Mercy Hospital Medical Staff Credentialing Manual - Mercy Health

CREDENTIALING MANUAL REVISED AND APPROVED BY THE BOARD OF DIRECTORS JANUARY 24, 2008receipt of notice of any formal charges or the commencement of a formal investigation byany professional regulatory or licensing agency; the filing of charges by the Department ofHealth and Human Services; Peer Review Organization, or any law enforcement agency orhealth regulatory agency of the United States or the State of Ohio, initiation, settlement orentry of a final judgment against the AHP for professional liabilityb. any other change in the information from the date the AHP knew of the change.SUPERVISORY AND COLLABORATIVE RELATIONSHIPSA. Physician Supervisory Plans for Physician Assistants and Collaborative Agreements forAdvanced Practice NursesPhysician Assistants are required to obtain Physician Supervisory Plans which have been signedby the AHP and each supervising physician. Advanced Practice Nurses (APNs) (excludingCRNAs) are required to obtain Collaborative Agreements which have been signed by the AHPand the appropriate physician. A copy of the agreement will be maintained in the AHP’scredentialing files. The Agreement shall describe the arrangements for personal and responsiblesupervision or collaboration which have been made between the AHP and the physician. It isalso the responsibility of the AHP and the physician to provide the Hospital(s), in a timelymanner, with any revisions or modifications that are made to the agreement. The Agreementmust meet all requirements of applicable laws and regulations, as well as all criteria set forth inthis Plan and the applicable AHP Position Description.It is the AHP’s responsibility to obtain the Agreement and to adhere to the requirements of theAgreement. Failure to do so may result in termination of the AHP’s authorization to practice.B. Supervising PhysiciansEach supervising physician must annually sign an acknowledgment for each AHP, acceptingresponsibility for the actions of the AHP and agreeing to provide appropriate supervision of theirservices.The number of Dependent Practitioners acting under the supervision of one physician, as well asthe acts they may undertake, shall be consistent with applicable State statutes and regulations,the rules and regulations of the Medical Staff and policies of Mercy Health Partners. An AHPmay have multiple physician supervisors, as permitted by law (for example: a physicianassistant may work for more than one physician).In the event the Medical Staff appointment or clinical privileges of the supervising physiciancease for any reason (including suspension for incomplete medical records), permission for theAHP to practice at the Hospital and scope of practice shall automatically cease unless or until the27