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NEW YORK STATE OFFICE OF MENTAL HEALTH CREEDMOOR PSYCHIATRIC CENTER POLICY / PROCEDURE POLICY / PROCEDURE: PRIVILEGING DATE ISSUED: July, 1997 TO: See Distribution FROM: Charlotte Seltzer, CSW Chief Executive Officer SUBJECT: Policy/Procedure The attached policy/procedure, under the subject above, has been reviewed and approved for inclusion in the manuals listed below: Approved, Charlotte Seltzer, Chief Executive Officer William A. Fisher, M.D. Clinical Director Eunice D'Souza, M.D. President, Medical Staff Organization Caterina Grandi, M.D. Chief of Psychiatry Margaret Malone MPS, RN Director for Quality Assurance INSTRUCTIONS: ATTACHMENT DISTRIBUTION LIST: Cabinet, All Physician , Chiefs of service, Medical Legal Director INSERT IN THE FOLLOWING MANUALS: Rules and Regulations of Medical Staff Organization (REVISED 7/97)) CREEDMOOR PSYCHIATRIC CENTER DEPARTMENT OF PSYCHIATRY POLICY AND PROCEDURE: PRIVILEGING July, 1997 Policy: The scope of care delivered by psychiatrists shall reflect their qualifications to deliver such care. Definitions: Privileges are of a specific type (e.g., full, probationary, or temporary) and of a specific scope (e.g., General, ECT and Supervisory). Temporary Privileges: Privileges of a specified scope granted by the Chief Executive Officer for up to 90 days, upon the recommendation of the Chief of Psychiatry, pending review and approval by the Credentials and Privileges Committee. Probationary Privileges: Privileges of a specified scope granted by the governing body for a period of one year, with the understanding that the physician thus privileged Is being evaluated by another physician (supervisor) who has full privileges of that scope. Full Privileges: Privileges of a specified scope granted by the governing body following successful completion of a year of probationary privileges. Full privileges are Initially granted for a period of one year and are renewable every two years. Scope of Privileges: Those activities which the physician Is privileged to perform. These Include: a. General Privileges: (Probationary/Full) Privileges to perform the following activities for adult Inpatients and outpatients of any age with any DSM IV diagnoses. I. Admission. II. History Taking. Ill. Physical Examination. IV. Mental Status Examination V. Ordering Diagnostic Tests. VI. Requesting Consultations Including Referrals to Local Hospitals. VII. Diagnostic Assessment. VIll. Formulation and Approval of the Treatment Plan. IX. Ordering Medication and other Somatic Interventions (excluding ECT - Paragraph "b"). 1 X. Ordering Therapeutic and Milieu Interventions. XI. Ordering Special Diets. XII. Group and Family Meetings: Individual, Supportive, Behavioral, Cognitive, Insight, Oriented and any other commonly recognized Intervention In the course of patient management. XIII. Ordering Restraint and Seclusion. XIV. Performing Routine Minor Procedures (e.g., phlebotomy, starting of intravenous line, suturing of minor lacerations), and routine medical care. XV. Ordering Patient Privileging Level, Leaves and Passes. XVI. Discharge. XVII. Documentation In the Medical Record. XVIII. Practical Oversight of Residents In Patient Management during "On Call." b. ECT Privileges: (Probationary/Full) Privileges to perform ECT on patients. c. Supervisory Privileges: (Probationary/Full) Privileges to supervise other physicians and residents In training: 1. Residency Training II. General Adult Inpatient Ill. General Adult Outpatient d. MICA Treatment/Supervisory Privileges: (Probationary/Full Privileges to treat and/or supervise the treatment of MICA patients on a specialized MICA unit. e. Geriatric Consultation Privileges: Privileges to consult with and advise other staff on Issues In the treatment of geriatric patients. f. Creedmoor Psychiatric Center does not grant privileges in psychosurgery. Procedure: A) Temporary Privileges and Probationary Privileges Responsibility Action 2 Policy/Procedure: Privileging Applicant Department Chairman 1. Applies for membership in the medical staff and for privileges as specified In Medical Staff Organization Bylaws. 2. In the application, the applicant will provide Information on health, licensure (including current license registration), narcotics registration, training, previous experience, specialty or subspecialty board certification, and professional society memberships. The application will also Include Information on any adverse action concerning licensure, registration, professional society memberships, hospital privileges, or third party payers; and Information on professional liability (malpractice) litigation pending or completed. 3. Verifies the Information mentioned In #2 as well as he/she can, using primary sources wherever possible. 4. Gathers relevant Information about clinical competence from supervisors In previous employment or training. Also obtains Information from Continuous Quality Improvement (CQI) monitoring of previous employer, If obtainable. Queries the National Practitioner Data Bank. 3 Policy/Procedure: Privileging Executive Director Credentials and Privileges Committee MSO Executive Committee Complies a physician profile on the applicant, containing the above information. 