Academic Catalog

Policy Statement

This policy explains the credentialing and privileging process for providers at Campus Health Services – Medical Services.

Reason For This Policy

This policy explains how and when providers are credentialed or re-credentialed and privileged. The committee provides a recommendation to the Governing Body of Campus Health Services regarding this function.  The committee has the authority and the responsibility to review all documents in the providers credentials file, data from the Continuous Quality Improvement program, patient satisfaction surveys and other relevant information where appropriate. 

Entities Affected By This Policy

Executive director of Campus Health Medical Services, Governing body at Campus Health Medical Services, and medical providers at CHS Medical Services.

Who Should Know This Policy

Executive director of Campus Health Medical Services, Governing body at Campus Health Medical Services, and providers at CHS Medical Services.

Definitions

Governing Body of Campus Health is the leadership team.

Credentialing –

     1. Establishes minimum training experience and other requirements for health care professionals

2. Establishes a process to review assess and validate an individual’s qualifications, including education, training experience, certification, licensure and any other competence–enhancing activities against the organization’s established minimum requirements

     3. Carries out the review, assessment and validation

Privileging -

1. Determines the clinical procedures and treatments that are offered to patients
2. Determines the qualifications related to training and experience that are required to authorize an applicant to obtain such a privilege.
3. Establishes a process for evaluating the applicant’s qualification using appropriate criteria and approving, modifying or denying any or all the requested privileges in a non- arbitrary manner.

Policy

The credentialing committee of Campus Health will review matter related to credentialing and privileging of medical providers including new applications, recredentialing and changes in status.  Medical providers include primary care providers, medical specialists and psychiatric providers.  These providers may be physicians or nurse practitioners.

MEMBERSHIP:

The membership of this committee will include the following voting members:

• Medical Director, Chairman (In the case of the Medical Director’s privileges or in response to a concern about the Medical Director, another staff physician will replace the Medical Director on the committee for that deliberation)
• Staff physician, membership rotated among all full time CHS physicians
• Nurse Practitioner or Physician’s assistant, membership rotated among all full time non-physician providers 
• Psychiatric provider

An administrative support staff member responsible for coordinating credentialing activities will be appointed by the committee Chairperson to serve in a non-voting role.

All members of the committee are appointed by the Medical Director.

Responsibilities

ACTIONS AND COMMUNICATIONS:

The following actions may be taken by the Credentialing and Privileging Committee. This list may not be all inclusive but should serve as a guide to the Committee in their decision making:

Review of requests for credentialing:

1. Approval of credentialing
2. Denial of credentialing
3. Change in credentialing status

Review of requests for privileges:

1. Approval of requested privileges
2. Partial approval of requested privileges
3. Denial of requested privileges

Review of existing privileges when called by the Chairman on an ad hoc basis. This may arise when an adverse incident (see Occurrence/Adverse Incident policy for definition) has been brought to the attention of the clinic or as a response to a staff member’s concern about a clinician. Action taken by the committee may include, but is not limited to:

1. No action required.
2. Internal action that does not meet the oversight authority of the appropriate regulatory agency. This internal action may include for example, recommendations to comply with a policy/guideline and/or an increasing level of review and/or oversight to monitor compliance but no withdrawal of privileges.
3. A partial withdrawal of clinical privileges.
4. A complete withdrawal of clinic privileges.
5. Report action taken by the committee to the appropriate regulatory agency if provider’s action rises to the level where that jurisdiction may apply (see Arizona Revised Statutes).  These regulatory agencies may include:
   1. Arizona Medical Board
   2. Arizona Board of Osteopathic Examiners in Medicine and Surgery
   3. Arizona Board of Nursing

The Committee Chairperson will report all actions and recommendations of the Committee to the Executive Director of Campus Health Services and the Governing Body.  The Medical Director will notify the provider who has requested privileges what action has been taken.  This notification will be in writing.

