The Christ Hospital Credentials Policy & Procedure Manual

The Christ HospitalCredentialsPolicy & Procedure Manual

TABLE OF CONTENTSNATURE AND QUALIFICATIONS OF APPOINTMENT1.1 NATURE OF APPOINTMENT TO THE MEDICAL STAFF ........................................................11.2 MINIMUM QUALIFICATIONS FOR ACCEPTANCE OF APPLICATION.................................11.3 RELEASE AND IMMUNITY OF HOSPITAL AND HOSPITAL REPRESENTATIVES ............22.1 APPLICATION FOR INITIAL APPOINTMENT ...........................................................................42.2 PROCEDURE FOR PROCESSING.................................................................................................42.3 PROCEDURE FOR APPOINTMENT .............................................................................................62.4 CONDITIONS AND DURATION OF APPOINTMENT AND REAPPOINTMENT ....................92.5 CHANGE IN APPOINTMENT OR CLINICAL PRIVILEGES......................................................92.6 REDUCTION IN CLINICAL PRIVILEGES .................................................................................102.7 NOTICES AND AUTHORIZED COMMUNICATIONS EQUIPMENT......................................103.1 PROCEDURE FOR REAPPOINTMENT......................................................................................114.1 DURATION....................................................................................................................................134.2 EFFECT OF ADVERSE RECOMMENDATION..........................................................................135.1 DELINEATION OF CLINICAL PRIVILEGES ............................................................................145.2 TEMPORARY PRIVILEGES ........................................................................................................145.3 EMERGENCY PRIVILEGES........................................................................................................165.4 TELEMEDICINE PRIVILEGES....................................................................................................165.5 AFFILIATE STAFF .......................................................................................................................175.6 PRIVILEGE AUTHORIZATION—RESIDENTS.........................................................................175.7 PRIVILEGE AUTHORIZATION--RESIDENTS FROM NON-AFFILIATEDPROGRAMS...................................................................................................................................176.1 PURPOSE.......................................................................................................................................186.2 POLICY ..........................................................................................................................................186.3 PROCEDURE.................................................................................................................................187.1 HOSPITAL PHYSICIANS.............................................................................................................227.2 APPOINTMENT ............................................................................................................................227.3 EFFECT OF TERMINATION OF AGREEMENT........................................................................227.4 DUES, ASSESSMENTS, MEETING ATTENDANCE, VOTE, OFFICE.....................................227.5 AGREEMENT TO ABIDE BY BYLAWS ....................................................................................228.1 GENERAL......................................................................................................................................238.2 MINIMUM QUALIFICATIONS ...................................................................................................238.3 ADDITIONAL QUALIFICATIONS/REQUIREMENTS..............................................................248.4 CLINICAL PRIVILEGES ..............................................................................................................258.5 SCOPE OF CLINICAL PRIVILEGES...........................................................................................258.6 PROCESS FOR GRANTING CLINICAL PRIVILEGES..............................................................258.7 PERFORMANCE IMPROVEMENT.............................................................................................258.8 APPLICATION OF BYLAWS/PREROGATIVES........................................................................268.9 TERMINATION OF PRIVILEGES ...............................................................................................268.10 GRIEVANCE PROCEDURE.........................................................................................................268.11 PREROGATIVES OF AN EMPLOYED AHP ..............................................................................278.12 DEVELOPMENT OF AHP POLICY MANUAL ..........................................................................279.1 DEFINITIONS................................................................................................................................289.2 PRELIMINARY REPORT.............................................................................................................289.3 SELF REPORTING........................................................................................................................299.4 REFERRAL TO THE PRESIDENT OF THE MEDICAL STAFF................................................299.5 PRACTITIONERS’ AID COMMITTEE........................................................................................309.6 ALLIED HEALTH PROFESSIONALS.........................................................................................309.7 HOSPITAL PHYSICIANS.............................................................................................................319.8 CONFIDENTIALITY / IMMUNITY.............................................................................................319.9 NON-COMPLIANCE BY IMPAIRED PHYSICIAN....................................................................319.10 CORRECTIVE ACTION ...............................................................................................................31

10.1 PERSONAL / FAMILY LEAVE....................................................................................................3210.2 IMPAIRMENT LEAVE .................................................................................................................3210.3 TERMINATION OF PERSONAL / FAMILY LEAVE.................................................................3210.4 TERMINATION OF IMPAIRMENT LEAVE...............................................................................3210.5 FITNESS TO RETURN..................................................................................................................3310.6 ONGOING MONITORING ...........................................................................................................3311.1 REHABILITATION .......................................................................................................................3411.2 REINSTATEMENT / REAPPOINTMENT ...................................................................................3411.3 CONDITIONS OF REINSTATEMENT / REAPPOINTMENT ....................................................3411.4 AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS ................................................35

Approved by MEC 9/30/08Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalNature and Qualifications of AppointmentPolicy #1-CRApproved by: Medical Executive Cte. and the Board of DirectorsEffective Date: 3/26/92Reviewed/Revised Date: 3/95, 7/01, 10/04, 07/06, 12/06, 08/07, 10/08_____________________________________________________________________________________________1.1 NATURE OF APPOINTMENT TO THE MEDICAL STAFF1.1.1 Appointment to the Medical Staff of The Christ Hospital (“Hospital”) is a privilege that shall beextended only to professionally competent Practitioners who continuously meet the qualifications,standards, and requirements of, and agree to abide by and follow, all applicable Medical StaffBylaws, Rules and Regulations and other policies of the Medical Staff and the Hospital.1.1.2 Practitioners shall be considered for appointment without regard to race, color, creed, sex, nationalorigin, or disability. For purposes of this Credentials Policy & Procedure Manual, a “Practitioner”shall be interpreted to include any individual applicant or appointee to the Medical Staff.1.2 MINIMUM QUALIFICATIONS FOR ACCEPTANCE OF APPLICATION1.2.1 Physicians, Dentists and Podiatrists: An application for appointment shall only be acceptedfrom a physician (MD, DO), dentist (DDS, DMD), or podiatrist (DPM) who is: (1) a graduate,respectively, of an accredited medical, dental school, or college of podiatry; (2) legally authorizedor licensed to practice in the State of Ohio without restriction on his or her ability to practiceindependently, to receive and examine patients, diagnose conditions and prescribe and implementa treatment plan and to prescribe all medications necessary for the treatment of conditions anddiagnoses within the Practitioner’s area of practice; (3) a member of or qualified to become amember of the local medical, dental or podiatry society; (4) a participant in an appropriateprogram of continuing education; (5) willing to carry minimum professional liability coverage,with reasonable limits to be determined on an annual basis by Hospital administration and theMedical Executive Committee, and provide verification of such coverage on an annual basis; (6)willing and able to practice within a reasonable distance of the Hospital; and (7) able to documenthis or her: (i) background, experience, training and demonstrated competence; (ii) adherence to theethics of his or her profession; (iii) good reputation and character; and (iv) ability to workharmoniously with others. The applicant shall possess such additional qualifications as the Board,upon recommendation of the Medical Executive Committee, may add to the eligibilityrequirements from time to time. All Practitioners appointed to the Medical Staff shall adhere toand agree to abide by the applicable Code of Medical Ethics, Principles of Ethics and Code ofProfessional Conduct, or Code of Ethics, and any other competency based guidance promulgatedfrom time to time by the American Medical Association, American Osteopathic Association,American Dental Association or the American Podiatric Medical Association, as applicable basedon the Practitioner’s field of practice.1.2.2 Clinical Psychologists: An application for appointment will only be accepted from a clinicalpsychologist holding a doctoral degree in psychology, school psychology, or a doctoral degreedeemed equivalent by the Ohio State Board of Psychology. The applicant must also hold acurrent, valid, and unrestricted certificate to practice psychology from the Ohio State Board ofPsychology. Clinical psychologists shall be assigned to the Department of Psychiatry and shall beunder the general supervision of the Department of Psychiatry. Appointment to the Medical Staffdoes not convey any clinical privileges, and applicants may not be granted clinical privileges

outside the scope of their licensure. For example, Ohio statutes do not permit psychologists toadmit patients to the Hospital, nor to prescribe prescription medications.1.2.3 Limitations on Appointment: No applicant shall be entitled to appointment to the Medical Staffor to the exercise of particular clinical privileges in the Hospital merely by virtue of the fact thathe or she is duly licensed to practice in the State of Ohio, or that he or she meets any writtenminimum criteria which may from time to time be adopted by the Board of Directors (“Board”) ofthe Hospital, or that he or she had in the past, or presently has, such privileges at anotherhealthcare entity.1.2.4 Board Certification: Physicians making application for initial appointment to the Medical Staffon or after September 1, 2006 must be either board certified or board eligible. If the applicableboard eligibility requirements include the successful completion of a residency program, theresidency program must be completed through a postgraduate training program accredited by theAmerican Board of Medical Specialties, the American Osteopathic Association, or an equivalentresidency program approved by the Medical Staff Credentials Committee, the Medical ExecutiveCommittee and the Board. Continued Medical Staff membership will require a Practitioner whoseapplication for initial appointment was made on or after September 1, 2006, and who is boardeligible to obtain board certification in the proposed area of practice within five (5) years ofinitially becoming board eligible. An applicant for reappointment whose board certification haslapsed will have twelve (12) months or the equivalent of two (2) exam cycles, whichever is thelonger period, to remedy the lapse. The requirements set forth in this Section 1.2.4 may be waivedunder extraordinary circumstances with the approval of the Medical Staff Credentials Committee,Medical Executive Committee and the Board.1.2.5 Board Responsibility: The Board shall have final authority to make all decisions relating toinitial appointment, reappointment, changes in staff category, and changes in clinical privileges.The Board may delegate responsibility over some or all of these functions in its sole discretion.1.3 RELEASE AND IMMUNITY OF HOSPITAL AND HOSPITAL REPRESENTATIVES1.3.1 By applying for appointment or reappointment to the Medical Staff, the Practitioner authorizes:1.3.1.a the Hospital to solicit and act upon information bearing on his or her application,including information that would otherwise be privileged or confidential, and which isprovided by third parties;1.3.1.b third parties to release information, including otherwise privileged or confidentialinformation, as well as reports, records, statements, recommendations and otherdocuments in their possession (collectively referred to as “Practitioner Data”), andconsents to the inspection and procurement by any Hospital representatives participatingin the appointment process of such Practitioner Data;1.3.1.c the Hospital and Hospital representatives participating in the appointment, reappointmentor privileging process (an “Agent”) to release Practitioner Data, on proper request, toother heath care entities and their agents, who solicit such Practitioner Data for thepurpose of evaluating the Practitioner’s professional qualifications pursuant to a requestby the Practitioner for appointment, reappointment or clinical privileges;1.3.1.d the Hospital to maintain information concerning the Practitioner’s age, training, boardcertification, licensure and other confidential information in a centralized Practitionerdatabase for the purpose of making aggregate Practitioner information available for useby the Hospital and its affiliates;2

