198832.11

MEDICALSTAFFBYLAWS,POLICIES,ANDRULESANDREGULATIONS

OFEMORYJOHNSCREEKHOSPITAL

POLICYONALLIEDHEALTHPROFESSIONALS

AdoptedbytheMedicalExecutiveCommittee:October14,2017ApprovedbytheBoard:October17,2017

198832.11

a 198832.11

TABLEOFCONTENTS

PAGE1. GENERAL ............................................................................................................................ 1

1.A. DEFINITIONS ........................................................................................................... 11.B. TIMELIMITS............................................................................................................ 11.C. DELEGATIONOFFUNCTIONS.................................................................................. 1

2. SCOPEANDOVERVIEWOFPOLICY ................................................................................... 2

2.A. SCOPEOFPOLICY ................................................................................................... 22.B. CATEGORIESOFALLIEDHEALTHPROFESSIONALS ................................................. 22.C. ADDITIONALPOLICIES ............................................................................................ 2

3. GUIDELINESFORDETERMININGTHENEEDFOR NEWCATEGORIESOFALLIEDHEALTHPROFESSIONALS................................................... 3

3.A. DETERMINATIONOFNEED..................................................................................... 33.B. DEVELOPMENTOFPOLICY ..................................................................................... 4

4. QUALIFICATIONS,CONDITIONS,ANDRESPONSIBILITIES ................................................. 5

4.A. QUALIFICATIONS .................................................................................................... 5

4.A.1. EligibilityCriteria......................................................................................... 54.A.2. WaiverofEligibilityCriteria ........................................................................ 64.A.3. FactorsforEvaluation................................................................................. 74.A.4. NoEntitlementtoMedicalStaffAppointment........................................... 84.A.5. Non-DiscriminationPolicy .......................................................................... 8

4.B. GENERALCONDITIONSOFPRACTICE ..................................................................... 8

4.B.1. AssumptionofDutiesandResponsibilities ................................................ 8

b 198832.11

4.B.2. BurdenofProvidingInformation.............................................................. 11

PAGE

4.C. APPLICATION ........................................................................................................ 11

4.C.1. Information............................................................................................... 114.C.2. GrantofImmunityandAuthorization toObtain/ReleaseInformation ................................................................ 12

5. CREDENTIALINGPROCEDURE.......................................................................................... 15

5.A. PROCESSINGOFINITIALAPPLICATIONTOPRACTICE ........................................... 15

5.A.1. RequestforApplication............................................................................ 155.A.2. InitialReviewofApplication..................................................................... 155.A.3. DepartmentorDivisionChairProcedure ................................................. 155.A.4. CredentialsCommitteeProcedure ........................................................... 165.A.5. MECProcedure......................................................................................... 175.A.6. BoardAction............................................................................................. 18

5.B. CLINICALPRIVILEGES ............................................................................................ 19

5.B.1. General ..................................................................................................... 195.B.2. FPPEtoConfirmCompetence .................................................................. 19

5.C. TEMPORARYCLINICALPRIVILEGES....................................................................... 20

5.C.1. RequestforTemporaryClinicalPrivileges ................................................ 205.C.2. TerminationofTemporaryClinicalPrivileges........................................... 21

5.D. PROCESSINGAPPLICATIONSFORRENEWALTOPRACTICE .................................. 21

5.D.1. SubmissionofApplication ........................................................................ 215.D.2. RenewalProcessforCategoryIandCategoryIIPractitioners ................. 215.D.3. RenewalProcessforCategoryIIIPractitioners......................................... 22

6. CONDITIONSOFPRACTICEAPPLICABLETO CATEGORYIIANDCATEGORYIIIPRACTITIONERS .......................................................... 23

6.A. STANDARDSOFPRACTICEFORTHEUTILIZATION OFCATEGORYIIPRACTITIONERSINTHE

c 198832.11

INPATIENTHOSPITALSETTING ............................................................................. 236.B. OVERSIGHTBYSUPERVISINGPHYSICIAN ............................................................. 24

PAGE

6.C. QUESTIONSREGARDINGAUTHORITYOFACATEGORYII ORCATEGORYIIIPRACTITIONER .......................................................................... 256.D. RESPONSIBILITIESOFSUPERVISINGPHYSICIAN ................................................... 25

7. PEERREVIEWPROCEDURESFORQUESTIONSINVOLVING ALLIEDHEALTHPROFESSIONALS..................................................................................... 27

7.A. COLLEGIALINTERVENTION................................................................................... 277.B. ONGOINGANDFOCUSEDPROFESSIONAL PRACTICEEVALUATIONS ...................................................................................... 277.C. INVESTIGATIONS .................................................................................................. 27

7.C.1. InitiationofInvestigation ......................................................................... 277.C.2. InvestigativeProcedure............................................................................ 287.C.3. Recommendation ..................................................................................... 29

7.D. ADMINISTRATIVESUSPENSION ............................................................................ 297.E. AUTOMATICRELINQUISHMENT/ACTIONS ........................................................... 307.F. ACTIONATANOTHEREMORYHEALTHCAREHOSPITAL ....................................... 317.G. LEAVEOFABSENCE............................................................................................... 31

8. PROCEDURALRIGHTSFORALLIEDHEALTHPROFESSIONALS......................................... 338.A. PROCEDURALRIGHTSFORCATEGORYI ANDCATEGORYIIPRACTITIONERS....................................................................... 33

8.A.1. NoticeofRights ........................................................................................ 338.A.2. HearingCommittee .................................................................................. 338.A.3. HearingProcess ........................................................................................ 348.A.4. HearingCommitteeReport ...................................................................... 35

d 198832.11

8.A.5. AppellateReview...................................................................................... 35

8.B. PROCEDURALRIGHTSFORCATEGORYIIIPRACTITIONERS................................... 36

9. HOSPITALEMPLOYEES..................................................................................................... 37PAGE

10. AMENDMENTS................................................................................................................. 3811. ADOPTION........................................................................................................................ 39APPENDIXA– LICENSEDINDEPENDENTPRACTITIONERS (CATEGORYIPRACTITIONERS)APPENDIXB– ADVANCEDDEPENDENTPRACTITIONERS (CATEGORYIIPRACTITIONERS)APPENDIXC– DEPENDENTPRACTITIONERS (CATEGORYIIIPRACTITIONERS)

198832.111

ARTICLE1

GENERAL1.A.DEFINITIONS

ThedefinitionsthatapplytotermsusedinalltheMedicalStaffdocumentsaresetforthintheMedicalStaffCredentialsPolicydocument.

1.B.TIMELIMITS

TimelimitsreferredtointhisPolicyareadvisoryonlyandarenotmandatory,unlessitisexpresslystatedthataparticularrightiswaivedbyfailingtotakeactionwithinaspecifiedperiod.

1.C.DELEGATIONOFFUNCTIONS

(1) WhenafunctionistobecarriedoutbyamemberofHospitalmanagement,byaMedicalStaffmember,orbyaMedicalStaffcommittee,theindividual,orthecommitteethroughitschair,maydelegateperformanceofthefunctiontooneormoredesignees.

(2) WhenaMedicalStaffmemberisunavailableorunabletoperformanecessary

function,oneormoreoftheMedicalStaffLeadersmayperformthefunctionpersonallyordelegateittoanotherappropriateindividual.

198832.112

ARTICLE2

SCOPEANDOVERVIEWOFPOLICY2.A.SCOPEOFPOLICY

(1) ThisPolicyaddressesthoseAlliedHealthProfessionalswhoarepermittedtoprovidepatientcareservicesintheHospitalandarelistedintheAppendicestothisPolicy.

(2) ThisPolicysetsforththecredentialingprocessandthegeneralpractice

parametersfortheseindividuals,aswellasguidelinesfordeterminingtheneedforadditionalcategoriesofAlliedHealthProfessionalsattheHospital.

2.B.CATEGORIESOFALLIEDHEALTHPROFESSIONALS

(1) OnlythosespecificcategoriesofAlliedHealthProfessionalsthathavebeenapprovedbytheBoardshallbepermittedtopracticeattheHospital.AllAlliedHealthProfessionalswhoareaddressedinthisPolicyshallbeclassifiedaseitherCategoryI,CategoryII,orCategoryIIIpractitioners.

(2) CurrentlistingsofthespecificcategoriesofAlliedHealthProfessionals

functioningintheHospitalasCategoryI,CategoryII,andCategoryIIIpractitionersareattachedtothisPolicyasAppendicesA,B,andC,respectively.TheAppendicesmaybemodifiedorsupplementedbyactionoftheBoard,afterreceivingtherecommendationoftheMEC,withoutthenecessityoffurtheramendmentofthisPolicy.

2.C.ADDITIONALPOLICIES

TheBoardshalladoptaseparatecredentialingprotocolforeachcategoryofAlliedHealthProfessionalthatitapprovestopracticeintheHospital.TheseseparateprotocolsshallsupplementthisPolicyandshalladdressthespecificmatterssetforthinSection3.BofthisPolicy.

198832.113

ARTICLE3

GUIDELINESFORDETERMININGTHENEEDFORNEWCATEGORIESOFALLIEDHEALTHPROFESSIONALS

3.A.DETERMINATIONOFNEED

(1) WheneveranAlliedHealthProfessionalinacategorythathasnotbeenapprovedbytheBoardrequestspermissiontopracticeattheHospital,theMECshallappointanadhoccommitteetoevaluatetheneedforthatparticularcategoryofAlliedHealthProfessionalandtomakearecommendationtotheMECforitsreviewandrecommendationsandthentotheBoardforfinalaction.

(2) Aspartoftheprocessofdeterminingneed,theAlliedHealthProfessionalshall

beinvitedtosubmitinformationaboutthenatureoftheproposedpractice,whyHospitalaccessissought,andthepotentialbenefitstothecommunitybyhavingsuchservicesavailableattheHospital.

(3) Theadhoccommitteemayconsiderthefollowingfactorswhenmakinga

recommendationtotheMECandtheBoardastotheneedfortheservicesofthiscategoryofAlliedHealthProfessionals:

(a) thenatureoftheservicesthatwouldbeoffered;(b) anystatelicenseorregulationwhichoutlinesthescopeofpracticethat

theAlliedHealthProfessionalisauthorizedbylawtoperform;(c) anystate“non-discrimination”or“anywillingprovider”lawsthatwould

applytotheAlliedHealthProfessional;(d) thebusinessandpatientcareobjectivesoftheHospital,includingpatient

convenience;(e) thecommunity’sneedsandwhetherthoseneedsarecurrentlybeingmet

orcouldbebettermetiftheservicesofferedbytheAlliedHealthProfessionalwereprovidedattheHospital;

(f) thetypeoftrainingthatisnecessarytoperformtheservicesthatwould

beofferedandwhetherthereareindividualswithmoretrainingcurrentlyprovidingthoseservices;

(g) theavailabilityofsupplies,equipment,andothernecessaryHospital

resources;

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(h) theneedfor,andavailabilityof,trainedstafftosupporttheservicesthat

wouldbeoffered;and(i) theabilitytoappropriatelysuperviseperformanceandmonitorqualityof

care.

