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Hospital Administration San Francisco General Hospital and Trauma Center
1001 Potrero Avenue ◦ Suite 2A5 ◦ San Francisco, CA 94110 Telephone (415) 206-3517 ◦ Fax (415) 206-3434
San Francisco General Hospital and Trauma Center
Susan A. Currin, RN, MS Chief Executive Officer
City and County of San Francisco
Department of Public Health Gavin Newsom Mayor
M E M O R A N D U M TO: Honorable Dr. Edward A. Chow, M.D. Chair
Health Commissioner Honorable David J. Sanchez, Jr., Ph.D. Health Commissioner Honorable Catherine Waters, R.N., Ph.D. Health Commissioner FROM: Susan A. Currin, RN, MS Chief Executive Officer San Francisco General Hospital and Trauma Center DATE: November 5, 2009 SUBJECT: Action Item: Approval of Medical Staff Policies The following items are submitted for your approval pursuant to the anticipated findings of the CMS physician surveyor. 1. The Medical Staff Credentialing Policy and Procedure 2. Autopsy Authorization Policy and Procedure 3. Radiology License, Certification, and Permit Requirements Policy 4. Radiology Clinical Service House Staff Training Program and Supervision Policy 5. Staff Radiologist: Credentials and Privileges Policy 6. Frequency and Detail of Quality Data Collection Copies to: SFGH Joint Conference Committee Members James M. Illig, President, Health Commission
SFGH MEDICAL CENTER Medical Staff Organization
Credentialing Manual
Office of Origin: Medical Staff Office (415) 206-2342
I. PURPOSE: San Francisco General Hospital (SFGH) and Clinics ensure that licensed health care providers meet the minimum credentials standards for Medical Staffor Affiliate Staff membership.
ll. REFERENCES: • Medical StaffBylaws, Rules and Regulations • Joint Commission Medical Staff Standards • NCQA Credentialing Standards • CMS Conditions ofParticipation • Committee on Interdisciplinary Practice (CIDP) Policy and Procedures
ill. DEFINITIONS:
Practitioner: Any currently licensed physician (M.D. or D.O.), dentist, clinical psychologist, or podiatrist, unless otherwise expressly limited.
Affiliate Health Professional: Categories include: Advanced practice registered nurses (NP - nurse practitioner, CNM - certified nurse midwife, or CRNA - certified registered nurse anesthetist), PA - physician assistant, advanced practice Pharm.D and other categories as approved by the Governing Body.
Provider: For purposes of this document, provider means practitioners and affiliates.
Complete Application: A complete application., at the point that verifications are finished, means the following: • all information was verified and any missing information is explained or
accounted for; • all gaps in time of three months or more are accounted for; • any discrepancies between information provided by the applicant and the
information verified by SFGH have been resolved.
IV. POLICY:
A. The Medical Staff Office conducts credentialing for all clinical venues within SFGH and will only delegate credentialing to any outside entities if needed. Credentialing is performed prior to appointment and reappointment to the SFGH Medical Staff
• I
B. Each provider has a confidential credentials file, which contains verification documents. For Medical Staff members, the credentials file includes quality
SFGH Medical Staff Credentialing Manual 1009.docI of 8 11/512009 3:04 PM
information as described in Appendix A. These files are re-verified at least every two (2) years. Expirable documents are updated on an ongoing basis. All required verifications must be no more than 180 days old at the time of Governing Body review.
C. Credential files are treated as confidential and are kept within file cabinets with access by Medical Staff Office personnel only. These files are protected from discovery pursuant to Evidence Code Section 1156, et seq. Documents in these files may not be reproduced or distributed, except as permitted pursuant to State Law, including Section 1156, et seq.
1. The credentials file may be reviewed by contracting health plan representatives (pursuant to delegated credentialing agreements), except that irlformation determined to be confidential.
A provider has the right to review the items in their credentials file, except the following elements: National Practitioner Databank Reports and Letters of Reference. The provider may submit a signed addendum offering additional information about documents, indicators or events included in the credentials file.
2. The quality information may be reviewed by contracting health plan representatives for the following elements: malpractice claims history, disciplinary actions by hospitals, managed care organizations or State Medical Boards and outcomes of those actions. Other quality items are subject to review pursuant to delegated quality agreements or the National Commission on Quality Assurance (NCQA) credentialing standards.
A provider has the right to review the items in their quality file, except letters of reference or documents related to peer review activities. The provider may submit a signed addendum offering additional information about documents, indicators or events included in the quality file.
D. Provider Rights to obtain Status of Application Upon request, providers will be notified of the status of their application during the credentialing process.
E. Provider Rights to Amend Application The provider attests that all information submitted for the credentialing process is accurate and agrees to immediately report any changes in information. Ifany submitted items differ substantially from documentation disclosed throughout the verification process, the provider will be asked (via phone, letter or email) to resolve this discrepancy. The provider will be given opportunity to resolve the discrepancies, with response to the Credentials Committee Chair. Any attempts to intentionally hide or misrepresent information are addressed during the Credentials Committee review. . ,
SFGH Medical S1aff ered P&P 2of8 1115/2009 3:04 PM
F. Notification of Provider Rights: Pursuant to the Medical Staff Bylaws, providers are notified of their rights to: • review information submitted to support their credentialing application; • correct erroneous information; and • be informed of the status of their application upon request.
G. Upon delegation of credentialing activities, audits may be performed by health plan representatives and other payers, based upon the following guidelines: 1. Audits must be scheduled in advance at a time mutually agreed upon by SFGH
and the auditing entity. 2. Selected documents regarding peer review may not be subject to auditing. 3. Auditors may not photocopy or remove documents.
If credentialing is not delegated, the health plan/payer is responsible for credentialing providers for their health plan.
V. PROCEDURE
A. Initial Appointments
I. The following information is required to begin the Initial Appointment process: • Request from Department • Applicant Name • Curriculum VitaelResume including all professional work history • Faculty Appointment (if applicable) • Requested PrivilegesIProtocols (Standardized Procedures), when applicable • Requested Start Date for Temporary Privileges/Credentials only • ill attestation per Joint Commission guidelines
2. Providers must complete the following items: • Application for Medical Staff or Affilate Staff appointment including
Confidentiality Statement and Consent to Release Information, Privileges, or for Affiliate, Standardized Procedures.
• Agreement to abide by the Medical StaffBylaws, Rules and Regulations • Health Plan Attestation form (as applicable) • Environmental Safety form
3. In addition to returning the above documents, providers also must submit any relevant licensure/certificates as applicable to the requested privileges or clinical activity, including but not limited to: • Copy of California License(s) (an on-line query is acceptable) • Copy of DEA Certificate and/or Furnishing certificate as appropriate (a query is
acceptable) • Evidence of Current Malpractice Coverage, if applicable • Fluoroscopy Certificate as appropriate • Current Photo
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• CPR, BLS/ACLS, PALS, NALS, if applicable • Current Curriculum Vitae (CV)
4. The Medical Staff Office reviews the documents as follows: a. All items on the application form, which includes answering all questions on the
application, enclosing copies of requested documentation, and providing attachments or written explanation for any irregularities on certain questions about practice issues, legal matters and health status.
b. Applicant's signature is present and dated on all forms. The applicant must have signed the application and request for clinical privileges.
c. Clinical venues are specified and appropriate. d. Complete addresses, phone and fax numbers as listed for:
• Medical school, Internships, Residencies, Fellowships; • Hospitals and affiliations; • Peer references; and • Malpractice insurance company(ies)
e. Privileging forms or Standardized Procedures are completed as appropriate. f Continuing Medical Education (CME) materials document any courses relevant to
specific privileges requested. g. California License(s), DEA Certificate, and Fluoroscopy Certificate are current
5. Verification of information begins as soon as the application appears complete and is conducted as specified in Appendix B - Verification Methods. Verification for some items must be obtained from primary sources and are received in writing from the primary sources, although oral verification may be done. Verbal verification requires a dated, signed note in the credentialing file stating who at the primary source verified the item, the date and time of verification.
