2019 REAPPOINTMENT INSTRUCTIONS

This reappointment application will be accepted at the following WMCHealth Facilities:

HealthAlliance Hospital: Broadway CampusHealthAlliance Hospital: Mary’s Avenue CampusMargaretville HospitalMountainside Residential Care CenterMidHudson Regional HospitalWestchester Medical CenterMaria Fareri Children’s Hospital

1. Please read the application carefully and follow the instructions for each section. ALL SECTIONS MUST BE COMPLETED OR LABELED “NOT APPLICABLE.”

2. If you are reappointing to any HealthAlliance facility, the following documents will be required:

Application and Consent CME Certificates Explanation of Professional Liability Actions Conflict of Interest Statement Restraint and Seclusion Quiz Fire Safety for Physicians and Allied Health Professionals Hyperglycemia acknowledgement Health Assessment Dues - $300 – check made payable to HealthAlliance Hospitals’ Medical Staff (will cover the two

years of reappointment)

For HealthAlliance facilities, all questions should be directed to Jane Sexton at 845-334-2723 OR Jane.sexton@hahv.org

MEDICAL / DENTAL / PODIATRIC / ALLIED HEALTH STAFF REAPPOINTMENT APPLICATION

PLEASE COMPLETE THE FOLLOWING:Name:       Contact Email:      

Office Address:      

Office Phone:       Office Fax:      

Home Address:      

Home Phone:       Cell Phone:      

Office Manager/contact:      

I am requesting reappointment for the following facilities:

HealthAlliance Hospital: Broadway Campus HealthAlliance Hospital: Mary’s Avenue Campus Margaretville Hospital Mountainside Residential Care Center MidHudson Regional Hospital Westchester Medical Center Maria Fareri Children’s Hospital

IN THE LAST TWO YEARS:

Has your license to practice medicine in any state or jurisdiction been involuntarily revoked, suspended (to include those stayed), restricted, subject to any other penalty of misconduct (censure, reprimand, probation, fine, community service, etc.) or been involuntarily or voluntarily surrendered, irrespective of reinstatement?

YES NO

Has your license to practice as a physician been denied in any state or jurisdiction? YES NO

Are there any charges currently pending against your license in any state or jurisdiction? YES NO

Has your DEA registration been involuntarily suspended, revoked, placed under probation or involuntarily or voluntarily modified, irrespective of reinstatement? YES NO

Are there any charges currently pending against your DEA registration in any state or jurisdiction? YES NO

Have your training, employment, association or clinical privileges at any hospital or healthcare facility been denied, revoked, suspended, diminished, modified to require consultation; subject to probation, monitoring or continuing medical education

YES NO

requirements; or not renewed or involuntarily or voluntarily reduced or withdrawn?

Are you currently the subject of an investigation or corrective or disciplinary action concerning your association or clinical privileges at any hospital or healthcare facility? YES NO

Are there any charges currently pending against your training, employment, association or clinical privileges at any hospital or healthcare facility in any state or jurisdiction? YES NO

Have you ever voluntarily or involuntarily resigned or withdrawn, limited, reduced or lost your association or clinical privileges at another hospital or healthcare entity, irrespective of reinstatement or withdrawal of an application for medical staff membership, prior to final action by the hospital or healthcare entity?

YES NO

Have you ever been denied professional liability insurance, in whole or in part; or has your policy ever been cancelled, involuntarily restricted or denied renewal; or has a surcharge ever been assessed because of the nature or volume of claims against you? If “Yes,” please explain on a separate sheet.

YES NO

Are there any pending professional medical-misconduct proceedings concerning you in this state or any other jurisdiction? YES NO

Have you ever been convicted of a crime (a misdemeanor or felony), regardless of whether a sentence was imposed or subsequently vacated? This does not include minor traffic or parking violations.

YES NO

Since your last appointment, have you been the subject of a report to the National Practitioner Data Bank? YES NO

Are you involved in any pending medical malpractice actions in this state or any other state or jurisdiction? If “Yes,” complete Attachment B for each case. YES NO

Have there been any findings (judgments or settlements) of medical malpractice proceedings or actions in this state or any other state or jurisdiction? If “Yes,” complete Attachment B for each case.