1.3.1.e the Hospital to release Practitioner Data, including peer review and/or quality assuranceinformation, obtained from or about the Practitioner to peer review and other standing orad hoc committees of the Hospital and affiliates to be used in the conduct of peer reviewor any quality improvement initiative; and1.3.1.f the Hospital or any Hospital Agent to report information to the National Practitioner DataBank, the Ohio State Medical Board, or any other state or federal agency having authorityover such matters, where the Agent making such report has a good faith belief that thereport is required by law.1.3.2 Release from liability: The Practitioner further releases from any liability: (i) the Hospital; (ii)all Hospital Agents for acts performed in connection with the evaluation of his or her credentialsand for the release of information to other health care entities, on proper request, where the otherhealth care entity is conducting an evaluation of the Practitioner’s credentials; and (iii) all thirdparties who provide Practitioner Data to the Hospital and/or Hospital Agents, unless suchinformation is false and the third party providing it knew it was false at the time it was provided.1.3.3 Immunity: By applying for and/or accepting appointment to the Medical Staff, and by applyingfor and/or exercising clinical privileges within the Hospital, the Practitioner extends absoluteimmunity to, and releases from all claims, damages and liability whatsoever: (i) the Hospital andany Hospital Agent for any action taken or statement or recommendation made by any such Agent,where the action, statement or recommendation was made in compliance with the Medical StaffBylaws and any other applicable Medical Staff and Hospital policy; and (ii) any third party forreleasing or disclosing Practitioner Data to any Hospital Agent concerning former or currentappointment status or privileges, unless such information is false and the third party providing itknew it was false at the time it was provided.3

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalInitial Appointments, Category Change, Change in Clinical PrivilegesPolicy #2-CR2.2.2.a A legible and personally signed application form upon which there is a printed responsefor each item on the form and any additional information to be supplied is enclosed asdirected on the application form;2.2.2.b Evidence, in the form of valid photo identification, demonstrating that the applicant is thesame person as that individual identified in the assorted credentialing documents;2.2.2.c A properly completed and personally signed delineation of privileges form;2.2.2.d A photocopy of current Ohio licensure and confirmation of the applicant’s licensurestatus from the Ohio State Medical Board;2.2.2.e A photocopy of the applicant’s DEA certificate;2.2.2.f Evidence of current professional liability coverage specific to the clinical privilegesrequested and in the amounts specified by the Board, (current requirement is $1 millionper occurrence/$3 million aggregate) and documentation of any past/present/pendingprofessional liability claims and outcomes;2.2.2.g Verification of completion of an approved residency training program or othereducational curricula and direct confirmation from those institutions sponsoring suchprogram;2.2.2.h Verification from appropriate medical specialty and/or sub-specialty Board indicatingcurrent Board status;2.2.2.i2.2.2.jAdditional information/documentation as needed or directed on the application form;Verification of graduation from an accredited medical school, or verification from TheEducation Commission for Foreign Medical Graduates if the applicant is a graduate of aforeign medical school;2.2.2.k Letters of recommendation received directly from at least three practitioners as identifiedby the applicant on the application form. These are to be practitioners, preferably in thesame specialty as the applicant, who have recently worked clinically with the applicant,who have directly observed the applicant’s professional performance, and who can andwill provide reliable attestation regarding the applicant’s current abilities andcompetencies as identified, adopted and amended from time to time by the ACGME as itsgeneral competency domains of (i) patient care, (ii) medical knowledge,(iii) interpersonal and communication skills, (iv) professionalism, (v) systems-basedpractice, and (vi) practice-based learning and improvement, and any other comments thepractitioner reference wishes to relay;2.2.2.lNational Practitioner Data Bank (“NPDB”) Profile;2.2.2.m Verification from the Office of Inspector General or Department of Justice that theapplicant is not on an excluded provider list, which would indicate that the applicant isexcluded from participation in Medicare, Medicaid or other Federal health care programs;2.2.2.n Confirmations and clinical evaluations from hospital or past clinical practice affiliationsfrom the appropriate individuals or institutions;5

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalInitial Appointments, Category Change, Change in Clinical PrivilegesPolicy #2-CR2.2.2.o Receipt of other pertinent information sought from those institutions or individuals whomight have information necessary for a proper evaluation of the applicant’s qualification;2.2.2.p Payment of application fee; and2.2.2.q Completion of the Health and Physical Information Questionnaire. The CredentialsCommittee shall review the completed Health and Physical Information Questionnaireand conduct its own investigation if needed to determine if the applicant has any physicalor mental condition which would interfere with or impede the safe and competentexercise of requested clinical privileges. If, in the opinion of the Credentials Committee,the applicant has such a condition, the Credentials Committee shall consider whetheraccommodation to the condition is reasonable or possible so as to allow the applicant tosafely and competently exercise the requested clinical privileges.2.3 PROCEDURE FOR APPOINTMENT2.3.1 Department Director Consideration of Applications: A complete application shall be reviewedand a final decision will be made, normally within ninety (90) days from the date on which theapplication is deemed complete by the Medical Staff Services Office. The completed applicationshall be forwarded by the Medical Staff Services Office to the appropriate Department Director,and he or she will have two (2) weeks to review the application and provide a recommendationwith respect to the applicants’ appointment and clinical privileges. Following therecommendation of the Department Director of the department in which the applicant’s primarypractice would occur, the application, if the nature of the appointment and requested privileges sowarrants, will be presented to any other appropriate Department Director for review andrecommendation within a subsequent two (2) week period. Any application which has not beenacted upon by the Department Director within the designated period should be referred to theChairperson of the Credentials Committee. In all other cases, the Department Director or his orher designee shall refer the application, along with recommendation(s) relating to appointment andthe delineation of clinical privileges, to the Credentials Committee (or, for certain categories ofAllied Health Professional Staff, first to the Advanced Practice Nurse/Allied Health ProfessionalCommittee, then on to Credentials Committee) for consideration at the next regularly scheduledCredentials Committee meeting. If the department in which the applicant seeks privileges is notyet in existence, the Medical Executive Committee shall assign the application to an appropriateexisting department for consideration.2.3.2 Credentials Committee Consideration of Applications: The Credentials Committee shallinvestigate the character and qualifications of the applicant and, from that investigation, one ofthree outcomes are possible:2.3.2.a To recommend the applicant for appointment to the Medical Staff;2.3.2.b To defer consideration of the application until a subsequent Credentials Committeemeeting as result of findings that the application is incomplete, or that the applicant is inthe process of completing necessary training or board certification processes; or2.3.2.c To recommend denial of appointment to the Medical Staff.Where the Credentials Committee recommends approval or denial of the application, theCredentials Committee shall send the application, together with all findings and recommendationsto the Medical Executive Committee. A decision by the Credentials Committee to deferconsideration of the application shall be communicated to the Medical Staff Services Office if anyassistance is needed to cure a deficiency in the application, and shall be considered at eachsubsequent meeting of the Credentials Committee until a decision is made to recommend or notrecommend appointment.6

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalInitial Appointments, Category Change, Change in Clinical PrivilegesPolicy #2-CR2.3.3 Medical Executive Committee Consideration of Applications: The Medical ExecutiveCommittee shall review all applications, together with all recommendations of the DepartmentDirector and Credentials Committee for appointment to the Medical Staff, and shall formulate arecommendation for approval or disapproval to be forwarded to the Board. All recommendationsto appoint must also specifically recommend the clinical privileges to be granted, which may bequalified by probationary conditions relating to any or all such clinical privileges. Three possibleoutcomes from consideration of the application by the Medical Executive Committee are possible:2.3.3.a To recommend the applicant for appointment to the Medical Staff;2.3.3.b To defer consideration of the application until a subsequent Medical ExecutiveCommittee meeting as result of findings that the application is incomplete, or that theapplicant is completing necessary training or board certification processes; or2.3.3.c To recommend a denial of the application to join the Medical Staff.2.3.4 Medical Executive Committee Recommendation to Approve: When the recommendation ofthe Medical Executive Committee is favorable to the applicant, the application, along with allrecommendations shall be forwarded to the Board for consideration.2.3.5 Medical Executive Action to Defer: When the action of the Medical Executive Committee is todefer the application for further consideration, the application must be considered at eachsubsequent meeting of the Medical Executive Committee until a decision is made to recommendor not recommend appointment.2.3.6 Medical Executive Committee Recommendation to Disapprove: When the recommendation ofthe Medical Executive Committee is adverse to the Practitioner, either in respect to appointment orclinical privileges requested, the President and CEO of the Hospital shall promptly so notify thePractitioner by certified mail, return receipt requested, at the address listed on the application or onfile in the Medical Staff Services Office. No such adverse recommendation need be forwarded tothe Board until after the applicant has exercised his or her right to request a hearing, or has beendeemed to have waived such right as provided in the Fair Hearing Plan. A waiver by thePractitioner of his or her hearing rights shall constitute acceptance of the adverse recommendation,and the decision shall be deemed final.2.3.7 Medical Executive Committee Action Following Hearing: If the Practitioner exercises his orher hearing right under the Fair Hearing Plan, the Medical Executive Committee shall, after thehearing, reconsider the application in light of the report and recommendation of the hearingcommittee. The Medical Executive Committee shall forward its recommendation and all priorrecommendations and documentation to the Board for consideration.2.3.8 Full Board Action to Approve: After receipt of a favorable recommendation from the MedicalExecutive Committee for appointment, or receipt of any recommendation from the MedicalExecutive Committee after reconsideration subsequent to a hearing , the Board shall consider theapplication, and either recommend that the application for appointment be approved or that theapplication for appointment be denied. When the action of the Board is to approve the application,it shall be forwarded to the Secretary / Treasurer of the Medical Staff for approval, and thePresident and CEO of the Hospital shall then give notice of the appointment, together with astatement of clinical privileges granted, to the Practitioner and to the President of the MedicalStaff.2.3.9 Limited Board Action to Approve: The Board may, between regularly scheduled meetings,delegate final decision-making responsibility to approve applications for initial appointment,reappointment applications, and delineations of privileges to a subcommittee of two (2) or moreBoard members.7

