the children's medical center - Dayton Children's Hospital

DAYTON CHILDREN'S HOSPITAL OF DAYTON PROFESSIONAL STAFF
POLICIES AND PROCEDURES Draft 8/96 Bylaws Committee Approval 2/97
Professional Staff Approval 6/2/97
Approved - Board of Trustees 6/17/97
Approved - Board of Trustees 5/15/98
Approved - Board of Trustees 3/16/99
Approved - Board of Trustees 6/3/99
Approved - Board of Trustees 9/21/99
Approved - Board of Trustees 1/18/00
Approved - Board of Trustees 3/21/00
Approved - Board of Trustees 3/18/03
Approved - Board of Trustees 5/2/03
Approved - Board of Trustees 6/17/03
Approved - Board of Trustees 1/20/04
Approved - Board of Trustees 11/16/04
Approved - Board of Trustees 6/21/05
Approved - Board of Trustees 12/23/05
Approved - Board of Trustees 3/14/06
PSEC Review 4/10/06
Approved - Board of Trustees 1/16/07
Approved - Board of Trustees 9/18/07
Approved - Board of Trustees 3/18/08
PSEC Review 5/12/08
Approved - Board of Trustees 9/16/08
Approved - Board of Trustees 11/18/08
Approved - Board of Trustees 6/16/09
Approved - Board of Trustees 11/17/09
Approved - Board of Trustees 9/21/10
Approved - Board of Trustees 11/22/10
PSEC Review 5/9/11
Approved - Board of Trustees 3/20/12
Approved - Board of Trustees 2/19/13
Approved - Board of Trustees 9/16/14
PROFESSIONAL STAFF POLICIES AND PROCEDURES
TABLE OF CONTENTS Qualifications for Appointment to the Professional Staff 3 Criteria for Appointment and Reappointment 5 Policy on National Practitioner Data Bank 6 Academic/Administrative Active Staff 11 Procedure to Obtain Application for Membership
12 Procedure to Obtain Application for Reappointment
14 Revision of Existing Privileges 16 Procedure for Appointment and Reappointment 17 Terms of Appointment 18 Policies & Procedures for Initial Appointment and Reappointment
20 Virtual Meetings 24 Hospital Policy on Appointment and Privileges
25 Responsibilities of Membership 28 Telemedicine Privileges 30 Temporary Privileges 32 Emergency Management Credentialing Process 34 Peer Review 36 Interim Changes in Hospital Appointment/Privileges
39 Confidentiality of Professional Staff Records
46 Corrections, Additions, or Deletions of professional Staff Records
52 Sanctions 53 Emergency Medical Screening, Treatment & Transfer Policy
58 On-Call Policy
66 Code of Conduct 69 Professional Staff Health 75 Approval/Amendment Process 82 PROFESSIONAL STAFF POLICY QUALIFICATIONS FOR APPOINTMENT TO THE PROFESSIONAL STAFF Section 1 - General Qualification for Appointment: Appointment to the Professional Staff is a privilege which shall be
extended only to professionally competent individuals who continuously meet
the qualifications, standards and requirements set forth in this policy and
in such policies as are adopted from time to time by the Board of Trustees.
All individuals practicing medicine, dentistry, osteopathy and psychology
in this hospital, unless exempted by specific provisions of this policy,
must first have been appointed to the Professional Staff. Decisions
regarding appointment, reappointment, and initial, renewed, or revised
clinical privileges are rendered based on the merits of the applicant's
credentials. Gender, race, creed, or national origin are not used in
making decisions regarding the granting or denying of medical staff
membership or clinical privileges.
Section 2 - Specific Qualifications: Only physicians and dentists who satisfy all of the following threshold
conditions (unless specifically waived in bylaws or by recommendations of
the Board) as determined by the pre-application process described in this
policy shall be qualified for appointment to the Professional Staff: a) are currently licensed to practice in this state; 1) Commissioned Officers of the Uniformed Services who are conducting
official Department of
Defense business at Dayton Children's Hospital are exempt of
the requirement to have a
valid Ohio License.
