MARTIN HEALTH SYSTEM
CREDENTIALING PROCEDURES MANUAL
FOR ALLIED HEALTH PROFESSIONALS/DEPENDENT
PRACTITIONERS
Last Amended September 24, 2014
Approved 04/2012
Last reviewed in its entirety by Medical
Staff Bylaws Committee: 7/16/14; 7/11/16
Revised 11/15/12; 9/24/14
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DEFINITIONS
The following definitions apply to this Manual.
Affiliate shall refer to an entity which is owned in whole or in part by Martin Health System, or a subsidiary
of Martin Health System and which has a legitimate need to credential and grant privileges to an Allied
Health Professional (AHP)/Dependent Practitioner (DP).
Allied Health Professional or AHP/Dependent Practitioner or DP. See Part 1.1.
ARNP means an individual licensed as an R.N. in an expanded role as a nurse practitioner.
Associate shall refer to an individual who is an employee of Martin Health System or any Affiliate.
Board of Directors or Board means the governing body of the applicable Martin Health System affiliated
entity responsible for overseeing the credentialing of AHPs/DPs in the applicable Martin Health System
affiliated Facility. Except as provided herein and as appropriate to the context and consistent with the
Bylaws of the entity and delegations of authority made by the Board, it may also mean any committee of
the Board or any individual authorized by the Board to act on its behalf on certain matters.
Bylaws mean the corporate Bylaws of the applicable entity.
CNM means an individual licensed as an ARNP in an expanded role as a certified nurse midwife.
Credentials Committee or CC shall mean the Credentials Committee of Martin Health System standing
committee of the Board of Directors of Martin Health System charged with the responsibility of
coordinating all Allied Health Professional/Dependent Practitioner and Medical Staff credentialing
functions performed by Affiliated Facilities.
CRNA means an individual licensed as an ARNP in an expanded role as a certified registered nurse
anesthetist.
Department Chairman/Service Chief, and similar references, shall refer to the Department Chairman or
Service Chief of the Facility in which the AHP/DP is being credentialed and, where applicable Department
Chairman and Service Chiefs do not exist, such references shall be construed as meaning the applicable
Medical Director of a Facility or a Department within a Facility.
Medical Staff Services Credentialing Specialist shall refer to an individual or group of individuals
designated by Martin Health System Administration to accept and process applications by Physicians or
AHPs/DPs requesting permission to provide specified services in a Facility.
Entity shall refer to any enterprise which is legally affiliated with Martin Health System or legally affiliated
with a subsidiary of Martin Health System not-for-profit Florida Corporation.
Facility shall mean the Martin healthcare facilities, including all mobile units, where applicable, which are
operated by an Affiliate and which grants clinical privileges to AHPs/DPs.
Martin Health System shall, for the purposes of this manual, be used to collectively refer to all facilities
operated by Martin Health System or any affiliate, where the context permits. It shall not be construed as
referring to Martin Health System individually as a not-for-profit Florida corporation.
Medical Executive Committee or MEC shall mean the Medical Executive Committee of the applicable
Facility or, if no committee has been designated as the “Medical Executive Committee,” then each such
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reference shall be construed as including the highest level Facility committee whose membership includes
healthcare providers credentialed and privileged to practice in the Facility.
Medical Staff or Staff is the organizational component of the applicable entity that includes all
practitioners who are appointed to it and are privileged to attend patients or to provide other diagnostic,
therapeutic, teaching or research services at the entity’s facilities.
Medical Staff Bylaws and related manuals, Medical Staff Bylaws or Bylaws means and refers to all of
the following documents as appropriate to the context:
· Bylaws of the Medical Staff
. Medical Staff Credentialing Procedures Manual
· Medical Staff Fair Hearing Plan
· Medical Staff Organization Manual
· General Rules and Regulations of the Medical Staff
. Medical Staff Member shall mean those practitioners granted Medical Staff membership
and clinical privileges by a board to practice at a Facility which has an organized Medical
Staff. AHPs /DPs are not Medical Staff members.
Medical Staff President means that member of the Active Staff elected pursuant to the applicable Bylaws
and Medical Staff Bylaws to be the principal elected officer of the Staff. If there is no Medical Staff or a
principal elected officer to represent the Healthcare providers, all such references shall be construed as
meaning the highest ranking physician representative of the applicable Facility.
Medical Staff Services or MSS means the administrative unit of Martin Health System responsible for
organizing and managing the administrative aspects of the credentialing and privileging processes and for
providing support for the Medical Staff organizations, their officers and structural components in the
fulfillment of their required functions.
PA means an individual with a P.A. degree, who is licensed as a physician assistant, and who may provide
medical services appropriate to his or her training, experience and skills under the supervision of a
physician.
Physician means an individual with an M.D. or D.O. degree, who is licensed to practice medicine.
President means the individual appointed by the Board as the chief executive officer of the applicable
entity to be responsible for the overall executive supervision and management of the entity. The President
may, consistent with his responsibilities under the Bylaws, designate a representative to perform his
responsibilities under the Medical Staff Bylaws and related manuals.
Professional Affairs Committee or PAC means the Professional Affairs Committee of the Board.
Psychologist means an individual with a doctoral degree in psychology from an accredited educational
institution, who is licensed to practice psychology.
Scope of Practice means extent of treatment, activity or influence defined for each AHP/DP.
Special Notice means written notification sent, unless otherwise specified, by certified mail, return receipt
requested, or by personal delivery service with signed acknowledgment of receipt.
Written Notice means written notification sent, unless otherwise specified, by regular mail, electronic mail,
facsimile transmission, delivery to the members’ boxes in the Hospital, or by personal delivery.
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Specified Services means the specific clinical functions or activities in the treatment of patients granted
to an AHP/DP.
Supervising Physician means a physician holding an unrestricted full medical license in Florida who has
been designated as a Supervising Physician for an AHP/DP or who has developed and signed mutually
agreed upon guidelines with a PA or nurse engaged in an expanded role and/or in prescriptive practice.
Vice President for Medical Affairs or VPMA means the individual designated by the Board to hold this
title, and who is the Chief Medical Officer of all Martin Health System facilities. The VPMA may,
consistent with his responsibilities under the Bylaws, Medical Staff Bylaws and related manuals, and his
employment arrangement, designate a representative to perform his responsibilities hereunder.
CONSTRUCTION OF TERMS AND HEADINGS
Pronouns having gender refer to persons of both sexes. The captions or headings in the Bylaws and
related manuals are for convenience only and are not intended to limit or define the scope or effect of any
provision herein.
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PART ONE. AUTHORIZATION AND CONTROL PROVISIONS
1.1
DEFINED
1.1-1 GENERALLY
An allied health professional (“AHP”) / dependent practitioner (DP) is an individual, other
than a Medical Staff member, who is qualified by academic and clinical training and by
prior and continuing experience and current competence in a discipline which the Board
has determined to allow to practice in a Martin Health System affiliated Facility and who,
at the time of initial application and continuously thereafter, satisfies the basic
qualifications set forth in Section 1.2 of this Manual, and either:
A.
B.
1.1-2
is licensed and permitted by the state and the Board to provide patient services in
the Facility without the direction or contractual agreement with a physician (i.e.,
"Independent Practitioner");
or
is licensed by the state to perform patient care services ordinarily performed by a
physician under the direction of the physician and with mutually agreed upon
guidelines (i.e., "Dependent Practitioner").
CURRENT CATEGORIES OF ALLIED HEALTH PROFESSIONALS/DEPENDENT
PRACTITIONERS
Martin Health System permits the following categories of independent practitioners and
physician-directed practitioners to be credentialed pursuant to this Manual to provide
services in its affiliated facilities:
A.
B.
Independent Practitioners:
Psychologist
Dependent Practitioners:
Certified Nurse Midwife
Certified Registered Nurse Anesthetist
Advanced Registered Nurse Practitioner
Physician Assistant
For the purposes of this Manual, all other healthcare professionals’ scope of permitted services
not referenced above shall be processed through the Human Resources Department and will be
defined by a job description or contractual agreement, and this Manual shall not apply to them,
including but not limited to:
Surgical Assistants
Audiologists
LPN-Assistants
Surgical Technicians
RNFAs
Pathology Assistants
Cardiothoracic Perfusionists
1.2
QUALIFICATIONS OF ALLIED HEALTH PROFESSIONALS/Dependent Practitioners
(Reference Medical Staff Bylaws Article Seven) Every AHP/DP who applies for or is exercising
specified services must at the time of initial application for permission to practice and, if approved,
continuously thereafter, demonstrate to the satisfaction of the appropriate Martin Health System
authorities the following minimum qualifications (any individual Entity may require such additional
qualifications it deems appropriate):
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1.2-1
LICENSURE
Current license, registration, certificate or such other credential, if any, as may be
required by Florida law.
1.2-2
CONTROLLED SUBSTANCE REGISTRATION
If applicable, currently valid U.S. Drug Enforcement Administration (DEA) and Florida
controlled substances registrations.
1.2-3
PROFESSIONAL EDUCATION AND TRAINING
As defined in the applicable threshold criteria for each specific AHP/DP specialty.
1.2-4
EXPERIENCE AND PROFESSIONAL PERFORMANCE
Current experience, clinical results and utilization practice patterns, documenting the
continuing ability to provide patient care services at an acceptable level of quality and
efficiency in each applicable Facility.
1.2-5
COOPERATIVENESS
Demonstrated ability to work cooperatively and in a professional manner with others (Staff
members, members of other health disciplines, Hospital management and employees, the
Hospital Board, visitors and the community in genera), specifically to include refraining
from conduct which constitutes a pattern of disruption that could adversely affect the
quality or efficiency of patient care services in the applicable Facility.
1.2-6
PROFESSIONAL ETHICS AND CONDUCT
To be of high moral character and to adhere to generally recognized standards of
professional ethics.
