ࡱ> k bjbj88 4BxRbxRb  RRRRRfff8< fA.2D$A A A A A A A$DGDAR"""DARRYA)))"rRRA)"A))r.T2/H^($ / AoA0A$/H4%H2/J/HR"1Ar)S \ AAADADA 'AAAA""""HAAAAAAAAA B :  STONY BROOK UNIVERSITY HOSPITAL MEDICAL STAFF SERVICES DEPARTMENT CREDENTIALING POLICY Stony Brook University Hospital (SBUH) has established policy guidelines for credentialing and recredentialing providers of patient care services at this institution. These guidelines ensure that physicians/dentists (MD, DO, DMD, DDS) and other health care practitioners (nurse practitioners, nurse midwives, psychologists, physician assistants, specialist assistants, podiatrists, speech pathologists, audiologists, neuropsychologists, optometrists, certified registered nurse anesthetists, social workers with R psychotherapy credentials per New York State Education Dept, acupuncturists, and registered nurse first assists appointed to serve our patients will meet uniform standards of education, specific training and experience, current competence and ability to perform the privileges assigned to them. The policies and procedures delineated below have been established by the Medical Executive Committee of the Medical Board (MEC) in accordance with all applicable regulatory and accreditation standards, such as the University Hospital Medical Staff Bylaws, the New York State Department of Health, the Joint Commission on Accreditation of Healthcare Organizations, the National Committee for Quality Assurance, etc. The MEC and the Medical Board will review changes to this policy. SBUH does not sub-delegate credentialing or recredentialing. CREDENTIALING PROCEDURE The Chief Medical Director has overall responsibility for the credentialing process. Duties include: Direct the medical staff organization in accordance with New York State Health Department regulations. Be a voting member of the Medical Quality Assurance committee of the medical board. Coordinate the clinical programs of the medical staff of Stony Brook University Hospital. Assist the medical staff in establishing goals/objectives and mediate conflicts that arise. Participate in medical school/hospital planning as a member of the joint planning committee. Assist with the regulatory requirements in relation to graduate and postgraduate medical education programs. Direct the medical staff organizations in accordance with Joint Commission standards while maintain accreditation status. Standards for Participation All applicants (except Physician Assistants, Specialist Assistants, Certified Nurse Anesthetists and Social Workers with R psychotherapy credentials per New York State Education Dept) must possess a faculty appointment in the School of Medicine or Dental Medicine to be eligible to apply for appointment to the medical staff and/or privileges in the hospital. (Interim appointments are granted for 120 days pending faculty appt this appointment is with full privileges as approved. Practitioners applying for the category of Affiliate/Referring with Outpatient Privileges must possess a current faculty appointment at the time of appointment review.) All applicants shall submit a completed medical staff application form with appropriate documentation as requested on the application form. This includes signed statements and a release of information page. All applicants shall allow for applicable facility on-site review of their records and medical record keeping practices as designated by the rules and regulations of the medical staff and the facility. All applicants must be licensed as delineated in the medical staff bylaws, and currently registered (or certified) in New York State. All applicants should have a current unrestricted DEA registration, if applicable to their specialty and practice. Applicants with pending DEAs may be appointed provided the Chief of Service delegates another practitioner for prescribing. All applicants must possess a current and valid certificate of infection control training as authorized by the State of New York. All applicants must submit a complete SBUH physical examination form, which is reviewed by Employee Health Services. Employee Health Service will determine if the practitioner meets the health requirements for appointment to the staff. A copy of the health information is maintained by Employee Health Services. Applications are not considered complete until clearance is obtained by Employee Health Services. All applicants will remain eligible to treat our Medicare and Medicaid patients if they remain free of any sanctions imposed by the Medicare/Medicaid or other governmental health related program. All applicants must have at least the minimum professional malpractice insurance with limits as defined by the SBUH Medical Staff Bylaws, Rules and Regulations and any other hospital requirement. All applicants must submit a complete work history (CV), chronologically outlined from graduation to the present. All applicants must provide, on their completed application, a full disclosure of malpractice history for the past ten (10) years, including any cases that are pending/outstanding in any state where the applicant has practiced. CREDENTIALING/RECREDENTIALING CRITERIA The following information will be reviewed/queried as indicated below (timeframe for verification). Primary source information is obtained as indicated below. All information is electronically saved in the practitioners