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PROFESSIONAL STAFF POLICY

POLICY ORIGIN: Jt. Medical Advisory Committee POLICY NO: PSP08-001

SECTION TITLE: PROFESSIONAL STAFF CREDENTIALING

TOPIC: COMPREHENSIVE APPOINTMENT AND CREDENTIALING POLICY

PART A: CONTENTS OF APPLICATION... 5

1.0–INITIALAPPOINTMENT...5

2.0RE-APPLICATIONPROCESS...7

3.0–ALTERATIONINPRIVILEGES ...10

PART B: PROCESSING OF THE APPLICATION... 11

4.0–PROCESSINGOFTHEAPPLICATION ...11

5.0–CRITERIAFORAPPOINTMENT,RE-APPOINTMENTORALTERATIONINPRIVILEGES...14

PART C: STREAMLINED PROCESSING OF APPLICATION... 17

6.0–STREAMLINEDAPPLICATIONPROCESS...17

PART D: MID-TERM REVOCATION... 19

7.0–SUSPENSION/REVOCATIONOFPRIVILEGES...19

APPENDIX A: ... 24

PURPOSE

Pursuant to the Corporations Act and the Public Hospitals Act, the Board of Directors/Trustees of a public hospital is responsible for the governance of the hospital, including the management of risk and the quality of care. The implementation of a system to ensure and monitor the quality of care provided by the ph-ysicians, dentists, midwives and extended class nursing staff in the hospital is one of the primary responsibilities of the Board. In exercising this responsibility, the directors must:

(a) act honestly and in good faith with a view to the best interests of the hospital;

and

(b) exercise the care, diligence and skill that a reasonably prudent director would

exercise in comparable circumstances.

The Policy outlines a clear and reasonable system that will allow the Board to consider an application by physicians and other professionals for appointment to the Medical or Professional Staff of the Hospital in a manner that ensures that the Board is capable of managing the quality of care offered in the Hospital and minimizing the attendant risks to patients. The policy further recognizes the Board’s responsibility to efficiently and effectively utilize the resources of the hospital in the provision of patient care.

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Under the Public Hospitals Act, hospitals are required to review all physicians’ delivery of care on an annual basis as well as on an as-needed basis. As such, the credentialing policy puts in place a two-stage re-appointment process:

• One re-appointment process takes place every three years and is a detailed and

comprehensive review and update of the Applicant’s file, which requires the Applicant to produce evidence of his/her current registration, insurance, competence and history of practice with the Hospital.

• The other re-appointment process is less onerous and is conducted in the intervening years

to serve as review of the Applicant’s past year and to update any significant information in the Applicant’s file.

The policy also addresses the process by which privileged staff members may apply for a change in the nature or scope of their privileges.

The appointment and credentialing process also sets out the procedures to be followed where complaints are lodged against privileged staff members regarding a serious problem in the diagnosis, care or treatment of a patient or an outpatient.

Finally, the policy is independent of a recruitment policy of any hospital which is a member of the Policy Group in that the recruitment process as set out in any such recruitment policy shall in no way bind or fettered the requirements of this Common Appointment and Credentialing Policy.

Purpose of a Common Appointment and Credentialing Policy

Each member of the Policy Group has as an objective the ability to more readily access the pool of physicians and other professionals who have been granted privileges by the Boards of each of the Hospitals in the Policy Group. The development and approval of this common credentialing policy by each of the Hospitals will help to achieve that objective, as follows:

• With a common credentialing policy, each Hospital will be assured that reasonable

processes and criteria (i) are in clearly written form agreed upon by all the Hospitals; (ii) apply to the processes of appointment, re-appointment, change in privileges and suspension, revocation or restriction of privileges, and (iii) are adopted and approved by each Hospital’s Board in order to manage the quality of care at the Hospital.

• Given that a common credentialing policy has been established and implemented, each

Hospital will have assurance that physicians who have been granted privileges at one of the Hospitals in the Policy Group have provided proper evidence of qualification and

competence in order to gain those privileges. The Hospitals are also assured that privileges are revoked, suspended or restricted based on a fair process consistent with their own. Given these assurances, the Board of a Hospital will be acting reasonably and exercising adequate due diligence if it allows for a streamlined process to expedite application of physicians or other professionals who are already privileged at another Hospital in the Policy Group.

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Amendments

No member of the Policy Group shall amend this Policy or cease to apply this Policy without

providing written notice of the nature and date of the amendment or cessation to the other Hospitals. The members of the Policy Group agree that they will meet at least every three (3) years for a formal review and evaluation of this Policy, with the objectives to keep the Policy up-to-date, effective and practical and to enhance the ability of each Hospital to streamline applications in a safe and

reasonable manner.

