Allied Health Professional Rules and Regulations

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Allied Health Professional

Rules and Regulations

I. Purpose

To maintain an organized Allied Health Professional Staff committed to promoting effective delivery of patient services, and continuous review and improvement of clinical performance. To provide acceptable quality health care to patients treated at CHRISTUS Santa Rosa Health Care within standards that satisfy or exceed requirements published by the Joint Commission on Accreditation of Healthcare Organizations.

II. Professional Standards

Allied Health Professionals shall be expected to adhere to and observe the rules of ethics of their respective specialty specific associations and the Ethical Religious Directives for Catholic Health Facilities.

III. Definition

A. Independent Allied Health Professionals. Individuals not employed by CHRISTUS Santa Rosa Health Care who have completed a formal course of education and training and licensed by the State to perform or function as an independent practitioner. Such individuals may be granted delineated clinical privileges commensurate with their training, skills and experience and shall be required to maintain appropriate state licensure or certification when applicable in one of the allied health professions.

Independent Allied Health Professionals are permitted by the State to provide healthcare services within their scope of licensure and training with the requirement for physician oversight and supervision.

B. Dependent Allied Health Professionals. Individuals not employed by CHRISTUS Santa Rosa Health Care who have completed a formal course of education and training and licensed or certified by the state or nationally recognized board in one of the allied health professions. Such individuals may be granted defined duties and responsibilities commensurate with their training, skill and experience and shall be required to maintain appropriate licensure or certification when applicable. Dependent Allied Health

Professionals are permitted by the State to provide healthcare services within their scope of licensure and training with the requirement for direct physician oversight and

supervision.

IV. General Requirements for Participation

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A. Initial Application

Allied Health Professionals shall be required to submit an application with supporting documents which relates in detail to the specific privileges or defined duties and

responsibilities requested and the name(s) of the responsible Medical Staff member, as outlined in the "Credentialing" section of this Manual.

B. Obligation and Responsibility

1. Maintain current Medical Liability Coverage ($100,000/$300,000).

2. Maintain current specialty specific licensure, board certification, and level of life support certification appropriate to scope of practice, as applicable. Life support certification must be sponsored by the American Heart Association.

3. Participate in specialty specific Continuing Education Programs. Maintain documentation of continuing education specific to training and the clinical privileges or defined duties and responsibilities being requested.

4. Allied Health Professionals shall be expected to abide by and adhere to

CHRISTUS Santa Rosa Health Care and Department/Service guidelines, policies and procedures, and rules and regulations, which relate to their approved list of clinical privileges or defined duties and responsibilities.

5. Allied Health Professionals shall be expected to abide by and adhere to Medical Staff bylaws, guidelines, policies and procedures, and rules and regulations, which relate to their approved list of clinical privileges or defined duties and responsibilities

6. Allied Health Professionals may not admit patients in their own name. Their activities in the CHRISTUS Santa Rosa Health Care facilities shall be under the supervision of a current member of the Medical Staff who assumes responsibility for their performance.

7. Unless approved otherwise recorded history and physical examination must be performed by a physician member of the Medical Staff responsible for the management of the medical/surgical conditions during the patient’s hospitalization.

8. In the event an Allied Health Professional fails to perform his/her duties and responsibilities in a satisfactory manner, the concern shall be brought to the attention of the sponsoring physician, Chair or Chief of the appropriate Department or Section, and the Director, Physician Services.

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V. Clinical Privileges/Defined Duties and Responsibilities C. General Requirements

Treatment provided by Allied Health Professionals is limited to those areas of

documented competence indicated by the scope of their delineated clinical privileges or defined duties and responsibilities.

Allied Health Professionals accorded clinical privileges or defined duties and

responsibilities shall be expected to provide services limited to those approved by the CHRISTUS Santa Rosa Health Care Board of Directors on the recommendation of the Medical Board/Medical Executive Committee, Allied Health Professional Subcommittee, Credentials Committee Chair or Chief of the Department or Section, and the appropriate physician sponsor.