1.2-7
HEALTH STATUS
A.
Physical or Mental Impairment: Must be free of any mental or physical
impairment that could interfere with the performance of all or any of the specified
services requested or granted, unless reasonable accommodation can be made
for such impairment consistent with the interests of sound patient care. In the
event of a physical or mental impairment, the Practitioner shall promptly notify the
VPMA so that a determination can be made as to whether or not there is a
reasonable accommodation that can be made for the impairment that will permit
the Practitioner to continue his/her duties.
B.
Substance/Chemical Abuse: To be free from abuse of any type of substance or
chemical that interferes with, or presents a reasonable probability of interfering
with, the Practitioner's ability to satisfy any of the qualifications required by this
Part 1.2 or ability to perform any or all of the specified services requested or
granted. Practitioner shall be subject to all drug testing policies then in effect for
Associates.
1.2-8
COMMUNICATION SKILLS
Ability to read, write and understand the English language, to communicate in the English
language in an intelligible manner, and to prepare any authorized medical record entries
and other required documentation in a legible manner.
1.2-9
FOR MARTIN HEALTH SYSTEM EMPLOYEES
Associates of Martin Health System affiliates must also satisfy any additional
requirements applicable to employment.
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1.2-10 PROFESSIONAL LIABILITY INSURANCE
If not a Martin Health System Associate, professional liability insurance coverage issued
by a recognized company and of a type and in an amount equal to or greater than the
limits established by the Board.
1.3
EFFECTS OF OTHER AFFILIATIONS (Reference Medical Staff Bylaws Article Seven 7.1-8)
No AHP/DP shall be automatically entitled to provide any services merely because the
Practitioner:
A.
B.
C.
D.
E.
F.
1.3-1
1.4
NONDISCRIMINATION: (Reference Medical Staff Bylaws Article Seven 7.1-9)
No aspect of the AHP/DP affiliation with Martin Health System or particular clinical
privileges/competencies shall be denied on the basis of: age; sex, race, creed, color,
national origin, a handicap unrelated to the ability to fulfill patient care and required
obligations; or any other criterion unrelated to the delivery of quality and efficient patient
care in the Hospital facilities, to professional qualifications, or to the Hospital’s purposes,
needs and capabilities.
PREROGATIVES OF ALLIED HEALTH PROFESSIONALS/DEPENDENT PRACTITIONERS
(Reference Medical Staff Bylaws Article Two [2.3-2; 2.3-5; 2.4; 2.4-2; 2.4-5; 2.4-9])
The prerogatives of an AHP/DP are to:
A.
B.
C.
D.
E.
1.5
is authorized to practice in this or in any other state; or
is a member of any professional organization; or
is certified by any clinical board or professional organization; or
had, or presently has, specified clinical privileges/competencies or permission to provide
the requested specified services at another healthcare facility or in another practice
setting; or
had, or presently has, those requested specified services or is employed at any Martin
Health System affiliated Facility; or
is or is about to become affiliated with a practitioner or another AHP/DP who is, or with a
group of practitioners or AHPs/DPs one or more of whose members are, affiliated with a
Martin Health System affiliated Facility through employment, contract, Medical Staff
appointment or otherwise.
perform such specified services as are defined by the appropriate Martin Health System
authorities, and consistent with any limitations stated in the policies governing the
AHP's/DPs practice in the applicable Facility and any other applicable Medical Staff,
Board or Administrative policies;
serve on committees, if so appointed, and with vote, if so specified by the appointing
authority;
attend, when invited, clinical meetings of the Medical Staff, a Department or other clinical
unit when appropriate to his discipline;
attend education meetings of the Medical Staff, a Department or other clinical unit; and
exercise such other prerogatives as the appropriate Martin Health System authorities may
accord AHPs/DPs in general or a specific specialty of AHPs/DPs.
LIMITATIONS OF ALLIED HEALTH PROFESSIONALS/DEPENDENT PRACTITIONERS
AHPs/DPs are not:
A.
B.
C.
D.
E.
eligible to become members of the Medical Staff; or
eligible to vote in meetings of, or hold office on the Medical Staff; or
required to pay dues to the Medical Staff; or
governed by the due process defined by the Fair Hearing Plan of the Medical Staff; or
with the exception of Certified Nurse Midwives, eligible for admitting privileges.
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8
OBLIGATIONS OF ALLIED HEALTH PROFESSIONALS/DEPENDENT PRACTITIONERS
(Reference Medical Staff Bylaws Article Two [2.3-6; 2.4-3; 2.4-6] Each AHP/DP shall have a
continuing obligation to at all times:
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
provide patients with care or other services at the level of quality and efficiency
professionally recognized as the appropriate standard of care by the Medical Staff and
Board;
provide or arrange for appropriate and timely medical coverage and care for patients for
whom he is responsible;
when necessary and as appropriate, notify Supervising Physician of the need to arrange
for a suitable alternative for care and supervision of the patient;
participate in quality assessment/improvement program, risk management, and corporate
compliance activities appropriate to his discipline, and discharge such other related
functions as may be required from time to time;
when requested, attend clinical and education meetings of the Staff and of the
Department and any other clinical units with which he is affiliated and any individual
conference requested by any applicable Department Chairman/Service Chief, Medical
Director of a special unit, or Medical Staff committee, or other Martin authorities;
abide by the applicable sections of the Medical Staff Bylaws, this Manual and those
appended to any particular specialty of AHP/DP, and all other relevant standards, policies,
and rules of the Medical Staff, the Board, Administration and other applicable Martin
Heath System authorities;
prepare and complete in timely fashion, as appropriate and authorized, those portions of
patients' medical records documenting services provided, and any other required records;
provide upon request evidence of current Florida license/certificate, professional liability
insurance coverage, and if applicable, Federal DEA and Florida controlled substances
registration;
immediately notify the Medical Staff Services’ Credentialing Specialist of: (1) Any criminal
charges brought against the AHP/DP (other than minor traffic violations not involving a
DUI charge); (2) any change made or formal action initiated that could result in a change
in the status of his license/certificate to practice, professional liability insurance coverage;
(3) all changes in employment or affiliation relationships involving a termination,
disciplinary action or reduction in practice privileges with (i) a physician identified as one
who supervises the AHP/DP, (ii) an affiliation with or privileges at any other institutional
affiliation where he provides specified services; and (4) any change in the status of
current or initiation of new malpractice claims involving his professional performance, and
any change in health status that could affect his ability to perform safe and sound patient
care; and
refrain from any conduct or acts that are or could reasonably be interpreted as being
beyond, or an attempt to exceed, the authorized scope of practice.
unless otherwise specified in the relevant Threshold Criteria or Criteria for Clinical
Competencies in the applicable specialty, to maintain permission to provide services the
practitioner must have a minimum of forty (40) patient encounters per biennial review. As
used herein, patient encounters mean any encounter with a patient where the practitioner
is required to document the encounter. In the event of fewer encounters, the practitioner
will be given a special notice advising of the foregoing and afford the practitioner thirty
(30) days to provide documentation demonstrating compliance with this requirement.
Failure to demonstrate compliance with the patient encounter requirement, the
practitioner’s permission to provide services and clinical competencies shall terminate.
Such termination shall not be deemed to be a professional review action for purposes of
reporting to the National Practitioner Data Bank under Title IV of public law 99.660 (“the
Healthcare Quality Improvement Act of 1986”).
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Failure to satisfy any of these obligations is grounds, as warranted by the circumstances, for
termination or nonrenewal of permission to provide specified services or for such other
disciplinary action as deemed appropriate under the circumstances.
1.7
TERMS AND CONDITIONS OF PERMISSION TO PROVIDE SERVICES
An AHP/DP shall be individually assigned to the clinical Department/Service appropriate to his/her
professional training and authorized scope of practice. The AHP/DP is subject to an initial
probationary period, formal periodic reviews, termination of permission to provide specified
services, and disciplinary procedures as set forth in this Manual.
An AHP’s/DP’s authorized specified scope of practice within any Department/Service is subject to
the rules and regulations of that Department/Service and to the authority of the Department
Chairman/Service Chief. The quality and efficiency of the care provided by AHPs/DPs within any
such Department/Service shall be monitored and reviewed.
1.8
LIMITATIONS ON SCOPE OF PRACTICE
Limitations may be placed on the AHP's/DP’s authorized scope of practice in the Facility as
deemed necessary either for the efficient and effective operation of the Facility or any of its
departments or services, or for management of personnel, services and equipment, or for quality
or efficient patient care, or as otherwise deemed by the Board or other appropriate Martin Health
System authorities to be in the best interests of patient care.
1.8-1
INDEPENDENT AHP/DP SPECIFIED SERVICES
The specified services available to any type of AHPs/DPs shall be established by the
Board in accordance with applicable state and federal laws, subject to review and
approval as provided herein, and with input from the Credentials Committee (CC),
Medical Executive Committee (MEC), Professional Affairs Committee (PAC), and any
applicable Department Chairman/Service Chief, appropriate representatives from
Administration, and/or representatives from applicable AHP/DP specialties.
1.8-2
DEPENDENT AHP/DP SPECIFIED SERVICES
Written guidelines defining the specified services that may be provided by each specialty
of Dependent AHP/DP shall be established in accordance with applicable state and
federal laws by the appropriate Martin Health System authorities, subject to review and
approval as provided herein, and with input, as applicable, from the Medical Staff,
Administration, the Facility's other professional staffs, and applicable AHP/DP specialties.
1.8-3
SPECIFIC SERVICES AUTHORIZATION REQUIRED
AHPs/DPs will receive a written document establishing the specific services the AHP/DP
is being granted permission to provide. This document will identify the applicable
Facilities.
A.
B.
C.
D.
E.
F.