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalInitial Appointments, Category Change, Change in Clinical PrivilegesPolicy #2-CR2.3.10 Board Action to Disapprove: If, after consideration of the application, the decision of either thefull Board or the Board subcommittee is adverse to the applicant in respect to either appointmentor clinical privileges requested, the President and CEO of the Hospital shall promptly notify theapplicant, by certified mail, of such adverse decision.2.4 CONDITIONS AND DURATION OF APPOINTMENT AND REAPPOINTMENT2.4.1 Appointment to the Medical Staff does not confer specific clinical privileges. Such privilegesmust be requested at the time of initial appointment, and the granting of such privileges shall be onthe basis of the Practitioner’s training, experience, demonstrated competence, references, otherrelevant information, and availability of appropriate Hospital facilities and services. The applicantshall have the burden of establishing his or her qualifications and competency for the clinicalprivileges requested.2.4.2 Every application for appointment shall be signed by the applicant and shall contain theapplicant’s specific acknowledgement of his or her obligation to provide continuous care andsupervision of patients; to read and abide by the Medical Staff Bylaws, Rules and Regulations, andother policies and procedures of the Medical Staff and the Hospital; to accept committeeassignments; to accept consultation assignments; and to be available and respond when on call.Each applicant shall sign a pledge that he or she will conduct his or her practice in accordancewith high ethical traditions; will refrain from fee splitting or other monetary inducements relatingto patient referral; will delegate in his or her absence the responsibility for diagnosis and care ofhis or her patients only to a Practitioner who is qualified to undertake this responsibility or who isadequately supervised; and will not deceive a patient as to the identity of an operating surgeon orother medical personnel providing treatment or service.2.4.3 Practitioners engaged by the Hospital either in a full- or part-time administratively responsiblecapacity, but whose activities also include clinical responsibilities, must make application to andmaintain Medical Staff appointment through the same procedures provided for all appointees.Medical Staff appointment and clinical privileges in the Hospital shall not be terminated withoutthe same due process provided for any other appointee of the Medical Staff, unless otherwisestated in an employment contract.2.4.4 Medical Staff appointment and clinical privileges shall be automatically terminated in the event ofsuspension, revocation or restriction of licensure, and other occurrences set forth in the FairHearing Plan at Section 1.11. It shall be the responsibility of the Practitioner to notify thePresident and CEO immediately of an event which results in automatic termination of appointmentand privileges.2.5 CHANGE IN APPOINTMENT OR CLINICAL PRIVILEGESDecisions about changes in Medical Staff category or clinical privileges shall be based on the Practitioner’straining, experience and demonstrated competence at the Hospital since the Practitioner was initiallyappointed. A Practitioner who desires a change in his or her Medical Staff category or clinical privilegesshall direct a written request for such a change to the President of the Medical Staff, which shall include allappropriate documentation, and outlining the nature and the rationale for the requested change. If therequest is to change clinical privileges, the President of the Medical Staff shall submit the change request tothe Medical Staff Services Office for license and NPDB verification. Once the verification process iscomplete, the change request shall then be submitted for approval by the Chairperson of the CredentialsCommittee, the Credentials Committee, Medical Executive Committee and Board, and be subject to all theprovisions outlined in this policy relevant to an initial application for appointment. In the event that theCredentials Committee makes a recommendation against the requested change, such recommendation isforwarded to the President of the Medical Staff, who shall notify the Practitioner of the proposed adverse9

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalInitial Appointments, Category Change, Change in Clinical PrivilegesPolicy #2-CRrecommendation and the right to a hearing as set forth in the Fair Hearing Plan. No Practitioner may seekclinical privileges that were previously requested and denied, unless the request is supported by evidence ofadditional training and/or commensurate clinical experience.2.6 REDUCTION IN CLINICAL PRIVILEGESWhere a reduction in the clinical privileges of a Practitioner is deemed appropriate as result of nonuse, arecommendation to reduce clinical privileges can be made by the President of the Medical Staff, and, wherethe Medical Executive Committee and Board concur, the reduction in clinical privileges shall beimmediately effective.2.7 NOTICES AND AUTHORIZED COMMUNICATIONS EQUIPMENTUnless otherwise specified hereunder, all notices under these Credentials Policies and Procedures shall beby either ordinary mail or authorized communications equipment, which means communications equipmentthat provides a transmission including, but not limited to, telephone, telecopy, electronic mail, or otherelectronic means from which it can be determined that the transmission was authorized by, and accuratelyreflects the intention of the parties involved, and with respect to meetings, allows all parties participating tocontemporaneously communicate with each other.10

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalReappointmentsPolicy #3-CRApproved by: Medical Executive Cte.Effective Date: 3/26/92Reviewed/Revised Date: 3/95, 10/96, 7/01,10/04, 07/06, 12/06, 10/083.1 PROCEDURE FOR REAPPOINTMENT3.1.1 Frequency and Schedule: Each appointment to the Medical Staff shall be reviewed and adecision made to reappoint or deny reappointment to the Medical Staff on a biennial basis.3.1.2 Forms, Completion and Return: Each appointee shall make application for reappointment andrenewal of clinical privileges using the prescribed application for reappointment form. Theappointee shall also supply all pertinent information relative to any change in his or her education,health status, licensure status, all of which shall be subject to verification by the Medical StaffServices Office, a CVO or other designee of the Medical Staff Services Office. In addition tocompletion of the reappointment form, each applicant must provide a minimum of two peerreferences, one of which should be by the Department Director of the department where theappointee is most active.Requests for a change in Medical Staff category or clinical privileges must be made in writing andincluded with the reappointment form. Such requests for Medical Staff category or clinicalprivilege changes shall be processed separately from the reappointment application, which shallhave the effect that the appointee shall be reappointed at the existing category with the existingprivileges and the requested changes shall be acted upon by separate Board action which will notnecessarily coincide with Board action on the reappointment.3.1.3 Basis for Review: Each applicant for reappointment will be evaluated based on a variety offactors, which include, but shall not be limited to, their abilities and competencies as identified,adopted and amended from time to time by the ACGME as its general competency domains of(i) patient care, (ii) medical knowledge, (iii) interpersonal and communication skills,(iv) professionalism, (v) systems-based practice, and (vi) practice-based learning andimprovement, compliance with Hospital and Medical Staff Bylaws, Rules and Regulations andpolicies; professional behavior and ethics; professionalism and professional relationships;communication skills, health status; cooperation and ability to work with other Hospital personnel;medical record currency and quality; patient care, patient management skills; fulfillment ofMedical Staff obligations, including attendance at Department meetings and participation inMedical Staff and Hospital activities; continuing education effort made since the previousappointment; verification of current professional liability coverage and documentation and reviewof any past-present-pending professional liability claims and peer recommendations.3.1.4 Department Director Assessment: Each Department Director (and Section Chief, if applicable)will review the application for reappointment and current clinical privileges held by eachappointee in his or her Department or Section, including all enclosures and addenda. TheDepartment Director shall make a recommendation whether to reappoint or not reappoint, andwhether to renew or not renew clinical privileges.3.1.5 Credentials Committee Assessment: The Credentials Committee shall review the appointee’sapplication for reappointment, along with all Department recommendations, and shall make arecommendation to approve or disapprove the application for reappointment. The CredentialsCommittee shall then forward its recommendations to the Medical Executive Committee.11

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalReappointmentsPolicy #3-CR3.1.6 Medical Executive Committee Assessment: The Medical Executive Committee shall review, atits next regularly scheduled meeting, all Practitioner applications for reappointment, along withevaluations of the Department Director and recommendations of the Credentials Committee. TheMedical Executive Committee may either: (i) recommend approval of the reappointment; (ii) deferthe application for reappointment until the next meeting; or (iii) deny the reappointmentapplication. The Medical Executive Committee shall present all recommendations to approvereappointments to the Board in writing.3.1.7 Adverse Medical Executive Committee Recommendation: When the recommendation of theMedical Executive Committee is adverse to the Practitioner, the President and CEO shall promptlynotify the Practitioner by certified mail, return receipt requested. No such adverserecommendation need be forwarded to the Board until after the applicant has exercised his or herright to request a hearing, or after he or she has been deemed to have waived the right to a hearingas provided in the Fair Hearing Plan. A waiver by the Practitioner of his or her hearing rightsshall constitute acceptance of the disapproval of the application for reappointment, and thedecision shall be deemed final.3.1.8 Medical Executive Committee Action Following Hearing: If the Practitioner exercises his orher hearing right under the Fair Hearing Plan, the Medical Executive Committee shall, after thehearing, reconsider the application for reappointment in light of the report and recommendation ofthe hearing committee. The Medical Executive Committee shall forward its recommendation andall prior recommendations and documentation to the Board for consideration.3.1.9 Board Action to Approve: After receipt of a favorable recommendation from the MedicalExecutive Committee for re appointment, or after any recommendation from the MedicalExecutive Committee after a hearing, the Board shall consider the application, and eitherrecommend approval of the application for reappointment or denial of the application forreappointment. When the action of the Board is to approve the application, it shall be forwardedto the Secretary / Treasurer of the Medical Staff for signature, and the President and CEO shallthen give notice of the reappointment, together with a statement of clinical privileges granted, tothe Practitioner and to the President of the Medical Staff.3.1.10 Board Action to Disapprove: If, after consideration of the application for reappointment, theBoard’s decision is adverse to the applicant in respect to either reappointment or clinical privilegesrequested, the President and CEO shall promptly notify the applicant, by certified mail deliveredto the address on file in the Medical Staff Services Office, of such adverse decision.3.1.11 Board Final Decision: When the Board’s decision is final, the Board or its designee shall sendwritten notice to the President and CEO, the President of the Medical Staff , the Chairperson ofthe Medical Executive Committee, to the Department Directors and/or Section Chief involved, andto the Practitioner. The Board, or any representative(s) delegated such authority by the Board,reserve the right, in their sole discretion, to appoint, not appoint, reappoint, not reappoint, demote,dismiss or discipline appointees of the Medical Staff after consultation with the Medical ExecutiveCommittee.12