3.B.DEVELOPMENTOFPOLICY

(1) IftheadhoccommitteedeterminesthatthereisaneedfortheparticularcategoryofAlliedHealthProfessionalattheHospital,thecommitteeshallrecommendtotheMECandtheBoardaseparatepolicyforthesepractitionersthataddresses:

(a) anyspecificqualificationsand/ortrainingthattheymustpossessbeyond

thosesetforthinthisPolicy;(b) adetaileddescriptionoftheirauthorizedscopeofpracticeorclinical

privileges;(c) anyspecificconditionsthatapplytotheirfunctioningwithintheHospital

beyondthosesetforthinthisPolicy;and(d) anysupervisionrequirements,ifapplicable.

(2) Indevelopingsuchpolicies,theadhoccommitteeshallconsulttheappropriatedepartmentchair(s)ordivisiondirectorsandconsiderrelevantstatelawandmaycontactapplicableprofessionalsocietiesorassociations.TheadhoccommitteemayalsorecommendtotheBoardthenumberofAlliedHealthProfessionalsthatareneededinaparticularcategory.

198832.115

ARTICLE4

QUALIFICATIONS,CONDITIONS,ANDRESPONSIBILITIES4.A.QUALIFICATIONS4.A.1.EligibilityCriteria:

TobeeligibletoapplyforinitialandcontinuedpermissiontopracticeattheHospital,AlliedHealthProfessionalsmust:(a) haveacurrent,unrestrictedlicense,certification,orregistrationtopracticein

Georgia(ifapplicable)andhaveneverhadalicense,certification,orregistrationtopracticerevokedorsuspendedbyanystatelicensingagency;

(b) whereapplicabletotheirpractice,haveacurrent,unrestrictedDEAregistration;(c) beavailableonacontinuousbasis,eitherpersonallyorbyarrangingappropriate

coverage,torespondtotheneedsofinpatientsandEmergencyDepartmentpatientsinaprompt,efficient,andconscientiousmanner.(“Appropriatecoverage”meanscoveragebyanotherpractitionerwithappropriatespecialty-specificprivilegesasdeterminedbytheCredentialsCommittee.)Compliancewiththiseligibilityrequirementmeansthatthepractitionermustdocumentthatheorsheiswillingandableto:

(1) respondwithin30minutes,viaphone,toallinitialpages;and(2) appearinpersontoattendtoapatientwithin60minutesofbeing

requestedtodoso(ormorequicklybasedupon(i)theacutenatureofthepatient’sconditionor(ii)asrequiredforaparticularspecialtyasrecommendedbytheMECandapprovedbytheBoard);

(d) havecurrent,validprofessionalliabilityinsurancecoverageinsuchformandin

amountssatisfactorytotheBoard;(e) haveneverbeenconvictedof,orenteredapleaofguiltyornocontestto,

Medicare,Medicaid,orotherfederalorstategovernmentalorprivatethird-partypayerfraudorprogramabuse,norhavebeenrequiredtopaycivilmonetarypenaltiesforthesame;

(f) haveneverbeen,andarenotcurrently,excluded,precluded,ordebarredfrom

participationinMedicare,Medicaid,orotherfederalorstategovernmentalhealthcareprogram;

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(g) haveneverhadclinicalprivileges,scopeofpractice,orstatusasaparticipating

providerdenied,revoked,orterminatedbyanyhealthcarefacilityorhealthplanforreasonsrelatedtoclinicalcompetenceorprofessionalconduct;

(h) haveneverrelinquishedorresignedaffiliation,clinicalprivileges,orascopeof

practiceduringaninvestigationorinexchangefornotconductingsuchaninvestigation;

(i) haveneverbeenconvictedof,orenteredapleaofguiltyornocontestto,any

felony;ortoanymisdemeanorrelatingtocontrolledsubstances,illegaldrugs,insuranceorhealthcarefraudorabuse,childabuse,elderabuse,orviolence;

(j) havenotresignedpermissiontopracticewithin365daysprecedingthe

application;(k) havenothadanapplicationseekingpermissiontopracticedeemedtohavebeen

withdrawnorineligibleforcontinuedprocessingduetofailureoftheapplicanttorespondtimelytoarequestforinformation;

(l) havenothadpermissiontopractice,clinicalprivileges,orscopeofpractice

automaticallyrelinquishedatthisoranyaffiliatedHospitalastheresultofanomissionormisrepresentationontheapplicationorsupportingmaterials(unlesswaivedbytheCredentialsCommittee,MECandBoardforgoodcausedemonstratedbytheapplicant);

(m) satisfyalladditionaleligibilityqualificationsrelatingtotheirspecificareaof

practicethatmaybeestablishedbytheHospital;(n) documentcompliancewithallapplicabletrainingand/oreducationalprotocols

thatmaybeadoptedbytheMEC,including,butnotlimitedto,thoseinvolvingelectronicmedicalrecords,patientsafety,andinfectioncontrol;and

(o) ifseekingtopracticeasaCategoryIIorCategoryIIIpractitioner,havea

supervisionagreementand/orcollaborativeagreementwithaphysicianwhoisappointedtotheMedicalStaff(the“SupervisingPhysician”).

4.A.2.WaiverofEligibilityCriteria:

(a) Anyindividualwhodoesnotsatisfyoneormoreofthecriteriaoutlinedabovemayrequestawaiver.

(b) ArequestforawaiverwillbesubmittedtotheCredentialsCommitteefor

consideration.Theindividualrequestingthewaiverbearstheburdenof

198832.117

demonstratingexceptionalcircumstances,andthathisorherqualificationsareequivalentto,orexceed,thecriterioninquestion.

(c) Inreviewingtherequestforawaiver,theCredentialsCommitteemayconsider

thespecificqualificationsoftheindividualinquestion,inputfromtherelevantdepartmentchair,andthebestinterestsoftheHospitalandthecommunitiesitserves.Additionally,theCredentialsCommitteemay,initsdiscretion,considertheapplicationformandotherinformationsuppliedbytheapplicant.TheCredentialsCommittee’srecommendationwillbeforwardedtotheMEC.Anyrecommendationtograntawaivermustincludethespecificbasisfortherecommendation.

(d) TheMECwillreviewtherecommendationoftheCredentialsCommitteeand

makearecommendationtotheBoardregardingwhethertograntordenytherequestforawaiver.Anyrecommendationtograntawaivermustincludethespecificbasisfortherecommendation.

(e) NoindividualisentitledtoawaiverortoahearingiftheMECrecommends

and/ortheBoarddeterminesnottograntawaiver.(f) Adeterminationthatanindividualisnotentitledtoawaiverisnota“denial”of

permissiontopractice,clinicalprivileges,orscopeofpractice.(g) Thegrantingofawaiverinaparticularcaseisnotintendedtosetaprecedent

foranyotherindividualorgroupofindividuals.(h) Anapplicationformthatdoesnotsatisfyaneligibilitycriterionwillnotbe

processeduntiltheBoardhasdeterminedthatawaivershouldbegranted.

4.A.3.FactorsforEvaluation:

ThesixACGMEgeneralcompetencies(patientcare,medicalknowledge,professionalism,system-basedpractice,practice-basedlearning,andinterpersonalcommunications)willbeevaluatedasapplicable,aspartofarequestforpermissiontopractice,asreflectedinthefollowingfactors:(a) relevanttraining,experience,anddemonstratedcurrentcompetence,including

medical/clinicalknowledge,technicalandclinicalskills,clinicaljudgment,andanunderstandingofthecontextsandsystemswithinwhichcareisprovided;

(b) adherencetotheethicsoftheirprofession,continuousprofessional

development,anunderstandingofandsensitivitytodiversity,andresponsibleattitudetowardpatients,families,andtheirprofession;

198832.118

(c) abilitytosafelyandcompetentlyperformtheclinicalprivilegesorscopeofpracticerequested;

(d) goodreputationandcharacter;(e) abilitytoworkharmoniouslywithothers,including,butnotlimitedto,

interpersonalandcommunicationskillssufficienttoenablethemtomaintainprofessionalrelationshipswithpatients,families,andothermembersofhealthcareteams;and

(f) recognitionoftheimportanceof,andwillingnesstosupport,theHospital’sand

MedicalStaff’scommitmenttoqualitycareandarecognitionthatinterpersonalskillsandcollegialityareessentialtotheprovisionofqualitypatientcare.

4.A.4.NoEntitlementtoMedicalStaffAppointment:

AlliedHealthProfessionalsshallnotbeappointedtotheMedicalStafforentitledtotherights,privileges,and/orprerogativesofMedicalStaffappointment.

4.A.5.Non-DiscriminationPolicy:

NoindividualshallbedeniedpermissiontopracticeattheHospitalonthebasisofgender,race,creed,ornationalorigin.

4.B.GENERALCONDITIONSOFPRACTICE4.B.1.AssumptionofDutiesandResponsibilities:

AsaconditionofpermissiontopracticeattheHospital,allAlliedHealthProfessionals(andtheirSupervisingPhysicians,asapplicable)shallspecificallyagreetothefollowing:(a) toattendandparticipateinanappropriateorientationprogramattheHospital

beforeactivelyseeingortreatingpatients;(b) toprovidecontinuousandtimelyqualitycaretoallpatientsintheHospitalfor

whomtheindividualhasresponsibility;(c) toabidebyallbylaws,rulesandregulations,andpoliciesoftheMedicalStaffand

Hospital;(d) toacceptcommitteeassignmentsandsuchotherreasonabledutiesand

responsibilitiesasmaybeassigned;

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(e) tomaintainacurrente-mailaddresswiththeMedicalStaffOffice,whichwillbetheofficialmechanismusedtocommunicateallinformationtothepractitionerotherthanpeerreviewinformationpertainingtothepractitionerand/orprotectedhealthinformationofpatients(thise-mailaddresswillnotbesharedoutsideofEmoryHealthcare;also,thisprovision(e)shallnotbeinterpretedtolimittheabilityofMedicalStaffLeaderstoutilizeconfidentiale-mailtocommunicateaboutongoingpeerreviewmattersamongandbetweenthemselves);

(f) tonotifytheMedicalStaffOffice,inwriting,ofanychangeinthepractitioner’s

statusoranychangeintheinformationprovidedonthepractitioner’sapplicationform.Thisinformationwillbeprovidedwithorwithoutrequest,atthetimethechangeoccurs,andwillinclude,butnotbelimitedto:

• changesinlicensureorcertificationstatus,DEAcontrolledsubstance

authorization,orprofessionalliabilityinsurancecoverage;• thefilingofaprofessionalliabilitylawsuitagainstthepractitioner;• changesinthepractitioner’sstatusatanyotherhospitalorhealthcare

entityasaresultofpeerreviewactivitiesorinordertoavoidinitiationofpeerreviewactivities;

• knowledgeofacriminalinvestigationinvolvingthepractitioner,arrest,

charge,indictment,conviction,orapleaofguiltyornocontestinanycriminalmatterotherthanamisdemeanortrafficcitation;