Independent Allied Health Professionals requesting for additional clinical privileges shall be expected to provide documented evidence of training and/or competence specific to the privileges being requested. Such requests shall be approved by the CHRISTUS Santa Rosa Health Care Board of Directors on the recommendation of the Medical

Board/Medical Executive Committee, Allied Health Professional Subcommittee,

Credentials Committee, and the Chairperson or Chief of the Department or Section, and the appropriate physician sponsor.

D. 90-Day Evaluation

Allied Health Professionals on initial appointment shall be evaluated at 90 days of their appointment submitted to the sponsoring physician at least one(1) month prior to the 90 days. The evaluation of activity shall include number of patient contacts, quality of care provided, health status, and current clinical competence. Results of the 90-day review shall be forwarded to the Credentials Committee, the respective Medical Executive Committees and Board of Directors for consideration.

E. Annual Competency Evaluation

Allied Health Professionals will be evaluated yearly, opposite the year of the

reappointment cycle. This evaluation will include the applicant’s credentials and current competence.

F. Biannual Re-Credentialing / Approval

Allied Health Professionals shall be evaluated biannually by the sponsoring physician at least one (1) month prior to the date clinical privileges or defined duties and

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V. Credentialing

Application for Allied Health Professional delineated clinical privileges or duties and

responsibilities shall be processed in accordance with established Medical Staff credentialing and verification procedures and considered for approval or denial by the Allied Health Professional Credentials Subcommittee, Credentials Committee and Medical Board/Medical Executive Committee. Applications shall then be submitted to the CHRISTUS Santa Rosa Health Care Board of Directors for final approval or denial.

A. Application Every application for initial appointment must contain complete and accurate information concerning at least the following:

1. Training, including the names and locations of each institution, degrees granted or programs completed, and dates attended;

2. All currently valid professional licensure, registrations and certifications, as well as controlled substances registration, with the date and number of each; 3. Health status including any disabilities affecting the Allied Health Professional's

ability to perform patient care duties and exercise the requested clinical privileges and information on any accommodations that may be required;

4. Professional liability insurance coverage as required by the Board and narrative information on malpractice claims history and experience (suits and/or

settlements made, whether concluded or pending) during the past five (5) years; 5. The nature and specifics of any investigation or action (whether concluded or

pending) involving voluntary or involuntary denial, revocation, suspension, reduction, limitation, probation, non-renewal, failure to seek renewal, withdrawal of application or voluntary/involuntary relinquishment (by resignation or

expiration) of any professional license, registration or certificate in any

jurisdiction; controlled substances registration; membership or fellowship in local, state or national professional organization; staff membership, status,

prerogatives, or clinical privileges at any hospital or other health care entity; 6. Location of office of supervising physician or group, and residence;

7. Names and locations of any other hospital or other health care entities where the practitioner provides or provided health care services with the inclusive dates of each affiliation and the reason for termination of the affiliation;

8. Any current felony charges pending against the Practitioner and any past charges including their resolution;

9. Designation of Department (and Section if available) assignment, Allied Health Professional category, and specific clinical privileges being requested;

10. One letter of recommendation from supervising physician in the form required who have substantive knowledge of the Allied Health Professional's professional competence, ethical character and any other matter requested;

11. An acknowledgment that the applicant has received and read the Allied Health Professional Rules and Regulations and that applicant agrees to be bound by the terms thereof if granted membership and/or clinical privileges;

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- Background Check;

13. Verification of OIG/MC Sanctions; and

14. An acknowledgment that the applicant has received and read the Orientation packet.

B. Effect of the Application. The Allied Health Professional must sign the application and in so doing agrees to comply with the obligations of appointment, as well as: attests to the correctness and completeness of all information furnished; signifies his/her

willingness to appear for interviews and provide requested information in connection with his/her application; authorizes and consents to Hospital and Medical Staff

representatives consulting with any third parties who may have information bearing on professional competence and conduct or other matters under review and to their inspecting all records and documents pertaining to such information; and releases from any liability all those who, in good faith and without malice, provide, review or act on information regarding the Allied Health Professional's competence, professional ethics, character, health status, and other qualifications for Allied Health Professional

appointment and clinical privileges as provided in the Medical Staff Bylaws. C. Appointment Process.