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalProvisional AppointmentsPolicy #4-CRApproved by: Medical Executive Cte.Effective Date: 3/26/92Reviewed/Revised Date: 3/95, 7/01, 10/04, 8/06, 12/06, 10/084.1 DURATIONAll initial appointments to the Medical Staff (with the exception of Honorary Staff) shall be provisional forone (1) year; provided that, at the end of the first year of provisional appointment, the Department Directormay recommend to the Credentials Committee to consider extending the provisional period for up to oneadditional year. Thereafter, the appropriate Department Director shall recommend either removal or nonremovalof the provisional status. The Department Director’s recommendation for or against removal ofsuch provisional status shall be referred to Credentials Committee, and if approved, then to the MedicalExecutive Committee. The Medical Executive Committee shall recommend either removal of provisionalstatus or non-removal of provisional status. A recommendation by the Medical Executive Committee ofnon-removal of provisional status shall be deemed to be a termination of appointment.4.2 EFFECT OF ADVERSE RECOMMENDATIONWhen the recommendation of the Medical Executive Committee is for non-removal of provisional status,the President and CEO shall promptly notify the Practitioner by certified mail, return receipt requested anddelivered to the address on file in the Medical Staff Services Office. No such adverse recommendationshall be forwarded to the Board until after the Practitioner has exercised his right or has been deemed tohave waived his right for procedural due process as provided for in the Fair Hearing Plan. A waiver by thePractitioner of his or her hearing rights shall constitute acceptance of the non-removal of provisional status,and the decision shall be deemed final.13

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalClinical PrivilegesPolicy #5-CRApproved by: Medical Executive Cte.Effective Date: 3/26/92Reviewed/Revised Date: 3/95, 10/97; 7/01, 10/04, 08/06, 12/06, 3/07, 10/085.1 DELINEATION OF CLINICAL PRIVILEGES5.1.1 Each Practitioner shall be entitled to exercise only those clinical privileges as are specificallygranted to him or her by the Board. Notwithstanding the foregoing, the proper exercise oftemporary, emergency or disaster privileges shall be permitted as set forth in this and otherHospital and Medical Staff policies.5.1.2 The specific clinical privileges desired by an applicant or appointee must be set forth in theDelineation of Privileges form (“DOP”) accompanying the application for initial appointment orreappointment, and determinations about the granting of clinical privileges shall, like appointmentand reappointments, be subject to approvals by the Department Director, Credentials Committee,Medical Executive Committee and the Board. Decisions about clinical privileges will be madebased on (i) the Practitioner’s training, experience, demonstrated competence and judgment; (ii)peer references from physicians in the same professional discipline as the applicant or appointeewho have personal knowledge of the applicant or appointee; (iii) the availability of appropriateHospital facilities and services; and (iv) any other department specific written criteria, which maybe established from time to time, in the discretion of the Department Director. Before grantingprivileges, an evaluation of the following items, if applicable, shall also be conducted by theBoard or any designee of the Board: (i) challenges to or any relinquishment of licensure orregistration; (ii) termination of medical staff membership or any limitation, restriction or loss ofprivileges at other health care facilities; (iii) evidence of any unusual pattern or number ofprofessional liability actions resulting in final judgment against the applicant; (iv) the health statusof the applicant; and (v) morbidity and mortality data, when available. The applicant shall have theburden of establishing his or her qualifications and competency for the clinical privilegesrequested.5.1.3 A Practitioner’s qualifications shall be evaluated biennially at the time of reappointment by areview of the Practitioner’s exercise of his or her clinical privileges by the appropriate DepartmentDirector, by direct observation of other Medical Staff members, and by the review of thePractitioner’s medical records (which may include, but shall not be limited to, Surgical CaseReviews, Utilization review, Blood Utilization, Infection Control and drug utilization records).5.1.4 The scope and extent of privileges that a dentist or podiatrist may exercise shall be specificallydelineated and granted based on the relevant training, experience and demonstrated competenceand judgment of the Practitioner.5.2 TEMPORARY PRIVILEGESThe President of the Medical Staff (which for purposes of this Policy shall include a designee to whomsuch authority is delegated), may, in his or her sole discretion, grant temporary privileges to a Practitionerin two circumstances. The circumstances are: (i) to fulfill an important patient care, treatment or serviceneed; or (ii) during processing by the Medical Staff Services Office of a completed application forappointment, and nothing in that application has raised any concerns. Temporary privileges will not begranted where the Board has previously made a final determination about appointment or clinical privilegeswhich was adverse to the Practitioner, or has granted restricted privileges. Any Practitioner applying fortemporary privileges who has experienced one of the following will, absent extraordinary circumstances, be14

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalClinical PrivilegesPolicy #5-CRineligible for temporary privileges: (i) a current or previously successful challenge to licensure orregistration; (ii) an involuntary termination of medical staff membership at another health care entity; (iii)an involuntary limitation, reduction, denial or loss of clinical privileges at the Hospital or another healthcare entity; or (iv) an unusual pattern or excessive number of professional liability actions resulting in finaljudgment against the Practitioner.5.2.1 Temporary Privileges for the Care and Treatment of Specific Patients: Temporary admittingand clinical privileges to meet important patient care needs may be granted by the President of theMedical Staff, upon recommendation by the Department Director and after receipt of thefollowing information verified orally or in writing by a primary source or designated equivalentsource:a. current and unrestricted Ohio licensure;b. a completed Temporary Privileges Request Form;c. current and unrestricted DEA registration;d. professional liability insurance at or in excess of specified limits;e. Educational Commission for Foreign Medical Graduates (“ECFMG”) certificate(if applicable);f. Evidence of Board Eligibility / Certification (if applicable);g. Curriculum vitae;h. National Practitioner Data Bank query review; andi. a statement by another Medical Staff appointee that the appointee is prepared to“sponsor” the Practitioner in his or her exercise of temporary privileges.On receipt of evidence of the above, the request for temporary privileges will be reviewed by theapplicable Department Director, and the President of the Medical Staff. If a request for temporaryprivileges is approved by the Department Director and the President of the Medical Staff, suchapproval shall be communicated to the Practitioner in writing by the President of the MedicalStaff. No temporary privileges may be exercised prior to the receipt by the Medical Staff ServicesOffice of a signed statement that the Practitioner is willing to be bound by the Medical StaffBylaws (which are available from the Medical Staff Services Office or the Hospital intranet).Temporary privileges granted for the care and treatment of specific patient(s) shall be restricted tothe treatment of not more than three (3) patients in any one calendar year by any Practitioner, andshall be subject to the provisions herein governing termination.5.2.2 Temporary Privileges Granted While Pending Application for Appointment: After receipt ofa completed application for appointment to the Hospital, the President of the Medical Staff, onrecommendation of the Department Director, may grant temporary admitting and clinicalprivileges to an applicant, while his or her application is being processed providing that nothing inthe application raises any concerns, for a period not to exceed ninety (90) days, on the basis ofreceipt of oral or written verification by a primary source or designated equivalent source of thefollowing information:a. current and unrestricted Ohio licensure;b. current and unrestricted DEA registration;c. professional liability insurance in the limits currently required;d. ECFMG certificate (if applicable);e. evidence of Board Eligibility or Certification (if applicable);f. curriculum vitae; andg. National Practitioner Data Bank query review.On receipt of evidence of the above, the request for temporary privileges will be reviewed by theapplicable Department Director, and the request and recommendation of the Department Director15

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalClinical PrivilegesPolicy #5-CRwill be submitted to the President of the Medical Staff. If a request for temporary privileges isapproved by the Department Director and the President of the Medical Staff, such approval shallbe communicated to the Practitioner in writing by the President of the Medical Staff. Notemporary privileges may be exercised prior to the receipt by the Medical Staff Services Office ofa signed statement that the Practitioner is willing to be bound by the Medical Staff Bylaws (whichare available from the Medical Staff Services Office or the Hospital intranet).5.2.3 Termination of Temporary Privileges: Special requirements of supervision and reporting maybe imposed by the appropriate Department Director on any Practitioner to whom temporaryprivileges are granted. Temporary privileges may be immediately terminated by the President ofthe Medical Staff upon notice of any failure by the Practitioner to comply with such specialrequirements or the Medical Staff Bylaws. The President of the Medical Staff may, at any time,terminate a Practitioner’s temporary privileges on or after the date of discharge from the Hospitalof the patients for whose care and treatment the temporary privileges were granted. However, if itis determined that the life or health of such patients would be endangered by continued treatmentby the Practitioner, the temporary privileges can be immediately terminated by the President of theMedical Staff.5.2.4 Visiting Professionals / Professors: A visiting medical professional / professor is a physician,dentist, or other medical professional, in good standing at another medical facility, who has anunrestricted license to practice his or her profession. The visiting medical professional / professormust agree to exercise any temporary privileges granted him or her within the confines ofapplicable Ohio law, and, when required, to apply for and be issued the appropriate temporarycertificate or license from the Ohio State Medical Board. Temporary clinical privileges forvisiting medical professionals/professors who will render patient care, shall be granted subject torequirements (a), (c), (d), (e), (f), (g), and (i) set forth in Section 5.2.1, and in accordance withapplicable Ohio State Medical Board licensure laws and regulations.5.3 EMERGENCY PRIVILEGES5.3.1 For the purposes of this section, an emergency is defined as a condition in which the life of apatient is in immediate danger and in which any delay in administering treatment would add tothat danger. In such circumstance, any appointee of the Medical Staff (to the extent that theadministration of the treatment is permitted by his or her licensure) shall be permitted to exerciseemergency privileges, where in the exercise of good clinical judgment, such exercise in necessaryto save the life of a patient(s).5.3.2 Once the emergency situation no longer exists, the appointee of the Medical Staff must makeformal request for any clinical privileges which are necessary to continue to treat the patient. Inthe event that such privileges are denied or the appointee does not formally request suchprivileges, another Medical Staff appointee shall be assigned to attend the patient by theappropriate clinical Department Director or his designee.5.4 TELEMEDICINE PRIVILEGESTelemedicine privileges may be granted to Practitioners who prescribe, diagnose or otherwise provideclinical treatment to patients in the Hospital from sites physically located outside of the Hospital.Individuals providing telemedicine services shall be subject to the same credentialing and privilegingprocess required of all applicants to the Medical Staff, and shall be eligible for appointment to the Active orTelemedicine categories of the Medical Staff.Individuals appointed as Telemedicine Medical Staff members, and credentialed for telemedicine privilegesmay provide medical consultation in accordance with the Medical Staff’s Telemedicine Policy, and shall16