G.
qualifications applicable to the specified services authorized and special
requirements that attach to those services;
specification of specialties and ages of patients that may be seen;
description of the services to be provided and procedures to be performed,
including any special equipment, procedures or protocols that specific tasks may
involve, and responsibility for charting services provided in the patient's medical
record;
if applicable, specific guidelines governing the issue of prescriptions or
medication orders;
the degree of physician supervision required;
the circumstances in which physician consultation or referral is required; and
provisions for managing emergencies.
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Each AHP/DP and each Supervising Physician must agree in writing that the AHP/DP will
not provide any services in any Martin Health System Facility unless the AHP/DP has
been granted specific written permission to provide, and that the failure to at all times
comply with this restriction shall be grounds for the immediate revocation of permission to
provide any or all specified services, and to take such other disciplinary action as is
deemed appropriate by the applicable Martin Health System authorities.
1.9
SUPERVISING PHYSICIAN
1.9-1 PHYSICIAN SUPERVISOR QUALIFICATIONS
All Physicians who wish to use a Dependent Practitioner to assist with the provision of
services to patients at any Martin Health System facility must submit a formal written
request to Medical Staff Services and receive formal written notice of approval from the
Board of Directors regarding the specific services the Dependent Practitioner may provide
before utilizing the Dependent Practitioner.
The physician supervisor of an AHP/DP must be a member of the Medical Staff, who is
trained and legally authorized to act in that capacity, and who must agree to supervise the
activities of the AHP/DP in accordance with this Manual, the applicable Bylaws, Medical
Staff Bylaws, and all applicable Martin Health System policies, procedures and applicable
laws and regulations. If the AHP/DP is to work with a group of physicians, the group shall
designate a primary Supervising Physician and an alternate Supervising Physician.
1.9-2
SUPERVISING PHYSICIAN’S OBLIGATIONS
Any physician supervising a physician-directed AHP/DP in the care of a specific patient
must:
A.
be a member of the Medical Staff and accept full legal and ethical responsibility
for the AHP's/DP’s performance;
B.
accept full responsibility for the proper conduct of the AHP/DP within the Facility,
in accordance with all Bylaws, policies and rules of the Facility and Medical Staff,
and for the correction and resolution of any problems that may arise;
C.
be immediately available in person or by telephone to provide further guidance
when the AHP/DP performs any task or function;
D.
maintain ultimate responsibility for directing the course of the patient's medical
treatment;
E.
assure that the AHP/DP provides services in accordance with accepted medical
standards;
F.
May not delegate duties or responsibilities to the Dependent Practitioner that they
have not been granted or are not considered competent to perform.
G.
provide active and continuous overview of the AHP's/DP’s activities in the Facility
to ensure that directions and advice are being implemented;
H.
abide by all bylaws, policies and rules governing the use of AHPs/DPs in the
Facility, and the AHP's/DP’s authorized scope of practice in the Facility;
I
immediately notify the Medical Staff Services Credentialing Specialist in the event
any of the following occur;
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2.
3.
4.
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the scope or nature of his professional arrangement with the AHP/DP
changes;
his legal authority to supervise the AHP/DP is revoked, limited, or
otherwise altered by action of the applicable state licensing authority;
notification is given of investigation of the AHP/DP or of his/her
supervision of the AHP/DP by the applicable state licensing authority;
his/her professional liability insurance coverage is changed insofar as
coverage of the acts of the AHP/DP is concerned or the AHP's/DP’s
professional liability insurance coverage is changed;
J.
comply with all laws and regulations and all policies, procedures and restrictions
specific to the AHP/DP;
K.
When a Supervising Physician is unable or unavailable to be the principal medical
decision maker, it is the obligation of the Supervising Physician and AHP/DP to
inform and provide to Medical Staff Services written confirmation from another
physician who has agreed to assume temporary supervisory responsibilities with
respect to the AHP/DP. The temporary assumption of supervisory responsibilities
must be in place prior to the principle Supervisor’s taking his/her leave.
If the AHP/DP is an Employed/Associate of a Martin Health System affiliate, the
Supervising Physician must notify the Department of Human Resources of the
need to replace the Supervising Physician. For affiliate Employed/Associate
AHPs/DPs, the VPMA is responsible for assigning a temporary Supervising
Physician and notifying Medical Staff Services and Human Resources.
Regardless of the AHP/DP status (Employed/Associate or Non-Employed), if a
temporary supervising physician is not immediately available/assigned, the
AHP/DP permission to provide services and clinical privileges/competencies will
be immediately suspended until such time as the Supervising Physician returns or
a temporary Supervising Physician is named. The Suspension shall not exceed
ninety days; thereafter, the AHP/DP will be deemed to have voluntarily resigned
and relinquished all clinical privileges/competencies.
Reinstatement of the AHP’s/DP’s permission to provide services and clinical
privileges/competencies may occur anytime during the time frame referenced and
only upon receipt of the official notice of the Supervising Physician’s return or
upon assigning a temporary new Supervising Physician.
L.
For all patients who are seen initially on admission to the Hospital by a Physician
Assistant or Advanced Registered Nurse Practitioner, the Dependent Practitioner
can perform the initial assessment, but the supervising physician must see the
patient within 24 hours of admission, sign off on orders, H & P, and write an initial
progress note. Thereafter, the Supervising Physician must see all inpatients once
every 48 hours at a minimum and provide evidence of such within the Progress
Notes or Orders section of the patient’s Medical Record.
ICU patient admissions must be seen timely by the supervising physician
regardless of the length of the ICU admission; and thereafter at least once each
24 hours. [NOTE: CNM/CRNA’s: Due to the scope and nature of their practice,
this provision shall not apply to CNMs and CRNAs so long as the care is provided
pursuant to an established protocol and is within the licensed scope of practice.]
Examples of appropriate documentation would include self-entry or co-signing;
including date and time; the Physician Assistant’s or Advanced Registered Nurse
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Practitioner’s progress note indicating agreement with said PA/ARNP’s
documentation. [NOTE: CNMs: Due to the scope and the nature of their
practice, this provision shall not apply to CNMs so long as the care is provided
pursuant to the established protocol and is within the licensed scope of practice.]
M.
CONSULTATIONS:
a) The Supervising physicians will not refer Initial consultations to the Dependent
Practitioner unless it is for a specific service for which the Dependent Practitioner
has been approved to provide
b) The Dependent Practitioner must consult with the Supervising Physician and
document all consultations prior to discharge from the Hospital, including the
Emergency Room.
c) If a patient seen by the AHP/DP in the ER requires transfer to another facility, the
Supervising Physician must speak directly with the Emergency Department
physician.
1.9-3
LEVEL OF SUPERVISION
“Indirect Supervision” is defined as supervision of the Dependent Practitioner accomplished by
easy availability of the Supervising Physician to the Dependent Practitioner, which includes the
ability to communicate directly (telecommunication is acceptable). The Supervising Physician
must be within a reasonable physical proximity.
“Direct Supervision” is defined as the physical presence of the Supervising Physician on the
premises, so that the Supervising Physician is immediately available to the Dependent
Practitioner.
1.10
ORIENTATION OF AHP/DP
As referenced in the Threshold Criteria for Permission to Provide Services, approval of an
AHP's/DP’s application shall be conditional upon satisfactory completion of an orientation process
then in effect, which must occur within six (6) months of the date permission is granted and prior
to the AHP/DP exercising any privileges in a Facility.
1.11
IDENTIFICATION
At all times while on Facility premises, the AHP/DP shall wear the identification badge provided by
Martin Health System clearly identifying the AHP/DP by name and professional designation.
1.12
EVALUATION OF INDIVIDUAL ALLIED HEALTH PROFESSIONAL/DEPENDENT
PRACTITIONER APPLICATIONS
1.12-1 AFFILIATE EMPLOYED/NON-EMPLOYED AHP/DP
The procedure for evaluating an application from an AHP/DP or a prospective AHP/DP is
set forth in Part Two of this Manual.
Affiliate Employed AHP/DP shall also be subject to the Facility’s Human Resources
policies. Evaluation of the application shall include review and reports by the same
authorities as provided in Part Two of this Manual. An offer of employment may be
extended with conditions that the prospective applicant successfully completed the
credentialing process as provided herein.
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PART TWO. APPLICATION PROCEDURE FOR ALLIED HEALTH
PROFESSIONAL/DEPENDENT PRACTITIONER
2.1
APPLICATION AND CONTENT
(Reference Medical Staff Credentialing Procedure Manual Part One) An application for permission
to provide specified services must be submitted to the Medical Staff Services Credentialing
Specialist by the AHP/DP in writing, signed, and on the approved forms. The application must
furnish complete information concerning at least the following:
A.
Personal Information: Full name, Social Security number, addresses, telephone (landlines/cell) numbers, email address(es) for all offices and residence.
B.
Physician Supervision Information: Name of the physician/group who employs the
AHP/DP, if applicable, and the names of the physician members of the Medical Staff who
will supervise the AHP/DP. Each such physician or, in the case of a group, the group’s
official designee, must sign the Supervising Physician acknowledgment form
accompanying the application for the AHP/DP.
C.
Education: School name and location, major, degrees awarded, and dates attended for
all undergraduate and/or professional/other graduate schools relevant to the specified
services/clinical privileges/competencies requested.
D.
Postgraduate/Continuing Education: Institution/school name and location, title and
summary description or content of program, program director, dates attended, date
completed.
E.
Professional Licenses/Registration/Certifications:
A current and valid license/registration/certificate issued by the State of Florida to
practice within the specialty of application;
All past and currently valid other State Professional licensures or certifications;
Date of certification by the professional college or board, where applicable (e.g., National
Commission on Registration of Physician Assistants);
Current professional college/board certificate, where applicable;
If applicable to area of practice, current valid U.S. DEA and Florida Controlled
Substances registrations.
F.
Chronology of Professional Career (all present and prior): Facility affiliations, other
institutional affiliations, employment with solo/group/partnership practice, with name,
nature and location of each, inclusive dates, and experience at each in the specified
services being requested. The chronology must cover all periods from professional
education and training to current.
