VA244-17-R-1154-002.docx

ATTACHMENT 1 MS-001

CREDENTIALING AND PRIVILEGING OF THE MEDICAL STAFF

(Includes Physicians, Dentists, Podiatrists, Optometrists, Social Workers, Psychologists, Audiologists, Speech Pathologists) AND ADVANCED PRACTICE PROVIDERS (Includes Clinical Nurse Specialists, Nurse Practitioners, Nurse Anesthetists, Physician Assistants)

I. PURPOSE

To provide guidance on the credentialing and privileging process for the Medical Staff and Advanced Practice Providers and to ensure that patient care is provided by well-qualified, competent health care practitioners.

II. POLICY

1. The Medical Staff includes all fully licensed physicians, dentists, podiatrists, optometrists, psychologists, social workers, audiologists and speech pathologists. Medical Staff who provide patient care services independently at the VAPHS and are appointed on a full-time (FT), part-time (PT), intermittent, consulting/attending, without compensation (WOC), or on station fee basis, contract, or sharing agreement basis will have proper credentials and specifically delineated clinical privileges. This policy includes residents who function outside the scope of their training program (Medical Officer of the Day).

1. The Advanced Practice Providers include all fully licensed Clinical Nurse Specialists, Nurse Practitioners, Nurse Anesthetists and Physician Assistants who provide patient care services under the direction of a Supervising Physician at the VAPHS and are appointed on a full time (FT), part-time (PT), intermittent, consulting, without compensation (WOC), or on station fee basis, contract or sharing agreement basis will have proper credentials and a specifically delineated scope of practice.

1. Reappraisal and re-privileging is done every two years, with privileges or scopes of practice renewed or amended, and review of current licensure, health status, professional performance and judgment, and any actions involving license restrictions, disciplinary actions or privilege limitations. Reappraisal of professional performance, judgment, and clinical and/or technical skills is based in part on results of performance improvement activities. Exception: Please note that credentialing and privileging of contracted providers will occur every year. Privileges of contracted providers will automatically expire after one year if the contract has not been renewed.

1. The Director has delegated assessment and evaluation of medical staff to the Medical Executive Board and for Advanced Practice Providers to the Discipline-Specific Professional Standards Board, but retains ultimate responsibility for credentialing and granting, modification, and denial of clinical privileges or scopes of practice.

1. Service Line Vice Presidents must document their own review of all licensed healthcare practitioners in Vet Pro and may not delegate other staff to enter the approval unless they are acting in the absence of the Service Line Vice President.

1. One standard of care must be provided for any given treatment or procedure, regardless of the practitioner, service or location in the facility. For credentialing and privileging/scopes of practice, the standard for granting privileges or scopes of practice to perform any given procedure will be the same for all services or locations.

G. A minimum of 40 hours of continuing medical education (CME) in the field of practice over a two-year period (to be prorated if the cycle is less than two years) will be required for medical staff for reappointment to the VAPHS. Please note that of the 40 hours CME, 20 hours Category I CME are required for physicians.

H. Advanced Cardiac Life Support (ACLS) certification is required by the VAPHS for the Cardiopulmonary Resuscitation Physician Team Leaders, physicians in the Emergency Department, Critical Care, Telemetry, Medical Officers of the Day (MOD) at University Drive, and physicians with moderate sedation and airway management privileges (Interventional Cardiologists, Interventional Gastroenterologists, Interventional Pulmonologists, Anesthesiologists).

I. Each provider of services for patients with Acute Coronary Syndrome/Acute MI is required to complete a minimum of two Continuing Medical Education (CME) Credits per year.

J. VAPHS physicians who prescribe, diagnose, or treat patients via telemedicine are to obtain clinical privileges from the facility receiving the telemedicine services.

III. DEFINITIONS

A. Credentialing is the systematic process of reviewing the health status and qualifications of practitioners to ensure that patients receive care, treatment and services from qualified providers. An evaluation of licensure, education, training, experience, competence and ability to perform the privileges requested is conducted. Documentation of credentialing will be maintained in a paper or electronic file, as required by VHA regulations. Verification of information is sought to minimize the possibility of granting privilege(s) based on the review of fraudulent documents.