1. Submission of Application. The application for appointment shall be submitted to the Physician Services Department which shall issue appropriate inquiries to third parties and perform verification. An application shall not be considered complete until all requested information has been received. If the application remains incomplete six months after receipt, it will automatically be withdrawn and special notice issued to the applicant.

2. Allied Health Professional Subcommittee. Upon receipt of the complete application, the Physician Services Department shall forward a copy of the application and clinical privileges requested to the Allied Health Professional Subcommittee, the Subcommittee shall review and investigate the Allied Health Professional's qualifications and may interview the Allied Health Professional and request additional information. The Allied Health Professional Subcommittee shall advise the Department chairperson as to whether the Allied Health Professional possesses the necessary qualifications and satisfies the subcommittee's criteria for exercising the clinical privileges requested and

whether any conditions should be imposed on his/her exercise of such privileges. If the Allied Health Professional Subcommittee concludes that the Allied Health Professional is not qualified to be granted the requested clinical privileges or should have certain conditions imposed, it shall include the reasons therefore in the recommendation.

3. Department. Each Department chairperson shall review the Allied Health

Professional's requested clinical privileges, as recommended by the Allied Health Professional Subcommittee. As necessary, the Department shall review and investigate the Allied Health Professional's qualifications and may interview the Allied Health Professional and request any additional information. The

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whether the Allied Health Professional possesses the necessary qualifications and satisfies the Department’s criteria for exercise of the clinical privileges requested and whether any conditions should be imposed on his/her exercise of such privileges. If the Department concludes that the Allied Health Professional is not qualified to be granted the requested clinical privileges or should have certain conditions imposed, it shall include the reasons therefore in the recommendation. 4. Credentials Committee. The Credentials Committee shall review the

recommendations of the Allied Health Professional Subcommittee and

Department(s) and investigate the qualifications of the Practitioner and shall, within sixty (60) days of receipt of the application and all requested information, issue a written recommendation that the application be accepted, accepted with modifications, or denied. The Credentials Committee shall obtain appropriate peer references and other information, and conduct such other investigation as it finds necessary. As necessary, the Credentials Committee may interview the Allied Health Professional Subcommittee or may appoint a subcommittee to conduct additional investigation. The Credentials Committee’s recommendation shall be forwarded to the Medical Board and shall be accompanied by the completed application, results of the investigation and all other documentation considered by the committee.

5. Medical Executive Committee. At its next regular meeting after receipt of a recommendation from the Credentials Committee, the Medical Executive Committee shall review and submit a recommendation to the Board. D. Reappointment Process.

1. Submission of Application. At least one hundred twenty (120) days prior to the expiration of the term of appointment, each Allied Health Professional shall be mailed an application for reappointment form. Each Allied Health Professional who desires reappointment shall, at least ninety (90) days prior to such

expiration date, send the completed application for reappointment form to the Credentials Committee. An application shall not be considered complete until all requested information has been received. Following receipt of a complete application for reappointment, the application shall be processed in accord with the procedures set out in this Manual.

Failure to return a complete application for reappointment within the time periods required shall result in non-consideration of the application and termination of appointment on the expiration date, without any procedural rights of review. Thereafter, the Allied Health Professional shall be required to submit an initial application which shall be processed pursuant to this Manual. Every application for reappointment must contain complete and accurate information as required in this Manual.

2. Data Collection. Prior to consideration for reappointment, the Physician

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during the prior term of appointment. Such information shall be available to the Allied Health Professional Subcommittee, Department and Committees reviewing the reappointment application and should include patterns of care as

demonstrated in the findings of quality assurance/improvement activities; participation in relevant internal teaching and continuing education activities; level/amount of clinical activity (patient care contacts at the Hospital); timely accurate completion of medical records and compliance with all applicable records policies; compliance with all Medical Staff Bylaws, Allied Health Professional Rules and Regulations, Policies and Procedures, Manuals and requirements of the Hospital; general attitude toward his/her patients and the Hospital; and cooperativeness in working with other Practitioners, Allied Health Professionals and Hospital personnel.

