Mercy Hospital Medical Staff Credentialing Manual - Mercy Health

CREDENTIALING MANUAL REVISED AND APPROVED BY THE BOARD OF DIRECTORS JANUARY 24, 2008This policy does not apply to AHPs whose discipline is listed in Category 2 but who areemployed by Mercy Health Partners or who have a contractual arrangement with Mercy HealthPartners (by individual, group or staff agency contract or lease).The Governing Board, with recommendations from Administration and the MedicalExecutive Committee, shall approve categories of AHPs who may practice at its site as well asgrant clinical privileges or authorization to practice to each AHP. If AHP services are alreadyprovided by Mercy Health Partners associates, the Governing Board may choose to disapprovethat category. Governing Board, Medical Staffs and management staff are involved in thecredentialing or authorization process for AHPs.PURPOSEThe purpose of this Credentialing Plan (“Plan”) is:1. To establish the procedures to assess, evaluate and review the qualifications,professional conduct, quality and appropriateness of care provided by AHPs in approvedcategories; and2. To establish the procedures and guidelines for consideration of new categories ofAHPs to practice at Mercy Health Partners facilities and sites, based upon the available medicalresources, equipment, supplies and staff, patient convenience, community need, quality of care,efficiency of operations, provider qualifications, and other business and patient care objectivesof Mercy Health Partners.III.CATEGORIESCategory 1- Physician Assistants (PAs)-Advanced Practice Nurses (APNs) – including Certified Registered Nurse Anesthetist,Certified Nurse Midwife, Advanced Practice Nurse, Certified Clinical Nurse SpecialistPAs must be: 1) credentialed through medical staff processes, 2) granted delineatedclinical privileges, 3) afforded rights of hearing as set forth in this Plan but not a Medical StaffFair Hearing Plan, 4) monitored through the hospital’s performance improvement activities, 5)subject to reappointment and evaluation at least every two years through medical staff processesand, 6) subject to all The JC standards relevant to practitioners with delineated clinicalprivileges.APNs are subject to all of the above except with regard to the credentialing process,which may be the same as, or equivalent to the Medical Staff process in one of the followingways:a) same as PAs,b) same as PAs with the additional participation of a Nurse Management Reviewer, or21