B. Clinical privileging is the process by which a licensed independent practitioner is permitted by law and the facility to provide 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 experiences, health status, education, training and licensure. Clinical privileges will be provider- specific, will be granted only for site-specific procedures that the practitioner will perform in the facility and will be in effect for no more than two years.

C. Reappraisal/recredentialing is the process of evaluating the professional credentials and clinical competence of licensed independent practitioners who have been granted clinical privileges at least every two years.

D. Reprivileging is the renewal of clinical privileges at least every two years.

E. Competencies are general areas used to evaluate a provider’s performance. The areas of general competencies include patient care, medical / clinical knowledge, practice-based learning, and improvement, interpersonal and communication skills, professionalism and system-based practice.

F. Focused Professional Practice Evaluation is a review of a specific aspect of a practitioner’s performance. This process is used when a practitioner has the credentials to suggest competence, but additional information or a period of evaluation is needed to confirm competence in the organization’s setting; or when questions arise regarding a practitioner’s professional practice during the course of the ongoing professional practice evaluation.

G. Ongoing Professional Practice Evaluation is a process designed to continuously evaluate a practitioner’s performance. The process requires the Medical Staff to conduct an ongoing evaluation of each practitioner’s professional performance. This process not only allows any potential problems with a practitioner’s performance to be identified and resolved as soon as possible, but also fosters a more efficient, evidence-based privilege renewal process.

H. The National Practitioner Data Bank (NPDB) is a secondary source of information that will report only those malpractice reports made in behalf of the practitioner and reportable formal disciplinary actions taken by medical licensing and disciplinary boards, professional societies, and health care facilities.

I. Vet Pro is an internet enabled system for the credentialing of VHA health care providers that facilitate completion of a uniform, accurate, and complete credentials file and has sharing capabilities throughout the national VA healthcare system.

IV. RESPONSIBILITIES

A. The Director is responsible for ensuring that all independent practitioners are properly credentialed and privileged. Procedures for credentialing and privileging will be strictly adhered to and documented, and the process will meet VA requirements. The credentialing and privileging process for all licensed independent practitioners will adhere to the same requirements.

B. The Chief of Staff, through the Credentialing Office, is responsible for maintenance of a credentialing and privileging file for each licensed independent practitioner. These files will contain all documents relevant to the credentialing and privileging process and will be in compliance with VHA regulations and Joint Commission standards or equal accrediting body that meets or exceeds the standards of The Joint Commission.

C. The Service Line Vice Presidents are responsible for recommending members of the medical staff and for assuring that each individual requesting clinical privileges has demonstrated competency and that the quality of the individuals’ performance is evaluated on an ongoing basis. Each clinical service will propose to the Medical Executive Board criteria for granting clinical privileges within designated clinical areas for all categories of medical staff based on available resources.

D. The Executive Assistant to the Chief of Staff is the technical advisor for the medical center for credentialing and privileging and supervisor of the Credentialing Staff.

E. The Credentialing Staff are responsible for verifying that all information submitted for credentialing and privileging is valid and that all required information is available. The Credentialing Staff are responsible for advising each physician and other health care professionals that failure to fulfill this obligation and/or falsification of documents may lead to medical center liability and/or individual prosecution. The Credentialing Staff will ensure that all medical staff and advanced practice providers are provided with a copy of the medical staff bylaws and agree to accept the professional obligations reflected therein. The Credentialing Staff will maintain records of all documents relevant to the credentialing and privileging process including enrollment and maintenance of VetPro and internal credentialing and privileging databases. The Credentialing Staff will present cases for review to the Medical Executive Board or Discipline Specific Professional Standards Boards and will ensure timely completion of documentation, verification of state license, education, board certification, etc., as required.

F. Human Resource Management Service is responsible for assuring legal and administrative requirements are met and provide a technical review of all board actions to ensure compliance with VA policies.

G. The Medical Executive Board and Discipline Specific Professional Standards Boards will make recommendations for initial appointment and for delineation of clinical privileges/scopes of practices based on established criteria mutually agreed upon by the medical staff. The Medical Executive Board will make recommendations to the Director on requested privileges to initiate, alter, or terminate privilege requests.

