E-HOSPITAL SERVICES, INC.
POLICIES & PROCEDURES
To encourage and facilitate the highest standards of safety and quality, E-HOSPITAL SERVICES, INC. has adopted this these Policies & Procedures, shall be the primary means for review and disciplining members for inappropriate or disruptive behavior. A high standard of professional behavior, ethics and integrity are expected of each individual member of the Medical Staff at E-HOSPITAL SERVICES, INC. These Policies & Procedures are a statement of the ideals and guidelines for professional behavior of the Medical Staff in all dealings with patients, other health, professionals, employees, government agencies, and others, aiming for the highest levels of patient care, trust, integrity and honesty.
II. POLICY STATEMENT
Medical Staff members have a responsibility for the welfare, well-being, and betterment of their patients, along with a responsibility to maintain their own professional and personal well-being. Each Medical Staff member is expected to treat all fellow medical staff members and patients with courtesy and respect and with regard for their dignity. When a member is found to have fallen short of these expectations, E-HOSPITAL SERVICES, INC. supports non-confrontational intervention strategies focused on restoring trust, placing accountability on, and rehabilitating the offending Medical Staff member. However, the safeguarding of patient care and safety is paramount, and E-HOSPITAL SERVICES, INC. will enforce this policy with disciplinary measures whenever necessary. The evaluation, monitoring and regulation of professional behavior are essential elements of Professional Practice Evaluation.
1. "Appropriate behavior" includes any reasonable conduct to advocate for patients, to recommend improvements in patient care, to participate in the operations, leadership or activities of the organized Medical Staff, or to engage in professional practice. Appropriate behavior is not subject to discipline under these Policies & Procedures.
2. "Inappropriate behavior" means conduct that is unwarranted and is reasonably interpreted to be demeaning or offensive. Persistent, repeated inappropriate behavior can become a form of harassment and thereby become disruptive, and subject to treatment as "disruptive behavior."
3. "Disruptive behavior" means any abusive conduct including sexual or other forms of harassment, or other forms of verbal or non-verbal conduct that harms or intimidates others to the extent that quality of care or patient safety could be compromised.
4. "Harassment" means conduct toward others based on but not limited to their race, religious creed, color, national origin, physical or mental disability, marital status, sex, age, sexual orientation, or veteran status; which has the purpose or direct effect of unreasonably interfering with a person's work performance or which creates an offensive, intimidating or otherwise hostile work environment.
5. "Sexual harassment" means unwelcome sexual advances, requests for sexual favors, or verbal or physical activity through which submission to sexual advances is made an explicit or implicit condition of employment or future employment-related decisions; unwelcome conduct of a sexual nature which has the purpose or effect of unreasonably interfering with a person's work performance or which creates an offensive intimidating or otherwise hostile work environment.
6. "Medical Staff member" means physicians and others granted permission ro participate with E-HOSPITAL SERVICES, INC. temporary clinical privileges.
IV. STANDARDS OF BEHAVIOR
A) Inappropriate Behavior
Inappropriate behavior by Medical Staff members is strongly discouraged. Persistent inappropriate behavior can become a form of harassment and thereby become disruptive, and subject to treatment as "disruptive behavior." Examples of inappropriate behavior include, but are not limited to, the following;
B) Disruptive Behavior
Disruptive behavior by Medical Staff members is prohibited. Examples of disruptive behavior include, but are not limited to, the following:
A. Delegation by Chief of Staff
At the discretion of the Chief of Staff for E-HOSPITAL SERVICES, INC. (or Vice Chief if the Chief of Staff is the subject of the complaint), the duties here assigned to the Chief of Staff can be delegated to a designee. Designees may be other elected representatives of the Medical Staff or individuals such as medical directors, who have been confirmed by the Medical Executive Committee.