YES NO

Have you ever been denied membership or renewal thereof, or been subject to disciplinary proceedings in any medical organization, professional society or specialty board? YES NO

Have you ever been suspended, sanctioned or otherwise restricted from participating in any private, state or federal health insurance program (i.e. Medicaid, Medicare)? YES NO

NEW AFFILIATIONS ONLY (last two years)HOSPITAL NAME ADDRESS PHONE AND FAX OF MEDICAL STAFF

OFFICEPhone:

Fax:

Contact:Phone:

Fax:

Contact:

Phone:

Fax:

Contact:

HEALTH STATUSDo you have a physical or mental condition that would affect your ability to exercise the clinical privileges requested or that would require an accommodation in order for you to exercise the privileges requested safely and competently? If “YES,” please provide an explanation.

YES NO

Do you have a physical, mental or emotional condition or substance-abuse problem that could affect your ability to exercise the clinical privileges requested or that would require a reasonable accommodation for you to exercise those privileges safely and competently?

YES NO

BOARD CERTIFICATION

Since your last reappointment, has there been any change to your certification status, i.e., have you become board eligible, board certified or recertified?

      Yes       No

American Board of      

Date of Certification: From       to      

Are you meeting maintenance of certification (MOC) requirements:      Yes       No If yes, please include MOC transcript. If no, are you in the certification process?      Yes      No If yes, indicate your anticipated date of completion:

CLINICAL PEER REFERENCE

If you are a dentist, podiatrist or allied health professional, please provide a peer reference name, address and contact information below for a peer who can give you a clinical reference. Please notify the named individual that this reference must be received in order to move your reappointment forward.

NAME OF PEER REFERENCE:      

ADDRESS :      

PHONE:       (required)

FAX:       (required)

EMAIL ADDRESS:       (required)

CONTINUING MEDICAL EDUCATION

Please check all that apply and provide evidence of CMEs earned within the last two (2) years.

I have attached documentation for the following CMEs:

      No. of Hours – Specialty Specific (Certificate Attached)

      Online Education       Class/Ground Rounds/Meeting

      No. of Hours – Specialty Specific Journal Articles (Certificate Attached)

     No. of Hours – Nonspecialty CME (Attach Certificate and/or Copy of Article)

     Online Education      Class/Ground Rounds/Meeting       Journal Articles

PRIVILEGE ATTESTATION

Your current privileges were sent to you via email with notification of your reappointment.

Please review and keep in mind your clinical practice pattern. If you have not used a procedure in several years, you might wish to relinquish this privilege. If you request additional privileges or procedures, please enclose documentation of additional education, training and current clinical competence in the specific privileges requested. Privileges relinquished during the reappointment process are not reportable; Privileges denied at reappointment are reportable.

      I have reviewed my clinical privileges and request that my clinical privileges remain unchanged.

      I have reviewed my clinical privileges and request to relinquish the following privileges:

__________________________________________________________________________________

      I have reviewed my clinical privileges and request additional privileges. Please go to the website and complete a new privilege form for your specialty.

NOTE: All requests for new privileges must be accompanied by documentation of training and/or a clinical activity report from another facility where you have been practicing the privilege(s) for this request to be considered.

NOTE: Current nitrous oxide training required for anesthesia and OB with reappointment.

PROCEDURAL (CONSCIOUS) SEDATION

      I do not have conscious sedation privileges

     I wish to retain my privileges in conscious sedation. If yes, please complete the quiz below and return with this application. Current ACLS is required for this privilege.

     I wish to relinquish my privileges in conscious sedation.

     I wish to obtain privileges in conscious sedation. If yes, please complete the quiz attached and return with this application. Current ACLS is required for this privilege.

PROCEDURAL SEDATION FOR THE NON-ANESTHESIOLOGISTASSESSMENT TEST

Please write the correct answer to each question below. To receive a successful score on this assessment test, you may not get more than two incorrect answers.

