Chapter 1 GENERAL ROLES AND RESPONSIBILITIES
Section 1A- General Roles and Responsibility
1.1. Air Force Surgeon General (HQ USAF/SG).
18.104.22.168. Provides corporate-level guidance for patient safety, accreditation, risk management, clinical consultation and clinica.
22.214.171.124. Provides clinical consultation, defining and/or clarifying standards of care and practice in each consultant's area of expertise.
126.96.36.199. Administers the risk management programs for the AFMS to include adverse actions and malpractice claims.
188.8.131.52. Provides policy guidance, consultation, monitoring and review of Medical Incident Investigations (MII) conducted within the AFMS.
184.108.40.206. Monitors trends in processes and outcomes of care to include sentinel events (SE); disseminates information both up and down the chain.
220.127.116.11. Serves as the AFMS liaison with national accreditation organizations.
18.104.22.168. Provides policy guidance, consultation, program management, monitoring and review of the Medical Facility Assessment and Complaince Tracking System (MedFACTS) and Centralized Credentials and Quality Assurance System (CCQAS), (refer to
1.2. Medical Inspection Directorate, Air Force Inspection Agency (HQ AFIA/SG).
1.3. Headquarters, Air Force Recruiting Service (HQ AFRS).
1.4. Medical Service Officer Management Division of Directorate of Assignments (HQ AFPC/ DPAM).
1.5. Air Force Centralized Credentials Verification Office (AFCCVO).
1.6. Command Surgeon (HQ MAJCOM/SG, ARC HQ MAJCOM/SG).
1.6.1. Individual offices within the MAJCOM will provide MAJCOM level guidance for their areas of expertise. In addition, MAJCOM.
1.7. Medical Treatment Facility Commander (MTF/CC) or Medical Wing Commander (MDW/ CC) for 59 MDW; Medical Squadron Commander (MDS/CC) or Medical Group Commander (MTF/CC) for ARC:
1.7.1. Responsible for MTF programs for patient safety, accreditation, credentialing, performance-based privileging, risk management, clinical consultation and clinical performance improvement. Ensures organizational compliance IAW this instruction.
1.7.2. Is the approval authority (or may designate approval authority during a temporary absence only) for award of privileges a.
1.7.3. The ARC privileging authority (or AD MTF/CC for collocated reserve units) must ensure that ARC providers possess current .
1.7.4. Considers input from the medical staff and appoints/selects the chief of the medical staff (SGH) and other members of the executive staff.
1.7.5. Establishes the organizational mission and vision which includes strategic planning.
1.7.6. Oversees the off-duty employment program IAW Air Force Instruction (AFI) 44-102.
1.8. Chief of the Medical Staff (SGH or the ARC Designated Senior Physician):
1.8.1. Must be a privileged physician holding an active appointment to the medical staff and be appointed by the chief executive officer (MTF/CC).
1.8.2. Is the principal executive staff advisor to the MTF/CC concerning matters of provider regulations, quality and scope of medical care, utilization of professional resources, and medical policy and planning.
1.8.3. Is responsible for and has oversight of the credentialing, privileging, and peer review process.
1.8.4. Acts as the liaison between the members of the medical staff and the executive leadership.
1.8.5. Chairs the Executive Committee of the Medical Staff (ECOMS), the Credentials Function and the Professional Staff Function.
1.8.6. Is authorized to intervene on behalf of the MTF/CC to immediately hold in abeyance or suspend privileges when a provider'.
1.8.7. Is responsible for orienting all medical staff applicants concerning Air Force (AF) bylaws governing patient care, medica.
1.8.8. May singularly review and award temporary privileges during periods of medical necessity (i.e., pressing patient care need).
1.8.9. Is responsible for ensuring the quality of professional services provided by all privileged providers.
1.8.10. Acts as the Medical Director of Patient Safety. Advises patient safety manager on initiatives to improve safety and quality of care. Champions patient safety activities with the medical staff.
1.8.11. Advises the SQ and MTF/CC when off-duty employment issues arise involving privileged providers that may negatively affect patient care and/or ability to accomplish mission requirements.