file with the exception of the NYS license, which is queried and saved through the medical staff database. Licenses and certifications are entered into the Medical staff database and the image is attached. All primary source verifications have a date on the document. Additionally, the date of verification obtained is indicated on the appointment/reappointment checklist. All updates/changes i.e., date, user and change, are tracked within Medical staff database via the audit logger or the actual image. Access to data and the ability to enter or revise data is delineated by the category of user and controlled by the administrator (see Computer Access policy). Information is updated as delineated below. Every appointment and reappointment application, including examination of attached images is audited by either the director or assistant director before it is processed. An audit checklist is completed for every appointment file. If corrections/revisions are indicated, the audit checklist is amended when items are resolved. Items audited on the reappointment checklist are initialed by either the Director or Assistant Director. Input of privileges is reviewed for accuracy by a staff member other than the staff member who originally entered the data. Refer to Computer Access policy for information on database security. CredentialSourceMethodTime Frame for VerificationNYS Licensure Other state licenses NYS Education Dept and/or Federation of State Med Bds  HYPERLINK "http://www.op.nysed.gov/opsearches.htm" http://www.op.nysed.gov/opsearches.htm http://www.fsmb.org/directory_smb.html Electronic query through database or internet query NYS - Upon application, reappointment & date of expiration Other states Upon appointment (within 180 calendar days*) Additional privileges (NYS)DEA (in all states indicated by practitioner)DEA  HYPERLINK "https://apps.deadiversion.usdoj.gov/webforms/validateLogin.jsp" https://apps.deadiversion.usdoj.gov/webforms/validateLogin.jsp Internet queryUpon application, reappointment & date of expiration (currently not required at appointment if applied for) (within 180 calendar days) NOTE: if practitioner does not have a valid DEA or the current DEA does not have a NYS address, the file must contain a waiver stating a provider who will prescribe on their behalf, with the exception of those practicing in an area that does not require a DEA (i.e, including but not limited to radiologist, pathologist)Education - graduate of medical/dental or other professional schoolMedical/Dental professional school registrar or AMA Physician Profile  HYPERLINK "https://profiles.ama-assn.org/amaprofiles/" https://profiles.ama-assn.org/amaprofiles/ or AOA https://osteopathic.org/Internet query with AMA, AOA or direct query to school registrarUpon application (within 180 calendar days)Post-graduate trainingResident and/or fellowship program director  HYPERLINK "https://profiles.ama-assn.org/amaprofiles/" https://profiles.ama-assn.org/amaprofiles/ or AOA  HYPERLINK "https://osteopathic.org/" https://osteopathic.org/ Internet query - AMA or AOA Physician Profile or direct query to program/institution Upon application & reappointment, if applicable (NYS 2805K law) (within 180 calendar days)Board CertificationSpecialty Boards  HYPERLINK "http://www.certifacts.org/" http://www.certifacts.org/ (MD)  HYPERLINK "https://www.doprofiles.org/" https://www.doprofiles.org/ (DO)  HYPERLINK "http://www.abgd.org/" http://www.abgd.org/ (DDS)  HYPERLINK "http://abgd.org/boardcertified.php" http://abgd.org/boardcertified.php (DDS)  HYPERLINK "http://www.abpd.org/" http://www.abpd.org/ (DDS/Peds)  HYPERLINK "http://www.aae.org/certboard/ " http://www.aae.org/certboard/  (Endodontists)  HYPERLINK "http://www.nccpa.net/Employers.aspx" http://www.nccpa.net/Employers.aspx (PA)  HYPERLINK "http://www.nursingworld.org" www.nursingworld.org  HYPERLINK "http://www.nursecredentialing.org/Certification/VerifyCertification" http://www.nursecredentialing.org/Certification/VerifyCertification (NP)  HYPERLINK "https://www.aanpcert.org/ptistore/control/verification/select" https://www.aanpcert.org/ptistore/control/verification/select (NP)  HYPERLINK "http://www.abps.org/content/credentialers/PrimarySourceInfo.aspx" http://www.abps.org/content/credentialers/PrimarySourceInfo.aspx (podiatrists)  HYPERLINK "https://www.abpmed.org/pages/credentialers/verification" https://www.abpmed.org/pages/credentialers/verification (podiatrists)  HYPERLINK "https://www.aboms.org/publicpages/verifications/verifications.aspx" https://www.aboms.org/publicpages/verifications/verifications.aspx (oral surgeons) https://www.aana.com/ (CRNA)  HYPERLINK "https://www.amcbmidwife.org/" https://www.amcbmidwife.org/  HYPERLINK "http://www.midwife.org/Certification" http://www.midwife.org/Certification (Midwife) or respective board as indicated. Direct query and/or internet query Certifacts or ABMS Compendium or AOA internet (if applicable), or appropriate agency as indicated. Upon application, reappointment, or change in status or expiration (within 180 calendar days) Effective, February 18, 2023, in cases when the board certification has not been updated in Certifacts (reverification date is expired, but provider is still indicated as certified, or if there is information that the board has not been upated), the board will be queried again in one month. A query will