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalClinical PrivilegesPolicy #5-CRhave an appropriate professional relationship with a member of the Active or Courtesy Staff who shall beresponsible for the service provided by the remote telemedicine Practitioner.5.5 AFFILIATE STAFFAffiliate staff privileges may be granted to Practitioners who meet the general requirements forappointment to staff. Affiliate staff members may refer patients to the Hospital, but may not admit patientsto the Hospital. Affiliate staff may attend Medical Staff, Department and Section meetings, and continuingmedical education programs. Affiliate staff members may not hold Medical Staff, Department, Section, orCommittee office, and may not vote on any Medical Staff, Department, Section, or Committee matter.5.6 PRIVILEGE AUTHORIZATION—RESIDENTSResidents shall not hold appointments to the Medical Staff and shall not be granted specific clinicalprivileges, rather residents shall be authorized to exercise only those privileges set out in training protocolsdeveloped by the appropriate Director of Residency Training Programs and approved by the appropriateResident Advisory Committee and/or the University of Cincinnati College of Medicine.5.7 PRIVILEGE AUTHORIZATION--RESIDENTS FROM NON-AFFILIATED PROGRAMS5.7.1 Clinical privileges, excluding admitting privileges, may also be authorized for residents throughthe training protocols developed within non-affiliated residency programs (those other thanthrough the University of Cincinnati College of Medicine) if the resident: (i) is a current student ingood standing or a graduate of an accredited medical/dental/podiatric school; (ii) is sponsored by aMedical Staff appointee; and (iii) has professional liability coverage provided through his or hertraining institution, or the sponsoring Medical Staff appointee agrees, in writing, to acceptprofessional liability for the resident. The sponsoring Medical Staff appointee must complete andsubmit a “Request for Authorization for a Visiting Resident” form, available in the GraduateMedical Education Office.5.7.2 The sponsoring Medical Staff appointee agrees to: (i) maintain total responsibility for the care ofhis or her patients; and (ii) be the primary contact for questions from all Hospital personnel forquestions related to patient care. The ongoing exercise of clinical privileges by residents will bemonitored by all other physicians within the appropriate department and the Department Director.5.7.3 Privileges shall be authorized only for the time period stated on the Request for Authorization fora Visiting Resident Form. At the conclusion of the stated time, privileges will be automaticallyterminated, and such termination will not give rise to any rights pursuant to the provisions of theFair Hearing Plan.17

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalDisaster PrivilegesPolicy #6-CRApproved by: Medical Executive Cte.Effective Date: 3/26/92Reviewed/Revised Date: 3/95, 10/96; 7/01, 10/04, 08/06, 12/06, 3/07; 12/07, 10/086.1 PURPOSEWhen the Disaster Plan for the Hospital has been activated (under Administrative Policies 1.02.100 and1.03.100), the Hospital may be unable to handle the immediate and emergent patient needs with existingavailable credentialed Medical Staff. At that time, it may become necessary to grant temporary disasterprivileges to non-credentialed practitioners to help care for an unusually large volume of critically ill and /or injured patients.6.2 POLICYDuring disaster(s) in which the Disaster Plan has been activated, the Emergency Incident Commander(“EIC”), or the designee(s) of the EIC may, if the Hospital is unable to handle immediate and emergentpatient needs, grant disaster privileges to individual practitioners deemed qualified and competent, for theduration of the disaster situation. Granting of these privileges will be handled on a case by case basis and isnot a “right” of the requesting practitioner.If the EIC is unable to fulfill these duties, or to name a designee, the responsibility will pass (in order ofauthority) to: the President and CEO, the President of the Medical Staff, the President-Elect of the MedicalStaff, the Vice President for Medical Affairs, and to any other designee(s) identified to carry out the task ofevaluating whether to grant disaster privileges (with these persons being collectively referred to herein asdisaster privilege administrators, in the singular abbreviated as a “DPA”, collectively “DPAS”).6.3 PROCEDURE6.3.1 Once the Disaster Plan is activated, and the EIC determines that the grant of disaster privileges isnecessary, the EIC will inform the Medical Staff Services Office of such determination.6.3.2 A Disaster Privileges Request Form (“Form”) will be given to any practitioner who reports to theEmergency Operations Center, Command Post or other location specified by any DPA, andrequests the issuance of disaster privileges. The Form must be completed, signed by the requestingpractitioner, and returned to a DPA who will verify whatever information is verifiable given thenature of the disaster, and evaluate whether to approve or disapprove the granting of disasterprivileges. To the extent that it is practicable, the Form, along with any supporting documentation,may be forwarded to the Medical Staff Services Office to conduct additional verification prior tothe grant of disaster privileges. The Form at minimum must be accompanied by a validgovernment-issued photo identification issued by a state or federal agency (e.g., driver’s license orpassport) and at least one key identification document such as:• Current hospital photo ID card;• Current medical license with valid photo ID issued by a state, federal, or regulatoryagency;• Primary source verification of license;• An ID that certifies the practitioner is a member of a state or federal disaster medicalassistance team;• An ID that certifies the practitioner has been granted authority by a federal, state, ormunicipal entity to administer patient care in emergencies; or18

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalDisaster PrivilegesPolicy #6-CR• Presentation by a current TCH Medical Staff member who can vouch for thepractitioner’s identity and licensure status.6.3.3 Any Disaster Privileges Request Form and any supporting documents sent to the Medical StaffServices Office for verification will be forwarded to any DPA for final approval.6.3.4 Once approved, the practitioner will be notified via phone, e-mail, or in person, that he/she maybegin working. An identification badge which will identify the practitioner as having been granteddisaster privileges will be provided to the practitioner along with any relevant reference materials,which may include resources outlining management of supplies, staff, space, communications,evacuation, admissions and transfers, patient scheduling and information, and computer andmedical equipment usage. The practitioner may begin working prior to all verifications beingdone only if directed by a DPA. On issuance of disaster privileges or at the direction of a DPA,the practitioner shall report to and act under the supervision and oversight of the DepartmentDirector having oversight over the department in which the practitioner’s specialty or subspecialtycan best be utilized.6.3.5 Each DPA will send a list of practitioners who have been granted disaster privileges, which will besent, where, when and how appropriate, and updated as regularly as possible, to the following:• Emergency Department• Radiology• Pharmacy• Clinical Laboratory• Medical Records• Appropriate Section Chiefs and Department Directors• Admitting• Hospital Administration• Operating Room• Emergency Operations Center or Command Post6.3.6 The Medical Staff Services Office will begin appropriate primary source verification of licensureas soon as the immediate disaster is under control. Primary source verification will, except inextraordinary circumstances where there is no means of communication or a lack of resources, becompleted for each practitioner who requests disaster privileges within seventy-two (72) hours ofthe practitioner presenting at the Hospital. In the event of an extraordinary circumstance, theMedical Staff Services Office will document why primary source verification could not becompleted on a timely basis and evidence that the practitioner demonstrates the ability to continueto render care. In addition to primary source verification of licensure, the Medical Staff ServicesOffice shall verify the following additional information for all practitioners who have requesteddisaster privileges:• Education• Training• Credentialing status at other hospitals• Current competence• DEA certification• National Practitioner Data Bank query (if not done initially), and• Other verifications deemed necessary and appropriate19

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalDisaster PrivilegesPolicy #6-CR6.3.7 If any adverse information is uncovered during this verification process, it will be brought to theattention of a DPA. The DPA will then determine whether or not to immediately terminate thedisaster privileges for that practitioner. If disaster privileges are terminated, a notification will besent to the distribution list stated in Section 6.3.5, the appropriate Department Director, and to thepractitioner. In such event, the DPA or his or her designee shall coordinate for the provision ofalternative medical coverage for all patients who have received care by the terminated practitioner.No denial of disaster privileges, or the termination of such disaster privileges based on adverseinformation uncovered during verification by Medical Staff Services, will trigger any rights onpart of the affected practitioner under the TCH Fair Hearing Plan.6.3.8 Once the Hospital has deemed that the Disaster Plan is no longer active, all practitioners who havebeen granted disaster privileges pursuant to this policy will be expected to coordinate with a DPA,or his or her designee, to provide for alternative medical coverage for all patients then receivingcare from the practitioner. Once this transition for alternative medical coverage is adequatelyaddressed, all disaster privileges will immediately terminate. This termination of disasterprivileges will not trigger any rights under the Fair Hearing Plan.20

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalDisaster PrivilegesPolicy #6-CREXHIBIT ATHE CHRIST HOSPITALDISASTER PRIVILEGES REQUEST FORMPhysician Name: ____________________________________Phone Number: _____________________________________Mailing Address: _______________________________________________________________________________________SSN: _____________________________ Date of Birth: ______________Medical School(s) Attended:(if more than one, please identify which medical school you graduated from by circlingit) __________________________________________________________________________________________Year of Graduation: ________State of licensure: _____________ License Number: _________________Specialty / Subspecialty: ______________________________________I, ________________________________, certify and represent that the information provided on this DisasterPrivileges Request Form is true and accurate in all respects, that any identification or credentials I have presented toHospital personnel is valid, in force and unaltered, that I am the holder of a current medical license, and that I amaware of no reason that I should not be granted Disaster Privileges by The Christ Hospital.______________________________________Practitioner Printed Name______________________________________Practitioner SignatureFOR DPA USE ONLY:Type of Identification Presented: ____________________________________Verification of license / reference number: ____________________________________________________________________DPA Printed Name_______________________________________DPA Signature21

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalHospital PhysiciansPolicy #7-CRApproved by: Medical Executive Cte.Effective Date: 3/26/92Reviewed/Revised Date: 3/95, 10/96; 7/01, 10/04, 08/06, 12/06, 10/087.1 HOSPITAL PHYSICIANS7.1.1 Physicians who have been engaged on a full- or part-time basis by the Hospital to coveremergency and assigned routine medical care for inpatients shall be called Hospital Physicians(also referred to as “House Doctors”).7.1.2 Applications for appointment as a Hospital Physician shall be processed through the Director ofInternal Medicine and shall additionally require review and approval by the Vice President/ChiefMedical Officer, President and CEO, the Credentials Committee, the Medical ExecutiveCommittee and the Board. Prior to appointment as a Hospital Physician and periodicallythereafter, when reasonably requested by the Hospital, a Hospital Physician, other than onecurrently enrolled in a residency training program, shall be required to submit the names of andcontact information for as many as three (3) peer references.7.2 APPOINTMENTIf the application for appointment as a Hospital Physician is approved by the Medical ExecutiveCommittee, the appointment may be made by the Board. The applicant will be notified by the Presidentand CEO of the decision to approve or disapprove the application for appointment.7.3 EFFECT OF TERMINATION OF AGREEMENTAppointment as a Hospital Physician ceases when the agreement between the Hospital and the HospitalPhysician is terminated for any reason.7.4 DUES, ASSESSMENTS, MEETING ATTENDANCE, VOTE, OFFICEHospital Physicians shall not be required to pay dues or assessments and shall not be required to attendmeetings of the Medical Staff. Hospital Physicians shall have no Medical Staff voting rights and are noteligible to hold Medical Staff office.7.5 AGREEMENT TO ABIDE BY BYLAWSAppointees shall agree to abide by the Medical Staff Bylaws, Rules and Regulations and Policies;departmental rules and regulations; and other Hospital policies and procedures.22