1) Objectives of conscious sedation include all of the following except: Answer:      a. Anxiolysisb. Amnesiac. Cooperation during procedured. Decreased pain thresholde. Stable vital signs

2) Flumazenil (Romazicon) reverses the effects of Midazolam (Versed): Answer:      a. Trueb. False

3) The recommended initial dosage of Versed is: Answer:      a. 1 – 2.5 mgb. 5 mgc. 7 mgd. 10 mg

4) Moderate Sedation: Answer:      a. Allows protective reflexes to be maintained by the patientb. Pertains to the patient that is unconscious or in a state of depressed consciousness

where the patient cannot respond purposefully to verbal or physical stimulic. Requires mask ventilation to maintain respirationsd. Requires the use of Naloxone at the end of the procedure

5) Monitoring parameters include: Answer:      a. Heart rate, blood pressure, respirationsb. Heart rate, blood pressure and oxygen saturationc. Heart rate and rhythm, blood pressure, respirations, oxygen saturation,

and level of consciousnessd. Heart rate and rhythm, blood pressure, respirations, and oxygen saturatione. Heart rate, blood pressure, respirations, and oxygen saturation

6) What of the following information is needed in the history of a patient undergoing Conscious sedation: Answer:      a. Allergiesb. Past experiences with anesthetic drugsc. NPO statusd. Pregnancy or menstrual historye. All of the above

7) Moderate sedation, a medically controlled state of depressed consciousness,allows protective reflexes to be maintained: Answer:      a. Trueb. False

8) If you find a patient has ceased breathing, which of the following is to be done first?a. Intubate Answer:      b. Place an oral airway c. Perform head tilt/jaw thrustd. Call anesthesia

9) The most common cause of airway obstruction is the tongue: Answer:      

a. Trueb. False

10) Prior to administering sedation for any procedure, documentation Answer:      should include:a. History and physical (H&P)b. Baseline vital signsc. Age and weightd. NPO statuse. Evidence of informed consentf. Results of pregnancy test (if warranted)g. All of the above

11) During the procedure, the vital signs should be taken and documented: Answer:      a. Pre- and post-procedureb. Every five (5) minutesc. Every ten (10) minutesd. Every fifteen (15) minutese. As the physician feels necessary

12) The RN monitoring a patient receiving conscious sedation: Answer:      a. May be the charge nurseb. May also circulate in the room and get equipmentc. May not apply oxygen if neededd. May not be engaged in any other activity during this periode. Should do the preoperative history and physical prior to the procedure

13) A patient currently undergoing bronchoscopy has received Versed for Answer:      sedation and, within a few minutes, the oxygen saturation has begun to drop. You should:a. Halt the procedureb. Increase FiO2 (Oxygen) deliveryc. Check for respirationd. Arouse the patiente. All of the above

14) The following may be an indication of a difficult airway, except : Answer:      a. Large neck circumference b. Edentulous mouth c. Mallampati score of III or greaterd. Limited neck and jaw range of motione. Short thyromental distance (receded jaw)

Answer True or False

15) Conscious sedation would be appropriate for patients needing pain control Answer:      or mechanical ventilation.

16) The goal of conscious sedation is to produce a depressed level of consciousness without the loss of protective airway reflexes.

Answer:      

17) The monitoring RN is permitted to leave the room at the discretion of the physician.

Answer:      

18) Post-procedure monitoring must continue every five (5) minutes until vital signs have returned to the pre-procedure range, protective reflexes are intact, O2 saturation is > 92% on room air (or at pre-procedure level), and there is age-appropriate verbalization response.

Answer:      

19) An outpatient may be discharged to his own care if his mental status has returned to its baseline level (scheduled/planned outpatient procedure) Answer:      

20) Ketamine is restricted to anesthesiologist and emergency departmentuse ONLY.