Application

This Policy describes the credentialing process for physicians. It may be applied to credential dentists, midwives, and extended class nurses, with appropriate changes to reflect the different health profession being reviewed.

Definitions

In this Policy, the following capitalized terms shall have the following meanings:

“Administrator” means the person appointed by the Board of the Hospital with direct and actual superintendence and charge of the Hospital, as contemplated in the Hospital Management

Regulation.

“Appeal Board” means the Health Professions Appeal and Review Board established pursuant to the Ministry of Health Appeal and Review Boards Act, 1998.

“Applicant” means the physician or other Professional who is applying for privileges at the Hospital in accordance with this policy.

“Dental Staff” mean those members of the Royal College of Dental Surgeons of Ontario who have been granted privileges at the Hospital.

“Department/Service” means a department/service of the professional staff comprised of the

chief/head of the service and such other persons who may be designated authority to recommend granting privileges.

“Extended Class Nursing Staff” means that registered nurse in the extended class to whom the Board has granted privileges with respect to the ordering of diagnostic procedures for outpatients in the Hospital.

“Hospital” means each of the hospitals whose Board has approved this Policy and has provided the other hospitals who’s Boards have approved this Policy with a certificate signed by its

Administrator indicating such approval.

“Hospital Management Regulation” means Regulation 965 “Hospital Management” passed pursuant to the Public Hospitals Act.

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“Medical Staff” mean those members of the College of Physicians and Surgeons of Ontario who have been granted privileges at the Hospital.

“Midwifery Staff” mean those members of the College of Midwives of Ontario who have been granted privileges at the Hospital.

“Policy Group” means those Hospitals whose Board has adopted this Policy.

“Professional Staff” means a member of the Medical, Dental, Midwifery or Extended Class Nursing Staff to whom the Board grants the privilege of attending patients in the Hospital.

“Public Hospitals Act” means the Public Hospitals Act (Ontario), together with all regulations there under, as amended from time to time.

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PART A CONTENTS OF APPLICATION

1.0 – INITIAL APPOINTMENT

1.1 Receipt of Request for Application

The Administrator of the Hospital shall provide an application package to every physician who requests the opportunity to apply to the Hospital for Professional Staff privileges. The application package provided to the Applicant shall consist of a covering letter of instruction from the Administrator and an application form, together with a copy of each Hospital’s By-laws, the Professional Staff Rules and Regulations, the Public Hospitals Act and regulations thereunder, the Mission Statement of each Hospital, and the Health Ethics Guide of the Catholic Health Association of Canada. A record shall be kept of the date the application package was sent to the Applicant and by what means it was sent (mail, courier, etc). The covering letter shall indicate that the application must be returned within a period of time specified in the letter. In addition, the covering letter will indicate that all documentation relating to the application must be received within 90 days of the Applicant’s submission of the application. If the Applicant fails to ensure that either of these deadlines is met, the application will be incomplete and therefore deemed inactive and void.

1.2 Content of Application

Each application provided to an Applicant for an initial appointment to the Professional Staff of the Hospital shall require that the application be submitted to the Administrator and shall further contain additional relevant information, including without limitation the following:

(a) a statement by the Applicant that she/he has read Sections 34 and 35 of the Public

Hospitals Act, the Hospital Management Regulation, the Hospital’s By-laws, the Professional Staff Rules and Regulations, the Hospitals’ Mission Statements, the Health Ethics Guide of the Catholic Health Association of Canada and a copy of this Common Appointment and Credentialing Policy;

(b) an undertaking that, if the Applicant is appointed to the Professional Staff of the

Hospital, the Applicant will provide the services to the Hospital (and will govern him/herself) as stipulated in the Application in accordance with the Public Hospitals Act and Regulation 965 “Hospital Management” there under, and with the Hospital’s By-laws, its Professional Staff Rules and Regulations, the Hospitals’ Mission

Statements, the Health Ethics Guide of the Catholic Health Association of Canada, its Common Appointment and Credentialing Policy and its Hospital policies, as established or revised by the Hospital from time to time;

(c) an acknowledgement by the Applicant that:

(i) the failure of the Applicant to provide the services as stipulated in the

Application in accordance with applicable legislation, Hospital By-laws and policies and Professional Staff Rules and Regulations will constitute a breach of his or her obligations to the Hospital, and the Hospital may, upon

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consideration of the individual circumstances, remove access by the physician to any and all Hospital resources, including the limiting or

restricting of Operating Room time, or take such actions as is reasonable, in accordance with the Hospital’s By-laws and rules and regulations; and

(ii) the Hospital may refuse to appoint an Applicant to the Professional Staff

where the Applicant refuses to acknowledge the responsibility to abide by a commitment to provide services in accordance with the privileges granted by the Board, and in accordance with the Hospital’s By-laws, policies and rules and regulations;