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalAllied Health ProfessionalsPolicy #8-CRApproved by: Medical Executive Cte.Effective Date: 3/26/92Reviewed/Revised Date: 3/95, 10/96, 7/97, 7/01, 10/04, 08/06, 12/06, 10/088.1 GENERALAllied Health Professionals (“AHPs”) authorized to provide services in the Hospital shall be limited to thecategories of Non-Employed AHPs and Employed AHPs [This category includes AHPs in the directemploy of the Hospital] approved by the Board upon the recommendation of Medical ExecutiveCommittee. The Board may, from time to time, review and modify the categories or types of AHPsauthorized to function in the Hospital, upon the recommendation of the Medical Executive Committee.8.2 MINIMUM QUALIFICATIONSBoth Employed and Non-Employed AHPs must meet, and be able show satisfactory evidence, of thefollowing minimum qualifications:8.2.1 Document their licensure, experience, background, training, ability, judgment, and physical andmental health status so as to demonstrate that any patient treated by them will receive care at thegenerally recognized professional level of quality and efficiency established by the Medical Staffand Hospital and that they are qualified to exercise the clinical privileges that they seek or havebeen granted;8.2.2 Have demonstrated, on the basis of documented references, to adhere to the lawful ethics of theirrespective professions;8.2.3 Commit to participate in and properly discharge such responsibilities as they are reasonablyassigned and cooperate with the Medical Staff in assisting the Hospital in fulfilling its obligationsrelated to patient care;8.2.4 Demonstrate the ability to work with and relate to Medical Staff Members, members of otherhealth disciplines, Hospital management and employees, the Board, and the community in general,in a cooperative, professional manner that is essential for maintaining an environment appropriateto quality and efficient patient care;8.2.5 Be free of, or have under adequate control, any significant physical or mental health impairmentand be free from abuse of any type of substance or chemical that affects cognitive, motor orcommunication ability in a manner that interferes with, or presents a reasonable probability ofinterfering with, the required qualifications;8.2.6 Be able to write and speak the English language so as to be understood by others, to understandboth written and spoken English, and to prepare medical record entries other requireddocumentation in a legible manner; and8.2.7 Be located closely enough (office and residence) to the Hospital, as determined by the MedicalExecutive Committee, to provide continuous care to patients in the Hospital.23

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalAllied Health ProfessionalsPolicy #8-CR8.3 ADDITIONAL QUALIFICATIONS/REQUIREMENTSAHPs must:8.3.1 Hold a valid license, certification, registration or other credential as required by the State of OhioProfessional Licensing Division or, if not regulated by the Professional Licensing Division, mustat a minimum have been trained at a level consistent with certification standards in the AHP’sspecialty and have obtained such certification.8.3.2 Meet the applicable responsibilities and comply with the applicable provisions set forth in theBylaws;8.3.3 Refrain from any conduct or acts that are or could reasonably be interpreted as being beyond, or anattempt to exceed, the scope of practice or clinical privileges authorized within the Hospital;8.3.4 Each AHP must accept assignment by the Credentials Committee to the Department of theMedical Staff most appropriate to the AHP’s professional training and qualifications;8.3.5 AHPs must carry professional liability insurance in the amount and coverage established by theBoard. Documentation of coverage must be provided at the time of application for designation asan AHP, and at any subsequent time as requested by the Medical Staff Services Office. Themalpractice insurance policy may be that of the AHP or, in the case of a Non-Employed AHP whois in the employee of a physician, may be that of the employing / collaborating Physician, as longas the policy covers the AHP;8.3.6 A statement of additional qualifications for each category of AHP may be developed by theCredentials Committee (or, where the Credentials Committee so delegates, the AdvancedPractitioner Committee), and will be subject to approval by the Medical Executive Committee andthe Board;8.3.7 An Employed AHP must identify a supervising Practitioner who (i) is a member of the MedicalStaff, (ii) has agreed to be legally responsible for every action of that AHP and (iii) satisfies anyadditional qualifications set forth in the rules, regulations and policies of the Medical Staff and theHospital;8.3.8 The Employed AHP must apply, using all Hospital approved forms and applications and be hiredby the Hospital for the appropriate AHP position and his or her scope of practice shall be largelydefined by the member of the Medical Staff with whom the Employed AHP has a Standard CareArrangement;8.3.9 A Non-Employed AHP must identify a collaborating Physician who is a member of the MedicalStaff, and with whom the Non-Employed AHP has a valid Standard Care Arrangement;8.3.10 All AHPs must apply for specified clinical privileges on a Hospital approved application. Theapplication must be completed and returned to the Medical Staff Services Office. Once theMedical Staff Services Office determines that the application is complete, it is forwarded to theAdvanced Practitioner Committee for review. Each application shall be reviewed by theAdvanced Practitioner Committee (if applicable), the Credentials Committee, the MedicalExecutive Committee and the Board. The burden of producing all information reasonablynecessary to conduct a proper evaluation of the AHP’s experience, training, current competenceand judgment is the sole responsibility of the AHP.24

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalAllied Health ProfessionalsPolicy #8-CR8.4 CLINICAL PRIVILEGES8.4.1 A Non-Employed AHP may exercise only such clinical privileges as are specifically individuallygranted and in accordance with the instruction and supervision of the AHP’s collaboratingPhysician.8.4.2 An Employed AHP may perform only those patient care services that are in accordance with theinstruction and supervision of the AHP’s supervising Practitioner.8.5 SCOPE OF CLINICAL PRIVILEGESWritten guidelines, policies, rules and regulations for the scope of clinical privileges and specified servicesthat may be exercised or provided by each category of AHP shall be developed by the CredentialsCommittee or, where appropriate, the Advanced Practitioner Committee with input, as appropriate, from (a)Physicians supervising or consulting with AHPs, (b) representatives of the AHP category underconsideration, (c) the Department Director, and (d) other representatives of the Medical Staff, Hospitaladministration, and the Hospital’s other professional staff. Such guidelines, policies, rules and regulationsare subject to the approval of the Medical Executive Committee. For each category of AHP, the guidelines,policies, rules and regulations shall include:a. A description of the services to be provided and procedures to be performed, includingany special equipment, procedures or protocols specific tasks may require, and anassignment of responsibility for medical record documentation; andb. A definition of the degree of assistance that may be provided by an AHP in the care ofpatients in the Hospital and any limitations thereon, including the degree of physiciansupervision, consultation, or collaboration required.8.6 PROCESS FOR GRANTING CLINICAL PRIVILEGESTo practice at the Hospital, both Non-Employed and Employed AHPs must apply and qualify for privilegesand be subject to biennial review of those privileges. Applications for the initial granting of privileges andbiennial renewal, along with a complete list of the clinical privileges sought, shall be submitted to theMedical Staff Services Office for verification and processing. Failure to complete the application orprovide required information on a timely basis shall be deemed a withdrawal of the application.Prior to the AHP exercising any clinical privilege or providing patient care at the Hospital, his or herapplication for privileges must be approved. The application of an AHP who is a professional registerednurse will be subject to approval by each of the following: (i) the Advanced Practitioner Committee; (ii) theCredentials Committee; (iii) the Medical Executive Committee and (iv) the Board. The application of anAHP who is not a professional registered nurse will be subject to approval by each of the following: (i) theCredentials Committee; (ii) the Medical Executive Committee; and (iii) the Board. Any representative ofany committee or body having responsibility to evaluate and make a recommendation on the applicationmay, at any time while the AHP’s application is being processed, request additional information from theAHP in order to permit the approving committee or body to make a recommendation to approve ordisapprove the application. Where the committee or body has insufficient information to make arecommendation, that committee or body can defer action on the application until the next regularlyscheduled meeting after the committee or body receives the needed information.8.7 PERFORMANCE IMPROVEMENTThe quality and efficiency of the care provided by all AHPs within the Hospital shall be monitored andreviewed as part of the regular Medical Staff, Advanced Practitioner Committee. Hospital Performance25

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalAllied Health ProfessionalsPolicy #8-CRImprovement/risk management/utilization management processes, and AHPs shall cooperate and provideassistance as required by such bodies.8.8 APPLICATION OF BYLAWS/PREROGATIVESAHPs shall be subject to the Bylaws unless specifically and expressly excepted therefrom, insofar as theirterms and conditions logically apply or unless specifically provided otherwise in this policy or otherapplicable provisions of the Bylaws. Although governed by the Bylaws, AHPs are not: (i) Members of theMedical Staff; (ii) required to pay Medical Staff dues; (iii) entitled to the hearing rights set forth in the FairHearing Plan; (iv) eligible to hold Medical Staff office or vote on Medical Staff issues, or (v) eligible toadmit or discharge patients. AHPs may, however:a. serve on Committees when so appointed and vote therein;b. attend the meetings of the Department to which he or she is assigned; andc. exercise such other prerogatives as the Medical Executive Committee, with the approvalof the Board, may accord to all AHPs in general or to a specific category of AHPs.8.9 TERMINATION OF PRIVILEGES8.9.1 A Non-Employed AHP’s privileges, and an Employed AHP’s duties and responsibilities toperform patient care, shall automatically terminate when the AHP’s certificate or license expiresor is revoked, suspended or restricted.8.9.2 A Non-Employed AHP’s privileges, or an Employed AHP’s duties and responsibilities to performpatient care, may also be terminated for cause by the President and CEO or by the DepartmentDirector of the Department to which the AHP is assigned.8.9.3 An Employed AHP’s duties and responsibilities to perform patient care automatically terminatewhen:8.9.3a8.9.3b8.9.3cthe Medical Staff membership or applicable privileges of the supervising Practitioner areterminated, whether voluntary or involuntary,the supervising Practitioner no longer agrees to act as the supervising Practitioner,regardless of the reason;the relationship between the AHP and the supervising Practitioner is otherwiseterminated, regardless of the reason;8.9.4 An AHP’s privileges or duties and responsibilities to perform patient care may also be terminatedin any other manner set forth in the Bylaws applicable to a Practitioner.8.9.5 It shall be the responsibility of the AHP to report any event set forth in this section to theappropriate Department Director and President and CEO as soon as the AHP becomes aware ofsuch event.8.10 GRIEVANCE PROCEDURE8.10.1 Grievance Procedure. An AHP shall have the right to challenge the termination of the AHP’sprivileges pursuant to Section 8.9 of this policy in accordance with the procedure set forth in thisSection. Within fifteen (15) days after the date of receipt of a notice of a proposed adverse action,the AHP may file a written grievance with the Medical Executive Committee. Upon receipt of the26