• exclusionorpreclusionfromparticipationinMedicare/Medicaidorany

sanctionsimposed;• anychangesinthepractitioner’sabilitytosafelyandcompetently

exerciseclinicalprivileges,orscopeofpractice,ortoperformthedutiesandresponsibilitiesofpermissiontopracticebecauseofhealthstatusissues,including,butnotlimitedto,impairmentduetoaddiction,alcoholuse,orothersimilarissue(allofwhichshallbereferredforreviewunderthepractitionerhealthpolicy);and

• anychargeof,orarrestfor,drivingundertheinfluence(“DUI”)(AnyDUI

incidentwillbereviewedbytheChiefofStaffandtheCMOsothattheymayunderstandthecircumstancessurroundingit.Iftheyhaveanyconcernsafterdoingso,theywillforwardthematterforfurtherreviewunderthepractitionerhealthpolicyorthisAHPPolicy.);

198832.1110

(g) toimmediatelysubmittoanappropriateevaluationwhichmayincludediagnostictesting(suchasbloodand/orurinetest)ortoacompletephysical,mental,and/orbehavioralevaluation,ifatleasttwoMedicalStaffLeaders(oroneMedicalStaffLeaderandonememberoftheAdministrativeteam)areconcernedwiththeindividual’sabilitytosafelyandcompetentlycareforpatientsandrequestsuchtestingand/orevaluation.Thehealthcareprofessional(s)toperformthetestingand/orevaluationswillbedeterminedbytheMedicalStaffLeaders,andtheAlliedHealthProfessionalwillexecuteallappropriatereleasestopermitthesharingofinformationwiththeMedicalStaffLeaders;

(h) toappearforpersonalorphoneinterviewsinregardtoanapplicationfor

permissiontopracticeasmayberequested;(i) torefrainfromillegalfeesplittingorotherillegalinducementsrelatingtopatient

referral;(j) torefrainfromassumingresponsibilityfordiagnosisorcareofhospitalized

patientsforwhichheorsheisnotqualifiedorwithoutadequatesupervision;(k) torefrainfromdeceivingpatientsastotheindividual’sstatusasanAlliedHealth

ProfessionalandtoalwayswearproperHospitalidentificationoftheirnameandstatus;

(l) toseekconsultationwhenappropriate;(m) toparticipateintheperformanceimprovementandqualitymonitoringactivities

oftheHospital;(n) tocomplete,inatimelyandlegiblemanner,themedicalandotherrequired

records,containingallinformationrequiredbytheHospital;(o) tocooperatewithallutilizationoversightactivities;(p) toperformallservicesandconducthimself/herselfatalltimesinacooperative

andprofessionalmanner;(q) tosatisfyapplicablecontinuingeducationrequirements(e.g.,statelicensure;

certification;privilegeeligibilitycriteria);(r) topayanyapplicableapplicationfees,assessments,and/orfines;

198832.1111

(s) tostrictlycomplywiththestandardsofpracticeapplicabletothefunctioningofCategoryIIpractitionersintheinpatienthospitalsetting,assetforthinSection6.AofthisPolicy;

(t) toconstructivelyparticipateinthedevelopment,review,andrevisionofclinical

practiceandevidence-basedmedicineprotocolsandpathwayspertinenttohisorherspecialty(includingthoserelatedtonationalpatientsafetyinitiativesandcoremeasures),andtocomplywithallsuchprotocolsandpathways;

(u) tocomplywithallapplicabletrainingand/oreducationalprotocolsthatmaybe

adoptedbytheMEC,including,butnotlimitedto,thoseinvolvingelectronicmedicalrecords,patientsafety,andinfectioncontrol;and

(v) that,ifthereisanymisstatementin,oromissionfrom,theapplication,the

Hospitalmaystopprocessingtheapplication(or,ifpermissiontopracticehasbeengrantedpriortothediscoveryofamisstatementoromission,thepermissionmaybedeemedtobeautomaticallyrelinquished).Ineithersituation,thereshallbenoentitlementtotheproceduralrightsprovidedinthisPolicy.TheindividualwillbeinformedinwritingofthenatureofthemisstatementoromissionandpermittedtoprovideawrittenresponsefortheCredentialsCommittee’sconsideration.

4.B.2.BurdenofProvidingInformation:

(a) AlliedHealthProfessionalsseekingpermissiontopracticeorrenewalofpermissiontopracticeshallhavetheburdenofproducinginformationdeemedadequatebytheHospitalforaproperevaluationofcurrentcompetence,character,ethics,andotherqualifications,andforresolvinganydoubtsaboutsuchqualifications.

(b) AlliedHealthProfessionalsseekingpermissionorrenewalofpermissionto

practicehavetheburdenofprovidingevidencethatallthestatementsmadeandinformationgivenontheapplicationareaccurate.

(c) Anapplicationshallbecompletewhenallquestionsontheapplicationform

havebeenanswered,allsupportingdocumentationhasbeensupplied,andallinformationhasbeenverifiedfromprimarysources.Anapplicationshallbecomeincompleteiftheneedarisesfornew,additional,orclarifyinginformationatanytimeduringthecredentialingprocess.Anyapplicationthatcontinuestobeincomplete30daysaftertheindividualhasbeennotifiedoftheadditionalinformationrequiredshallbedeemedtobewithdrawn.

198832.1112

(d) Itistheresponsibilityoftheindividualseekingpermissiontopracticeorrenewalofpermissiontopracticetoprovideacompleteapplication,includingadequateresponsesfromreferences.Anincompleteapplicationwillnotbeprocessed.

4.C.APPLICATION4.C.1.Information:

(a) TheapplicationformsforbothinitialandrenewedpermissiontopracticeasanAlliedHealthProfessionalshallrequiredetailedinformationconcerningtheapplicant’sprofessionalqualifications.TheAlliedHealthProfessionalapplicationformsexistingnowandasmayberevisedareincorporatedbyreferenceandmadeapartofthisPolicy.

(b) Inadditiontootherinformation,theapplicationsshallseekthefollowing:

(1) informationastowhethertheapplicant’sclinicalprivileges,scopeofpractice,permissiontopractice,and/oraffiliationhaseverbeenvoluntarilyorinvoluntarilyrelinquished,withdrawn,denied,revoked,suspended,reduced,subjectedtoprobationaryorotherconditions,limited,terminated,ornotrenewedatanyhospital,healthcarefacility,orotherorganization,oriscurrentlybeinginvestigatedorchallenged;

(2) informationastowhethertheapplicant’slicenseorcertificationto

practiceanyprofessioninanystate,DEAregistration,oranystatecontrolledsubstancelicense(ifapplicable)isorhaseverbeenvoluntarilyorinvoluntarilyrelinquished,suspended,modified,terminated,restricted,oriscurrentlybeinginvestigatedorchallenged;

(3) informationconcerningtheapplicant’sprofessionalliabilitylitigation

experienceand/oranyprofessionalmisconductproceedingsinvolvingtheapplicant,inthisstateoranyotherstate,whethersuchproceedingsareclosedorstillpending,includingthesubstanceoftheallegationsofsuchproceedingsoractions,thesubstanceofthefindingsofsuchproceedingsoractions,theultimatedispositionofanysuchproceedingsoractionsthathavebeenclosed,andanyadditionalinformationconcerningsuchproceedingsoractionsastheCredentialsCommittee,MECorBoardmaydeemappropriate;

(4) currentinformationregardingtheapplicant’sabilitytoperform,safely

andcompetently,theclinicalprivilegesorscopeofpracticerequestedandthedutiesofAlliedHealthProfessionals;and

(5) acopyofgovernment-issuedphotoidentification.

198832.1113

(c) Theapplicantshallsigntheapplicationandcertifythatheorsheisableto

performtheclinicalprivilegesorscopeofpracticerequestedandtheresponsibilitiesofAlliedHealthProfessionals.

4.C.2.GrantofImmunityandAuthorizationtoObtain/ReleaseInformation:

Byrequestinganapplicationand/orapplyingforpermissiontopractice,theindividualexpresslyacceptsthefollowingconditions:(a) Immunity:

Tothefullestextentpermittedbylaw,theindividualreleasesfromanyandallliability,extendsimmunityto,andagreesnottosuetheHospitalortheBoard,anymemberoftheMedicalStaffortheBoard,theirauthorizedrepresentatives,andthirdpartiesforanymatterrelatingtopermissiontopractice,clinicalprivileges,scopeofpractice,ortheindividual’squalificationsforthesame.Thisimmunitycoversanyactions,recommendations,reports,statements,communications,and/ordisclosuresinvolvingtheindividualthataremade,taken,orreceivedbytheHospital,itsauthorizedagents,orthirdpartiesinthecourseofcredentialingandpeerreviewactivities.

(b) AuthorizationtoObtainInformationfromThirdParties:

TheindividualspecificallyauthorizestheHospital,MedicalStaffLeaders,andtheirauthorizedrepresentatives(1)toconsultwithanythirdpartywhomayhaveinformationbearingontheindividual’sprofessionalqualifications,credentials,clinicalcompetence,character,abilitytoperformsafelyandcompetently,ethics,behavior,oranyothermatterreasonablyhavingabearingonhisorherqualificationsforinitialandcontinuedpermissiontopracticeattheHospital,and(2)toobtainanyandallcommunications,reports,records,statements,documents,recommendations,ordisclosuresofthirdpartiesthatmayberelevanttosuchquestions.TheindividualalsospecificallyauthorizesthirdpartiestoreleasethisinformationtotheHospitalanditsauthorizedrepresentativesuponrequest.Further,theindividualagreestosignnecessaryconsentformstopermitaconsumerreportingagencytoconductacriminalbackgroundcheckontheindividualandreporttheresultstotheHospital.

(c) AuthorizationtoReleaseInformationtoThirdParties:

TheindividualalsoauthorizesHospitalrepresentativestoreleaseinformationtootherhospitals,healthcarefacilities,managedcareorganizations,governmentregulatoryandlicensureboardsoragencies,andtheiragentswheninformationisrequestedinordertoevaluatehisorherprofessionalqualificationsfor

198832.1114

permissiontopractice,clinicalprivileges,scopeofpractice,and/orparticipationattherequestingorganization/facility,andanylicensureorregulatorymatter.

(d) AuthorizationtoShareInformationWithinEmoryHealthcare:

TheindividualspecificallyauthorizesalloftheHospitalswithinEmoryHealthcaretosharecredentialingandpeerreviewinformationpertainingtotheindividual’sclinicalcompetenceand/orprofessionalconduct.Thisinformationmaybesharedatinitialappointment,reappointment,and/oranyothertimeduringtheindividual’sappointment.

(e) ProceduralRights:

TheAlliedHealthProfessionalagreesthattheproceduralrightssetforthinthisPolicyarethesoleandexclusiveremedywithrespecttoanyprofessionalreviewactiontakenbytheHospital.

(f) LegalActions:

If,despitethisSection,anindividualinstituteslegalactionchallenginganycredentialing,privileging,peerreview,orotheractionaffectingthepermissiontopracticeanddoesnotprevail,heorshewillreimbursetheHospitalandanymemberoftheMedicalStafforBoardinvolvedintheactionforallcostsincurredindefendingsuchlegalaction,includingreasonableattorney’sfeesandlostrevenues.