Many primary sources have on-line access available, which is the preferred method of verification for primary source items. When an automated verification system is used, the documentation notes the date the query was performed.
6. File Triaging: Once all of the information is gathered, the applicant's file is triaged by the Medical Staff Office and flagged for potentially adverse information to be carefully evaluated during the Credentials Committee review.
7. Temporary Privileges for Initial Appointments: For Initial Appointments involving clinical urgency, a Service Chief may request temporary privileges up to 120 days. Request for Temporary Privileges/Credentials must be approved by the CEO (or authorized designee) on the recommendation of the Chief of Staff (or authorized designee).
Actions on temporary privileges/credentials are updated in the Medical Staff Office database upon approval and appropriate areas are notified. The Medical Staff Office database updates the applicant's status and privileges/protocols are displayed on intranet websites for inquiry by the applicant or other Medical Center staff
SFGH Medical Staff Cred P&P 4of8 11/512009 3:04 PM
Notification is forwarded to the applicant within 10 days of the decision on the request for temporary privileges.
B. Reappointments
1. Reappointment Application Packet At least five (5) months prior to the end of the two (2) year appointment period, the provider is mailed an application for reappointment. Previously submitted information is queried to produce the reappointment application. The reappointment packet includes: • Preprinted Reappointment Application • Copy of current clinical privileges
2. The provider is required to return the application and supporting documents within thirty (30) days, and include the following: • Copy of current DEA Certificate as appropriate • Fluoroscopy Certificate as appropriate • CPR, BLS/ACLS, PALS, NALS, if applicable • Current CV
3. Ifthe application is not returned within the designated time period, the provider and Department Chair will be notified for a delinquent reappointment and will receive a (15) day extension to complete the paperwork. Failure to submit a reappointment application at least 45 days before the expiration date of the current appointment may be deemed to be a voluntary resignation from the Medical Staff, and the provider will be submitted as "resigned" to the Credentials Committee.
Practitioners/Affiliates who automatically resign shall be required to complete a reinstatement form to reapply for membership. Reinstatement shall be processed in a manner parallel to the reappointment process. Reinstatement application forms shall be accepted within one (1) month from the date the practitioner membership expires.
All Practitioners/Affiliates whose membership has expired longer than one (1) month shall be required to complete the initial appointment process.
4. The Medical Staff Office reviews the documents as follows: a. All items on application form. This includes answering all questions on the
application, enclosing copies of requested documentation, and providing attachments or written explanations for any irregularities on certain questions about practice issues, legal matters and health status.
b. Applicant's signature is present and dated on all forms. c. Privileging forms and Standardized Procedures are completed as appropriate. d. Clinical venues are specified and appropriate. e. Completed addresses, phone and fax numbers as listed for:
• Hospitals and affiliations . I
• Peer references; and
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• Malpractice insurance company(ies) f. Continuing Medical Education (CME) materials document any courses relevant to
specific privileges requested. g. California License(s) and applicable certificates (e.g. DEA, Fluoroscopy) are
current.
5. Verification ofInformation Verification of information begins as soon as the application appears complete, and is conducted as specified in Appendix B - Verification Methods. Verification for some items must be obtained from primary sources and are received in writing from the primary sources, although oral verification may be done. Verbal verification requires a dated, signed note in the credentialing file stating who at the primary source verified the item, the date and time of verification.
Many primary sources have on-line access available, which is the preferred method of verification for primary source items. When an automated verification system is used, the documentation notes the date the query was performed.
6. Reappointment Performance Improvement The results of performance monitoring, evaluation, and identified opportunities to improve care and service are documented in this file. Data Summary sheets are collected and provided as evidence of the practitioner's current competence and suitability for medical staff membership.
7. Pre Credentials Committee Meeting (See Appendix C).
Co Evaluation And Approval Process
1. Clinical Services Evaluation Process If an issue is identified, the related documentation is flagged for the Service Chief to review. The complete file (including application, supportive documents, and privileges request form) is sent to the appropriate Service Chief for review and recommendation to the Credentials Committee. If the applicant's file was flagged, the reviewer must document sufficient review to support making a recommendation for appointment/reappointment.
If the Service Chief is disinclined to make a favorable recommendation based on: • a perceived medical disciplinary cause or reason, indicating the potential for a
provider's conduct to be detrimental to patient safety or to the delivery of patient care; or
• perceived conduct or professional competence which affects or could adversely affect the health or welfare of a patient or patients,
the Service Chief drafts a report to the Credentials Committee indicating concerns with the appointment/reappointment. . I
SFGH Medical Staff Cred P&P 60f8 lJIS12009 3:04 PM
After the Service Chief s recommendation, the file is prepared for the montWy Credentials Committee and the applicant is added to the next monthly Credentials Committee Summary Report.
2. Credentials Committee Evaluation Process The Credentials Committee reviews the Summary Report and Committee makes a recommendation for appointment/reappointment. This report is then sent to the Medical Executive Committee (MEC).
3. Medical Executive Committee and Governing Body Evaluation Process The Credentials Committee Summary Report is reviewed by the Medical Executive Committee, then the Joint Conference Committee, and then referred to the Health Commission as the Governing Body.
Actions on appointments/reappointments are updated in the Medical Staff Office database within 10 days of Governing Body approval. The Medical Staff Office database updates are displayed on intranet websites for inquiry by the applicant or other Medical Center staff Notification of the Governing Body decision is forwarded to the applicant within 30 days.
4. Provider Enrollment Upon Governing Body approval, the Credentials Committee Summary Report is sent to the contracted Health Plans.
D. Visiting Privileges I. In circumstances involving clinical necessity when clinical services require the
services of a physician, dentist, podiatrist or clinical psychologist who is not a member of the Medical Staff, visiting privileges may be granted on a case by case basis.
2. The following information is required to begin the Visiting Privileges process: • Completed Application • Curriculum VitaelResume including all professional work history • Faculty Appointment (if applicable) • Service ChiefRecommendation • Requested Privileges • Requested Start Date
3. Providers must complete the following items: • Visiting Application including Confidentiality Statement and Consent to Release
Information and Privileges. • Review the Medical Staff Bylaws, Rules and Regulations
4. In addition to returning the above documents, providers must also submit any relevant licensure/certificates as applicable to the requested privileges or clinical activity, including but not limited to:
SFGH Medical Staff ered P&P 70f8 111512009 3:04 PM
• •
• • • •
Copy of California License(s) (an on-line query is acceptable) Copy of DEA Certificate and/or Furnishing certificate as appropriate (a query is acceptable) Evidence of Current Malpractice Coverage Fluoroscopy Certificate as appropriate CPR, BLS/ACLS, PALS, NALS, if applicable Current Curriculum Vitae (CV)
5. The Medical Staff Office reviews the documents as follows: • All items on the application form, which includes answering all questions on the
application, enclosing copies of requested documentation, and providing attachments or written explanation for any irregularities on certain questions about practice issues, legal matters and health status.
