opi: program number: date: subject: credential … · · 2013-11-15participation in the national...

ProgramStatement

U.S. Department of Justice Federal Bureau of Prisons

OPI: HSD/SRS NUMBER: P6027.01 DATE: 1/15/2005SUBJECT: Health Care Provider

CredentialVerification,Privileges, andPractice AgreementProgram

1. PURPOSE AND SCOPE. To establish procedures for primarysource credential verification, and granting of clinicalprivileges, or practice agreements for health care providers atBureau institutions. These providers include Bureau staff,Public Health Services (PHS) staff, consultants, and those whoprovide treatment using tele-health.

This Program Statement (PS)also establishes guidelines forcorrective action procedures related to deficient clinicalskills, knowledge or practice, and establishes guidelines forparticipation in the National Practitioner Data Bank (NPDB). This Program Statement:

� Establishes requirements for primary source credentialverification of professional credentials, licenses, andcertifications for all health care providers discussed inthis PS, including consultants, at Bureau institutions.

� Requires “Clinical Privileges” for health care providersclassified as “Licensed Independent Practitioners (LIP)”,such as physicians, dentists, optometrists, and podiatrists. Providers in these categories are authorized by a currentand valid state license to practice medicine, dentistry,optometry or podiatry, independently. Additionally,licensed clinical psychologists at Medical Referral Centersmay be privileged while working in Behavioral Health Units.

� Requires “Practice Agreements” between non-independentpractitioners, such as a mid-level practitioners, dentalhygienists, etc., and the LIPs who must authorize theirclinical performance and provide clinical supervision. Practice agreements delegate specific clinical or dentalduties to staff under an LIP’s supervision.

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� Establishes requirement for Clinical Specialty Consultantsand Dental Consultants to review credentials for allphysician, psychiatrist, and dental officer candidates foremployment, in their respective region.

� Establishes the requirement for routine annual peer reviewof all providers who function under clinical privileges orpractice agreements.

� Establishes requirement for a formal Clinical Director (CD),Chief Dental Officer (CDO), and Chief Psychiatrist (CP) peerreview, once every two years, by a trained BOP trainedreviewer, for any CD, CDO, or CP at a Bureau institution.

� Establishes procedures to follow when a health careprovider’s clinical knowledge/skills requires immediatereview to determine whether corrective action is indicatedto ensure knowledge/skills of the practitioner, orprotection of patients.

� Establishes guidelines for participation in the NationalPractitioner Data Bank (NPDB).

� Establishes the option of using a Credential Committee atBureau institutions for credential verification andrecommendations for privileges and practice agreements.

2. PROGRAM OBJECTIVES. The expected results of this programare:

a. Institutions will have established methods to participatein appropriate credentialing procedures and knowledge/skillsbased privileging or establishment of practice agreements forhealth care practitioners.

b. Clinical supervisors will have established procedures tofollow, prior to considering actions based on clinicalknowledge/skills.

c. Patients will be protected by procedures to ensure thequality and efficiency of care delivered in the Bureau ofPrisons.

d. The rights of the health care practitioners involved invarious health care reviews will be protected by affording themdue process and ensuring the timely resolution of any issuesrelated to their professional knowledge or skills.

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3. DIRECTIVES REFERENCED

P3000.02 Human Resource Management Manual (11/1/93)P6010.02 Health Services Administration (1/15/05)P6031.01 Patient Care (1/15/05)

45 CFR, Part 60, 1-14

4. STANDARDS REFERENCED

a. American Correctional Association 4th Edition Standards forAdult Correctional Institutions: 4-4380(M), 4-4381(M), 4-4382(M),4-4384(M), and 4-4411(M)

b. American Correctional Association 3 Edition Standards forrd

Adult Local Detention Facilities: 3-ALDF-4E-9(M) and 3-ALDF-4E-10(M)

5. APPLICABILITY. The requirements of this Program Statementapply to all Bureau institutions. For Medical Referral Centers(MRC), adjustments to this Program Statement will be made toaddress the organization of various committees described in theirMedical Staff By-Laws. Medical Staff By-Laws will be negotiatedwith the Union locally.

