D.6 Bylaws Harry S. Truman Memorial Veterans' Hospital.pdf

MEDICAL STAFF BYLAWS

AND

MEDICAL STAFF RULES AND REGULATIONS

HARRY S. TRUMAN MEMORIAL VETERANS’ HOSPITAL

COLUMBIA, MISSOURI

Revised May 8, 2009

D.6 BYLAWS Harry S. Truman Memorial Veterans' Hospital

MEDICAL STAFF BYLAWS

PARAGRAPH PAGE

PREAMBLE

DEFINITIONS

ARTICLE I. NAME

ARTICLE II. PURPOSE

ARTICLE III. MEDICAL STAFF MEMBERSHIP

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

ARTICLE IV. APPOINTMENT AND INITIAL CREDENTIALING

Section 1. General Provisions Section 2. Application Procedures Section 3. Credentialing Section 4. Process and Terms of Appointment

ARTICLE V. CLINICAL PRIVILEGES

Section 1. General Provisions Section 2. Process and Requirements for Requesting Clinical Privileges Section 3. Expedited Credentialing and Privileging Process Section 4. Exceptions Section 5. Disaster Privileges

ARTICLE VI. IMPAIRED PROFESSIONAL PROGRAM

Section 1. Purpose Section 2. Responsibilities Section 3. Procedures

ARTICLE VII. Fair Hearing and Appellate Review Section 1. Denial of Medical Staff Appointment Section 2. Self-Governance Actions Section 3. Actions Against Clinical Privileges Section 4. Reporting Adverse Actions Section 5. Reporting Malpractice Payments Section 6. Termination of Appointment

ARTICLE VIII. ORGANIZATION OF THE MEDICAL STAFF

Section 1. Officers Section 2. Leadership

ARTICLE IX. COMMITTEES

Section 1. Clinical Executive Board (Executive Committee of the Medical Staff) ... 40 Section 2. Professional Standards Board Section 3. Standing Committees Section 4. Committee Records

ARTICLE X. CLINICAL SERVICES (SERVICE LINES)

Section 1. Characteristics Section 2. Functions Section 3. Selection and Appointment of Service Line Directors Section 4. Duties and Responsibilities of Service Line Directors

ARTICLE XI. MEDICAL STAFF MEETINGS

ARTICLE XII. RULES

ARTICLE XIII. AMENDMENTS

ARTICLE XIV. ADOPTION

MEDICAL STAFF RULES AND REGULATIONS

A. INTRODUCTION

B. GENERAL

C. PATIENTS' RIGHTS

1. Patients' Rights and Responsibilities

2. Advance Directive

3. Informed Consent

D. GENERAL RESPONSIBILITY FOR CARE

1. Conduct of Care

2. Emergency Services

3. Admissions

4. History and Physical (H&P) Examination

5. Procedures

6. Tests

7. Transfers

8. Consultations

9. Discharge Planning

10. Discharge

11. Autopsy

E. PHYSICIANS' ORDERS

1. General Requirements

2. Medication Orders

3. Standing Orders

4. Verbal Orders

5. Investigational Orders

6. Submission of Surgical Specimens

7. Special Treatment Procedures

F. ROLE OF ATTENDING PHYSICIAN STAFF

1. Supervision of House Staff and Non-Physicians

2. Documentation of Supervision

G. MEDICAL RECORDS

1. Authentication

2. Use of Abbreviations

3. Diagnostic/Therapeutic Reports

4. Release of Information

5. Basic Patient Information Requirements

6. Inpatient Medical Record

7. Ambulatory Care and Emergency Department Medical Record

8. Operating Room Record

H. INFECTION CONTROL

I. DISASTERS

J. IMPAIRED PROFESSIONAL PROGRAM

1. Purpose

2. Responsibilities

3. Procedures

K. UNANTICIPATED OUTCOMES

BYLAWS AND RULES OF THE MEDICAL STAFF

OF THE HARRY S. TRUMAN MEMORIAL VETERANS' HOSPITAL

COLUMBIA, MISSOURI

PREAMBLE

Recognizing that the Medical Staff is responsible for the quality of care delivered by its members and accountable to the Governing Body for all aspects of that care, the Medical Staff practicing at the Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri, hereby organizes itself for self governance in conformity with the laws, regulations and policies governing Veterans Health Administration (VHA) and the Bylaws and Rules hereinafter stated.

These Bylaws and Rules are consistent with all laws and regulations governing Department of Veterans Affairs (VA) and they do not create any rights or liabilities not otherwise provided for in laws or VA regulations.