(g) ScopeofSection:

AlloftheprovisionsinthisSectionareapplicableinthefollowingsituations:(1) whetherornotpermissiontopractice,clinicalprivileges,orscopeof

practiceisgranted;(2) throughoutthetermofanyaffiliationwiththeHospitalandthereafter;(3) shouldpermissiontopractice,clinicalprivileges,orscopeofpracticebe

denied,revoked,reduced,restricted,suspended,and/orotherwiseaffectedaspartoftheHospital’sprofessionalreviewactivities;and

(4) asapplicable,toanythird-partyinquiriesreceivedaftertheindividual

leavestheHospitalabouthisorhertenureasamemberoftheAlliedHealthProfessionalStaff.

198832.1115

198832.1116

ARTICLE5

CREDENTIALINGPROCEDURE5.A.PROCESSINGOFINITIALAPPLICATIONTOPRACTICE5.A.1.RequestforApplication:

(a) AnyindividualrequestinganapplicationforpermissiontopracticeattheHospitalshallbesent(i)aletterthatoutlinestheeligibilitycriteriaforpermissiontopracticeasoutlinedinthisPolicy,(ii)anyeligibilityrequirementsthatrelatetotheAlliedHealthProfessional’sspecificareaofpractice,and(iii)theapplicationform.

(b) AnAlliedHealthProfessionalwhoisinacategoryofpractitionersthathasnot

beenapprovedbytheBoardtopracticeattheHospitalshallbeineligibletoreceiveanapplication.AdeterminationofineligibilitydoesnotentitleanAlliedHealthProfessionaltotheproceduralrightsoutlinedinArticle8ofthisPolicy.

5.A.2.InitialReviewofApplication:

(a) Acompletedapplication,withcopiesofallrequireddocuments,mustbesubmittedtotheMedicalStaffOfficewithin30daysafterreceiptoftheapplicationiftheAlliedHealthProfessionaldesiresfurtherconsideration.Theapplicationmustbeaccompaniedbytheapplicationprocessingfee,ifapplicable.

(b) Asapreliminarystep,theapplicationwillbereviewedbytheMedicalStaffOffice

(andCMO,ifnecessary)todeterminethatallquestionshavebeenansweredandthattheindividualsatisfiesallthresholdcriteria.IndividualswhofailtoreturncompletedapplicationsorfailtomeettheeligibilitycriteriasetforthinSection4.A.1ofthisPolicywillbenotifiedthattheyarenoteligibleforpermissiontopracticeattheHospitalandthattheirapplicationwillnotbeprocessed.AdeterminationofineligibilitydoesnotentitleanAlliedHealthProfessionaltotheproceduralrightsoutlinedinArticle8ofthisPolicy.

(c) TheMedicalStaffOfficeshalloverseetheprocessofgatheringandverifying

relevantinformationandconfirmingthatallreferencesandotherinformationormaterialsdeemedpertinenthavebeenreceived.IfanapplicationiscompleteinaccordancewithSection4.B.2(c),itshallbeprovided,alongwithallsupportingdocumentation,totheapplicabledepartmentchair.

198832.1117

5.A.3.DepartmentorDivisionChairProcedure:

(a) TheMedicalStaffOfficeshallprovidethecompleteapplicationandallsupportingmaterialstotheappropriatedepartmentordivisionchairortheindividualtowhomthedepartmentordivisionchairhasassignedthisresponsibility.Eachchairshallprepareareport(onaformprovidedbytheMedicalStaffOffice)regardingwhethertheapplicanthassatisfiedallofthequalificationsforpermissiontopracticeandtheclinicalprivilegesorscopeofpracticerequested.

(b) Aspartoftheprocessofmakingthisreport,thedepartmentordivisionchairhas

therighttomeetwiththeapplicantandtheSupervisingPhysician(ifapplicable)todiscussanyaspectoftheapplication,qualifications,andrequestedclinicalprivilegesorscopeofpractice.Thedepartmentordivisionchairmayalsoconferwithexpertswithinthedepartmentandoutsideofthedepartmentinpreparingthereport(e.g.,otherphysicians,relevantHospitaldepartmentheads,nursemanagers).

(c) Intheeventthatthedepartmentordivisionchairisunavailableorunwillingto

prepareawrittenreport,theChairoftheCredentialsCommitteeortheChiefofStaffshallappointanindividualtopreparethereport.

(d) Thedepartmentordivisionchairshallbeavailabletoansweranyquestionsthat

mayberaisedwithrespecttothatchair’sreportandfindings.

5.A.4.CredentialsCommitteeProcedure:

(a) TheCredentialsCommitteeshallreviewthereportfromtheappropriatedepartmentordivisionchairandtheinformationcontainedinreferencesgivenbytheapplicantandfromotheravailablesources.TheCredentialsCommitteeshallexamineevidenceoftheapplicant’scharacter,professionalcompetence,qualifications,priorbehavior,andethicalstandingandshalldeterminewhethertheapplicanthasestablishedandsatisfiedallofthenecessaryqualificationsfortheclinicalprivilegesorscopeofpracticerequested.

(b) TheCredentialsCommitteemayusetheexpertiseofanyindividualonthe

MedicalStafforintheHospital,oranoutsideconsultant,ifadditionalinformationisrequiredregardingtheapplicant’squalifications.TheCredentialsCommitteemayalsomeetwiththeapplicantand,whenapplicable,theSupervisingPhysician.Theappropriatedepartmentchairmayparticipateinthisinterview.

(c) Afterdeterminingthatanapplicantisotherwisequalifiedforpermissionto

practiceandtheclinicalprivilegesorscopeofpracticerequested,theCredentials

198832.1118

Committeeshallreviewtheapplicant’sHealthStatusConfirmationFormtodetermineifthereisanyquestionabouttheapplicant’sabilitytoperformtheprivilegesorscopeofpracticerequestedandtheresponsibilitiesofpermissiontopractice.Ifso,theCredentialsCommitteemayrequiretheapplicanttoundergoaphysical,mental,and/orbehavioralexaminationbyaphysician(s)satisfactorytotheCredentialsCommittee.TheresultsofthisexaminationshallbemadeavailabletotheCommitteeforitsconsideration.FailureofanapplicanttoundergoanexaminationwithinareasonabletimeafterbeingrequestedtodosoinwritingbytheCredentialsCommitteeshallbeconsideredanincompleteapplicationandallprocessingoftheapplicationshallcease.Thecostofthehealthassessmentwillbebornebytheapplicant.

(d) TheCredentialsCommitteemayrecommendtheimpositionofspecific

conditions.Theseconditionsmayrelatetobehavior(e.g.,personalcodeofconduct)ortoclinicalissues(e.g.,generalconsultationrequirements,appropriatedocumentationrequirements,proctoring,completionofeducationrequirements).TheCredentialsCommitteemayalsorecommendthatpermissiontopracticebegrantedforaperiodoflessthantwoyearsinordertopermitclosermonitoringofanindividual’scompliancewithanyconditions.

(e) TheCredentialsCommittee’srecommendationwillbeforwardedtotheMEC.

5.A.5.MECProcedure:

(a) Atitsnextmeeting,afterreceiptofthewrittenfindingsandrecommendationoftheCredentialsCommittee,theMECshall:

(1) adoptthefindingsandrecommendationsoftheCredentialsCommittee

asitsown;or(2) referthematterbacktotheCredentialsCommitteeforfurther

considerationandresponsestospecificquestionsraisedbytheMEC;or(3) setforthinitsreportandrecommendationclearandconvincingreasons,

alongwithsupportinginformation,foritsdisagreementwiththeCredentialsCommittee’srecommendation.

(b) IftheMEC’srecommendationisfavorabletotheapplicant,theCommitteeshall

forwarditsrecommendationtotheBoard,throughtheCEO,includingthefindingsandrecommendationofthedepartmentchairandtheCredentialsCommittee.TheMEC’srecommendationmustspecificallyaddresstheclinicalprivilegesorscopeofpracticerequestedbytheapplicant,whichmaybequalifiedbyanyprobationaryorotherconditionsorrestrictionsrelatingtosuchclinicalprivilegesorscopeofpractice.

198832.1119

(c) IftheMEC’srecommendationisunfavorableandwouldentitletheapplicantto

theproceduralrightssetforthinthisPolicy,theMECshallforwarditsrecommendationtotheCEO,whoshallnotifytheapplicantoftherecommendationandhisorherproceduralrights.TheCEOshallthenholdtheMEC’srecommendationuntilaftertheindividualhascompletedorwaivedtheproceduralrightsoutlinedinthisPolicy.

5.A.6.BoardAction:

(a) TheBoardmaydelegatetoacommittee,consistingofatleasttwoBoardmembers,actiononapplicationsiftherehasbeenafavorablerecommendationfromtheCredentialsCommitteeandtheMEC(ortheirdesignees)andthereisnoevidenceofanyofthefollowing:

(1) acurrentorpreviouslysuccessfulchallengetoanylicense,certification,

orregistration;(2) aninvoluntarytermination,limitation,reduction,denial,orlossof

permissiontopractice,clinicalprivileges,orscopeofpracticeatanyotherhospitalorotherentity;or

(3) anunusualpatternof,oranexcessivenumberof,professionalliability

actionsresultinginafinaljudgmentagainsttheapplicant.AnydecisionreachedbytheBoardcommitteetoappointandgranttheclinicalprivilegesorscopeofpracticerequestedshallbeeffectiveimmediatelyandshallbeforwardedtotheBoardforratificationatitsnextmeeting.

(b) WhentherehasbeennodelegationtoaBoardcommittee,uponreceiptofarecommendationthattheapplicantbegrantedpermissiontopracticeandclinicalprivilegesorscopeofpracticerequested,theBoardmay:

(1) granttheapplicantpermissiontopracticeandclinicalprivilegesorscope

ofpracticeasrecommended;or(2) referthematterbacktotheCredentialsCommitteeorMECortoanother

sourceinsideoroutsidetheHospitalforadditionalresearchorinformation;or

(3) rejectormodifytherecommendation.

(c) IftheBoarddeterminestorejectafavorablerecommendation,itshouldfirstdiscussthematterwiththeChairoftheCredentialsCommitteeandtheChiefof

198832.1120

Staff.IftheBoard’sdeterminationremainsunfavorabletotheapplicant,theCEOshallpromptlysendspecialnoticetotheapplicantthattheapplicantisentitledtorequesttheproceduralrightsasoutlinedinthisPolicy.

(d) AnyfinaldecisionbytheBoardtogrant,deny,revise,orrevokepermissionto

practiceand/orclinicalprivilegesorscopeofpracticewillbedisseminatedtoappropriateindividualsand,asrequired,reportedtoappropriateentities.