3. Status Pending Review. Unless action is taken under the provisions of these Allied Health Professional Rules and Regulations regarding corrective action, the current status of a Allied Health Professional seeking reappointment with respect to his/her rights and privileges shall remain in effect during processing and consideration of a complete application for reappointment, pending the outcome of any procedural rights of review and final action by the Board.

4. Procedure for Delineating Privileges Requests. Each application for appointment and reappointment must contain a request for the specific clinical privileges desired by the Practitioner. Specific requests must also be submitted for temporary privileges.

5. Processing Requests. All requests for clinical privileges will be processed according to the procedures outlined herein, as applicable. If a Allied Health Professional already appointed to the Medical Staff requests additional clinical privileges at a time other than in connection with reappointment, the request shall be in writing and processed as a request for initial appointment in accord with the procedures in this Manual.

6. Privilege Determinations. Upon documentation by the Allied Health Professional of satisfaction of the minimum or threshold criteria for the clinical privilege(s) requested, the application shall be considered and granted upon demonstration of current competence. Privileges are granted consistent with the Allied Health Professional's documented training and/or experience in categories of treatment area or procedures, the results of treatment, and the conclusions drawn from quality assessment and improvement activities when available. The Allied Health Professional shall have the burden of establishing his/her

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VII. Quality Improvement

Allied Health Professionals shall provide continuous quality care for his/her patients treated at CHRISTUS Santa Rosa Health Care and participate in Medical Staff and organizational wide quality improvement activities within their area of specialty.

VIII. Specialty Specific Requirements

In addition to the General Requirements for Participation, Allied Health Professionals shall be required to satisfy specialty specific guidelines and criteria.

A. Independent Allied Health Professionals 1. Advanced Nurse Practitioner

a. Employed by a member of the Medical Staff or through an approved agency b. Licensed by the Texas Board of Nursing

c. Letter from the Texas Board of Nursing indicating approval to practice as an Advanced Nurse Practitioner

d. Basic Life Support (BLS) Certification sponsored by the American Heart Association.

e. Advanced Cardiac Life Support (ACLS), Pediatric Advance Life Support (PALS) or Neonatal Resuscitation Program (NRP) certification, as appropriate to scope of practice, sponsored by the American Heart Association and the American Academy of Pediatrics.

f. Documentation of current TB test submitted annually; for positive TB applicants an initial chest X-ray report is required with subsequent TB questionnaire required annually.

g. Current certification, or qualified for such, by the appropriate certification body. Advanced Nurse Practitioners shall be expected to complete and obtain such certification within one year of application.

1) Pediatrics - National Association of Pediatric Nurse Associates and Practitioners or National Certification Board of Pediatric Nurse Practitioners. For PNPs working in the Pediatric Intensive Care Unit, the following is required: Formal completion of an

educational program and Board certification as an ACPNP;

or current enrollment in a formal educational program leading to certification as an ACPNP to be completed within two years of appointment.

2) Ob/Gyn - National Certification Corporation for the Obstetric, Gynecologic and Neonatal Nursing Specialties or American College of Nurse Midwives or the American Certification of Nurse Midwives Council

3) American Nurses Association - American Nurses Credentialing Center

4) American Academy of Nurse Practitioners

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2. Licensed Professional Psychologist Associate

a. Licensed by the Texas State Board of Examiners of Psychologist with provision to render psychological services under supervision of licensed psychologist

b. Documentation of current TB test submitted annually; for positive TB applicants an initial chest X-ray report is required with subsequent TB questionnaire required annually.

3. Licensed Professional Counselor

a. Licensed by the Texas State Board of Examiners of Professional Counselors

b. Two (2) years experience as a Licensed Professional Counselor c. Documentation of current TB test submitted annually; for positive TB

applicants an initial chest X-ray report is required with subsequent TB questionnaire required annually.