6. Determines whether to recommend to the Executive Director that the applicant be granted temporary privileges. 7. Upon the recommendation of the Department Chairman, grants the applicant temporary privileges for up to 90 days, pending review and approval by the Credentials and Privileges Committee. 8. Evaluates the Information in the physician profile and submits to the Executive Committee of the Medical Staff Organization (MSO) Its recommendations on granting or denying privileges and membership In the MSO. 9. Submits to the Governing Body a recommendation for either granting or denying privileges and membership In the MSO. If the majority of the membership of the MSO Executive Committee Is present at the Credentials and Privileges Committee meeting and If said majority of the MSO Executive Committee concurs with the recommendation of the Credentials and Privileges Committee, then the MSO Executive Committee shall be deemed to have endorsed that 4 Policy/Procedure: Privileging Governing Body (or its designee) Applicant Department Chairman Supervisor Department Chairman decision, and It shall be so recorded In the minutes. 10. Grants or denies privileges. In granting probationary privileges, the Governing Body does so with the understanding that these privileges may be converted to full privileges as specified in section B. 11. May appeal an adverse decision as stated In the MSO Bylaws Article XI. Assigns the newly privileged psychiatrist to a work location. When the assignment Is to a patient ward, the supervisor generally will be the chief psychiatrist. 13. Submits to the Department Chairman (Chief of Psychiatry) a quarterly report on the newly privileged physician based on an assessment by direct observation and/or discussion of cases and/or review of medical records. The report shall contain an overall rating of "good", "average", or "below average." 14. Brings any "below average" report to the attention of the Credentials and Privileges Committee for reconsideration of privileges (e.g., restriction 5 Policy/Procedure: Privileging B. Full Privileges or denial of privileges, extension of probation, or Increased supervision. Full privileges are granted automatically at the end of a year of probationary privileges, providing no "below average" reports have occurred. Full privileges remain In effect for one year and may then be renewed every two years. Physician Chairman of Credentials & Privileges Committee Credentials & Privileges Committee Completes a year of probationary privileges with no "below average" ratings. Informs physician of conversion of privileges from probationary to full on the recommendation of the department chairman. May convert privileges from probatlonary to full after one year even with a "below average" quarterly report If, In Its opinion, the problem prompting thebelow average evaluation has been corrected adequately. C. ECT Privileges - (Probationary or Full): The applicant must have general privileges (full or probationary). Must have completed 50 hours of theoretical and practical training In ECT, which meets with the approval of the head of the ECT program at Creedmoor Psychiatric Center (CPC) or must submit a plan approved by the head of the ECT program at CPC to acquire such training, while performing ECT only under direct supervision of a physician privileged In ECT during his probationary year. If the applicant already has full general privileges and already meets the 50 hours requirement, full ECT privileges may be granted without a probationary year. 6 Policy/Procedure: Privileging D. Supervisory Privileges (Probationary or Full) a. Residency Training: The applicant must have general privileges (full or probationary) and must demonstrate to the satisfaction of the Director of Residency Training significant training or experience In the teaching or supervision of residents or must submit to the Director of Residency Training a plan for acquiring such experience, while working under supervision during his probationary year. If the applicant has full general privileges and already has significant training or experience In the teaching or supervision of residents, full supervisory privileges may be granted without a probationary year. b. Inpatient Supervisory: The applicant will be granted supervisory privileges only In conjunction with general privileges. The applicant must demonstrate a high level I of clinical skill In In-patient psychiatry. (Examples of evidence or such skill might be board certification; or a year of Inpatient experience at CPC or elsewhere with appropriate supervisory evaluations). If the applicant already has Full General Privileges and meets the above criteria, Full Supervisory Privileges may be granted without a probationary year. c. Outpatient Supervisory: The applicant will be granted supervisory privileges only In conjunction with general privileges. The