B. Initiation of Complaints
Medical Staff Members have an obligation to address and/or report incidents of inappropriate and disruptive behavior. Complaints about a member of the Medical Staff regarding allegedly inappropriate or disruptive behavior are encouraged to be in writing, signed, and directed to the Chief of Staff or, if the Chief of Staff is the subject of the complaint, to the Vice Chief of Staff, and include to the extent feasible:
- the date(s), time(s) and location of the inappropriate or disruptive behavior;
- a factual description of the inappropriate or disruptive behavior;
- the circumstances which precipitated the incident;
- the name and medical record number of any patient or patient's family member who was involved in or witnessed the incident;
- the names of other witnesses to the incident;
- the consequences, if any, of the inappropriate or disruptive behavior as it relates to patient care or safety, or operations; and
- any action taken to intervene in, or remedy, the incident, including the names of those intervening.
Persons making a complaint should be aware that a written and signed complaint is quite helpful in enabling the Medical Staff to conduct a thorough and valid investigation, although anonymous complaints will also be accepted, investigated and addressed to the degree possible.
C. Handling of Complaints
The Chief of Staff or designee will screen all complaints to determine the authenticity and severity of the complaint. If the complaint is clearly not valid, it may be summarily dismissed. If it is determined that the complaint may have substantial validity, the COS or designee will speak with the complainant and the subject of the complaint.
2. Medical Staff members who arc the subject of a complaint shall be provided a summary of the complaint and a copy of this Policy in a timely fashion, in no case more than 30 days from receipt of the complaint by the Chief of Staff or designee. The subject shall be offered an opportunity to provide a written response to the complaint, and any such response will be kept along with the original complaint in all relevant files.
3. The Medical Staff member will be notified that attempts to confront, intimidate, or otherwise retaliate against the complainant is a violation of these Policies & Procedures and may result in corrective action against the Medical Staff member.
4. The complainant will also be provided a written acknowledgment of the complaint and an explanation of how complaints are handled. If the complaint is determined to have no substance or validity, the complainant will be counseled regarding appropriate use of the incident reporting system.
5. After discussion with the Medical Staff member, the COS or designee will document the disposition of each complaint, as outlined below, and a record shall be kept in COS office files.
1. If this is the first incident of inappropriate behavior, the COS or designee shall discuss the matter with the offending Medical Staff member, emphasizing that the behavior is inappropriate and must cease. The offending Medical Staff member may be asked to apologize to the complainant. The approach during t his initial intervention should be collegial and helpful.
2. Further isolated incidents that do not constitute persistent, repeated inappropriate behavior will be handled by providing the offending Medical Staff member with notification of each incident, and a reminder of the expectation the individual comply with this Code of Behavior.
3. If the COS or designee determines the Medical Staff member has demonstrated persistent, repeated inappropriate behavior, constituting harassment (a form of disruptive behavior), or has engaged in disruptive behavior on the first offense, the case will be referred to the Chief of Staff (COS) The subject will be notified of this decision and given an opportunity to provide a written response both prior to and subsequent to meeting with the COS.
4. If it is determined that the subject has engaged in disruptive behavior, a letter of admonition will be sent to the offending member, and, as appropriate, a rehabilitation action plan developed by the COS.
5. If, in spite of this admonition and intervention, disruptive behavior recurs, the COS or designee shall meet with and advise the offending Medical Staff member such behavior must immediately cease or corrective action will be initiated. This "final warning" shall be sent to the offending Medical Staff member in writing.
6. If after the "final warning" the disruptive behavior recurs, corrective action (including possible suspension or termination of privileges) shall be initiated.
7. If a single incident of disruptive behavior or repeated incidents of disruptive behavior constitute an imminent danger to the health of an individual or individuals, the offending Medical Staff member may be summarily suspended.
8. A confidential file summarizing the disposition of the complaint, along with copies of any written warnings, letters of apology, and written responses from the offending Medical Staff member, shall be retained in the COS office for up to ten years.
VI. BEHAVIOR DIRECTED AGAINST A MEDICAL STAFF MEMBER:
Inappropriate or disruptive behavior which is directed against any Medical Staff or directed against an employee, or other member of E-HOSPITAL SERVICES, INC. shall be reported by the Medical Staff member to the COS, E-HOSPITAL SERVICES, INC. governing board, the state or federal government, or relevant accrediting body, as appropriate.
VII. ABUSE OF PROCESS:
Threats or actions directed against the complainant by the subject of the complaint will not be tolerated under any circumstance. Retaliation or attempted retaliation by Medical Staff members against complainants will give rise to corrective action which could include suspension or termination of the offender.