• Applicant's signature is present and dated on all forms. The applicant must have signed the application and request for clinical privileges.
• Clinical urgency and venues are specified and appropriate. • Complete addresses, phone and fax numbers as listed for:
o Hospitals and affiliations; o Peer references; and o Malpractice insurance company(ies)
• Privileging forms are completed as appropriate. • California License(s), DEA Certificate, and Fluoroscopy Certificate are current.
6. Verification of information begins as soon as the application appears complete and is conducted as specified in Appendix B - Verification Methods. Verification for some items must be obtained from primary sources and are received in writing from the primary sources, although oral verification may be done. Oral verification requires a dated, signed note in the credentialing file stating who at the primary source verified the item, the date and time of verification, and how it was verified.
Many primary sources have on-line access available, which is the preferred method of verification for primary source items. When an automated verification system is used, the documentation notes the date the query was performed.
7. The Chief of Staff and the Executive Administrator (or authorized designees) may grant Visiting privileges for a specified period of time after the above information has been evaluated by the applicable service chief and he/she has made an affirmative recommendation.
E. Expirables/Ongoing Monitoring Sanctions and expirables are monitored on a montWy basis as indicated in Appendix B - Verification Methods.
I•
SFGH Medical Staff Cred P&P 80f8 111512009 3:04 PM
APPENDIX A - CREDENTIALS AND QUALITY FILES A. CREDENTIALS FILE
The following documents are kept current and maintained in the Credentials file (as applicable): 1. Application for membership. 2. Delineation of privileges, recommended by the Service Chief in the service which
privileges are being requested. 3. Current California State Medical (or other professional) License 4. Valid DEA certification, as applicable 5. Current X-ray Supervisor and Operator Certificate, as applicable 6. Verification of graduation from medical (or other professional) school and
completion of residencies and fellowships 7. Verification of previous affiliations priorto SFGH Medical Staff appointment 8. Curriculum Vitae that includes a comprehensive work history 9. Evidence of current, adequate malpractice insurance 10. Professional liability claims history 11. Verification ofBoard Status Certification or Candidacy, as applicable 12. National Practitioner Data Bank Query Report (which includes Medicare and
Medicaid Sanctions activity) 13. California Medical Board Status check for validation oflicense and sanction
activity 14. Letters ofReference that attests to clinical competence and ethical character of the
applicant. 15. Continuing Medical Education Compliance 16. Consent to release relevant information. 17. Copies ofthe Governing Body Approval letters confirming Medical Staff
appointment and/or approved privileges 18. For Affiliate Staff only: CPR (BLSIACLS) certification
B. QUALITY FILE The quality files contain the following historical and current documents (as applicable): 1. Any action taken as a result of a malpractice claim within the previous three (3)
years. 2. Reports of disciplinary actions and the outcome of those actions. 3. Results of internal and health plan quality management review such as Peer
Review, Surgical Case and Hospital Mortality Review, Transfusion Committee reviews, patient complaints, clinical activity reports, and other quality indicators.
4. State Medical Board reports on any state sanction activity (e.g. 805 reports). 5. Any supplemental information or documentation regarding quality of care
including, but not limited to, letters of reference or service.
. ,
T:IMSSD Credentialing & Office Procedures\Credentialing\SFGH Medical Staff Credentialing Manual Appendix 1009.doc 1 of 9
APPENDIX B - VERIFICAnON METHODS I I
[il CREDENTIALING METHOD OF
~ ITEM VERIFICATION INITIAL APPOINTMENT
NEW PRIVILEGES
REAPPOINT
IHENT
UPDATE AS EXPIRES
VISITING! TEMP
PRIVILEGES I. I License to Website as available for
Practice in the type of provider. If California website that is considered
prime source verification is Includes I not available, credentialer information related to
confirms in writing. I X I X I X I X I X
licensure sanctions monitored monthly
2. IDEA Obtain on line verification. Registration Ifwebsite that is
considered prime source Provider attests verification is not ifDEA is not available, credentialer I X I X I X I X I X applicable to confirms in writing. scope of practice.
3. Fluoroscopy Obtain on line verification. Certificate Ifwebsite that is
considered prime source Provider attests if certificate is
verification is not available, credentialer I X I X I X I X I X
not applicable to confirms in writing. scope of ractice.
T:IMSSD Credentialing & Office Procedurcs\Credentialing\SFGH Medical Staff Credentialing Manual Appendix 1009 .doc 2 of 9
APPENDIX B - VERIFICAnON METHODS I I
iil I CREDENTIALING I METHOD OF
~ ITEM VERIFICATION INITIAL NEW REAPPOINT UPDATE AS VISJ'l'ING/
AJ'}'OINTl\IRNT PRIVILEGES l\IENT EXPIRES TE~IP
PRI\lLEGES
4. Medical School May be obtained (in (Domestic writing or orally) from the Graduates) institution(s) where
medical school/other Or Other professional school Professional completed or the AMA or x Schools (non- AOA profile service, as physician applicable. applicants)
5. ECFMG www.ecfmg.org or in (Foreign writing from ECFMG Graduates)
For physicians x who 'enter USA-based internship/residency programs.
6. I Internship/other May be obtained (in professional training
writing or orally) from the institution(s) where training completed or the AMA or AOA profile x service, as applicable.
SFGH Medical Staff Credentialing Manual Appendix 1009 .doc 30f9 11/5/2009 3:02 PM
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APPENDD( C - FILE TRIAGING CATEGORMSInitid Aooointment ReappointmentThe provider's file may includequestionable information, suchtts:o Peerreferences and prior
affiliations indicatepotential problems.
o malpractice claimso Criteria for Privileges
requested is not met.o InternationalMedical
Graduate
The provider's file may includequestionable information, suchas:o Peer refsrences and prior
affiliations indicatepotential problems.
r malpractice claims in past 3years
o Health problem identifiedwhich will likely haveimpact on exercise ofclinical privileges orstandardized procedures.
r Lack of clinical activity ordifficulty in obtainingmonitoring reports
The provider's file showspotentially adverseinformatioq including:o Unsatisfactory peer
references or prioraffiliations
o Disciplinary actions orreports filed by anyverifi cation organization(NPDB, Federations, MBC,Medicare Sanctions, AMA)
o Clinical privileges revoked,diminished or altered byanother Healthcareorganization
o Any existing informationshows a quality of care orcompetency issue
The provider's file showspotentially adverseinformation, including :o Disciplinary actions or
reports filed by anyverifi cation organization(NPDB, Federations, MBC,Medicare Sanctions, AMA)
o Clinical privileges revoked,diminished or altered byanother Healthcareorganization
o New privileges requestedoutside of normal scope ofspecialty
o Any existing informationshows a quality of care orcompetency issue
T:WISSD Credentialing & Office Procedures\Credentialing\SFGH Medical StaffCredentialing Manual Appendix 1009.doc 8 of 9
APPENDD( D - SOURCES OF PERFORMANCE IMPROVEMENT DATAWhen available. information from these sources is inteerated into the credentialins orocess:
1 . Patient Complaints and Grievances: Significant issues are forwarded to QualityImprovement and/or Risk Management for further analysis with communication to theService Chief. Ifthe Service Chief determines immdiate action is required, the Chief ofthe Medical Staffis notified and initiates appropriate resolution.