The Harry S. Truman Memorial Veterans' Hospital is a federal institution organized under the laws of the United States of America. Its mission is to improve the health of the veterans we serve by providing primary care, specialty care, extended care and related social support services in an integrated health care delivery system. It provides education and research, and support to the Department of Defense in times of national emergency.

DEFINITIONS

1. HOSPITAL means Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri and associated Community-Based Outpatient Clinics (CBOCs).

2. MEDICAL STAFF or STAFF means the formal organization of all medical physicians and osteopathic physicians holding unlimited licenses, and duly licensed dentists, podiatrists, optometrists, doctoral psychologists, doctoral audiologists, doctoral speech pathologists, and doctoral nurses who possess qualifications identified by VA as necessary to attend patients, provide consultation and teach in the hospital. House Officers (resident physicians) or academic consultants are not included. The Medical Staff is organized under a single category of membership known as the active Medical Staff.

3. GOVERNING BODY refers to the VHA Under Secretary for Health, the individual to whom the Secretary of the Department of Veterans Affairs has delegated authority for administration of the Veterans Health Administration; and, for purposes of local facility management and planning, it refers to the VA Hospital Director.

4. HOSPITAL DIRECTOR or DIRECTOR means the "Chief Executive Officer" who is appointed by the Governing Body to act as its agent in the overall management of the hospital.

The Chief of Staff (with the Clinical Executive Board) and the Associate Director assist the Director.

5. AFFILIATION PARTNERSHIP COUNCIL is chaired by the Dean of the University of Missouri-Columbia School of Medicine. This council is responsible for providing input into strategic planning for the affiliated institutions. Membership on the Affiliation Partnership Council includes deans and senior faculty members of the affiliated institution. Meetings of the Affiliation Partnership Council will be held quarterly and serve as an efficient vehicle to disseminate information to the leadership of both institutions.

6. PRACTITIONER means any member of the Medical Staff applying for or exercising granted clinical privileges in the Hospital and/or at CBOCs.

7. TELECONSULTING means 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 health care provider.

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

9. MEDICAL OFFICER OF THE DAY means a physician in training privileged to work in the Emergency Department without supervision.

10. ADVANCE PRACTICE NURSES AND PHYSICIAN ASSISTANTS are credentialed through VetPro but are not eligible for Medical Staff membership. They function through a scope of practice with a collaborating or supervising physician.

11. APPOINTMENT, as used in this document, refers to appointment to the Medical Staff. It does not refer to appointment as a VA employee but is based on having an appropriate personnel appointment action, scarce medical specialty contract, or other authority for providing patient care services at the facility. VA employees, contractors, WOC and other practitioners in approved categories may receive appointment to the Medical Staff.

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

13. CLINICAL EXECUTIVE BOARD (CEB) means the Executive Committee of the Medical Staff.

14. CLINICAL PRIVILEGES or PRIVILEGES means the permission granted to an individual to render specific diagnostic or therapeutic medical, dental, podiatric, surgical, or other patient care services.

15. MEDICAL STAFF YEAR means the period from October 1 to September 30.

16. EX OFFICIO means service as a member of a body by virtue of an office or position held and, unless otherwise expressly provided, without voting rights.

17. SPECIAL NOTICE means written notification.

18. HOUSE STAFF (HOUSE OFFICER) means a licensed physician participating in an approved residency or fellowship program who engages in medical activities under the supervision of a Medical Staff member.

19. EXECUTIVE COMMITTEE OF THE MEDICAL STAFF means the Clinical Executive Board (CEB).

20. VETPRO is the Internet system for credentialing of VHA health care providers that facilitates completion of a uniform, accurate and complete credentials file.

21. RESEARCH PHYSICIAN means a physician without clinical privileges who will not participate in the care/treatment of patient but is required to be credentialed through VetPro.

ARTICLE I. NAME

The name of this organization shall be the Medical Staff of the Harry S. Truman Memorial Veterans' Hospital.

ARTICLE II. PURPOSE

The purpose of the Medical Staff shall be to:

a. Ensure that all patients treated at the Harry S. Truman Memorial Veterans' Hospital on any service will receive efficient, timely, appropriate care that is subject to continuous quality improvement practices.

b. Ensure all patients treated for the same health problem or with the same methods/procedures receive the same level of care.

c. Establish and assure adherence to ethical standards of professional practice and conduct.

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

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

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

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

h. Bring the dimension of Medical Staff leadership to deliberations by the Hospital Director and the Governing Body.

i. Develop and implement performance improvement activities in collaboration with the facility staff.