(d) a copy of the Applicant’s current registration or license to practice in Ontario;

(e) a record of eligibility for certification for specialty/sub-specialty and for

re-certification;

(f) a copy of fellowship/certification documentation;

(g) an up-to-date curriculum vitae, including a record of the Applicant’s professional

education and post-graduate training and a chronology of academic and professional career, organizational positions and committee memberships;

(h) a request for a current, certificate of Professional Conduct (physicians), certificate

of registration (dentists and midwives), or annual registration payment card as a registered nurse in the extended class and consent to the release of the information from the Registrar of the College;

(i) a certificate from the licensing authority for out-of-province applicants;

(j) a recital and description of pending or completed disciplinary actions, competency

investigations, previous or ongoing performance reviews, and details with respect to prior privileges disputes with other hospitals regarding appointment, re-appointment, change of privileges, or mid-term suspension or revocation of privileges;

(k) a statement with respect to failures to obtain, reduction in classification or voluntary

or involuntary resignation of any professional license or certification, professional society membership or fellowship, professional academic appointment or privileges at any other hospital or health care institution;

(l) the name of the department/service to which the application is being made;

(m) the category of Professional Staff privileges requested;

(n) the procedures requested;

(o) information regarding the Applicant’s health, including any impairments, medical

conditions, diseases or illnesses, and current treatments therefor, as well as the date of the Applicant’s last examination, which may impact on the Applicant’s practice, relevant to the nature and scope of privileges requested, as well as the name of the treating health professional and an authorization to the treating health professional to release relevant information to the Hospital;

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(p) confirmation of professional liability insurance coverage or membership in the Canadian Medical Protective Association satisfactory to the Board, including a record of the Applicant’s past claims history;

(q) information regarding any criminal proceedings or convictions involving the

Applicant;

(r) information regarding any civil suit where there was a finding of professional

negligence or battery or where there was an out-of-court settlement in respect of such action;

(r) (s) a direction to the Administrator authorizing the Administrator to contact any

previous hospitals where the applicant has provided services for the purposes of conducting a reference check, such direction to include names and addresses of at least three (3) appropriate references including:

(i) Administrator or Chief of Staff of the last hospital where Applicant held

privileges or received training;

(ii) Service Director or Head of Training Program if enrolled in a Graduate

Training Program within the past three years;

(iii) Dean of Medicine of the last educational institution in which the Applicant

held an appointment or was trained [latter applicable to recent graduates];

(t) if over the age of 65, a medical certificate of fitness;

(u) a signed authorization to any applicable regulatory body for release of information

relating to any of the above;

(v) a signed Confidentiality Agreement Form; and

(w) a passport size photograph.

2.0 – RE-APPLICATION PROCESS

The Public Hospitals Act dictates that every physician appointed to the Professional Staff of a hospital shall be appointed for a period of not more than one year. Therefore, each physician is required to apply for re-appointment on an annual basis prior to the expiry of the member’s privileges. The application for re-appointment, along with supporting documentation, must be submitted within 90 days of receipt. Failure to do so may result in delayed reappointment and lapse of appointment and privileges.

2.1 Re-application Process Requirements – Annual Review

Annually, the Applicant shall provide the following to the Chief of Staff and/or the Chief of Department, as directed, by completing the re-application form, and the Chief of Staff and/or the Chief of Department will review same with the Applicant, as necessary:

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(a) an undertaking that, if the Applicant is re-appointed to the Professional Staff of the Hospital, the Applicant will provide the services to the Hospital as stipulated in the Application, and will govern him/herself in accordance with the Public Hospitals Act and Regulation 965 “Hospital Management” there under, and with the Hospital’s By-laws, its Professional Staff Rules and Regulations, , the Hospitals’ Mission Statements, the Health Ethics Guide of the Catholic Health Association of Canada , its Comprehensive Appointment and Credentialing Policy and its Hospital policies, as established or revised by the Hospital from time to time;

(b) an acknowledgement by the Applicant that:

(i) the failure of the Applicant to provide the services as stipulated in the

Application in accordance with applicable legislation, Hospital By-laws and policies and Professional Staff Rules and Regulations will constitute a breach of his or her obligations to the Hospital, and the Hospital may, upon

consideration of the individual circumstances, remove access by the physician to any and all Hospital resources, including the limiting or

restricting of Operating Room time, or take such actions as is reasonable, in accordance with the Hospital’s By-laws and rules and regulations; and

(ii) the Hospital may refuse to re-appoint an Applicant to the Professional Staff

where the Applicant refuses to acknowledge the responsibility to abide by a commitment to provide services in accordance with the privileges granted by the Board, and in accordance with the Hospital’s By-laws, policies and rules and regulations;