Clinical Activity Reports: For monthly reappointment cycles, physician volume statisticsand comparative data are gathered by the Medical StaffOffice. Providers with no clinicalactivity may provide supporting information for consideration by the Service Chief toensure appropriate recommendation of membership/privileges.
Quality Measures: Physician specific quality data identified for Credentials Committeereview as appropriate.
Peer Review: Individualized profiling information is assessed by the Service Chief.
Medical Record Delinquencies: The Service Chief reviews and notates as appropriate.
Risk Management/l}lelpractice Claims: Risk Management entities report UC Regentsand San Francisco City and County claims history. Providers are obligated to disclose pastand pending liability actions and provide further details regarding these actions, includingspecific discussion with the Service/Division Chief. Claims histories also are requestedfrom external professional liability insurance companieg as applicable. Providers with oneor more claims are flagged for review by the Service Chief and the Credentials Committee.
Suspensions/Sanctions: Physicians may be suspended for non-compliance with policies asoutlined in the Medical StaffBylaws, and for infractions, such as a license revocation orother action by the Medical Board or Governing Body (please see the Medical StaffBylawsfor further information). These suspensions are monitored by the Medical StaffOffice andidentified for Service Chief and Credentials Committee review.
Service Quality Indicators: Each clinical service establishes and monitors qualityindicators. The Service Chief considers applicable indicators when recommendingappropriate membership/privileges and indicates any issues for Credentials Committeeconsideration.
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SFGH Mdical StaffCredentialingl\{arual Appendix 1009 .doc 9 of 9 lllsl2ffig 3:03 PM
ADMIN: 1.23 Autopsy Authorization
lroPl
Policy Number: 1.23
TITLE: AUTOPSY AUTHORIZATION
PURPOSE
Page I of4
The purpose of this policy is to outline the procedures for securing authorization to perfo(m an autopsy.
STATEMENT OF POLICY
It is the policy of San Francisco General Hospital Medical Center (SFGHMC) to seek authorization toperform an autopsy on a patient whose death occurs at SFGHMC.
PROCEDURE
I. Valid Authorization
A. Pursuant to California Health and Safety Code, Section 7113, an autopsy may beperformed on the remains of any patient whose death occurred at SFGHMC if anauthorization has been obtained as follows:
1. From the patient in his/her will or other written instrument prior tohis4rer death: or.
2. From an "authorized person" in writing, by telegram, or by fax.
An "authorized person" is the closest next of kin and should be considered inthe following order:
a. An individual who has been appointed an attorney-in fact inthe decedent's Durable Power of Attorney for Health Care:
b. The surviving spouse;c. A surviving child or parent;d. A surviving brother or sister;e. Any kin or person who has acquired the right to control the
disposition of the remains;f, A public administrator; org. A medical examiner or any other duly licensed public
officer.
B. Questions or conflicts among the next of kin regarding the authority to consent to orthe validity of a consent should be directed to either the SFGHMC Risk Manager at206-6600 or the UCSF Risk Manager at 206-6052.
II. Reporting of Deaths to the Medical Examiner's Office
A. Before an effort is made to obtain authorization for an autopsy, the physician whocared for the deceased patient must consult with the Medical Examiner by telephone
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ADMIN: 1.23 Autoosv Authorization Page 2 of 4
(415) 553-1694 to obtain hisftrer release of any jurisdiction over the case (SeeSFGHMC's Administrative Policy
B. A note should be made on the "Authorization for Autopsy" form (See Appendix A)indicating the date, time, and the name of the person in the Medical Examiner'sOffice who gave the release ofjurisdiction.
m. Consent for Autopsy
A. Persons authorized to give consent for autopsy must be approached in a respectful andtactful manner. The reasons and value of performing an autopsy should be explained tothem. An autopsy should not be performed if at the time of death the deceased person wasknown to be a member of a religion which relies solely upon prayer for the healing ofdisease. This exception may be overruled by the City and County of San Francisco (CCSF)Medical Examiner.
Written authorization should be obtained on the SFGHMC "Authorization forAutopsy" Form (See Appendix A). This form may be obtained from the DeathRegistry in the Health Information Services Department (HIS) (NH Room 2B1,telephone # 206-8015). The physician on duty or designee (who signs as a witness)should obtain the signature of the "authorized person".
If authorization is obtained by telegram or fax, the "authorized person" should be instructedto send the following:
"I, [name and relation] , give authorization for an autopsy on [full name of
deceased] ." Any limitations may follow this statement and should be specificand include the anatomic part. Modifications of this procedure may result in adelay, require a second telegram or fax from the "authorized person", and/ormay result in the loss of an important autopsy. Any modifications should becarefully reviewed by the Pathologist on-call.
The "authorized person" unwilling to give authorization for a complete autopsy maybe willing to permit a limited autopsy examination of organs of major clinical interestsuch as the heart, lungs, liver, etc. Any restrictions or limitations must be clearlystated on the "Authorization for Autopsy" form and communicated to the Pathologiston-call.
The pathologist on-call should be notified after the authorization for autopsy isobtained. He/she may be contacted before authorization is obtained if there are anyquestions concerning the authorization andlor the proposed time of the autopsy.
The physician requesting an autopsy is responsible for sending or taking the medicalrecord and the "Authorization for Autopsy" form to the Death Registry, HIS.
The physician who is most familiar with the deceased patient's case should discussthe case with the pathologist assigned to the case, the chief resident in the Departmentof Anatomic Pathology, or other members of the Anatomic Pathology staff. Suchcommunications provide the opportunity for delivering maximum benefit from theexamination and provide guidelines for special studies, cultures, etc. During non-
B.
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ADMIN: 1.23 Autopsy Authorization Page 3 of4
business hours, the Switchboard Operator can contact the Pathologist on-call.
H. Death Registry in HIS is available from 7:30 a.m. to 4:00 p.m., Monday throughFriday, at 206-8015 for information. HIS ensures that the medical record and"Authorization for Autopsy" form are then forwarded immediately to the Departmentof Anatomic Pathology.
ry. Requirements for Performing an Autopsy
A. The Pathologist on-call cannot perform an autopsy unless the following requirementsare fulfilled:
1. The Medical Examiner has released jurisdiction of the case;
2. The physician on duty has obtained the authority for an autopsy from an"authorized person";
3. A note regarding the circumstances of the patient's death has been writtenin the progress notes of the deceased patient's medical record. Theautopsy will be delayed until the Death Note is documented. The DeathNote is required in addition to completing the "Postmortem Form" (SeeAppendix B); and,
4. If the case was reported to the Medical Examiner, the Death Note mustinclude a statement that the case was reported to the Medical Examiner,the name of the Medical Examiner or his designee, and that the MedicalExaminer has released the body for autopsy to Anatomic Pathology.