ARTICLE III. MEDICAL STAFF MEMBERSHIP

Section 1. Membership Eligibility

a. Membership on the Medical Staff is a privilege extended only to, and continued for, professionally competent practitioners who continuously meet the qualifications, standards and requirements of VHA, this Hospital and these Bylaws. Membership may be considered for other licensed health care providers who are permitted by law to provide patient care services independently and who meet the qualifications, standards and requirements of VHA, this Hospital and these Bylaws.

b. Research physicians without clinical responsibilities are credentialed through the standard credentialing process (VetPro) but not granted privileges. These physicians are not members of the Medical Staff.

c. Categories: The Medical Staff shall include clinically active members who assume all the functions and responsibilities of membership on the Medical Staff including, where appropriate, emergency service care and consultation assignments and affiliated members who generally serve in support roles including call coverage. Members of the clinically active Medical Staff shall be appointed to a specific service line, shall be eligible to vote and to serve on Medical Staff committees. Clinically active membership requires 200 onsite patient encounters over a two year period. Clinically active members may be in Category I or II below. Affiliated members shall be appointed to a specific service line and may serve on Medical Staff committees, but will not be eligible for voting privileges. Affiliated members may be in Category II or III below. Members of the Medical Staff shall be further sub-classified into the following categories:

1) Category I: Medical Staff members who are employed by the Department of Veterans Affairs on at least a half-time basis or hold official administrative appointments.

Unless formally excused, members in this category are required to attend Medical Staff meetings and the staff meetings of the clinical service line to which they are assigned.

Physicians who practice off-site at Community-Based Outpatient Clinics (CBOCs) and are appointed on a half time basis or greater are excused from Medical Staff meetings and staff meetings because they provide care at a remote location. They will have the opportunity to vote in absentia and will be provided copies of minutes of all Medical Staff meetings.

2) Category II: This category includes Medical Staff members employed on less than a half time basis. These members are encouraged to attend meetings of the Medical Staff; however, attendance shall not be mandatory because of the intermittent nature of their clinical activities at this Hospital.

3) Category III: This category includes Medical Staff members who are appointed as consultants and attendings, on-station fee basis physicians, contract physicians, without compensation (WOC) physicians, telemedicine physicians, and Medical Officers of the Day. These members are encouraged to attend meetings of the Medical Staff and the clinical service line to which they are assigned. However, attendance shall not be mandatory because of the intermittent nature of their clinical activities at this Hospital.

d. Decisions regarding Medical Staff membership are made without discrimination for such reasons as race, color, religion, national origin, sex, lawful partisan political affiliation, marital status, physical or mental handicap (when the individual is qualified to do the work), age, or membership/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

To qualify for Medical Staff membership and clinical privileges, individuals who meet the eligibility requirements identified in Section 1 must submit evidence of:

a. An active, current, full and unrestricted license to practice their profession in a State, Territory or Commonwealth of the U.S. or the District of Columbia as required by VA employment and utilization policies and procedures.

b. Education applicable to individual Medical Staff members as defined, e.g., hold a degree of Doctor of Medicine, Osteopathy, Dentistry, Podiatry, Optometry, a degree of Ph.D. in Psychology, Speech Pathology or Nursing from an approved college or university.

c. Relevant Training and/or Experience consistent with the individual's professional assignment and privileges for which he/she applies. This includes any internships, residencies, board certification or specialty training. Physician members must be board certifiable in their area of specialty.

d. Current competence consistent with the individual's assignment and the privileges for which he/she applies.

e. Health Status consistent with physical and mental capability to satisfactorily perform the duties of the Medical Staff assignment within clinical privileges requested.

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

g. Satisfactory findings relative to previous professional competence and professional conduct.

h. English Language Proficiency.

i. For those individuals providing service under contracts, current professional liability insurance as required by Federal and VA acquisition regulations.

Section 3. Basic Responsibilities of Medical Staff Membership

Medical Staff members are accountable for and have responsibility to:

a. Provide for continuous care of patients assigned to their care.

b. Observe Patients' Rights in all patient care activities.

c. Participate in continuing education, peer review, Medical Staff monitoring and evaluation.

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

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

2) Provide care to patients within the scope of privileges and advise the Hospital Director, through the Chief of Staff, of any change in ability to meet fully the criteria for Medical Staff membership or to carry out clinical privileges.

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

4) Contribute to, and abide by, high standards of ethics in professional practice and conduct.

e. Abide by the Medical Staff Bylaws and Rules and all other lawful standards and policies of the Hospital and Veterans Health Administration.