(c) confirmation of professional liability insurance coverage or membership in the

Canadian Medical Protective Association satisfactory to the Board, including a record of the Applicant’s claims history over the past year;

(d) information and evidence relating to the Applicant’s prior year with the Hospital,

including:

(i) participation in continuing education programs;

(ii) ability to communicate with patients and staff, together with information

regarding patient or staff complaints regarding the Applicant, if any;

(iii) information related to a complaints investigation procedure pursuant to

the Hospital’s “Physician Code of Conduct and Complaint Management Policy”;

(iv) quality of care issues including, but not limited to, complications, infection

rate, tissue and audit committee reports etc.;

(v) general compliance with Sections 34 and 35 of the Public Hospitals Act, the

Hospital’s By-laws and its Professional Staff Rules and Regulations; and

(e) an update of information provided during the Applicant’s most recent appointment

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(i) a copy of the professional’s current license;

(ii) regarding disciplinary actions, College investigations, civil suits, criminal

proceedings or convictions, or and/or any other relevant legal problems;

(iii) information regarding the Applicant’s health, including any impairments,

medical conditions, diseases or illnesses, and current treatments therefore, as well as the date of the Applicant’s last examination, which may impact on the Applicant’s practice, as well as the name of the treating health

professional and an authorization to the treating health professional to release relevant information to the Hospital.

2.2 Re-application Process Requirements – Comprehensive Review

Every three years, the Applicant shall provide the requirements of the annual re-application process to the Chief of Staff and/or the Chief of Department, as directed, along with the following:

(a) information and evidence relating to the Applicant’s performance in the previous

three years, including:

(i) relationship with peers, staff and patients, together with information

regarding patient or staff complaints regarding the Applicant, if any;

(ii) clinical practice (admission, investigation and treatment), together with

evidence of appropriate clinical record documentation;

(iii) program or department participation;

(iv) attendance at meetings;

(v) staff and committee responsibilities;

(vi) ability to supervise staff;

(vii) on call availability;

(viii) appropriate and efficient use of Hospital resources including, but not limited

to, operating room time;

(b) the effect of appointments, if any, to other hospitals on the Applicant’s

duty/obligations and quality of care provided at the Hospital; and

(c) updated listing of procedural privileges

The Chief of Staff and/or the Chief of Department will complete the appropriate section of the Review Form upon completion of the review of the Applicant’s practice.

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3.0 – ALTERATION IN PRIVILEGES 3.1 Application for Alteration in Privileges

(a) Where a physician wishes to change his/her privileges, an original application, shall

be submitted to the Administrator listing the changes that are requested, along with evidence of appropriate training, competence and insurance coverage.

(b) The MAC is entitled to request any additional information or evidence that it deems

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PART B

PROCESSING OF THE APPLICATION Preamble

This Part of the Policy sets out the standard process to be followed where an Applicant has

submitted an application for appointment, re-appointment or alteration of privileges at the Hospital, and that Applicant is not currently privileged at any other hospital in the Policy Group.

Please refer to Part III, “Streamlined Processing of the Application”, where the Applicant is currently privileged at another hospital within the Policy Group.

4.0 – PROCESSING OF THE APPLICATION 4.1 Request for Application

Upon receiving a written request from an Applicant for appointment, re-appointment or alteration in privileges, the Administrator shall supply the Applicant with the appropriate application form. An Applicant for appointment or re-appointment to any group of the Professional Staff or for alteration in privileges shall submit a written application on the prescribed form to the Administrator.

4.2 Refer to MAC

The Administrator shall refer the original application immediately to the Chair of the MAC, who shall keep a record of each application received and then refer the original forthwith to the Chair of the Credentials Committee.

4.3 Credentials Committee Review

The Credentials Committee shall:

(a) investigate each application, with specific attention to the Applicant’s qualifications,

experience and his/her professional reputation;

(b) if a re-application, review and consider the Applicant’s Hospital file;

(c) receive a “Department/Service Report” from the Chief of the appropriate medical

services;

(d) receive an Impact Analysis Report from senior management (where required);

(e) complete the “Credentials Committee Report”, in the form of minutes sent to the

MAC; and

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4.4 MAC Review

The MAC shall:

(a) Receive and consider the application, the reports of the Credentials Committee, and

the Impact Analysis (where required);

(b) make its recommendation in writing to the Board within 60 days from the date of the

application. The MAC will also send its recommendation to the Applicant pursuant to the Public Hospitals Act. In the case of a recommendation for appointment, the MAC shall specify its recommendation with respect to privileges the Applicant should be granted and procedures the Applicant should be permitted to perform.