1.9. Chief Nurse Executive (SGN)
1.10. Chief, Aerospace Medicine (SGP)
1.11. Chief, Dental Services (SGD)
1.12. MTF Administrator (SGA)
1.13. The Medical Staff:
1.13.1. Are healthcare providers privileged to practice in the MTF and appointed to the medical staff by the MTF/CC.
1.13.2. Will participate in quality, patient safety and risk management activities.
1.13.3. Will acknowledge their intent, in writing, at the time of initial privileging to abide by AF bylaws. (Examples include, .
1.13.4. Individual members of the Medical Staff are responsible for maintaining the currency of required training, licenses and .
1.14. Quality/Performance Improvement (PI) Manager:
1.14.1. Is responsible for the organization-wide improvement program and is an active member of and advisor to the MTF executive.
1.14.2. Participates in the development and coordination of applicable policies, including the MTF Strategic Plan.
1.14.3. Directs the performance improvement training and education for MTF staff and organizational leaders. When improvement teams are formed, provides just-in-time training on PI tools.
1.14.4. Coordinates the dissemination of performance improvement information within the organization, ensuring basic analysis and comparative processes are included.
1.14.5. Reports the results of continuous monitoring activities to the MTF/CC and executive staff on a routine basis, as determined by the executive staff, for use in making performance-based decisions about the organization.
1.14.6. Facilitates and advises the executive leadership in the development and implementation of organization-wide strategic planning and the organization's goals and objectives.
1.14.7. Assists the organization in identifying and developing performance indicators and related measures.
1.14.8. Advises the MTF executive leadership on the organization's compliance with applicable Federal, State, and DoD healthcare.
1.14.9. Develops and coordinates written policies and procedures applicable to all aspects of the Quality/PI programs.
1.14.10. Collaborates with the credentials manager and medical staff to identify and collect performance-based provider data for ongoing performance improvement initiatives and as part of the re-privileging process.
1.14.11. Guides the organization in effectively collecting and using internal and external (comparative) data to be used for identifying, developing, implementing and sustaining performance improvements.
1.14.12. Uses or coordinate the use of process analysis tools to display and analyze data, e.g., fishbone, Pareto chart, run chart, control chart, scatter gram, etc.
1.14.13. Routinely collaborates with patient safety manager, risk manager, and credentials manager to integrate results of data .
1.15. Risk Manager (RM):
1.15.1. Designated in writing by the MTF/CC.
1.15.2. Directs all RM administrative and management activities within the medical facility. Member of committee that performs and reviews risk management functions.
1.15.3. Develops, implements and reports risk management activities and other related topics as required locally, to the executive leadership.
1.15.4. Collaborates with the patient safety manager on institutional risk management programs such as Sentinel Event (SE) repor.
1.15.5. Ensures comprehensive management control of real and potential risks for all employees, patients, visitors, and volunteers.
1.15.6. Implements and evaluates plans to decrease facility and government liability and financial loss associated with accidents and untoward events.
1.15.7. Directs actions to preserve, protect, and secure evidence and equipment involved in untoward medical incidents.
1.15.8. Works closely with the quality manager to trend organizational risks and resolve them.
1.15.9. Should be aware and inform Staff Judge Advocate (SJA) representatives of every potential litigation case and potentially compensable event and should take action to mitigate damages.
1.15.10. Provides frequent consultative information and reports to the executive leadership, committees, functions, individuals, and all levels of staff on both general and specific medical risk management issues and events.
1.15.11. Initiates and ensures timely notification/briefing of the commander and/or the Executive Committee on individual events or when trend analysis indicates a potential for major liability or a catastrophic event.
1.15.12. Facilitates MTF adverse clinical action and Healthcare Integrity and Protection Data Bank (HIPDB) processing.
1.15.13. Disseminates and manages HQ USAF/SG Notice to Airmen (NOTAM).
1.16. Patient Safety Manager:
1.16.1. Responsible for all incident and event reporting related to patient safety to include collecting, routing and tracking.
1.16.2. Coordinates the implementation of national patient safety goals.
1.16.3. Provides for medical team training.
1.16.4. Coordinates with the risk manager, quality manager, and others on all patient safety, risk management and process improvement activities as required.
1.16.5. Collaborates with all other facility functions on items/issues related to risk identification, risk assessment, and risk.
