hurley medical center professional staff policy...d. provide a letter of support from another hmc...

HURLEY MEDICAL CENTER

PROFESSIONAL STAFF POLICY

Title: Board Certification and Maintenance of Certification

Policy:

New Applicants: Effective January 1, 1999 all new Professional Staff members (Allied Health and Medical Staff) are required to be Board Certified within their specialty, or Board Eligible as prescribed by their Specialty Board. Board certification from one or more of the following shall be acceptable for meeting this requirement:

American Board of Medical Specialties (ABMS) American Board of Podiatric Medicine American Board of Foot and Ankle Surgery American Board of General Dentistry or Pediatric Dentistry American Board of Professional Psychology American Board of Nurses Credentialing Center National Coalition of Certification of Physician Assistants (NCCPA) American Board for Certification in Orthotics, Prosthetics & Pedorthics In lieu of an American Board, a physician may be certified by the Royal College of

Physicians & Surgeons of Canada (RCPSC)

Limited Grandfather. Those Medical Staff and Allied Health Staff Members that were appointed prior to January 1, 1999, remained a member of the Professional Staff, and who were not board certified as of that date shall be grandfathered and shall not be subject to the requirements of this policy. All such individuals shall be governed by the board certification requirements that were in effect at the time of their initial appointments to the Hurley Medical Center Professional Staff.

Requesting a Waiver/Exception: Process for requesting an exception to the Board Certification requirement. An individual applicant may not request a waiver of these requirements. Any current Medical Staff Member or HMC Vice President may request a waiver. The requestor bears the burden of demonstrating exceptional and unusual circumstances. The request must, at a minimum, satisfy the following:

a. Demonstrated community need for a particular specialty b. Demonstrated difficulty in recruiting a particular specialty c. Narrowly written exception specifying the reason for the request and

the reason why the requester believes that it is in the best interest of Hurley Medical Center patients to grant the request

d. Review and consideration by the applicable department e. Review and approval by the Credentials Committee f. Review and approval by the Medical Executive Committee

g. Review and approval by the Hurley Medical Center Board of Managers

Approved Waivers/Exceptions:

1. A Professional Staff Member is not required to become board certified as long as he/she remains board eligible in accordance with the expectations set forth by his/her applicable board,

2. Board certification requirements are waived for experienced physicians requesting privileges in the Department of Psychiatry, if all of the following are met:

a. Physician has completed an ACGME/AOA recognized residency training program in psychiatry.

b. In the last ten (10) years, physician has had at least two (2) years of experience in an inpatient/acute care psychiatric unit, and can provide a letter of recommendation confirming the experience.

c. Physician is able to satisfactorily complete all other Hurley Medical Center Professional Staff credentialing and privileging requirements.

Maintaining Certification. If board certification is required, failure to maintain board certification in accordance with the applicable board’s timeframes shall result in the following:

1. The Medical Staff Office will maintain a database with a Practitioner’s board certification information, as well as recertification and expiration dates.

2. Each Practitioner should make every attempt to notify his/her Department Chair and the Medical Staff Office that his/her board certification has or will lapse.

3. Notification to the Department Chair and Medical Staff Office should include the individual’s plan to become recertified within the timeframes specified by the Practitioner’s specialty Board. The Practitioner shall be eligible for an extension of six months or the next recertification testing date, whichever is longer. The plan will be reviewed by the Department Chair and clarified, if necessary, with the Professional Staff Member requesting the extension. As long as the Practitioner remains board eligible, he or she may request additional extensions, as needed.

4. However, if a Practitioner’s Board considers the Practitioner to be board eligible indefinitely, the Practitioner must submit the following with each request for an extension:

a. Documentation supporting CME participation during the previous six months b. If an Allied Health Practitioner, a letter of support from the Practitioner’s

Collaborating Physician and another member of the Medical Staff. 5. The Medical Staff Office will, at least quarterly, run reports identifying any

Practitioners whose board certification has lapsed. Information on lapsed certification will be reported to the Department Chair and Credentials Committee.

6. To be eligible for the extension, the Professional Staff member must: a. Have been an HMC Professional Staff Member for at least three (3) years;

and

b. Not currently be the subject of a peer review investigation, in a focused professional practice evaluation (FPPE), and have had no significant peer review issues identified during the prior twenty-four (24) months; and

c. Provide a letter from the appropriate certifying board confirming that the individual remains eligible to take the recertification examination and the date of the scheduled completion of the recertification examination; and

d. Provide a letter of support from another HMC Professional Staff Medical Staff member.

7. If approved, the request and plan will be submitted to the Credentials Committee, Medical Executive Committee, and HMC Board of Managers for review and consideration.

8. Failure to obtain re-certification within the specialty board’s timeframes will result in the automatic termination of Professional Staff membership and privileges. Professional Staff Membership termination for losing board eligibility following failure to obtain recertification shall not be appealable and the not subject to the Fair Hearing requirements set forth in the Professional Staff bylaws.

9. Waiver of Recertification Requirements in Unique Circumstances: a. Practitioners with Sub-Specialty Board. In the event that a Professional Staff

Member 1) has more than one board certification, 2) has had privileges at Hurley Medical Center for at least two (2) years, 3) currently practices a sufficient amount at Hurley to allow for adequate review of the Practitioners professional competency through the quality and peer review process, and 4) primarily practices in a subspecialty, then the Professional Staff Member may choose to allow his or her primary board certification to lapse. The Practitioner must notify the Credentials Committee through the Medical Staff Office so that the primary board certification can be closed in the Practitioner’s file and the Practitioner’s delineation of privilege form can be reviewed to confirm that privileges are limited to the subspecialty area.

b. Practitioners Notifying the Medical Staff Office of Retirement. In the event that a Professional Staff Member 1) notifies the Medical Staff Office of his/her intent to retire in no longer than five (5) years, 2) has had privileges at Hurley Medical Center for at least two (2) years, 3) currently practices a sufficient amount at Hurley to allow for adequate review of the Practitioners professional competency through the quality and peer review process, then the Professional Staff Member may, upon advance written notification to the Credentials Committee, choose to allow their board certification to lapse. The board recertification requirement waiver shall be in effect until the earlier of the timeframe specified by the Practitioner in his or her initial written request or the Practitioner’s voluntary retirement.

OUTSIDE PROCTORING

Purpose: To determine whether an individual not previously credentialed and privileged by

Hurley Medical Center is qualified and capable of serving as a Proctor for a Current Professional

Staff Member to become privileged for a new procedure or re-evaluated and re-trained for a

current privilege.

Definitions:

Current Professional Staff Member (“CPSM”): An individual that is currently an HMC

Professional Staff Member who either

1. has requested a new clinical privilege, the HMC Credentials Committee and Medical

Executive Committee determined that the CPSM must first provide evidence of

satisfactorily completing the clinical privilege under the supervision of a proctor, and the

CPSM cannot obtain evidence of the proctoring outside of Hurley Medical Center; or

2. has been requested by his/her Department Chair, Credentials Committee and Medical

Executive Committee to receive some additional proctoring in one or more clinical areas

or procedures.

Proctor: An individual who will assist in the training, evaluation and assessment of a current

HMC Professional Staff Member.

Proctoring: An objective and focused evaluation of a practitioner’s clinical competency.

Proctoring may include pre and post procedure assessment, patient selection, observation of

procedural skill, assessment of clinical judgment, etc.