6. CREDENTIAL VERIFICATION. Each Health Services Unit (HSU)will ensure that professional credentials for all health careproviders inside the institution are verified at the primarysource (the issuer of the credential). Providers include Bureaustaff, PHS staff, part-time staff, contract and consultant staff,and those who provide a diagnosis or treatment using tele-health.

a. Credential Committee. Institutions may elect to form aCredential Committee (recommended method) to evaluate verifiedcredentials and make privilege or practice agreementrecommendations to the privileging authority. Committeemembership must include three members, including one person ofthe peer group of the individual seeking privileges, or practiceagreements, and at least one LIP.

b. Applicant Responsibility. Applicants for privileges and/orpractice agreements as health care practitioners must provide allrequired credentials for verification. Failure to providerequired credentials precludes the granting of privileges orpractice agreements. Credentials in the portfolio must beverified by primary source. Primary source verification ofcredentials may be accomplished through written, telephonic, orelectronic contact with the primary source.

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Each credential portfolio must contain the following documentsalong with evidence of primary source verification for eachcredential:

(1) Documentation of professional education (diploma,FLEX/USMLE, ECFMG, Fifth Pathway, for foreign graduates).

(2) Post-graduate training (internship, residency,preceptorship, etc.).

(3) Professional licensure (active and inactive) or anycertification such as NCCPA certification for PA-C. The filemust always contain a current verified license. Licenseverification should occur not sooner than 30 days from the datethe provider is granted privileges of a practice agreement. Aninactive license that remains on inactive status, requiresinitial verification only.

(4) All past and pending actions taken against apractitioner’s license or registration (state or district, DrugEnforcement Administration), clinical privileges, or thevoluntary relinquishment of such. Complete details of anymalpractice history.

(5) National Practitioner Data Bank (NPDB) inquiryinitiated, completed, and renewed every two years for licensed orcertified staff by the Central Office, Health Services Division. See Attachment A for NPDB queries. This form must be filled outcompletely and submitted to the Office of Quality Management(OQM), Health Services Division (HSD), Central Office.

(6) Reference letters from two professional peers forinitial privileges. Peer reviews required in the Peer ReviewSection of this Program Statement are required for privilege orpractice agreement renewal.

(7) Names and addresses of affiliations (work history,hospital affiliations, etc.) for the past ten years or sincecompletion of residency or fellowship.

(8) Documentation of continuing medical education for thepast three years or since completion of residency or fellowship.

c. File Maintenance. The verified credentials will be kept ina credential portfolio for each provider and maintained in theHSU. Each employee has the right to review, or receive a copy ofany information in his or her credential file, if requested.

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d. Credentialing Sources. The preferred manner, and order,for primary source credential verification is as follows:

(1) Written Confirmation from the Issuing Authority. Thepreferred manner to verify credentials is for the institution toseek verification of documents in the form of letters written tothe issuing authority or by using the inter-agency agreement(IAG) with the Armed Forces Institute of Pathology (AFIP). Whenusing AFIP, Central Office pays the cost of the credentialverification (for Bureau or PHS staff). Institutions can useAFIP to verify credentials of consultants; however, theinstitution must purchase those verifications through normalpurchasing procedures at the negotiated cost. AFIP may becontacted at:

Department of Legal MedicineArmed Forces Institute of Pathology1335 East-West HighwaySuite 600Silver Spring MD 20910Phone: (301) 295-7274/or 8118(Address and phone number subject to change withoutUnion negotiation)

(2) From a Credential Verification Organization. Institutions may accept primary source credential verificationfor contract/consultant staff from a JCAHO accredited hospitalwith which the health care provider is affiliated. Then, thehospital is performing as a Credential Verification Organization(CVO). If the Bureau institution accepts credential verificationfrom this source, the following conditions must be met:

(a) A copy of the hospital's credential verificationpolicy will be maintained at the institution. Ifthis information is contained in the hospital’sBy-Laws, or Rules and Regulations, a copy of thosedocuments are required. The hospital acting asthe CVO should also provide evidence to the Bureauinstitution that the hospital satisfied standardsapplicable to credentialing and privileging ontheir most recent accreditation audit. A copy ofthe most recent accreditation report should bemaintained on file.

(b) Copies of all verified credentials, with astatement that certifies these credentials wereverified at the primary source, must be maintainedat the institution. If the hospital will notprovide copies of the credentials, the hospital

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will provide a letter stating that the physicianis a member in good standing on the hospital staffand that the physician meets all requirements forstaff membership/employment as defined in thehospital’s By-Laws, or Rules and Regulations.