VIII. AWARENESS OF CODE OF CONDUCT:
The Medical Staff shall, in cooperation with E-HOSPITAL SERVICES, INC., promote continuing awareness of this Code of Behavior among the Medical Staff and others within E-HOSPITAL SERVICES, INC. by disseminating this Code of Behavior Policy to all current Medical Staff members and all new applicants to E-HOSPITAL SERVICES, INC.
IX. RELATED DOCUMENTS
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X. DOCUMENT INFORMATION
This Policy was enacted on _______________________, 20__. The COS (or designee), will be responsible for initiating its review and revision. The Policy will reside in the Policies & Procedure Manual, a copy of which is kept in the COS office records. This Policy will be reviewed and/or revised every three years or as required by change of law or practice.
COMPLAINTS GRIEVANCES FROM PATIENTS/FAMILIES
This policy establishes a uniform process which allows patient and/or patient's authorized representative grievances, concerns, and complaints from all sources to be evaluated and resolved in a manner that assures quality care and service throughout E-HOSPITAL SERVICES, INC.
II. POLICY STATEMENT
E-HOSPITAL SERVICES, INC. provides and adheres to a procedure for receiving, researching, and responding to the grievances/complaints and concerns of a patient's and/or a patient's authorized representatives. E-HOSPITAL SERVICES, INC. has designated the COS, or his designee, to provide a centralized system for:
- Informing a patient and/or a patient's authorized representative of the right to file a grievance/complaint and the mechanism for doing so.
- Investigating the grievance/complaint or concern.
- Ensuring a resolution occurs.
- Response to a patient and/or a patient's authorized representatives' grievances/concerns and complaints as required under applicable state and federal law.
A. Procedure for informing a patient and/or a patient's authorized representative of the right to file grievances/complaints:
- Patient Rights and Responsibilities shall be posted on all media sites, and shall include a statement about a patient's right to file a complaint with the Department of Public Health Services, Licensing and Certification Division, whether or not the patient uses E-HOSPITAL SERVICES, INC.'S grievance process.
- Workforce members should promptly inform patients who want to file a grievance or complaint to contact the COS of E-HOSPITAL SERVICES, INC..
- Patients/Patients' authorized representatives may register a grievance or complaint with E-HOSPITAL SERVICES, INC.:
- Upon receipt of the grievance or complaint, immediately record all grievances complaints or concerns expressed, including information sufficient to identify the complainant, date and nature of the problem, any steps taken to resolve the grievance/complaint. If an individual other than the patient expresses a complaint on behalf of an adult patient, the patient's authorization will be obtained before discussing any Protected Health Information.
- All grievances/complaints will be investigated by the COS, or his designee, until a final determination of the grievance/complaint is reached.
a. By calling the COS, or his designee, at __________________ - This is a 24-hour line answered by a Patient Representative.
b. In writing by sending the written complaint to:
B. Initial Acknowledgement: The COS, or his designee, must acknowledge the grievance/complaint within five (5) business days, explain the process that will be followed in investigating the complaint and advise them of the time frame in which to expect a response.
C. Time frame: The COS, or his designee, should provide the complainant with a written response to the complaint or grievance within 30 days or advise the complainant that the investigation is continuing and provide the patient with a estimated date of completion.
D. Letter content: The letter should include a written notice of E-HOSPITAL SERVICES, INC.'S decision regarding the complaint/grievance, an explanation of the steps taken to investigate the grievance, results of the review to resolve the grievance, date of completion of the review, name of E-HOSPITAL SERVICES, INC. contact person. Copies of the response are sent to those named on grievant's' complainant's letter and to other appropriate individuals/agencies subject to medical authorization requirements.
E. Gatekeeper of Original Document: COS, or his designee.
COMPLAINTS GRIEVANCES FROM PATIENTS/FAMILIES
This policy provides for the confidentiality of all records maintained by or on behalf of the Medical Staff, including the records and minutes of all Medical Staff meeting, Medical Staff credentials, quality and/or peer review files concerning Medical Staff.