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalAllied Health ProfessionalsPolicy #8-CRgrievance, the Medical Executive Committee shall afford the AHP an opportunity for an interviewconcerning the grievance. Before the interview, the AHP must be informed of the nature of thecircumstances giving rise to the action and may present relevant information at the interview. Arecord of the interview and a written report of the decision on the grievance must be made by theMedical Executive Committee. A copy of the report shall be provided to the AHP.8.10.2 Appellate Procedure. Within ten (10) days of receipt of a copy of an adverse decision reportprepared by the Medical Executive Committee under this Section, the AHP may request that theBoard review the decision. The request must be in writing, delivered to the President and CEO bycertified mail or in person, and must include a statement of the reason for appeal and the specificfacts or circumstances that justify further review. The Board shall consider the recommendation ofthe Medical Executive Committee, together with any written comments by the AHP, and make awritten final decision. If the AHP does not make a timely request for the Board to review theMedical Executive Committee decision, the decision shall be treated as final.8.10.3 Applicability of the Medical Staff Hearing Procedures to AHPs. This Section 8.10 is the sole andexclusive remedy available to an AHP who has his or her privileges terminated, and nothing in theBylaws may be interpreted to entitle an AHP to the procedural, hearing, or appeal provisions ofthe Fair Hearing Plan applicable to the Medical Staff. Notwithstanding the preceding sentence, theMedical Executive Committee or the Board, as the case may be, may, in its sole discretion, applyall or part of such provisions as it deems necessary or appropriate under the circumstances.8.11 PREROGATIVES OF AN EMPLOYED AHPAn Employed AHP shall:8.11.1 Be able to exercise such patient care duties and responsibilities as are granted to him/her, withinthe clinical department to which he/she has been assigned and subject to the supervision ofPractitioner members of that department.8.11.2 Not be members of the Medical Staff but shall be subject, generally, to the same terms andconditions as other Hospital employees. AHP’s shall also be subject and shall be governed by theusual Hospital personnel practices, including termination or suspension of services and privilegesauthorized.8.12 DEVELOPMENT OF AHP POLICY MANUALIf, at any future date, a separate AHP Policy Manual is developed and subsequently approved byappropriate Hospital representatives, setting forth specific credentialing and privileging proceduresgoverning the relationship between the Hospital and AHPs, such provisions within this Credentials Policy& Procedure Manual shall be deemed to be automatically superseded by such AHP Policy Manual effectiveas of the date on which such AHP Policy Manual is approved.27

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalImpaired Health Care PractitionerPolicy #9-CRApproved by: Medical Executive Cte.Effective Date: 3/26/92Reviewed/Revised Date: 3/95, 6/95, 11/95, 5/99, 1/00, 7/01, 10/04, 8/06, 12/06, 07/07, 10/08This policy provides a process for evaluating whether a Practitioner on the Medical Staff is an Impaired Physician.The objectives of this policy are to place the highest priority on the protection of each patient’s right to competentmedical care, and to promote prompt, effective, confidential, comprehensive evaluation, referral and treatment of aPractitioner suffering an Impairment.9.1 DEFINITIONS9.1.1 For the purpose of this Policy, an “Impairment” shall mean a condition which is, or may be,adversely affecting patient care at the Hospital, including, but not limited to: physical or medicalconditions, psychiatric disorders, emotional disorders, behavioral disorders, deterioration throughthe aging process or loss of motor or perceptive skill, sexual misconduct and/or harassment, orhabitual or excessive use or abuse of drugs, including alcohol.9.1.2 An “Impaired Physician” is one who is unable to practice with reasonable skill and safety topatients because of the Impairment. An HIV/HBV positive physician is not an Impaired Physicianfor purposes of this policy unless the physician fails to report his or her positive status, continuesto perform invasive procedures and/or fails to adhere to recommendations of any Hospital internalreview panel or an Ohio Department of Health panel.9.1.3 A “Reasonable Suspicion” must arise from the personal observations or knowledge of any personworking in the Hospital who has reason to suspect that a Practitioner is Impaired. Indications ofImpairment include, but are not limited to: disorientation; hallucinations; emotional instability;paranoia; smell of alcohol on breath; slurred speech; unsteady gait; red eyes; diversion ofmedications; deterioration or inconsistencies in work performance; chronic tardiness orunavailability; changes in behavior and decline in clinical or technical skills.9.2 PRELIMINARY REPORTAny person having a Reasonable Suspicion that a Practitioner suffers an Impairment shall file a writtenreport with the Department Director of the primary department in which the Practitioner practices, with acopy to the President of the Medical Staff summarizing the facts and circumstances upon which theReasonable Suspicion is based. If a Department Director is the Practitioner about whom a ReasonableSuspicion of Impairment exists, the written report should be directed to the President of the Medical Staff.Reporting is an ethical obligation of all licensed independent practitioners, which shall at all times respectthe confidentiality of the potentially Impaired Physician, and seek to aid the potentially Impaired Physicianin retaining and regaining optimal professional functioning and health.Upon receipt of a preliminary report of a possible Impairment, the Department Director (or if theDepartment Director is the Practitioner about whom the report is made, the President of the Medical Staff)will meet with the potentially Impaired Physician and initiate discovery and evaluation of the facts andcircumstances on which the preliminary report is based. From that evaluation, the following outcomes arepossible:a. A finding of no basis for the report, which ends the evaluation;28

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalImpaired Health Care PractitionerPolicy #9-CR9.3 SELF REPORTINGb. A finding of some basis for the report, which the potentially Impaired Physician and theDepartment Director agree to handle within the department;c. A finding that the matter should be referred to the Human Resources department of theHospital;d. Referral to the Practitioners’ Aid Committee (described below); ore. A finding that the matter should be referred to the President of the Medical Staff.A Practitioner on the Medical Staff having any indication that he or she may suffer any Impairment isstrongly encouraged to make a confidential self-report to his or her Department Director, whether or not thePractitioner believes the Impairment to be having an adverse affect on his or her ability to practiceaccording to acceptable and prevailing standards of care.9.4 REFERRAL TO THE PRESIDENT OF THE MEDICAL STAFFWhere the Department Director deems the preliminary report of Impairment to be of a nature that warrantsthe involvement of the President of the Medical Staff, the Department Director shall meet with thePresident of the Medical Staff to review the preliminary report and the findings from the initial evaluation.The President of the Medical Staff and the Department Director shall then interview the potentiallyImpaired Physician with the objective of the interview being to better assess the facts and circumstances asto whether the Practitioner is suffering from an Impairment. From that interview, and/or any otherevaluation, the President of the Medical Staff and the Department Director, and to the extent practical, thepotentially Impaired Physician, shall agree on a plan of action. The President of the Medical Staff mayalso, on his or her own initiative, participate in the initial meeting of the Department Director and thepotentially Impaired Physician, and/or any other step of the evaluation process that he or she deemsappropriate. Each situation in which a Practitioner is determined to be an Impaired Physician is unique,and shall be treated as such. It is the intent of this policy to return the Impaired Physician to health and toprotect patients, Hospital employees, other members of the Medical Staff, and the Impaired Physician fromharm during this process. A full array of alternatives designed to achieve this objective will be employed.As result, the plan of action to address the specific needs of an Impaired Physician will be specificallytailored to the unique facts and circumstances surrounding the Impairment. Each plan of action will be setforth in writing, and the Impaired Physician will be asked to sign the plan of action indicating his or heracceptance. Plans of action may include one or more of, but shall in no way be limited to, the following:a. Continued monitoring of the behavior of the Practitioner without further action;b. Further confidential assessment of the facts and circumstances leading to the preliminaryreport;c. Where the circumstances so warrant, the making of a reasonable accommodation by theHospital to allow continued exercise of clinical privileges by the Impaired Physician;d. Referral to a licensed independent professional for further assessment and/or ongoingtreatment;e. Referral to the Human Resource department of the Hospital;f. Referral to the Ohio Physician Health Program;g. Referral to the Practitioners’ Aid Committee (described below);h. Voluntary or involuntary medical leave;i. Structured monitoring of the exercise of clinical privileges by the Impaired Physician;j. Imposition of requirements for ongoing screening or testing;k. Recommendation for corrective action under the Informal Corrective Action policy of theFair Hearing Plan;l. Where the health or safety of any patient or other individual might be compromised by afailure to take immediate action, the Impaired Physician’s clinical privileges may besummarily suspended; and29

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalImpaired Health Care PractitionerPolicy #9-CRm. Reporting to the state medical board, the National Practitioner Data Bank, as deemed bythe President of the Medical Staff to be necessary and appropriate, and/or any otherreporting required under applicable law.9.5 PRACTITIONERS’ AID COMMITTEE9.5.1 Composition: The Practitioners’ Aid Committee shall be composed of not less than three (3)Medical Staff members and other appropriate professionals, AHP’s, and/or staff members whorepresent a variety of disciplines, including a psychiatrist and a Medical Staff member who hasexpertise in chemical dependency matters, and possibly a psychologist. The Committee membersshall be appointed by President of the Medical Staff, who shall appoint one (1) person to serve asChairperson. Each Committee member shall serve for a three (3) year period.9.5.2 Duties: The Committee shall carry out the following duties:9.5.2a Serve as the identified point within the Hospital for self-referral by a Practitioner andconfidential referral by other organization staff with respect to potential impairments;9.5.2b Educate the Medical Staff and other organization staff about illness and impairmentrecognition issues specific to Practitioners;9.5.2c Refer the affected Practitioner to the appropriate internal or external resources fordiagnosis and treatment of the condition or concern pursuant to Hospital policies and procedures,and monitor compliance with such referrals;9.5.2d Maintain the confidentiality of the Practitioner seeking referral or referred for assistance,except as limited by law, ethical obligation, or when the safety of a patient is threatened;9.5.2e Monitor the affected Practitioner and the safety of patients until the rehabilitation or anydisciplinary process is complete; and9.5.2f Report to the Medical Staff leadership instances in which a Practitioner is providingunsafe treatment, and make appropriate recommendations to the appropriate Medical Staffcommittees in connection with appropriate treatment plans for impaired Practitioner; provided thatnothing contained herein may modify any provisions or requirements of the Medical Staff Bylawsor Fair Hearing Plan.9.5.3 Meeting Frequency: The Practioners’ Aid Committee shall meet as needed.9.5.4 Reporting: The Practitioners’ Aid Committee shall maintain a permanent record of its activitiesand report regarding specific Practitioner issues to the Medical Executive Committee; providedthat nothing contained herein may modify any provisions of the Medical Staff Bylaws or FairHearing Plan. The Practitioners’ Aid Committee shall also report to the Medical ExecutiveCommittee on an annual basis. Records of individual Practitioners who are being followed by theCommittee shall be strictly confidential.9.6 ALLIED HEALTH PROFESSIONALSImpairment of an Allied Health Professional (AHP) may represent a significant hazard to patients, coworkersand to the AHP who suffers from an Impairment. The Human Resources department of theHospital has resources available for the confidential diagnosis, treatment and rehabilitation of any AHPwho suffers from an Impairment. If any individual working in the Hospital has a Reasonable Suspicion30