Proctoring Levels:

1. General: The proctor’s presence is not required while the care activity is being

performed. This level of supervision is not used for proctoring procedures but may be

used to assess competency in management of care situations through a retrospective

review of documentation and/or discussion of cases.

2. Direct: The proctor is present in the area and immediately available. It does not mean the

proctor must be present in the room while the procedure is performed. This level of

supervision would rarely be used.

3. Personal: The proctor must be in attendance in the room while the care, activity or

procedure is provided or performed.

Policy:

A. In the event that Hurley Medical Center has approved a new clinical procedure (See

related policy on Clinical Privileges for New Procedures) and no other HMC Professional

Staff Member has been privileged to perform the particular clinical procedure, or no other

Professional Staff Member is willing and able to serve as a Proctor to the CPSM, and

Hurley Medical Center determines that it is in the best interests of its patients for another

Professional Staff Member to become qualified to perform the particular procedure,

Hurley Medical Center will conduct an appropriate assessment of the clinical competency

of an external Proctor to allow that Proctor to be present at Hurley Medical Center to

oversee, evaluate and train the current Professional Staff Member in performing the

procedure.

B. The expectations set forth in this policy and procedure describe the expectations for the

Proctor to be deemed qualified to serve in the role of a proctor. In order for the CPSM to

be deemed qualified to participate in the proctoring, he/she must still fulfill the separate

requirements set forth in the Clinical Privileges for New Procedures policy or the

expectations set forth by his/her Department, Credentials Committee and/or Medical

Executive Committee.

C. Proctoring may also be used for an individual Practitioner who is unable to meet the

competency measurement required as identified on the privilege form for a particular

procedure or for an individual practitioner whose clinical or technical skill needs further

assessment as determined by the Credentialing Committee/Medical Executive

Committee.

D. In accordance with the related policy on Clinical Privileges for New Procedures, the

Credentials Committee and Medical Executive Committee shall determine the following

before a CPSM may request the new privilege.

1. the type of proctoring level recommended

2. the number of cases, admissions or procedures

3. the duration of proctoring to be imposed

4. the method of proctoring.

E. The current Professional Staff Member is responsible for obtaining a proctor who is

acceptable to the Credentials Committee/MEC unless the Credentials Committee/MEC is

requiring a specific proctor for further assessment of clinical performance, in which case

a proctor would be assigned.

F. The expectations for the Proctor will vary based on whether or not the proctor will be

providing patient care.

a. Proctor Not Providing Patient Care: If the Proctor will not participate in the

diagnosis and treatment of the patient, and it will not be necessary or even

potentially necessary for the Proctor to intervene in the procedure on behalf of the

Current Professional Staff Member, the following must be provided:

b. Proctor Providing Patient Care: If it will be necessary for the Proctor to

participate in the diagnosis and treatment of the patient, or to potentially intervene

in the procedure on behalf of the CPSM, the Proctor must meet the minimum

requirements set forth below:

i. be licensed in the state of Michigan

ii. be credentialed at another hospital that is accredited by The Joint

Commission and privileged to perform the particular procedure that is

being proctored

iii. be willing to provide a letter from the Proctor’s home hospital, confirming

his/her qualifications, competence, and privileges

iv. meet any additional requirements set forth by the Credentials Committee

or Medical Executive Committee given the nature and risks of the

particular procedure to be proctored

v. Obtain temporary privileges in accordance with the Hurley Medical

Center temporary privileges policy

c. The CPSM must submit a plan, describing the extent of care to be provided by the

CPSM, the expected involvement by the Proctor, the consent form utilized to

inform the patient, and the plan in the event any complications arise

G. The CPSM Current Professional Staff Member shall be responsible for the cost of the

Proctor.

H. The Proctor must provide the CPSM with documentation sufficient to demonstrate to the

HMC Credentials Committee and Medical Executive Committee that the CPSM is

qualified and capable of performing the procedure independently after the proctoring

occurs.

I. The Proctor may not bill the patient for this service. The Proctor should, however, render

any emergency care to the patient for medical or surgical complications arising from the

care provided.

Procedure:

A. The CPSM shall submit the Proctor Request Form (Appendix A) to the Medical Staff

Office and must identify who will be serving as the proctor. The practitioner as well as

the proctor must sign the Proctor Request Form.

B. The Proctor will submit his/her delineation of privilege form with a letter signed by the

Proctor’s home hospital Chief of Staff within the last thirty days, demonstrating that

Proctor is capable for performing the procedure to be proctored and is a member in good

standing at a hospital credentialed by The Joint Commission. The Proctor will also

submit any other documents requested by the HMC Credentials Committee and Medical

Executive Committee based on the nature and risk of the procedure being performed.

C. The Credentials Committee and MEC will review the request for proctoring and

documentation submitted by the Proctor. If approved, the request will be submitted to the

Hospital Board of Managers.

Title: Leave of Absence Policy

Policy: This policy outlines the process for Hurley Medical Center Practitioner’s requests for a Leave of

Absence. This policy applies to any credentialed practitioner who plans to suspend their hospital

privileges for a period not less than three months and not more than one year. Leaves of absence for

periods of time outside these criteria will be considered on a case-by-case basis by the Medical

Executive Committee.

Procedure:

I. Requesting a Leave of Absence

A. All requests for leaves of absence must be in writing and submitted to the Medical Staff

Office and include the following:

1. A brief description of the reason for the leave;

2. Type of leave requested: Professional/ Educational/ Personal/ Medical/Military;

3. Date that the leave will begin and estimated length of the leave;

4. Contact information during the leave period;

5. Plan for patient coverage; and,

6. Signature and date on the request letter.

B. All written requests will be reviewed by the Practitioner’s Department Chair, Chief Medical

Officer, and Credentials Committee - whose recommendations will be forwarded to MEC

and to the Board of Managers for final approval and action.

II. During the leave of absence:

A. If already a member of the Professional Staff, the Practitioner will maintain membership on

the medical staff.

B. The Practitioner shall complete all unfulfilled responsibilities prior to the leave of absence.

C. The Practitioner will be responsible for annual dues and these must be paid during leaves of

absence unless waived by the Medical Executive Committee.

D. The practitioner will hold NO clinical privileges.

E. The practitioner is not required to maintain malpractice insurance

F. A leave of absence shall NOT suspend the disciplinary process.

III. Return from Leave of Absence:

A. At least forty-five (45) days prior to termination of the leave of absence, the Practitioner will

request reinstatement of his/her privileges, prerogatives and obligations by submitting a

written request to the Credentials Committee via the Medical Staff Office. The request for

reinstatement of clinical privileges will be processed and must be approved before the

Practitioner resumes work in the hospital. Expedited review and approval may be

considered (see Expedited Credentialing Policy).

B. The request for reinstatement shall include the following:

1. Written summary of activities during the leave of absence;

2. Documentation of current DEA and state pharmacy license;

3. Professional liability insurance;

4. Michigan Licensure;

C. The staff member shall submit a written summary of his or her relevant education and or

activities during the period of the leave of absence. Should the Leave of Absence extend

beyond a normal OPPE period (8 months), in addition to the specifications already

established in the Bylaws, the practitioner will need to undergo a period of focused review

(FPPE) in the event that the physician was not practicing in his specialty area during the

leave of absence.

D. Physicians returning from leave of absence following a medical leave of absence must

submit a written release from their physician that they are fit for duty/able to perform

his/her requested privileges, and specify any applicable restrictions. The Credentials

Committee reserves the right to request further documentation of fitness to perform the

privileges requested.