V. Autopsy and Authorization for Unclaimed Dead
A. All bodies of adult patients that are unclaimed and/or indigent must be reported tothe Public Administrator and Medical Examiner by HIS.
o A body is "unclaimed" if the decedent has no known relative and noknown arrangements have been made for burial.
o The decedent is "indigent" if no financial resources for burial are known.
B. The CCSF's Public Administrator, in cooperation with the SFGHMC HIS, conducts asearch to identiff and locate relatives and/or financial resources ofthe decedent. Ifnone are located, the Public Adminishator declares the decedent unclaimed and/orindigent as appropriate and officially notifies HIS. This search takes at least24 hoursand sometimes as long as 72 hours. Following declaration as unclaimed, the PublicAdministrator makes arrangements for disposition of the remains and notifies theDeath Registry staff.
C. An autopsy request on an unclaimed body can be made by a clinical service byindicating this interest on the "Postmortern Form" (See Appendix B) which issubmitted to HIS. HIS will noti$ the State Curator at (415) 476-1981.
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ADMIN: 1.23 Autopsy Authorization
Approval:
Nursing Executive Committee:Medical Executive Committee:Executive Committee:
Page 4 of 4
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In order to authorize an autopsy, the State Curator must have the followinginformation: the name, age, and gender of the decedent; the date, time, and suspectedcause of death; the name of the Physician signing the certificate of death;documentation that CCSF's Public Administratoi has been notified; and plans fordisposal of remains.
Authorization for autopsy, including an authorization number, is issued verbally bythe State Curator. HIS completes the "Authorization for Autopsy" Form (AppendixA) and fills in the authorizationnumber. HIS also indicates thi authorization ntrmUeron the Death Registry form. The original is filed in the decedent's medical record anda copy is forwarded to the Department of Anatomic pathology.
HIS is notified after_Anatomic Pathology Department has completed the autopsy.Death Registry notifies the undertaker, arranged by the Public Administrator,^that theremains may be picked up. Autopsy results are retained in the decedent's medicalrecord.
APPENDICESAppendix A: "Authorization for Autopsy" formAppendix B: "Postmortem Form"Appendix C: "Release of Remains to Mortuary" form
INCORPORATES AND SUPERSEDES:SFGHMC Administrative P&P: 1.24 Autopsy Consents for Unclaimed Dead and
Retention of Bodies and pathology Specimens
CROSS REFERENCESFGHMC Administrative p&p's :
3.1I Medical Examiner's Cases15.3 Organ and Tissue Donations
s/01t075103t076104t07
Date Adopted: 07/14189Reviewed: 11195,06/07Revised: 7193,04199,0812001, 512004
IEnd]
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( Y ' '
Radiology Policy #:
Date Adopted:
Revised:
AD-002
10nt92
10195 :3 196. 09 /04. lr 107
TITLE: Radiology License, Certification, and Permit Requirements
Supersedes: Non-Medical Staff Licenses & Certificates
POLICY: Radiologic Technologists, RN's, Diagnostic Medical Sonographers, and theMedical Records Technician Supen isor are required to maintain cunent licensesand certifications to perform their work.
Employees in technical job classes as stated in the policy title are required to maintain certificatesand licenses as outlined below:
o Radiologic Technologists are required to have a CRT (Califomia Radiologic Technologist)' license issued by the State of Califomia, deparhnent of Public Health, Radiologic HealthBranch GIA) to operate radiologic equipment in the performance of x-rayprocedures. As ofJanuary I,2007, radiologic technologists are also required to have a State-issued FluoroscopyPermit;. Radiologic Tecbnologists (except for those grandfathered tn) in c1assifications2467,2468,2469, AND 2496 (Dn 1, DII 11, DIT Itr, Superrrising) are required to have ARRT (AmericanRegrsty of Radiolo gic Technologists) certifi cation;o Radiologic Technologists who are or maybe assigned to Mammogaphy are required tohave a current Mammography License, issued bythe State of California, RHB. This isobtained by:
1. Taking a 40 hour course2. Passing a State exam to qualiff to begin taining for the ARRT exam3. Training for the ARRT exam4. Taking the ARRT exam and submitting the results to the State of California
o Diagnostic Imaging Techs 2467 ,2468,2469 nd 2470 (DIT I, [, [, IV) and 2424 X-rayLab Aides are required to have a current CPR certificate;. Radiology technologists assigned to specialty areas require advanced certification i.e., CT:ARRT-CT; MR[: ARRT-MR;IR: ARRT-IRo Nurses are required to have a license (RN) issued by the Board of Registered Nurses and aminimum of BLS certification, ACLS certifi.cation is recommended;o Diagnostic Medical Sonographers (2470, DIT IV) are required to have a cu:rentcertification (RDMS) through the American regishy of Diagnostic Medical Sonographers. TheDirector of Radiologymay exempt new graduates for up to 4 months to allow for RDMS examschedules:
Ho
AD-002 License, Certification, and Permit Requirements.doc Page 1
o The Medical Records Technician Supervisor is required to have a current certification(ART) through the American Health Infonnation Management Association.
A curent listing of employees, their license numbers and license expiration dates is postedconspicuously in the departrnent's waiting room.
AD402 License, Certifi cation, and.Permit Requirements,doc Page2
TITLE:
Supersedes:
POLICY:
Radiology Pol #z lvD-224
Date Adopted:
Revised: 01104: 11107
Radiology Clinical Service Housestaff Training Program and Supervision
The Department of Radiology considers all physicians participating in ACGMEapproved training programs to be resident physicians. It is the policy of thedepartment that no residents perform diagnostic or interve,ntional clinical serviceswithout supewision by an attending faculty physician.
MarkWilsbn, M.D.
PROCEDURE:
All diagnostic imaging examinations performed bythe Departrnent ofRadiolory are interpreted andreported by one of the following procedures:
1. The examination is personally reviewed, interpreted and dictated by an attending facultyphysician.
2. A resident physician performs a review contemporaneous with an attending phlsician andthendictatesapreliminaryreportoftheresults. Thereportisthenreviewedbytheatte,ndingfacultyphysician who signs a statement in the report confirming that he or she has personally reviewedboth the examination and the resident's preliminary report and either agrees with the resident'sdescription of the attending physicians interpretation as originally dictated or has edited theresident's report to reflect his or her opinion of the findings on the examination.
3. A resident physician performs a prelirninary review of the examination and dictates apreliminary report of the results. The examination and the report are then reviewed by an attendingfaculty physician who signs a statement in the report confirming that he or she has personallyreviewed both the examination and the resident's preiiminary report and either agrees with theresident's interpretation as originally dictated or has edited the resident's findings.
MD-224 Radiology Clinical Service Housestaff Trainingi Program and Supervision.docPaee I of I
If the resident's preliminary interpretation has been kansmitted for use in the fieatne,lrt ofthe patient(either orally or in writing) prior to the attending faculty physician's review of the exarnination andthe attending physician significantly disagrees with the resident's findings after personnallyreviewing the examination, the attending phlaician notifies the referring physician of his/her ownopinion in addition to editing the resident's findings in the medical record. Attending facultyphysicians must make evelT effort to review the examination in a timelymanner after the resident'spreliminary interpretation.