G.
Professional Society Memberships: Current and pending.
H.
Actions (full details must accompany application): Any Pending or completed
action(s) involving denial, revocation, suspension, reduction, limitation, probation, nonrenewal, involuntary or voluntary relinquishment (by resignation or expiration) of or
withdrawal of application for any of the following:
license or certificate to practice any profession in any state or country;
Drug Enforcement Administration or other controlled substances registration (if
applicable);
membership or fellowship in local, state or national professional societies/organizations;
academic appointment;
hospital/other institutional affiliation;
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authority to provide services;
authority to perform privileges;
board certification.
I.
Pending Disciplinary Investigations: Any currently pending disciplinary investigations
by any healthcare entity, third party payment source, professional society or any
government or other regulatory body.
J.
Professional Liability Insurance: Current professional liability insurance coverage and
information on malpractice claims history and experience (claims, suits and settlements
made, concluded and pending), including the names and addresses of present and past
insurance carriers. A copy of the face sheet of the current policy showing the insured's
name, coverage amounts, and any coverage limitations or exclusions must accompany
the application.
Any pending or completed action involving denial, revocation, cancellation, suspension,
reduction, limitation of professional liability insurance. All insurance policies must satisfy
the current Board policies regarding such coverage.
K.
Health Status: Details of any current or prior physical or mental condition or chemical
(alcohol, drug or other) dependence that could affect or has affected the practitioner’s
ability to provide professional services (i.e., that is related to the capability to perform the
clinical privileges requested).
L.
Criminal Charges: Any current criminal charges (other than motor vehicle violations)
and any drug or alcohol-related charges (including motor vehicle violations) pending
against the applicant and any past charges including their resolution.
M.
Release and Immunity: Notification of the authorization, release and immunity
provisions of the appropriate sections of the Bylaws, Medical Staff Bylaws, and this
Manual, and their applicability to consideration of the AHP's/DP’s application and the
provision of clinical privileges/competencies in the Facility and evidence of the applicant's
agreement with them.
N.
Compliance with Requirements: Acknowledgment by the AHP/DP and by the
Supervising Physician that they will abide by this Manual, the Bylaws, and any other
applicable rules, regulations, policies and procedures of the Medical Staff and Facility in
all matters relating to the AHP's provision of clinical privileges in the Facility.
O.
Supervising Physician Acknowledgement: Supervising Physician acknowledgment to
assume and carry out the obligations required to adequately supervise the AHP/DP, and a
specific agreement to the requirements of Section 1.8-3 of this Manual.
P.
References: The names of at least one (1) professional in the Practitioner’s own
discipline and of one (1) physician, not newly associated (less than one (1) year) or about
to become associated with the applicant in professional practice or personally related to
the applicant, who have personal knowledge of the applicant's current clinical ability,
ethical character, and ability to work cooperatively with others and who will provide
specific written comments on these matters upon request from the Facility or Medical
Staff authorities. The named individuals must have acquired the requisite knowledge
through recent (within the past three (3) years) observation of the applicant's professional
performance over a reasonable period of time and should also have an acute care
hospital affiliation.
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2.2
15
Such other information or references as may be established in the specific policies
governing the specialty for which application is being made.
EFFECT OF APPLICATION
(Reference Medical Staff Credentialing Procedure Manual Part One 1.4)
The AHP/DP must sign the application, and in so doing:
A.
attests to the correctness and completeness of all information furnished and
acknowledges that any misstatement or misrepresentation in or omission from the
application, whether intentional or not, constitutes grounds for denial of permission to
provide requested services or for automatic revocation of previously authorized
permission (in the event it was granted prior to the discovery of the misstatement,
misrepresentation, or omission);
B.
signifies his/her willingness to appear for interviews in connection with the application;
C.
agrees to abide by the terms of this Manual, the Bylaws and related manuals, rules,
regulations, policies and procedure manuals of the Medical Staff (as applicable) and
those of the Facility;
D.
agrees to maintain ethical behavior and to refrain from misrepresenting his position,
status, clinical privileges or scope of authorized service to any patient, Facility visitor,
Facility employee, Medical Staff member, or any other person affiliated with or coming in
contact with the Facility;
E.
agrees to notify, promptly and in writing, the Medical Staff Services Credentialing
Specialist of any change in any of the information provided on the application, to include
any actions or investigations in any way related to the applicant’s professional license or
permit to practice, DEA or state controlled substance registration, professional liability
insurance coverage, membership/employment status or clinical privileges at this or other
institutions/facilities/organizations, or the status of current or initiation of new malpractice
claims;
F.
authorizes and consents to Facility representatives consulting with prior associates or
others who may have information bearing on professional or ethical qualifications and
competence and consents to their inspecting all records and documents that may be
material to evaluation of said qualifications and competence;
G.
releases from any liability all those who, in good faith and without malice, review, act on or
provide information regarding the
applicant’s background, experience, clinical
competence, professional ethics, character, health status, and other qualifications; and
H.
agrees to not provide any services in a Martin Health System Facility unless having first
been granted specific written permission to provide such services by the appropriate
Martin Health System authorities.
For purposes of this section, the term "Facility representative" means: the Board of the Facility
and any member or committee thereof; the CEO, CMO or their respective designees; the Medical
Staff and any member, officer, clinical unit or committee thereof; registered nurses and other
employees of the Facility and all Affiliates; and any individual authorized by any appropriate
authority of the Medical Staff or Facility to perform specific information gathering, analysis, use or
disseminating functions.
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PROCESSING THE APPLICATION
Processing the AHP/DP application will be performed in the same manner and have the same
effect as that of the Medical Staff Credentialing Procedures Manual:
1.5-1 Applicant’s Burden
1.5-2 Verification of Information
1.5-3 Medical Staff Input
1.5-4 Department/Service Evaluation
1.5-6 THRU 1.5-12 Processing each Application Category
1.6 Reapplication after Adverse Credentialing Decision
2.3-1
CATEGORIZING APPLICATIONS:
(Reference Medical Staff Credentialing Procedures Manual Part One 1.5-5)
After the application and its supporting documentation have been reviewed by the Martin
Health Systems’ applicable Department Chairperson/Chief of Service, the Director of
Medical Staff Services will place the application into one (1) of three (3) categories as
defined below.
(a) Category One Applications:
1. All application information is promptly verified;
2. Written primary source verification for (at minimum) the immediate past 10 years
for all employment, affiliations and work history must be received and fully
positive;
3. All professional references are fully positive;
4. a) There is no history of any prior malpractice settlements or judgments, or
b) There is a history of one prior malpractice settlement or judgment not exceeding
$10,000, or c) a history of one malpractice settlement or judgment in excess of
$10,000 that occurred more than 10 years prior to the date of application;
5. There is no history of prior disciplinary actions, licensure restrictions, or any other
professional investigations;
6. All requested competencies are consistent with the practitioner’s training,
experience, and established criteria;
7. All input received from the Martin Health Systems’ Credentialing Staff
Dependent Practitioner’s Supervising Physician is fully positive.
and
(b) Category Two Applications: Applications which do not satisfy the requirements to be
considered a Category One application, but otherwise satisfy each of the following
criteria, shall be considered Category Two applications:
1. All application information is promptly verified, or difficulties occur during the
verification of application information, but all such information is verified;
2. All references are fully positive, or are generally positive but contain some
information suggesting minor problems (Written primary source verification for (at
minimum) the immediate past 10 years for all employment, affiliations and work
history must be received);
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3. The application satisfies the malpractice settlement/judgment criteria for a
Category One application, or there is a history of one (1) malpractice settlement or
judgment in excess of $10,000 that occurred within the immediate past 10 years;
4. No prior disciplinary action, licensure restrictions or any other professional
investigations, or a history including professional investigations which have been
fully and completely resolved and which resulted in no disciplinary action or
restrictions of any kind;
5. (a) All requested competencies are consistent with the practitioner’s training,
experience, and established criteria; or
(b) Due to lack of experience or inability to provide documentation of clinical
experience or specialized training to support the practitioner’s competency/
qualifications, a Focused Evaluation will be imposed as part of the Provisional
Period. The focused evaluation will be time limited and may include, but not be
limited to, a preceptorship/proctorship for a period not to exceed twelve months or
until such time as satisfactory evidence exists to support the practitioner’s
competence to perform the requested procedure (whichever comes first).
6. All input received from the Martin Health Systems’ Credentialing Staff and
Dependent Practitioner’s Supervising Physician is fully positive or is generally
positive but contains some information suggesting minor problems.
(c)
2.3-2
Category Three Applications:
All applications which do not satisfy the criteria for being considered Category One
applications or Category Two applications shall be considered Category Three
applications
PROCESSING CATEGORY ONE/TWO/THREE APPLICATIONS
Processing the relevant Category AHP/DP application will be performed in the same
manner and have the same effect as that of the Medical Staff Credentialing Procedures
Manual:
1.5-6 Processing Category One Applications
1.5-7 Processing Category Two Applications
1.5-8 Processing Category Three Applications
2.3-3 Contents of Reports and Basis for Recommendations and Actions: Will be performed
in the same manner and have the same effect as that of the Medical Staff Credentialing
Procedures Manual 1.5-9.
2.3-4 Conflict Resolution: Will be performed in the same manner and have the same effect as
that of the Medical Staff Credentialing Procedures Manual 1.5-10
2.3-5 Notice of Final Decision: Will be performed in the same manner and have the same effect
as that of the Medical Staff Credentialing Procedures Manual 1.5-11
2.3-6 Time Periods for Processing: Will be performed in the same manner and have the same
effect as that of the Medical Staff Credentialing Procedures Manual 1.5-12.
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2.4
REAPPLICATION AFTER ADVERSE CREDENTIALS DECISION:
Will be performed in the same manner and have the same effect as that of the Medical Staff
Credentialing Procedures Manual 1.6.