(c) Evidence of periodic peer review by peers at thehospital or group practice.

(d) If the Bureau institution accepts queries from theNPDB on consultants affiliated with that hospital,the Medical Director must clear any query thatreflects a “match” for a malpractice payment orclinical knowledge/skills issue, as described inNPDB section of this PS.

(3) Telephonic verification from the primary source.Verification of credentials by telephone should be done when suchverifications are needed on a short term notice (not allowingtime for a written verification) such as in granting temporaryprivileges. When verifying a credential by phone, an annotationwill be made on the credential indicating:

� the date of the phone call;� the agency contacted;� the agency phone number; and� the name of the agency representative who verified

the information.

The Bureau staff member who performed the telephoneverification must also date and sign the document.

(4) The AMA Masterfile Physician Profile may be used forprimary source credential verification for license, U.S. medicalschool, or residency graduation. The AMA will charge theinstitution a nominal fee for this service. Contact the AMA at1-800-665-2882 or http//www.ama-assn.org for further information.

(5) Internet or World Wide Web Verifications are acceptableonly if they meet the criteria for primary source verification. This must be accomplished by links to state licensingdepartments, or educational institutions.

� Verifications from license “clearing houses” arenot considered primary source verification.

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e. Physician and Dentist Candidates for Employment. Verifiedcredentials for physician and dentist employment candidatesshould be forwarded to the institution’s appropriate ClinicalSpecialty Consultant, or Dental Consultant for clearance prior tobeing offered a position.

f. Renewal. Once the credentials in the portfolio areinitially verified, there is no need to re-verify all of themwhen renewing privileges or practice agreements. Only thosedocuments that have expired and have been renewed, such aslicense(s) and certification(s), need to be re-verified at theprimary source (each and every time they are renewed).

It is the practitioner's responsibility to provide a copy ofrenewed professional licenses or certifications (or evidence ofapplication to renew) to the HSU on or before the date thecurrent license or certification expires. It is the HealthService Administrator's or designee’s responsibility to verifythe renewed license(s) or certification(s) with the primarysource.

7. GRANTING OF CLINICAL PRIVILEGES, PRACTICE AGREEMENTS ANDPROTOCOLS. Only LIPs will apply for, and be granted, clinicalprivileges in the Bureau. All physicians, dentists, and other LIPs, including contract/consultants, and those who provide adiagnosis or recommend treatment using tele-health, must haveapproved clinical privileges before delivering health care insidethe institution, or by use of tele-health.

a. Granting Privileges

(1) Physicians and Dentists. A physician seeks privilegesby completing the Application for Appointment to Medical Staffform (BP-S601.63), and Dental Officers complete the Applicationfor Dental Privileges form (BP-S603.063). These privileges areto be granted based on the practitioner's qualifications,knowledge/skills, and experience as identified and verified inthe credentials portfolio. Clinical privileges may be grantedfor a period not to exceed two years. Newly employed Physiciansand Dental Officers should be granted privileges for a period ofone year. Licensed Clinical Psychologists at an MRC withBehavioral Health Programs may also be included in this category.

(2) Mid-level practitioners (MLP) which include graduatephysician assistants (certified or non-certified), nursepractitioners, and unlicensed medical graduates must have a“Practice Agreement” with a licensed physician prior to providingany health care in the institution. MLPs represent a category ofpractitioners who do not practice independently.

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These Practice Agreements are to be granted based on theMLP's qualifications, knowledge/skills and experience, asidentified and verified in the credentials portfolio. Practiceagreements will be valid for a period not to exceed two years. (See Practice Agreement for MLP form (BP-S612.063).

Dental Hygienists and Dental Assistants must have a“Practice Agreement” with a licensed dentist prior to providingany dental care in the institution.

(3) Other healthcare providers, such as clinical nurses, emergency medical technicians, or any others that a localgoverning body deems appropriate, must work under guidance of LIPapproved protocols (physician or dentist) while delivering healthcare inside the institution. When approving protocols, theinstitution should ensure that the protocols comply with thestate practice act for the appropriate profession.

b. Privilege Conditions

� Privileges, Practice Agreements and Protocols must beinstitution specific (limited to those services andprocedures that are actually performed in theinstitution).