A11 invasive imaging procedures and therapeutic interventions are performed by attendingradiologists or residents with direct personal supervision of an attending facultyradiologist. Someinvasive therapeutic interventions performed in the Radiolory Deparhnent (such as thoracentesis) arealso performed at the bedside by non-radiologists without the need for imaging quidance. Since onlythose patients wrth the most complex pathologic anatomy are referred for image-guided procedures,direct attending radiologist supervision is always required when radiology residents perform theseprocedures.
In accordancewithHCFAregulations, invasiveimagingprocedures andtherapeutic interventions areconsidered either maj or or minor procedures based on procedure complexity. For minor proceduresperformed by residents, the attending radiologist is in the procedure room throughout the entireprocedure. For major procedures performed by residents, the attending radiologist is in theprocedure room directly supervising during the key portions of the procedure and in the immediatevicinity dwing the remainder of the procedure. The minor and major procedures included in thispolicy are listed later in this manual. For each major procedure the key components are described.To document the attending radiologist's involvement in the procedure he or she must sign apersonalnote on the radiology report describing his or her participation.
Following is a list of Major and Minor procedures performed in the departrnent. For all majorprocedures, the key components are described.
MD-224 Radiology Clinical Servicc Housestaff Trainingi Program and Supervision.docPase? of2
Major and Minor Procedures Requiring Staff Radiologist Supervision
Maior Procedures , Key Comnonents19000 ASP BREAST CYST Gdlrpt"*-""t19030 GALACTOGRAM Needle placement19102 PERC CORE BX BREAST Needle placement19103 PERC coRE BX BREASTROT/VAC AS Needle plur"*.ot19290 BREAST NEEDLE LOC Needle plu."*rrrt19291 BREAST NEEDLE LOC EACH ADD,L Needle placement19295 PLACE METAL cLIp IN BREAST BX Needle placement20000 soFT TIssuE ABs DRN SUPERFICIAL percutaneous entry20205 MUSC BX DEEP Needle placement20206 SOFT TISSUEA4USCLE BX Needle placement20220 SUPERFICIAL BONE BX Needle ilacement20225 DEEP BONE BX Needle placement20605 ASP/INJ SMALL JOINT Needle placement20610 ASP/INJ LARGE JOINT Needle placement21116 ASP/INJ SHOULDER JOINT Needle placement22521 PERC vERTEBopLAsry UNI/BI TIIOR Needle placement22521 PERC VERTEBROPLASTY LINI/BI LUMB Needle placernent22522 PERC vERTEBRopLAsry EACH ADD Needle placement23350 SHOULDER ARTHROGRAM Needle placement24220 ARTHROGRAM ELBOW Needle placement25246 ARTHROGRAM WRIST Needle placement27093 HIP ARTHROGRAM Needle placement27096 SI JOINT ARTHROGRAM Needle placement27370 KNEE ARTHROGRAM Needle placanent27648 ARTT{ROGRAMANKLE Needleplacement32000 THORACENTESIS Needle placement32002 THORACENTESIS (PNEUMOTIIORAE Needte placemenr32020 THORACOSTOMY percutaneous enry32201 PERC LUNG ABSCESS percuraneous enry32400 NEEDLE BX PLELTRA Needle Dlacemenr32405 LLING BX Needle placement35470 PTA TIBIOPERONEAL Cathetei placement35471 PTA VISCERAL Catherer placement35472 PTA AORTA Catleter placement35473 PTA ILIAC Catheter placement35474 PTAFEM-POP Catheterplacement35476 PTAVENOUS Catheterplacement35491 AT.HERECTOMYAORTA Catheterplacement35492 ATHERECTOMYILIAC Catheterplacement35493 ATHERECTOMY FEM-POP Catheterplacement35494 ATHERECTOMy BRACHIAL Carheterplacement35495 ATIIERECTOMY TIBIAL Catheterplacement36005 EXTVENOGRAM Catheterplacement36010 ryC/SVC Catheterplacement36011 lst ORDER VEIN Catheterplac.ement36012 2nd ORDER \rEIN Catheterplacement
Obtain specimenInjection ofcontastObtain specimenObtain specimen
Catheter placementObtain specimenObtain specimenObtain specimenObtain specinrenObtain specimenObtain specimenObtain specimenInjection of cementInjection of cementIqjection of cementInjection ofcontastI4jection of confrastlnjection ofcontrastInjection ofcontastlnjection ofcontastIqjection of contastlnjection ofcontastObtain specimenObtain specimenTube insertionCatheter placementObtain specimenObtain specimenBalloon inflationBalloon inflationBalloon inflationBalloon inllationBalloon inflationBalloon inllationAtherectomyAtherectomyAtlerectomyAtherectomyAtherectomy
MD-224 Radiology clinical Service Housestaff rrainingi program and Supervision.docPage 3 of3
36014 PULMARTCATH SELECT36015 PULMART CATH SUBSELECT36140 DIRECT STICKARTERY36145 DIALYSIS FISTI.ILA CATH36160 TRANS LUMBAR36200 CATIIETERAORTA36215 SELECTIVE 1SORDERTTIAO36216 SELECTIVE 2ND ORDER IIEAD36217 SELECTIVE 3M ORDER }IEAD36218 ADD'L2M OR3rc ORDERIIEAD36245 lSORDERABD/PELVIS/LEG36246 2NDORDERABDIPELVISILEG36247 3ro ORDERABDIPELVISILEG36249 ADD'L2MOR3m3648I PORTAL VEIN CATWANY METHOD36489 PLACE CENTRAL LINE36493 REPOSITION CENTRAL LINE36500 VENOUS SAMPLE36533 IMPLANT VENOUS PORT36534 REVISE VENOUS PORT36870 DECLOT DIALYS FIST ANY METHOD37140 TIPS37200 TRANS CATHETER BIOPSY37201 FIBRINOLYTIC INFUSION37202 OTI{ER RX INFUSION37203 FOREIGN BODY RETRIEVAL37204 EMBOLZATION37205 VASCLII..A,R STENT IMTTAL VESSEL37206 STENT-EACTI ADD'L VESSEL37209 MANIPULATE UK CATH37620 IVC FILTER38200 SPLENOPORTOGRAMPI}NCT38505 LYMPHNODE BX38790 LYMPHANGIOGRAM42400 BX SALIV GLA.ND42550 SIALOGRAM43456 DII/.TE ESOPHAGUS43750 GASTROSTOMY44300 TI.'BE ENEROSTOMY/CECOSTOMY44901 PERC DRN APPENDIX ABSCESS47OOO. LIVERBIOPSY47OII PERC DRAIN LTVERABSCESS47490 PERC CHOLECYSTOSTOMY47500 PTC47510 PTBD EXTERNAL DRAIN47511 PTBD INTERNAL OR STENT47530 REVISE T-TUBE47555 DILATE BIL STRICT w/O STENT47556 DILATE BIL STRICTW STENT
Catheter placementCatheter placementCatheter placementCatheter placementCatheter placementCatheter placementCatheter placementCatheter placementCatheter placementCatheter placementCatheter placementCatheter placementCatheter placementCatheter placementCatheter placementPercutaneous entryPercutaneous entryCathetgr placementPercutaneous entryPercutaneous entyPercutaneous ertyPortal V catheterizationCatheter placementCatheter placementCatheter placementCatheter placementCatheter placementCatheter placementCatheter placementCatheter placementCatheter placementNeedle placementNeedle placementNeedle placementNeedle placementNeedle placementCatheter placementPercutaneous entyPercutaneous entryPercutaneous entryNeedle placementPercutaneous entryPercutaneous entryNeedle placementPercutaneous enbyPercutaneous entryCatheter placementCatheter placementCatheter placement