Answer:      

21) Benzodiazepines will not amplify the respiratory depressanteffects of narcotics. Answer:      

Match the ASA classification to each of the following patients. Place the corresponding letter on the line provided below:

A) ASA Class IB) ASA Class IIC) ASA Class IIID) ASA Class IVE) ASA Class V

22) Answer:       A patient with marked signs of cardiac insufficiency

Answer:       A normal, healthy patient

Answer:       A patient not expected to survive twenty four (24) hours

Answer:       A patient with well-controlled essential hypertension

Answer:       A morbidly obese patient

ATTESTATION

By applying for reappointment to the medical or allied health staff of WMCHealth facilities, I hereby agree to abide by the bylaws, rules and regulations of the medical staff to which I am appointed; and as a member of a particular department and/or committee where information of a privileged and confidential nature is discussed, such information shall be held in strict confidence and not be divulged.

I further agree that I am obligated to promptly notify the facilities if any of the information provided changes at any time in the future. In addition, if the hospital(s) activate(s) their incident command program for a disaster, I agree, if called upon, to confirm my availability to provide care within the scope of my privileges and competency. Updated 7.29.14

I hereby attest that all information submitted by me in this application for reappointment is complete, true and accurate to the best of my knowledge, and I have not requested privileges for which I am not qualified. By signing this document I consent to allow centralized information gathering for reappointment of medical staff privileges.

THIS IS A LEGAL DOCUMENT. BEFORE SIGNING THIS APPLICATION PLEASE REVIEW IT CAREFULLY, REGARDLESS OF WHO COMPLETED THE APPLICATION, AS YOU ARE ATTESTING

TO ITS ACCURACY AND ARE RESPONSIBLE FOR ITS CONTENT.

Applicant’s Printed Name:       Signature:      

CONSENT FOR RELEASE OF INFORMATION

I understand and agree that I, as an applicant for reappointment for medical staff membership and/or privileges, have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics and other qualifications and for resolving any doubts about such qualifications. I further agree that this application will not be processed until it is deemed complete by the each facility. I have not requested privileges for any procedures for which I am not qualified. I am familiar with the laws of the state governing the practice of medicine/dentistry/podiatry/allied health professions and pledge to abide by these laws. I further understand that any significant misstatements in or omissions from this application constitute cause for denial of appointment or cause for summary dismissal from the medical staff. All information submitted by me in this application (including attachments) is true to my best knowledge and belief and I agree to update this application should there be any change in the information provided.

In making this application for reappointment to the medical staff, I hereby give my consent to the disclosure, inspection and copying of information and documents relating to credentials, health status and qualifications. I signify my willingness to appear for the interviews in regard to my application, authorize the facilities, their medical staff and their representatives to consult with administrators and members of medical staffs of other hospitals or institutions with which I have been associated and with others, including but not limited to, past and present malpractice carriers, professional societies, specialty boards and professional schools and training programs that may be material to an evaluation of my professional qualifications and competence to carry out the clinical privileges requested as well as my moral and ethical qualifications for staff membership.

I hereby release from liability all representatives of the facilities and their medical staff for their acts performed in good faith and without malice in connection with evaluating my application and my credentials, qualifications, and competence and in the process of Focused Professional Practice Evaluation or Ongoing Professional Practice Evaluation. I hereby release from any liability any and all individuals or organizations that provide information to the facilities, or their medical staff, in good faith, without malice, and in accordance with current federal and state laws, and I hereby release from liability the facilities, their medical staffs and their authorized representatives to the full extent permitted by law for so doing. Nothing in this document shall be construed as limiting or superseding any immunities otherwise provided by law.

I understand that, although the medical staff of the facilities will make a recommendation concerning my application for reappointment, the facilities governing body/bodies retain(s) the final authority to determine whether my reapplication will be accepted and, if accepted, what privileges will be granted to me.

I understand that I will notify the hospital administration in writing of any voluntary or involuntary termination or reduction of clinical privileges at this hospital or any other healthcare facility, as well as any action taken by a regulatory agency.

In signing this attestation and consent, I acknowledge that I agree to abide by the medical staff bylaws, rules and regulations and policies for all facilities concerned. I agree to be bound by the terms thereof, if I am granted membership or clinical privileges in all matters relating to the consideration of my application for appointment, and I further agree to abide by such hospital and staff rules and regulations, which may be from time to time enacted.

By signing this document you consent to allow centralized information gathering for reappointment of medical staff privileges.