1.16.6. Facilitates the completion of Root Cause Analyses (RCAs) and Failure Mode and Effects Analyses (FMEAs); reports significant events or findings to the DoD Patient Safety Center as required.
1.16.7. Serves as the MTF patient safety advisor/resource and confers with MTF personnel at all levels to direct patient safety initiatives.
1.16.8. Conducts an annual appraisal of the adequacy of organization-wide patient safety activities/ policies/procedures to ensu.
1.16.9. Responsible for patient safety education and training to include new employee orientation.
1.16.10. Collects, routes and tracks facility incident reports related to patient safety events.
1.16.11. Establishes mechanism to inform executive leaders of patient safety activities at least quarterly, including lessons learned and risk reductions/elimination actions taken as a result of event analysis.
1.17. Credentials Manager (CM):
1.17.1. Technical advisor to the MTF/CC, credentials function chairperson, squadron commanders, and assigned providers on issues.
1.17.2. Educates the commander, chief of the medical staff, credentials function members, squadron commanders, and medical staff on new policies and changes to current directives.
1.17.3. Monitors and maintains standards of compliance with regulatory guidelines, directives, and mandates associated with the credentialing and privileging process.
1.17.4. Maintains resource information for credentialing and privileging including, but not limited to, clinical privileges lists, other AF forms, and AFIs 44-102, Medical Care Management; AFI 41-117, Medical Service Officer Education; and this instruct
1.17.5. Provides administrative support to the MTF credentials function as needed.
1.17.6. Serves as point of contact (POC) for fee-exempt DEA registration and National Provider Identifier (NPI) Type 1 registration.
22.214.171.124. Serves as the POC for initial applications for privileges, medical staff appointment and for annual and biennial re-appointments for the same.
1.17.7. Initiates the credentialing, privileging and medical staff appointment process.
1.17.8. Provides guidance, support to providers during the initial and renewal privileging process.
1.17.9. Obtains clinical peer/supervisor reviews of healthcare providers during the initial medical staff appointment/privileging process, for those in a supervisory status and during the renewal of privileges.
1.17.10. Routinely collaborates with the PI Manager, risk manager, and medical staff to assist in collecting performance-based provider data as part of the re-privileging process.
1.17.11. Manages and updates documents of evidence relevant to provider education, experience, licensure/certification, and training in the Provider's Credentials File (PCF) to ensure accuracy and currency of information.
1.17.12. Conducts and/or coordinates with the AFCCVO to perform National Practitioner Data Bank (NPDB), Healthcare Integrity Pro.
1.17.13. Establishes and maintains Centralized Credentials and Quality Assurance System (CCQAS) electronic records. Works with c. NOTE: The individual responsible for maintaining the PCF is also responsible to input and update the information into CC
1.17.14. Maintains PCFs IAW Section 5E of this instruction.
1.17.15. Prepares and transfers credentials and interfacility transfer briefs (ICTB) to gaining MTF/ medical unit within specified time requirements.
1.17.16. Works cooperatively with ARC in the following activities:
126.96.36.199. Responsible for credentialing, privileging, and medical staff appointment process and maintenance of PCFs for collocated reserve units and assigned IMAs.
188.8.131.52. Provides support to ARC personnel participating in annual tours within the MTF including, but not limited to, the entire credentialing, privileging, and medical staff appointment process.
1.17.17. Serves as POC for release of information on a provider's clinical practice who have or previously had an affiliation with the MTF.
1.17.18. Serves as the MTF CCQAS Database Administrator, authorizing new user status and training individuals as required.