In the event that the Committee takes negative action in regards to a provider’s credentials and/or privileging the Chairperson will provide details related to that action to the Executive Director of Campus Health Services.  The Executive Director will present the information to the provider.   The provider will be afforded the opportunity to meet with the Credentialing and Privileging Committee to answer questions and respond to the committee’s concerns. This meeting will take place within 14 calendar days of the original notification of adverse action. After this meeting, the Credentialing and Privileging Committee Chairperson will provide a final report and recommendation to the Executive Director of Campus Health Services within five working days.

APPEALS:

If a provider has been denied clinical privileges which he or she requested or has had clinical privileges removed, a written appeal may be directed to the Executive Director of Campus Health Services.  The Executive Director will decide how the appeal should be reviewed and responded to and will have five working days to make the determination.  The Executive Director’s decision is final and will be presented to the provider in writing within one working day after the decision is made. 

REQUIREMENT TO REPORT:

At any time, providers must notify the Medical Director of any notice of complaint, advisory letter or disciplinary action that may have been received from their respective regulatory agencies.  In addition, providers must report to the Medical Director any notice of legal action related to professional activities at NAU or other outside practices. The Medical Director will notify the Committee of this information. It may be used in subsequent credentialing and privileging decisions.

RELIEF FROM REQUIREMENT TO MAINTAIN BOARD CERTIFICATION:

Campus Health Services requires medical providers to hold and maintain current board certification from a recognized certifying agency.  A medical provider may request relief from this requirement while maintaining all other aspects of credentialing and privileging.  Such an individual must meet the following requirements:

1. Generally, may provide clinical care in the Urgent Care/Blue Clinic Center only.  However, under limited circumstances may provide general medical care in the non-Urgent Care Setting.
2. Work on average less than 20 hours per week.
3. While maintaining current board certification have worked for a minimum of one academic year within the NAU CHS setting or be working towards board certification within one year of hire.
4. Submit written request to Committee to be afforded relief from board certification requirement including rationale for doing so.

The Committee may take the following action and forward such a recommendation to the Executive Director of Campus Health Services:

1. Providing relief from board certification requirement
2. Denying relief from board certification requirement

In arriving at such a decision the Committee may review information including, but not limited to:

1. Patient Satisfaction Survey results
2. Any adverse incident/unusual occurrence documentation
3. Any recommendations from the Internal Review Committee
4. Chart reviews, medical decision making, peer review summaries
5. Measurements of compliance with policies such as timeliness in completing charts, attendance at assigned shifts, reliability
6. Complaints filed with the appropriate regulatory agency
7. Legal proceedings related to professional medical activities at NAU CHS or other outside practices
8. Legal proceedings not related to professional medical activities

TEMPORARY CREDENTIALS AND PRIVILEGING:

A medical provider may be hired and need to provide services prior to formal review of their application and supporting documentation by the full Credentialing and Privileging Committee.  Under these circumstances, the Medical Director is authorized to confer temporary credentials and privileges for a maximum of 90 days.  The following information must be current:

1. Current AZ licensure
2. Current DEA Registration
3. Current Board Certification or working toward Board Certification within 1 year of hire
4. Completed and signed Credentialing Application
5. Signed Job description
6. Completed and signed Privileging Sheet
7. Current CV
8. Current NPI number
9. Current NPDB report
10. References (peer reference documentation)

VERIFICATION OF COMPETENCE TO PERFORM REQUESTED PRIVILEGES:

The process to grant privileges whether on temporary basis by Medical Director or on permanent basis by the Committee will require verification of the provider’s competence to perform requested privileges.  Various methods will be utilized to verify that competence.  Privileging list from a prior institution may be utilized in this process but cannot be the sole source of verification.  Other methodologies may include, but are not limited to:

1. References—either written or verbal
2. Documentation from formal training course
3. Copies of encounter notes
4. Documentation of procedures performed from prior institution
5. Self-reported list detailing procedures performed
6. Curriculum report or detailed list of procedures performed from training program

Procedures

MEETINGS:

Credentialing committee meetings will be held on a quarterly basis or ad hoc as needed. Meetings will be held at a time and place designated by the Committee Chairperson and will be held during regular working hours. All members have one vote and decisions are made by a formal vote by a show of hands.  If the privileges of one of the committee members are being considered, that provider will be excused from the committee and will be replaced by another staff member of the same discipline. In the case of the Medical Director’s privileges, another Staff Physician will replace the Medical Director on the committee for that deliberation.