H. Each Health Care Provider will respond to requests for information in a timely manner and must provide evidence of licensure registration, certification, and for 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, rules and regulations provided to them. They are responsible for keeping the VA apprised of anything that would adversely affect or otherwise limit their clinical privileges. Failure to keep VA informed on these matters may result in administrative or disciplinary action.

V. PROCEDURES

A. The credentialing and privileging process involves a series of activities designed to collect, verify and evaluate data relevant to a practitioner’s professional performance. These activities serve as the foundation for objective, evidence-based decisions regarding appointments to membership on the Medical Staff, and recommendations to grant or deny initial and renewed privileges. In the course of the credentialing and privileging process, an overview of each applicant’s licensure, education, training, current competence, and physical ability to discharge patients care responsibilities is established.

a. Practitioners must be fully credentialed and privileged prior to initial appointment, reappointment, or after a break in service. The credentialing process includes verification, through the appropriate primary sources, the individual's professional education, training, licensure, certifications, review of health status, previous experience (including any gaps in employment or training greater than 30 days), clinical privileges, professional references, malpractice history, adverse actions or criminal violations as appropriate. Employment commitments will not be made until applicants have been properly screened through the state licensing boards and National Practitioner Data Bank (NPDB). All information obtained through the credentialing process will be carefully considered before employment and privileging decision actions are made. The applicable service line will review the credentialing folder and requested privileges and make recommendations regarding appointment. The VetPro database information and recommendations will be reviewed by the Service Line and Medical Executive Board and recommendations will be forwarded to the Director. All applicants applying for clinical privileges will be provided a copy of the Medical Staff Bylaws, rules and regulations and must agree in writing to accept the professional obligations reflected therein.

2. Licensure

a. Except as described in VHA Handbook 5005.2, Chapter 2, every VA physician, dentist, podiatrist, optometrist, psychologist, social worker, audiologist and speech pathologist must have a current, full active, and unrestricted license to practice their specialty in any state, territory or Commonwealth of the United States, or the District of Columbia. If required by the state of licensure, current registration must also be maintained. Physicians and dentists who have a current unrestricted license in one or more states, but who have, or have had, a license restricted, suspended or revoked, will be hired in accordance with VHA Handbook 1100.19, Credentialing and Privileging. The Chief of Staff will document on VA Form 10-2850,"Application for Physicians, Dentists, Podiatrist and Optometrists", and on VA Form 10-2850c, "Application for Associated Health Occupations", that the status of all licensure/registration has been verified with the appropriate state licensing board for all states in which the applicant lists licensure.

b. The National Practitioner Data Bank (NPDB) and Federation of State Medical Boards (FSMB) are secondary information sources; any reported information must be validated with the primary source (i.e., State Licensing Board, healthcare entity, malpractice payer). Screening applicants and appointees with the NPDB or FSMB does not abrogate the Chief of Staff's responsibility for verifying all information prior to appointment, privileging/re-privileging or proposed personnel action. This requirement does not apply to individuals functioning within the scope of a training program.

3. Pre-employment References

a. To assess experience, ability and current competence, documented contact must be made with at least three professional references that are from the same professional discipline as the applicant, including one from the current or most recent employer or institution where the applicant practiced or had privileges.

b. Information must be obtained relative to the scope and level of professional and clinical competence in the areas in which privileges are sought, health status, and fulfillment of responsibility as a member of the medical staff. Documentation of adequate information to fully assess the applicant's educational background and/or prior professional experiences must be present in the credentialing and privileging file.

c. Supplemental information may be required to fully evaluate the educational background and/or prior professional experiences of an applicant. These reference checks may be obtained orally, but must be documented and filed with other references.

d. For an applicant with prior VA or other Federal government service, the official personnel folder should be obtained as well as the credentialing and privileging folder before the individual is appointed. If an applicant has prior VA service, an effort should be made to obtain a reference from officials at the facility where the applicant was previously employed.

e. All licensed independent practitioners must have their National Provider Identifier (NPI) and Taxonomy Code to complete the VetPro process. If the practitioner does not have this number, he/she must complete the online form and provide the tracking number. Once a ten digit number is assigned, this must be given to the Service Line ADPAC for entry into Vista. Assistance with obtaining an NPI number is provided by the service line.

f. All providers listed below, must be enrolled with the Centers for Medicare & Medicaid Services (CMS) under the Provider Enrollment Chain of Ownership System (PECOS). If the provider is not enrolled, he/she must complete the online form and submit evidence of application. Assistance with enrolling in PECOS is provided by the service line.