E. The Credentials Committee will review the request for reinstatement and forward their

recommendations on to the MEC and Board for final approval. In acting upon the request

for reinstatement the Credentials Committee and Medical Executive Committee may

recommend that the Board approve reinstatement either to the same or a different staff

category, and may limit or modify the clinical privileges to be extended to the individual. The

Board will notify the practitioner in writing of the final decision and recommendations as

determined by the Board and MEC.

F. Failure to request reinstatement or to provide the requested summary of activities shall

result in automatic termination of Professional Staff membership without a right of hearing

or appeal.

G. Proctoring may be required depending on the length of the absence, activity by the

Practitioner during the leave of absence, and specialty of the Practitioner.

IV. Reappointment During Leave Of Absence:

A. If the duration of the leave of absence extends beyond the Practitioner’s current full

appointment expiration date, he/she must complete full reappointment application and

requirements, requesting a conditional reappointment (membership only) and submit

to the Medical Staff Office according to the reappointment schedule.

B. If the Practitioner does not apply for a conditional reappointment and his/her

appointment and privileges lapse during the leave of absence, he/she will need to

reapply to the Professional Staff, submitting a new application for initial appointment,

including the initial application fee. This application must be processed and approved

before the Practitioner returns to work. A request for Professional Staff membership

and/or privileges subsequently received from a Practitioner previously terminated

pursuant to this Leave of Absence policy shall be submitted and processed in the same

manner as applications for initial appointment.

V. Extensions to Leaves of Absence: Appropriate documentation of reasons must be submitted to

the Credentials Committee. Requests for extension must be submitted and processed as

described in the first paragraph.

Title: Allied Health and Medical Staff Collaboration

Purpose: To outline the collaboration and supervision that must occur between an Allied Health and

Medical Staff member of the Professional Staff in the care of patients at Hurley Medical Center, as is

required by Michigan state law and/or the Hurley Medical Center Professional Staff Bylaws and

Professional Staff policies and procedures, as well as other applicable laws, regulations and third-party

payor guidelines.

Definitions:

Allied Health Professional (AHP): As defined in the Hurley Medical Professional Staff Center bylaws.

Collaborating Physician: A Physician Medical Staff member who has signed the Allied Health member’s

Practice Agreement, agreeing to the terms and conditions contained therein, and has agreed to provide the

supervision and oversight required in the Practice Agreement, in accordance with this policy and

applicable laws and regulations.

Direct Supervision: A physician who is in the hospital and immediately available to provide assistance

and direction. The physician providing direct supervision must have, within his or her state scope of

practice and hospital granted privileges, the knowledge, skills, ability and privileges to perform services

or procedure being supervised. Direct Supervision is not always required.

Medical Staff Professional: As defined in the Hurley Medical Center Professional Staff bylaws.

Practice Agreement: An agreement, signed by a Medical Staff Professional and an Allied Health

Professional, that complies with the Michigan Public Health Code and any additional requirements

deemed appropriate by the HMC Professional Staff.

Supervising Physician: May or may not be the same physician that signed the AHP’s Practice

Agreement. This is the physician that is responsible for overseeing the AHP, when required for clinical

or billing purposes, at the time that care is being provided to a specific patient. The nature and type of

supervision required (General or Direct) will vary based on the circumstances.

Policy:

1. AHPs are a valuable part of the Hurley Medical Center Professional Staff and key to Hurley

Medical Center fulfilling its mission. However, AHPs are considered dependent practitioners

when practicing at any Hurley Medical Center location and must practice within the limitations

set forth in the following:

a. state licensure

b. state scope of practice

c. Michigan Public Health Code

d. as outlined in the Hurley Medical Center Professional Staff Bylaws, Policies and

Procedures

e. individual AHP delineation of privilege forms

f. within the scope of delegation as set forth in the written expectations of the Practice

Agreement

2. All persons admitted to Hurley Medical Center shall be under the continuing daily care of a

physician licensed to practice in Michigan. A Medical Staff member of the Professional Staff

serving as an AHP’s Collaborating Physician may not delegate the ultimate responsibility for

the patient’s medical care or services to an AHP. The patient’s condition and reason for

admission shall determine the frequency and level of involvement by the Medical Staff

member.

3. The Collaborating Physician(s) will be responsible for the general supervision of the Allied

Health member. For the purposes of this policy, general supervision shall be defined as the

following:

a. Continuous availability of direct communication in person, , telephone or

telecommunication

b. Availability of physician on a regular basis to review practice of the PA

c. Participation in the review of the AHP’s practice, including but not limited to FPPE,

OPPE and reappointment.

4. Because the AHPs are acting as an agent of the Collaborating Physician, the AHP must also

agree to any additional standards that the Collaborating Physician may reasonably require.

5. If the AHP is acting in his/her capacity as an employee or contractor of Hurley Medical Center,

the Collaborating Physician is prohibited from billing or collecting for the services of the AHP,

and may not use the documentation of the AHP to support the professional billing of the

Collaborating Physician, unless a separate written agreement between Hurley Medical Center

and the Collaborating Physician, or Collaborating Physician’s group or employer, is in place.

Each individual submitting a claim is responsible for complying with applicable payor rules

regarding the documentation or supervision that may be required in support of the professional

bill. Hurley Medical Center shall be responsible for ensuring compliance with applicable

payor rules regarding the documentation or supervision that may be required in support of the

facility bill.

6. By signing the Practice Agreement, the Allied Health member and Medical Staff member shall

agree to the following:

a. The duties and responsibilities of the AHP and Collaborating Physician, including a

process between the AHP and the Collaborating Physician for communication,

availability and decision-making when providing medical treatment to a patient. This

process should use the knowledge and skills of both the AHP and the Collaborating

Physician, taking into consideration their respective education, training and experience.

In addition, it should include, but is not limited to, the level of supervision, as well as the

method and frequency of AHP and Collaborating Physician interaction (daily check in,

weekly record review, patient-specific calls, etc.)

b. The parties will Adhere to the requirements set forth in Michigan law and the HMC

Professional Staff Policy – Allied Health and Medical Staff Collaboration

c. The names and signatures of at least two alternative physicians who are willing and able

to consult in situations when the Collaborating Physician is not available.

d. A provision allowing the AHP or Collaborating Physician to terminate the Practice

Agreement by providing written notice at least 30 days before the date of termination.

e. Communication/Supervision

i. Patient record must demonstrate physician involvement daily as demonstrated by

documentation in the medical record.

ii. In all instances of admissions, discharges or clinical deterioration of patients, the

medical record must reflect communication with the collaborating physician.

f. Physician Responsibilities

i. Provide continuous availability of direct communication.

ii. Maintain responsibility for the care of any patient at all times.

iii. Participate and co-sign the following (admit orders, op-notes, procedure notes,

H&P, Discharge Summary, Consultations or others as directed by third party

payors)

iv. Delegate prescriptive authority, as defined in Delegation Agreement of

Prescribing Controlled Substances, if applicable

v. Review and evaluate practice/performance of Allied Health Practitioner on an

ongoing basis (FPPE/OPPE per hospital policy)

vi. Participate in the re-appointment evaluation of the Allied Health Practitioner

vii. Immediately notify the Medical Staff Office in the event of any changes in the

relationship between the Physician and Allied Health Practitioner.

viii. Be knowledgeable of the Allied Health Practitioners privileges, training,

experience and capabilities so as to provide appropriate supervision and never

delegate a task for which the Allied Health Practitioner is not capable of

performing.