4. Perfusionist

a. Licensed by the Texas State Board of Examiners of Perfusionist

b. Certified by the American Board of Cardiovascular Perfusion (ABCP), or c. Qualified for examination. Individuals qualified for examination shall be

expected to actively pursue and successfully attain certification within two (2) years of privileges being granted.

d. Basic Life Support (BLS) certification sponsored by the American Heart Association.

e. Documentation of current TB test submitted annually; for positive TB applicants an initial chest X-ray report is required with subsequent TB questionnaire required annually.

5. Pharmacist

a. Licensed by the Texas State Board of Pharmacy

b. Certification by Board of Pharmaceutical Specialites or certification by another nationally recognized board (e.g. National Certification Board of Diabetes Educators) or demonstration of significant training and/or experience in specialized area of pharmacy practice.

c. Documentation of current TB test submitted annually; for positive TB applicants an initial chest X-ray report is required with subsequent TB questionnaire required annually.

6. Physician Assistant

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b. Qualified for examination. Individuals qualified for examination shall be expected to actively pursue and successfully attain certification within two (2) years of privileges being granted

c. Letter from the Texas State Board of Medical Examiners indicating that the Sponsor/Supervising Medical Staff member is an approved supervisor d. Individuals qualified for licensure shall be expected to actively pursue and

successfully attain licensure from the Texas State Board of Medical Examiners within two years of clinical privileges being granted. e. Basic Life Support (BLS), Advance Cardiac Life Support (ACLS),

or Pediatric Advance Life Support (PALS) certification, as appropriate to scope of practice sponsored by the American Heart Association.

f. Documentation of current TB test submitted annually; for positive TB applicants an initial chest X-ray report is required with subsequent TB questionnaire required annually.

7. Psychologist – Clinical and Counseling

a. Licensed at the Doctoral level for the Independent Practice of Psychology by the Texas State Board of Examiners of

Psychologists

b. Two (2) years experience as a Clinical Psychologist or Counselor c. If the licensed doctoral psychologist does not have the above noted

experience, they may be granted privileges that would include concurrent Medical Record review during his/her Provisional year.

d. Documentation of current TB test submitted annually; for positive TB applicants an initial chest X-ray report is required with subsequent TB questionnaire required annually.

8. Registered Nurse First Assistant

a. Licensed by the Texas Board of Nursing

b. National certification as a perioperative nurse (CNOR) as recognized by the Certification Board of Perioperative Nursing (CBPN) or licensed and certified as an Advanced Nurse Practitioner

c. Documentation of completion of a certified RNFA program as recognized by the Certification Board of Perioperative Nursing (CBPN)

d. Minimum of 2 years experience as a Registered Nurse First Assistant or documentation of 150 monitored internship hours during initial

credentialing.

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9. Social Worker

a. Licensed by the Texas State Board of Social Workers Examiners as Licensed Master Social Worker - Advanced Clinical Practitioner (CSW-ACP)

b. At least three (3) years experience as a certified clinical social worker c. Documentation of current TB test submitted annually; for positive TB applicants an initial chest X-ray report is required with subsequent TB questionnaire required annually.

B. Dependent Allied Health Professional

Dependent Allied Health Professionals shall be required to meet the essential

qualifications and minimum requirements of the approved CHRISTUS Santa Rosa Health Care position/job description relevant and applicable to the defined duties and

responsibilities being requested. 1. Dental Assistant

a. Successful completion of a Dental Assistant Training Course, or

b. Documented proof of training and experience in dental office, a minimum of 5 years

c. Radiology certificate by the Texas State Board of Dental Examiners d. Basic Life Support (BLS) certification sponsored by the American Heart

Association.

2. Orthopedic Technologist

a. Documentation of completion of a certified training program in Orthopedic Technology or documentation of completion of military training

b. Current certification as an Orthopedic Technologist from the National Board for Certification of Orthopedic Technologists or registration with the American Society of Orthopedic Professionals

c. Basic Life Support (BLS) certification sponsored by the American Heart Association.