1. Psychiatrist

1. Psychologist, Clinical

1. Speech and Language Pathologist

4. Health Status

a. The VAPHS complies with the Americans with Disabilities Act, which bars discrimination both on physical or mental impairments. Each applicant's health status, and physical and mental capability, must be consistent with their ability to satisfactorily perform the duties of their medical staff assignment and the clinical privileges being sought. Determination of the applicant's health status includes a declaration of appropriate health status by the applicant with a confirmation by a physician designated by or acceptable to the facility, such as the employee health physician or physician service/section chief. When doubt has been raised about an applicant’s ability to meet the requested clinical privileges, the MEB may request further evaluation.

5. Board Certification

a. Board Certification is an excellent benchmark and is considered when delineating clinical privileges. Physician and/or dentist service chiefs should be certified by an appropriate specialty board. For candidates not board certified, or board certified in a specialty (ies) not appropriate for the assignment, the Medical Executive Board affirmatively establishes and documents through the privilege delineation process, that the person possesses comparable competence. The Credentialing Staff have been delegated the responsibility to document, prior to appointment, evidence of certification by an American Specialty Board(s), if claimed by a physician, or a Dental Specialty Board for dentists. Physicians' board certification may be confirmed by the listings in the Compendium of Certified Medical Specialists, or the Directory of Medical Specialists, or by direct communication with the Specialty Board; dentists' certification must be confirmed by the listing in the American Dental Directory published annually by the American Dental Association or by contacting the appropriate Dental Specialty Board. Other healthcare practitioners may be confirmed by direct communication with officials of the certification in question or approved website verification.

6. Malpractice

a. VA application forms require written details be provided on any administrative, professional or judicial proceedings in which professional malpractice on the applicant's part is, or was alleged. A full evaluation of any such claim will take place by officials participating in the credentialing, selection and approval processes prior to making recommendations or decisions on the applicant's suitability for VA employment. The evaluating officials will consider the VA's obligation as a health care provider to exercise reasonable care in determining that applicants are properly qualified, recognizing that many allegations of malpractice are proven groundless. Providers who have 3 or more medical malpractice payments in their payment history, or a single medical malpractice payment of $550,000 or more, or 2 medical malpractice payments totaling $1,000,000 or more will have their VetPro file reviewed by the VISN Chief Officer prior to presentation to the VA Pittsburgh Healthcare System Medical Executive Board. The VISN Chief Medical Officer will provide a recommendation whether to continue the appointment and privileging process.

7. Education

a. Educational and training credentials inform the organization of the applicant’s clinical knowledge and skill set and will be verified from the primary source whenever possible. Verification of all privileged healthcare practitioners will be conducted by the Credentialing Staff and will include medical/dental/graduate school as well as residency/fellowship training.

b. Primary source verification of other advanced education/clinical practice program is required if the applicant offers this credential(s) as a primary support for requested specialized clinical privileges. All efforts to verify educational credentials, particularly credentials from foreign countries, will be fully documented by the Credentialing Staff. For graduates of foreign medical schools who possess ECFMG (Educational Council of Foreign Medical Graduates) certificate, primary source verification will be obtained by the Credentialing Office. A certified ECFMG verification will suffice for medical school training verification if written requests for verification are unavailable. Applicants are required to provide information on all educational and training experience including all gaps greater than 30 days in educational history.

8. Drug Enforcement Administration (DEA)

a. DEA certification is not a requirement for employment in a Department of Veterans Affairs Medical Center. Physicians and dentists may apply for and be granted renewable certification by the DEA to prescribe controlled substances. Each applicant will be required to indicate on the application form information about the most recent or current DEA certificate. In addition, any applicant with a DEA certification revoked, suspended, limited, restricted in any way, or voluntarily relinquished, will be required to provide a written explanation at the time of application. A copy of the current DEA certification will be obtained.

9. Bylaws

a. All practitioners being considered for appointment will be forwarded a copy of the Medical Staff Bylaws, Rules and Regulations for review and must agree in writing to abide by them.