ARTICLE IV. APPOINTMENT AND INITIAL CREDENTIALING

Section 1. General Provisions

a. All Veterans Health Administration (VHA) physicians, dentists, and other Medical Staff members as defined by the Medical Staff Bylaws are credentialed and privileged. The requirements of The Joint Commission and VHA policies have been used to define the credentialing, privileging, reappraisal/reprivileging, and modification of privilege processes. This process applies to all members of the Medical Staff involved in patient care who are appointed or utilized on a full-time (FT), part-time (PT), intermittent, consultant and attending (C&A), without compensation (WOC), on-station fee-basis, on-station contract or on-station sharing agreement basis.

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

1) Provisions of 38 U.S.C. in accordance with Department of Veterans Affairs Manual MP-5, part II, chapter 2, and its supplements and provisions of 5 U.S.C. in accordance with Department of Veterans Affairs Manual MP-5, part I, chapter 315, and applicable Agreement(s) of Affiliation in force at the time of appointment.

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

c. Probationary Period. Initial and certain other appointments made under 38 U.S.C. 7401(1), 7401(3), and/or 5 U.S.C. 3301 are probationary. During the probationary period, professional competence, performance, and conduct will be closely evaluated under applicable VA policies and procedures. If, during this period, the employee demonstrates an acceptable level of performance and conduct, the employee will successfully complete the probationary period. Supervisors and managers apply similar processes to the evaluation of individuals employed under provisions of 38 U.S.C. 7405 and those utilized under contracts and sharing agreements.

Section 2. Application Procedures

a. Applicants for appointment to the Medical Staff must submit a complete credentialing application which includes entering credentialing information in VetPro and completing application forms. The application must be on forms approved by the VA and/or the Hospital and include authorization for release of information pertinent to the applicant.

1) The applicant must provide evidence of the items specified in Article III, Section 2, and Qualifications for Medical Staff Membership:

a) Active, current, full and unrestricted license;

b) Education and training;

c) Board certifiable in area of specialty;

d) Current competence;

e) Physical and mental health status;

f) English language proficiency; and

g) Professional liability insurance, if applicable.

2) U.S. Citizenship. Applicants must be citizens of the United States. When it is not possible to recruit qualified citizens, practitioners otherwise eligible for Medical Staff appointment who are not citizens will be eligible for consideration for appointment, with proof of current VISA status and documentation from Immigration and Naturalization Service of employment authorization, pursuant to qualifications as outlined in 38 U.S.C. 7405 and VA Manual MP-5, part II, chapter 2.

3) References. Names and addresses of a minimum of three (3) practitioners in the same professional discipline who have personal knowledge of the applicant's ability to practice and are qualified to provide authoritative information regarding training/experience, competence, health status and/or fulfillment of obligations as a Medical Staff member within the privileges requested.

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

a) Name of health care institution or practice;

b) Term of appointment or employment; and

c) Privileges held and any disciplinary actions taken against the privileges, including suspension, voluntary or involuntary limitation, reduction or loss.

5) DEA (Drug Enforcement Administration) registration information including previously successful or currently pending challenges or the voluntary relinquishment of such registration.

6) Challenges to licensure or registration, including suspension, revocation, and voluntary or involuntary relinquishment.

7) Status of any claims made against the practitioner in the practice of any health occupation. NOTE: Final judgments or settlements of professional liability actions are the minimum requirement. This information is reviewed to determine if there is evidence of an unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the applicant.

8) Voluntary or involuntary termination of Medical Staff membership and/or employment.

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

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

11) Morbidity and mortality data and relevant practitioner-specific data are compared to aggregate data, when available.

b. Applicants are required to provide the following documents in addition to those listed above:

1) Names and addresses for a minimum of three peers able to provide authoritative information regarding the individual's training/experience, professional competence and conduct and health status. At least one of the references must be from the current or most recent employer(s) or institution(s). In the case of individuals completing residencies or other education/training programs, one reference must come from the program director.

2) Names and addresses of institutions at which he/she holds or has held current or recent clinical privileges.

3) A list of licenses (and license status) for all states in which the applicant ever held a license.

4) For foreign medical graduates, evidence of the ECFMG (Educational Commission for Foreign Medical Graduates) certificate.

5) Evidence of board certification, if claimed.

6) Names and addresses of institutions at which he/she trained for the education credentials used to qualify for appointment including all postgraduate training.

Applicants are required to provide information on all educational and training experiences including all gaps of more than 30 days in educational history.

7) Signed Declaration of Health.

8) Agreement to abide by the Bylaws and Rules, and to provide continuous patient care.

c. Burden of Proof. 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 doubts concerning such qualifications. Failure to provide necessary information in a timely manner may serve as a basis for denial of consideration for employment and medical staff membership.

Section 3. Credentialing

a. General Provisions

1) Individuals are fully credentialed prior to initial appointment or reappointment after a break in service of more than 15 workdays.

