PurposeThe Credentials and Privileges Committee reviews the credentials of providers applying for initial appointment orreappointment to the Medical Staff at SHC, and makes recommendations for membership and delineation ofprivileges in compliance with the Medical Staff Bylaws, Credentialing Policies and Procedures, and Clinical Servicerequirements; reviews and approves new or revised credentials and privileges, forms and processes; reviews andapproves credentialing policies and procedures.In addition, the Credentials and Privileges Committee reviews and acts upon reports from the InterdisciplinaryPractice Committee (IDPC) of appointment and evaluations of Advanced Practice Providers. The IDPC is asubcommittee of the Credentials and Privileges Committee and is accountable to the Medical Executive Committeeand the Governing Body.Chair Hospital Committee General functions: Areas of responsibility Formulate policies Coordinate MonitorExecom (Executive Quality services andCommitttee) organizational directionMancom (Management Quality services andCommittee) operational managementQuality Council Quality services and quality management systemCommittee on Medical Quality medical servicesServices rendered by physiciansBioethics Committee Bioethical matters in patient carePharmacy and Drug therapyTherapeutic CommitteeInfection Control Infection controlCommitteeWaste Management Waste managementCommitteeMedical Audit and Tissue Outcome in patient careCommittee such as mortality, morbidity, and tissue reviewTumor Board Cancer managementMedical Records Medical recordsCommittee
Credentials Committee Credentialing of physicians Blood Transfusion Blood transfusion Committee Home » Medical Staff Main Page » e-Newsletters » Medical Staff Leader Connection E-mail Print RSS ShareThis Credentialing monthly: What is the role of the credentials committee in addressing unprofessional conduct? Medical Staff Leader Connection, November 18, 2009 Want to receive articles like this one in your inbox?Subscribe to Medical Staff Leader Connection! If you believe everything you read, it may appear that we are in the midst of a disruptive physician behavior epidemic. As I travel to hospitals across the country, I am not convinced that the frequency or severity of unprofessional conduct (the term I prefer to use instead of “disruptive behavior”) has increased. Rather, I believe that we are changing our expectations of physician behavior. In other words, medical staffs are no longer tolerating behavior that they tolerated in the past. The Joint Commission has weighed in on this issue withSentinel Event Alert #40, which highlights the adverse affect unprofessional conduct has on patient safety. The Joint Commission also issued leadership standard LD.03.01.01, which requires hospitals to address unprofessional conduct throughout all levels of the hospital, including management, staff, and board members—not just physicians. As members of the self-governed medical staff, department chairs are accountable for the behavior of physicians within their department. Thus, they are responsible for intervening when a physician displays inappropriate or disruptive behavior.
In addition to department chairs, the credentials committee plays an important role in keeping problem behavior incheck. I’d like to share with you a clear set of actions a credentials committee can take to fulfill its role in eliminatingunprofessional conduct:1. Take a close look at the criteria for medical staff membership, which are located in your bylaws or credentials manual, and make sure they address professional conduct. If you don’t have criteria in place that address professional conduct, consider this sample language: “Physician must produce a history of consistently acting in an appropriate and professional manner in previous clinical settings.” This would not preclude a physician who has had a rare outburst from joining your medical staff if he or she acts in an appropriate and professional manner the majority of the time. This would however, prevent chronic offenders from joining your medical staff.2. Once the credentials committee has established criteria for membership that address professional conduct, it now has the grounds for gathering information on an applicant’s conduct in previous clinical settings. This is where references come in handy, especially those your medical staff services department sends to MSPs at those settings (not the handpicked references of the applicant’s choosing). The credentials committee owns the content of those reference queries and needs to ensure it has answered any questions about an applicant’s conduct.3. One of the credentials committee’s most important roles is to prevent what I like to call an “information error.” An information error occurs when information existed that