Section 1B- Committees and Functions
1.18. AFMS Policy on the Use of Functions.
1.19. Functional Review (Summary) Reports.
1.20. Required Committees:
1.20.1. MTF Executive Committee
1.20.2. Executive Committee of the Medical Staff (ECOMS).
1.21. Recommended Functions:
1.21.1. Environment of Care
1.21.2. Pharmacy and Therapeutics/Medication Management
1.21.3. Medical Records Function
1.21.4. Credentials Function
1.21.5. Infection Control Function
1.21.6. Tissue, Blood and Blood Components Function
1.21.7. Operative and Other Invasive Procedures Function
1.21.8. Cancer Function
1.21.9. Professional Staff Function
1.21.10. Population Health Function
1.21.11. Ethics Function
1.21.12. Resuscitative Care and/or Special Care Function
1.21.13. Education and Training Function
1.21.14. Performance Improvement/Risk Management/Patient Safety Function
1.21.15. Information Management/Data Quality Function
1.21.16. Nurse Executive Function
Chapter 2 PATIENT SAFETY AND HEALTHCARE RISK MANAGEMENT
2.1. Framework for Safer and More Effective Healthcare
2.2. Focused Efforts to Drive Safe, High Quality Care within the AFMS.
2.2.1. Every member of the AFMS shall strive to create a non-punitive, learning culture by focusing on improved communication an.
2.2.2. This chapter provides a framework for healthcare activities using the Operational Risk Management (ORM) concepts of risk .
Figure 2.1. ORM Patient Safety Framework Model
2.3. The AFMS Patient Safety goals for healthcare delivery are:
2.3.1. For leadership to instill patient safety as a core value in all aspects of healthcare delivery.
2.3.2. For staff to embrace patient safety as an uncompromising core value with all they do.
2.3.3. To maximize the use of technology to enhance patient safety.
2.3.4. Develop and maintain a culture which fosters communication without fear of retribution.
2.4. Risk Identification.
2.4.1. Risk Identification Activities. The organization shall implement processes to reduce the risks of preventable adverse eve.
184.108.40.206. Processes requiring measurement over time are designated by accrediting agencies, the DoD, and at the discretion of the.
220.127.116.11. Proactive Risk Identification via FMEA. Each MTF shall complete at least one health care failure mode and effect analys.
18.104.22.168. Event and Near Miss Reporting. The organization shall establish a mechanism for staff, patients, and patients' families.
22.214.171.124.1. Patient safety event reporting is to identify systems and process issues that could have or did result in patient har.
126.96.36.199.2. The reporting process requires the person most knowledgeable of the event to record information related to what, when.The following Do's and Don'ts apply to event reporting:
188.8.131.52.2.1. Do notify the patient safety manager or designee by next duty day of becoming aware of the event. The patient safety manager will notify chain of command within two duty days of event. Sentinel Event notification shall occur immediately.
184.108.40.206.2.2. Do report at minimum the patient demographic information, facility related information (admission date, admitting diagnosis, unit, etc.) and factual description of the event and extent of injury.
220.127.116.11.2.3. Do route event review form to patient safety manager who will then route to other departments as appropriate.
18.104.22.168.2.4. Do maintain the confidentiality of the event review form and stamp with the Quality Assurance protection statement which protects this information from public disclosure under the provisions of 10 U.S.C. §1102.
22.214.171.124.2.5. Don't indicate in the patient's medical record that an event review form was completed, do not allow the event review form to become part of the medical record. Do record a factual account of the patient's condition in the medical record.
126.96.36.199.2.6. Don't assign blame or admit liability on the event review form or in the medical record.
188.8.131.52.2.7. Don't delay routine event review form for extra review and/or signatures.
184.108.40.206.2.8. Don't make copies of the event review form.
2.5. Risk Assessment.
2.5.1. Categorizing Reported Events. Upon receipt of event reports, the patient safety manager classifies the event in the following categories and helps determine the level of assessment required:
220.127.116.11. Near Miss. Any process variation, error or other circumstance that could have resulted in harm to a patient but through chance or timely intervention did not reach the patient. These events are also known as "close call" or "good catch".
18.104.22.168. Actual Event. Occurrences or conditions associated with care or services when they cause unexpected harm to a patient. These may be due to acts of commission or omission. These events will be further defined using current DoD 6025.13-R Military
22.214.171.124. Sentinel Event (SE). SEs are unexpected occurrences involving death or serious physical or psychological injury or risk.
126.96.36.199. Intentional Unsafe Act. Any alleged or suspected act or omission of a provider, staff member, contractor, trainee, or v.
2.5.2. Analyzing Reported Events.
188.8.131.52. Level of Analysis Required. Near misses and actual events will be scored using the format specified by the DoD Patient Safety Program guidance.
184.108.40.206. Aggregate Reviews. Near miss and actual events that do not require an individual RCA shall undergo aggregate analysis to determine contributing factors most common among the events and actions to reduce or avoid future risk from these factors.