5.B.CLINICALPRIVILEGES5.B.1.General:

TheclinicalprivilegesrecommendedtotheBoardforCategoryIandCategoryIIpractitionerswillbebaseduponconsiderationofthefollowingfactors:(a) education,relevanttraining,experience,anddemonstratedcurrentcompetence,

includingmedical/clinicalknowledge,technicalandclinicalskills,clinicaljudgment,interpersonalandcommunicationskills,andprofessionalismwithpatients,familiesandothermembersofthehealthcareteamandpeerevaluationsrelatingtothesame;

(b) abilitytoperformtheprivilegesrequestedcompetentlyandsafely;(c) informationresultingfromongoingandfocusedprofessionalpracticeevaluation

andperformanceimprovementactivities,asapplicable;(d) adequateprofessionalliabilityinsurancecoveragefortheclinicalprivileges

requested;(e) theHospital’savailableresourcesandpersonnel;(f) anypreviouslysuccessfulorcurrentlypendingchallengestoanylicensureor

registration,orthevoluntaryorinvoluntaryrelinquishmentofsuchlicensureorregistration;

(g) anyinformationconcerningprofessionalreviewactionsorvoluntaryor

involuntarytermination,limitation,reduction,orlossofappointmentorclinicalprivilegesatanotherhospital;

(h) practitioner-specificdataascomparedtoaggregatedata,whenavailable;(i) morbidityandmortalitydata,whenavailable;and

198832.1121

(j) professionalliabilityactions,especiallyanysuchactionsthatreflectanunusualpatternorexcessivenumberofactions.

5.B.2.FPPEtoConfirmCompetence:

AllnewclinicalprivilegesforCategoryIandCategoryIIpractitioners,regardlessofwhentheyaregranted(initialpermissiontopractice,renewalofpermissiontopractice,oratanytimeinbetween),willbesubjecttofocusedprofessionalpracticeevaluation(“FPPE”)inordertoconfirmcompetence.TheFPPEprocessforthesesituationsisoutlinedinthePolicyRegardingFPPEtoConfirmPractitionerCompetence.

5.C.TEMPORARYCLINICALPRIVILEGES5.C.1.RequestforTemporaryClinicalPrivileges:

(a) Applicants:TemporaryprivilegesforanapplicantforinitialpermissiontopracticemaybegrantedbytheCEO,uponrecommendationoftheChiefofStaffandthedepartmentchair,whenaCategoryIorCategoryIIpractitionerhassubmittedacompletedapplicationandtheapplicationispendingreviewbytheCredentialsCommittee,theMEC,andtheBoard.Priortotemporaryprivilegesbeinggrantedinthissituation,thecredentialingprocessmustbecomplete,including,whereapplicable,verificationofcurrentlicensure,relevanttrainingorexperience,currentcompetence,abilitytoexercisetheprivilegesrequested,andcompliancewithcriteria,andconsiderationofinformationfromtheNationalPractitionerDataBankandfromacriminalbackgroundcheck.Inordertobeeligiblefortemporaryprivileges,anindividualmustdemonstratethattherearenocurrentorpreviouslysuccessfulchallengestohisorherlicensureorregistrationandthatheorshehasnotbeensubjecttoinvoluntaryterminationofmembership,orinvoluntarylimitation,reduction,denial,orlossofclinicalprivilegesatanotherhealthcarefacility.

(b) LocumTenens:TheCEO,uponrecommendationoftheChiefofStaffandthe

applicabledepartmentchair,maygranttemporaryprivilegestoaCategoryIorCategoryIIpractitionerservingasalocumtenensforanindividualwhoisonvacation,attendinganeducationalseminar,orill,and/orotherwiseneedscoverageassistanceforaperiodoftime.Priortotemporaryprivilegesbeinggrantedinthissituation,theverificationprocessmustbecomplete,including,whereapplicable,verificationofcurrentlicensure,relevanttrainingorexperience,currentcompetence,abilitytoexercisetheprivilegesrequested,andcompliancewithcriteria,andconsiderationofinformationfromtheNationalPractitionerDataBankandfromacriminalbackgroundcheck.Inordertobeeligiblefortemporaryprivileges,anindividualmustdemonstratethattherearenocurrentorpreviouslysuccessfulchallengestohisorherlicensureorregistrationandthatheorshehasnotbeensubjecttoinvoluntarytermination

198832.1122

ofmembership,orinvoluntarylimitation,reduction,denial,orlossofclinicalprivilegesatanotherhealthcarefacility.

(c) Priortotemporaryprivilegesbeinggranted,theindividualmustagreeinwriting

tobeboundbyallapplicablebylaws,rulesandregulations,andpolicies,procedures,andprotocols.

(d) Temporaryprivilegeswillbegrantedforaspecificperiodoftime,nottoexceed

120days,andwillexpireattheendofthetimeperiodforwhichtheyaregranted.

5.C.2.TerminationofTemporaryClinicalPrivileges:

(a) TheCEOmay,atanytimeafterconsultingwiththeChiefofStaff,theChairoftheCredentialsCommittee,thedepartmentchair,ortheCMO,terminatetemporaryprivilegesforanyreason.

(b) Thegrantingoftemporaryprivilegesisacourtesy.Neitherthedenialnor

terminationoftemporaryprivilegeswillentitletheindividualtotheproceduralrightssetforthinArticle8.

5.D.PROCESSINGAPPLICATIONSFORRENEWALTOPRACTICE5.D.1.SubmissionofApplication:

(a) Thegrantofpermissiontopracticewillbeforaperiodnottoexceedtwoyears.Arequesttorenewclinicalprivilegesorscopeofpracticewillbeconsideredonlyuponsubmissionofacompletedrenewalapplication.

(b) AtleastfourmonthspriortothedateofexpirationofanAlliedHealth

Professional’sclinicalprivilegesorscopeofpractice,theMedicalStaffOfficewillnotifytheindividualofthedateofexpirationandprovidetheindividualwitharenewalapplication.AcompletedrenewalapplicationmustbereturnedtotheMedicalStaffOfficewithin30days.

(c) Failuretosubmitacompleteapplicationatleasttwomonthspriortothe

expirationoftheindividual’scurrenttermwillresultinautomaticexpirationofclinicalprivilegesorscopeofpracticeattheendofthethencurrentterm,unlesstheapplicationcanstillbeprocessedinthenormalcourse,withoutextraordinaryeffortonthepartoftheMedicalStaffOfficeandtheMedicalStaffLeaders.

198832.1123

(d) Onceanapplicationforrenewalofclinicalprivilegesorscopeofpracticehasbeencompletedandsubmitted,itwillbeevaluatedfollowingthesameproceduresoutlinedinthisPolicyregardinginitialapplications.

5.D.2.RenewalProcessforCategoryIandCategoryIIPractitioners:

(a) Theprocedurespertainingtoaninitialrequestforclinicalprivileges,includingeligibilitycriteriaandfactorsforevaluation,willbeapplicableinprocessingrequestsforrenewalforthesepractitioners.

(b) Aspartoftheprocessforrenewalofclinicalprivileges,thefollowingfactorswill

beconsidered:

(1) anassessmentpreparedbytheapplicabledepartmentchair;(2) anassessmentpreparedbyapeer,ifpossible;(3) resultsoftheHospital’sperformanceimprovementandongoingand

focusedprofessionalpracticeevaluationactivities,takingintoconsideration,whenapplicable,practitioner-specificinformationcomparedtoaggregateinformationconcerningotherindividualsinthesameorsimilarspecialty(providedthat,otherpractitionerswillnotbeidentified);

(4) resolutionofanyverifiedcomplaintsreceivedfrompatientsorstaff;and(5) anyfocusedprofessionalpracticeevaluations.

(c) ForCategoryIIpractitioners,thefollowinginformationmayalsobeconsidered:

(1) anassessmentpreparedbytheSupervisingPhysician(s);or(2) anassessmentpreparedbytheapplicableHospitalsupervisor(i.e.,OR

Supervisor,NursingSupervisor).

5.D.3.RenewalProcessforCategoryIIIPractitioners:

(a) Theprocedurespertainingtoaninitialrequestforascopeofpractice,includingeligibilitycriteriaandfactorsforevaluation,willbeapplicableinprocessingrequestsforrenewalforthesepractitioners.

(b) Aspartoftheprocessforrenewalofscopeofpractice,thefollowingfactorswill

beconsidered:

198832.1124

(1) acompetencyassessmentoftheindividualperformedbytheSupervisingPhysician(s)and/ortheapplicableHospitaldepartmentheads(i.e.,ORSupervisor,NursingSupervisor);and

(2) resolutionofanyvalidatedcomplaintsreceivedfrompatientsorstaff.

198832.1125

ARTICLE6

CONDITIONSOFPRACTICEAPPLICABLETOCATEGORYIIANDCATEGORYIIIPRACTITIONERS

6.A.STANDARDSOFPRACTICEFORTHEUTILIZATIONOFCATEGORYII PRACTITIONERSINTHEINPATIENTHOSPITALSETTING

(1) CategoryIIpractitionersarenotpermittedtofunctionindependentlyintheinpatientHospitalsetting.AsaconditionofbeinggrantedpermissiontopracticeattheHospital,allCategoryIIpractitionersspecificallyagreetoabidebythestandardsofpracticesetforthinthisSection.Inaddition,asaconditionofbeingpermittedtoutilizetheservicesofCategoryIIpractitionersintheHospital,allMedicalStaffmemberswhoserveasSupervisingPhysicianstosuchindividualsalsospecificallyagreetoabidebythestandardssetforthinthisSection.

(2) ThefollowingstandardsofpracticeapplytothefunctioningofCategoryII

practitionersintheinpatientHospitalsetting:

(a) AdmittingPrivileges.CategoryIIpractitionersarenotgrantedinpatientadmittingprivilegesandthereforemaynotadmitpatientsindependentoftheSupervisingPhysician.

(b) Consultations.CategoryIIpractitionersmaynotindependentlyprovide

patientconsultationsinlieuofthepractitioners’SupervisingPhysicians.ACategoryIIpractitionermaygatherdataandordertests;however,theSupervisingPhysicianmustpersonallyperformtherequestedconsultationwithin24hours(ormoretimelyinthecaseofanyemergencyconsultationrequest)unlessthephysicianrequestingtheconsultationagreesthattheCategoryIIpractitionermayprovidetheconsultation.IfitisagreedthattheCategoryIIpractitionermayprovidetheconsultation,theSupervisingPhysicianshallreviewandcountersigntheconsultationreportwithin24hoursofitscompletion.

(c) EmergencyOn-CallCoverage.CategoryIIpractitionersmaynot

independentlyparticipateintheemergencyon-callroster(formally,orinformallybyagreementwiththeirSupervisingPhysicians),inlieuoftheSupervisingPhysician.ItshallbewithinthediscretionoftheEmergencyDepartmentpersonnelrequestingassistancewhetheritisappropriatetocontactaCategoryIIpractitionerpriortotheSupervisingPhysician.However,whencontactedbytheEmergencyDepartment,theSupervisingPhysician(orhisorhercoveringphysician)mustpersonallyrespondtoallcallsinatimelymanner,inaccordancewithrequirements

198832.1126

setforthintheMedicalStaffCredentialsPolicy.FollowingdiscussionwiththeEmergencyDepartment,theSupervisingPhysicianmaydirectaCategoryIIpractitionertoseethepatient,gatherdata,andordertestsforfurtherreviewbytheSupervisingPhysician.However,theSupervisingPhysicianmustpersonallyseethepatientwhenrequestedbytheEmergencyDepartmentphysician.