your hospital could have or should have discovered but didn’t, and that information would have caused the committee to make a different credentialing decision. In this case, the credentials committee needs to gather all the information it needs regarding the applicant’s behavior in previous clinical settings to make a well informed decision. If the committee has any concerns about the applicant’s conduct, the committee should drill down into those concerns to resolve them to the satisfaction of your medical staff’s professional conduct policy. The credentials committee is responsible for making sure this policy is well written and consistently implemented. The credentials committee should not make any decisions regarding an applicant when concerns regarding his or her conduct remain unresolved.4. The credentials committee needs to guard against the second kind of credentialing mistake: a “decision error.” A decision error occurs when the medical staff and hospital are aware of potential issues regarding an applicant but lack the wisdom, clarity, or courage to make a wise decision. When the credentials committee receives a recommendation from the department chair regarding each applicant and re-applicant, it is responsible for ensuring that the department chair appropriately understood the physician’s past behavior and made a wise decision. Typical concerns that occur at this stage include:
The physician admits a lot of patients to the hospital and may have been given too much latitude with his or her behavior in the past. The physician is well-liked, resulting in their friends on the credentials committee approving the reapplication based on camaraderie, not objective evidence. Members of the credentials committee or others are afraid to lose referrals from the applicant or reapplication and continue to approve his or her membership on the medical staff in spite of significant, chronic behavior problems. The physician threatens to sue the hospital if it tries to affect his or her membership or privileges based on behavior concerns, and the hospital backs down. Credentials committee members and other medical staff leaders lack a consensus concerning whether to take poor physician conduct seriously and what types of behavior are tolerable.5. The credentials committee needs to remember that the goal of the medical staff professional conduct policy is not to “kick physicians off the staff” for bad behavior, but to help every physician act in an appropriate and professional manner as much as possible. Therefore, the credentials committee should recognize when to recommend to a department chair that further interventions are warranted to address a physician’s behavior. This may warrant initial or reappointment for a period of less than two years while the interventions regarding their behavior are carried out.By fulfilling its role, your credentials committee can help make unprofessional conduct a thing of the past, and in sodoing enhance patient safety and collegiality throughout your hospital.Richard A. Sheff, MD, CMSL, is the chair and executive director of The Greeley Company, a division of HCPro, Inc. inMarblehead, MA.Want to receive articles like this one in your inbox?Subscribe to Medical Staff Leader Connection!PROFESSIONAL STAFFORGANIZATION
ANDFUNCTIONS MANUALCarondelet Health NetworkCarondelet Holy Cross HospitalNogales, ArizonaPROFESSIONAL STAFF ORGANIZATION AND FUNCTIONS MANUAL Carondelet Holy Cross HospitalOrganization and Functions ManualNogales, Arizona 1Carondelet Holy Cross HospitalTABLE OF CONTENTSTOPIC PAGEEnabling Procedures ........................................................................................Approval and Modification..............................................................................Current Organization .......................................................................................Departments .....................................................................................................Divisions ..........................................................................................................Committees ......................................................................................................Medical Executive Committee.........................................................................Infection Control Function...............................................................................Quality Council (QC) ......................................................................................Credentials Committee of the Board of Directors ...........................................Carondelet Health Network Human Subjects Committee ...............................Nominating Committee....................................................................................