Signature:       Date:      

Name:      

ATTACHMENT B

EXPLANATION OF PROFESSIONAL LIABILITY ACTIONS Please copy and complete for each claim/suit

Applicant’s name:      

Name of Patient:       Date of Incident:      

Date Lawsuit Filed:      

What was/is your status:

     Sole defendant

     Co-defendant

     other: ____________________________________________________

Nature of Claim:      

Status of Case (with reference to you, specifically)

     Pending     Dismissed     Closed without payment / Date:           Pre-trial settlement: $           Verdict for defendant     Verdict for plaintiff $      

CONFLICT OF INTEREST DISCLOSURE STATEMENTInstructions

This Conflict of Interest Disclosure Statement must be completed by all “personnel” of WMCHealth facilities, subsidiaries and affiliated entities (Organization) who are covered by the Conflict of Interest Policy as defined below.

A. Personnel Covered by the Conflict of Interest Policy. This policy applies to the following personnel of HealthAlliance of the Hudson Valley, its subsidiaries and affiliated entities (Organization): members of the board of trustees, officers, “Leadership Management” (defined to be the president and chief executive officer, senior vice presidents and vice presidents), assistant vice presidents, department heads and other employees (including physicians) in a position to influence any substantive business decision between the Organization and a vendor. Such business decisions include, but are not limited to, decisions to purchase goods or services for the Organization and any other decisions affecting the course of a business transaction being considered or entered into by the Organization. This policy applies to “immediate family” members of such personnel.

B. Immediate Family. The term “immediate family” includes your spouse, siblings, children, parents, or in-laws of any of them.

C. Vendor. The term “vendor” includes all vendors, suppliers, consultants, and other third parties seeking to do or currently engaged in business with the Organization.

D. Disclosable Interest. Personnel members have a disclosable “interest” if they have a contractual or an employment relationship with a vendor, or if they are a member, owner, director, trustee or officer of a vendor; or if they have any other financial interest in a vendor:

(i) from which the Organization purchases or leases equipment, services or supplies, or that provides services that compete with the organization.

(ii) with which the Organization negotiates real estate transactions (such as the leasing of space), and which either benefits from the real estate transactions or competes with the Organization in the leasing or purchase of real estate; or

(iii) which renders directive, managerial, or consulting services to any organization that does business with, or competes with, the Organization in providing services.

An “interest” in a vendor also includes any service as a member of the governing board or officer of another healthcare organization licensed, registered or approved under Articles 28, 28A, 36, or 44 of the New York Public Health Law.

An “interest” also includes the employment by or contracting with the Organization of a personnel member’s immediate family.

If the financial interest is the ownership of securities that are publicly traded, such interest does not have to be disclosed, unless the combined holdings of the securities of both the person and his or her immediate family constitute 5% or more of the outstanding securities of the vendor.

CONFLICT OF INTEREST DISCLOSURE STATEMENT

If the answer to any of the following questions is YES, please explain in the space provided below or attach additional information, as needed:

1. I, or a member of my immediate family, have a disclosable interest in a vendor that either conducts business or is seeking to conduct business with the Organization.

     Yes       No

2. A member of my immediate family is employed by or has a compensation arrangement with the Organization.

     Yes      No

3. I, or a member of my immediate family, hold a financial interest aggregating more than 5 percent (5%) of publicly traded securities in a vendor doing or seeking to do business with the Organization.

     Yes      No

4. I, or a member of my immediate family, serve as a member of the governing board or officer of another healthcare organization licensed pursuant to Articles 28 (Facility), 28A (Facility), 36 (Home Health Agency) or 44 (Health Maintenance Organization) of the Public Health Law which does business or is affiliated with the Organization.

     Yes      No

5. I am, or a member of my immediate family is, involved in any other activity, except as disclosed above, that raises a potential conflict of interest for the Organization.

     Yes      No

6. Identify any instance in which you or any member of your immediate family has rendered or is rendering directive, managerial, or consultative services to any outside concern that competes with the services of the Organization.

7. Identify any instance in which you or any member of your immediate family has accepted or is accepting a gift, gratuity or entertainment from any outside concern that does, or is seeking to do, business with or is a competitor of the Organization or its affiliates under circumstances from which it may be reasonably inferred that such an act involves interest that could result in a conflict..

