Hospitals and Clinics Administration
ENTERPRISE 0108
DATE:
TO: Enterprise Medical Staff
FROM: Paul E. Lorenz
Chief Executive Officer, Enterprise Yvonne Karanas
President of Medical Staff, Enterprise
SUBJECT: SCOPE:
Allied Health Professionals Secondary Site Approval and Onboarding Process Enterprise Medical Staff and Allied Health Professionals
POLICY:
The Enterprise Medical Staff is the medical staff for three hospitals consolidated on a single license: Santa Clara Valley Medical Center (SCVMC), O’Connor Hospital (“OCH”) and St. Louise Regional Hospital (“SLRH”). This policy establishes the process for credentialed Allied Health Professionals to designate a primary hospital where the AHP performs the majority of patient care (“Primary Hospital” or “Primary Site”), and if applicable, also establishes the process for currently credentialed AHPs to request administrative approval to exercise privileges at any of the other enterprise hospitals by designating a secondary hospital(s) (“Secondary Hospital” or “Secondary Site”) and receiving additional privileges (if any and
Location (includes hospital and all inpatient and outpatient locations and
subacute facilities of the hospital, unless otherwise indicated)
Enterprise Wide
X
O’Connor Hospital
Santa Clara Valley Medical
Center
St. Louise Regional Hospital
Who May Perform This Procedure
RN
MUC
LVN
HSR
HSA
Techs
MA
MD
X
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needed), onboarding support, and the approvals to do so. This policy also describes the process for utilizing AHPs to meet urgent or emergent patient care needs at a Secondary Hospital in the Enterprise.PROCEDURE:
Responsible Party Action
Chief Medical Officer
Allied Health Professional
The Chief Medical Officer, in consultation with the relevant department chair, the AHP’s supervising physician, and/or the Director of Advanced Practice will assess the need for the AHP to work at a secondary site. If there is a need, the AHP will be instructed to designate a secondary site on the Hospital Designation form (Attachment A) and return it to the Medical Staff Office (MSO).
Medical Staff Office of Primary Hospital
The Primary Hospitals MSO forwards a copy of the applicable Attachments and the Joint Commission (TJC) Profile, including approved privileges, and supervision related documents (e.g., Physician Assistant Practice Agreement or relevant protocols) to Secondary Hospital MSO.
Medical Staff Office of Secondary Hospital(s)
Reviews the AHP’s documents and the Joint Commission
Practitioner Profile including the approved privileges to ensure all documentation is in order. Determines if any additional
documentation is required and works with the AHP to meet these requirements. Forwards required documents to the Secondary Hospital’s Hospital Physician Executive/Medical Director and the President of the Hospital’s Medical Leadership Council (“Medical Leadership”) for review and approval.
Secondary Hospital Medical Leadership
Reviews request, taking into consideration coverage needs and contract requirements (if any). If approved, the Secondary Site MSO forwards to department chair. If denied the secondary site MSO notifies the Primary Site MSO, who will notify AHP. A Secondary Hospital Designation denial shall not entitle the AHP to a hearing and appeal rights under the Medical Staff Bylaws.
Department Chair of Secondary Hospital
After approval, the department chair or their designee shall: 1) Review the privileges at the Primary Hospital and any
additional requested privileges for the Secondary Hospital and determine if any new privileges are needed.
2) Create an individualized onboarding plan for the practitioner at the Secondary Hospital considering the practitioner’s competency, experience, and familiarity with the processes and equipment at the Secondary Hospital (“Onboarding Plan”). The Onboarding Plan shall set a timeline and may include, but is not limited to, assessment of clinical
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Enterprise Interdisciplinary Practice Committee of the Secondary Hospital
Medical Leadership Council of Secondary Hospital
Enterprise Credentials Committee
Enterprise Medical Executive Committee
capabilities at the Secondary Hospital, professionalism, identification of a supervising physician if needed, identification of proctor as needed, and proctor requirements.