ix. Review records of patients treated by Allied Health Practitioner, provide

consultation and education for the Allied Health Practitioner, and notify the

Medical Staff Office of any unresolved issues.

x. Reviewing and approval of the AHP’s delineation of privileges

g. Allied Health Practitioner Responsibilities

i. Adhere to the requirements set forth in Michigan law and the HMC Professional

Staff Policy – Allied Health and Medical Staff Collaboration

ii. Follow mutually agreed upon protocols and limitations set forth by the

Collaborating Physician(s)

iii. Be responsible for finding another Collaborating Physician in the event that the

Primary or any alternate physician refuse to serve as the Collaborative

Physician(s)

h. Physician and Allied Health Practitioner also agree to comply with State and Federal

Laws regarding the prescription of drugs, including controlled substances included in

schedules 2-5, and recognize the education, training, and experience in determining the

prescriptive responsibilities of the Allied Health Practitioner. Any prescriptive

restrictions for the Allied Health Practitioner are detailed in the Practice Agreement.

i. Any additional standards or requirements that the Collaborating Physician may

reasonably require to ensure that quality of care and safety of the patient.

j. Language in which both the Collaborative Physician and AHP acknowledge that failure

to adhere to the terms and conditions set forth in the Practice Agreement could result in

disciplinary action by the Hurley Medical Center Professional staff and applicable

Michigan licensing body.

k. The signatures of both the AHP and the Collaborating Physician(s).

7. The Practice Agreement should not include any duty or responsibility of the AHP or

Collaborating Physician that the AHP or Collaborating Physician is not qualified to

perform by education, training or experience and that is not within the scope of the license

held by the AHP or Collaborating Physician.

8. See separate policy on delegation of authority to prescribe medications, including controlled

substances, and providing complimentary starter doses.

9. See separate policy on the physician supervision required in order for Hurley Medical Center

to bill for its services.

Title: Maintaining Professional Liability Coverage

Policy:

Each Practitioner granted clinical privileges in the Hospital, shall, at all times, maintain professional

liability (medical malpractice) insurance in amounts, of a type, and with a carrier as required by the

Medical Executive Committee and Board of Managers.

As of the effective date of this policy, each Practitioner granted clinical privileges in the Hospital shall

maintain in force professional liability insurance in an amount not less than $200,000.00 per occurrence

and $600,000.00 in the aggregate, and shall be on an occurrence basis or, if on a claims made basis, the

practitioner shall agree to obtain tail coverage covering his/her practice at the Hospital.

In the event that Hurley Medical Center enters into a separate contractual relationship with a

Practitioner, physician group, professional corporation, etc., nothing in this policy shall preclude Hurley

Medical Center from requiring a Practitioner, physician group, or professional corporation to maintain

professional liability, or other coverages, in an amount higher than the minimum requirement set forth

in this policy.

Cancellation, lapse, reduction or other changes in the amount or scope of the Practitioner’s malpractice

insurance may result in the automatic suspension of all or part of the Practitioner’s clinical privileges as

outlined in the HMC Professional Staff Bylaws.

In addition, Practitioner agrees to indemnify Hurley Medical Center for any losses suffered by Hurley

Medical Center as a result of Practitioner’s failure to comply with the expectations set forth in this

policy.

TEMPORARY PRIVILEGES

Purpose:

To define when temporary privileges may be considered, criteria for granting temporary

privileges, and the rights and responsibilities of the Practitioner if and when temporary privileges

are granted or denied.

Policy:

1. Temporary clinical privileges must be approved by both the Chief of Staff and

President/CEO. Temporary privileges may only be considered in the following

situations:

a. Category One: In the event of an urgent patient care need, as long as the

Minimum Requirements (set forth below) have been submitted and validated.

The request must specify the urgent patient care need and the determination will

be made by the Chief of Staff or his/her designee in consultation with the

applicable Department Chair. Need will not be determined by the applicant or the

applicant’s employer or professional group.

b. Category Two: In the event that a full, clean application has been submitted, all

required validations have occurred, none of the exceptions noted in Procedure

Paragraph 2 below have been identified, and the Department Chair (or designee)

and Credentials Committee have already approved the application.

2. NOTE: Applicants with any of the following shall not be eligible for Temporary

Privileges in either Category One or Category Two:

a. Incident reported to the National Practitioner Data Bank in the last five (5) years

b. Any current or previously successful challenge to licensure or registration

c. Any involuntary termination of membership at another hospital or health care

facility

d. Any limitation, reduction, denial, or loss of clinical privileges

3. Temporary clinical privileges confer upon the recipient no membership on the

Professional Staff and give rise to no rights whatsoever under the Professional Staff

Bylaws.

4. Temporary clinical privileges are not automatically considered. Temporarily privileges

must be requested by the applicant, HMC administrative or Medical Staff leadership and

will only be approved in accordance with the Professional Staff Bylaws and this policy.

5. At all times, Practitioners who have been granted temporary privileges shall agree to and

be responsible for adhering to the policies of the hospital, the Professional Staff Bylaws,

and policies of the Professional Staff, including Focused Professional Practice Evaluation

(FPPE).

6. If the Practitioner’s license is not renewed, becomes revoked and/or restricted or if there

is cessation of appropriate liability insurance coverage, temporary privileges shall cease

immediately.

7. Disaster Volunteer Staff privileges are addressed in the Disaster policy.

8. Expedited Credentialing is addressed in the Expedited Credentialing policy.

9. Temporary privileges for applicants for new privileges are granted for no more than 120

calendar days from the day temporary privileges are first granted. Temporary privileges

shall automatically terminate at the end of the designated period unless affirmatively

renewed or earlier terminated.

10. On the discovery of any information, or the occurrence of any event of a nature which

raises a question about a Practitioner’s professional qualifications, ability to exercise

temporary privileges granted, or compliance with these Bylaws, the Chief of Staff,

responsible Department Chair, Chief Medical Officer, or Chief Executive Officer after

conferencing with the Chief of Staff or responsible Department Chair, may terminate any

and all of the Practitioner’s temporary privileges. In the event of a termination, the

Practitioner’s patients in the hospital shall be assigned to another Practitioner. The

wishes of the patient shall be considered, when feasible. The termination of temporary

privileges shall not be appealable.

11. There is no right to temporary privileges by virtue of meeting the Professional Staff

membership criteria. Category One temporary privileges shall not be granted unless an

urgent patient care need exists and the available information supports, with reasonable

certainty, a favorable determination regarding the requesting Practitioner’s qualifications,

professional competence and judgment.

12. Neither Category One nor Category Two temporary privileges should be granted unless

the available information supports, with reasonable certainty, a favorable determination

regarding the requesting applicant’s qualifications, ability and judgment to exercise the

privileges requested. If available information is inconsistent or casts any reasonable

doubts on the applicant’s qualifications, action on the request for temporary privileges

shall be deferred until the doubts have been satisfactorily resolved.

13. A determination to grant temporary privileges shall not be binding or conclusive with

respect to an applicant’s pending request for Professional Staff membership. A decision

to not process the application under this Temporary Privileges policy or the Expedited

Credentialing policy shall not be appealable.

14. If an applicant requests and qualifies for temporary privileges, the HMC Hospital Board

of Managers authorizes the Chief of Staff (or designee) and CEO (or designee), with the

written approval of the Department Chair, to grant temporary privileges to a qualified

Practitioner under the circumstances and subject to the conditions set forth below. If the

applicant is granted temporary privileges, his/her application must still follow the full

review process, as outlined in the HMC Professional Staff Bylaws, Policies and

Procedures.