4.5 MAC Recommendation

The written notice provided by the MAC to the Applicant (4.4(b)) shall inform the Applicant that he/she is entitled to:

(a) written reasons for the recommendation if a request for reasons is received by the

MAC within 7 days of the receipt of a notice of the recommendation by the Applicant; and

(b) a hearing before the Board if a written request is received by the Board and the MAC

within 7 days of the Applicant’s receipt of the written reasons.

4.6 Extension of Notice Period

The MAC may make its recommendation later than the 60 day period set out in the Public Hospitals Act and above if, prior to the expiry of the 60 day period, it indicates in writing to the Board and the Applicant that a final recommendation cannot yet be made, and gives the written reasons therefore.

4.7 Board Decision

Subject to the provisions of the Public Hospitals Act, where no hearing is requested, the Board shall either implement the recommendation of the MAC or it shall reject the MAC’s recommendation. In either case, the Board shall cause the MAC and the Applicant to be informed of the Board’s decision regarding the recommendation.

4.8 Request for Hearing

Where an Applicant requests a hearing before the Board within 7 days of the Applicant’s receipt of the written reasons, the Board shall appoint a time for and hold the hearing and shall decide the matter within its authority. The parties to the proceedings before the Board are the Applicant, the MAC and such other persons as the Board may specify.

4.9 Opportunity to Review Evidence

Where the Board is required to hold a hearing, the person requiring the hearing shall be given the opportunity to examine any documentary evidence that will be produced or any

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report, the contents of which will be given orally in evidence at the hearing, prior to the hearing.

4.10 Continuation of Appointment

Where a member of the Professional Staff has applied for re-appointment within the prescribed time, his/her appointment shall be deemed to continue until:

(a) the re-appointment is granted; or

(b) where the Applicant has been served with notice that the Board refuses to grant the

re-appointment, until the time for giving notice requiring a hearing by the Appeal Board has expired and, where a hearing is required, until the decision of the Appeal Board has become final.

4.11 Impartiality

Members of the Board holding a hearing must not have taken part in any investigation or consideration of the subject-matter of the hearing prior to the hearing and must not

communicate directly or indirectly in relation to the subject-matter of the hearing with any person or with any party or representative of a party except upon notice to, and advice from, an advisor independent from the parties. In such a case, the nature of the advice should be made known to the parties in order that the parties may make submissions as to the relevant law.

4.12 Participation in Decision-Making

No member of the Board shall participate in a decision of the Board pursuant to a hearing unless he/she was present throughout the entire hearing and heard all of the evidence and arguments of the parties. No decision of the Board shall be given unless all members present participate in the decision except with the consent of all of the parties.

4.13 Extension of Notice

Despite any limitation of time for the giving of any notice requiring a hearing by the board, the Board may extend the time for giving the notice either before or after the expiration of the time period for giving the notice where it is satisfied that there are apparent grounds for granting relief and where there are reasonable grounds for applying for the extension. It may give such directions as it considers proper as a result of the extension.

4.14 Appointment not to Exceed One Year

Every Applicant who is appointed to the Professional Staff of the Hospital is appointed for a period of not more than one year. Each physician currently on the Professional Staff of the Hospital is entitled to apply for re-appointment or a change in his/her privileges prior to the expiry of the twelve month period in accordance with the Public Hospitals Act.

4.15 Where Hospital Ceases to Operate

If the Board determines that the Hospital will cease to operate as a public hospital or the Minister of Health has directed the Board to cease to operate as a public hospital, the Board

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may make any decision with respect to privileges that the Board considers necessary or advisable in order to implement the Board’s determination or the Minister of Health’s direction including, but not limited to, refusing the application for appointment or re-appointment or for a change in privileges, revoking the re-appointment of any physician, and canceling or substantially altering the privileges of any physician.

4.16 Where Hospital Ceases to Provide Service

If the Board determines that the Hospital will cease to provide a specific service or the Minister of Health has directed the Board to ensure that the Hospital ceases to provide a service, the Board may make any of the following decisions that it considers necessary or advisable in order to implement the Board’s determination or the Minister of Health’s direction:

(a) refuse the application of any physician for appointment or re-appointment to the

Professional Staff of the Hospital if the only privilege to be attached to the appointment or re-appointment relate to the provision of that particular service;

(b) refuse the application of any physician for a change in privileges if the only

privileges attached to the physician’s appointment relate to the provision of that service;

(c) revoke the appointment of any physician if the only privileges attached to the

appointment relate to the provision of that service; and/or

(d) cancel or substantially alter the privileges of any Professional Staff member which

relate to the provision of that service.

4.17 No Hearing Required

The Board may make a decision under certain conditions without holding a hearing, unless a hearing is required by or under the Public Hospitals Act.

