Clinical Faculty Credentialing and               RecredentialingRecredentialing

CLINICAL PRACTICE COMMITTEE:The Clinical Practice Committee (CPC) shall function as a standing committee of the School andThe Clinical Practice Committee (CPC) shall function as a standing committee of the School and derives its authority from the Dean. It oversees and addresses issues relating to patient care, clinical practice activities and systems that support the delivery of patient care. Oversight responsibilities include credentialing, privileging, peer review, development of clinical policies/procedures and standards medical records patient care information systems qualitypolicies/procedures and standards, medical records, patient care information systems, quality management, process improvement, formulary management, access to care, compliance and risk management. This committee will also provide a periodic report to the DFA.Membership:The membership of the Clinical Practice Committee is approved by the Dean and shall beThe membership of the Clinical Practice Committee is approved by the Dean and shall be comprised of the Associate Dean of Clinical Affairs (CPC chair), the chairs of each of the CPC’s sub-committees and clinical faculty representatives of each of the clinical divisions. Additional faculty and campus representatives can be added as deemed necessary by the chairperson of this committee and as approved by the Dean Appointments shall represent a balance of clinicalcommittee and as approved by the Dean. Appointments shall represent a balance of clinical programs. Terms will be two years or as otherwise determined by the Dean.Meetings:The Clinical Practice Committee will meet at minimum once a month. Additional meetings may be called by the chairperson with at least 72 hours advanced noticethe chairperson with at least 72 hours advanced notice.Voting:All faculty members of the Clinical Practice Committee may vote. Quorum:A majority of members constitutes a quorum.A majority of members constitutes a quorum.

Clinical Practice Sub-CommitteesQuality Process Improvement Sub-Committee: The Quality Process Improvement (QPI) Sub-Committee will, under the oversight of the CPC, implement the School’s Clinical Quality Management Plan. Its responsibilities include the ongoing implementation of Quality Management/Improvement Programs assessment of compliance with school standards of careQuality Management/Improvement Programs, assessment of compliance with school standards of care, patient safety, policies and protocols, systematic evaluation of appropriateness, accessibility, and outcomes of care, and such other duties and responsibilities as may be delegated to it by the Clinical Practice Committee.This sub-committee is empowered to conduct surveys, chart audits and other types of assessments which are needed to satisfy the charge as stated above. Membership:The Quality Process Improvement (QPI) Committee will be composed of twelve (12) members to include the Associate Dean for Clinical Affairs , one full time faculty person from each of the following: Divisions of Dental Public Health & Pediatric Dentistry Division of Periodontology Diagnostic Sciences & Dentalof Dental Public Health & Pediatric Dentistry, Division of Periodontology, Diagnostic Sciences & Dental Hygiene, Division of Endodontics, Oral and Maxillofacial Surgery & Orthodontics, Division of Restorative Sciences, Division of Biomedical Sciences, Division of Physical Therapy and the Division of Occupational Therapy, one staff person, and one part-time faculty person .Faculty members will be selected by the Dean based from a panel of names derived from an annual poll

f f lt d ti f th QPI h i d ti f th Dof faculty, recommendations from the QPI chairperson, recommendations from the Dean, recommendation from the President of the Part-time Faculty Association for the part-time faculty member, and recommendation of the Division Chairpersons.Members will serve two-year terms and may be appointed for an additional two-year term based on the recommendation of the QPI chair in agreement with the Dean.gMeetings:The Quality Process Improvement Sub-Committee will meet at minimum once a month. Additional meetings may be called by the chairperson with at least 72 hours advanced notice.Voting:gAll members of the QPI Sub-Committee may vote.Quorum:A majority of members constitutes a quorum

Compliance and Credentialing Sub-Committee: The Compliance and Credentialing Sub-Committee will, under the oversight of the CPC, 1) review and act upon all information received during the credentialing and re-credentialing process as defined by the S h l’ li f th ti i h i t i ti titi ’ li i l tiSchool’s policy for the granting, renewing, changing or terminating a practitioner’s clinical practice privileges; 2) oversee the implementation of the School’s compliance program developed as part of the University's Healthcare Compliance Program.Membership:Th b hi f th C li d C d ti li C itt (CCC) i d b th D dThe membership of the Compliance and Credentialing Committee (CCC) is approved by the Dean and shall be comprised of representatives from each of the clinical divisions and the Compliance Officer who shall constitute the voting membership. Also represented on this committee in the status of ex-officio members are the Director of Faculty Aff i Di t f Q lit A Di t f H lth C li Di t f Cli i l Fi i lAffairs, Director of Quality Assurance, Director of Healthcare Compliance; Director of Clinical Financial Services; Manager of Electronic Health Records/axiUm and the Assistant Vice President of Healthcare Compliance for the University. Additional faculty and campus representatives can be added as deemed necessary by the chairperson of thi itt d d b th D A i t t h ll t b l f li i lthis committee and as approved by the Dean. Appointments shall represent a balance of clinical programs. Terms will be two years or as otherwise determined by the Dean.Meetings:Th C li d C d ti li S b C itt ill t t i i th Additi lThe Compliance and Credentialing Sub Committee will meet at minimum once a month. Additional meetings may be called by the chairperson with at least 72 hours advanced notice.Voting:All faculty members of the Compliance and Credentialing sub-committee may vote. Non-faculty

b id d ffi i b d ti bmembers are considered ex-officio members and are non-voting members.Quorum:A majority of the voting members constitutes a quorum