Procedure: 1. Unless rare and extenuating circumstances exist, requests for Temporary Privileges must

be made a minimum of five (5) full working days (Monday – Friday) in advance of the

date temporary privileges will be needed in order to allow for the required verifications to

take place. A written request must be submitted to Medical Staff Office, Monday through

Friday, 8:00 a.m. to 4:30 p.m.

2. For Category One temporary privileges, a letter describing the urgent patient care need

must be submitted, and signed by either the Department Chair or Chief of Staff and either

the Chief Medical Officer or Chief Executive Officer.

3. Minimum Requirements

a. for Category One

i. Completed Urgent Patient Care Need application

ii. Curriculum Vitae (CV)

iii. Copy of Current State of Michigan Practitioner License

iv. Copy of Current State of Michigan Pharmacy License (if applicable)

v. Copy of Current Professional Liability Insurance Certificate

vi. Copy of Board Certification

vii. Copy of Current DEA Certificate

viii. Copy of Current TB Skin Test (less than 1 year old)

ix. Delineation of Privileges form and case logs, if applicable

x. Signed Release from Liability Form

xi. Signed Collaboration Agreement & DEA Delegation Agreement (if

applicable)

xii. Reference evaluation from a department or section chair at the hospital

from which the practitioner was most recently appointed or reappointed,

the most recent supervising/collaborating physician or in the event of a

recently graduated student, resident or fellow, from their training director.

xiii. NPDB, LARA, AOIA or AMA Profile, Board Certification and OIG/SAM

validations

b. For Category Two: A full application and all required documentation must have

been submitted by the applicant and validated by the Medical Staff Office.

4. In addition to the Non-Refundable Application Fee of $200, the fee for processing

applications with a request for temporary privileges will be $300.00 payable at the time

the Request for Temporary Privileges is submitted.

5. The Department Chair, Chief of Staff, Credentials Committee and Chief Medical Officer

have the discretion to determine if additional information is necessary prior to granting

temporary privileges. Such information may include, but not be limited to: case

summaries or other documentation regarding performance of specific procedures, and

reference(s) from additional peers.

EXPEDITED CREDENTIALING Purpose: To ensure the timely processing of applications for appointment/reappointment and granting of privileges to the Practitioners applying for membership and/or privileges at Hurley Medical Center. Policy: This policy applies to all Practitioners as defined in the Hurley Medical Center Professional Staff Bylaws who fulfill the criteria for expedited credentialing and privileging. Policy:

A. Each application and request for clinical privileges shall be reviewed and assessed by the following:

a. Medical Staff Office personnel b. Department Chair and Section Chair, if appropriate c. Credentials Committee d. Medical Executive Committee e. Board of Hospital Managers

B. In the event that the Practitioner requests expedited review and the Medical Staff Office, Department Chair, Credentials Committee and Medical Executive Committee determine that the application and request for clinical privileges meets criteria to be expedited, the application and request for clinical privileges may be expedited.

C. In the event that the Medical Staff Office, Department Chair, Credentials Committee or Medical Executive Committee decide that the application does not qualify for expedited review, the application will be processed under the normal timelines and the Practitioner may not appeal.

D. Initial applications for appointment and requests for clinical privileges may be processed as expedited when the following criteria are met: 1. A complete application is received; 2. All primary source verifications are received; 3. There is no current challenge or previously successful challenge to licensure

or registration; 4. The applicant has not received an involuntary termination of medical/allied

staff membership at another organization; 5. The applicant has not received involuntary limitation, reduction, denial, or loss

of clinical privileges; or 6. The hospital determines that there has not been either an unusual pattern of,

or an excessive number of professional liability actions resulting in a final judgment against the applicant.

7. The Department Chair, Credentials Committee and Medical Executive Committee have all reviewed and approved the application.

A. Reappointment applications and requests for clinical privileges may be processed as expedited when the following criteria are met:

a. During the past two years: i. There are no new pending malpractice claims;

ii. There is no record of judgments against the practitioner and/or monetary settlement(s) on pending claims.

b. There are no licensure restrictions. c. There are no indications of investigations or potential problems. d. Information has been returned in a timely manner and contains nothing

that suggests the practitioner is anything other than qualified in all areas. e. Practitioner-specific profile indicates that performance has been

satisfactory in all areas (clinical practice, quality of care, behavior, etc.) f. There are no identified health problems that would affect the practitioner

performing the privileges requested. g. There are no disciplinary actions or sanctions since time of last

appointment/reappointment. h. The Department Chair, Credentials Committee and Medical Executive

Committee have all reviewed and approved the reappointment application.

B. Medical Staff Office personnel shall process the initial or reappointment application, obtain all documentation and verifications, assess the application, and recommend expedited processing if expedited processing is requested and all criteria is fulfilled.

C. Applications and Requests for Clinical Privileges shall be forwarded to the appropriate Department Chair (and Section Chair, if appropriate) for review and recommendation to the Credentials Committee. The Department Chair shall review the application and request for clinical privileges to ensure it fulfills the established standards for membership and clinical privileges.

D. If approved by the Department Chair, the application and request for clinical privileges shall be presented to the Credentials Committee for review and recommendation.

E. If the Credentials Committee recommends continuation as an expedited application, the application and request for clinical privileges shall be presented to the Medical Executive Committee for review and recommendation.

F. If the Medical Executive Committee recommends approval for expedited processing, the Chair of the Medical Executive Committee shall sign the request and forward the application and request for clinical privileges to the two (2) voting members of the Board of Hospital Managers authorized to review requests for expedited review.

G. The Board of Hospital Managers has designated the Board Chair and the Quality & Accreditation Committee Chair as the two (2) members (“Members”) authorized to review and approve an expedited application and clinical privileges on behalf of the Board of Managers. In the event that both Members approve the application and clinical privileges, the Practitioner may begin exercising those clinical privileges at that time. If both Members do not agree, the application and request for clinical privileges must be presented to the full Board of Managers and the Practitioner may not begin exercising clinical privileges until the full Board of Hospital Managers makes its decision.

H. If the Members approve as expedited, the full Board of Managers shall review and ratify all appointments and/or reappointments at its next regularly scheduled

meeting. The approval date shall be the date when the appointment, reappointment or privileges received expedited approval by the Members. In the event that the full Board of Managers does not ratify the appointment or reappointment, the Practitioner shall be afforded his or her appeal rights as set forth in Article V of HMC Professional Staff Bylaws.

TELEMEDICINE (TELEHEALTH)

Definitions:

1. Telemedicine: the use of an electronic media to link patients with health care professionals in

different locations. The health care professional must be able to examine the patient via a real-

time, interactive audio or video, or both, telecommunications system and the patient must be

able to interact with the off-site health care professional at the time the services are provided.

2. Non-simultaneous: involves after-the-fact interpretation or assessment (such as teleradiology)

3. Simultaneous: involves real time interpretation or assessment (such as tele-ICU or tele-

Psychiatry)

4. Originating Site Hospital: the hospital or entity where the patient receiving the Teleheath

services is located.

5. Practitioner: as defined in HMC Professional Staff Bylaws

6. Distant Site Hospital: a Medicare-participating hospital that provides the practitioner who is

providing the Telemedicine services.

7. Telehealth: the use of electronic information and telecommunication technologies to support

or promote long-distance clinical health care, patient and professional health-related education,

public health, or health administration. Telehealth may include, but is not limited to,

telemedicine.