5.0 – CRITERIA FOR APPOINTMENT, RE-APPOINTMENT OR ALTERATION IN PRIVILEGES

Unless otherwise noted, this Article applies to applications for appointment, re-appointment and alteration in privileges from Applicants where such application has not previously been made to another hospital in the Policy Group.

5.1 Credentials Committee

(a) Each reference listed on the application will be contacted in writing and may be

personally contacted by telephone by a member of the Credentials Committee to obtain information relating to the past performance, experience, and reputation of the Applicant. The Committee member will make a detailed note to file regarding the time and substance of the conversation and will note on the Professional Staff Application checklist when the referees have been successfully contacted.

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(b) The accuracy of the application information will be determined and noted on the Application Checklist.

(c) The report of the Department Chief shall be received and noted on the Application

Checklist.

(d) The Impact Analysis report shall be received and noted on the Application Checklist.

(e) When a file is complete, including all references checked and the above noted

reports received, the Credentials Committee shall review the Application noting any comments on the Credentials Committee report.

5.2 Department/Service Review

(a) Interviews

(i) Interviews are compulsory for new Applicants. Interviews will be held at the

discretion of the Hospital for Applicants seeking re-appointment and/or alteration in their privileges.

(ii) All interviews shall be arranged with the Chief of Staff and Chief of the

appropriate department/service and may occur at any time.

(iii) Written comments shall be made and filed with the Application Checklist.

(b) External Review

An external review of an Applicant’s performance for those seeking reappointment and/or alteration of privileges may be instituted at the discretion of the appropriate Chief of Department or Chief of Staff.

(c) Physicians Over Age 65

Any privileges granted to the members of the Professional Staff over the age of sixty-five (65) may be subject to an enhanced peer review supervised by the MAC according to the applicable Department’s/Service’s rules and regulations approved by the MAC, with the expressed objective of ensuring ongoing competency of all members of the Professional Staff. The enhanced peer review may include an external review (i.e., by a physician who is not privileged at the Hospital appointed by the Chief of Staff).

(d) Department/Service Report

The Department Chief shall review the application and complete a report. This report shall include commentary with respect to:

(i) category of staff and procedural privileges requested by the Applicant;

(ii) the privileges, duties and responsibilities proposed to be assigned to the

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(iii) a statement of the portion of the Applicant’s time that will be devoted to clinical practice;

(iv) whether the activities requested are consistent with the service’s goal;

(v) whether appropriate supervision may be afforded to the Applicant;

(vi) the Applicant’s ability to supervise others;

(vii) the interview;

(viii) the anticipated impact that the Applicant may have on the allocation of Hospital personnel and services, resource allocation, operating room time and the need for special equipment and/or facilities as well as the estimated fiscal impact of the above, including statement as to whether the activities of the applicant can be safely delivered;

(ix) the service’s specific recommendation regarding the appointment, noting any

dissenting view(s);

(x) the references; and

(xi) any concerns with respect to possible or potential problems with regard to

the Applicant’s competence, collegiality, clinical knowledge, professional attitudes/ethics/character, or any other matter which may impact upon the Hospital’s corporate duty to maintain the safe operation of the Hospital, including ensuring patient well-being.

5.3 Impact Analysis

Senior management will complete an Impact Analysis Report. This report shall include commentary with respect to:

(a) the type of appointment or reappointment;

(b) whether it will be funded by new or expanded funding and the source of that

funding;

(c) the effect on the following matters, including, but not limited to:

(i) bed capacity;

(ii) lab use;

(iii) operating room time;

(iv) anaesthetic use;

(v) radiology use;

(vi) office use; and

(vii) research space;

(d) the impact on nursing;

(e) the impact on other health professionals, e.g., physiotherapists, occupational

therapists, social workers, therapeutic dieticians, etc.; and

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PART C

STREAMLINED PROCESSING OF APPLICATION

6.0 – STREAMLINED APPLICATION PROCESS

6.1 Each Hospital member of the Policy Group acknowledges that it may be beneficial for other

hospitals that are not members of the Policy Group to participate in this common credentialing Policy to allow for a greater pool of Professional Staff from which the

Hospitals may draw. The Hospitals agree to pursue discussions with such other hospitals as the opportunity or need may arise.

6.2 A hospital that is not a member of the Policy Group may become a member upon the

approval of a majority of the member Hospitals’ Boards and the hospital provides evidence that this Policy has been approved and adopted by its Board.