2.5
TERM OF SERVICE
Permission to provide specified services may be amended or revoked by the CEO at any time.
Appointments/Reappraisal and grants of clinical privileges/competencies are for a period of up to
two years with the exceptions referenced in the Medical Staff Bylaws 7.3 Term of Appointment
and Reappraisal:
(a) new appointees are subject first to an initial provisional period as provided in Medical Staff
Bylaws Section 7.4 and upon satisfactory conclusion of that period are placed in the appropriate
reappointment/reappraisal cycle as determined by the Hospital's system of staggered
reappointment/reappraisal which may result in the appointment period that immediately follows
satisfactory conclusion or waiver of the provisional period being less than two (2) full years;
(b) the Professional Affairs Committee after considering the recommendation of the applicable
Departments/Services, the Credentials Committee, and the Medical Executive Committee may set
a more frequent reappraisal period for the exercise of particular clinical privileges/competencies
in general, for AHPs/DPs who have reached a defined age, or for AHPs/DPs who have identified
health disabilities;
(c) disciplinary action involving membership and/or clinical privileges/competencies may be
initiated and taken in the interim under the appropriate provisions of the Medical Staff Bylaws and
the related manuals; and
(d) in the case of a practitioner providing professional services by contract/employment
(see Medical Staff Bylaws Section 7.6), termination or expiration of the contract/employment may
result in a shorter period of membership or clinical privileges/competencies if that is the effect
under the Medical Staff Bylaws Section 7.6-3.
2.6
PRACTITIONERS PROVIDING CONTRACTUAL PROFESSIONAL SERVICES:
Will be subject to and have same effect as the Medical Staff Bylaws Practitioners Providing
Contractual Professional Services 7.6.
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PART THREE. PROVISIONAL PERIOD
The Provisional Period will be performed in the same manner and have the same effect as the Medical
Staff Bylaws 7.4 Provisional Period; 7.5 Procedures for Appointment/Reappointment and Concluding the
Provisional Period; and Medical Staff Credentialing Procedures Manual Part Four – Conclusion and
Extension of Provisional Period.
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PART FOUR. REEVALUATION/REAPPRAISAL PROCEDURES
The Reevaluation/Reappraisal process for the AHP/DP will be performed in the same manner and
have the same effect as that of the Medical Staff Credentialing Procedures Manual – Part Two - 2.1
thru 2.9:
2.1: Information Collection and Verification
2.1-1 From Staff Member
2.1-2 From Internal Sources
2.2
Department/Service Evaluation
2.3
Categorizing Reappointment Applications
2.4
Processing Category One Reappointment Applications
2.5
Processing Category Two Reappointment Applications
2.6
Processing Category Three Reappointment Applications
2.7
Basis for Recommendations and Action
2.8
Time Periods for Processing
2.9
Requests for Modification of Status/Privileges
PART FIVE: SYSTEMS AND PROCEDURES FOR DELINEATING
CLINICAL PRIVILEGES/COMPETENCIES
The Delineation of Clinical Privileges/Competencies will be performed in the same manner and have the
same effect as the Medical Staff Credentialing Procedures Manual Part Three – Systems and Procedures
for Delineating Clinical Privileges.
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PART SIX. CORRECTIVE ACTION PROCEDURES
6.1
CRITERIA FOR INITIATING CORRECTIVE ACTION OTHER THAN SUMMARY OR
AUTOMATIC SUSPENSION (reference Medical Staff Bylaws Article 9 and Medical Staff
Credentialing Procedures Manual Article 5)
Whenever a practitioner with permission to provide services or clinical privileges/competencies
engages in, makes or exhibits acts, statements, demeanor or professional conduct, either within
or outside of the Hospital, and the same is, or is reasonably likely to be, either:
(a) contrary to the Bylaws and related manuals, rules, policies or standards of the
Facility or Medical Staff; or
(b) detrimental to patient safety or to the delivery of quality or efficient patient care; or
(c) disruptive to operations such that the quality or efficiency of patient care is or is likely to be
affected,
corrective action against the practitioner may be initiated by any of the following:
(a) any general Staff officer;
(b) any Chairperson of any Department/Chief of any Service;
(c) any Medical Director;
(d) any standing committee or subcommittee of the Staff, or a chairperson thereof;
(e) the Chief Executive Officer;
(f) the Professional Affairs Committee;
(g) the VPMA; or
(h) the Board of Directors
6.2
INTERVIEW PRIOR TO CORRECTIVE ACTION (reference Medial Staff Bylaws Article Nine: 9.2)
Prior to initiating or proceeding with corrective action other than summary or automatic suspension
against a practitioner, the initiating or acting party must afford the practitioner an interview at which
time the circumstances prompting the corrective action are discussed and the practitioner is
permitted to present relevant information in his/her own behalf. An interview must be initiated by
special notice to the practitioner, with copies transmitted to the Supervising Physician(s), the
President of the Staff and the Chief Executive Officer. A written record reflecting the substance and
conclusion of the interview must be made and transmitted to the practitioner, the President of the
Staff, the Chief Executive Officer, and the practitioner's file. The Supervising Physician(s), the
President of the Staff and the Chief Executive Officer or their respective designees may, at their
option, be present as observers at an interview. If the practitioner fails to respond to the special
notice or declines to participate in the interview, corrective action must immediately proceed in
accordance with the Medical Staff Credentialing Procedure Manual Section 5.1. The interview
provided in this need not be conducted according to the procedural rules provided in the Fair
Hearing Plan.
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SUMMARY SUSPENSION (reference Medical Staff Bylaws Article Nine: 9.3;
Medical Staff Credentialing Procedures Manual 5.2)
Any two (2) of the following, or their respective designated representatives, have the authority to
suspend the practitioner and all or any portion of his/her clinical privileges/competencies
whenever failure to take such action may result in an imminent danger to the health and/or safety
of any individual or to the orderly operation of the Facility:
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
President of the Staff
Any Department Chairman/Service Chief
Any Medical Director
Chief Executive Officer
Vice President/Medical Affairs
Medical Executive Committee
Professional Affairs Committee
Board of Directors
Such a suspension shall be deemed an interim precautionary step in the professional review
activity related to the ultimate professional review action that will be taken with respect to the
suspended practitioner but is not a complete professional review action in and of itself. It shall not
imply any final finding of responsibility for the situation that caused the suspension.
Such a suspension is effective immediately upon imposition and the person(s) or group(s)
imposing the suspension is to follow it promptly by giving special notice of the suspension to the
practitioner. It shall also be reported; in writing; to any of the above referenced authorities not
immediately involved in the action, and include a copy to the Supervising Physician and Director of
Medical Staff Services.
It shall be the duty of all Medical Staff members to cooperate with the President of the Medial
Staff, MEC, and CEO in enforcing all suspensions.
6.3-1
SUBSEQUENT ACTION (reference Medical Staff Credentialing Procedures Manual 5.2-2
Subsequent Action)
As soon as reasonably possible, but within seventy-two (72) hours after the summary suspension
is imposed, the MEC shall convene to review and consider the action taken for the purpose of
making a recommendation to the Board of Directors. The meeting may be held by conference
call, e-mail, or facsimile transmission or other written documentation evidencing the members’
intention concerning the business transacted.
The MEC may recommend modification, continuation or termination of the terms of the
suspension. Such an investigation shall be completed within a reasonable time period not to
exceed thirty (30) days unless good cause for the delay exists, in which case the factual basis
constituting good cause shall be transmitted to the Board so that the Board may consider whether
the suspension should be lifted.
Upon completion of its investigation, the MEC shall forward its findings and recommendation to
the Board of Directors.
An MEC recommendation to continue the suspension or to take any other adverse action as
defined below, entitles the practitioner to procedural rights.
An MEC recommendation to terminate or to modify the suspension to a lesser sanction not
triggering procedural rights is transmitted with all supporting documentation to the Board.
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The terms of the summary suspension as originally imposed remain in effect pending a final
decision by the Board.
A summary suspension which extends beyond thirty (30) days pending an MEC investigation and
recommendation to the Board shall not be deemed a professional review action for purposes of
reporting to the National Practitioner Data Bank (NPDB) under Title IV of Public Law 99-660 (The
Health Care Quality Improvement Act of 1986) unless the MEC makes a recommendation to the
Board to continue the suspension on the terms that are otherwise reportable to the NPDB.
6.4
AUTOMATIC SUSPENSION: (reference Medical Staff Bylaws 9.4-9.4-5 and Medical Staff
Credentialing Procedures Manual 5.3)
6.4-1: MEC DELIBERATION AFTER AUTOMATIC SUSPENSION
Subsequent to a practitioner’s automatic suspension (circumstances described below), the MEC
shall convene to review and consider the facts under which such action was taken. The MEC
may then recommend further corrective action as is appropriate to the facts disclosed in the
investigation, including limitation of privileges.
6.4-2: CIRCUMSTANCES
Whenever any of the actions specified below occur, the practitioner must immediately report it to
the President of the Staff and the Chief Executive Officer. Failure to so report, without good
cause, is grounds for automatic revocation of permission to provide services and clinical
privileges/competencies.
6.4-3 LICENSE
a) Revocation: Whenever a practitioner's license to practice in this state is revoked, his/her
permission to provide services and clinical privileges/competencies are immediately and
automatically revoked.
b) Restriction: Whenever a practitioner's license is limited or restricted in any way, those clinical
privileges/competencies which he/she has been granted that are within the scope of the limitation
or restriction are similarly limited or restricted, automatically.
c) Suspension: Whenever a practitioner’s license is suspended, his/her permission to provide
services and clinical privileges/competencies are automatically suspended effective upon and for
at least the term of the suspension.
d) Probation: Whenever a practitioner is placed on probation by his/her licensing authority, his/her
services are automatically suspended effective upon and for at least the term of the probation.