Policy:

In order to provide a broad range of high quality, safe and efficient care to its patients, Hurley Medical

Center may provide some services via Telehealth. The Hospital Board of Managers, after receiving

feedback from the CEO, Chief Medical Officer, and Chief of Staff, shall have the ultimate authority to

determine which services, if any, would be appropriately provided via Telehealth.

Once a determination is made that certain services will be provided via Telehealth, the CEO, working in

collaboration with the Chief Medical Officer and Chief of Staff, and taking into consideration the nature

and risk of the services being performed, including but not limited to whether the Telehealth services

are Simultaneous or Non-Simultaneous, will determine whether Hurley Medical Center may rely on the

credentialing and privileging performed at the Distant Site Hospital, or if Hurley Medical Center will

credential and privilege each Practitioner individually.

In the event that the CEO makes the determination that Hurley Medical Center may rely on the

credentialing and privileging performed at the Distant Site Hospital, all of the following must be in place

before a Practitioner may provide Telehealth services to Hurley Medical Center patients.

1. The Distant Site hospital is a Medicare-participating hospital

2. All of the Practitioners providing Telehealth services are credentialed and privileged by the

Distant Site Hospital.

3. Each practitioner has a license to practice in the state of Michigan.

4. A written agreement, complying with applicable regulatory requirements, is in place between

Hurley Medical Center and the Distant Site Hospital. The written agreement includes the

following requirements:

a. The Distant Site Hospital will share the Practitioner’s performance review information, if

requested.

b. At the Distant Site Hospital, all credentialing and privileging expectations set forth in the

Medicare Conditions of Participation and the The Joint Commission standards are being

met.

c. Hurley Medical Center will receive a copy of each Practitioners delineation of privilege

form, current Michigan license, and latest appointment letter.

d. Language specifying that the Distant Site Hospital must immediately notify Hurley

Medical Center of any change in privileges or status of a Practitioner providing

Telehealth services to Hurley Medical Center

e. Language confirming that the credentialing and privileging policies, procedures and

practices at the distant site comply with the Medicare Conditions of Participation and

The Joint Commission standards.

f. Language confirming how the Distant Site Hospital and Originating Site Hospitals will

work collaboratively for the ongoing evaluation of the Practitioner.

g. Language stating that the Distant Site Hospital has notified each Practitioner of the

following, and has received acknowledgement of same:

i. Practitioner may be subject to additional privileging requirements by HMC

ii. Practitioner will no longer be eligible to provide Telehealth services in the event

that the contract between HMC and Distant Site Hospital is terminated

iii. HMC may request that Practitioner be prevented from providing Telehealth

services to HMC patients and Practitioner will not be eligible under the HMC

Professional Staff Bylaws to appeal.

iv. In the event that Practitioner resigns or is terminated from Distant Site Hospital,

his/her ability to provide Telehealth services at HMC shall automatically and

immediately terminate, without a right of appeal

h. Indemnification, risk sharing, and liability insurance language as approved by HMC legal

counsel.

5. Any other requirements that may be specified in the Medicare Conditions of Participation or The

Joint Commission standards at the time the agreement is signed.

Effective Date: July 7, 2009 Bulletin No. 6305

Distribution Date: July 7, 2009 Page 1 of

13

Revised: January 30, 2015

Hurley Medical Center Standard Practice COMPLETION OF MEDICAL RECORDS

Supersedes Bulletin Dated: July 7, 2009

Distribution: All Departments

Originating Department: Health Information Services

____________________________________

Melany Gavulic, President and CEO

POLICY: It shall be the policy of Hurley Medical Center that attending physicians

shall complete all inpatient and outpatient medical records within 28 days

of the patient’s discharge, in accordance with Medical Staff Bylaws, Rules

and Policies.

It shall be the policy of Hurley Medical Center that house staff physicians

shall complete all medical records within 7 days after the record has been

posted to the resident’s file.

It shall be the responsibility of Hurley Medical Center’s Administrative

and Medical Staffs to ensure that this policy is carried out. It shall be the

responsibility of the Health Information Services Department to report

delinquent record status in accordance with established procedures and

support enforcement with the weekly Temporary Off Staff list.

PROCEDURES:

1. All records will be available through EPIC for completion by the

attending physician or the house staff physicians.

a. Records that house staff physicians have not completed will be

given to the attending physician for completion.

2. Assistance to physicians in completing medical records or in using

EPIC is available upon request. Please call Health Information

Services Department.

a. Please reference Exhibit A for required Medical Record

Documentation

3. Health Information Services personnel will routinely report

delinquent record status associated with attending and house staff

physicians. Detailed procedures are maintained in Health

Information Services.

4. Compliance with this policy by a Medical Staff Member shall be

implemented by the Delinquent Medical Records Policy.



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____________________________________


5. Compliance with this policy by house staff shall be governed by

house staff policies.



13






____________________________________


Exhibit A

Required Medical Record Documentation

Face Sheet

Demographic information is entered at time of patient admission as follows, if

available:

Patient name, social security number, address, phone number, sex,

race, age, birthdate, marital status, religion, church

Next of kin, address, phone number, relationship

Emergency Contact, address, phone number, relationship

Patient employer, occupation

Responsible party, relationship, employer, address, phone number,

social security number

Insurance information

Coded Diagnosis Sheet

The coded diagnosis sheet shall include:

All pertinent diagnosis(es), including complications, which can be

coded using ICD-10-CM

All operative procedures, including invasive diagnostic procedures

which can be coded using ICD-10-PCS and/or CPT in accordance

with coding guidelines.

Emergency Room Report

All reports shall be completed within a timely manner.

It is recommended that the Emergency Room Report be completed

immediately following the conclusion of treatment.



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____________________________________


Note the following when completely Emergency Room Records:

o Clinical appropriateness

o Standard of care to support patient’s visit to the ER

History: including how, when and where an injury

occurred or when symptoms first appeared.

Physical Findings: including the site and

approximate extent of lacerations; site, degree and

percent of body surface burns.

Management: treatment given including anesthetic

used, if any, and number and type of sutures,

injections, shots, dressing or cast application.

Diagnostic Test Ordered: include the specific

(diagnostic x-ray/lab/cardio) test ordered and

results.

Diagnosis: including specific detailed diagnosis,

state medical condition or site, including right, left

or bilateral; state type of trauma or injury, such as

abrasion, contusion, concussion, lacerations, etc.

When a patient is pronounced DIE or DOA in the Emergency

Room, the physical findings which established the diagnosis

should be included in the record.

History and Physical Examination

A clinically pertinent medical history and physical examination

must be completed and documented for each patient no more than

30 days before or 24 hours after admission or registration, but prior

to surgery or a procedure requiring anesthesia services.

The medical history and physical examination must be completed

and documented by a physician, or oral-maxillofacial surgeon, or

other qualified licensed individual in accordance with State law

and hospital policy.



13






____________________________________


An updated examination of the patient, including any changes in

the patient’s condition, must be completed and documented within

24 hours after admission or registration, but prior to surgery or a

procedure requiring anesthesia services, when the medical history

and physical examination are completed within 30 days before

admission or registration.

The updated examination of the patient, including any changes in

the patient’s condition, must be completed and documented by a

physician, or an oral-maxillofacial surgeon, or other qualified

licensed individual in accordance with State law and hospital

policy.

Failure to complete the History and Physical as noted above may

result in cancellation of the procedure unless the physician states in

writing that such as delay would be detrimental to the patient.