2.6. Risk Control.
2.6.1. Competency Assessment (refer to Chapter 3, Section 3C and Chapter 8 Peer Review).
2.6.2. Education and Training Activities. The organization shall establish a mechanism to orient and educate all staff on risk i.
2.6.3. Healthcare Team Coordination Program (HCTCP). Working toward a culture of safety through improved communication and teamw.
2.6.4. Savvy or well-informed, fully-engaged patients: Offer every opportunity to maximize patient education and engage the pati.
2.6.5. All MTFs regardless of accrediting organization will adhere to National Patient Safety Goals. Information on compliance and implementation may be obtained at
2.7. Root Cause Analysis (RCA) on Events.
2.7.1. RCAs will be completed on all Sentinel Events as defined by Joint Commission and those meeting DoD requirements. This req.NOTE: MTFs shall forward notifications of sentinel events and completed RCAs to their respective MAJCOM. The MAJCOM will t
2.7.2. The RCA team shall be comprised of leadership and those with clinical expertise necessary to review the processes and systems surrounding the event. The team membership will vary according to the type of event that has occurred.
2.7.3. Upon determination that an RCA shall be performed, the MTF patient safety manager or designee will notify the respective .
2.7.4. Action Plan. The product of the RCA is the action plan. The action plan shall identify strategies the organization intend.
2.7.5. The RCA and action plan shall be completed within
2.7.6. The RCA team shall brief the commander and senior leadership upon completion of the RCA and obtain written approval for t.
2.7.7. The organization shall establish a mechanism to track completion, effectiveness, and sustainment of action items resulting from RCAs and analysis of near miss and actual events not requiring an RCA.
2.7.8. MTFs will forward a copy of all RCAs to the MAJCOM/SG for review and feedback.
2.7.9. MAJCOM/SG will be responsible for forwarding all redacted sentinel event and completed RCAs to AFMOA/SG3OQ within
2.7.10. If, during the course of a RCA, the competence of an individual involved in the medical event is in question, the team w.
2.8. Medical Incident Investigation (MII).
2.8.1. The MII process is completed in addition to an RCA in most cases, or in lieu of an RCA when an internal unbiased review i.
2.8.2. MIIs are protected from disclosure under 10 U.S.C. §1102 and the Privacy Act of 1974.
2.8.3. Major Incidents Suggesting an MII. The decision to initiate an MII rests with the MTF/CC and HQ MAJCOM/SG. The MTF/CC mus.
220.127.116.11. All inpatient suicides or active duty member suicides when the member was receiving care in Life Skills Support Center .
18.104.22.168. Infant/Patient Abduction.
22.214.171.124. Those incidents where a full objective evaluation cannot be accomplished internally at the organization or base level, incidents with media attention or of a notorious nature, and incidents with high-level interests (i.e., IG complaint.)
126.96.36.199. An unanticipated death (i.e., full-term fetus/infant, pediatric death or perioperative death), a significant injury fro.
188.8.131.52. Any other event or series of events which either caused, or could cause, injury or death to a person who, in the opinion of the MTF/CC or HQ MAJCOM/SG, deserves a formal investigation.
184.108.40.206. Those incidents where the findings of such an investigation are likely to be applicable throughout a MAJCOM or on an AF-wide basis.
2.8.4. Areas of Responsibility with MII:
220.127.116.11. The MTF/CC will:
18.104.22.168.1. Report medical incidents (of a nature noted above) and consult with HQ MAJCOM/ SG to initiate an MII. This should occur
22.214.171.124.2. Designate an organization POC for the MII team support (to ensure dedicated office space, equipment and administrative support for report preparation, etc.). This task may be delegated to the organization Risk Manager.
126.96.36.199.3. Ensure involved staff are offered initial or acute post traumatic stress intervention.
188.8.131.52.4. Develop and implement a corrective action plan based upon MII report findings and recommendations.
184.108.40.206.5. Send the action plan and response briefing slides to HQ MAJCOM/SG
220.127.116.11. The MTF Risk Manager or Patient Safety Manager:
18.104.22.168.1. Sequesters and secures all relevant medical records, x-rays, recordable medical information devices, pertinent MTF/un.