E-HOSPITAL SERVICES, INC. recognizes that it is vital to maintain the confidentiality of Medical Staff Records. E-HOSPITAL SERVICES, INC. and the members of the Medical Staff understand and agree that the confidentiality of all Medical Staff Records is to be preserved and that any communications, reports, and records will be disclosed only in the furtherance of credentialing, peer review and performance improvement activities, and only in accordance with this policy and the law. This requirement of confidentiality extends to the records and minutes of all Medical Staff meetings or committees, the records of all Medical Staff credentials/peer review files, and the discussions and deliberations which take place under the aegis of Medical Staff meetings or committees.
III . ACCESS TO RECORDS
All requests for Medical Staff Records by persons within E-HOSPITAL SERVICES, INC. shall be presented to the COS, or his designee. Those requests shall require approval by the COS, or his designee. A person permitted access under this policy shall he given a reasonable opportunity to inspect the records in question and to make notes, but will not be allowed to remove them from there location, or to make copies of them. Removal or copying shall only be allowed upon the express permission of the COS, or his designee. Health Plan Representatives and Other Payers: Health Plan representatives and other payers will be permitted access to perform audits in regarding credentialing, only in accordance with this policy. Subpoenas: Subpoenas of Medical Staff Records shall be referred to the COS, who will consult with legal counsel and follow said counsel's recommendation regarding the appropriate response.
CONFLICT OF INTEREST FOR MEDICAL STAFF
A. To safeguard the integrity and reputation of E-HOSPITAL SERVICES, INC. and its Medical Staff, by fostering the proper and unbiased conduct of all Medical Staff activities.
B. To educate Medical Staff members about situations that generate conflicts of interest, to provide means for the Medical Staff and E-HOSPITAL SERVICES, INC. to disclose and manage conflicts of interest, to promote the best interests of patients, their families, employees, and other practitioners, and to describe situations that are prohibited.
A conflict of interest (COI) arises when there is a divergence between an individual's private interests and his/her professional obligations to the Medical Staff and E-HOSPITAL SERVICES, INC., such that an independent observer might reasonably question whether the individual's professional actions or decisions are determined by considerations of personal gain, financial or otherwise. A conflict of interest depends on the situation and not on the character of the individual. Conflicts of interest arc common and can arise due to the fact that E-HOSPITAL SERVICES, INC. and its Medical Staff promote the public good by fostering the transfer of knowledge gained through research and scholarship. Two important means of accomplishing these goals include Medical Staff consulting, and commercialization of technologies derived from research. While it is appropriate for a Medical Staff member to be compensated for these activities, it is never appropriate for an individual's actions or decisions made in the course of his/her Medical Staff activities to be determined or influenced by considerations of personal financial gain. Such behavior calls into question the professional objectivity and ethics of the individual and it also reflects negatively on the Medical Staff and E-HOSPITAL SERVICES, INC.
Medical Staff members should conduct their affairs so as to avoid or minimize conflicts of interest when possible, but most importantly must respond appropriately when conflicts of interest arise. A conflict of interest, in and of itself, is not grounds for any adverse actions with regard to an individual's Medical Staff status or privileges. However, a conflict of interest may well require an individual to recuse him or herself from participating in discussion determination of a given issue, and individuals with severe or multiple potential conflicts of interest should consider whether their involvement in the relevant activity of the Medical Staff is advisable. The COS, or his/her designee, will have the ability and duty to limit or terminate any individual's activities on behalf of the Medical Staff if it is judged that real or potential conflicts so justify.
The following arc representative, but not all inclusive, of conflict of interest situations:
Whenever a Medical Staff member is confronted with a situation which might be reasonably perceived as presenting a conflict of interest, that person should complete the submit a Conflict of Interest Statement to the COS, or his/her designee.
If unforeseen conflicts arise, it is incumbent on the conflicted member to make an immediate disclosure.
III. VIOLATIONS AND ENFORCEMENT
A. Persons in positions which require a Conflict of Interest Statement according to these guidelines, but who do not complete the Statement as required, will be relieved of their relevant duties until they comply.
B. Any other suspected violations of this policy should be reported to the COS, or his/her designee. Such reports may be made confidentially, and even anonymously, although the more information given, the easier it is to investigate the reports. Raising such concerns will not jeopardize anyone's employment or Medical Staff membership.