If such is stated, the History and Physical is to be completed within

24 hours of the emergency procedure as documented by the

physician. (These provisions should be waived in extreme

emergency, but a preoperative diagnosis shall be recorded in the

medical record and a physical completed within 24 hours post-

procedure).

The history and physical of each inpatient shall include, at a minimum, the following:

1) Identification data – at least two patient identifiers

2) Chief complaint or reason for admission

3) History of the present illness

4) Pertinent medical and surgical history

5) Medications with current dosages

6) Allergies / sensitivities

7) Pertinent social history and family history

8) Review of systems pertinent to reason for admission

9) Physical Exam pertinent to reason for admission

10) Results of pertinent diagnostic studies leading up to admission

11) Conclusion/impression/diagnostic considerations



13






____________________________________


12) Plan of care

Readmission Note

An interval Readmission note may be recorded as the History and

Physical, if a complete history and physical has been recorded and

a physical examination performed within 30 days prior to the

patient’s current admission to the hospital for the same or related

condition.

Readmission note shall include:

o Pertinent additions to the history;

o Subsequent changes in physical findings;

o Statement patient was re-examined and chart reviewed.

Admit Note

Contains sufficient history, physical findings, and enough

documented medical complexity to support the need for care to be

rendered on either an inpatient or observational basis.

o For acute care admissions the documentation must also

support the need for a stay that will likely span two

midnights.

o Additionally, the physician must be sure that there is an

appropriate admission order, as well as the necessary

certification required for inpatient admission.

o The admit note may be used as the History and Physical if

the History and Physical contents are present.

o An admitting note is required at the time of the acute

hospital admission, unless the History and Physical have

already been completed.

o While a complete History and Physical by the attending

physician is preferred, if all elements of the History and

Physical are documented elsewhere in the record in a single

source, indications that the record is being used for a



13






____________________________________


History and Physical and that the attending is in agreement

must be included in the admit note for the previous

documentation to be considered in a History and Physical.

Consultations

A consultation report shall be completed within the timeframes

specified for consultation. If the consultation report is dictated, a

consultation note e including the consultant’s impression and plan

of treatment must be documented in the notes.

o Consultation Types: Urgent and Routine

Urgent consults shall be expected to be done as

soon as possible but not greater than 12 hours.

When accepting orders for urgently needed

consultations on seriously ill patients, the attending

physician must contact the consultant to ascertain

his/her availability and to explain the urgent nature

of the patient.

Routine consults shall be expected to be done

within a 24-hour period.

o Consultation Categories: The attending physician must

specify on the patient chart which of the three following

consultation categories is applicable.

Consult only (examine the patient and provide an

opinion and advice).

Consult and assume care of the patient.

Consult and assist in the management of the illness.

Note: when completeing a consult or

management order, identify the name of the

physician to perform the service rather than

the physician or group to which they belong

(i.e. GI, Pulmonary). Notwithstanding the

foregoing, a physician may specify a



13






____________________________________


particular Physician or his/her designee to

participate in the consultation or

management of a patient, as above.

Note: If the category is note designated, the

default shall be “consult and assist” in

management of the illness.

o Consultations shall be dictated or handwritten only during

downtimes

o Consultations content shall include:

Date and time of reply

Notification that the patient was examined and

medical record reviewed

Physical examination: except in cases involving

emergency surgery; consultation, when indicated,

must be recorded prior to surgery.

Impression

Recommendations

Authentication (signature)

Note: When a full consultation report is

dictated, a brief consultation shall be

documented on the Consultation Record

immediately following examination and

shall include: presumptive diagnosis (es),

pertinent findings and recommendations.

Except in an emergency, consultation with another

qualified physician is required in:

Amputations above the mid-

metacarpal/tarsal level

Cases in which, according to the judgement

of the physician or dentist:

o Patient is not a good risk for

operation or treatment



13






____________________________________


o Diagnosis is obscure

o There is doubt as to the best

therapeutic measures to be utilized

o All cases of critical illnesses or

severe complications

Cases when services needed are outside of

the attending’s clinical privileges

All premature infants:

o Under four (4) pounds

o Suffering from infections

o Those who fail to gain in one week

Record of Operation and Reports of Other Invasive Procedures

Required for:

o An operative/procedure report is required for operative or

other procedures involving anesthesia or conscious

sedation.

o Reports of operative and invasive procedures must be typed

o or dictated immediately following the procedure.

o A post-operative progress note about the procedure(s) is

entered immediately in the medical record to briefly

describe the pre-operative and post-operative diagnosis(es),

procedure(s), findings, specimens removed, complication

(if any), estimated blood loss, and name of

surgeon(s)/assistant(s).

Contents, as applicable:

o Patient Identification

o Date of Procedure(s)

o Primary Surgeon/Assistant(s)

o Pre-operative Diagnosis(es)

o Post-operative Diagnosis(es)

o Description of procedure(s) performed, to include:



13






____________________________________


Specific procedure(s) or technique(s) employed

Nature of specimen(s) removed and sent to

Pathology

Estimated blood loss

Condition of patient upon leaving the operating

room


The document must be signed AND dated

by the author, or if dictated by a medical

student or resident must also be signed by

the attending/supervising physician.

Progress Notes

Frequency

o Daily progress notes shall be documented for all patients as

evidence that the patient is under the care of a physician in

an acute care setting.

Content

o Pertinent chronological documentation of the patient’s

course in the hospital showing change in the patient’s

condition and the result of treatment

o A statement of the patient status, whether improved,

unchanged, repression, etc.

o Any pertinent x-ray or laboratory data, physical findings or

addendum to history of present illness.

o Current assignment

o Be legible

o Dated/timed/signed by author

o To document an omitted note the caregiver should date the

note and indicate that his/her observations reflect the

condition of the patient on the previous date.



13






____________________________________


Note: progress notes are required if a patient signs

his/her own release prior to being seen by the

attending physician, except it must be stated that the

patient signed his/her own release against medical

advice.

Paramedic Record

Allied Health Professional Staff shall be allowed to write and sign

progress notes in the progress record. The person making the entry

shall sign each progress note, the signature to include either his/her

professional initials or title.

Orders

Orders for treatment shall be in writing or electronically entered as

authored by the physician. All previous orders are canceled when

patients go to surgery or enter/leave the Special Care Units.

Following surgery or transfer to/from Special Care Units, new

orders need to be entered in the EMR and shall include any order

by authorized house staff member and those individuals who have

been assigned independent practice privileges.

Daily orders such as laboratory, diagnostic imaging and EKGs

must be renewed every three days.

Telephone or verbal orders may be accepted and transcribed by the

following qualified individuals:

o Registered Nurse

o Physician Assistant

o Pharmacist

o Other allied health professional within their scope of

practice as delineated by the Medical Staff Credentialing

Committee.

Telephone, verbal, standing or protocol orders are recommended to

include:



13






____________________________________


o Order (Designate TO=Telephone order; VO=Verbal orders;

SO= Standing orders; PO=Protocol order)

o Physician Name giving order (at a minimum shall include)

First initial and last name/credentials of physician

(MD/DO).

Date and time order was given; and

Individual’s name taking and recording the order (at

a minimum shall include first initial and last

name/title).

o Telephone, verbal, standing or protocol orders shall be

signed at the next patient encounter by the authorizing,

supervising or legal partner physician.

o Standing or protocol orders are individualized for patient

care specifically initiated by the Medical Staff.