10. Medical Executive Board

a. The Medical Executive Board will review credentialing and privileging documentation and will make recommendations to the Director for actions on medical staff appointments/re-appointments and initial privileging and re-privileging of licensed independent practitioners.

11. Deans Committee

a. The Deans Committee may nominate for consideration by the Director, full and part-time physicians and dentists, including service chiefs, and consultant and attending staff.

12. Verification of Identity

1. Human Resources will complete the following clearance processes to ensure that an individual requesting clinical privileges is the same individual identified in the credentialing documents: verification of identity; verification of employment eligibility; background check; fingerprinting; and screening the OIG Exclusionary List.

B. Temporary Appointment for Urgent Patient Care Need

1. Temporary appointments for urgent patient care needs may require appointment before full credentialing information has been received. Since credentialing is a key component in any patient safety program, the appointment of providers with less than complete credentials packages warrants serious consideration and thorough review of the available information.

b. confirmation of current comparable clinical privileges;

c. response from NPDB-HIPDB with no match

d. response from FSMB with no reports;

e. receipt of at least one peer reference who is knowledgeable of and confirms the provider’s competence, and has reason to know the individual’s professional qualifications; and,

f. documentation by the Director of the specific patient care situation that warranted such an appointment.

3. Temporary appointments must be completed in VetPro including the NPDB query and response, and the FSMB query and response. These appointments may not be renewed or repeated.

4. An application through VetPro will be completed within three calendar days of the date the appointment is effective. This will include Supplemental Questions, a Declaration of Health and a Release of Information. This additional information will facilitate the required completion of the practitioner credentialing for these practitioners used in urgent patient care needs situations as well as provide additional information for evaluation of the current Temporary Appointment and reduce any potential risk to patients.

5. If the Temporary Appointment is not converted to another form of medical staff appointment, complete credentialing will be completed even if completion occurs after the practitioner’s temporary appointment is terminated or expires. At a minimum, the licensed independent practitioner will submit a VetPro application, and all credentials will be verified. If unfavorable information was discovered during the course of the credentialing, a review of the care provided may be warranted to ensure that patient care standards have been met. NOTE: Temporary appointments are for emergent patient care only and NOT to be used for administrative convenience.

C. Expedited Appointment

1. The credentialing process for an Expedited Appointment to the Medical Staff cannot begin until the licensed independent provider completes the entire credentials package, including VetPro.

2. Credentialing requirements for this process include confirmation of:

a. The physician’s education and training;

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

c. Confirmation of the declaration of health, by a physician designated by or acceptable to the VAPHS, of the applicant’s physical and mental capability to fulfill the requirement of the clinical privileges being sought;

d. Query of licensure history through the Federation of State Medical Boards Action Data Center with no report documented;

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

f. Current comparable privileges held in another institution; and,

g. National Practitioner Data Bank query with documentation of no match.

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

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

5. For those providers where there is evidence of current or previously successful challenge to any credential or any current or previous administrative or judicial action, the expedited process cannot be used and complete credentialing must be accomplished though routine processes by the Medical Executive Board documentation should include the numbers, types and outcomes of related cases.

D. Clinical Privileging - Clinical privileging is the process by which a practitioner is granted permission by the facility to independently provide medical or other patient care services within the scope of the practitioner's license and on an individual's clinical competence as determined by peer references, professional experience, health status (as it relates to the individual's ability to perform the requested clinical privileges), education, training, and licensure and registration. Prior to granting of a privilege, the resources necessary to support the requested privileges are determined to be currently available or available within a specified time frame.

1. Only practitioners who are licensed and permitted by law and the facility to practice independently may be granted clinical privileges and the privileges are not to be extended beyond a two-year period. Clinical privileges of contract providers will automatically expire after one year if the contract will not be renewed. Privileges should be requested for only those procedures, which the medical staff member will perform within the facility. Admitting privileges are granted to physicians, oral surgeons and dentists. The medical staff bylaws specify that any medical staff member is permitted to provide emergency care to an individual whose life is in immediate danger and where delay would place the individual at risk.