be done monthly until it is determined the information (reverification date and or status) is updated. Malpractice Insurance Clinical Practice Management Plan, Respective dept, or information provided by practitioner. Copy of insurance binder/certificate Upon application, reappointment & expiration date (current or future insurance documented at time of appointment and current insurance at reappointment.). Peer RecommendationResidency/Fellowship Director or appropriate peer who has knowledge of applicants current clinical competence.A minimum of two recommendations will be solicited by the MSO from peers who can attest to the clinical competence of the applicant and ability to perform the procedures requested. (the request for privileges form completed by the applicant is submitted with the request for a competency judgment.)Upon application for all applicants and at reappointment, for low volume/no activity practitioners as determined by the individual service. (within 180 calendar days)Licensure Sanctions NY State Office of Professional Medical Conduct  HYPERLINK "http://www.health.state.ny.us/professionals/doctors/conduct/" http://www.health.state.ny.us/professionals/doctors/conduct/ (physicians and physician assistants)  HYPERLINK "http://www.op.nysed.gov/opd/rasearch.htm" http://www.op.nysed.gov/opd/rasearch.htm (other than physician and physician assistants) Email listserv from NYS e.g. notify01@health.ny.gov Internet query or electronic query through database List serve from NYS Upon application, reappointment & expiration date of NYS license via OPMC website. (within 180 calendar days) Reports from OPMC are also checked as frequently as they are available on the internet (office of the professions) or via email. If a practitioner receives any sanctions, the medical director and the chief of service are immediately notified. Depending upon the sanction, appropriate action will be taken (ie., report to the MEC, Medical Board and Governing Body-reference to Bylaws) SBUH is on the automatic email list and receives updates to the list immediately. Therefore, all practitioners are being checked as often as the list is updated.Malpractice Claims HistoryApplication (appointment and reappointment), NPDB 2805K responses. NPDB is queried via medical staff database  HYPERLINK "https://www.npdb-hipdb.hrsa.gov/" https://www.npdb-hipdb.hrsa.gov/ Electronic query through database or direct query to NPDB, hospital affiliations per 2805 regs, and carrier when possibleUpon application & reappointment (within 180 calendar days) Hospital clinical privilegesApplication (appointment and reappointment)Direct query with hospital 2805 letterUpon application & reappointment (within 180 days)Work history gaps** Application and/or CVDirect query with source/ explanation from applicantUpon applicationAttestation regarding health status Health form with applicationDelivered to Employee Health Service for clinical reviewUpon application & annually thereafter (health form) Medicare & Medicaid Sanctions Medicare Opt Out National Practitioner Data Bank /  HYPERLINK "https://www.npdb-hipdb.hrsa.gov/" https://www.npdb-hipdb.hrsa.gov/ OIG, OMIG, OFAC, Opt Out, SAM are queried via Streamline Streamlineverify.com *Staff Exclusion List (SEL) *Statewide Central Register Database Social Security Death Masterfile Streamlineverify.com Source SSA-DMFElectronic query through database Internet query *For Psychiatry only. *Queries are done by HR Internet query Upon application, reappointment and monthly as available and/or required by regulation (within 180 calendar days) At appointment At appointment and reappointment ComplaintsManaged Care Companies/OtherIf a complaint is received in the MSSD, it will be immediately referred to the respective Clinical Chief for review and resolution. Complaints not submitted to the MSSD are handled according to hospital policyAs neededInfection Control Certification NY State Approved Course CertificateVisual inspection of certificateUpon application & expiration dateCriminal Background CheckCastlebranch Castlebranch.com Internet queryAppointmentPractitioner Identification Original government issued photo presented in person to MSSD or departmental representativeIdentify practitioner, complete form, copies to fileUpon appointmentWorkmans Compensation (10/05) HYPERLINK "https://www.wcb.ny.gov/HealthCareProviderSearch/?submitHome=Search+for+Health+Care+Provider" https://www.wcb.ny.gov/HealthCareProviderSearch/?submitHome=Search+for+Health+Care+ProviderInternet queryUpon notification from CPMP that the practitioner has been accepted as an authorized provider (CPMP Only) Medicaid Status HYPERLINK "https://health.data.ny.gov/Health/Medicaid-Enrolled-Provider-Listing/keti-qx5t/data\\" https://health.data.ny.gov/Health/Medicaid-Enrolled-Provider-Listing/keti-qx5t/data\  HYPERLINK "https://nam11.safelinks.protection.outlook.com/?url=https%3A%2F%2Furldefense.com%2Fv3%2F__https%3A%2Fnam11.safelinks.protection.outlook.com%2F%3Furl%3Dhttps*3A*2F*2Fwww.emedny.org*2Finfo*2FProviderEnrollment*2FManagedCareNetwork*2Findex.aspx%26data%3D04*7C01*7CJoyce.Klein*40stonybrookmedicine.edu*7Cea4e141698c84e83448708d9fad51c74*7Ceafa1b31b194425db36656c215b7760c*7C0*7C0*7C637816615507758251*7CUnknown*7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0*3D*7C3000%26sdata%3DWcz*2B6uLSjbmvHiqBUko7fswnSBsMgbzjqzVlYSFVlko*3D%26reserved%3D0__%3BJSUlJSUlJSUlJSUlJSUlJSUlJSUl!!Js732Vmb!9Ldc5GXAtFo9JQqE45qwFONqmG-WDuGvbap_CusGhyvEPlFAnsoGTXg2fL2HRoE3%24&data=04%7C01%7CJoyce.Klein%40stonybrookmedicine.edu%7C819be03b648247f443a908d9fae2e759%7Ceafa1b31b194425db36656c215b7760c%7C0%7C0%7C637816674752246301%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000&sdata=1IJv2lpdqAizSPdvhCKL7%2F2bB3Ujlf91P2596A2RLz4%3D&reserved=0" https://www.emedny.org/info/ProviderEnrollment/ManagedCareNetwork/index.aspx