8. Identify any instance in which you or any member of your immediate family has disclosed or used or is disclosing or using information relating to the Organization’s or its affiliates’ business for personal profit or advantage to you or the member of your immediate family. (This does not apply to information that is or will generally become available to the general public)

Explanation      

ATTESTATION AND ACKNOWLEDGEMENT

I attest that my answers to the above questions are true and accurate to the best of my knowledge. I further acknowledge that I understand that if I believe a transaction may involve a potential or actual Conflict of Interest, I shall advise in writing the compliance officer or such other person designated by the president of such potential or actual conflict of interest prior to the consummation of the transaction.

I further understand that I am required to revise, in writing, my Conflict of Interest Statement to reflect any changes which occur during the year.

NAME:      

SIGNATURE:      

DATE:      

Department/Specialty:      

Contact Phone Number:      

Contact Email Address:      

_______________________________Reviewed By

FIRE SAFETY FOR PHYSICIANS AND ALLIED HEALTH PROFESSIONALS

Please read and comply with the following fire regulations for our hospitals.

Fire drills will be conducted on a regular basis and physicians will be expected to participate.

1. Report every fire regardless of its size. Under no circumstance consider a fire to be easily controllable.

2. Rescue patients in the immediate area of the fire or smoke

3. Pull fire alarm and call emergency number (4911) to give exact location. CODE RED is the alert to be called.

4. Close all doors to rooms and corridors and windows

If you are in the patient’s room when a fire starts, do the following:

1. Remove all portable gases, and place in a safe area.

2. Turn off all medical gas and electrically operated equipment and valves.

3. Leave all lights on.

4. Turn off all X-ray equipment and mainline switches for all equipment.

5. Extinguish the fire with fire extinguisher only when safe to do so.

6. Evacuate if necessary.i. Ambulatory patients should be escorted by a staff member to the closest safe area, usually through

one set of fire doors. A staff member should stay with the group of patients.ii. Nonambulatory patients should be placed in wheelchairs or on stretchers and moved to the closest

safe area, usually through one set of fire doors.

I acknowledge that I have received training in fire safety regulations and will comply with these regulations when I am present in any WMCHealth facility.

NAME:      

SIGNATURE:      

DATE:      

HEALTH ASSESSMENT

Printed Name: ____________________________________ Date of Birth: ________________________________

Do you have a physical, mental, or emotional condition or substance abuse problem that could affect your ability to exercise the clinical privileges requested or that would require a reasonable accommodation for you to exercise those privileges safely and competently?

Yes No

Please Print Primary Care Physician’s Name: ______________________________________ Phone: _______________

ANNUAL TB SCREENING – FOR NEGATIVE PPD REACTORS

Complete the PPD (Mantoux) test information below or submit equivalent form. New York State Regulation 405.3 requires PPD (Mantoux) skin test annually.

Date administered: _____________________ Lot #:__________________________ Left or Right Forearm Manufacturer: ________________________ Expiration Date: ______________ Administered By: ______________________

Date read: ________________________ Results: _______________________mm Induration (Indicate Zero if No Reaction)

Signature of Medical Professional Reading Test (other than yourself): ____________________________________________

ANNUAL TB SCREENING - FOR POSITIVE PPD REACTORSYes No

Have you ever had a positive PPD (TB skin test)?Were you ever placed on medication for having a reaction to the PPD (TB skin test)?Have you ever received a BCG vaccine?

If you answered YES to any of the above, you are required to answer the questions below on an annual basis.Do you experience any of the following symptoms?

Yes No Yes NoProductive, prolonged cough (over two week’s duration)?

Unusual or unexpected weight loss?

Fever or chills? Bloody sputum?Night sweats? Chest pain?Unusual fatigue? Hoarseness?Loss of appetite?

I hereby state that the information provided on this form is complete, true and accurate.

Signature: _______________________________________ Date: ______________________________

Please submit this form to the Medical Staff Service OfficeFax: 845-943-6021 or email to Credentialing@hahv.org