Carondelet Health Network Pharmacy & Therapeutics Committee................Professional Behavior Committee ......................................ORGANIZATION AND FUNCTIONS MANUALENABLING PROCEDURESThis Organization and Functions Manual has been created pursuant to and under the authority ofthe Professional Staff Bylaws of Carondelet Holy Cross Hospital. The purpose of the Manual isto describe the current organization of the Professional Staff and to define the mechanisms thatthe Professional Staff will utilize to accomplish the following functions as outlined in the currentProfessional Staff Bylaws.This Manual is one of three that have been designed to support the Professional Staff Bylaws.1. Credentialing Policy and Procedures Manual2. Organization and Functions Manual3. Professional Staff Rules and RegulationsThis Manual and its contents are subject to the approval of the Medical Executive Committeeusing the procedures found in the Professional Staff Bylaws.APPROVAL AND MODIFICATIONThis Manual and its contents are subject to the approval of the Medical Executive Committeeand of the Board of Directors. Once approved, the Manual will become effective subject tofuture amendments as may from time to time be required and approved by the Medical ExecutiveCommittee. All such amendments will be reviewed by the Board of Directors for theirconcurrence.CURRENT ORGANIZATIONThe Professional Staff of Carondelet Holy Cross Hospital will be organized as adepartmentalized professional staff. At the present time, three (3) departments exist:1. Department of Family Practice/Internal Medicine
2. Department of Surgery/OB-Gyn3. Department of PediatricsIn addition, the following committees have been created:* Medical Executive Committee* Quality Council* Credentials Committee of the Board* Carondelet Health Network Human Subjects Committee* Professional Staff Bylaws Committee* Nominating Committee* Professional Behavior CommitteeDEPARTMENTSCarondelet Holy Cross Hospital Organization and Functions ManualNogales, Arizona 2Professional Staff will be assigned to one of the three (3) departments depending on theirprimary area of practice. In the event a member of the Professional Staff wishes to attenddepartment meetings other than the one to which he/she is assigned, this is entirely permitted.However, the individual attending a department other than his/her official department will not bepermitted to vote on issues within the department.At the discretion of the department chairperson, professional staff specific specialties mayorganize themselves into "divisions" for purposes of education, discussion, policy direction, orfor purposes of generating recommendations to the department chair concerning departmentalissues. Additionally, divisions may at times be requested to address specific issues pertinent totheir department.Departments will be required to hold regular meetings, not less than quarterly. At thesemeetings, the chairperson of the department (or designee) will present a report of departmentalactivities based upon the past quarters work. This report is expected to include a brief report
covering the quality of services provided by members of the department, any new policies orprocedures that impact a significant number of the departments members, significanthospitalwide/administrative issues, as well as other issues that affect overall departmental organization.Any specific actions taken by the Medical Executive Committee that should be communicated toall members of the department will also be touched upon in this report.Attendance requirements will be determined by each specific department. All members areencouraged to attend; attendance will be recorded.DIVISIONSAny division, if organized, will not be required to hold any number of regularly scheduledmeetings. Nor will attendance be required unless the division chairperson calls a special meetingto discuss a particular issue. (Such special meetings must be preceded by at least two weeksprior notification to all of those individuals expected to attend.) The department will select theirchairpersons.At the present time, the following divisions exist:1. Department of Surgery/OB-Gyn• Obstetrics/Gynecology2. Department of Family Practice/Internal Medicine• Obstetrics• Emergency MedicineCOMMITTEESThe professional staff of Carondelet Holy Cross Hospital will operate through the followingcommittee structure:MEDICAL EXECUTIVE COMMITTEECarondelet Holy Cross Hospital Organization and FunctionsManualNogales, Arizona 3The Medical Executive Committee will conduct those activities and functions specified in the