6.3 Applicants may qualify for a Streamlined Application Process provided they hold and agree

to maintain a primary appointment at another Ontario Hospital. The application provided to such Applicants for an initial appointment to the Professional Staff of the Hospital shall require that the application be submitted to the Administrator and shall further contain additional relevant information, including without limitation the following:

(a) a statement by the Applicant that she/he has been appointed, and maintains Active

appointment and privileges in good standing at another Ontario Hospital;

(b) an original document from the Hospital, where the Applicant holds primary

appointment, confirming the Applicant’s appointment and privileges;

(c) an undertaking that, if the Applicant is appointed to the Professional Staff of the

Hospital, the Applicant will provide the services to the Hospital (and will govern him/herself) as stipulated in the Application in accordance with the Public Hospitals Act and Regulation 965 “Hospital Management” there under, and with the Hospital’s By-laws, its Professional Staff Rules and Regulations, the Hospitals’ Mission

Statements, the Health Ethics Guide of the Catholic Health Association of Canada and this Common Appointment and Credentialing Policy, as established or revised by the Hospital from time to time;

(d) an acknowledgement by the Applicant that:

the failure of the Applicant to provide the services as stipulated in the Application in accordance with applicable legislation, Hospital By-laws and policies and

Professional Staff Rules and Regulations will constitute a breach of his or her obligations to the Hospital, and the Hospital may, upon consideration of the individual circumstances, remove access by the physician to any and all Hospital resources, including the limiting or restricting of Operating Room time, or take such actions as is reasonable, in accordance with the Hospital’s By-laws and rules and regulations;

(e) a copy of the Applicant’s current registration or license to practice in Ontario;

(f) confirmation of professional liability insurance coverage or membership in the

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(g) an undertaking that, if the Applicant is appointed to the Professional Staff of the Hospital they will inform the Chief of Staff/Administrator if their primary appointment terminates or concludes; and

(h) a direction to the Administrator authorizing the Administrator to contact the Hospital

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PART D

MID-TERM REVOCATION

7.0 – SUSPENSION/REVOCATION OF PRIVILEGES

The Board or Chief of Staff may at any time in accordance with the Public Hospitals Act and this Policy revoke, suspend, restrict or otherwise deal with the privileges of a member of the

Professional Staff.

7.1 Standing to Issue a Complaint

(a) Any member of the Professional Staff or other person may advance a complaint

concerning any alleged violation by a member of the Professional Staff (in this Article 7 referred to as the “Respondent”) of the By-laws, Rules or Regulations of the Hospital or alleged professional misconduct, incompetence, or professional incapacity, unethical behavior, or other conduct giving reasonable cause for complaint to the Administrator, Chief of Staff, Chief of Department, and/or their respective delegates (in this Article 7, the Chief of Staff and Chief of Department are referred to as Professional Staff Officers”).

(b) Where possible, the Professional Staff Officer notified in Section 7.1(a) shall

inform at least two (2) other Professional Staff Officers and together they shall immediately make a determination as to whether the Respondent’s privileges shall be immediately and temporarily suspended in accordance with Sections 7.2 or 7.3 below or whether the appropriate action is to commence a preliminary

investigation in accordance with Section 7.4 below. Immediate action shall only be taken where the patient’s safety is an issue, and immediate action must in such circumstances be taken to protect the patient(s).

(c) Upon receipt of a complaint about the Respondent, any one of the Professional

Staff Officers and/or the Administrator of the Corporation shall forthwith advise the Respondent as to the nature of the complaint and the manner in which the complaint is being handled.

(d) The Chief of Staff must be advised of all complaints.

7.2 Immediate Suspension of Privileges with Respect to a Specific Patient(s)

(a) Where a Professional Staff Officer and/or the Administrator becomes aware that,

in his/her opinion, a serious problem exists in the diagnosis, care or treatment of a patient or outpatient, such Professional Staff Officer and/or the Administrator shall forthwith discuss the condition, diagnosis, care and treatment of the patient with the attending Professional Staff member, and if satisfactory changes in diagnosis, care or treatment are not made promptly, such Professional Staff Officer shall assume forthwith the responsibility for any necessary investigation and diagnosis of, prescribing for and treatment of the patient, and shall notify the attending member of the Professional Staff, the Administrator, and, if possible, the patient or outpatient that the attending member of the Professional Staff (also, the

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Professional Staff Member for the patient or outpatient. Notwithstanding the foregoing, the due process procedure set out in Section 7.4 through 7.6 must be followed subsequent to the suspension, but before a final determination is made with respect to the suspension of the Respondent’s privileges.

(b) The Professional Staff Officer responsible in Section 7.2(a) may delegate any or

all of his/her responsibilities and duties hereunder to a member of the active Professional Staff in his/her Department, but shall remain accountable to the MAC for the management of the patient by the Professional Staff member to whom any such responsibility or duty is delegated.