(d) CallsRegardingSupervisingPhysician’sHospitalizedInpatients.Itshallbe

withinthediscretionoftheHospitalpersonnelrequestingassistancewhetheritisappropriatetocontactaCategoryIIpractitionerpriortotheSupervisingPhysician.However,theSupervisingPhysicianmustpersonallyrespondtoallcallsdirectedtohimorherinatimelymanner.CategoryIIpractitionersmaynotindependentlyrespondtocallsfromthefloororspecialcareunitsregardinghospitalizedinpatientsthatwerespecificallydirectedtotheSupervisingPhysician.

(e) DailyInpatientRounds.ACategoryIIpractitioner(specificallyaNurse

Practitioner,PhysicianAssistant,orCertifiedNurseMidwife)ispermittedtoperformdailyinpatientrounds;however,allinpatientsmustalsobevisitedbytheSupervisingPhysician(oradesignatedphysician)whenrequested.

6.B.OVERSIGHTBYSUPERVISINGPHYSICIAN

(1) AnyactivitiespermittedtobeperformedattheHospitalbyaCategoryIIorCategoryIIIpractitionershallbeperformedonlyunderthesupervisionordirectionofaSupervisingPhysician.

(2) CategoryIIorCategoryIIIpractitionersmayfunctionintheHospitalonlysolong

as(i)theyaresupervisedbyaSupervisingPhysicianwhoiscurrentlyappointedtotheMedicalStaff,and(ii)theyhaveacurrent,writtensupervisionagreementwiththeSupervisingPhysician.Inaddition,shouldtheMedicalStaffappointmentorclinicalprivilegesoftheSupervisingPhysicianberevokedorterminated,theCategoryIIorCategoryIIIpractitioner’spermissiontopracticeattheHospitalandclinicalprivilegesorscopeofpracticeshallbeautomaticallyrelinquished(unlesstheindividualwillbesupervisedbyanotherapprovedphysicianontheMedicalStaff).

(3) Asaconditionofclinicalprivilegesorascopeofpractice,aCategoryIIor

CategoryIIIpractitionerandtheSupervisingPhysicianmustprovidetheHospitalwithacopyoftheirwrittensupervisionagreementaswellasnoticeofanyrevisionsormodificationsthataremadetosuchagreementsbetweenthem.ThisnoticemustbeprovidedtotheMedicalStaffOfficewithinthreedaysofanysuchchange.

198832.1127

6.C.QUESTIONSREGARDINGAUTHORITYOFACATEGORYII ORCATEGORYIIIPRACTITIONER

(1) ShouldanyMedicalStaffmemberorHospitalemployeewhoislicensedorcertifiedbythestatehaveanyquestionregardingtheclinicalcompetenceorauthorityofaCategoryIIorCategoryIIIpractitioner,eithertoactortoissueinstructionsoutsidethephysicalpresenceoftheSupervisingPhysicianinaparticularinstance,theMedicalStaffmemberorHospitalemployeeshallhavetherighttorequirethattheCategoryIIorCategoryIIIpractitioner’sSupervisingPhysicianvalidate,eitheratthetimeorlater,theinstructionsoftheCategoryIIorCategoryIIIpractitioner.AnyactorinstructionoftheCategoryIIorCategoryIIIpractitionershallbedelayeduntilsuchtimeasthestaffmemberorHospitalemployeecanbecertainthattheactisclearlywithinthescopeoftheCategoryIIorCategoryIIIpractitioner’sactivitiesaspermittedbytheBoard.Inthesesituations,theMedicalStaffmemberorHospitalemployeeshallfirstdiscussthematterwiththeSupervisingPhysician.Ifthatdoesnotresolvethematter,theChiefofStaffortheCMOwillbecontacted.

(2) Anyquestionregardingtheclinicalpracticeorprofessionalconductofa

CategoryIIorCategoryIIIpractitionershallbeimmediatelyreportedtotheChiefofStaff,theChairoftheCredentialsCommittee,therelevantdepartmentchair,theCMO,ortheCEO,whoshallundertakesuchactionasmaybeappropriateunderthecircumstances.TheindividualtowhomtheconcernhasbeenreportedwillalsodiscussthematterwiththeSupervisingPhysician.

6.D.RESPONSIBILITIESOFSUPERVISINGPHYSICIAN

(1) PhysicianswhowishtoutilizetheservicesofaCategoryIIorCategoryIIIpractitionerintheirclinicalpracticeattheHospitalmustnotifytheMedicalStaffOfficeofthisfactinadvanceandmustensurethattheindividualhasbeenappropriatelycredentialedinaccordancewiththisPolicyorwithHumanResourcespoliciesandproceduresbeforetheCategoryIIorCategoryIIIpractitionerparticipatesinanyclinicalordirectpatientcareofanykindintheHospital.

(2) TheSupervisingPhysicianwillremainresponsibleforallcareprovidedbythe

CategoryIIorCategoryIIIpractitionerintheHospital.(3) SupervisingPhysicianswhowishtoutilizetheservicesofCategoryIIpractitioners

intheinpatientsettingspecificallyagreetoabidebythestandardsofpracticesetforthinSection6.Aabove.

198832.1128

(4) ThenumberofCategoryIIorCategoryIIIpractitionersactingunderthesupervisionofoneSupervisingPhysician,aswellasthecaretheymayprovide,willbeconsistentwithapplicablestatestatutesandregulationsandanyotherpoliciesadoptedbytheHospital.TheSupervisingPhysicianwillmakeallappropriatefilingswiththeStateBoardofMedicineregardingthesupervisionandresponsibilitiesoftheCategoryIIorCategoryIIIpractitioner,totheextentthatsuchfilingsarerequiredandshallprovideacopyofthesametotheMedicalStaffOffice.

(5) ItwillbetheresponsibilityoftheSupervisingPhysiciantoensurethatthe

CategoryIIorCategoryIIIpractitionermaintainsprofessionalliabilityinsurancecoverageinamountsrequiredbytheBoard.TheinsurancemustcoveranyandallactivitiesoftheCategoryIIorCategoryIIIpractitionerintheHospital.TheSupervisingPhysicianwillfurnishevidenceofsuchcoveragetotheHospital.TheCategoryIIorCategoryIIIpractitionerwillactintheHospitalonlywhilesuchcoverageisineffect.

198832.1129

ARTICLE7

PEERREVIEWPROCEDURESFORQUESTIONSINVOLVINGALLIEDHEALTHPROFESSIONALS

7.A.COLLEGIALINTERVENTION

(1) AspartoftheHospital’sperformanceimprovementandprofessionalpracticeevaluationactivities,thisPolicyencouragestheuseofcollegialeffortsandprogressivestepswithAlliedHealthProfessionals(andtheirSupervisingPhysicians,asapplicable)byMedicalStaffLeadersandHospitalmanagementinordertoarriveatvoluntary,responsiveactionsbyindividualstoresolvequestionsthathavebeenraised.CollegialinterventioneffortsarenotmandatoryandshallbewithinthediscretionoftheappropriateMedicalStaffLeaders.

(2) Collegialinterventioneffortsmayinclude,butarenotlimitedto,counseling,

sharingofcomparativedata,monitoring,andadditionaltrainingoreducation.Allsucheffortsshallbedocumentedinanindividual’sconfidentialfile.

(3) CollegialinterventioneffortsareapartoftheHospital’songoingandfocused

professionalpracticeevaluationactivities.(4) TheChiefofStaff,inconjunctionwiththeCEOortheCMO,shalldetermine

whethertodirectthatamatterbehandledinaccordancewithanotherpolicy(e.g.,codeofconductpolicy;practitionerhealthpolicy;professionalpracticeevaluationpolicy)ortodirectthemattertotheMECforfurtherreviewand/orinvestigation.

7.B.ONGOINGANDFOCUSEDPROFESSIONALPRACTICEEVALUATIONS

AllongoingandfocusedprofessionalpracticeevaluationsshallbeconductedinaccordancewiththeProfessionalPracticeEvaluationPolicy.MattersthatarenotsatisfactorilyresolvedthroughcollegialinterventionorthroughtheProfessionalPracticeEvaluationPolicyshallbereferredtotheMECforitsreviewinaccordancewithSection7.Cbelow.Suchinterventionsandevaluations,however,arenotmandatoryprerequisitestoMECreview.

7.C.INVESTIGATIONS7.C.1.InitiationofInvestigation:

198832.1130

WhenaquestioninvolvingclinicalcompetenceorprofessionalconductofanAlliedHealthProfessionalisreferredto,orraisedby,theMEC,theMECwillreviewthematteranddeterminewhethertoconductaninvestigation,todirectthemattertobehandledpursuanttoanotherpolicy,ortoproceedinanothermanner.

7.C.2.InvestigativeProcedure:

(a) TheMECwilleitherinvestigatethematteritself,requestthattheCredentialsCommitteeconducttheinvestigation,orappointanadhoccommitteetoconducttheinvestigation(“investigatingcommittee”).TheinvestigatingcommitteewillnotincluderelativesorfinancialpartnersoftheAlliedHealthProfessionalor,whereapplicable,theAlliedHealthProfessional’sSupervisingPhysician.

(b) Theinvestigatingcommitteewillhavetheauthoritytoreviewrelevant

documentsandinterviewindividuals.ItwillalsohaveavailabletoitthefullresourcesoftheMedicalStaffandtheHospital.

(c) Theinvestigatingcommitteewillalsohavetheauthoritytouseoutside

consultants,ifneeded.(d) Theinvestigatingcommitteemayrequireaphysical,mental,and/orbehavioral

examinationoftheindividualbyahealthcareprofessional(s)acceptabletoit.Theindividualbeinginvestigatedshallexecutearelease(inaformapprovedorprovidedbytheinvestigatingcommittee)allowing(i)theinvestigatingcommittee(oritsrepresentative)todiscusswiththehealthcareprofessional(s)conductingtheexaminationthereasonsfortheexamination;and(ii)thehealthcareprofessional(s)conductingtheexaminationtodiscussandprovidedocumentationoftheresultsofsuchexaminationdirectlytotheinvestigatingcommittee.Thecostofsuchhealthexaminationshallbebornebytheindividual.

(e) Theindividualwillhaveanopportunitytomeetwiththeinvestigatingcommittee

beforeitmakesitsreport.Priortothismeeting,theindividualwillbeinformedofthegeneralquestionsbeinginvestigated.Atthemeeting,theindividualwillbeinvitedtodiscuss,explain,orrefutethequestionsthatgaverisetotheinvestigation.Norecording(audioorvideo)ortranscriptofthemeetingshallbepermittedormade.Asummaryoftheinterviewwillbeprepared.Thismeetingisnotahearing,andnoneoftheproceduralrulesforhearingswillapply.Theindividualbeinginvestigatedwillnothavetherighttoberepresentedbylegalcounselatthismeeting.