Internet query or letter from MedicaidAppointment at a minimum, until verifiedNPPE (NPI Number)  HYPERLINK "https://npiregistry.cms.hhs.gov/" https://npiregistry.cms.hhs.gov/ Or Streamlineverify.comElectronic query through database or internet queryAppointment and reappointment 12/17 *180 days of date applicant signs appointment application. ** Primary source verification of work history for all practitioners that was completed more than 10 years ago, only requires one verification attempt. Unverified >10 yrs will be indicated on the checklist and will not be presented to the MEC/Medical Board. CONFLICTING INFORMATION/INFORMATION REVIEW BY PRACTITIONER The practitioner will be sent a letter at the time the application is received in the Medical Staff Services Dept (MSSD) advising him/her that the application has been received, and elements that are missing. The practitioner has the right to review his/her entire application, with the exception of peer review/faculty reference letters or any document which has been submitted to the MSSD and is marked confidential and the National Practitioner Data Bank response. The letter will also state that upon request, the applicant will be advised of the status of their application, by telephone. Status of application includes providing information on items which are missing to make the application complete (i.e, verifications from other institutions, peer recommendations, etc). Status also includes where the applicant is in the credentialing process (i.e., at credentials committee, medical board, etc) The practitioner will be notified via mail, email or phone call if primary source verification data is not in agreement with information submitted in the appointment application package. The practitioner will have two weeks to correct this information with an explanation. All corrected information must be primary source verified. Corrected information shall be submitted in writing, via fax, email or mail, to the MSSD. The practitioner will be notified in writing, via fax, email or letter, when the corrected information has been received. LEVELS OF REVIEW Appointment to the Medical Staff and approval of privileges will follow the review process delineated in the Medical Staff Bylaws, Rules and Regulations, Article II, Section 3B. Levels of Review. Once an application has been processed and determined to be complete++ by the MSSD, the complete application file is submitted to the respective department. The file is reviewed at the applicants level of specialty, by the Division Chief, (if one exists). The file is then reviewed by the Credentials Committee which considers the completed application and supporting materials, makes such investigations as it deems proper and necessary, and makes a recommendation, including specific recommendations for delineating the applicant's clinical privileges to the Chief of Service. The file is then reviewed by the Chief of Service and his/her recommendation is submitted to the MEC and Medical Board who then recommends to the Governing Body for final approval. Minutes which reflect the recommendation of the credentials committee are submitted to the MSSD. The Director, Advanced Practice Providers/Nurse Practitioner, or their designee reviews all Nurse Practitioner applications and makes a recommendation to the respective departmental credentials committee. ++Complete application file is defined as a file that contains: primary source verification for licensure and license sanctions (NPDB response is considered acceptable for PSV for license sanctions), DEA (if applicable), board certification (if applicable), education and residency/fellowship training and work history; NPDB response; queries to OIG, OPMC, other regulatory agencies detailed above, hospital affiliation(s); peer references; infection control certificate; completed medical staff application document (information is complete and accurate; all questions are answered; all signatures and dates are evident), photo and privilege sheet (if applicable); verified identification, completed orientation training, criminal background check completed, application fee, if applicable, clearance from Employee Health Service; practice agreement, if applicable, department interview, if applicable, indication of malpractice coverage, life support, if required, delineation of malpractice cases since inception of training, DRG statement signed, completed SEL and Child Abuse verification, if applicable, Addiction Medicine-Code of Conduct, if applicable, Hazard Drug Education, if applicable. A gap exceeding six months must be clarified by the applicant, reviewed and documented in the file. Administrative Privileges may be granted to a health care practitioner while waiting final approval by the MEC, Medical Board and Governing Body. Such privileges are granted only when the practitioner has completed the credentialing process, the