Professional Staff Bylaws but will be specifically required to do or perform the followingfunctions, though not limited to:1. Receive, review and act upon the reports of other medical staff committees anddepartments responsible to it;2. Perform the safety oversight function on behalf of the professional staff;3. Perform the disaster plan oversight on behalf of the professional staff;4. Provide leadership for the organizational performance improvement and patient safetyactivities to include process measurement and improvement;5. Ensure that process measurement and improvement include:- medical assessment and treatment of patients- use of blood and blood components- use of medications and operative and other procedures- efficiency of clinical practice patterns;6. Identify opportunities to improve patient care and patient safety, and set priorities for itsevaluation using relevant indicators, quality, improvement tools and appropriate clinicalcriteria;7. Review reports from Risk Management, Safety and other departments/services;8. Review Patient Satisfaction Survey results and complaints and make appropriaterecommendations;9. Receive Performance Improvement (PI) Team Reports;10. Provide guidance to the review of hospital systems and processes and report findings todepartments with recommendations for improvement;11. Other patient care functions to include Pharmacy and Therapeutics, Medical Recordreview and Sentinel Event review processes; and12. Approve the sources of patient care provided outside the hospital. This applies to
“medical care providers” caring for hospital patients OUTSIDE of the hospital. TheMEC will ratify any source of patient care service (not the contract) that originatesoutside the hospital. The purpose is to assure that there are no “quality problems”related to a specific provider or group of providers with whom service is beingcontemplated.The Medical Executive Committee will meet at least nine times per year for the performance ofthe functions outlined above and further defined elsewhere in this Organization and FunctionsManual. The Medical Executive Committee will maintain a permanent record of its activitiesand will be staffed by at least one designee from the medical staff office.The Medical Executive Committee may go into "executive session" during which time all nonmemberswill be excused. The Hospital Chief Executive Officer or designee may remain unlessthe Medical Executive Committee wishes to discuss that individual.NOTE: Any Professional Staff member may submit a request for a meeting with the MedicalExecutive Committee. Such request will ordinarily be honored unless the individual has notdiscussed the issue with his/her department chair in advance.The Medical Executive Committee will arrange for the performance of other medical stafffunctions such as institutional review of experimental procedures and research protocols,continuing medical education, ethics and ethics review functions, intensive/coronary careoversight and monitoring as well as participation in policy and procedure development in allareas directly impacting upon the provision of medical care provided within the institution. Chief of StaffDuties/Responsibilities:1. Act in coordination and cooperation with the hospital CEO or designee in all matters ofmutual concern with the hospital;2. Call, preside at, and be responsible for the agenda of all general meetings of theProfessional Staff;3. Serve as Chairperson of the Medical Executive Committee;
4. Serve as a voting member of the Board of Directors;5. Serve as ex officio member of all other Professional Staff committees without vote;6. Be responsible for the enforcement of Professional Staff Bylaws, Rules and Regulations,for implementation of sanctions where these are indicated, and for the Professional Staffscompliance with procedural safeguards in all instances where corrective action has beenrequested against a practitioner;7. Appoint a committee chairperson to all standing special and multidisciplinary ProfessionalStaff committees except the Quality Council. (This does not include Departments);8. Appoint a department chairman if the department is unable to vote on one.9. Represent the views, policies, needs and grievances of the Professional Staff to the Boardof Directors and to the Hospital CEO or designee;10. Receive and interpret the policies of the Board of Directors to the Professional Staff andreport to the Board of Directors on the performance and maintenance of quality withrespect to the Professional Staffs delegated responsibility to provide medical care;11. Be responsible for the educational activities of the Professional Staff; and12. Be the spokesperson for the Professional Staff in its external professional and publicrelations.INFECTION CONTROL FUNCTIONComposition - The Infection Control Function will be delegated to the Quality Council (QC) foroversight and monitoring. (See Quality Council for composition and functions). These membersof QC will participate actively in the affairs of the Infection Control Function.QUALITY COUNCIL (QC)Membership - The Committee shall be multidisciplinary and shall be composed of at least thefollowing representatives: Physician Chairperson shall be recommended by the Chief of Staffand the CEO or designee and confirmed by the Medical Executive Committee. The appointment