applicant must demonstrate a high level of clinical skill In outpatient psychiatry. (Examples of evidence of such skill might be board certification; or a year of outpatient experience at CPC or elsewhere with appropriate supervisory evaluations). If the applicant already has Full General Privileges and meets the above criteria, the applicant may be granted his privileges without a probationary year. E. 1) MICA Treatment Privileges The applicant must have general privileges (Full or Probationary). The applicant must also have completed 400 hours of participation on a multi-disciplinary MICA team and 7 Policy/Procedure: Privileging have completed either one course or its equivalent In substance abuse or 40 hours of supervision by a supervisor with MICA supervisory privileges. Probationary MICA privileges may be granted to an applicant with general privileges (Probationary or Full) If he/she meets the above requirements under the supervision of an Individual with MICA supervisory privileges. 11) MICA Supervisory Privileges The applicant must have (Full or Probationary) Inpatient or outpatient supervisory privileges (as appropriate to the specialized MICA setting In which he/she Is supervising). The applicant must also have met the requirements In (EI) above. F. Residents and Fellows Residents and Fellows are not privileged. They are allowed to work under supervision by the governing body at the recommendation of the Director of Residency Training, who ascertains the adequacy of their prior training, ethics and health. Residents and Fellows may perform all those actions specified under General Privileges, but may only do so under the supervision of an appropriately privileged physician. Their scope of work may be restricted at any time by their supervisors or by the Director of Residency Training. PGY-IV's and Fellows may also supervise more junior residents, provided that this activity Is carried out with the permission and under the supervision of an appropriately privileged physician. Please refer to the policy on supervision of residents. G. Reprivileging Reprivileging is done every two years by the Governing Body at the recommendation of the Credentials & Privileges Committee and MSO Executive Committee. Physicians are presented for reprivileging by the Department Chairman based on Information from the Physician Profile (which includes updated Information as In Items A2, A3 and A4, as 8 Policy/Procedure: Privileging well as the results of monitoring and evaluation, and peer review and supervisory activities involving that physician, queries to outside employment and to the National Practitioner Data Bank). Physicians must simultaneously reapply and be reappointed to the MSO using the medical staff reappointment form. Physicians requesting reappointment must document a minimum of 20 hours of CME I per year. This requirement will become effective July, 1998. Physicians may appeal reprivileging decisions as in Article XI of the MSO Bylaws. H. Restriction or Revocation of Privileges The Governing Body may revoke or restrict the privileges of a physician, at the recommendation of the MSO Executive Committee which, In turn, acts on the recommendation of the C&P Committee or Peer Review Committee. The C&P Committee may Initiate such action based on Its own deliberations or at the request of the Peer Review Committee, the Department Chairman or the Clinical Director. Such restriction or revocation must constitute a clinically appropriate response to the problems Identified and may not be arbitrary or malicious In nature. The physician may appeal such a decision as per article XI of the MSO Bylaws. I. Emergency Suspension When the Clinical Director decides that a particular physician constitutes an Immediate risk to patients, the Clinical Director may enact an emergency suspension or restriction of that physician's privileges. This action must be followed within two weeks by a Peer Review Committee Investigation, which can then Initiate the process described In paragraph H. J. Increased Supervision The Department Chairman, Clinical Director or Associate Medical Director may unilaterally decide to Increase the level of supervision of a physician. This action Is not considered a restriction or revocation of privileges (unless the physician Is forbidden from performing a certain activity without such 9 Policy/Procedure: Privileging supervision) and hence, Is not an action of the governing body and not appealable under Article XI. K. Privileging Rev. 7/97 Emergency Privileges In the case of an emergency, any individual who Is a member or associate of the medical staff or who has been granted delineated clinical privileges Is permitted to do everything possible, within the scope of his/her license to save a patient's life or to save a patient from serious harm, regardless of the Individual's staff status or clinical privileges. Privileging Decisions Privileging decisions shall be made without regard to sex, age, race, creed or national origin. 10 |
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