C. Violations may result in the removal of an individual from a committee and/or the application of appropriate disciplinary action up to and including termination of Medical Staff membership.
D. If violations of any applicable laws or regulations are suspected, the COS, or his/her designee, and/or E-HOSPITAL SERVICES, INC.'S Staff Attorney will be notified.
Telemedicine seeks to improve a patient's health by permitting two-way, real time interactive communication between the patient, and the physician or practitioner at a distant site. Telemedicine is viewed as a cost-effective alternative to the more traditional face-to-face way of providing medical care.
Distant or Hub site: Site at which the physician or other licensed practitioner delivering the service is located at the time the service is provided via telecommunications system.
Originating or Spoke site: Location of the Medicaid patient at the time the service being furnished via a telecommunications system occurs. Telepresenters may be needed to facilitate the delivery of this service.
Asynchronous or "Store and Forward": Transfer of data from one site to another through the use of a camera or similar device that records (stores) an image that is sent (forwarded) via telecommunication to another site for consultation. Asynchronous or "store and forward" applications would not be considered telemedicine but may be utilized to deliver services.
Medical Codes: States may select from a variety of HCPCS codes (T1014 and Q3014), CPT codes and modifiers (GT, U1-UD) in order to identify, track and reimburse for telemedicine services.
Telehealth (or Telemonitoring) is the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distance.
Telehealth includes such technologies as telephones, facsimile machines, electronic mail systems, and remote patient monitoring devices, which are used to collect and transmit patient data for monitoring and interpretation. While they do not meet the Medicaid definition of telemedicine they are often considered under the broad umbrella of telehealth services. Even though such technologies are not considered "telemedicine," they may nevertheless be covered and reimbursed as part of a Medicaid coverable service, such as laboratory service, x-ray service or physician services (under section 1905(a) of the Social Security Act).
GUIDELINES FOR TELEMEDICINE HEALTHCARE PROVIDERS
Documentation for telemedicine should be the same as for any patient that you may see in person with the following additions:
Notation that consult was held via telemedicine, to include patient location, how the patient located E-HOSPITAL SERVICES, INC., names of all people present during the telemedicine consultation and their role.
All electronic communications in regard to patient consult (faxes, digital pictures, etc).
Copy of the digitally signed informed consent from the patient site should be added to your record (HIPAA form).
Healthcare Providers are required to obtain informed consent for telemedicine consultations, just as they are for treating patients in person. To assist with this process a patient education handout and an informed consent have been created and routed to remote sites. A Telemedicine Consent form needs to be signed by the patient/legal representative prior to a telemedicine consult.
Patients have a right to be treated with dignity and respect.
Patients have a right to choose to stop a telemedicine consult at any time.
Patients have a right to know the name of the treating Physician.
Patients have the responsibility to completely read any and all medical disclaimers.
Patients have the responsibility to honestly, and completely, disclose their medical history, and any and all medications they may be taking, whether legal or illegal.
Patients have the responsibility to follow the treating Physician's orders and/or instructions completely.
Patients have the responsibility to notify E-HOSPITAL SERVICES, INC. In the event of any medical complications resulting from their consult, if feasible to do so.
PRIVACY AND CONFIDENTIALITY
Patients should be introduced to who is present at each location and their role in the consultation.
The consult should be held in an area that provides visual and auditory privacy.
Consent to photograph, videotape, or digitally record any images must be signed by the patient/legal representative prior to the event. This consent does not authorize the use of images for other purposes, such as teaching or publicity.
All staff present will need to comply with facility policies on privacy, confidentiality, and electronic security.
Telemedical records should be treated as any other medical record and not released without the receipt of written authorization from the patient/legal representative.
It is the policy of E-HOSPITAL SERVICES, INC. to credential any physician providing services to our patients via Tele-medicine based on procedures and specific criteria as they relate to distant site (site where the providing professional services is located ) and originating site (site where the patient is located).
This policy and the implementing procedure describe recommended actions to comply with statutory or regulatory requirements, and will be updated according to need.