2. General criteria for privileging will be uniformly applied to all applicants. Such criteria will include:

a. Current licensure and / or certification, as appropriate, verified with the primary source.

b. The applicants specific relevant training, verified with the primary source.

c. Evidence of physical ability to perform the requested privilege.

d. Data from professional practice review by an organization that currently privileges the applicant (if available).

e. Peer and / or faculty recommendation.

f. When renewing privileges review of the practitioner’s performance within the organization.

g. Each Service Line Vice President will establish additional criteria for granting clinical privileges within the service consistent with the needs of the service and the facility. Clinical privileges must be based on evidence of an individual's current competence. When privilege delineation is based primarily on experience, the individual's credentials record should reflect that experience and the documentation should include the numbers, types and outcomes of related cases.

3. Privileges granted to an applicant must be facility specific and based on the procedures and types of services that are provided with the facility. The requirements and standards for granting privileges to perform any given procedure, if performed by more than one service, must be the same. One standard of care must be guaranteed regardless of practitioner, service or location within the facility. Each practitioner will be assigned to and have clinical privileges in one clinical service and may be granted privileges in other clinical services. The exercise of clinical privileges within any service will be subject to the policies and procedures of that service and the authority of that Service Line Vice President.

a. Initial Privileges

(1) Clinical privilege requests must be initiated by the practitioner and reviewed and recommended by the Service Line Vice President responsible for the particular specialty area in which the privileges are requested. Clinical privileges held by the applicant practitioner at other hospitals may also be reviewed as part of the granting of privileges. The Service Line Vice President will verify clinical experience and determine the appropriate level of initial privileging based on an applicant's health status, past experience, training, and clinical competence and other appropriate information. The Service Line Vice President will recommend approval, disapproval or modification of the requested clinical privileges. This may include a limited period of direct supervision by an appropriately credentialed practitioner for privileges that are high risk.

(2) Residents who elect to work as fee basis, and/or MOD physicians must be licensed, credentialed and privileged for the duties they are expected to perform. In this capacity they are not working under the auspices of a training program, and must meet the same requirements as all medical staff appointed at the facility.

(3) Clinical privileges by provider are available to hospital staff on a need-to-know basis in order to ensure providers are operating within the scope of their clinical privileges. Employees performing procedures outside the scope of their privileges may be subject to disciplinary or administrative action.

b. Temporary Privileges

(1) The Director/Acting Director may grant temporary clinical privileges for emergent or urgent patient care needs for a period not to exceed 60 calendar days. Such privileges will be based on evidence of current licensure; relevant training or experience; current competence; ability to perform the privileges requested; a query and evaluation of NPDB information; a complete application; no current or previously successful challenge to licensure or registration; no subjection to involuntary termination of medical staff membership at another organization; and no subjection to involuntary limitation, reduction, denial, or loss of clinical privilege. The recommendation for temporary privileges will be made by the Chief of Staff and approved by the Director. Special requirements of supervision and reporting may be imposed on any practitioner granted temporary privileges by the responsible Service Line Vice President. The Director may at any time, upon recommendation of the Chief of Staff, terminate a practitioner's temporary privileges. Such individuals are not entitled to a hearing or appeal.

c. Disaster Privileges

(1) In circumstances of disaster (s), in which the emergency management plan has been activated and the Medical Center is unable to handle the immediate patient needs, the Director/Chief of Staff/or Designee may grant disaster privileges to licensed independent practitioners from another Joint Commission accredited healthcare facility on a case by case basis at his/her discretion. The practitioner must present a current photo ID from the healthcare facility where he/she is employed and a valid photo ID used by a federal, state or regulatory agency (e.g. driver’s license), present evidence of current professional licensure, and must be queried whether his/her professional license is in good standing. The individual may also present identification as being a member of a disaster medical assistance team to render patient care, treatment and services in disaster circumstances with such authority granted by federal, state, or municipal entity. Verification of the practitioner’s identity may also be made by a current member of the hospital or medical staff with personal knowledge regarding the provider’s identity.