(2) these individuals must maintain any valid state license. b) are located (office and residence) within the geographic service area
of the hospital as defined by the Board of Trustees, close enough to
provide timely and continuous care for their patients in the hospital; c) possess current, valid professional liability insurance coverage in
such form and in amounts satisfactory to the hospital; d) have successfully completed training approved by the Accreditation
Council for Graduate Medical Education (ACGME) or The American
Osteopathic Association (AOA), of at least three (3) years, in the
specialty in which the applicant seeks clinical privileges; and e) are certified by the appropriate specialty board (if applicable) or
admissible for examination for certification by the American Board of
Medical Specialties or AOA, in the area in which privileges are
requested, and thereafter certified within the timeframe indicated by
the member's respective specialty board, unless such requirement is
waived by the Board of Trustees after considering the specific
competence, training, and experience of the individual in question, or
waived by the Board of Trustees for those applicants and appointees
who practice in medical subspecialties where there are specific
practice prerequisites for admissibility to board examination. This
requirement shall be applicable only to those individuals who apply
for initial Professional Staff appointment and for clinical privileges
after 1989. f) can document their: 1) background, experience, training and demonstrated competence;
(2) adherence to the ethics of their profession;
3) good reputation and character, including the ability to perform the
clinical privileges requested safely and competently;
4) ability to work harmoniously with others sufficiently to convince
the hospital that all patients treated by them at the hospital will
receive quality care and that the hospital and its Professional
Staff will be able to operate in an orderly manner;
g) have no record of conviction for Medicare, Medicaid, or insurance
fraud and abuse, payment of civil penalties for the same or exclusion
from such programs.
h) have no record of conviction of any felony, or any misdemeanor related
to the practice of your profession, other health care related matters,
third-party reimbursement, violence, or controlled substance
violations. i) have no record of denial, revocation, or termination of appointment or
clinical privileges by any hospital for reasons related to
professional competence or conduct. j) acknowledge receipt of competition resolution. k) maintain current federal DEA registration and Ohio controlled
substance license (if applicable), unless waived by the Board. l) have received favorable recommendations from references. No individual shall be entitled to appointment to the Professional Staff or
to the exercise of particular clinical privileges in the hospital merely by
virtue of the fact that such individual: a) is licensed to practice a profession in this or any other state; b) is a member of any particular professional organization; c) has had in the past, or currently has, Professional Staff appointment
or privileges at any hospital or health care facility; d) resides in the geographic service area of the hospital as defined by
the Board of Trustees; or e) is affiliated with, or under contact to, any managed care plan,
insurance plan, Health Maintenance Organization, Preferred Provider
Organization, or other entity. CRITERIA FOR APPOINTMENT AND REAPPOINTMENT CATEGORY ONE = APPOINTMENT ALL APPLICANTS FOR APPOINTMENT MUST MEET ALL CRITERIA UNDER CATEGORY ONE AS
FOLLOWS (unless waived in bylaws or with approval of the Board): 1) Valid license in the State of Ohio (except active duty military
physicians) 2) Complete/truthful application 3) Appropriate level of education, training, and certification 4) Current, adequate malpractice insurance 5) Must live within a reasonable distance of hospital 6) No involuntary loss of license in any other state 7) Applications must disclose information regarding professional
litigation experience concerning filed claims, pending claims, final
judgments, or settlements, including the substance of the allegations,
the findings, the ultimate disposition and any additional information
requested by the credentials and nominating committee or the board of
trustees. Individuals applying for initial appointment must disclose
all previous professional litigation experience, while individuals
applying for reappointment must disclose any professional litigation
experience since the date of their last application. 8) Must have practice and/or residency and/or other training path for
past five years 9) Provide information regarding be