Division Chief, if applicable, Credentials Committee and Chief of Service have reviewed the application and have recommended appointment. Practitioners who are granted administrative privileges will be granted provisional credentialing (per NCQA regs). Physicians will not be permitted to see patient members of any managed care company which delegates credentialing to SBUH until the credentialing process is completed and they have received final approval by the Governing Body, unless they have been provisionally credentialed as defined above. Once the Governing Body grants approval, the applicant will be sent a letter of appointment. The letter of appointment will be sent to the applicant within 60 days of the Governing Body approval. All applications for medical staff privileges will be completed (submitted to the MEC/Medical Board for review) within 180 days of the signature of the applicant. All verifications will be completed within 180 days. In rare cases, if the application is not completed within 180 days, the applicant will be asked to attest that nothing in their clinical practice has changed, or if there have been changes to indicate such changes. Verifications more than 180 days will be reverified. The applicant will review his request for privileges and indicate that there are no changes. Initial applications will be processed and presented to the credentials committee within 60 days of receipt of completed++ application. DATA VERIFICATION For verification purposes and to ensure that listings in rosters, directories, etc are accurate, after the practitioner is appointed to the staff, he/she will be sent a verification form indicating the education, training, board certification and specialty information that has been input into the medical staff database (eff 5/05). The practitioner will be asked to verify the information and contact the MSSD with any revisions/corrections. Any corrections/revisions to data received from the practitioner will be reviewed with data currently in the database and in the practitioner credentials file. All data must be primary source verified. If this is additional data, not previously identified, primary source verification must be completed. (Note: Data contained in the medical staff database is the source of data utilized by the managed care department for reporting to managed care companies. REAPPOINTMENT There is a process in place to review each practitioner credentialed through the MSSD every two years. However, a two-year review does not eliminate ongoing surveillance and review of quality issues presented during the two years prior to reappointment. Reappointment is alphabetical and occurs quarterly (reappointment date is tracked in medical staff database). The practitioner receives notification of this review and is sent a reappointment application to complete. S/he is expected to sign off on the reappointment application that contains, among other things, a request for updated physical and mental health status, and an attestation of lack of impairment due to chemical dependency/substance abuse. The file will first be reviewed in the MSSD that does primary source verification (see table above). Additionally, education, training, experiences and competencies since the last appointment or reappointment are reviewed and if applicable, primary source verification is done. All complaints submitted to the MSSD from managed care companies will be included in the reappointment application. A checklist will be used to indicate the date information was received in the MSSD. The medical staff office will also utilize a checklist to indicate the date all required items were verified to be current and in good standing. A date stamp will be used on all incoming mail. Documents received via the fax, will automatically have a date and time printed on them from the fax machine. A reappointment file is only submitted to the department when it is determined to be complete. A complete file includes: (NOTE: not all items are available for all practitioners whatever is submitted to the MSSD is included): Complete reappointment application Request for privilege form (with the exception of Affiliate/Referring category) Malpractice Summary Sheet citing actions within the past 2 yrs, if applicable National Practitioner Data Bank Query Response CME information submitted by practitioner Clinical activity log from SBUH for practitioners with activity at SBUH Verification responses (per NYS law 2805) from other hospital affiliations Quality assurance data, including adverse events, which are specifically attributed to the practitioner. A checklist will be included indicating if there is no information to review; (i.e., practitioner has had no quality issues, practitioner has not had any mortality/morbidity reviews, practitioner has not had any patient complaints, etc since the last appointment/reappointment). Summary of QA reviews Comparative database report QA data submitted by managed care companies, if applicable and/or submitted Surgical site infection rates if applicable Patient complaints Actions by any regulatory agencies Disciplinary reviews Medical record delinquencies OPPE Reports Current health clearance from Employee Health Service A checklist completed by the MSSD indicating: Primary source verification of current licensure, board certification status, and DEA, if