and temporary appointments for urgent patient care needs. Credentialing is required to ensure that an applicant has the required education, training, experience, physical, and mental health and skill to fulfill the requirements of the position and to support the requested clinical privileges. This section contains the administrative requirements and procedures related to the initial credentialing and recredentialing.

(1) The credentialing process includes verification, through the appropriate primary sources, of the individual's professional education; training; licensure; certification and review of health status; previous experience, including any gaps [greater than 30 days] in training and employment; clinical privileges; professional references; malpractice history and adverse actions; or criminal violations, as appropriate. Medical Staff appointment and employment commitments must not be made until the credentialing process is complete, except as identified under Section 7 of this policy. This includes screening through the appropriate State Licensing

Board (SLB), FSMB and the PDS-NPDB-HIPDB. All information obtained through the credentialing process will be carefully considered before appointment and privileging decision actions are made.

(2) The applicant has the burden of obtaining and producing all needed information for a proper evaluation of 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 questions concerning these qualifications. Failure to provide necessary information within 90 calendar days may serve as a basis for denial of

Medical Staff appointment and/or privileges, as defined in the Medical Staff Bylaws and Rules and Regulations.

(3) All applicants applying for clinical privileges must be provided with a copy of the

Medical Staff Bylaws and Medical Staff Rules and Regulations, and must agree in writing to accept the professional obligations reflected therein.

(4) The applicable service chief or care line manager reviews the credentialing folder and requested privileges and makes recommendations regarding appointment. The folder and recommendations are reviewed by the Professional Standards Board and then submitted with recommendations to the Medical Executive Board.

b. Application Forms. Candidates seeking appointment or reappointment must complete appropriate forms for the position for which they are applying.

NOTE: A copy of the appropriate application form and any supplemental form(s) are maintained electronically in VetPro and may be filed in Section I of the credentialing and privileging folder. If the applicant provides a resume or curriculum vitae, this is also filed in

Section I.

(1) All candidates requiring credentialing in accordance with this policy must complete an electronic submission of VetPro. VetPro's supplemental information form requires applicants to answer questions to meet The Joint Commission and VHA requirements. This supplemental information form requires the applicant to provide information concerning malpractice, adverse actions against licensure, privileges, hospital membership, research, etc.

(2) An applicant is required to provide information on all educational, training and employment experiences, including all gaps greater than 30 days in the candidate’s history.

(3) The sign and submit screen in VetPro addresses the applicant's agreement to provide continuous care and to accept the professional obligations defined in the Medical Staff Bylaws, Rules and Regulations of the facility, as well as attesting to the accuracy and completeness of the information submitted.

(4) If the delay between the candidate’s appointment and reporting for duty is greater than

180 calendar days, the credentialing staff must update all time-limited credentials and information including, but not limited to, licensure, current competence and supplemental questions. The updated information must be verified prior to the candidate reporting for duty.

Verification of a time-limited credential cannot be greater than 120 days old at the time a practitioner reports for duty. This requirement includes a response from the NPDB-HIPDB.

Delays from the candidate’s application to reporting for duty most frequently occur in the case of an individual for whom special waivers (i.e., visa waiver) may be required. Since these processes can be time-consuming, information on the candidate’s practice or non-practice during the period of delay must be obtained to ensure the most appropriate placement of the candidate.

c. Documentation Requirements

(1) Each LIP and allied health professional must have a credentialing file established electronically in VetPro with any paper documents maintained according to the requirements of the standardized folder identified in the Attachment B. Other credentialed LIP’s have a credentialing file maintained in the same system of records even though they may not be granted clinical privileges. Duplication of information documented and maintained in the electronic

VetPro file for filing in the paper credentialing and privileging file is not necessary and is discouraged.

(2) Information obtained for use in the credentialing process must be primary source verified, unless otherwise noted, and documented in writing either by letter, report of contact or web verification. The credentialing staff is expected to secure all credentialing and privileging documents. Any facsimile copy must be followed up with an original document.