Catheter placementCatheter placement
Catheter placementCatheter placementPerformDeclotStent placementNeedle placement
Foreign body retrievalEmbolizationStent placementStent placement
Filter placementInjection ofcontrastObtain specimenInjection ofcontastObtain specimenInjection ofcontrastBalloon inflationCatheter placementCatheter placementCatheter placementObtain specimenCatheter placementCatheter placementInjection ofcontastCatheter placementCatheter placement
Balloon inJlationBalloon inJlation'
MD-224 Radiology clinical service Housestaff rrainingi program and supervision.docPage 4 of 4
47630 STONEEX48000 'ANCREATT. ABScEss ;;fffrjjil""Til'48102 PANCREATIC BIOpSy percutaneous enry48511 PERC DRAIN PSEUDOCYST percutaneous enrry'49020 PERITONEAL ABSCESS percutaneous enry49041 SUBPHRENIC ABSCESS percutaneous enry49061 RETR''ERIT.NEAL ABSCESS percutaneous enry49080 PARACENTESIS4gr80 Blopsy ABD MAss
Needle placement
4s420 rNsERr pERrroNEAL CArHrEMp lHtTi::,Tf;49427 LEVEEN SHLNTOGRAM Needle placement50021 RENAL ABSCESS percutaneous ennry50390 ASP RENAL CYST OR PELVIS Needle placement50392 ANTEGRADEpyELoarEpHRosroMy percutaneous enuy50393 LIRETERAL STENTs03s4 rNrECr FoR ANTEcRADE prrgr.o i,'ffi:filT#"
50395 DIL NEPHROST TRACT Catheteiplacement51010 SUPRAPUBIC TUBE percutanious entry51080 DRAIN PERVESICLE ABSCESS percutaneous enrry51610 CATHBLADDER percutaneous enry52007 BRU'H BX URETER oR RENAL 'ELVIS catrreter pracement54230 CORPOM CAVERNOSOGRAM Needle piacement55700 PROSTATEBIOPSYs8340 us soNonysrERocRAM il;:l#::tril58823 TRANS VAGINAL DRAIN Catheter ptacemenr6OIOO BX T}TYROID61050 crsrERNALoRcr-2pLrNCruRE N:ij[iltrH:l:61055 MYELOGR By Cl PLNCTURE Needleplacernent61070 PLNCTURE SHLNT OR RESERVOIR Needle placement6t624 EMBO CNS61626 EMB'N'NCN'HEAD&NE.K 3:H:ffli:::il:ll62268 ASP SPINAL CORD CYST Neeale piacemeni62269 BX SPINAL CORD TUMOR Needleplacernent62270 SPINALPUNCTURELUMBARFORDX N"rdb;i;;;;;;62272 SPINALPUNCTURELUMBARFORRX Nrraf.pi*"**i62273 INJECT EPIDURAL PATCH Needle placement62284 CERVICAL MYELOGRAM Needle placernent62284 TTTORACIC MYELOGRAM Needleplacement62284 LUMBAR MYELOGRAM Needle placement62284 COMPLETE MYELOGRAM Needleplacernent62290 DISCOGMM LUMBAR Needle placement62291 DISCOGRAM CERVICAL NeedteplacemJ64795 BXNERVE68850 DACRocysrocRAM il:iji:ii::HHlMinor Procedures2O5OO SCLEROSECYST20501 FISTLILA INJECTION .
32005 PLEURODESIS34808 ILIAC OCCLUS DEVICE WAAA REPA36410 VENAPI..TNCTURE/PHYSICIAN SKILL36470 INJ SCLBROSING SOL VEIN36535 REMOVE VENOUS PORT36550 DECLOTVASCULARDEVICE43760 GASTROSTOMYCHANGE
Stone removalCatheter placementCatheter placementCatheter placementCatheter placementCatheter placementCatheter placernentObtain specimenObtain specimenCatheter placementInjection ofcontastCatheter placementObtain specimenCatheter placement
Injection ofcontrastBalloon inflationCatheter placementCatheter placementCatheter placernentBrush bx placementInjection ofcontrastObtain specimenCatheter placement
Obtain specimenInjection ofcontrastInjection ofcontrastInjection ofcontrastInjection of embo materialInjection of embo materialObtain specimenObtain specimenInjection ofconfastInjection ofcontrastInjecfion ofbloodInjection of contrastInjection ofcontrastInjection of contrastInjection ofcontrastInjection ofcontrastInjection ofcontrastObtain specimanIqjection ofconfrast
MD-224 Radiology crinicar Service HousestaffTrainingi program and supervision.docPage 5 of 5
43761 NASO-JEJI.INALFEEDINGTLIBE43761 FEEDING TI.JBE44500 INTRODUCE LONG GI TUBE47505 CHOLANGIO THRU EXISTING TUBE47525 CHANGE PERC BILDRAIN49423 ABSCESSTUBECHANGE49424 ABSCESS TTJBE CHECK50398 CHANGENEPHROSTOMYTUBE
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TITLE:
Supersedes:
Policy:
Radiology Pol #: MD-226
Date Adopted:
Revised:
Staff Radiologists: Credentials and Privileges Policy
Attending Radiologists are appointed and re-appointed in accordance withHospital byiaws.
Chief, Deparfrnent of Radiology
PROCEDTJRE:
CREDENTIALING PROCEDIJRE
. rt '
"il
{ t r t r , , ,
y r r i
,,! /'"'n"
A- NEW APPOINTMENTSThe process of appiication for membership to the Medical Staff of SFGH through theRadiology Clinical Service is in accordance with SFGH Bylaws Article n, MedicalStaf Membership,Rules and Regulations, SFGH Credentialing Procedure Manual I- Appointments/ Re-appointments, and accompanytng manuals as well as theseCiinical Service Rules and Reguiations. Radiology Clinical Service staff fall intothe same staff categories which are described in Article III - Categories of theMedical Staff of the SFGH Bylaws, Rules and Regulations and accompanyingmanuals as well as these Clinical Service Rules and Rezulations.
The following additional docume,lrtation iterns, as appropriate, are acceptable verifiedby hard copy or by expianation of the applicant with no further verification:
1. American Board Certification Status (if not certified)2. General AnesthesiaPennit3. BLS4. ACLS
MD-226 Staff Radiologists Credentials and Privileges Policy'doc Page I of I
5. CPR6. PALS7. X-rayOperator/Supervisor'sLicense8. Nuclear Medicine License
The Radiology Ciinical Service at San Francisco General Hospital encourages butdoes not resuire faculty or fellows to have CPR training or DEA certification.Nuclear Medicine License is oniy required of those who perform and supewiseNuclear Medicine procedures
REAPPOINTMENTS
The process of reappoinbnent to the Medical Staff of SFGH through the RadioioryClinical Service is in accordance with SFGH Bylaws, Rules and Regulations,Credentialing Procedure Manual, 1.3 - Reappointment Process and accompanyrngmanuals as well as these Clinical Service Rules and Rezulations.