(f) Theinvestigatingcommitteewillmakeareasonableefforttocompletethe

investigationandissueitsreportwithin30daysofthecommencementofthe

198832.1131

investigation,providedthatanoutsidereviewisnotnecessary.Whenanoutsidereviewisnecessary,theinvestigatingcommitteewillmakeareasonableefforttocompletetheinvestigationandissueitsreportwithin30daysofreceivingtheresultsoftheoutsidereview.Thesetimeframesareintendedtoserveonlyasguidelines.

(g) Attheconclusionoftheinvestigation,theinvestigatingcommitteewillpreparea

reportwithitsfindings,conclusions,andrecommendations.

7.C.3.Recommendation:

(a) TheMECmayaccept,modify,orrejectanyrecommendationitreceivesfromaninvestigatingcommittee.Specifically,theMECmay:

(1) determinethatnoactionisjustified;(2) issuealetterofguidance,counsel,warning,orreprimand;(3) imposeconditionsforcontinuedpermissiontopractice;(4) imposearequirementformonitoring,proctoring,orconsultation;(5) imposearequirementforadditionaltrainingoreducation;(6) recommendreductionofclinicalprivilegesorscopeofpractice;(7) recommendsuspensionofclinicalprivilegesorscopeofpracticefora

term;(8) recommendrevocationofclinicalprivilegesorscopeofpractice;or(9) makeanyotherrecommendationthatitdeemsnecessaryorappropriate.

(b) ArecommendationbytheMECthatwouldentitletheindividualtorequestahearingwillbeforwardedtotheCEO,whowillpromptlyinformtheindividualbyspecialnotice.TheCEOwillholdtherecommendationuntilaftertheindividualhascompletedorwaivedahearingandappeal.

(c) IftheMECmakesarecommendationthatdoesnotentitletheindividualto

requestahearing,itwilltakeeffectimmediatelyandwillremainineffectunlessmodifiedbytheBoard.

7.D.ADMINISTRATIVESUSPENSION

198832.1132

(1) TheChiefofStaff,therelevantdepartmentchair,theCMO,theCEO,andtheMECwilleachhavetheauthoritytoimposeanadministrativesuspensionofalloranyportionoftheclinicalprivilegesofanyAlliedHealthProfessionalwheneveraquestionhasbeenraisedaboutsuchindividual’sclinicalcareorprofessionalconduct.

(2) Anadministrativesuspensionwillbecomeeffectiveimmediatelyupon

imposition,willimmediatelybereportedtotheCEOandtheChiefofStaff,andwillremainineffectunlessoruntilmodifiedbytheCEOortheMEC.TheimpositionofanadministrativesuspensiondoesnotentitleanAlliedHealthProfessionaltotheproceduralrightssetforthinArticle8ofthisPolicy.

(3) Uponreceiptofnoticeoftheimpositionofanadministrativesuspension,the

CEOandChiefofStaffwillforwardthemattertotheMEC,whichwillreviewandconsiderthequestion(s)raisedandthereaftermakearecommendationtotheBoard.

7.E.AUTOMATICRELINQUISHMENT/ACTIONS

(1) AnAlliedHealthProfessional’sclinicalprivilegesorscopeofpracticeshallbeautomaticallyrelinquished,withoutentitlementtotheproceduralrightsoutlinedinthisPolicy,inthefollowingcircumstances:

(a) theAlliedHealthProfessionalnolongersatisfiesanyofthethreshold

eligibilitycriteriasetforthinSection4.A.1oranyadditionalthresholdcredentialingqualificationssetforthinthespecificHospitalpolicyrelatingtohisorherdiscipline;

(b) theAlliedHealthProfessionalisarrested,charged,indicted,convicted,or

entersapleaofguiltyornocontesttoanyfelony;ortoanymisdemeanorinvolving(i)controlledsubstances;(ii)illegaldrugs;(iii)Medicare,Medicaid,orinsuranceorhealthcarefraudorabuse;(iv)childabuse;(v)elderabuse;or(vi)violenceagainstanother(DUIswillbeaddressedinthemanneroutlinedinSection4.B.1(f)ofthisPolicy);

(c) theAlliedHealthProfessionalfailstoprovideinformationpertainingto

hisorherqualificationsforclinicalprivilegesinresponsetoawrittenrequestfromtheCredentialsCommittee,theMEC,theCMO,theCEO,oranyothercommitteeauthorizedtorequestsuchinformation;

(d) theAlliedHealthProfessionalfailstocompleteorcomplywithrequired

trainingoreducationalrequirements;

198832.1133

(e) adeterminationismadethatthereisnolongeraneedfortheservicesofaparticulardisciplineorcategoryofAlliedHealthProfessional;

(f) aCategoryIIorCategoryIIIpractitionerfails,foranyreason,tomaintain

anappropriaterelationshipwithaSupervisingPhysicianasdefinedinthisPolicy;or

(g) anyAlliedHealthProfessionalemployedbytheHospitalhashisorher

employmentterminated.

(2) RequestsforReinstatement.

(a) Requestsforreinstatementfollowingtheexpirationofalicense/certification/registration,controlledsubstanceauthorization,and/orinsurancecoveragewillbeprocessedbytheMedicalStaffOffice.Ifanyquestionsorconcernsarenoted,theMedicalStaffOfficewillreferthematterforfurtherreviewinaccordancewith(b)below.

(b) AllotherrequestsforreinstatementwillbereviewedbytheChiefof

Staff,theCMO,andtheCEO.Ifeachoftheseindividualsmakesafavorablerecommendationonreinstatement,theAlliedHealthProfessionalmayimmediatelyresumeclinicalpracticeattheHospital.ThisdeterminationwillthenbeforwardedtotheCredentialsCommittee,theMEC,andtheBoardforratification.If,however,anyoftheseindividualsreviewingtherequesthasanyquestionsorconcerns,thosequestionswillbenotedandthereinstatementrequestwillbeforwardedtothefullCredentialsCommittee,MEC,andBoardforreviewandrecommendation.

7.F.ACTIONATANOTHEREMORYHEALTHCAREHOSPITAL

Anydisciplinaryaction,involuntarychangeinappointment,clinicalprivileges,and/orscopeofpracticestatus,orthedevelopmentofaPerformanceImprovementPlan(collectively“action”)thatoccursatanotherHospitalwithinEmoryHealthcare(exceptthoserelatingtomedicalrecordcompletioninfractions)shallautomaticallyandimmediatelybeeffectiveatthisHospital,withouttheindividual’srecoursetoanyadditionalreview,investigation,hearing,orappeal(asmaybeapplicable).ThisautomaticactionmaybewaivedbytheMECandtheBoardinexceptionalcircumstances,afterafullreviewofthespecificcircumstancesandanyrelevantpeerreviewdocuments(e.g.,professionalpracticeevaluation,investigation,andhearingdocuments)fromtheEmoryfacilitywheretheactionfirstoccurred.

198832.1134

7.G.LEAVEOFABSENCE

(1) AnAlliedHealthProfessionalmayrequestaleaveofabsence,foraperiodnottoexceedayear,bysubmittingawrittenrequesttotheMedicalStaffOffice.TheCEOwillthendeterminewhetherarequestforaleaveofabsenceshallbegranted.Requestsforreinstatementmustbemadeatleast30dayspriortotheconclusionoftheleaveofabsence.

(2) AlliedHealthProfessionalsmustreporttotheMedicalStaffOfficeanytimethey

areawayfrompatientcareresponsibilitiesforlongerthan30daysandthereasonforsuchabsenceisrelatedtotheirphysicalormentalhealthorotherwisetotheirabilitytocareforpatientssafelyandcompetently.Undersuchcircumstances,theCEO,inconsultationwiththeChiefofStaff,maytriggeranautomaticmedicalleaveofabsence.

(3) Individualsrequestingreinstatementwillsubmitawrittensummaryoftheir

professionalactivitiesduringtheleave,andanyotherinformationthatmayberequestedbytheHospital.RequestsforreinstatementwillthenbereviewedbytheChiefofStaff,theservicechief,theCMO,andtheCEO.Ifeachoftheseindividualsmakesafavorablerecommendationonreinstatement,theAlliedHealthProfessionalmayimmediatelyresumepractice.ThisdeterminationwillthenbeforwardedtotheCredentialsCommittee,theMEC,andtheBoardforratification.If,however,anyoftheindividualsreviewingtherequesthasanyquestionsorconcerns,thosequestionswillbenotedandthereinstatementrequestwillbeforwardedtothefullCredentialsCommittee,MEC,andBoardforreviewandrecommendation.IntheeventtheMECdeterminestotakeactionthatwouldentitletheindividualtotheproceduralrightssetforthinArticle8,theindividualwillbegivenspecialnotice.

(4) Iftheleaveofabsencewasforhealthreasons(exceptformaternityleaves),the

requestforreinstatementmustbeaccompaniedbyareportfromtheindividual’sphysicianindicatingthattheindividualisphysicallyand/ormentallycapableofresumingahospitalpracticeandsafelyexercisingtheclinicalprivilegesrequested.

198832.1135

ARTICLE8

PROCEDURALRIGHTSFORALLIEDHEALTHPROFESSIONALS

AlliedHealthProfessionalsshallnotbeentitledtothehearingandappealsproceduressetforthintheMedicalStaffCredentialsPolicy.AnyandallproceduralrightstowhichtheseindividualsareentitledaresetforthinthisArticle.

8.A.PROCEDURALRIGHTSFORCATEGORYIANDCATEGORYIIPRACTITIONERS

8.A.1.NoticeofRights:

(a) IntheeventarecommendationismadebytheMECthataCategoryIorCategoryIIpractitionernotbegrantedclinicalprivilegesorthattheprivilegespreviouslygrantedberestrictedforaperiodofmorethan30days,terminated,ornotrenewed,theindividualwillreceivespecialnoticeoftherecommendation.Thespecialnoticewillincludeageneralstatementofthereasonsfortherecommendationandwilladvisetheindividualthatheorshemayrequestahearing.

(b) TherightsandproceduresinthisSectionwillalsoapplyiftheBoard,withouta

prioradverserecommendationfromtheMEC,makesarecommendationnottograntclinicalprivilegesorthattheprivilegespreviouslygrantedberestricted,terminated,ornotrenewed.Inthisinstance,allreferencesinthisArticletotheMECwillbeinterpretedasareferencetotheBoard.

(c) IftheCategoryIorCategoryIIpractitionerwantstorequestahearing,the

requestmustbeinwriting,directedtotheCEO,within30daysafterreceiptofwrittennoticeoftheadverserecommendation.

(d) Thehearingwillbeconvenedassoonasispractical,butnosoonerthan30days

afterthenoticeofthehearing,unlessanearlierhearingdatehasbeenspecificallyagreedtobytheparties.