(3) When using an Internet source for verification, the following criteria must be considered in determining appropriateness as primary source verification:

(a) The website disclaimer must be reviewed to determine the organization's attestation to the accuracy and timeliness of the information. If there is no disclaimer, the web verification needs to be seriously considered as not adequate for verification.

(b) There must be evidence that the site is maintained by the verifying entity and that the verification data cannot be modified by outside sources. If not maintained by the verifying entity, the site must include an endorsement by the entity that the site is primary source verification or the transmission is in an encrypted format.

(c) The site must provide information on the status of the license and adverse action information.

(d) To avoid issues arising with surveyors, print the disclaimer when the verification is printed.

(4) There must be follow-up of any discrepancy found in information obtained during the verification process. The practitioner has the right to correct any information that is factually incorrect by documenting the new information with a comment that previously provided information was not correct. Follow-up with the verifying entity will be necessary to determine the reason for the discrepancy if the practitioner says the information provided is factually incorrect.

(5) LIPs and allied healthcare professionals with multiple licenses, registrations and/or certifications are responsible for maintaining these credentials in good standing and informing the Director, or designee, of any changes in the status of these credentials. The Director is responsible for establishing a mechanism to ensure that multiple licenses, registrations and/or certifications are consistently held in good standing or, if allowed to lapse, are relinquished in good standing. The practitioner is required to provide a written explanation for any credentials that were held previously but which are no longer held or are no longer full and unrestricted.

The verifying official must contact the state board(s) or issuing organization(s) to verify information provided regarding the change.

NOTE: There are circumstances when verification from a foreign country is not possible or could prove harmful to the practitioner and/or family. In these instances, full documentation of efforts and circumstances, including a statement of justification, should be made in the form of a report of contact and filed in the credentialing and privileging file in lieu of the document sought.

(6) If the search for documents is unsuccessful or primary source documents are not received after a minimum of two requests, full written documentation of these efforts, in the form of a report of contact, will be placed in the folder in lieu of the document sought. It is suggested that no more than 30 days elapse before the attempt is deemed unsuccessful. The practitioner should be notified and assist in obtaining the necessary documentation through a secondary source.

(7) Verification of Educational Credentials

(a) For healthcare professionals who are requesting clinical privileges, primary source verification of all residencies, fellowships, advanced education, clinical practice programs, etc., from the appropriate program director or school is required. If a physician or dentist participated in an internship(s) equivalent to the current residency years PG 1, 2 and 3, it is necessary to obtain primary source verification of the internship(s). Any fees charged by institutions to verify education credentials will be paid by the healthcare system.

(b) For foreign medical school graduates, healthcare system officials must verify with the

Education Commission for Foreign Medical Graduates (ECFMG) that the applicant has met requirements for certification, if claimed. The ECFMG is not applicable for graduates from

Canadian or Puerto Rican medical schools. Documentation of completion of a “Fifth Pathway” may be substituted for ECFMG certification. Additionally, TJC accepts the primary source verification of ECFMG for foreign medical school graduation. Documentation of this verification must meet the requirements of this policy.

(c) All efforts to verify education must be documented even if it is not possible to verify education, (e.g., the school has closed, the school is in a foreign country and no response can be obtained or other reason). In any case, the credentialing staff must verify and document that candidates meet appropriate VA qualification standards prior to appointment as an employee.

The credentialing staff is encouraged to obtain additional information concerning the education of the applicant from other authoritative sources.

(d) Applicants are required to provide information on all educational and training experiences including all gaps greater than 30 days in educational history. Primary source verification must be sought on medical, dental, and professional school graduation and all residency and fellowship training, as well as internships for non-physician and non-dentist applicants.

(e) An educational institution may designate an organization as its agent for primary source verification for credentialing. The verification from the agent is acceptable (e.g., National

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