applicable Malpractice insurance Infection control training Verification of current annual health assessment reviewed by Employee Health Service Query conducted for Medicaid/Medicare exclusions (OIG database), EPLS, Opt Out, OMIG, OFAC, SSDMF, NPPE and Professional actions by the Office of Medical Professional Conduct NPDB Life support as required A department reappointing a low volume/no activity practitioner who is requesting privileges, may require that the practitioner contact the Chief of Service or appropriate peer at their primary affiliation and request that they submit a reference attesting to clinical competency to the SBUH clinical department. This information will be collected by the respective department and included in the reappointment file. The complete file is submitted to the department for the same levels of review as the appointment process. Specifically, the Director, Advanced Practice Providers/Nurse Practitioner, or their designee reviews all Nurse Practitioner applications and makes a recommendation to the respective departmental credentials committee, the Division Chief, if applicable, and the Chief of Service will review the file and complete an Assessment of Competence for the Practitioner (attached). The Credentials Committee will review the file and complete the Credentials Committee Reappointment Assessment (attached). The entire file and the completed forms will be submitted to the Chief of Service for review, signature and recommendation. Minutes which reflect the recommendation of the credentials committee are submitted to the MSSD. Once the Governing Body grants approval, the applicant will be sent a letter of reappointment and a copy of the privileges granted, if applicable. The letter of reappointment will be sent to the applicant within 60 days of the Governing Body approval. REDUCING, SUSPENDING, TERMINATING PRIVILEGES There is a mechanism in place for reducing, suspending or terminating practitioners privileges. It is described in detail in Article II, Section 6 and Article III of the Medical Staff Bylaws. It describes the appeal process for use by the practitioner. SBUH reports the reduction, suspension or termination of practitioner privileges to the appropriate outside agencies in accordance with applicable law, accreditation standards and the process dictated by the respective agency (see reporting adverse actions). NON-DISCRIMINATORY CREDENTIALING DECISIONS Healthcare practitioners are appointed/reappointed/granted privileges based on the need for their services consistent with the objectives and programmatic needs of the institution. Appointment or reappointment to the medical staff shall not be denied to any individual for reason of gender, race, ethnic/national identity, creed, color, age, marital status, sexual orientation, the types of procedures or patients (e.g..medicaid) the practitioner specialize in, or disability, except where that disability renders the person incapable, despite reasonable accommodation, of performing the essential functions of the medical staff appointment. The MSSD will conduct a quarterly audit of denied practitioner applicant files, non-reappointment and terminated practitioner files to ensure that practitioners are not discriminated against as indicated above*. Findings indicating possible discrimination will be reported to the Medical Board. Additionally, members of the credentialing committee may not participate in the review of a provider in which their judgment may be compromised/influenced due to their relationship with the provider. CONFIDENTIALITY POLICY FOR THE MEDICAL STAFF SERVICES DEPARTMENT The records of the medical staff services department shall be considered confidential. They may be reviewed upon appropriate request and the approval of the President of the Medical Board or the Medical Director. The hard copy of the credentials files reside in the MSSD, which has daily security patrols by Public Safety. Personal ID and passwords allow entry by the staff to the computer databases in the MSSD. These are changed intermittently. If an employee leaves, their password is deleted. Back-ups of the system take place on a regular basis by office staff and Information Technology. The medical staff office is open from 8:30 a.m. - 5 p.m., Monday through Friday, except for major holidays. These rooms are never left unattended without being securely locked. Personnel are told during their orientation about the importance of file confidentiality and it is written in their job description that is reviewed annually during their evaluation. All personnel complete HIPAA training. With approval from the medical director, the practitioner has the right to review his credentialing file. The practitioner does not have the right to review any documentation that has been submitted and marked confidential by the submitter (i.e., faculty appointment letters that the writer has marked confidential). The practitioner does not have the right to view the NPDB response. CONTENT OF FILES The entire contents of the appointment and reappointment files will be maintained until the practitioner is no longer on the medical staff at which time, the entire file will be scanned and maintained in electronic format. ONGOING SANCTION MONITORING FOR LICENSURE, OIG EXCLUSIONS, DISCIPLINARY ACTIONS, SANCTION QUERY TIMEFRAME: LICENSURE: All NYS licenses