07 Aug 2013
We are looking at credentialing/privileging and appointing our psychologists to the medical staff as associate members. Does your facility do this for psychologists? If so would you be willing to provide copies of your criteria/privileging forms, to assist us as we move forward. Thanks so much. (email@example.com)
~RE: Speare does not currently have any Psychologists on our medical staff, when we did, we appointed them to the associate medical staff (along with our CRNAs, NPs, and PAs). We switched to Core Privileges since the last time we had Psychologists on staff, so we would probably edit the form below and use something similar to this, for any future Psychologists.
All new applicants must meet the following requirements as approved by the governing body effective: ____/____/______.
If any privileges are covered by an exclusive contract or an employment contract, practitioners who are not a party to the contract are not eligible to request the privilege(s), regardless of education, training, and experience. Exclusive or employment contracts are indicated by [EC].
Applicant: Check off the “Requested” box for each privilege requested. Applicants have the burden of producing information deemed adequate by the hospital for a proper evaluation of current competence, current clinical activity, and other qualifications, and for resolving any doubts related to qualifications for requested privileges.
[Department chair/chief]: Check the appropriate box for recommendation on the last page of this form. If recommended with conditions or not recommended, provide condition or explanation on the last page of this form.
• Note that privileges granted may be exercised only at the site(s) and/or setting(s) that have the appropriate equipment, license, beds, staff, and other support required to provide the services defined in this document. Site-specific services may be defined in hospital and/or department policy.
• This document is focused on defining the qualifications related to competency to exercise clinical privileges. The applicant must also adhere to any additional organizational, regulatory, or accreditation requirements that the organization is obligated to meet.
QUALIFICATIONS FOR PSYCHOLOGIST
To be eligible to apply for clinical privileges as a psychologist, the applicant must meet the following criteria:
Possess an earned doctorate degree (PhD or PsyD) in psychology from an accredited educational institution and have completed at least two years of clinical experience in an organized healthcare setting supervised by a licensed psychologist, one year of which must have been post-doctoral, and an internship endorsed by the American Psychological Association
Current active certification and license to practice issued by the [State Board of Examiners of Psychologists]
Professional liability insurance coverage issued by a recognized company and of a type and in an amount equal to or greater than the limits established by the governing body, (if applicable to the facility)
Required previous experience: The successful applicant must be able to demonstrate provision of care, treatment, or services reflective of the scope of privileges requested to at least 30 patients during the past 12 months.
Reappointment requirements: To be eligible to renew core privileges as a psychologist, the applicant must meet the following maintenance of privilege criteria:
Current demonstrated competence and an adequate volume of experience ([n] patients) with acceptable results reflective of the scope of privileges requested for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current ability to perform privileges requested is required of all applicants for renewal of privileges.
Medical record charting responsibilities
Clearly, legibly, completely, and in a timely fashion, the psychologist must describe each service provided to a patient in the hospital and describe relevant observations. Standard rules regarding authentication of, necessary content of, and required time frames for preparing and completing the medical record and portions thereof are applicable to all entries made. [All orders are to be countersigned by the supervising physician within [n] hours.]
PSYCHOLOGIST CORE PRIVILEGES
Requested Diagnose and provide treatment and consultation to children, adolescent, and adult patients who suffer from mental, behavioral, or emotional disorders. [May provide care to patients in the intensive care setting in conformance with unit policies.] Assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the procedures on the attached procedure list and such other procedures that are extensions of the same techniques and skills.
SPECIAL NONCORE PRIVILEGES (SEE SPECIFIC CRITERIA)
If desired, noncore services/procedures are requested individually in addition to requesting the core. Each individual requesting noncore services/procedures must meet the specific threshold criteria governing the exercise of the service/procedure requested including training, required previous experience, and for maintenance of clinical competence.
[Criteria: Evidence of satisfactory completion of training in an accredited program by the American Psychological Association, evidence of satisfactory completion or training in the practice of hypnosis under the supervision of a person qualified for hypnosis, and evidence of continuing education and/or supervision in hypnosis by significant attendance at courses and/or publication of articles in journals or books of good standing during the past five years. Required previous experience: Demonstrated current competence and evidence of the performance of at least [n] hypnotherapy procedures in the past 12 months. Maintenance of privilege: Demonstrated current competence and the performance of at least [n] procedures in the past 24 months.]
[Criteria: Completion of one year of approved verifiable graduate training in a program approved by the American Psychological Association in which the modality was specifically taught, and/or must be supervised by a fully licensed psychologist independently privileged in this area. Required previous experience: Demonstrated current competence and evidence of the performance of at least [n] behavioral modification therapy procedures in the past 12 months. Maintenance of privilege: Demonstrated current competence and the performance of at least [n] procedures in the past 24 months.]
[Criteria: Certification by the Biofeedback Certification Institute of America or documented equivalent training and experience. Required previous experience: Demonstrated current competence and evidence of the performance of at least [n] biofeedback therapy procedures in the past 12 months. Maintenance of privilege: Demonstrated current competence and the performance of at least [n] procedures in the past 24 months.]
[Criteria: Successful completion of systematic didactic and experiential training in neuropsychology and neuroscience at a regionally accredited university and two or more years of appropriate supervised training applying neuropsychological services in a clinical setting. Required previous experience: Demonstrated current competence and evidence of the performance of at least [n] neuropsychological testing procedures in the past 12 months. Maintenance of privilege: Demonstrated current competence and the performance of at least [n] neuropsychological testing procedures in the past 24 months.]
CORE PROCEDURE LIST
This list is a sampling of procedures included in the core. This is not intended to be an all-encompassing list but rather reflective of the categories/types of procedures included in the core.
To the applicant: If you wish to exclude any procedures, please strike through those procedures you do not wish to request, then initial and date.
• Family assessment/therapy
• Group therapy
• Marital or couples therapy
• Psychological assessment
ACKNOWLEDGEMENT OF PRACTITIONER
I have requested only those clinical privileges for which by education, training, current experience, and demonstrated performance I am qualified to perform and for which I wish to exercise at [hospital name], and I understand that:
a. In exercising any clinical privileges granted and in carrying out the responsibilities assigned to me, I am constrained by hospital and medical staff policies and rules applicable generally and any applicable to the particular situation.
b. Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such situation my actions are governed by the applicable section of the policies governing privileged allied health professionals.
[DEPARTMENT CHAIR/CHIEF]'S RECOMMENDATION
I have reviewed the requested clinical privileges and supporting documentation for the above-named applicant and make the following recommendation(s):
Recommend requested clinical privileges
Recommend clinical privileges with the following conditions/modifications:
Do not recommend the following requested clinical privileges:
[Department chair/chief] signature Date
FOR MEDICAL STAFF OFFICE USE ONLY
Credentials Committee Action Date _____________
Medical Executive Committee Action Date _____________
Board of Trustees Action Date _____________
~RE: CMRC has psychologists on staff as Allied Healthcare Professionals and are not part of our medical staff.
~RE: Core Physicians, LLC does not have any on staff.