Policy: Credentialing and Privileging

Date: December 6, 2011

CREDENTIALING: BEFORE HIRE

1. All provider applicants will submit the necessary documents for credentialing. Original Source Verification will be required of all essential documents. Every effort will be made to have all paperwork in order at every step in the process.

2. The following documents will be required and incorporated into the credentialing process:a. Curriculum Vitaeb. Applicationc. EEOCd. Professional Referencese. Release of Informationf. Credentialing Statement & Attestation as to

Correctness and Completeness of the Applicationg. Professional license and certification numbersh. Pre-Screening and Interview Notesi. Criminal/Education Background Formj. Google Searchk. Physician Profile -AMA, ECFMG (For MDs/DOs/PAs or

NCCPA -Not for NPs)l. American Nurses Credentialing Center (ANCC) or

American Academy of Nurse Practitioners (AANP) for NPs

m. NCCPA –Physician Assistant Verificationn. American Dental Association (For Dentists Only)o. License to Practice or NURSYS Nurse Practitioners

Out-of-State –For NPs there are two (RN and NP)

p. Minnesota Controlled Substanceq. DEA Registration r. Sanctions or Limitations on Licensure or Previous

Sanctions by Medicare/Medicaid s. National Practitioner Data Bank Healthcare Integrity

& Protection Data Bank (Malpractice/Loss History)t. Physical capacity and/or Functional capacity

assessment, as determined by job description

CREDENTIALING: AFTER OFFER/HIRE

1. An Employment Agreement will be reviewed with and signed by the provider applicant prior to commencing employment and clinical work.

2. The following documents will be assembled, organized and again verified:a. Collaborative Agreement (Non-Physician Providers)

as Appropriateb. Verification of Picture Identification -Must obtain

copy of state issued picture ID plus copy of one of the following federal government issued identification –social security card, passport, birth certificate, certificate of U.S. citizenship, certificate of naturalization, permanent resident card, unexpired temporary resident card.

c. Copy of Original Diplomasd. Copy of Original Specialty Licensee. Copy of Original Verified Training (i.e. residency or

NP program)f. Documentation of Continuing Professional Education

(as applicable)g. Life Support Training (BLS, ACLS, ATLS, CPR, PALS,

etc. as applicable)h. Copy of Original DEA Document

i. Copy of Original Controlled Substance Licensej. Copy of Residency Certificatek. Copy of Medical Education Certificatel. Copy of CPR and other position related

documentationm. Immunization/PPD/TB statusn. Pre-Employment Health Fitness assessmento. Copy of Car Insurance Companyp. Verified Current Competence (from last

Medical/Program Director)

PRIVILEGING

1. All providers providing clinical care at Cedar Riverside People’s Center will have privileges to practice and provide clinic care granted by the Board of Directors.

2. Recommendations for granting these privileges will be made by the Chief Medical Officer based on his/her review, and input from an ad hoc Professional Review Committee that might be established, composed of other appropriate clinicians on the medical staff.

3. Provider applicants for privileges should submit their credentials and allow enough time for the privileging process to be accomplished before starting their clinical practice at their clinical locations.

4. All providers at Cedar Riverside People’s Center will apply for specific procedures regarding their clinic practice in the clinic(see attached)

5. Documents needed to grant privileges will include, but not be limited to, the following documents:a. State medical licenseb. Specialty board certificationc. Curriculum vitae with past clinical experience, both

outpatient and inpatientd. Other documentation of formal training or

certificatione. Any documentation of prior adverse findings from a

specialty board or other regulatory board regarding the provider’s clinical practice

f. In general, the scope of practice and procedures that are a part of standard specialty training within the particular specialty training shall be granted to the provider. A specific checklist of scope of practice

and procedures shall be completed as part of the privileging process (see attached)

g. Copies of all relevant documents shall be kept in the provider’s personnel file

h. Additional training that would permit additional clinical privileges shall be presented to the Chief Medical Officer as well as any credentials committee in effect at the time, for review in order to grant additional clinical privileges.

6. Every effort will be made to make sure the new provider applicant returns all paperwork to the credentialing department and Chief Medical Officer, so the credentialing can copy all information and issue check if necessary.

7. The credentialing department will review all paperwork for accuracy and completeness.

8. There will be ongoing follow up with the provider regularly

ATTACHMENT:

PRIVILEGED AND CONFIDENTIAL

Proceedings and Records of the

Professional Review Committee

Cedar Riverside People’s Center

REQUEST FOR PRIVILEGES

LICENSED OR CERTIFIED HEALTH PROFESSIONALS

Position Title:

I hereby request the attached privileges/scope of practice/competencies for which I am trained and experienced to perform, as listed on the attached forms. I understand that it is my responsibility to demonstrate my competence to perform the listed privileges. I understand that the privileges requested may differ from those finally approved. I further understand that the completion of this form at this time does not preclude me from requesting additional privileges in the future.

Signature of Applicant Date

Print Name

Attachment (List of privileges, scope of practice or competencies)

Note:

The requested privileges must be reasonably comprehensive (i.e., not just specialty designation), must be based on documented education, training and/or experience, and must be specific to the job description you are applying for at the Center. Provide information on any special training you may have had that qualifies you for additional services or functions.