are primary source verified through the New York State licensing board at the time of appointment, reappointment, and expiration. Documentation of queries will be indicated by the verifier. Effective 2013, all verifications will be maintained electronically. Hardcopies with initials and dates will no longer be maintained. OPMC: OPMC is primary source verified for license sanctions at appointment, reappointment and licensure expiration and whenever received via email notifications ( HYPERLINK "mailto:notify01@health.state.ny.us" notify01@health.state.ny.us). Documentation of queries at appointment, reappointment and expiration will be indicated by the verifier on the NYS license verification on the reference to the OPMC website. Effective 2013, OPMC queries will be saved electronically in the medical staff database. . Hardcopies with initials and dates will no longer be maintained The NYS Professional Misconduct Enforcement website  HYPERLINK "http://www.op.nysed.gov/opd/rasearch.htm" http://www.op.nysed.gov/opd/rasearch.htm is queried for all other practitioners. NOTE: NPDB queries satisfy the requirement for querying state sanctions. OIG: OIG exclusions are reviewed via the OIG database (via Streamlineverify.com) at the time of appointment, reappointment and as frequently as a new exclusion list is posted to the website. OIG is queried within 30 calendar days of release via the medical staff database. All other agencies will be queried at the time OIG is queried. ACTION ON ADVERSE INFORMATION Any adverse information obtained from the above mentioned sources (license revocation, suspension, revocation, restriction, probation, loss of Medicare/Medicaid provider status, failure to comply with DOH mandated requirements, loss of malpractice insurance) is immediately referred to the Chief of Service, the Chief Medical Office, the MEC, Medical Board, and the Governing Body. The procedure for review and action on adverse information received from these sources adheres to the procedures set forth in the University Hospital Medical Staff Bylaws, Rules and Regulations (Article II and III). REPORTING ADVERSE ACTIONS SBUH conforms to the requirements and procedures for reporting adverse clinical privilege actions as dictated by the National Practitioner Data Bank and New York State. (reference:  HYPERLINK "http://www.npdb-hipdb.hrsa.gov/resources/NPDBGuidebook.pdf" http://www.npdb-hipdb.hrsa.gov/resources/NPDBGuidebook.pdf).Specifically, professional review actions, based on reasons related to professional competence or conduct, adversely affecting clinical privileges for a period longer than 30 days or voluntary surrender or restriction of clinical privileges while under, or to avoid, investigation will be reported. Copies of NPDB adverse action reports are also submitted to the Office of Professional Medical Conduct, 433 River St., Troy, NY 12180, Attn: Intake Unit. A copy of the adverse action report is maintained in the practitioners confidential credentials file. Information concerning the action is also maintained in the medical staff database. The Chief Medical Officer, President of the Medical Staff or Associate Director for Medical & Regulatory Affairs is responsible for reporting adverse actions ONGOING MONITORING Patient/visitor complaints within the hospital as well as those received from any managed care company, will be reviewed in accordance with the Administrative Policy on Patient/Visitor Complaints (RI:0005). Adverse events and/or quality issues regarding a practitioner will be reviewed at least monthly by a multidisciplinary group including risk management, physician and nursing leaders in accordance with the Medical Staff QA process outlined in the Medical Staff Bylaws, Rules and Regulations. PRIVILEGING FOR PROCEDURES All members of the medical staff shall be eligible for clinical privileges as demonstrated by their individual education, training, experience and competence, and as recommended by the Credentials Committee, the Chief of Service, the MEC, Medical Board, and approved by the Governing Body. These privileges must be consistent with the objectives and programmatic needs of the medical center. No member of the medical staff shall be permitted to perform any diagnostic or therapeutic procedure, which does not fall clearly under the commonly accepted and established guidelines of their specialty and has not been specified in the delineation of privileges, except in an emergency. In an emergency, a medical staff member is authorized to do everything possible to the degree permitted by his or her license, but regardless of his or her department affiliation, staff category or level of privileges, to save a patients life or to save a patient from serious harm. It is the responsibility of each applicant to establish their qualifications and competency for the clinical privileges desired or requested. SBUH utilizes the core privileging approach to delineating privileges. Core privileging involves specifying for each specialty a group of procedures and/or treatments (a combination of medical assessment and management as well as procedures) that a practitioner would almost always be qualified to perform upon completion of residency training in a particular specialty. Unless there is evidence to the contrary, every recent graduate of a specialty residency should be granted the core privilege