� Privileges and Practice Agreements granted to LIPs andMLPs will be valid for no more than two years.

� Temporary privileges or practice agreements may begranted for up to 120 days under special circumstances,such as a new or temporary-duty employee or temporaryCD. For permanent transfers or temporary dutyproviders, privileges or practice agreements must begranted at the new institution before the provider isallowed to deliver health care. When grantingtemporary privileges, or practice agreements, theinstitution must verify, at a minimum, the currentprofessional license or certification and professionaleducation/degree.

If the provider being granted temporary privileges or apractice agreement is on temporary duty from anotherBureau institution, evidence of verification from theemployee’s home institution, which must be in hard copyform and be on site at the new institution, willsatisfy this requirement.

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c. Authority. Authority to grant institution specificclinical privileges, practice agreements, and protocols isdefined as follows:

(1) The Medical Director is the privilege grantingauthority for institution physicians designated as the ClinicalDirector (CD) including a physician who is appointed as Acting CDwhile the permanent position is vacant.

(2) The Medical Director is the privilege granting authority for Clinical Specialty Consultants, Chief DentalOfficers, and Chief Psychiatrists.

(3) The institution CD is the privilege granting authorityfor other LIPs who deliver medical health care at the institutionincluding contractors/consultants, including those by using tele-health. The CD establishes Practice Agreements with MLPs;however, in institutions with a Credential Committee, PCPT(Primary Care Provider Teams), or more than one physician, the CDmay delegate this authority to another LIP (physician or dentistif appropriate).

An LIP (physician or dentist) approves all protocols used bystaff such as clinical nurses, dental assistants, and emergencymedical technicians.

(4) The Medical Director delegates the privilege grantingauthority for physicians occupying the position of Chief ofPsychiatry at Bureau institutions to the BOP Chief Psychiatrist.

(5) The BOP Chief Dental Officer is the privilege grantingauthority for all institution Chief Dental Officers.

(6) The institution Chief Dental Officer is the privilegegranting authority for dentists and establishes PracticeAgreements for dental hygienists and dental assistants, includingcontractors/consultants.

(7) When the institution privileging authority changes,previously granted privileges, practice agreements, andprotocols, the new privileging authority may continue for aperiod not to exceed 90 days. After the 90-day period, the newCD or CDO, even in an acting capacity, must renew the privileges,agreements, and protocols. At institutions with a CredentialCommittee, the Committee will convene to address credentialingneeds.

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(8) Each Warden is required to sign off on all privilegeapplications and practice agreements. This requirement does notindicate that a Warden has authority to grant these privileges,or practice agreements, but rather that the Warden is aware ofthe terms of the privileges or agreements granted, and to whom. This procedure is required because the Warden is theinstitution's representative to the Health Services GoverningBody.

(9) For the position of CD, the institution must seek theappropriate Regional Director's concurrence in memorandum format,prior to submitting the application for privileges, in additionto verified credentials described earlier, to the MedicalDirector. The Regional Director’s concurrence must accompany theprivilege application to the Medical Director.

The institution must request renewal of clinical privilegesfor CDs, to the Medical Director every two years and must beaccompanied by a current CD Peer Review and the documents listedin Section 6 of this Program Statement.

(10) All Health Service Administrators (HSA) or AssistantHSAs who are health care practitioners, and remain clinicallyactive at the institution, must have a current practice agreementor protocols pertinent to their professions prior to performingany clinical duties.

8. PEER REVIEW. Peer review is a routine function used toreview the current knowledge and skills of health care providers. All Bureau health care providers who are privileged, must have atleast one external peer review conducted every two years. Thosewho are working under a practice agreement must have at least oneroutine peer review conducted every two years, which may beconducted by a peer at the institution. A peer is defined asanother provider in the same discipline (physician, dentist, MLP,etc.) who has firsthand knowledge of the provider’s clinicalperformance.

The peer review should evaluate the professional care theprovider has given using a sample of the provider’s primarypatient load, and comment on the following aspects of providerknowledge/skills:

� actual clinical performance (treatment provided consistentwith assessment, etc);

� appropriate utilization of resources; � participation in, and results of, performance improvement

activity;

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� clinical judgement; and � technical skills.