will be reviewed every 2 years at the time of election of the Chief of Staff Elect. The MedicalExecutive Committee may revoke the appointment at any time without cause. Vice Chairpersonmay be delegated to assist the Chairperson in all review activities. The remaining members willinclude, but not be limited to the following chairpersons or their designees. (The designee mustbe a member of the respective Department):• Department of Pediatrics• Department of Family Practice/Internal Medicine• Department of Surgery/OB-Gyn• Chief of Staff - (optional)• Chief of Staff ElectCarondelet Holy Cross Hospital Organization and Functions ManualNogales, Arizona 4 Other members include:• Sr. VP/CEO or designee• Chief Nursing Officer-Acute/Administrator-Long Term Care or designee• Quality Management Coordinator or designee• Board of Directors Liaison or designee• Pharmacy Manager or designee• Medical/Post-Surgical Service Line Manager or designee• Long-Term Care/Transitional Care Unit Manager or designee• Education/Development Specialist or designee• Infection Control Manager or designee• Risk Management Director or designee• Medical Records Manager or designee• Information Systems Representative or designee• Laboratory Services Manager or designee
Representatives from other Ancillary/Care Continuum Services shall also be included asmembers/participants of the Council.Members present shall constitute a quorum.The Chairperson will make a report to the Medical Executive Committee (each month that ameeting is held) concerning the activities of QC. A report of PA&I activities will be made to theBoard of Directors at least quarterly. (See Appendix A for Quality Information Flow andAppendix B for Organizational Chart.)Function - Implementation of the program shall be the responsibility of the Quality Council.The Committee shall:1. Receive reports, bring focus and oversee the critical performance standards, expectations,and improvement activities of the Professional Staff departments and Hospital servicesfor appropriateness of care, to insure that processes for delivery of care are analyzed foropportunities to improve patient care, to insure that corrective action/education taken andthe action plans are evaluated for effectiveness in resolving the issue, to spotlightperformance that differs from the norm, to give management an opportunity to removeroadblocks to success, and to share best practices;2. Identify opportunities to improve patient care and set priorities for its evaluation usingrelevant indicators, quality improvement tools, and appropriate clinical criteria;3. Apprise Professional Staff and hospital services of opportunities to improve either care orprocesses and recommend appropriate reviews for evaluation;4. Coordinate and integrate activities to pursue the most efficient use of hospital resourcesfor the greatest benefit of patient care services provided;5. Insure that ongoing evaluation and improvement in the use of blood and medications isperformed for appropriate utilization;6. Establish a plan and carry out a program of concurrent utilization management. It shall
revise the program as necessary to analyze and evaluate different aspects of patient careCarondelet Holy Cross Hospital Organization and Functions ManualNogales, Arizona 5 or processes. It shall comply with applicable statutes and regulationsfor review ofpatient care;7. Appoint a Physician Advisor to review and assess activities of non-physicianPerformance Assessment & Improvement Department reviewers. It will empower thePhysician Advisor as delegated by the Executive Committee of the medical staff toperform procedures outlined in the Utilization Management Plan for decertification ofadmission and continued stay;8. Receive reports of Risk Management/Safety activities and provide for professionalreview of hospital claims and evaluation of alternative view-points;9. Receive reports of the hospital’s Quality Indicators and Financial Indicators;10. Receive QI Team reports;11. Provide review of Patient Satisfaction Survey results and make appropriaterecommendations; 12. Review hospital procedures and professional staff practices, and report findings todepartments and MEC with recommendations for appropriate changes for improvement; 13. Assist the Professional Staff in carrying out Infection Control, Surveillance andPrevention. Other functions include:A. Maintain surveillance over the Hospitals infection control program.B. Develop a system for reporting, identifying and analyzing the incidence and cause ofall infections.C. Develop and implement a preventive and corrective program designed to minimizeinfection hazards, including establishing, reviewing and evaluating aseptic isolationand sanitation techniques.
D. Develop, evaluate and review preventive, surveillance and control policies andprocedures relating to all phases of the Hospitals activities, including: operatingrooms, special care units, central service, housekeeping and laundry, sterilization anddisinfection procedures by heat, chemical, or otherwise isolation procedures;prevention of cross-infection by anesthesia apparatus or inhalation therapyequipment; testing of Hospital personnel for carrier status; disposal of infectiousmaterial; food sanitation and waste management; and other situations as requested.E. Review action on findings from the Professional Staffs review of the clinical use ofantibiotics.F. Conduct on a periodic basis statistical/prevalence studies of antibiotic usage andsusceptibility/resistance trend studies.G. Submit written reports at least quarterly to each department on the progress andresults of this activity and of any particular policies and procedures which mayimpact the affairs of