7.3 Interim Suspension of Privileges by Board

The Board may, where patient safety or the delivery of quality patient care is an issue and immediate action must be taken to protect the patient(s) and/or staff immediately and temporarily suspend the privileges of the Respondent or obtain an undertaking from the Respondent that he or she will not exercise his or her privileges. Notwithstanding the suspension or undertaking, before a final determination is made of the Respondent’s privileges, the due process procedures set out in subsections 7.4 to 7.6 must, where applicable, be followed.

7.4 Investigation/Complaint Process

(a) Responsibility

The Professional Staff Officers or the Administrator or their respective delegates shall be responsible for undertaking and directing the preliminary investigation of a complaint, in such a manner as is determined reasonably necessary.

(b) Referral to MAC

Following preliminary investigation, the Professional Staff Officers and/or the Administrator of the Hospital, where deemed appropriate, shall place the complaint before the MAC and report upon the investigation of the complaint.

(c) Investigation Terminated

Where the complaint and report of the preliminary investigation of the complaint is not placed before the MAC, the Respondent in question shall be informed of such decision. Where a complaint issued is not placed before the MAC, documentation of such complaint and any report created will not form part of the Respondent’s privileges record.

(d) MAC’s Duties

Where a complaint has been placed before the MAC, the MAC shall:

(i) receive and consider the complaint and report of the preliminary

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(ii) ensure that the Respondent is given no less than 72 hours’ prior notice of the MAC meeting and advise the Respondent that the meeting may proceed in his/her absence;

(iii) determine what recommendation, if any, is necessary with respect to the

privileges of the Respondent subject of the complaint;

(iv) provide to the member subject of the complaint its recommendation in

writing, the reasons and factual information in support of the recommendation and notice that the Respondent shall be given an

opportunity to be heard or respond with respect to the recommendation in advance of the recommendation being communicated to the Board of the hospital;

(v) convene a meeting to which the Respondent shall be invited, wherein the

Respondent shall be given an opportunity to be heard, or in the alternative, to which the Respondent may summit a written response;

(vi) provide notice that the MAC meeting is not a hearing, and as such there are

no formal rules of procedure or rules of evidence; and

(vii) send its final recommendation in writing to the Board and the Respondent

with respect to the Respondent’s privileges.

7.5 Board Process Where Respondent not Heard by MAC

The Board shall, where the Respondent has not been heard as set out in subsection 7.4(d)(v) above:

(a) ensure that the Respondent is given no less than 72 hours’ prior notice of the Board

meeting;

(b) advise the Respondent of the time and place of the meeting;

(c) provide to the Respondent the recommendation to be considered by the Board;

(d) make available to the Respondent the particulars and all supporting documentation

and any other information considered by the individual or individuals in support of the proposed recommendation;

(e) provide notice that the Respondent may appear in person or submit written

submissions;

(f) provide notice that the meeting may proceed in the absence of the Respondent; and

(g) provide notice that the Board meeting is not a hearing, and as such, there are no

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7.6 Board Process Where Respondent Heard by MAC

(a) Notice of Meeting

The Board shall, where the Respondent has been heard as set out in subsection 7.4(d)(v) above:

(i) provide the Respondent with at least seven (7) days notice of a meeting that

it will decide upon a recommendation of the MAC with respect to the Respondent’s privileges;

(ii) permit the Respondent to speak to the recommendation at the meeting;

(iii) provide to the Respondent the recommendation to be considered by the

Board;

(iv) make available to the Respondent the particulars and all supporting

documentation and any other information considered by the individual or individuals in support of the proposed recommendation;

(v) provide notice that the Respondent may appear in person or submit written

submissions;

(vi) provide notice that the meeting may proceed in the absence of the

Respondent;

(vii) provide notice that the Board meeting is not a hearing, and as such, there are

no formal rules of procedure or rules of evidence; and

(viii) inform the Respondent that he/she may be assisted by a representative in making presentation to the Board.

7.7 Members of the Board

Members of the Board holding a meeting shall not have taken part in investigation or consideration of the subject matter of the meeting before the meeting and shall not

communicate directly or indirectly in relation to the subject matter of the meeting with any person or with any party or representative of a party.

7.8 Board’s Decision

After consideration of the recommendation of the MAC or following a meeting of the Board, the Board shall either implement the recommendation or otherwise deal with the matter and cause the MAC and the Respondent to be so advised forthwith.

7.9 Statutory Powers Procedure Act Not Applicable

In the context of the above, a meeting shall not mean a hearing as defined in the Statutory Powers Procedure Act, but rather its terms of reference are to be determined by the Board or the MAC.

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APPROVAL: Joint Medical Advisory Committee, June 2008

DISTRIBUTION: All Professional Staff

REVIEW: Annual

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References

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