(e) Inactive: If a practitioner's license becomes inactive his/her permission to provide services and
clinical privileges/competencies are automatically suspended until his/her license becomes active.
6.4-4
DRUG ENFORCEMENT ADMINISTRATION (DEA)
a) Revocation: Whenever a practitioner's DEA or other controlled substances number is
revoked, he/she is immediately and automatically divested at least of his/her right to
prescribe medications covered by the number.
b) Restriction: Whenever a practitioner's use of his/her DEA or other controlled
substances number is restricted or limited in any way, his/her right to prescribe
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medications covered by the number is similarly restricted or limited effective upon, for at
least the term of, and consistent with any other conditions of the restriction or limitation.
c) Suspension: Whenever a practitioner's DEA or other controlled substances number is
suspended, he/she is divested at least of his/her right to prescribe medications covered
by the number effective upon and for at least the term of the suspension.
d) Probation: Whenever a practitioner is placed on probation insofar as the use of his/her
DEA or other controlled substances number is concerned, probation shall automatically
be deemed applicable to such use.
6.4-5
HEALTHCARE-RELATED CRIMINAL CONVICTIONS AND EXCLUSION FROM
PARTICIPATION IN STATE OR FEDERAL HEALTHCARE PROGRAMS
Whenever a practitioner is convicted of a healthcare-related criminal offense, including a
plea of no contest to such an offense, the practitioner’s Medical Staff membership and all
clinical privileges are immediately and automatically revoked. Whenever a practitioner is
excluded from participation in a state or federally funded healthcare program as a result
of the imposition of sanctions by a governmental body, the practitioner’s Staff
membership and clinical privileges are, at a minimum, automatically suspended effective
upon and for at least the term of the exclusion from participation in that program. Further
action on the matter proceeds under the Medical Staff Credentialing Procedures Manual
Section 5.3-2.
6.4-6
FAILURE TO MAINTAIN MEDICAL MALPRACTICE INSURANCE
A practitioner who fails to meet the requirements for malpractice insurance set forth in the
policies of the Board shall automatically and immediately be suspended from practicing.
6.4-7
INTENTIONAL FRAUD IN APPLICATION
In the event a practitioner has been granted permission to provide services and clinical
privileges/competencies prior to the discovery of intentional and significant
misrepresentation, misstatement in, or omission from an application
(initial/reappointment/reappraisal), such discovery shall result in automatic revocation of
the practitioner’s permission to provide services and clinical privileges/competencies.
6.4-8
PROCEDURAL RIGHTS
Practitioners under automatic, summary suspension or revocation are not entitled to
procedural rights.
6.4-9
CONTINUITY OF PATIENT CARE
Under the occurrence of automatic suspension, the suspended practitioner shall confer
with a substitute practitioner and/or his/her supervising physician (as applicable) to the
extent necessary to safeguard and continue the care of patients.
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INITIATION OF CORRECTIVE ACTION OTHER THAN AUTOMATIC OR SUMMARY
SUSPENSIONS (reference Medical Staff Credentialing Procedures Manual Part Five)
All requests for corrective action other than summary or automatic suspensions must be in writing,
submitted to MEC, and supported by reference to the specific activities or conduct which
constitute the grounds for request.
6.5-1
INVESTIGATION
After deliberation, the MEC may either act on the request or direct that investigation
concerning the grounds for the corrective action request be undertaken. The MEC may
conduct such investigation itself or may assign this task to a Medical Staff officer or
Department Chairperson/Service Chief, a standing or ad hoc committee, or any other
organizational component.
This investigative process shall not constitute a “hearing.” If the investigation is
accomplished by a group or individual other than the MEC, that group or individual must
forward a written report of the investigation to the MEC as soon as is practicable after the
assignment to investigate has been made. The MEC may, at any time within its
discretion, and shall at the request of the Board or its designee, terminate the
investigative process and proceed with action as provide below. The MEC or other
investigating group or individual shall have available to them the full resources of the
Medical Staff and the Facility as well as the authority to use outside consultants as
deemed necessary. As part of the investigation, the MEC or other investigating group or
individual may require the practitioner involved to procure an impartial physical, mental, or
laboratory evaluation within a specified time. Failure to provide such an evaluation,
without good cause, shall result in immediate suspension of the practitioner’s permission
to provide services and all clinical privileges/competencies until such time; not to exceed
ninety (90) days; as the evaluation is obtained and the results are reported to the MEC or
other investigating group or individual. Failure to comply within the time period specified
shall be deemed a voluntary resignation and relinquishment of clinical
privileges/competencies.
6.5-2
MEC ACTION
As soon as reasonably possible after the conclusion of the investigation, if any, but in any
event within six (6) months after receipt of the request for corrective action unless
deferred, the MEC acts upon such request. Its action may include, without limitation:
a) rejection of the request for corrective action
b) a verbal warning
c) additional education and/or training
d) individual medical/psychiatric treatment
e) a probationary period
f) suspension of prerogatives that do not affect clinical privileges/competencies
g) a formal letter of reprimand
h) individually imposed requirement of prior or concurrent consultation or direct
supervision
i) reduction, suspension or revocation of all or any part of the clinical privileges/
competencies granted
j) reduction, suspension or revocation of permission to provide services
6.5-3
PROCEDURAL RIGHTS
An MEC recommendation pursuant to subsections (i) or (j) immediately above, or any
combination thereof, is deemed adverse and entitles the practitioner to the procedural
rights described below.
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OTHER ACTION
An MEC recommendation pursuant to subsections (a), (b), (c), (d), (e), (f), (g), (h) or any
combination thereof is transmitted to the Board through the PAC together with all
supporting documentation.
PART SEVEN. PROCEDURAL RIGHTS
7.1
NECESSITY FOR ADVERSE ACTION OR RECOMMENDATION (reference Medical Staff
Bylaws Article Ten – Procedural Rights)
7.1-1 BY MEDICAL EXECUTIVE COMMITTEE
When a practitioner receives special notice of an adverse recommendation made by the Medical
Executive Committee as defined in the Fair Hearing Plan, he/she is entitled to a hearing upon
proper and timely request in accordance with the procedures set forth below.
7.1-2 BY BOARD OF DIRECTORS
When a practitioner receives special notice of an adverse decision made by the Board of
Directors as defined in the Fair Hearing Plan, he/she is entitled to a hearing upon proper and
timely request in accordance with the procedures set forth below.
7.2
PROCESS FOR HEARINGS AND APPELLATE REVIEWS
All hearings and appellate reviews are conducted in accordance with the procedures and
safeguards set-forth below.
PART EIGHT. LEAVE OF ABSENCE
8.1
LEAVE STATUS (reference Medical Staff Credentialing Procedures Manual Part Six)
An AHP/DP may obtain a voluntary leave of absence of up to three (3) months by completing and
submitting the Request for Leave of Absence (form to be obtained from Medical Staff Services)
demonstrating good cause for a leave of absence to Medical Staff Services for review,
recommendation and transmittal to the MEC.
The practitioner may obtain up to a three (3) month extension to a leave subsequent to submitting
a request demonstrating good cause for the extension. For exceptional circumstances, the MEC
may approve up to an additional six (6) months leave.
For the purposes of this section, “good cause” for such a request shall be limited to the following:
(a) Illness of the practitioner or a member of his/her immediate family.
(b) Pursuit of additional training or education.
(c) The existence of a restrictive covenant or other contractual obligation precluding the
practitioner from practicing in the Hospital’s service area.
(d) Military service.
(e) A bona fide sabbatical
(f) Other special circumstances approved in advance by the MEC.
Such leave of absence shall be effective immediately upon review and a recommendation for
approval by the MEC and approval by the Chief Executive Officer or VPMA or designee. The leave
of absence shall remain in force for the specified term if not disapproved by the Board of Directors.
The MEC shall report on any leave of absence to the Board of Directors.
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A practitioner is not entitled to the procedural rights afforded by this manual and the Fair Hearing
Plan because his/her request for leave of absence is refused, terminated, restricted, or limited in
any way.
8.2
RETURN FROM LEAVE
A practitioner desiring to return from leave of absence is required to submit the following
information to Medical Staff Services:
(a) Request for Return from Leave of Absence (form to be obtained from Medical Staff
Services)
(b) A copy of his/her current and valid license/registration/certificate issued by the State of
Florida to practice within his/her specialty for which privileges have been granted;
(c) If applicable, a copy of his/her current U.S. Drug Enforcement Administration (DEA)
and/or Florida controlled substances registrations.
(d) A certificate of current insurance which must comply with the requirements for
malpractice insurance policy of the Board of Directors;
(e) A statement of his/her activities during the leave of absence and appropriate supporting
documentation; and
(f) (1) If the Supervising Physician has Changed: Signed Physician’s Agreement to Supervise
Dependent Practitioner credentialed by Martin Health System to direct the practitioner’s
practice. According to a written agreement, the physician must:
assume responsibility for supervision/direction or monitoring of the AHP/DP practice as
stated in the Martin Health System’s Dependent Practitioners Process Standards;
be continuously available or provide an alternate to provide consultation when requested
and to intervene when necessary;
assume total responsibility for the care of any patient when requested by the AHP/DP or
required by policy or in the interest of patient care.
(2) If the Supervising Physician remains the same as the physician who signed the
initial/original Agreement, the Physician must submit a signed and dated attestation that
he/she will continue in the supervisory role and:
will continue to be responsible for supervision/direction or monitoring of the AHP/DP
practice as stated in the Martin Health System’s Process Standards;
be continuously available or provide an alternate to provide consultation when requested
and to intervene when necessary;
assume total responsibility for the care of any patient when requested by the AHP/DP or
required by policy or in the interest of patient care.
(g) Any additional supporting documentation which may be requested.