3. Physical Therapist

a. Licensed by the Texas State Board of Physical Therapy Examiners b. One year experience as a physical therapist

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4. Registered Nurse

a. Licensed by the Texas Board of Nursing

b. Basic Life Support (BLS) certification sponsored by the American Heart Association.

5. Research Professional

a. Letter from Primary Investigator attesting to competency, skills, character, and specifically delineating your duties as a Research Professional while participating in an IRB/CSRHC approved study. b. Current Texas license, as applicable

c. Current certification as qualified for such by the appropriate certification body, as applicable

d. Basic Life Support (BLS) certification sponsored by the American Heart Association (if direct patient contact).

6. Certified Surgical Tech / First Assist

a. National certification as a surgical tech/surgical assistant as recognized by the National Board of Surgical Tech & Surgical Assistant (NBST/SA)

b. Documentation of completion of a certified surgical tech first assist program as recognized by the National Board of Surgical Tech & Surgical Assistant

d. Copy of current Basic Life Support (BLS) certification sponsored by the American Heart Association

7. Surgical Tech

a. Licensed by the Texas Board of Nursing with a minimum of one (1) year experience as a Scrub Nurse,

or

b. Successful completion of a Surgical Technologist Training course with a minimum of one (1) year experience as a scrub nurse,

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c. Licensed by the Texas Board of Vocational Nurse Examiners with a minimum of one (1) year experience as a scrub nurse

d. Basic Life Support (BLS) certification sponsored by the American Heart Association.

8. L.V.N.

a. Licensed by the Texas Board of Vocational Nurse Examiners with a minimum of one (1) year experience.

b. Basic Life Support (BLS) certification sponsored by the American Heart Association.

7. Pathology Assistant

a. Successful completion of a NAACLS – approved training program, or

b. Baccalaureate degree with a major or minor in a biological or allied health field with a minimum of three years’ working experience.

c. Registered as a Histologic Technician (HT) by ASCP or other national certifying agency.

d. Documentation of current TB test submitted annually; for positive TB applicants an initial chest X-ray report is required with subsequent TB questionnaire required annually.

8. Diagnostic Sonographer

a. Successful completion of a course in ultrasonic technology

b. Minimum six-month experience as an ultrasound technician working in obstetrical and/or perintology setting.

c. Basic Life Support (BLS) certification sponsored by the American Heart Association.

IX. Operating Room

This section is applicable to all Allied Health Professionals approved for privileges and duties and responsibilities, which require the use of the Operating Room.

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Room Administrative Director or Manager who shall evaluate qualifications, review anesthesia and operating room policies, and discuss mutual expectations.

B. The Operating Room is not responsible for training Allied Health Professionals who are not directly employed or contracted by CHRISTUS Santa Rosa Health Care.

C. Allied Health Professionals shall be expected to maintain and adhere to the same standards, and policies and procedures, which apply to CHRISTUS Santa Rosa Health Care Operating Room personnel.

D. In the event that an Allied Health Professional demonstrates unsatisfactory surgical techniques or unacceptable work habits, concerns shall be reported to the sponsoring physician, Administrative Director or Manager and Chairman of the Operating Room Committee. Upon consultation with the sponsoring physician, the Operating Room Committee reserves the right to recommend revision or cancellation of approved Allied Health Professional privileges or defined duties and responsibilities to the Credentials Committee.

E. Allied Health Professionals approved for surgical tech staff defined duties and

responsibilities shall be expected to function and perform independently and shall accept the responsibilities of his/her position for all elective cases scheduled by his/her

sponsoring physician. In the event that a surgical tech staff is not available for an elective scheduled case, the Director of Surgical Services or his/her designee shall be notified of such at least two (2) days prior to the case in order to enable the Operating Room to provide adequate coverage.

F. Allied Health Professionals approved for surgical scrub staff defined duties and responsibilities shall be expected to count sponges, instruments, and sharps with the circulating nurse for each case, and remain scrubbed throughout the procedure. G. Allied Health Professionals shall be expected to assume all responsibilities for the care,