2) Credentialing is the systematic process of verifying and reviewing the qualifications and the health status of applicants to ensure that they possess the required education, training, experience, physical and mental health, and skill to fulfill the requirements of the position. This section contains the administrative requirements and procedures related to the initial credentialing and reappraisal of practitioners who plan to apply for clinical privileges.

3) The credentialing process includes the use of VetPro to obtain verification, through the appropriate primary source, of the individual's professional education, training, licensure, review of health status, previous experience, any gaps greater than 30 days in training and employment, clinical privileges, professional references, certifications, malpractice history, and adverse actions or criminal violations, as appropriate. Employment commitments are not made until applicants are properly screened through the appropriate state licensing boards and the Office of the Inspector General's Exclusions Database. Medical Staff members are also screened through the Federation of State Medical Boards (FSMB) and registered with National Practitioner Data Bank-Health (NPDB)-Health Integrity and Protection Data Bank (HIPDB) Proactive Disclosure Service (PDS). Individuals reappointed after a break in service of more than 15 workdays are screened again through the appropriate state licensing boards, the Exclusions Database, and the FSMB and NPDB-HIPDB, as appropriate. All information obtained through the credentialing process is carefully considered before an appointment decision is made.

b. Verification of Educational/Training Credentials

1) Written verification of all of the applicants' education and training is obtained from the primary source. Primary source verification of other advanced educational/clinical practice programs is required if a Medical Staff member offers that training as primary support for specialized clinical privileges. Any fees charged by institutions to verify education credentials are to be paid by the facility.

2) For international medical school graduates, written verification that the applicant has met requirements for certification with the Educational Commission for Foreign Medical Graduates (ECFMG) is obtained. The ECFMG is not applicable for graduates from Canadian or Puerto Rican medical schools. Verification of completion of a "Fifth Pathway" may be substituted for ECFMG certification. In accordance with The Joint Commission standards, primary source verification of ECFMG is accepted for international medical school graduation.

3) If education cannot be verified because the school has been closed, because the school is in a foreign country and no response can be obtained, or for other reasons, all efforts to verify the applicant's education and training are documented. A good faith effort to verify international education/training is defined as sending at least two verification letters a month apart without receiving a reply at the end of the second month. Documentation of the good faith effort is included in the practitioner's credentialing file.

4) An education institution may designate an organization as its agent for primary source verification for the purposes of credentialing. The verification from this agent is acceptable, i.e., National Student Clearinghouse.

5) For other health care providers, at a minimum, the level of education that is the entry level for the profession or permits licensure must be verified, as well as all advanced education to support approval of the scope of practice, i.e., for an advance practice nurse, qualifying degrees for the registered nurse and the advance practice nurse must be verified.

6) Primary source verification of other advanced educational and clinical practice programs is required if the applicant offers this credential as a primary support for requested specialized privileges.

7) Verification may be obtained from the American Medical Association (AMA) or the American Osteopathic Association (AOA) Physician Database, a profile listing of medical education a physician has received in this country. These data sources contain other information for follow-up, as necessary. The AMA Physician Masterfile is The Joint Commission's designated equivalent for primary source verification for physician education and residency training. NOTE: The AOA Physician Database is a designated equivalent for: pre-doctoral education accredited by the AOA Bureau of Professional Education, post-doctoral education approved by the AOA Council on Postdoctoral Training, and Osteopathic Board certification. In instances where these profiles do not stipulate primary source verification was obtained, the facility must pursue that verification. Any associated fee is paid by the facility.

c. Verifying Specialty Board Certification

1) Service Line Directors must be certified by an appropriate specialty board or possess comparable competence. For candidates not board-certified, or board certified in a specialty not appropriate for the assignment, the Clinical Executive Board affirmatively establishes and documents, through the privilege delineation process, that the person possesses comparable competence. If the Service Line Director is not board certified, the credentialing and privileging file must contain documentation that the individual has been determined to be equally qualified based on education and experience. Appointment of Service Line Directors without board certification must comply with VHA policy as appropriate.

2) Prior to appointment, the Chief of Staff signs the employment application, VA Form 10-2850, to confirm verification of certification by an American Specialty Board(s), if claimed by a physician applicant or a Dental Specialty Board for dentist applicants. At the request of the Chief of Staff, the Director may delegate responsibility for obtaining information about a candidate's board certification.