(2) Primary source verification of licensure and queries to the National Practitioner Data Bank and Federation of State Medical Boards, etc. will be completed within 72 hours or as soon as communication is available. The standards credentials verification process will be used. The practitioner will be granted disaster privileges to provide patient care at the VAPHS within the scope of his/her professional licensure and will be mentored by a currently credentialed and privileged medical staff member for guidance and direction. The practitioner will be identified as a volunteer by a medical manpower armband. The practitioner will be granted disaster privileges limited to one-week duration. If the disaster is of a critical nature, the situation will be reassessed within 72 hours and an extension of the disaster responsibilities may be authorized if warranted.

d. Provisional Privileges

(1) Provisional Privileges are time-limited privileges that may be requested by a provider when the provider has not fully met all criteria. Provisional privileges may be considered when:

(a) a provider has received initial training to perform a new procedure but has not fully developed the required technical skills;

(b) a provider has not met the required number of cases to be granted full privileges;

(c) a provider is new to the facility and the provider’s skill level is not known particularly for high risk / low volume procedures.

(2) Provisional privileges may be performed without direct supervision, however during this time the provider will practice under the direction of another provider with full privileges for those privileges granted as provisional. The fully privileged provider will monitor the performance of the provider with provisional privileges throughout the designated provisional period. The provider with provisional privileges will be expected to meet the competency requirements for full privileges before the completion of the provisional period.

1. In some situations, especially related to advances in technology of new procedures in the facility (e.g. robotic-assisted surgery), a fully privileged practitioner may not be available on site to provide direction to a provider with provisional privileges. In such cases, the Medical Executive Board will review a proposal from the requesting practitioner and/or Service Line to determine whether the Institutional Review Board and Human Studies Committee should regulate the procedure as research. Such proposals should include a summary of the procedure or technology, an assessment of its risks and benefits compared to other treatment options, and a justification for performance of the procedure.

(3) Upon recommendation from the sponsoring Service Line, the Medical Executive Board will review and determine whether the requirements for provisional privileges for each specific procedure have been met. In general, these requirements will include:

(a) The provider is fully privileged to perform standard procedures for the disease being treated; if applicable (e.g. a surgeon should be fully privileged to perform an open operation that corresponds to a minimally invasive surgical procedure).

(b) The provider received formalized training at another institution, if available.

(c) The Medical Executive Board will designate who should be assigned to monitor and report outcomes to assure patient safety.

(d) The Medical Executive Board will determine the number of cases to be performed by the provider to be eligible for full privileges that will be based upon the complexity of the procedure, experience of the provider with related procedures, and procedural risk profile.

(e) A contingency plan for management of complications will be presented.

(4) The Medical Executive Board may grant provisional privileges for a specified period of time that may range from 3 months but not to exceed 12 months. Provisional privileges up to 12 months may be needed in specialized areas when the caseload may be low to achieve competency within a shorter period of time.

e. Supervised Privileges

(1) Supervised Privileges are time-limited privileges that may not be performed independently by a provider and require the participation of another provider with full privileges during the delivery of care.

(2) Supervised privileges may be granted for a specified period of time from 6 months but not to exceed 26 months while a provider is learning how to perform a new procedure and/or developing a new skill. The level of supervision provided for supervised privileges will vary and will be determined on an individual’s case-by-case basis. The level of supervision may include one or more of the following:

1. direct hands-on training;

1. offering guidance or direction during performance of the procedure;

(3) Focused Professional Practice Evaluation will be conducted to assess competency for full privileges. Focused professional practice evaluation is a time limited process whereby the organization evaluates the privilege-specific competence of the practitioner who does not have documented evidence of competently performing the requested privileged at the organization. Information for focused professional practice evaluation may include chart review, monitoring clinical practice patterns, simulation, proctoring, peer review, and discussion with other individuals involved in the care of the patient (eg. consulting physician, surgical assistant, etc).

(a) The competency of the provider to practice independently will be assessed before the completion of the period of provisional or supervised privileges. The provider may voluntarily withdraw his or her request for privileges at any time during the provisional or supervised process without adverse action.

(b) Ninety days before the provider’s provisional or supervised privileges are due to expire, a formal reappointment review process will be initiated by the Credentialing Office. The Credentialing Office will send the provider documentation to apply for full privileges, initiate all of the requirements for reappointment (e.g. VetPro; hard copy documents), and complete the verification of credentials for reappointment as required by VA regulations.

(c) The provider with provisional or supervised privileges will summarize the details of cases performed to include outcomes and complications and a competency assessment will be conducted by the Service Line.

(d) The Service Line Vice President will review the provider’s summary and will provide a recommendation to the Medical Executive Board.