8.A.2.HearingCommittee:

(a) Ifarequestforahearingismadeinatimelymanner,theCEO,inconjunctionwiththeChiefofStaff,shallappointaHearingCommitteecomposedofuptothreeindividuals(including,butnotlimitedto,individualsappointedtotheMedicalStaff,AlliedHealthProfessionals,Hospitalmanagement,individualsnotconnectedtotheHospital,oranycombinationoftheseindividuals)andaPresidingOfficer,whomaybelegalcounseltotheHospital.TheHearing

198832.1136

Committeeshallnotincludeanyonewhopreviouslyparticipatedintherecommendation,anyrelativesorpracticepartnersoftheCategoryIorCategoryIIpractitioner,oranycompetitorsoftheaffectedindividual.

(b) AsanalternativetotheHearingCommitteedescribedinparagraph(a)ofthis

Section,theCEO,inconjunctionwiththeChiefofStaff,mayinsteadappointaHearingOfficertoperformthefunctionsthatwouldotherwisebecarriedoutbytheHearingCommittee.TheHearingOfficershallpreferablybeanattorneyatlaw.TheHearingOfficermaynotbeindirecteconomiccompetitionwiththeindividualrequestingthehearingandshallnotactasaprosecutingofficerorasanadvocatetoeithersideatthehearing.IftheHearingOfficerisanattorney,heorsheshallnotrepresentclientswhoareindirecteconomiccompetitionwiththeaffectedindividual.IntheeventaHearingOfficerisappointedinsteadofaHearingCommittee,allreferencesinthisArticletotheHearingCommitteeshallbedeemedtoreferinsteadtotheHearingOfficer,unlessthecontextwouldclearlyotherwiserequire.

(c) Thehearingshallbeconvenedassoonasispractical,butnosoonerthan30days

afterthenoticeofthehearing,unlessanearlierhearingdatehasbeenspecificallyagreedtobytheparties.

8.A.3.HearingProcess:

(a) Arecordofthehearingwillbemaintainedbyastenographicreporterorbyarecordingoftheproceedings.Copiesofthetranscriptwillbeavailableattheindividual’sexpense.

(b) Thehearingwilllastnomorethansixhours,witheachsidebeingafforded

approximatelythreehourstopresentitscase,intermsofbothdirectandcross-examinationofwitnesses.

(c) Atthehearing,arepresentativeoftheMECwillfirstpresentthereasonsforthe

recommendation.TheCategoryIorCategoryIIpractitionerwillbeinvitedtopresentinformationtorefutethereasonsfortherecommendation.

(d) Bothpartieswillhavetherighttopresentwitnesses.ThePresidingOfficerwill

permitreasonablequestioningofsuchwitnesses.(e) TheCategoryIorCategoryIIpractitionerandtheMECmayberepresentedat

thehearingbylegalcounsel.However,whilecounselmaybepresentatthehearing,counselwillnotcall,examine,orcross-examinewitnessesorpresentthecase.

198832.1137

(f) TheCategoryIorCategoryIIpractitionerwillhavetheburdenofdemonstrating,byclearandconvincingevidence,thattherecommendationoftheMECwasarbitrary,capricious,ornotsupportedbysubstantialevidence.ThequalityofcareprovidedtopatientsandthesmoothoperationoftheHospitalwillbetheparamountconsiderations.

(g) TheCategoryIorCategoryIIpractitionerandtheMECwillhavetherightto

prepareapost-hearingmemorandumforconsiderationbytheHearingCommittee.ThePresidingOfficerwillestablishareasonablescheduleforthesubmissionofsuchmemoranda.

8.A.4.HearingCommitteeReport:

(a) Within20daysaftertheconclusionoftheproceedingorsubmissionofthepost-hearingmemoranda,whicheverdateislater,theHearingCommitteewillprepareawrittenreportandrecommendation.TheHearingCommitteewillforwardthereportandrecommendation,alongwithallsupportinginformation,totheCEO.TheCEOwillsendacopyofthewrittenreportandrecommendationbyspecialnoticetotheCategoryIorCategoryIIpractitionerandtotheMEC.

(b) Withintendaysafternoticeofsuchrecommendation,theCategoryIor

CategoryIIpractitionerand/ortheMECmaymakeawrittenrequestforanappeal.Therequestmustincludeastatementofthereasons,includingspecificfacts,whichjustifyanappeal.

(c) Thegroundsforappealwillbelimitedtoanassertionthattherewassubstantial

failuretocomplywiththisPolicyduringthehearing,soastodenyafairhearing,and/orthattherecommendationoftheHearingCommitteewasarbitrary,capricious,ornotsupportedbysubstantialevidence.

(d) TherequestforanappealwillbedeliveredtotheCEObyspecialnotice.(e) Ifawrittenrequestforappealisnotsubmittedtimely,theappealisdeemedto

bewaivedandtherecommendationandsupportinginformationwillbeforwardedtotheBoardforfinalaction.Ifatimelyrequestforappealissubmitted,theCEOwillforwardthereportandrecommendation,thesupportinginformationandtherequestforappealtotheBoard.TheChairoftheBoardwillarrangeforanappeal.

8.A.5.AppellateReview:

(a) AnAppellateReviewCommitteeappointedbytheChairoftheBoardwill

considertherecorduponwhichtheadverserecommendationwasmade.Neworadditionalwritteninformationthatisrelevantandcouldnothavebeenmade

198832.1138

availabletotheHearingCommitteemaybeconsideredatthediscretionoftheAppellateReviewCommittee.Thisreviewwillbeconductedwithin30daysafterreceivingtherequestforappeal.

(b) TheCategoryIorCategoryIIpractitionerandtheMECwilleachhavetherightto

presentawrittenstatementonappeal.(c) AtthesolediscretionoftheAppellateReviewCommittee,theCategoryIor

CategoryIIpractitionerandarepresentativeoftheMECmayalsoappearpersonallytodiscusstheirposition.

(d) Uponcompletionofthereview,theAppellateReviewCommitteewillprovidea

reportandrecommendationtothefullBoardforaction.TheBoardwillthenmakeitsfinaldecisionbasedupontheBoard’sultimatelegalresponsibilitytograntprivilegesandtoauthorizetheperformanceofclinicalactivitiesattheHospital.

(e) TheCategoryIorCategoryIIpractitionerwillreceivespecialnoticeofthe

Board’saction.AcopyoftheBoard’sfinalactionwillalsobesenttotheMECforinformation.

8.B.PROCEDURALRIGHTSFORCATEGORYIIIPRACTITIONERS

(1) IntheeventthatarecommendationismadebytheMECthataCategoryIIIpractitionernotbegrantedthescopeofpracticerequestedorthatascopeofpracticepreviouslygrantedberestrictedorterminated,theindividualshallbenotifiedoftherecommendation.ThenoticeshallincludeaspecificstatementofthereasonsfortherecommendationandshalladvisetheindividualthatheorshemayrequestameetingwiththeMECbeforetherecommendationisforwardedtotheBoardforfinalaction.

(2) IftheCategoryIIIpractitionerdesirestorequestameeting,heorshemustmake

suchrequestinwritinganddirectittotheHospitalPresidentwithin30daysafterreceiptofthewrittennoticeoftheadverserecommendation.

(3) Ifameetingisrequestedinatimelymanner,itshallbescheduledtotakeplace

withinareasonabletimeframe.Themeetingshallbeinformalandshallnotbeconsideredahearing.TheCategoryIIIpractitionerandhisorherSupervisingPhysicianshallbothbepermittedtoattendandparticipateinthemeeting.However,nocounselforeithertheCategoryIIIpractitionerortheMECshallbepresent.

(4) Followingthismeeting,theMECshallmakeafinalrecommendationtothe

HospitalBoard.

198832.1139

198832.1140

ARTICLE9

HOSPITALEMPLOYEES

A. Exceptasprovidedbelow,theemploymentofanAlliedHealthProfessionalbytheHospitalshallbegovernedbytheHospital’sorEmoryHealthcare’semploymentpoliciesandmanualsandthetermsoftheindividual’semploymentrelationshipand/orwrittencontract.TotheextentthattheHospital’sorEmoryHealthcare’semploymentpoliciesormanuals,orthetermsofanyapplicableemploymentcontract,conflictwiththisPolicy,theemploymentpolicies,manualsanddescriptionsandtermsoftheindividual’semploymentrelationshipand/orwrittencontractshallapply.

B. ExceptasnotedinA,Hospital-employedAlliedHealthProfessionalsarebound

byallofthesameconditionsandrequirementsinthisPolicythatapplytonon-HospitalemployedAlliedHealthProfessionals.

C. Arequestforclinicalprivileges,onaninitialbasisorforrenewal,submittedbya

CategoryIorCategoryIIpractitionerwhoisseekingemploymentorwhoisemployedbytheHospitalshallbeprocessedinaccordancewiththetermsofthisPolicy.Areportregardingeachpractitioner’squalificationsshallthenbemadetoHospitalmanagementorHumanResources(asappropriate)toassisttheHospitalinmakingemploymentdecisions.

D. IfaconcernaboutanemployedAlliedHealthProfessional’sclinicalcompetence

orprofessionalconductoriginateswiththeMedicalStaff,theconcernwillbereviewedandaddressedinaccordancewithArticles7and8ofthisPolicy,afterwhichareportwillbeprovidedtoHospitalmanagementorHumanResources(asappropriate).

198832.1141

ARTICLE10

AMENDMENTS

ThisPolicymaybeamendedbyamajorityvoteofthemembersoftheMEC,providedthatthewrittenrecommendationsoftheCredentialsCommitteeconcerningtheproposedamendmentsshallhavefirstbeenreceivedandreviewedbytheMEC.NoticeofallproposedamendmentsshallalsobeprovidedtoeachvotingmemberoftheMedicalStaffatleast14dayspriortotheMECmeeting.AnyvotingmemberoftheMedicalStaffmaysubmitwrittencommentstotheMEC.NoamendmentshallbeeffectiveunlessanduntilithasbeenapprovedbytheBoard.

198832.1142

ARTICLE11

ADOPTION

ThisPolicyisadoptedandmadeeffectiveuponapprovaloftheBoard,supersedingandreplacinganyandallotherMedicalStaffbylawsorrulesandregulationsorHospitalpoliciespertainingtothesubjectmatterthereof.OriginallyadoptedbytheMedicalStaffonNovember15,2012andapprovedbytheBoardonNovember20,2012.RevisionsadoptedbytheMEC: October14,2017RevisionsapprovedbytheBoard: October17,2017

198832.11

APPENDIXA

ThoseindividualscurrentlypracticingasCategoryIpractitionersattheHospitalareasfollows:

ClinicalPsychologists

198832.11

APPENDIXB

ThoseindividualscurrentlypracticingasCategoryIIpractitionersattheHospitalareasfollows:

AnesthesiaAssistantsCertifiedNurseMidwivesCertifiedRegisteredNurseAnesthetistsNursePractitionersPhysicianAssistantsSurgicalAssistants,CertifiedSurgicalAssistants,CertifiedSurgicalFirstAssistants,OrthopedicTech–SurgeryCertified,RNFirstAssistants

198832.11

APPENDIXC

ThoseindividualscurrentlypracticingasCategoryIIIpractitionersattheHospitalareasfollows:

OrthopedicTechnicianCertifiedRegisteredNurses