3) A physician's board certification is generally verified through VetPro but may be confirmed in the Compendium of Certified Medical Specialists, published by the American Board of Medical Specialists, or the Directory of Medical Specialists, published by Marquis' Who's Who, or direct communication with the officials of the board in question, if necessary. A dentist's board certification may be confirmed by the listings in the American Dental Directory published annually by the American Dental Association or by contacting the appropriate Dental Specialty Board. If listings of specialists are used to verify board certification these must be from current or recently issued copies of the above publications and include copies of the cover page indicating publication date and the page listing the practitioner.

Osteopathic specialty certifications from the Advisory Board for Osteopathic Specialists should be confirmed in the Directory of Osteopathic Physicians and A.O.A. Approved Post-Doctoral Training.

4) Board certification and other specialty certificates, which are time-limited or carry an expiration date, must be reviewed and documented prior to expiration.

d. Licensure

1) Applicants must possess at least one full, active, current, unrestricted license to be eligible for appointment. As part of the credentialing process, the status of an applicant's license is primary source verified. (Current licensures are primary source verified at the time of initial appointment, at renewal and/or revision of privileges, and at the time of license expiration.)

2) Verification with state licensing board(s). The Chief of Staff documents on the employment application, VA Form 10-2850, that the status of all licensures/registrations has been verified with the appropriate state licensing board for all states in which the applicant listed having ever held a license. At the request of the Chief of Staff, the Director may delegate responsibility for contacting state licensing boards.

a) Verification can be obtained through a letter or by telephone and documented on a report of contact. Electronic means of verification also are acceptable, as long as the site is maintained by the primary source and there is no disclaimer regarding authenticity.

If verification of licensure is made by telephone or electronic means, a written request for verification must be made within 5 working days and tracked to ensure its receipt within 30 days.

b) If the State is unwilling to provide primary source verification of licensure or other requested information subsequent to written request, the facility must document the State's specifics of the refusal and secure an authenticated copy of the license from the applicant. If the reason for the SLB’s refusal is payment of a fee, the facility will pay the fee if the review is for initial appointment.

NOTE: Although credentialing is required for PAs, licensure is not required for employment, so verification of licensure is only required if claimed.

3) Qualification Requirements of Title 38 United Stated Code (U.S.C.)

Section 7402 (f). Applicants being credentialed for a position identified in 38 U.S.C. Section 7402(b) (other than a Director) for whom State licensure, registration, or certification is required and who possess or have possessed more than one license (as applicable to the position) are subject to the following provisions:

a) Applicants and individuals appointed on or after November 30, 1999, who have been licensed, registered, or certified in more than one State and who had such license, registration, or certification revoked for professional misconduct, professional incompetence, or substandard care by any of those States, or voluntarily relinquished a license, registration or certification in any of those States after being notified in writing by that State of potential termination for professional misconduct, professional incompetence, or substandard care, are not eligible for appointment, unless the revoked or surrendered license, registration, or certification is restored to a full, unrestricted status.

b) Individuals who were appointed before November 30, 1999, who have maintained continuous appointment since that date and who are identified as having been licensed, registered, or certified in more than one State and, on or after November 30, 1999, who have had such revoked for professional misconduct, professional incompetence, or substandard care by any of those States, or voluntarily relinquished a license, registration. or certification in any of those States after being notified in writing by that State of potential termination for professional misconduct, professional incompetence, or substandard care, are not eligible for continued employment in such position, unless the revoked or surrendered license, registration, or certification is restored to a full, unrestricted status. Individuals who were appointed prior to November 30, 1999, and have been on continuous appointment since that date are not disqualified for employment by any license, registration, or certification revocations or voluntary surrenders that predate November 30, 1999, provided they possess one full and unrestricted license as applicable to the position.

c) Where a license, registration, or certification has been surrendered, confirmation must be obtained from the primary source that the individual was notified in writing of the potential for termination for professional misconduct, professional incompetence, or substandard care. If the entity verifies written notification was provided, the individual is not eligible for employment unless the surrendered credential is fully restored.

d) Where the State licensing, registration, or certifying entity fully restores the revoked or surrendered credential, the eligibility of the provider for employment is restored. These individuals would be subject to the same employment process that applies to all individuals in the same job category. In addition to the credentialing requirements for the position, there must be documentation there was a complete review of the facts and circumstances concerning the action taken against the State license, registration, or certification and the impact of the action on the professional conduct of the applicant.

e) This policy applies to licensure, registration, or certification required, as applicable, for the position subsequent to the publication of this policy and required by statute or VA qualification standards, effective with the date the credential is required.