for his or her specialty area. Practitioners who have not recently completed a residency training program would be qualified based upon practice experience in their specialty. These procedures together form a single privilege, called the core privilege, for the specialty. Core privileges are described in a simple, straightforward paragraph. A list of core procedures, included but not limited to, is delineated for reference only. Criteria for requesting Core Privileges is also delineated on each privilege sheet. In instances where the equivalent as defined by the Chief of Service is considered as criteria, the equivalent as defined by the Chief of Service is interpreted to mean: for those practitioners who have not completed an accredited residency/fellowship program which allows them to be board certified or considered board admissible, foreign training, unaccredited fellowship training, peer recommendations, prior experience, foreign board status, and/or recognition in field of expertise is considered. The appointment of practitioners who have not completed an accredited residency/fellowship program which allows them to be board certified or considered board admissible, will also be reviewed by the Hospital credentials committee. If appointed to the medical staff, the practitioner will be proctored for a minimum of 10 cases or until clinical competence is determined by the proctor, whichever is greater There are usually special procedures or medical management of conditions that are not part of the core because they are either new, high risk or require additional training and experience. These procedures are referred to as Category 1 or Category 2 on the privilege sheets. Criteria for requesting these privileges are delineated on each privilege sheet. Renewal of Privileges. Clinical privileges will be renewed every two years at the time of the reappointment. The practitioner will be required to submit a request for privileges with consideration to their current clinical practice. Consideration of renewal of privileges will be based on the information contained in the reappointment file as delineated in this policy. Increase of privileges. Requests for an increase or a new privilege, which was not previously requested and/or reviewed, will require documentation of competency as delineated by the department and will follow the same level of review as delineated for appointment and reappointment. License verification and NPDB query will be conducted by the MSSD. General Privileges for Active Attending Physician appointed to the medical staff. All active attending physicians of the medical staff are automatically granted privileges to: Admit patients, except for services which do not admit patients (i.e. Pathology and Emergency Medicine) Perform histories and physicals Order diagnostic and therapeutic services Make referrals and request consultations Provide consultations within the scope of his or her privileges Use all skills they are currently competent to perform. Render any care in a life-threatening emergency Changes to this credentialing policy will be submitted to and approved by the MEC/Medical Board. The credentialing policy will be reviewed at least annually This policy was reviewed and approved by the MEC, on November 17, 2002 Revised July 2003. Revised March 2004 Medical Board Approval October 19, 2004 Revised Feb 28, 2005 Draft revision December 23 2004 Draft revision March 25, 2005 submitted to April 19, 2005 MEC Approved April 19, 2005 MEC Draft revision May 4, 2005 submitted and approved May 5, 2005 Medical Director, Associate Director for Medical Regulatory Affairs, Chair MEC, Legal Counsel SUNY 5/24/05 Medical Board Reviewed - Approved December 20, 2005 Draft created 11/07/06 Medical Board Reviewed Approved 12/06 Medical Board Reviewed Approved 01/08 Medical Board Reviewed Approved 12/08 (#6 General privileges) Medical Board Reviewed Approved 12/09 (nondiscriminatory section) Medical Board Reviewed Approved 12/10 (URLs added) Medical Board Reviewed no changes 12/11 Medical Board Reviewed no changes 12/12 Medical Board Reviewed Approved 12/13 Medical Board Reviewed Approved Dec 2014 Medical Board Reviewed Approved October 2015 Medical Board Reviewed Approved July 2016 (privileges) Medical Board Reviewed Approved October 2016 (Queries) Medical Board Reviewed Approved Sept 2017 Medical Board Reviewed Approved March 2018 Medical Board Reviewed Approved August 2018 Medical Board Reviewed Approved February 2019 Medical Board Reviewed Approved December 2019 Medical Board Reviewed Approved February 2020 Medical Board Reviewed Approved March 2020 (Insurance) Medical Board Reviewed Approved June 2020 (60 day) Medical Board Reviewed Nov 2020 CME Reviewed Medical Board Reviewed Approved Dec 2020 (DEA) Medical Board Reviewed Approved April 2021 Medical Board Reviewed Approved October 2021 Medical Board Reviewed Approved March 2022 Medical Board Reviewed Approved October 2022 Medical Board Reviewed Approved March 2023 Medical Board Reviewed Approved November 2023 Medical Board Reviewed Approved March 2024     &H\]^ K    @ G H p r t x ꢗ|qfXh0S$hI>,5CJ\aJh0S$hnCJaJh0S$hDCJaJh0S$h?5CJaJh0S$hoB*CJaJphh0S$hoCJaJh0S$h"YDCJaJh0S$hNCJaJh0S$h6; CJaJh0S$h -5CJ\aJh0S$h?5CJ\aJh0S$h{.CJaJh0S$h?CJaJh:h?CJaJ&H^_ s t #4Io & Fdd[$\$gdI>, 7$8$H$gdhgdhgd?$a$gd?gd? 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