Notify the MSO when documents are ready for submission. The MSO submits the Hospital Designation Form, additional privileges, and Onboarding Plan to the Enterprise
Interdisciplinary Practice Committee Note: If there is an urgent or emergent need for a practitioner to fulfill an important patient care, treatment, and service need at a Secondary Hospital pending completion of final approval process described below, the practitioner may provide the coverage temporarily pending these approvals only if there is a written Onboarding Plan that has been receive approved by the Secondary Hospital Medical Leadership Council President and Department Chair.
Reviews the Hospital Designation Form, additional privileges (if any), and Onboarding Plan. If approved, forwards to Medical Leadership Council of Secondary Hospital. If denied, returns to Department Chair and Secondary Hospital Medical Leadership Council President with the reason for denial, which may include insufficient onboarding process or lack of a supervising physician if needed. An AHP whose Secondary Hospital Designation is denied shall not be entitled to a hearing and appeal rights under the Medical Staff Bylaws unless denial is for a reason as defined in the Medical Staff Bylaws.
Reviews Hospital Designation Form, additional privileges, and Onboarding Plan. If approved, practitioner can begin onboarding and this information is forwarded to the Enterprise Credentials Committee. If denied, returns packet to Department Chair and to the Enterprise Interdisciplinary Practice Committee with reason for denial, which may include insufficient onboarding process.
Reviews information on the approved practitioners and forwards information to Enterprise Medical Executive Committee.
Reviews information on the approved practitioners and forwards information to Governing Body.
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Governing BodyAllied Health Professional
Medical Staff Office of Secondary Hospital(s)
Attachments:
Attachment A
Reviews recommendation and approves credentialing and privileges, including Primary and Secondary Hospital(s) designations.
Completes all requirements of the Onboarding Plan within the time allowed or the Secondary Hospital designation approval will
automatically be revoked without any hearing and appeal rights under the Medical Staff Bylaws. Extensions of the Onboarding Plan may be granted for good cause by the Secondary Hospital Medical Leadership.
Notifies AHP of approval and sets up onboarding date. Input any required data into credentialing system.
Enterprise Allied Health Application Hospital Designation Form
Issued: Revised:
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Attachment A
Enterprise Allied Health Application Hospital
Site Designation
Your application for privileges as an Allied Health Professional will be processed by the hospital that you designate as your Primary Hospital (the site where you provide the majority of your patient care). If approved by the Chief Medical Officer, Department chair and/or the Director of Advanced Practice, you may exercise your privileges at any of the three hospitals as long as you have designated that hospital(s) as either a Primary Hospital or a Secondary Hospital as indicated below, have obtained any necessary additional privileges required, have arranged for appropriate physician supervision, have been appropriately on-boarded and trained at each of those designated hospitals, and have satisfied all medical staff requirements, including completion of the Secondary Site Approval and Onboarding Process, Enterprise Policy #00##.
PRIMARY HOSPITAL
Please indicate one Primary Hospital where you provide the majority of your patient care.
☐
O’Connor Hospital Supervising Physician at Primary Hospital:
SECONDARY HOSPITAL
If you have been instructed to provide care at an additional hospital site(s), please designate the site(s) below. This site(s) will be designated as your Secondary Hospital(s). If you request different or additional privileges at the Secondary Hospital(s), please ensure that it is clearly reflected on your privilege request form. In addition, prior to rendering care at a Secondary Hospital where you do not currently hold privileges, you must complete the Secondary Site Approval and Onboarding Process including proctoring to ensure proper orientation to provide safe, quality care. If you function under protocols, you will need to have site specific protocols and site-specific supervising physicians.
Supervising Physician:
Print Name: Sub/Specialty:
Signature: Date:
County of Santa Clara Health System 751 South Bascom Avenue, San Jose, CA
95128
Tel: 408-885-5111 | Fax: 408-885-5117 | Web: scvmc.org