Additionally, each CD, CDO, and CP must have a peer reviewperformed and documented by an approved BOP Peer Reviewer, atleast once every two years, normally within six months ofprivilege expiration and renewal. The CD, CDO, CP Peer Reviewprograms are managed by OQM, HSD and this office is responsiblefor notification and scheduling of these reviews.

9. CORRECTIVE ACTION REVIEWS RELATED TO CLINICAL KNOWLEDGE,SKILL. Corrective action, discussed in this section, refers tothose actions necessary to correct deficiencies in clinicalknowledge/skills. Corrective actions may take the form of:

� increased clinical supervision; � additional clinical training; � additional education; or � changes to clinical privileges for LIPs or to the practice

agreement for MLPs.

Normally, additional training or education is the first step incorrecting deficient clinical knowledge or skills. Changes toMLP Agreement categories will normally be made in a progressivemanner, (i.e.; 1:2, 2:3).

a. Training and Education. Health care practitioners providepatient care dependent on their clinical knowledge, skills, andexperience. Medical technology and treatment modalitiesavailable for use in health care professions change continuously. Health care practitioners assume responsibility to maintain andimprove their knowledge and skills in order to deliver qualitycare consistent with accepted current standards of practice. TheBureau, in recognition of this, provides resources annually tohealth care practitioners so that they may request and receivecontinuing professional education (CPE) to address theircontinuing educational needs.

This section describes the management of health carepractitioners who function under clinical privileges, practiceagreement, or protocol, who demonstrate deficient clinicalknowledge or skills in performing their clinical duties. (Normally, additional training or education is the initial stepin correcting a clinical deficiency). For deficiencies relatedto clinical skills or knowledge, supervisors must adhere toapproved policies to document and discuss performance withemployees; i.e.; performance logs, performance improvement plans,etc.

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The HSA, CD, or CDO should always confer with the institutionHuman Resource Manager prior to initiating any level of clinicalperformance review described in this section. Bargaining Unitemployees, subject to any review described in this section, areentitled to Bargaining Unit representation through all phases ofthe review process described in this section, if requested, andwill be notified in writing upon initial notification.

Deficits health care practitioners demonstrate in clinicalknowledge, skills, expertise, or judgment can result in adversepatient outcomes, and such deficits require an intense review ofthe health care the practitioner provided.

� During the course of these reviews, the health carepractitioner’s clinical privileges, or practiceagreement, may be held in abeyance for a period not toexceed 30 calendar days during the course of a review. Attachment B provides a sample notification to employeeof privilege or practice agreement abeyance.

There are three levels of reviews to evaluate suspecteddeficiency in clinical knowledge/skills.

(1) Clinical Care Review. When a possible deficiency inclinical care is suspected, this is the initial internal step toevaluate the provision of care. This review is a health recordor other document review initiated by a physician, dentist, orpeer, in response to a specific negative patient outcome. A peerstaff member appointed by the CD or Chief Dentist will completethis review for MLPs or other non-independent practitioners. Only peers can conduct a clinical care review on a LIP (physicianor dentist). The affected practitioner is notified by memorandumof the nature of the review, and the review must be completedwithin 10 working days (from date of notice).

When the clinical care review is completed, a report isprovided to the CD or Chief Dentist who will determine whatcorrective action, if any, is warranted. The CD or Chief Dentistwill discuss the report with the affected employee, within sevenworking days of the review’s completion. Reports of clinicalcare reviews will be maintained in the employee’s credential fileuntil the next renewal of clinical privileges, practiceagreement, or protocol, not to exceed a period of two years. TheCD, or Chief Dentist may also recommend, if the result of thereview warrants, the next level of review, the internal focusreview. The affected employee can request an internal focusreview if the employee disagrees with the clinical care review.

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(2) Focus Review (Internal). When a clinical care reviewindicates there may be a significant deficiency in clinical knowledge/skills that may endanger patient care beyond anisolated episode, or it identifies trends in deficientknowledge/skills, the CD or Chief Dentist should initiate aninternal focus review. Internal focus reviews should consist ofa committee of at least three people, consisting of an LIP andtwo peers (excluding the peer who performed the clinical carereview), if staffing permits.

The focus review committee will review randomly selectedrecords of similar providers to determine if the level of caregiven by the provider under review is consistent with the levelof care provided by peers at that institution. The affectedpractitioner is notified by memorandum of the nature of theinternal focus review and is also notified that the focus reviewmust be completed within 15 working days (from date of notice).