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalImpaired Health Care PractitionerPolicy #9-CRthat an AHP suffers an Impairment, he or she should make a written report of the facts and circumstanceson which the Reasonable Suspicion is based to the supervising physician having primary responsibility forthe AHP in question and to the Practitioners’ Aid Committee, if appropriate..9.7 HOSPITAL PHYSICIANSImpairment of a Hospital Physician may represent a significant hazard to patients, co-workers and to theHospital Physician who suffers from the Impairment. The Human Resources department of the Hospitalhas resources available for the confidential diagnosis, treatment and rehabilitation of any HospitalPhysician who suffers from an Impairment. If any individual working in the Hospital has a ReasonableSuspicion that a Hospital Physician suffers an Impairment, he or she should make a written report of thefacts and circumstances on which the Reasonable Suspicion is based to the Department Director havingprimary responsibility for the Hospital Physician in question.9.8 CONFIDENTIALITY / IMMUNITYAll records, files, correspondence or other information or documents relating to an evaluation of aPractitioner for possible Impairment, shall be privileged and confidential and available only to the personsinvolved in the process of assessing whether a Practitioner is Impaired, developing an appropriate place ofaction to address an Impairment, and monitoring of Impaired Physicians. Such records shall not beincluded in the Practitioner’s credentialing file unless it is necessary to take action to suspend, modify orterminate the Impaired Physician’s Medical Staff membership or clinical privileges. All persons making apreliminary, good faith report of Impairment, participants in the evaluation of the report, persons involvedin the development of a plan of action, persons involved in any ongoing monitoring, and the Hospital shallhave the benefit of any and all immunity from suit available under federal or state law.9.9 NON-COMPLIANCE BY IMPAIRED PHYSICIANIn the event the Impaired Physician fails to comply with any requirement under the plan of action toaddress his or her Impairment, information relating to the evaluation as an Impaired Physician may beprovided to the Credentials Committee, the Medical Executive Committee, the Board, or such otherMedical Staff or Hospital representatives or committees as are appropriate. The President of the MedicalStaff may also, where the situation so warrants, make a recommendation for corrective action up to andincluding termination of Medical Staff membership and clinical privileges based on the non-compliancewith the plan of action by the Impaired Physician.9.10 CORRECTIVE ACTIONIf, as result of a finding that the Practitioner suffers an Impairment of a nature to warrant corrective actionunder the Fair Hearing Plan, corrective action is imposed on the Impaired Physician that adversely impactsclinical privileges or Medical Staff membership of the Impaired Physician, he or she shall have the right toa hearing after timely and proper request, as set forth in the Fair Hearing Plan.31

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalLeave of AbsencePolicy #10-CRApproved by: Medical Executive Cte.Effective Date: 3/26/92Reviewed/Revised Date: 3/95, 11/95, 3/96, 7/00, 10/04, 8/06, 12/06, 10/0810.1 PERSONAL / FAMILY LEAVEA Medical Staff member may request a voluntary Personal / Family leave of absence by making a writtenrequest to the President of the Medical Staff, which shall be forwarded to the appropriate DepartmentDirector and the Medical Executive Committee. The request must state the approximate period of time ofthe leave, which absent extraordinary circumstances, such as a leave for military service, may not exceedthe duration of such Medical Staff member’s credentialing cycle. A decision to approve or reject a requestfor a Personal / Family leave of absence will be made within a reasonable time, and delivered by thePresident of the Medical Staff to the Medical Staff member. The Medical Staff member’s clinicalprivileges remain unaffected during any period of Personal / Family leave.10.2 IMPAIRMENT LEAVEThe President of the Medical Staff, or his or her designee, may place a Medical Staff member on anImpairment leave of absence status where the Medical Staff member is determined to suffer from anImpairment, and, in the sole discretion of the President of the Medical Staff, such leave is in the bestinterest of the Hospital, patients and/or the Impaired Physician. The Impaired Physician may also requestthat he or she be placed on an Impairment leave. Any conditions for rehabilitation, ongoing treatment orother conditions which apply to the period of the Impairment leave of absence shall be set forth in writingand delivered to the Impaired Physician, by certified mail, at the address on file in the Medical StaffServices Office. During any Impairment leave of absence, the Impaired Physician’s clinical privileges andMedical Staff Membership are suspended.10.3 TERMINATION OF PERSONAL / FAMILY LEAVEThe returning Practitioner must send a written request to the President of the Medical Staff prior to his orher return to active practice at the Hospital, typically not less than forty-five days (45) prior to the date onwhich he or she wishes the Personal / Family leave of absence to end. In the event that a Personal/Familyleave is of a duration that is less than 45 days, the Practitioner shall send such notice not less than fourteen(14) days prior to the desired start date. If, for any reason, the duration of the Personal / Family leaveextends beyond eighteen (18) months, the returning Practitioner will be required to complete an applicationfor reappointment to the Medical Staff.10.4 TERMINATION OF IMPAIRMENT LEAVEThe returning Impaired Physician must request reinstatement to the Medical Staff from the MedicalExecutive Committee not less than forty-five (45) days prior to the date on which he or she desires to returnto active practice at the Hospital, and, if reinstatement is granted, the returning Impaired Physician shall berequired to submit the appropriate application for reappointment, Delineation of Privileges form, andsupporting documents to the Medical Staff Services Office with sufficient time to permit processing of theapplication for reappointment. In the event that an Impaired Physician’s leave is less than forty-five (45)days, the Practitioner shall request reinstatement at least fourteen (14) days prior to the desiredreinstatement date. The returning Impaired Physician shall also submit any and all appropriatedocumentation regarding any screening, treatment and/or other activities that were imposed as a conditionof the Impairment leave. The provisions of Policy #11 shall apply to the returning Impaired Physician.32

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalLeave of AbsencePolicy #10-CR10.5 FITNESS TO RETURNAt the termination of an Impairment leave of absence, the Medical Executive Committee has the right torequire confirmation of fitness to return to active practice from any licensed independent practitionertreating the Practitioner during the leave. Additionally, the Medical Executive Committee may require anyinformation, which in its reasonable judgment, is deemed relevant to evaluate the returning ImpairedPhysician’s competence to return to active practice at the Hospital.10.6 ONGOING MONITORINGAt the termination of an Impairment leave of absence, the Medical Executive Committee may assign aproctor to oversee and monitor the returning Impaired Physician’s activities and clinical competence forany period deemed, in the reasonable judgment of the Medical Executive Committee, appropriate andnecessary to ensure the health and safety of patients, Hospital employees, other members of the MedicalStaff and the Practitioner. Appointment of a proctor shall not constitute a restriction of clinical privileges,therefore such appointment does not trigger any right to a hearing under the Fair Hearing Plan.33

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalRehabilitation of Impaired PhysicianPolicy #11-CRApproved by: Medical Executive Cte.Effective Date: 6/27/95Reviewed/Revised Date: 7/01, 10/04, 8/06, 12/06, 10/0811.1 REHABILITATIONWhere an Impaired Physician is required to participate in a structured program of rehabilitation (such asone offered by the Ohio Physician Health Program), the Medical Executive Committee shall, in advance,approve the program.11.2 REINSTATEMENT / REAPPOINTMENTNo Impaired Physician who participates in a rehabilitation program (when coupled with an Impairmentleave of absence) may: (i) apply to the Medical Executive Committee for reinstatement; or (ii) apply forreappointment through the Medical Staff Services Office, until the Impaired Physician can demonstrate, tothe satisfaction of the Medical Executive Committee, that he or she can resume practice in compliance withacceptable and prevailing standards of care appropriate for the Impaired Physician’s licensure. TheImpaired Physician seeking reinstatement / reappointment will be expected to fully cooperate in thereinstatement / reappointment investigation, and will be expected to provide all information reasonablyrequested by the Medical Executive Committee, which may include, but shall in no event be limited to, thefollowing:a. Certification that the structured program of rehabilitation has been successfullycompleted;b. Evidence of full compliance with any after-care treatment; andc. Opinions from both the director of the rehabilitation program, and/or the ImpairedPhysician’s primary care physician that the Impaired Physician is able to resume his orher practice in compliance with acceptable and prevailing standards of care, and whetherany restrictions or limitations should be placed on the exercise of clinical privileges.The Medical Executive Committee may, after investigation of the request for reinstatement /reappointment: (i) deny the request (which then triggers the right to a hearing under the Fair Hearing Planon timely and proper notice); (ii) approve the request; or (iii) approve the request subject to certainconditions.11.3 CONDITIONS OF REINSTATEMENT / REAPPOINTMENTIf the Medical Executive Committee approves the reinstatement / reappointment of the Impaired Physiciansubject to certain conditions, compliance with the conditions will be monitored by the President of theMedical Staff. Applicable conditions may include, but shall not be limited to any or all of the following:a. The Impaired Physician may be required identify two other members of the Medical Staffwho are willing to assume responsibility for the care of any of the Impaired Physician’spatients in the event of the Impaired Physician’s future inability to provide care;b. The primary care physician for the Impaired Physician may be required to provideperiodic reports to the President of the Medical Staff on the Impaired Physician’scondition, his or her ability to provide patient care at or above the acceptable andprevailing standards, and his or her prognosis, and necessity for continued treatment;c. The Impaired Physician may be required to completely abstain from the use of alcoholand the use or possession of drugs, other than those properly dispensed or administered to34

Credentials Policy & Procedure ManualMedical Staff of The Christ HospitalRehabilitation of Impaired PhysicianPolicy #11-CRhim or her by an independent licensed practitioner providing ongoing treatment of theImpaired Physician;d. Agreement to submit to random urine and /or blood screens; ande. The Impaired Physician’s performance may be monitored, and the applicable time frameand nature of the monitoring shall be in the sole discretion of the Medical ExecutiveCommittee.11.4 AUTHORIZATION FOR RELEASE OF MEDICAL RECORDSThe Impaired Physician shall provide authorization for the release to the Medical Executive Committee ofany and all medical records and information directly related to the Impaired Physician’s rehabilitation,treatment and after-care. All such records shall be treated as confidential, and be used solely for purposesof the reinstatment / reappointment decision and to monitor the Impaired Physician’s rehabilitation progressand exercise of clinical privileges after reinstatement / reappointment.CINLibrary 0113651.0554388 1827565v1035