Please attach a delineation of privileges, scope of practice, competencies or detailed job description. If you are requesting privileges or functions in addition to those listed on the job description, please indicate accordingly on the attachment.

PRIVILEGED AND CONFIDENTIAL

Proceedings and Records of the

Professional Review Committee

Cedar Riverside People’s Center

APPLICATION FOR CLINICAL PRIVILEGES

General

Granting, reviewing, and changing of clinical privileges for the staff of the Cedar Riverside People’s Center will be accordance with Health Center policy. Assignments of such clinical privileges are based upon education, clinical training, experience, demonstrated current competence, documented results of patient care, and other quality review and monitoring deemed appropriate. The principle of “documented competency” will prevail. Primary care medicine is a dynamic and comprehensive field. Adult medicine, pediatric care, prenatal care, outpatient surgical care, and mental health care are integral components of Health Center continuity of care. As a result, privileges in these areas are identified to pertain to primary care, specialties of pediatrics, internal medicine, family practice, general practice, midwifery and obstetrics/gynecology.

The privileges for the Center will be granted in the following three classes:

Level One

(General)

This class includes privileges for uncomplicated, basic procedures and clinical application of cognitive skills. Physicians applying for privileges in this class will be graduates of approved medical/osteopathic schools who are properly licensed and demonstrate skills in appropriate general medicine practice.

Level Two

(Residency/Board Certification)

Privileges in this class include Level One privileges as well as privileges for those procedures and cognitive skills involving more serious medical problems which are normally taught in residency programs. This will include procedures and clinical application of cognitive skills appropriate to the care in perinatal, surgical, psychiatric, and critical care units. Physicians requesting privileges in this class will have to meet criteria in Level One and have either completed training in a residency program and/or will be Board Certified, or will have documentation experience, demonstrated abilities and current competence in primary care medicine.

Level Three

(Advanced Procedures)

Privileges in this category include privileges in Level One and Two. Additional privileges may be granted to physicians who have acquired added experience and/or training, and who have special skills and knowledge in specified areas of medicine. As appropriate, the Medical Director will review these additional privileges.

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It should be noted that, even though a physician is assigned to one of the three classes, he or she might also elect to apply for individual privileges that may be considered to be a higher level.

PRIVILEGED AND CONFIDENTIAL

Proceedings and Records of the

Professional Review Committee

PRIVILEGE REQUEST FORM

Print Name:

Hire Date:

Primary Location:

Board Certified: Date:

Subspecialty: Date:

Board Eligible:

Projected Certification Date:

Write the number of the level and clinical site that applies for each privilege

Privilege Level:

(General) (Residency/Board Certification)

(Advanced Procedures)

Procedures Requested

Level

Site

Medical Director Approval Special

Conditions/Comment

General Privileges

Management of Routine Adolescent Care

1 2 3

Management of Routine Adult Care

Management of Routine Geriatric Care

Supervision of Students

Procedures Requested Level

Site

Medical Director Approval Special

Conditions/Comment

Biopsy, skin

Cardiopulmonary resuscitation (BLS)

Excision, benign lesion, skin

Foreign body removal,

eye

Abscess I & D

Ingrown toenail excision

Lacerations, infected

Paranychia, I & D

Suturing of simple laceration

Privileges in Anesthesia Care

Use of local anesthetics for wound repair

Use of topical anesthetics

Privileges in Internal Medicine

Debridement, skin subcutaneous, tissue

Dressing/Debridement, burn

Incision and removal of foreign body

Laceration, simple

Privileges in Internal Medicine

Independent Care: Basic Life Support

Basic Diagnosis & Management

Full care of uncomplicated cases

EKG interpretation

Needle aspiration of subcutaneous lesion

PRIVILEGED AND CONFIDENTIAL

Proceedings and Records of the

Professional Review Committee

Procedures Requested Level Site

Medical Director Approval Special

Conditions/Comment

PFT (Pulmonary Function Test) interpretation

Superficial

Nerve block)

Privileges in Gynecological Care

I & D Bartholin Cyst

Cervical Biopsy

Coloposcopy/Cervical Cryotherapy

Endometrial Biopsy

IUD insertion and removal: Paragard

IUD insertion and removal:

Mirena

Privileges in Orthopedic Care

Initial evaluation of orthopedic problems

Treatment of acute back and neck pain

Treatment of contusions, simple lacerations, sprains

Treatment of bursitis, tendonitis, tennis elbow, etc.

Casting procedures for closed fractures requiring no reduction

Joint aspirations

Procedures involving destruction of nail beds

Treatment of corns, calluses and bunions

Foot care

Treatment of closed dislocations

Procedures Requested Level Site

Medical Director Approval Special

Conditions/Comment

Privileges in Pediatric Care

Management of routine pediatric care, including full-term newborns

Special Procedures for Level Three Privileges

Requested Level Site

Medical Director Approval Special

Conditions/Comment

I hereby request the privileges identified above. Furthermore, I am physically and mentally capable to perform the above requested privileges.

Applicant’s Signature Date

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The following recommendation is made to the Center Governing Board that has authority to grant or deny privileges.

As Chief Executive Officer and Medical Director, we recommend that:

Privileges for __________________________________ at the Center are:

Approved Approved with Modifications Denied

Modifications:

Denial based on:

Chief Executive Officer Signature Date

Medical Director Signature Date