1. Credentialing is done upon initial employment and at a minimum of every 36 months. This is done with information obtained by the National Practitioner Data Base.
2. The governing body establishes and is responsible for credentialing and the reappointment process.  The governing body has delegated recommendation authority to the Credentialing and Privileging committee.
3. All providers must be granted clinical privileges prior to providing patient care within Campus Health Services.  The Medical Director can grant clinical privileges temporarily until a request for privileges can be brought before the Credentials and Privileging Committee.
4. All providers must practice within their clinical privileges, both in terms of the general body of knowledge of their discipline and in terms of the performance of procedures.
5. Clinical privileges granted must be consistent with a provider’s training and experience.
6. Clinical privileges for all provider disciplines are granted for a period not to exceed thirty-six months.
7. The administrative office at Campus Health maintains all provider privileges files and credentials files in a locked file cabinet and controls access to these files. Access to these files is limited to the Executive Director of Campus Health Services and Medical Director, the providers have access to their own files, representatives of the accrediting organization, law enforcement or other investigative authority, and others at the discretion of the Medical Director who have a need to know the contents of provider files.
8. On application for initial privileges, the applicant is required to provide sufficient evidence of training, experience and current competence in performance of the procedures for which privileges are requested. On reapplication for clinical privileges, the applicant must provide comparable documentation for any new procedures for which privileges are requested. 
9. It is the provider’s responsibility to maintain current professional licensure, Drug Enforcement Administration certification and cardiopulmonary resuscitation or ACLS certification. A copy of each licensure and certification must be provided to the Medical Director or his or her designee to be included in the provider’s credentials file as soon as the document is available.  Providers who recertify through their specialty board must provide a copy of the recertification document as soon as this document is available.
10. It is the provider’s responsibility to provide for his or her credentials file information on licensure suspension or revocation; voluntary relinquishment of licensure; licensure probationary status or other licensure conditions or limitations; complaints or adverse action reports filed against the applicant with a local, state or national professional society or licensure board.  Providers must also report refusal or cancellation of professional liability coverage at any health facility or program; Drug Enforcement Administration license suspension or revocation; conviction of a criminal offense; and any currently present physical, mental health or chemical dependency problems that could interfere with a provider’s ability to provide high quality professional services. All such information must be provided as soon as the provider is aware of it.  All information is subject to source verification.
11. The National Practitioner Data Bank and the Arizona Medical Board will be queried each time a provider requests clinical privileges.
12. A provider may at any time request to voluntarily relinquish one or more clinical privileges such as procedures. The Medical Director will review the request with regard to the needs of the Campus Health Services and make a recommendation to the Credentials and Privileging Committee.
13. A provider may be asked to request additional clinical privileges based on the needs of the Campus Health Services. No provider will be asked or required to request additional privileges unless there is a program need and unless appropriate training is documented to support the privileges request.
14. The Medical Director may suspend a provider’s clinical privileges, in whole or in part, while a complaint or claim is being investigated or as a result of an internal investigation. The provider must be notified in writing of such a suspension of clinical privileges at the time of the suspension by the Medical Director and the suspension must be reported to the Credentials and Privileges Committee within two weeks to receive their concurrence. In the event that the Credentials and Privileges Committee does not support the suspension of privileges by a majority, the suspension is reversed. If the Credentials and Privileges Committee supports the suspension of privileges, the Executive Director of Campus Health Services will review the suspension of privileges within two weeks utilizing whatever resources he or she deems appropriate.  The decision of the Executive Director of Campus Health Services is final and must be presented in writing to the provider within one work day after the decision is made.
15. The requirements of the Arizona Medical Board and the National Practitioner Data Bank will be followed with regard to reporting termination of clinical privileges.
16. All members of the provider staff share responsibility for performing periodic peer review as described in the policy and procedure on peer review.  Peer review findings are considered in the decision to grant clinical privileges.

Related Information

Forms or Tools

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Cross-References

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Sources

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Appendix

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