Telemedicine means the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. Neither a telephone conversation nor an electronic mail message between a health care prouder and patient constitutes "telemedicine" for purposes of this policy.
Regard E-HOSPITAL SERVICES, INC., the following procedures will be applied.
E-HOSPITAL SERVICES, INC., and all Medical Staff are required to follow all federal and state telemedicine credentialing procedures.
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FAST TRACK REVIEW
To establish mechanisms for reviewing relevant data that will serve as the basis for decisions regarding licensed health care providers files and to ensure adverse information is carefully reviewed before recommendation for appointment as Medical Staff.
II. POLICY STATEMENT
It is the policy of E-HOSPITAL SERVICES, INC. to ensure all licensed health care providers are reviewed and ranked according to issues identified in their file.
When all of the information has been gathered, the file is to be reviewed by the COS, or his/her designee. This is to ensure that potentially adverse information is fully reviewed before recommending the provider for appointment as Medical Staff
I. General Issues:
IV. APPROVAL PROCESS
When the appointment or reappointment has been approved by the COS, or his/her designee, an email confirmation will be sent to each of E-HOSPITAL SERVICES, INC.'S Medical Staff indicating that such request for appointment or reappointment has received final approval from the COS, or his/her designee within 60 days of final approval. At this time, the credentialing database is updated and information is maintained by E-HOSPITAL SERVICES, INC. Any application still pending after 45 days based on information not received from the applicant will be placed in an inactive status. The applicant may have to ability to reapply at a later date. If denied, a denial letter will be sent to the applicant.
MEDICAL STAFF FOR CAUSE DRUG TESTING POLICY
To define the procedure by which medical staff may be tested for intoxicants. E-HOSPITAL SERVICES, INC. is committed to provide an environment that protects patients from impairment of their care by our members due to substance abuse or other causes.
E-HOSPITAL SERVICES, INC. recognizes the necessity to establish a procedure through which members who behave in a manner consistent with intoxication can be tested for known intoxicants in a manner which respects the rights of the individual member while at the same time protecting our patients against impaired caregivers.
III. ROLES AND RESPONSIBILITIES
The implementation, administration, and management of these procedures shall be the responsibility of the COS, or his/her designee. Concerns about possible intoxication may be raised by members of the medical staff, coworkers, other employees, patients, family members, or visitors.
V. VALID CAUSE
Valid causes for concern include the following:
- Practitioner has sustained a work related accident or injury which alone, or in combination with other observations listed below, might lead a reasonable observer to suspect intoxication of some kind.
- Practitioner has been involved in a clinical incident which alone, or in combination with other observations listed below, might lead a reasonable observer to suspect intoxication of some kind.
- Practitioner has otherwise unexplained difficulty with movements, balance, or coordination which alone, or in combination with other observations listed below, might lead a reasonable observer to suspect intoxication of some kind,
a. Loss of balance
d. Leaning on objects for support
- Practitioner's conduct, speech, content of speech, or slurring of words which, if not otherwise explained, justifies a reasonable concern about intoxication of some sort.
- Physical appearance which, if not otherwise explained, justifies a reasonable concern about intoxication of some sort; e.g.:
a. Eyes red or glassy
b. Pupillary changes (small-pinpoint or dilated)
- Direct evidence of possible alcohol/drug use at work:
a. There is odor of alcohol on practitioner's breath
b. Practitioner observed or discovered to be in possession of intoxicants or related paraphernalia on day of accident injury
c. Practitioner witnessed to be using alcohol or other intoxicants before or while on duty.
- Practitioner appears to have impaired judgment, concentration or ability to attend to current patient care tasks.
- Practitioner appears compromised and presents a hazard to patients, others, and/or self; or exhibits any pattern of behavior which justifies a reasonable concern about intoxication of any sort.
VI. GENERAL PROCEDURES
Any medical staff member or employee who is concerned about possible intoxication or other acute impairment of a medical staff member, or who is informed of such a concern, should immediately contact the COS, or his/her designee.
Consent for testing should be obtained only by the COS, or his/her designeea member of the COC, after it is confirmed that testing is indicated. Consent may be verbal and is confirmed by the cooperation of the individual being tested.