22.214.171.124.2. Upon MTF/CC request, notifies the supporting MLC or SJA of any incident that could result in a claim or litigation.
126.96.36.199.3. Maintains a copy of the MII report in a secure location at the MTF for a
188.8.131.52.4. Ensures all MII documents are marked with 10 U.S.C. §1102, QA protection disclosure statement.
184.108.40.206. The HQ MAJCOM/SG:
220.127.116.11.1. Provides consultative support to the MII process and determines funding.
18.104.22.168.2. Reports events to AFMOA/SG3OQ,
22.214.171.124.3. Nominates the MII Team Chief, and if this person is available assigns them to conduct the MII. The HQ MAJCOM/SG staff support and facilitate Team Chief training. NOTE: The team chief listing is maintained by AFMOA/SG3OQ.
126.96.36.199.4. Appoints the multidisciplinary team of investigators external to the MTF. The MII team of investigators should mirror.
188.8.131.52.5. Reviews the MII report and works with MTF to develop the corrective action plan and to prepare response slides for the brief to HQ USAF/SG3.
184.108.40.206.6. Sends a copy of the MII report, with accompanying executive summary, to AFMOA/SG3OQ
220.127.116.11.7. In coordination with MII Team Chief and investigative team, prepares a PowerPoint briefing to present the findings, recommendations, corrective actions, and make recommendations for any potential clinical NOTAMs to HQ USAF/SG3.
18.104.22.168.8. Consults with AFMOA/SG3OQ regarding MII briefing procedures for the HQ USAF/SGO.
22.214.171.124.9. Provides MII brief to MAJCOM/CC, Numbered Air Force Commander (NAF/CC), and Commander in Chief (CINC) if requested.
126.96.36.199.10. Coordinates with AFMOA/SGO3OQ to schedule briefing with the HQ USAF/ SGO, to be completed
188.8.131.52.11. Maintains executive summary file of MII for
184.108.40.206.12. Consults with AFMOA/SG3OQ regarding any requests to release or disclose information from MIIs to ensure quality assurance protection is maintained.
220.127.116.11.13. Followup with MTF to review implementation of the action plan at six months.
18.104.22.168.1. Provides training for MII Team Chiefs. In turn, Team Chiefs and HQ MAJCOM/SG will provide just-in-time training for i.
22.214.171.124.2. Analyzes incident data for systemic and other process problems. Reviews preventive and corrective actions posed by in.
126.96.36.199.3. Disseminates MII lessons learned to the AFMS through the MAJCOM/SGs and Corps leadership.
188.8.131.52.4. Requests follow-up from the HQ MAJCOM/SGs. As required, assists the HQ MAJCOM/SGs with implementation of recommendations.
184.108.40.206.5. Notifies the HQ USAF/IG of incidents, when directed or as appropriate. The Unit/ Wing Commander may order a Command D.not 10 U.S.C. §1102 protected.
220.127.116.11.6. Authorizes release or disclosure of an MII report, IAW 10 U.S.C. §1102 and the Privacy Act of 1974.
18.104.22.168.7. Archives MII reports for a
22.214.171.124. MII Team Chief:
126.96.36.199.1. Provides leadership for the MII team of investigators.
188.8.131.52.2. Facilitates a credible and thorough investigation
184.108.40.206.3. Ensures necessary resources are available for MII team to conduct the investigation.
220.127.116.11.4. Is the MII team liaison to MTF/CC and Wing Commander (WG/CC). Briefs MTF/ CC (and if requested WG/CC) prior to initiation of and completion of MII.
18.104.22.168.5. May advise the MTF/CC on the action plan based upon investigation findings.
22.214.171.124.6. Coordinates findings and recommendations with the MAJCOM prior to finalizing the report and briefing results with MTF leadership and the senior line commander.
126.96.36.199.7. Completes MII report (one copy for MTF/CC, one is forwarded to MAJCOM/SG and one copy to AFMOA/SG3OQ).
188.8.131.52.8. Coordinates brief to HQ USAF/SGO with MAJCOM/SG and AFMOA/SG3OQ (Chief, Risk Management Operations).
184.108.40.206.9. Identifies implications for the AFMS and suggest policy/procedure changes, NOTAMS, equipment issues, staffing, etc.