f) When a practitioner enters into an agreement (disciplinary or non-disciplinary) with a State licensing board to not practice the occupation in a State, the practitioner is required to notify VA of the agreement. Information concerning the circumstances surrounding the agreement must be obtained. This includes information from the primary source of the specific written notification provided to the practitioner, including, but not limited to: notice of the potential for termination of licensure for professional misconduct, professional incompetence, or substandard care. If the entity verifies written notification was provided, all associated documentation must be obtained and incorporated into the credentialing and privileging file and VetPro. The practitioner must be afforded an opportunity to explain, in writing, the circumstances leading to the agreement. Facility officials must evaluate the primary source information and the individual’s explanation of the specific circumstances, documenting this review in the credentialing and privileging file and VetPro.

g) There may be instances in which actions have been taken against an applicant’s license for a clinically-diagnosed illness. Those applicants are eligible for appointment when they are acknowledged by the licensing, registering, or certifying entity as stable, the licensure action did not involve substandard care, professional misconduct, or professional incompetence, and the license, certificate, or registration is fully restored.

4) Exceptions to Licensure. As part of the credentialing process, the status of an applicant's license and that of any required or claimed certifications must be reviewed and primary source verified. Except as provided in VA Handbook 5005, Part II, Chapter 3, subparagraph 14b, all LIPs must have a full, active, current, and unrestricted license to practice in any State, Territory, or Commonwealth of the United States, or in the District of Columbia.

The only exceptions provided in VA Handbook 5005 are:

a) An individual who has met all the professional requirements for admission to the State licensure examination and has passed the examination, but who has been issued a State license which is limited on the basis of non-citizenship or not meeting the residence requirements of the State.

b) An individual who has been granted an institutional license by the State which permits faculty appointment and full, unrestricted clinical practice at a specified educational institution and its affiliates, including the VA health care facility; or, an institutional license which permits full, unrestricted clinical practice at the VA health care facility. This exception is only used to appoint an individual who is a well-qualified, recognized expert in the individual’s field, such as a visiting scholar, clinician, and/or research scientist, and only under authority of 38 U.S.C. 7405. It may not be used to appoint an individual whose institutional license is based on action taken by an SLB.

c) An individual who has met all the professional requirements for admission to the State licensure examination and has passed the examination, but who has been issued a time-limited or temporary State license or permit pending a meeting of the SLB to give final approval to the candidate’s request for licensure. The license must be active, current, and permit a full, unrestricted practice. Appointments of health care professionals with such licenses must be made under the authority of 38 U.S.C. 7405 and are time-limited, not to exceed the expiration date of licensure.

d) A resident who holds a license which geographically limits the area in which practice is permitted or which limits a resident to practice only in specific health care facilities, but which authorizes the individual to independently exercise all the professional and therapeutic prerogatives of the occupation. In some States, such a license may be issued to residents in order to permit them to engage in outside professional employment during the period of residency training. The exception does not permit the employment of a resident who holds a license which is issued solely to allow the individual to participate in residency training.

5) SLBs may restrict the license of a practitioner for a variety of reasons. Among other restrictions, an SLB may suspend the licensee's ability to independently prescribe controlled substances or other drugs; selectively limit one's authority to prescribe a particular type or schedule of drugs; or accept one's offer or voluntary agreement to limit the authority to prescribe, or provide an “inactive” category of licensure. NOTE: In such cases, the license must be considered restricted for VA purposes, regardless of the official SLB status.

6) Some states authorize a grace period after the licensure and/or registration expiration date, during which an individual is considered to be fully licensed and/or registered whether or not the individual has applied for renewal on a timely basis. Facility officials will not initiate separation procedures for failure to maintain licensure or registration on a practitioner whose only license and/or registration has expired if the State has such a grace period and considers the practitioner to be fully and currently licensed and/or registered.

7) Physician applicants including physician residents who function outside the scope of their training program, i.e., who are appointed as a Medical Officer of the Day, must be screened with the FSMB prior to appointment.

a) The FSMB is a disciplinary information service and reports only those disciplinary actions resulting from formal actions taken by reporting medical licensing and disciplinary boards or similar official sources.

b) Screening applicants with the FSMB does not abrogate the medical facility’s responsibility for verifying current and previously held medical licenses with the SLB(s).

c) Appointment to the medical staff and granting of clinical privileges is not complete until screening against the FSMB is documented in VetPro. Information obtained through the query must be primary source verified and there must be documentation that this information was considered during the appointment process.

d) Those practitioners who were screened against the FSMB Disciplinary Files by VA Central Office in 2002, or subsequently screened through VetPro, are in VHA’s FSMB Disciplinary Alerts Service. Practitioners entered into the VHA’s FSMB Disciplinary Alerts Service are continuously monitored. Orders reported to the FSMB from licensing entities, as well as the Department of Health and Human Services (DHHS), Office of Inspector General (OIG) and the Department of Defense (DOD) initiate an electronic alert that an action has been reported to VHA’s Credentialing and Privileging Program Director.