(e) The Medical Executive Board will provide a final determination of whether the practitioner is competent to be granted full privileges.

(4) If the focused professional practice evaluation identifies that the provider is unable to perform the procedure(s) independently, the provider may elect to withdraw the request for full privileges without incurring an adverse action.

(5) If the provider was unable to complete the number of required cases during the initial provisional or supervised period, an extension may be requested by the provider. An extension will be considered only if the provider concurs with provisional or supervised privileges during the extension period. The Service Line must concur with the extension and submit the request to the Medical Executive Board for approval.

(6) At the request of the practitioner, and with concurrence of the Service Line Vice President, the Medical Executive Board may increase the number of cases to be performed during the period of provisional or supervised privileges to provide additional educational opportunities for the practitioner.

(7) If the provider disagrees with the findings of the focused professional practice evaluation, an appeal may be filed for adjudication by the Chief of Staff of Designee.

(8) If concern for patient safety is raised at any time during the period of time that the provider has provisional or supervised privileges or following the appeal process, the provider’s full privileges will be denied and the action will be reported as a reduction or revocation of the privileges to the National Practitioner Data Bank.

(9) Noncompliance with any element of the provisional or supervised privileging process will be cause for review by the Medical Executive board and may result in suspension of provisional or supervised privileges. Suspension of provisional or supervised privileges is considered an adverse action and is reportable to the National Practitioner Data Bank.

E. Reappraisal / Re-privileging

1. Reappraisal

a. Reappraisal is the process of evaluating the professional credentials, clinical competence and health status (as it relates to the ability to perform the requested privileges) of practitioners who hold clinical privileges within the facility. Reappraisal for the granting of clinical privileges must be conducted for each practitioner at least every 2 years.

b. The reappraisal process will include the practitioner's statements regarding successful or pending challenges to any licensure or registration; voluntary or involuntary relinquishment of licensure or registration; voluntary or involuntary limitation, reduction or loss of privileges at another hospital; voluntary or involuntary loss of medical/affiliate staff membership; any evidence of an unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the applicant’s mental and physical status (as it relates to the ability to perform the requested clinical privileges) and any other reasonable indicators of continuing qualifications. Additional information regarding licensure/certification status; NPDB; FSMB; query peer recommendations; continuing education accomplishments and copies of clinical privileges held at other institutions will be secured for review.

c. General competencies include the following: patient care, medical / clinical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practices. Evaluation of professional performance, judgment, clinical and/or technical competence and skills are to be based on peer recommendations, data and ongoing professional practice evaluation. Peer recommendation will include information regarding the provider’s current medical / clinical knowledge, technical and clinical skills, clinical judgment, interpersonal skills, communication skills, and professionalism. Ongoing professional practice evaluation by the Service line may include, when applicable, information from surgical case review, infection control reviews, drug usage evaluations, medical record review, blood usage review, pharmacy and therapeutic review, morbidity and mortality data, monitoring and evaluation of quality, utilization, risk and appropriateness of care. The reappraisal process should include consideration of such factors as the number of procedures performed or major diagnoses treated, rates of complications compared with those of others doing similar procedures and adverse results indicating patterns or trends in a practitioner's clinical practice. The information used in the ongoing professional practice evaluation may be acquired through periodic chart review, direct observation, monitoring of diagnostic and treatment techniques and discussion with other individuals involved in the care. Relevant information obtained from ongoing professional practice evaluation is integrated into performance improvement activities. Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to review existing privilege(s), or to revoke an existing privilege prior to or at the time of renewal.

d. If a provider voluntarily allows clinical privileges to expire, the provider must submit a complete credentialing and privileging package to request clinical privileges.

2. Re-privileging

a. Requests for renewal of clinical privileges will be processed in the same manner as initial privileges. Individual participation in continuing medical education is required at the time of reprivileging. The medical center requirement for continuing education is 40 hours during a two-year reprivileging cycle or will be pro-rated if the cycle is less than two years. Please note that of the 40 hours CME, 20 hours Category I CME are required for physicians.

b. A recommendation from peers (appropriate practitioners in the same professional discipline as the applicant who have pursued knowledge of the applicant) reflects a basis for recommending the granting of…