Professional Standards and Policy Sub-Committee: The Professional Standards and Policy (PSP) Sub-Committee will, under the oversight of theCPC, be responsible for the development of professional standards and policies that impact clinical practice These standards and policies will be developed to support best practices in the areas of: patientpractice. These standards and policies will be developed to support best practices in the areas of: patient care, patient service, safety, asepsis, medical records, and clinical information and to be responsive to findings as noted in the work of the Quality Process Improvement Sub-Committee. Membership:The Professional Standards and Policy Sub Committee will be composed of fourteen (14) members toThe Professional Standards and Policy Sub Committee will be composed of fourteen (14) members to include the Associate Dean for Clinical Affairs , one full time faculty person from each of the following: Divisions of Dental Public Health & Pediatric Dentistry , Division of Periodontology, Diagnostic Sciences & Dental Hygiene, Division of Endodontics, Oral and Maxillofacial Surgery & Orthodontics , Division of Restorative Sciences and Division of Biomedical Sciences one representative from InformationRestorative Sciences and Division of Biomedical Sciences, one representative from Information Technology, Director of Quality Assurance, Director of Medical Emergencies / Patient Safety and Asepsis , Division of Physical Therapy and the Division of Occupational Therapy, one clinical representative from Sedation or Dental Anesthesia, Director of Clinical Finances, one representative from Academic Affairs. Faculty members will be selected from a panel of names derived from an annual poll of facultyFaculty members will be selected from a panel of names derived from an annual poll of faculty, recommendations from the Dean, recommendations from the President of the Part-time Faculty Association for the part-time faculty member, recommendation of the Division Chairpersons.Members will serve two-year terms and may be appointed for an additional two-year term based on the recommendation of the PSP chair in agreement with the Deanrecommendation of the PSP chair in agreement with the Dean.Meetings:The PSP Sub-Committee will meet at minimum once a month. Additional meetings may be called by the chairperson with at least 72 hours advanced notice.Voting:Voting:All members of the PSP Sub-Committee may vote.Quorum:A majority of members constitutes a quorum

•Compliance and Credentialing  Subcommittee•Peer Review

•Malpractice•Education•MonitoringMalpractice

•Occurrence Reporting•Monitoring•Billing System•HIPAA

• Satisfaction Measurement• Quality Improvement

Initial Appointment :Initial Appointment :

• Providers are sent an application for Initial CredentialingTh   id   b it  th  f ll i  t  th  Di i i  Ch i  f   l• The provider submits the following to the Division Chair for approval:

‐the application and supporting documentation‐ a letter of  intent from the provider ‐ three letters of recommendation‐ three letters of recommendation

• Provider ‘s application is reviewed by the Credentialing Office• Provider is presented to committee for approval

Unless all of the abovementioned information is submitted the provider will not be presented to committee for approval

_______  Completed Application

_____  Current CA License (Primary Source Verification)

_____  Current CPR Certificate

_____  Current DEA Certificate (When Applicable)

_____  Curriculum Vitae

_____  Health Screening for TB / Hepatitis_____ g / p

_____ On‐line  Compliance Education

______ HIPAA  Certificate

 OIG  Exclusionary Check______ OIG  Exclusionary Check

______ Signature Verification Form

______ National Practitioner's Database Check

 Primary Source Verification of Work Experience______ Primary Source Verification of Work Experience

______ Compliance Member in Good Standing Memo

Process for Initial Credentialing Process for Initial Credentialing and Re‐Credentialing (cont.)

Re‐Credentialing:A provider that is involved in patient care is scheduled  to be presented to the Compliance and Credentialing Subcommittee (CCC) thirty days before the expiration of their dental licensure

Timetable:Ni t d  ( ) b f  th   id  i   h d l d t  b   t d t  th  CCC h / h  i   t      f th  • Ninety‐days (90) before the provider is scheduled to be presented to the CCC he/she is sent a copy of the 

re‐credentialing packet by the  Credentialing Office

• Provider submits  his/her re‐credentialing packet and all required supporting documentation to the Division Chair for approval

•Thirty‐days (30) before the provider is scheduled to be presented to CCC he/she  is sent a thirty day notice, if any of the required documentation is missing

•Provider is submitted for approval by CCC.

If at the time of the scheduled committee meeting all of the documentation is not in order or the provider If at the time of the scheduled committee meeting all of the documentation is not in order or the provider does not submit a re‐credentialing packet  the committee will suspend the provider’s clinical privileges until the required documentation is submitted and reviewed by the committee.

_____ Completed Application

_____  Current CA License (Primary Source Verification)

_____  Current CPR Certificate

  Current DEA Certificate (When Applicable)_____  Current DEA Certificate (When Applicable)

_____  Curriculum Vitae

_____  Health Screening for TB / Hepatitis

_____ On‐line  Compliance Education

______ HIPAA  Certificate

______ OIG  Exclusionary Check

______ Signature Verification Form

i l i i b h k______ National Practitioner's Database Check

______ Primary Source Verification of Work Experience

______ Compliance Member in Good Standing Memo

 Workplace Harassment Certificate (2009)_____ Workplace Harassment Certificate (2009)

Re credentialingRe-credentialing Process

All documentation

completed

Documentationincompletecompleted

Provider is presented to CRC

Thirty (30) day Notice sent to Provider

Committee recommends

follow-up action

Committee recommends

re-credentialing

Documentation complete

Documentation remains incomplete

at time of CCC Meeting

Provider sent Congratulatory

Letter

Present to CCCfor follow-up

action

P id N iProvider sent Noticeof Suspension

of Clinical Privileges

Professional Standards and PoliciesEducation to the policiesImplementation of the policies p e e tat o o t e po c esMonitoring of the processes