Medical Staff Services will transmit the request for reinstatement to the President of the Medical
Staff and the Chief Executive Officer or VPMA or designee for review and consideration. Based
upon the input, the Chief Executive Officer or VPMA or designee, in consultation with the President
of the Staff, may immediately reinstate the practitioner's permission to provide services and clinical
privileges/competencies.
If the MEC recommends disapproval of the requested reinstatement or if the Chief Executive
Officer or VPMA or designee disapproves the reinstatement of a practitioner, the practitioner will be
provided the procedural rights afforded by the Fair Hearing Plan.
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If the practitioner has not been actively practicing at another accredited healthcare facility
(TJC/AAAHC) during the term of the leave, implementation of a Focused Professional Practice
Evaluation (FPPE) may be imposed for a time period defined by the MEC.
8.3
RESPONSIBILITY
It is the responsibility of the individual practitioner who desires a leave of absence to keep record of his/her
current status. Therefore, a practitioner who does not submit a written request to reinstate or resign
his/her permission to provide services and clinical privileges/competencies will be considered as having
voluntarily resigned and relinquished all clinical privileges/competencies.
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PART NINE. AMENDMENT
9.1 AMENDMENT
This Credentialing Procedures Manual may be amended or repealed, in whole or in part, in the same
manner as provided in Article Thirteen of the Medical Staff Bylaws.
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PART TEN. HEARING RIGHTS
10.1
TRIGGERING EVENTS
10.1-1
Actions or Recommendations
Subject to the exceptions set forth below, the following actions or recommendations
entitle the practitioner to a hearing upon timely and proper request:
A.
B.
C.
D.
E.
F.
G.
I.
J.
denial to an applicant not currently possessing AHP/DP status or requested
AHP/DP status or requested clinical privileges;
denial of reappointment;
suspension of AHP/DP status, provided that summary suspension entitles the
practitioner to request a hearing only as specified in subsection (i) of this Section;
revocation of AHP/DP status;
denial of requested clinical privileges to a current AHP/DP unless otherwise
referenced in Section 8.1-3;
reduction in clinical privileges unless otherwise referenced in Section 8.1-3;
suspension of clinical privileges, provided that summary suspension entitles the
AHP/DP to request a hearing only as specified in subsection (i) of this Section;
revocation of clinical privileges; or
summary suspension of AHP/DP status or clinical privileges provided that the
recommendation of the MEC or action by the Board is to continue the suspension
or to take other action which would entitle the AHP/DP to request a hearing under
this Section.
10.1-2 When Deemed Adverse
An action or recommendation listed immediately above is deemed adverse to the
practitioner only when it has been:
A.
B.
recommended by the MEC; or
taken by the Board of Directors under circumstances where no prior right to
request a hearing existed.
10.1-3 Exceptions to Hearing Rights
A.
Certain Actions or Recommendations: Notwithstanding any provision in this Manual to
the contrary, the following actions or recommended actions do not entitle the AHP/DP to a
hearing:
1.
2.
3.
4.
5.
6.
7.
8.
the issuance of a verbal or written warning;
a letter of reprimand;
the imposition of a direct supervision or consultation requirement as a condition
attached to the exercise of clinical privileges/competencies,
the imposition of a probationary period involving review of cases;
termination/revocation of AHP/DP status and/or clinical privileges/competencies
for failure to successfully complete the probationary period set-forth in the
Alternate Pathway exception process;
denial/reduction/revocation of permission to provide services and clinical
privileges/competencies for failure to satisfy the provisions referenced in this
manual and/or failure to meet or maintain compliance with current Threshold
Criteria, Criteria for Privileges/Competencies, and/or guidelines;
the removal of an AHP/DP from an administrative office within the Facility unless
a contract or employment arrangement provides otherwise;
any other action or recommendation not specifically listed under Section 8.1-1;
and
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B.
3.
voluntarily imposed or accepted by the practitioner;
automatic suspension pursuant to any provision of the AHP/DP Credentialing
Procedure Manual;
summary suspension
(a) actions have potential to be detrimental to patient safety or to the delivery of
quality or efficient patient care; or
(b) actions are disruptive to operations such that the quality or efficiency of patient
care is or is likely to be affected
NOTICE OF ADVERSE ACTION OR RECOMMENDATION
The CEO shall, within fifteen (15) days of receiving written notice of an adverse action or
recommendation, give the AHP/DP special notice thereof. A copy of said notice shall be given to
the Supervising Physician(s). The notice shall:
A.
B.
C.
D.
E.
F.
10.3
the termination of employment of any Associate (who shall otherwise be entitled
to those procedural rights afforded Associates pursuant to Human Resources
policies and procedures then in effect).
Other Situations: An action or recommendation does not entitle the AHP to a hearing
when it is:
1.
2.
10.2
31
advise the practitioner of the nature of the proposed action or recommendation, including
the reasons for the proposed action or recommendation, and of his/her right to a hearing
upon timely and proper request;
specify that the practitioner has thirty (30) days after receiving the notice within which to
submit a written request for a hearing to the CEO;
state that failure to request a hearing within that time period and in the proper manner
constitutes a waiver of rights to a hearing and to an appellate review on the matter that is
the subject of the notice;
state that any higher authority required or permitted to act on the matter following a waiver
is not bound by the adverse recommendation or action that the practitioner has accepted
by virtue of the waiver but may take any action, whether more or less severe, it deems
warranted by the circumstances;
state that upon receipt of the hearing request, the practitioner will be notified of the date,
time and place of the hearing, the grounds upon which the adverse recommendation or
action is based, and a list of witnesses, if any; and
state that the hearing will be held before a hearing officer appointed by the CEO, that the
right to the hearing may be forfeited if the practitioner fails without good cause to appear;
and that the practitioner has the right to representation at the hearing by a person of the
practitioner’s choice; to have a record made of the proceedings, copies of which may be
obtained by the practitioner upon payment of any reasonable charges associated with the
preparation thereof; to call, examine and cross-examine witnesses; to present evidence
determined to be relevant by the presiding officer regardless of its admissibility in a court
of law; and to submit a written summary at the close of the hearing.
REQUEST FOR HEARING
The practitioner shall have thirty (30) days after receiving the above notice to file a written request
for a hearing. The request must be delivered to the CEO by Special Notice.
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WAIVER BY FAILURE TO REQUEST A HEARING
An AHP/DP who fails to request a hearing within the time and in the manner specified waives his
right to any hearing or any appellate review to which he might otherwise have been entitled. Such
waiver shall apply only to the matters that were the basis for the adverse recommendation or
action triggering the Section 8.2 notice. The CEO shall, as soon as reasonably practicable, send
the practitioner special notice of each action taken under any of the following. The effect of a
waiver is as follows:
10.4-1
After Adverse Action by the Board of Directors
A waiver shall constitute acceptance of the action, which shall become effective
immediately as the final decision of the Board.
10.4-2
After Adverse Recommendation by the MEC
A waiver shall constitute acceptance of the recommendation, which shall become and
remain effective immediately pending the decision of the Board. The Board shall consider
the adverse recommendation as soon as practicable following the waiver. Its action
becomes effective immediately.
10.5
ADDITIONAL INFORMATION OBTAINED FOLLOWING WAIVER
If, after waiver, the practitioner or an individual or group functioning directly or indirectly on the
practitioner’s behalf desires to provide additional factual information in favor of the practitioner to
the Board, the Board shall not consider the information unless it concludes that the information
was not reasonably discoverable in time for presentation to or consideration by the party taking
the initial adverse action. If new factual information is submitted to the Board which was not
available to or considered by the MEC and which is adverse to the practitioner, the Board shall not
consider the information in reaching its final decision unless it first affords the practitioner an
opportunity to request a hearing. The hearing shall be conducted in accordance with the
provisions hereof but shall be limited in scope to findings of fact surrounding both the new
information and the findings and recommendations of the MEC made prior to the practitioner’s
initial waiver.
10.6
HEARINGS FOR ASSOCIATE AHP/DP
As indicated in Section 1.12-2 of this Manual, the procedural rights of an Associate who is an
AHP/DP are governed by Human Resources policies and procedures then in effect. If those
policies and procedures do not so provide, however, and if the facts giving rise to the termination
of employment are based on the AHP’s/DP’s lack of clinical competence, the following conditions
must be satisfied or voluntarily waived by the AHP/DP:
A.
Notice of proposed action: The AHP/DP must be given notice stating:
1.
2.
3.
4.
5.
B.
that termination of employment has been proposed;
the reasons for the proposed action;
that the AHP/DP has the right to request a hearing on the proposed action;
any time limit of not less than thirty (30) days within which the AHP/DP may
request a hearing; and
a summary of rights in the hearing.
Notice of hearing: If a hearing is requested on a timely basis, the AHP/DP must be
given notice stating:
1.
2.
the place, time, and date of the hearing, which date may not be less than thirty
(30) days after the date of the notice; and
a list of witnesses (if any) expected to testify at the hearing in support of the
proposed action.
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Conduct of hearing and notice: If a hearing is requested on a timely basis, the hearing
shall be held before a hearing officer appointed by the Vice President/Human Resources,
which hearing officer may not be in direct economic competition with the AHP/DP or the
AHP’s/DP’s Supervising Physician.
D.
Representation of AHP/DP: At the hearing, the practitioner has the right:
1.
E.
to representation by an attorney or other person of the practitioner’s choice;
2.
to have a record made of the proceedings, copies of which may be obtained by
the practitioner upon payment of any reasonable charges associated with the
preparation thereof;
3.
to call, examine, and cross-examine witnesses;
4.
to present evidence determined to be relevant by the hearing officer, regardless
of its admissibility in a court of law; and
5.
to submit a written statement at the close of the hearing.
Upon completion of the hearing, the AHP/DP involved has the right:
1.
2.
10.7
33
to receive the written recommendation of the hearing officer, including a
statement of the basis for the hearing officer’s recommendations; and
to receive a written decision of the Vice President/Human Resources, including a
statement of the basis for the decision.