the department or its members.H. On an annual basis, the chairperson of QC will present an annual report to theMedical Executive Committee concerning the status and appropriateness of theinfection control procedures established by the institution; and 14. Other functions include: Pharmacy and Therapeutics and Medical Record Review.Meetings - The Committee should meet regularly (at least quarterly) at a designated time.Special meetings may be called at the discretion of the Chairperson. The Quality Council mayrecommend specific CQI topics to the Medical Executive Committee for further study andproblem resolution using the CQI Model.Carondelet Holy Cross Hospital Organization and Functions ManualNogales, Arizona 6 CREDENTIALS COMMITTEE OF THE BOARD OF DIRECTORSComposition - There will be a Credentials Committee of the Board of Directors, which will be
composed of the Chief of Staff or designee, Sr. VP/CEO or designee, and the Board Chairpersonor designee.The Credentials Committee will function pursuant to policies and procedures adopted anddocumented in the Credentialing Policy and Procedures Manual.Purpose: The primary purpose of the Credentials Committee shall be to coordinate all phases ofthe credentialing process.Duties:1. Coordinate consistency in overall credentialing policies.2. Develop a Credentialing Policy and Procedures Manual for Carondelet Holy CrossHospital.3. Review privileging criteria and recommend changes, whenever appropriate.4. Review recommendations on new appointments and reappointments from the MedicalExecutive Committee and present these to the Board of Directors for final action.5. Educate the Board of Directors on current and future national trends in hospital staffcredentialing.6. Recommend improvements in the credentialing system.Meetings: The Credentials Committee of the Board shall meet at least ten (10) times per year.CARONDELET HEALTH NETWORK HUMAN SUBJECTS COMMITTEEComposition - The chairperson is appointed by Administration, upon approval of the Chiefs ofStaff of St. Marys Hospital, St. Josephs Hospital and Holy Cross Hospital. The Committee iscomprised of the physicians appointed by the Chairperson.Term of Office - Members are appointed for a two (2) year term and may be reappointed to anadditional two (2) year term. Appointments shall be staggered so that no more than half of themembers will be new in any given year.Quorum - A quorum shall consist of 50% of the voting members of the committee. There shall
be no proxy voting.Duties - The Carondelet Human Subjects Committee shall review proposals of an experimentalnature, protocols, concerns with use of investigational or experimental drugs, and newprocedures still not generally accepted.Meetings - The Committee shall meet as needed at the request of the Chairperson.NOMINATING COMMITTEECarondelet Holy Cross Hospital Organization and Functions ManualNogales, Arizona 7 Composition - The committee shall be appointed by the MedicalExecutive Committee and shallinclude members of the Medical Executive Committee, the current president of the ProfessionalStaff and active members of the staff designated by the MEC.Duties - The Nominating Committee shall provide nominations for staff officers as required.The committee shall seek and welcome the advice of the members of the Professional Staff.Meetings - The committee shall meet as requiredCARONDELET HEALTH NETWORK PHARMACY & THERAPEUTICS COMMITTEEComposition: The committee shall be a multidisciplinary team with at least representatives fromPharmacy, Administration, Nursing, and Members of the Medical Staff.Duties: The committee will establish procedures for implementing the pharmacy formulary whilecontinually overseeing formulary changes/revisions. The committee will address Pharmacyissues as determined appropriate.Meetings: The committee will meet monthly.PROFESSIONAL BEHAVIOR COMMITTEEComposition - Membership is appointed from among members of the medical staff. TheChairperson of the committee will be a member of the Medical Executive Committee, other thanthe Chief of Staff. The committee will consist of three to seven voting members. Voting will berestricted to members of the Carondelet Holy Cross Hospital Professional Staff. Administration
will be represented by the Chief Medical Officer or designee.Term - To be determined by the Chief of Staff.Purpose - The purpose of the Professional Behavior Committee is to review reported instances ofunprofessional behavior by a member of the Professional Staff. Unprofessional behaviorincludes, but is not limited to, verbal or physical threats, demeaning or insulting remarks orcomments, sexual harassment of a physical or verbal nature, and any other activity which isthreatening, intimidating or abusive.Meetings - The committee shall meet as needed at the request of the Chairperson.Functions1. Receive and process all alleged incidents of Professional Staff misconduct.2. Review all alleged incidents of misconduct which have not been resolved by the departmentchairperson and the involved physician.3. Make recommendations to the appropriate department and/or the Medical ExecutiveCommittee on all reviewed incidents of misconduct.Adopted by: Revised:Carondelet Holy Cross Hospital