When the internal focus review is completed, a report isprovided to the CD or Chief Dentist who will determine whatcorrective action, if any, is warranted. The result of thereview will be discussed with the affected employee, within sevenworking days of the review’s completion. Reports of internalfocus reviews will be maintained in the employee’s credentialfile until the next renewal of clinical privileges, practiceagreement, or protocol, not to exceed a period of two years.

(3) Focus Review (External). When the internal focusreview indicates there may be a significant deficiency inclinical knowledge/skills that may endanger patient safety orthreaten the institution’s security, the Warden may request anexternal focus review. An external focus review may also be theoption when a sufficient number of LIP staff do not exist at theinstitution to conduct the internal focus review. The Wardenshould request this review by memorandum to the Medical Director,Health Services Division, through the respective RegionalDirector.

(a) The OQM will obtain all pertinent information for review (such as the health record). Variousreports generated regarding the issues will besent to the OQM for provisional review.

(b) When the preliminary review indicates furtherreview is not necessary, the Medical Director mayterminate the review. In some cases, it may benecessary to direct a corrective action.

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(c) When the preliminary review indicates furtherintensive study is necessary, the Chief of OQMwill constitute a Focus Review Committee (FRC). The FRC will consist of at least two physicians(one will be the Chairperson), one additionalperson depending on the issue, and any otherexperts needed. The additional person willrepresent the expertise in the area of the focusreview.

(d) Whenever the Medical Director suspects there aremedical legal implications in any case, based onOQM’s preliminary findings, the Medical Directorwill consult with the General Counsel. In theevent it is determined that legal action isprobable, the health care practitioner will benotified.

(e) The Warden will provide all necessary informationand support to the FRC to conduct the review. Therequesting institution should also providepertinent clinical information, such as copies ofmedical records or reports with the request to theMedical Director.

(f) The affected practitioner is notified bymemorandum of the nature of the external focusreview, and is also notified that the focus reviewmust be completed within 30 working days (fromdate of notice).

(g) The FRC will review all pertinent information,conduct interviews, and inspect relevantfacilities to conduct the review objectively.

(h) The FRC will report its findings andrecommendations to the Medical Director, who willthen report the findings and recommendations tothe Warden. If negative action is taken against a bargaining unit employee as a result of the FRCreport, the employee and/or his or her designatedrepresentative may request and receive a copy ofthis report, to include a listing of all medicalrecords used. Privacy concerns of other employeesnamed in this report must be adhered to inreleasing the report.

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When the external focus review is completed, a report isprovided to the Medical Director, who in turn submits a report tothe Warden. The Warden will determine what corrective, or otheraction, if any, is warranted. The result of the review will bediscussed with the affected employee, within seven working daysof the Warden’s receiving the report. Reports of external focusreviews will be maintained in the employee’s credential fileuntil the next renewal of clinical privileges, practiceagreement, or protocol, not to exceed a period of two years.

b. Revocation/Restriction of Privileges. If attempts atcorrective action fail to improve clinical knowledge/skills, adecision may be made to deny, restrict, or remove specificclinical privileges or specific areas of a practice agreementpreviously granted, or being requested. When a decision is madeto deny or revoke clinical privileges, practice agreement, orprotocol, the employee will be provided a written reportdetailing the rationale for such action. The employee will have30 working days to dispute the report. After the employee hassubmitted his or her response, the Warden will make a finaldecision.

If the employee is a bargaining unit member, he/she may pursuethe matter through the grievance process. If the employeepursues the issue through the grievance process, the proposedaction will be withheld pending the outcome of the disputedaction. During this period, clinical privileges, practiceagreement, or protocol will be held in abeyance pending theoutcome of the disputed action. It is recommended that any suchproposed action, based on deficient clinical knowledge or skills,should be discussed fully with the Human Resource ManagementDepartment.

10. NATIONAL PRACTITIONER DATA BANK (NPDB). The Bureau ofPrisons is required to participate in the National PractitionerData Bank (NPDB) which is operated by the Department of Healthand Human Services (HHS). These requirements are established inTitle V Regulations, 45 CFR; Part 60, 1-14. Further detail onNPDB participation and procedures for reporting staff to the NPDBare detailed the Inter Agency Agreement (IAG) between the Bureauand HHS.