Discharge Summary

May be typed or dictated

A discharge summary is required for:

o Patients who stay greater than two (2) calendar days

o Expirations

o Complicated Deliveries

o Complication Deliveries

o Newborn with Complications

o Transfers


o The document must be signed AND dated by the author or

his legal partner, or if dictated by a medical student of

resident must also be signed by the attending/supervising

physician.

Contents shall include

o Patient identification

o Attending physician



13






____________________________________


o Admission/Discharge date

o Reason for hospitalization

o Significant findings including pertinent clinical/diagnostic

findings

o Treatment course, including procedures performed

o Patient’s condition at discharge

o Instructions to the patient and family (if any)

For newborns with uncomplicated deliveries, or for patients

hospitalized for two (2) calendar days or less, a progress note may

be substituted for the discharge summary. The progress note,

which may be typed or dictated, documents the patient’s condition

at discharge, discharge instructions, and required follow-up care.

Effective Date: July 7, 2009 Bulletin No. XXXX

Distribution Date: July 7, 2009 Page 1 of 3

Revised Date: October 2, 2012

Hurley Medical Center

Standard Practice

MEDICAL STAFF DELINQUENT MEDICAL RECORDS

Courses of Action Policy for Implementation of Medical Staff Bylaws & Rules

Supercedes Bulletin Dated: July 7, 2009

Originating Department: Medical Staff Office, Health Information Services

.

Melany Gavulic, RN, MBA, President and CEO

POLICY: Medical Staff members are required to complete their medical records

within 28 days of the patient’s discharge. In the event that the Medical

Staff member does not have the medical record completed within this

period of time, he/she will be denied the exercise of clinical privileges in

the Hospital until the records have been completed. Physicians on the

temporary off staff list cannot admit patients, perform consultations or

schedule inpatient/outpatient surgical procedures. If delinquency continues

thereafter, sanctions may apply. The Epic In-Basket will be the official

delinquent record notification. As a courtesy, physicians will be notified

based on their preferred preference of communication.

PROCEDURE:

1. When the record is incomplete 7 days post discharge, the member

will be reminded to complete his/her incomplete records via a

notification in their Epic In-Basket and their preferred method of

notification.

2. When the record is incomplete 14 days post discharge, the member

will be sent a second reminder via a notification in their Epic In-

Basket and their preferred method of notification. The department

chair, program director, and service line administrator will also

receive a notification.

3. When the record is incomplete 21 days post discharge, the Member

will be sent a third reminder via a notification in their Epic In-

Basket and their preferred method of notification indicating that if

the records remain incomplete as of the 28th day after discharge,

his/her clinical privileges will be automatically temporarily

suspended. The department chair, program director, and service

line administrator will also receive a notification, as well as the

Chief of Staff, Chief Medical Officer and Chief Quality Officer.

4. If the Member has not completed the records by the 28th day after

discharge, the Member’s clinical privileges will be suspended on





Standard Practice





.


that day as confirmed by Suspension for Delinquent Records 28

Days Post Discharge Notification advising that:

(i) the Member’s medical records remain incomplete even

through it has been more than 28 days since discharge;

(ii) the Member’s clinical privileges are automatically

suspended so that the Member will not be able to exercise

clinical privileges until the records are completed; and

(iii) a referral will be made to the Medical Executive

Committee for further action if the delinquent records are

not timely completed.

The department chair, program director, and service line administrator will

also receive a notification, as well as the Chief of Staff, Chief Medical

Officer and Chief Quality Officer. Additionally, the Chief of Staff or

Chief Quality Officer will personally contact the physician notifying

him/her and he/she has been temporarily suspended due to their medical

records remaining incomplete after 28 days post discharge. The list of

physicians temporarily suspended will also be sent to the CEO, Admitting,

ER, Nurses Stations, the Operating Room suite and Risk Management.

5. When a physician is placed off staff, their delinquency status will

be checked daily. If a physician declines a record in their Epic In-

Basket, those records will be reviewed by the Health Information

Coordinator and if assigned to another physician, the notification

process will begin as usual.

6. Upon completion of all medical records in the Epic In-basket since

the time the member was placed temporarily off staff, the Health

Information Coordinator will inform the Member, Chief of Staff,

Chief of Quality, Admitting, ER, Nurses Station, and Risk

Management that the clinical privileges are reinstated.





Standard Practice





.


7. If records continue to be delinquent more than 7 days after the

temporary suspension the matter will be referred by the Chief

Medical Information Officer and the Chief of Staff (or the Chief of

Quality as alternate) to the Medical Executive Committee for a

recommendation to the Board of Hospital Managers for permanent

suspension. If you are deemed permanently off staff (suspended)

by the Board of Hospital Managers, according to the Bylaws, there

is no appeal process.

8. Every Member is deemed to know and understand the requirement

to timely complete medical records. In general, the giving of

notices under this policy is a courtesy to the Member and not a

prerequisite to Member compliance. In this respect, the failure of

Hospital staff to provide notice to a Member via their preferred

method of communication, shall not be an excuse for non-

compliance with the requirement that medical records be

completed within 28 days of discharge. However, this policy

provision does not excuse Hospital staff members of their

obligation to endeavor to comply in good faith with the notice

provisions of this policy.

9. Any duty of the Chief of Staff under this policy may be performed

by the Chief of Quality.

Effective Date: 4/11/2017 Bulletin No.

Distribution Date: 4/11/2017 Page 1 of 3

Hurley Medical Center Standard Practice

Organization of Departments and Sections

Supersedes Bulletin Dated: NEW


Originating Department: Medical Staff Office

____________________________________


POLICY: In accordance with the HMC Professional Staff Bylaws, Article VII, the Departments

and Sections have been designated as specified in Exhibit A. Any additions, changes or

deletions shall be made in accordance with the HMC Professional Staff Bylaws and following

approval by the Medical Executive Committee and Board of Hospital Managers.








____________________________________


EXHIBIT A

ORGANIZED DEPARTMENTS AND SPECIALTY AREAS

To promote efficiency and coordination among the various branches and specialties, the services

shall be divided into the following Departments and Sections.

Department of Anesthesia

Department of Emergency Medicine

Department of Medicine

o Allergy

o Cardiology

o Critical Care

o Dermatology

o Endocrinology

o Family Practice

o Gastroenterology

o Geriatrics

o Hematology

o Infectious Diseases

o Internal Medicine

o Nephrology

o Neurology

o Palliative Care

o Physical Medicine and Rehab

o Pulmonary Diseases

o Rheumatology

o Sleep Medicine

Department of Obstetrics & Gynecology

Department of Pathology

Department of Pediatrics

o Adolescent Medicine

o Allergy/Immunology

o Cardiology

o Critical Care








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o Gastroenterology

o General Pediatrics

o Hematology/Oncology

o Infectious Diseases

o Metabolism/Endocrinology

o Neonatology

o Nephrology

o Neurology

o Physical Medicine & Rehab

o Sleep Medicine

Department of Psychiatry

Department of Psychology

Department of Radiation Oncology

Department of Radiology

o Diagnostic Radiology

o Nuclear Medicine

o Interventional Radiology

Department of Surgery

o Bariatric Surgery

o Cardiothoracic Surgery

o Dentistry and Oral Surgery (oral/maxillofacial)

o General Surgery

o Hand Surgery

o Neurosurgery

o Ophthalmology

o Orthopedic Surgery

o Otolaryngology

o Pediatric Surgery

o Peripheral Vascular Surgery

o Plastic/Reconstructive Surgery

o Podiatry

o Trauma

o Urology

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