1. The registration of practitioners into this system is based on these queries and only on these queries.

2. This monitoring is on-going for registered practitioners.

3. Alerts received by VHA’s Credentialing and Privileging Program Director are forwarded to the appropriate VA facility for primary source verification and appropriate action. The disciplinary information that pertains to the practitioner can then be downloaded and forwarded to the appropriate facility for review and inclusion in the practitioner’s credentials file.

4. Facility credentialing staff must obtain primary source information from the State licensing board for all actions related to the disciplinary alert. Complete documentation of this action, including the practitioner’s statement, is to be scanned into VetPro before filing in the paper credentials file. Medical staff leadership is to review all documentation to determine the impact on the practitioner’s continued ability to practice within the scope of privileges granted.

8) Appointment of Candidates with Previous or Current Adverse Action Involving Licensure. Physicians and dentists, or other licensed practitioners who have had a license or licenses restricted, suspended, limited, issued and/or placed on probational status, or denied upon application, may be appointed under the appointment procedures that apply to other physicians, dentists, or other health professionals.

a) Officials included in the appointment process are to thoroughly review and document the review of all SLB documentation (findings of fact detailing the basis for the action against the applicant’s license, stipulation agreements, consent orders, and final orders), as well as the applicant’s subsequent professional conduct and behavior before determining whether the applicant can successfully serve as a physician, dentist, or other health care practitioner.

b) To be eligible for appointment, an applicant or employee must meet current legal requirements for licensure (see 38 U.S.C. §§ 7402(b) and (f).

c) If action was taken against the applicant’s sole license, or against all the applicant’s licenses, a review by the Manager, Human Resources, or Regional Counsel, is necessary to determine whether the applicant meets VA’s licensure requirements.

Documentation of this review must include the reason for the review, the rationale for conclusions reached, and the recommended action.

d) Those health care professionals who have a current, full and unrestricted license in one or more States, but who currently have or have ever had a license, registration, or certification restricted, suspended, limited, issued and/or placed on probational status, or denied upon application, must not be appointed without a thorough documented review. The credentials file must be reviewed with Regional Counsel to determine if the practitioner meets appointment requirements. Documentation of this review must include the reasons for the review, the rationale for the conclusions reached, and the recommended action. The review and the rationale for the conclusions must be forwarded to the VISN Chief Medical Officer for concurrence and approval of the appointment.

e. Drug Enforcement Administration (DEA) and Bureau of Narcotic and Dangerous Drug (BNDD) Certification:

1) Physicians, dentists, and certain other practitioners may apply for and be granted renewable certification by the DEA and/or state (BNDD) to prescribe controlled substances. Certification by DEA is not required for VA employment; employees may use the facility's institutional DEA certificate with a suffix.

2) Each applicant is required to provide information on his/her current or most recent DEA and BNDD certificates. Any applicant whose DEA or BNDD certification has ever been revoked, suspended, limited, restricted in any way, or voluntarily or involuntarily relinquished, or not renewed, is required to furnish written explanation at the time of filing the employment application and at the time of reappraisal. Certification must be verified for individuals who claim on the application form to currently hold or to have previously held DEA certification.

3) A state licensing board may obtain a voluntary agreement from an individual not to apply for renewal of certification or may decide to disapprove the individual's application for renewal as part of a disciplinary action taken in connection with the individual's professional practice. While there are a number of reasons a license may be restricted which are unrelated to DEA certification, an individual's state license is considered restricted or impaired for purposes of VA employment if the state licensing board has:

a) Suspended the person's authority to prescribe controlled substances or other drugs;

b) Selectively limited the individual's authority to prescribe a particular type or schedule of drugs; or

c) Accepted an individual's offer for voluntary agreement to limit authority to prescribe.

f. Employment Histories and Pre-employment References:

1) Clinical competence is verified by statements from individuals who are personally knowledgeable of the applicant's professional behavior and clinical performance. At a minimum, documented contact is made with three authoritative references obtained from the applicant, including one from the current or most recent employer or institution where the applicant practiced. Peer recommendations include evaluation of current medical/clinical knowledge, technical and clinical skills, clinical judgment, interpersonal skills, communication skills, and professionalism.

2) Information is requested relative to the scope and level of professional and clinical competence, health status, and fulfillment of responsibility as a member of the Medical Staff. Additionally, findings from the facility's quality improvement program including, but not limited to number of procedures/surgeries performed, number and types of patients treated, mortality rates and infection rates are requested.

3) Supplemental information may be required to evaluate…