� All Bureau staff, including Wardens, are prohibited fromentering into express or implied written or oral agreementsnot to report an employee in return for a personnel actionsuch as resignation, retirement, accepting a reassignment,etc.

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a. Definitions. The following definitions apply in the IAGbetween the Bureau and HHS for NPDB participation.

(1) Physician means a doctor of medicine or osteopathylegally authorized to practice medicine or surgery by a state. This definition applies for practitioners who are employed by theBureau, who are assigned to the Bureau by the United StatesPublic Health Service, or who provide consultant physicianservices to the Bureau.

(2) Dentist means a doctor of dental surgery, doctor ofdental medicine, or the equivalent, who is legally authorized topractice dentistry by a state. This definition applies topractitioners who are employed by the Bureau, who are assigned tothe Bureau by the United States Public Health Service, or whoprovide consultant services to the Bureau.

(3) Health Care Practitioner means an individual other thana physician or dentist, whom the Bureau authorizes to providedirect health care services. This definition applies topractitioners who are employed by the Bureau, who are assigned tothe Bureau by the United States Public Health Service, or whoprovide consultant services to the Bureau. For the purpose ofthis PS, these other health care practitioners include:

P Dental Hygienists P DieticiansP Emergency Medical Technicians P Medical AssistantsP Medical Technologists P Nurses AidesP Nurse Anesthetists P Nurse PractitionersP Registered Nurses P OptometristsP Pharmacists P Physician Assts.P Physical Therapists P PsychologistsP Radiologic TechnologistsP Respiratory TherapistsP Respiratory Therapy TechniciansP Social Workers, ClinicalP Occupational TherapistsP Licensed Practical/Vocational Nurses

b. Authority. The Medical Director is the Bureau's onlyauthorized official to approve and sign any submission of aBureau staff member to the NPDB. The Medical Director maydelegate authority for technical aspects of the query andreporting processes to the OQM, HSD, and may delegate authorityfor review of documents and development of NPDB recommendationsto the OQM, or to a panel of Bureau physicians.

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c. Queries. The Bureau is required to query the NPDB atinitial appointment, and no less than once every two years, onevery physician, dentist, or other health care practitionerproviding professional care in a Bureau institution. Thisapplies not only to permanent Bureau or PHS staff, but also toconsultants. Bureau institutions may accept NPDB queries fromhospitals they contract with for consultants associated with thathospital, provided they meet requirements for primary sourceverification (see Section 6 of this Program Statement).

The OQM and the Medical Director will evaluate the NPDB reportsof each health care provider and provide guidance to theinstitution regarding suitability for appointment, conversion toprobationary, or permanent appointments as appropriate. NPDBqueries are conducted at initial employment and at least onceevery two years during employment.

(1) If NPDB screening shows action in any of the coveredareas, the Bureau will verify that the applicant (or employee)fully disclosed the related information required and requested bythe Bureau in its pre-employment, credentialing, and/or clinicalprivileging procedures.

The OQM or Medical Director will evaluate the NPDB providedinformation and other documentation the individual provided toexplain or refute the evidence in the NPDB. The Medical Directoror OQM will provide guidance to the institution on theappropriate action to be taken. The institution will maintainall reports and information in the practitioner's credentials orprivileging folder as applicable.

(2) When any initial, biennial, or other NPDB reportcalls into question the professional competence or conduct of anindividual appointed or used by the Bureau, the OQM or MedicalDirector will review all the reports and relevant information. The Medical Director will provide guidance to the institutionabout the appropriate actions to be taken, including revision ofclinical privileges and removal as appropriate. The institutionand the individual are required to submit information regardingthe NPDB report during this process.

(3) The institution will maintain copies of the NPDBresults in the Credentials and Privileges folder for eachpractitioner.

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(4) Health care units in each institution will maintain acopy of the National Practitioner Data Bank Guidebook forreference. The Guidebooks are free from the NPDB Help Line (1-800-767-6732) or they are available on the Internet.Practitioners may directly contact the NPDB through the HelpLine.