HEARINGS FOR NON-ASSOCIATE AHPs/DPs
10.7-1 Notice of Time and Place for Hearing
Upon receiving a timely and proper request for hearing, the CEO, or designee, shall
schedule a hearing. The CEO shall send the AHP/DP a Special Notice of the time, place
and date of the hearing. The hearing date shall be not less than thirty (30) days nor more
than forty-five (45) days from the date of the Special Notice of the hearing; provided,
however, that a hearing for an AHP/DP who is under suspension then in effect may be
held sooner than thirty (30) days from the date of the Special Notice of the hearing.
10.7-2 Statement of Issues and Events
The notice of hearing must contain a concise statement of the AHP's/DP’s alleged acts or
omissions, a list by number of the specific or representative patient records in question,
and/or the other reasons or subject matter forming the basis for the adverse action which
is the subject of the hearing.
10.7-3 Appointment of Hearing Officer
When a hearing has been requested in a proper manner, the CEO shall appoint a hearing
officer. The hearing officer may be an attorney at law (who may also be legal counsel to
the Facility), a Medical Staff member, or any other individual who is qualified to conduct
such a hearing. The hearing officer may not be any individual who is in direct economic
competition with the individual requesting the hearing or with that individual’s Supervising
Physician. The hearing officer shall not act as an advocate to either side at the hearing.
Knowledge of the reasons or subject matter forming the basis for an adverse action or
recommendation shall not preclude any individual from serving as a hearing officer. Upon
receipt of notification of the identity of the hearing officer, the AHP/DP shall have ten (10)
days to advise the CEO of any perceived conflict of interest that might exist between the
hearing officer and the AHP/DP. It shall be the responsibility of the AHP/DP to state with
specificity the basis of the perceived conflict. Thereafter, the CEO shall evaluate the
alleged conflict. If a determination is made that the alleged conflict would or has the
potential to interfere with the ability of the hearing officer to fairly and objectively weigh the
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evidence and render an unbiased recommendation, then the hearing officer shall be
excused and an alternative member shall be appointed by the CEO.
10.7-4 List of Witnesses
At least five (5) days prior to the scheduled date for commencement of the hearing, each
party shall give the other party a list of the names of the individuals who, as far as is then
reasonably known, will give testimony or evidence in support of that party at the hearing.
Such list shall be amended as soon as possible when additional witnesses are identified.
The hearing officer may permit a witness who has not been listed to testify if he/she finds
that the failure to list such witness was justified, that such failure did not prejudice the
party entitled to receive such list, or that the testimony of such witness will materially
assist the hearing officer in making his report and recommendation.
10.7-5 Identification and Production of Exhibits
At least five (5) days prior to the scheduled date for commencement of the hearing, each
party shall give to the other party a list of all exhibits which, as far as is then reasonably
known, will or may be used as evidence in support of that party at the hearing. At such
time as the list of exhibits is provided, each party shall make available all such exhibits to
the other party for inspection and copying. Exhibit lists shall be amended as soon as
possible when additional exhibits are identified. The hearing officer may permit an exhibit
which has been listed to be admitted as evidence at the hearing if he/she finds that the
failure to list such exhibit was justified, that such failure did not prejudice the party entitled
to receive such list, and that the exhibit will materially assist the hearing officer in making
his/her report and recommendation.
10.7-6 Personal Presence
The personal presence of the AHP/DP is required throughout the hearing, unless such
personal presence is excused for any specified time by the hearing officer. The presence
of the AHP's/DP’s counsel or other representative does not constitute the personal
presence of the AHP/DP. An AHP/DP who fails, without good cause, to be present
throughout the hearing unless excused or who fails to proceed at the hearing shall be
deemed to have waived his rights to a hearing.
10.7-7 Hearing Officer
The hearing officer shall maintain decorum and assure that all participants have a
reasonable opportunity to present relevant oral and documentary evidence. He/she shall
determine the order of procedure during the hearing and make all rulings on matters of
law, procedure, and the admissibility of evidence. The hearing officer shall not act as a
prosecuting officer or as an advocate to any party to the hearing.
10.7-8 Representation
The AHP/DP may be accompanied and represented at the hearing by a member of the
Medical Staff in good standing, by a member of his/her specialty, by an attorney, or by
another person of his/her choice. He/she shall inform the CEO in writing of the name of
that person at least ten (10) days prior to the hearing date. The body whose adverse
recommendation or action prompted the request for hearing shall appoint an individual to
represent it. Such individual may be an attorney, a member of said body, or any other
person designated by said body.
10.7-9 Rights of Parties
During the hearing, each party shall have the following rights, subject to the rulings of the
hearing officer on matters of law, procedure and the admissibility of evidence, and
provided that such rights shall be exercised in a manner so as to permit the hearing to
proceed efficiently and expeditiously:
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B.
C.
D.
E.
35
call and examine witnesses;
introduce exhibits;
cross-examine any witness on any matter relevant to the issues;
impeach any witness; and
rebut any evidence.
If the AHP/DP does not testify in his/her own behalf, he/she may be called and examined
as if under cross-examination.
10.7-10 Procedure and Evidence
The process set forth herein is intended to resolve within the Facility itself matters bearing
on the professional conduct, competency and character of AHPs/DPs and is not intended
to be conducted as a formal legal proceeding. The hearing need not be conducted
according to rules of law relating to the examination of witnesses or presentation of
evidence. In the discretion of the hearing officer, any relevant matter upon which
responsible persons customarily rely in the conduct of serious affairs may be considered,
regardless of the admissibility of such evidence in a court of law. Each party shall be
entitled, prior to or during the hearing, to submit memoranda concerning any issue of law
or fact, and those memoranda shall become part of the hearing record. The hearing
officer may require such memoranda to be filed at a time specified by the hearing officer.
The hearing officer may ask questions of witnesses, call additional witnesses or request
documentary evidence if he/she deems it appropriate.
10.7-11 Official Notice
In reaching a decision, the hearing officer may take official notice, either before or after
submission of the matter for decision, of any generally accepted technical or scientific
matter relating to the issues under consideration and of any facts that may be judicially
noticed by the courts of the State of Florida. Participants in the hearing shall be informed
of the matters to be noticed and those matters shall be noted in the hearing record.
Either party shall have the opportunity to request that a matter be officially noticed and to
refute any officially noticed matter by written or oral presentation of authority, in a manner
to be determined by the hearing officer. Reasonable additional time shall be granted, if
requested, to present written rebuttal of any evidence admitted on official notice.
10.7-12 Burden of Proof
The body whose adverse action or recommendation occasioned the hearing shall present
the evidence in support thereof. Thereafter the AHP/DP shall have the burden of coming
forward with evidence and proving that the adverse action or recommendation lacks any
substantial factual basis or is otherwise arbitrary, unreasonable, or capricious.
10.7-13 Hearing Record
A record of the hearing shall be kept. The hearing officer shall determine whether this
shall be done by use of a court reporter, or a tape recording of the proceedings. The
hearing officer may, but is not required to, order that oral evidence shall be taken only on
oath or affirmation administered by any person designated by it and entitled to notarize
documents in the State of Florida.
10.7-14 Postponement
Requests for postponement or continuance of a hearing may be granted by the hearing
officer only upon a timely showing of good cause.
10.7-15 Recesses and Adjournment
The hearing officer may recess and reconvene the hearing without Special Notice for the
convenience of the participants. Upon conclusion of the presentation of oral and written
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evidence, the hearing shall be adjourned. The hearing officer shall conduct deliberations
outside the presence of the parties.
10.7-16 Hearing Officer Report
Within twenty (20) days after adjournment of the hearing, the hearing officer shall make a
written report of his/her findings and recommendations with such reference to the hearing
record and other matters considered as it deems appropriate. The report shall contain a
summary of the basis of the decision. If the AHP/DP sustains his/her burden of proving
that the adverse action or recommendation lacks any substantial factual basis or is
otherwise arbitrary, unreasonable or capricious, the hearing officer shall recommend for
the AHP/DP; in all other cases, the hearing officer shall recommend against the AHP/DP.
The hearing officer shall forward the report along with the record and other documentation
to the body whose adverse action or recommendation occasioned the hearing. The
AHP/DP shall also be given a copy of the report.
10.7-17 Action on Hearing Officer Report
Within twenty (20) days after receiving the hearing officer report, the body whose adverse
action or recommendation occasioned the hearing shall consider said report and shall
determine its result which may be to affirm, modify or reverse its action or
recommendation. It shall transmit the result, together with the hearing record, the hearing
panel report and all other documentation considered, to the CEO.
10.7-18 Notice and Effect of Result
As soon as is reasonably practicable, the CEO shall send a copy of the result including a
summary of the basis for the decision, to the AHP/DP by special notice and to the Medical
Staff President. The matter shall thereafter be referred to the Board for it to take final
action in the matter. Thereafter, the CEO shall promptly notify the practitioner and the
Supervising Physician(s) of the final action.
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PART ELEVEN. GENERAL PROVISIONS
11.1
NUMBER OF HEARINGS AND REVIEWS
Notwithstanding any other provision of the Bylaws, Medical Staff Bylaws, or this Manual, no
AHP/DP shall be entitled to more than one (1) hearing with respect to the subject matter that is
the basis of an adverse recommendation or action triggering the right.
11.2
RELEASE/IMMUNITY
By requesting a hearing, an AHP/DP agrees to be bound by the provisions of the Medical Staff
Bylaws relating to immunity from liability, the immunities from liability arising under the physician
peer review provisions of Chapter 395, Florida Statutes, and under the federal Health Care Quality
Improvement Act of 1986 in connection with professional review actions involving Physicians.
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PART TWELVE. AMENDMENT
12.1
AMENDMENT
The Fair Hearing Manual may be amended or repealed, in whole or in part, and at any time by a
majority vote of the Board of Directors of Martin Health System.