1. Practitioners Performance ProfilesProfiling documentation: The number of procedures of varioustypes paformed by physician since appointnent/last reappoinftnent wili be recorded.Data concerning report signattre will also be maintained by the chief of service foreach physician including the number and percent of reports signed by the physicianwithin 24 hours of the procedure and the number of reports signed greater than 7 daysafter the procedure. Data will be obtained from Radiology Department computersystem. If data on number of procedures is not available for entire period sinceappoinhnent/last reappointrnent, a representative period will be analped consisting ofat least three monthsPhysicians who have a Courtesy Staff appointaent and oniy provide occasional
services at SFGH may not perforrn a sufficient nurnber senrices to evaluateperformance profiles . A Courtesy staffphysician will be eligible for re-credentiaiingif the Chief of the Department of Radiolory at the hospital where he/she provides themajority of hisftrer clinical services submits a letter to the chief of the RadiologyService at SFGH attesting to the quaiity of the services provided by the physician atthe other hospital.
2. Staff Status Change The process for Staff Status Change for members of theRadiology Services is in accordance with SFGH Bylaws, Rules and Regulations .
3. Modification/Changes to PrivilegesThe process for Modification/Change to Privileges for members of the RadiologyService is in accordance with SFGH Byiaws, Rules and Reguiations andaccompanying manuais.
MD-226 Staff Radiologists Credentials and Privileges Policy.doc Page 2 of2
DELINEATION OF PRIVILEGES
A. DEVELOPMENT OF PRTVILEGE CRITERIA
Radiology Clinical Service privileges are developed in accordance with SFGH
MedicafstaffByiaws, Articie fY - Clinical Privileges, Rules and Reguiations and
accompanYing manuals'
B. ANNUAL REVIEW OF CLINICAL SERVICE PRTVILEGE REQT]EST
FORMThe Radiology Clinical Service Privilege Request Form shall be reviewed annually.
C. CLINICAL PRTVILEGES
Radiology Clinical Service privileges shall be authorized in accordance with the
SFGH Medical Staff Bylaws, Arficle TY - Clinical Privileges. Rules and Regulations
and accompanyurg manuals, as well as these Ciinical Service Rules and Regulations.
All requesis for clinical privileges will be evaluated and approved by the Chief of
Radiology Clinical Service. The specific quaiifications for each privilege will be
described in a departmental privilege form. Each staff physician will initial the
privileges they are requesting and the Chief of Service will add his/her initials to
confirm the individual fulfills the qualifications.
D. TEMPORARY PRTVILEGES
Temporary Privileges shall be authorized in accordance with the SFGH Medical Staff
Bylaws Article IY - Clinical Privileges, Rules and Regulations and accompanying
manuals.
PROCTORING AI{D MONITORING
A. REQUIREMENTSBefore any new staff radiologist can independentlyperform clinical services, he/she
will be assigned to a fully credentialed member of the Medical Staffbythe chief of
the service to act as a proctor. Any staffradiologist who already has privileges in
areas requested by the new staff radiologist may be asked to be a proctor. The
proctoring staff radiologist witl review a minimum of 5 0 exarrinations or procedures
that encompass every area in which privileges were requested by the new staff
radiologist. If the new staff radiologist has requested a privilege that is not inciuded
in the proctoring radiologist's privileges, a second proctor may be assigned for
evaiuation of the specific privilege. The proctoring physician(s) will report his/her
observations regarding the new radiologist and assess his/her abiiifyto perform in all
the areas that privileges were requested.
Each staff radiologist will undergo peer review (proctoring and monitoring) by
another staff radioiogist once each year. Review material will consist of ten (10)
MD-226 Staff Radiologists Credentials and Privileges Policy'doc Page 3 of 3
cases chosen by the exarnining physician to include cases in the primary area ofexpertise of the radiologist being proctored as well as additional cases that mayoccasionally be the responsibility of the radiologist (i.e., on call). 'Each
case will bedictatedbybothradiologists andthe two reports comparedbytheRadiologyClinicalService QI Medical Director. Records will be kept and reported to the RadiologyCiinical Service deparhnent Chief, and the QI Medical Director (see proctoring form,Staff Physician Credentials Section). Both examiner and examinee will reportsignificant error to the DeparEnent QI Chief or QI Committee. Action to be takenmay include consulting, remedial study, and/or clinical service inservice work, asappropriate.
B. ADDITIONAL PRTVILEGESRequests for additional privileges for Radiology Clinical Service shall be inaccordance with SFGH Bylaws, Rules and Reguiations and accompanying manuals.
C. REMOVAL OF PRIWLEGESRequests for removal of privileges for Radiology Clinicat Service shall be inaccordance with SFGH Bylaws, Rules and Regulations and accompanying manuals.
EDUCATIONA. AllRadioloryfacultyarerequiredto obtain ongoingACCME accredited continuing
medical education in the area of diagnostic radiology or nuclear medicine. Theminimum standards required are those that the American Medical Associationrequires for the certificate award.
B. Radiology and Nuciear Medicine faculty that are full-time are allotted five weeks ofmeetings per year.
C. Documentation of continuing education is provided on an annual curriculum vitarequired by all faculty prior to the June performance appraisal performed bythe Chiefof Service.
MD-226 Staff Radiologists Credentials and Privileges Policy.doc Page 4 of 4
City and County of San Francisco
Department of Public Health
M E M O R A ' V D U I f r
TO:
FROM:
San Francisco General Hospitaland Trauma Center
I m an N sze eri-S imm o ns, MPHAs so c iate H o sp itql Adm inistrutorGavin Newsom
Mayor
Honorable Dr. Edward A. Chow, M.D.ChairHealth Commissioner
Honorable David J. Sanchez, Jr., Ph.D.Health Commissioner
Honorable Catherine Waters, R.N., Ph.D.Health Commissioner
. t,1
Iman Nazeeri-S i^^ontfl '
Associate Administrator, Quality & Patient SafetySan Francisco General Hospital and Trauma Center
DATE: November 5, 2OO9
SUBJECT: Frequency and detail of quallty data collection
During SFGH's CMS Validation Survey (September 29 - October 8, 2009), it wasnoted by the physician surveyor that the hospital's governing body had notestablished the frequency and detail of quality data collection, as required by theConditions of Participation (CoP). In order to come into compliance with thisCoP, I am requesting that the governing body approve the frequency of qualitydata collection for the Performance Measures (reviewed and approved atOctober's JCC) as monthly and the Patient Safety Plan (also approved atOctober's JCC) data collection frequency as at least quarterly. I look forward todiscussing this with you at the November 11, 2OO9 JCC.
Thank you.
Copies to: SFGH Joint Conference Committee MembersJames M. Illig, President, Health Commission
Quality & Patient Safety DepartmentSan Francisco General Hospital and Trauma Center
l00l Potrero Avenue . Building 20, Suite 2300 " San Francisco, CA 941 l0Telephone (415)206-3455 . Fax (415) 2064008