The use of Attachment A is required to submit requests for NPDBqueries to OQM.

d. Notification to NPDB. The Bureau is required to submit areport to the NPDB for malpractice payments (within 30 days ofpayment) made for the benefit of a physician, dentist, or otherlicensed health care practitioner to satisfy a written claim ofjudgment for medical or dental malpractice. The employee will benotified of the intent to report the judgement to the NPDB. Prior to a report’s submission to the NPDB, the employee has theright to refute or comment (to the Medical Director) on thereport within seven working days of delivery of the notice of theintent to report.

The Bureau is also required to report physicians, dentists, orother health care practitioners, for deficiencies in professionalcompetence or conduct that adversely affects their clinicalprivileges for a period longer than 30 days. Any Bureauphysician, dentist or other health care practitioner who may bereported to the NPDB will receive written notice of the intent toreport to the NPDB and will have the opportunity to dispute thereport prior to its submission (see Section 11 of this ProgramStatement).

11. PROVIDER HEARING AND APPEALS RELATED TO NPDB REPORTS ORPRIVILEGING ACTIONS (SUSPENSION, REVOCATION OR DENIAL) THATEXCEED 30 DAYS. Any LIP whose clinical privileges are denied,reduced, restricted, or revoked for more than 30 days, isentitled to a fair and equitable remedy process.

Any practitioner (LIP or non-LIP) whom the Medical Directorintends to report to the NPDB as defined in Section 10 isentitled to a fair and equitable remedy process.

The provider who will be the subject of the privilege/practiceagreement action (i.e., suspension, denial, revocation) has 30calendar days from the date of receiving the Bureau’s intent torefute the intended action. As indicated in the MasterAgreement, bargaining unit employees have the right torepresentation.

P6027.011/15/2005

Once an employee has requested to refute the action, the employermust render a final decision with justification. All action willbe withheld until the final outcome of the process as outlined inthe Master Agreement.

� If the final decision is to suspend, deny, or revokeprivileges or a practice agreement for a period beyond 30days, the provider will be reported to the NPDB within 15days of the final action.

/s/Harley G. LappinDirector

P6027.011/15/2005

Attachment A

Information for Queries

One form is completed for each practitioner. Complete allapplicable information.

QUERY FOR: (SELECT ONE TYPE OF PRACTITIONER AND ONE QUERY TYPE)

PRACTITIONER TYPE: BOP/PHS STAFF CONTRACTOR

QUERY TYPE: INITIAL APPOINTMENT MANDATORY TWO YEAR

PRACTITIONER NAME:LAST NAME: FIRST NAME: MIDDLE NAME:

OTHER NAMES USED:LAST NAME: FIRST NAME: MIDDLE NAME:

SSN: - - DATE OF BIRTH: / /

HOME ADDRESS: CITY

STATE ZIP COUNTRY

BOP INSTITUTION ADDRESS:

CITY STATE ZIP

LICENSE NUMBER: STATE

FIELD OF LICENSURE:

IF LICENSED IN MULTIPLE STATES OR FIELDS, LIST ALL ON ANADDITIONAL SHEET.

FEDERAL DEA NUMBER

PROFESSIONAL SCHOOL(S) ATTENDED (USE ADDITIONAL SHEET IFNECESSARY)NAME OF SCHOOL:

CITY

STATE ZIP COUNTRY YEAR OF GRADUATION 19

P6027.011/15/2005

Attachment B

(Example Format For Notification of Privilege/Practice AgreementAbeyance)

MEMORANDUM FOR (NAME OF PROVIDER)

FROM: (Name of CD or CDO)

SUBJECT: Notification of Clinical Privilege/PracticeAgreement Abeyance

You are hereby notified that your clinical privileges are beingheld in abeyance for the following reason. This notice is beingprovided in compliance with procedures defined in ProgramStatement 6027.01,

(In this section, state the reason, type of review, [clinicalcare, internal focus, external focus], the specific deficienciesbeing evaluated, and the length of the review).

These deficiencies have, or could have had, the following adverseeffects on patient care. (List)

Abeyance is a temporary removal of clinical privileges for aperiod not to exceed thirty work days. It is during this periodthat the deficiencies will be evaluated as determined by theClinical Director. During this period of time you will beassigned to other duties, described as follows. (List here).

Abeyance is not an adverse clinical privilege action and need notbe disclosed as such on future applications for clinicalprivileges.

You will be notified of the results of this review process.

cc: credential fileAFGE Local

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