220.127.116.11. Medical Incident Investigators. A multidisciplinary team approach is the preferred method to evaluate a medical event and system of care. The investigation must begin
18.104.22.168.1. Complete a credible, thorough and unbiased investigation.
22.214.171.124.2. Finalize the report before departure from the MTF, leaving one copy with the MTF/ CC and sending the original plus on.
126.96.36.199.3. Under the oversight of the MII Team Chief, briefs the MTF/CC and WG/CC before and after the investigation. The WG/CC brief may be less medically detailed to facilitate understanding and discussion of the event.
188.8.131.52.4. Return all evidence (e.g., medical records, x-rays, equipment, etc.) to the MTF/CC (or designated individual) for safeguarding. EXCEPTION: In certain cases, especially those involving suspected criminal activity, the applicable law enforcemen
184.108.40.206. Selection of Medical Incident Investigators. The medical incident investigator:
220.127.116.11.1. Is not on staff at the MTF where the incident occurred.
18.104.22.168.2. Does not have a personal interest in the investigation, or with the staff involved in the incident, therefore can act objectively.
22.214.171.124.3. Is a competent healthcare professional with appropriate and current clinical or other pertinent experience.
126.96.36.199.4. Performs no other duties during the investigation.
188.8.131.52.5. Board certified is preferred, if applicable.
184.108.40.206.6. Shall have the same or similiar AFSC as those personnel involved in the medical incident.
220.127.116.11. Medical Incident Investigation (MII) Process. Several factors influence the scope of the investigation, including the s.
18.104.22.168.1. Determine the sequence of events; through a review of the medical records and any witness statements; map out the flo.
22.214.171.124.2. Compile physical evidence for review (medical records, laboratory studies, x-rays, EKGs, policies, procedures, emails, etc.).
126.96.36.199.3. Conduct witness interviews. Witnesses may include: all involved staff, MTF leadership, patient, patient's family memb. NOTE: Family, significant others, friends and co-workers may be appropriate witnesses in certain incidents, especially wi
188.8.131.52.3.1. It is not recommended to record witness interviews. If done, the witness must be informed and consent to the recording. Investigators should annotate relevant facts provided by the witnesses and summarize the interviews in the MII report.
184.108.40.206.3.2. Include those involved in the incident, those who saw or heard it, and those who's training and experience qualify them as experts.
220.127.116.11.3.3. Witnesses are not required to testify under oath and are not sworn in. Before performing the interview, the witness.
18.104.22.168.4. MII team identifies any contributing factors which may have culminated in the event.
22.214.171.124.4.1. Analyze each contributing factor to propose recommendations to prevent recurrence of the event. MII report must be consistent with the findings and not contradict itself.
126.96.36.199.5. Summarize facts, findings, contributing factors, recommendations, and corrective action plan in the MII report and PowerPoint brief.
188.8.131.52.6. Refer to the MII Team Chief/Process Training Guide (posted on the AFMOA/ SG3OQ WWW site at
184.108.40.206.7. The following Human Factors should be considered and addressed in the investigation:
220.127.116.11.7.1. Training/Licensure/Certification/Clinical Competency. Review these factors for each staff member involved.
18.104.22.168.7.2. Staff knowledge of related MTF operating instructions, AFIs, local and national standards of care/practice, and clinical guidelines.
22.214.171.124.7.3. Discipline issues, if applicable. For example, Letter(s) of Counseling (LOC) and/or Letter(s) of Reprimand(s) (LOR) related to clinical performance or professional misconduct affecting delivery of healthcare.
126.96.36.199.7.4. Fatigue factor.
188.8.131.52.7.8. Influence of drugs or alcohol.
184.108.40.206.8. The following Operational and Systemic Factors should be considered and addressed in the investigation:
220.127.116.11.8.1. Health care team communication (written and verbal, including communication between staff and with patient and patient's family).
18.104.22.168.8.2. Use of the MTF's Quality Improvement Program.
22.214.171.124.8.3. Equipment and other resources.
126.96.36.199.8.4. Adequate and consistent MTF and HQ MAJCOM Command and Control (supervision).
188.8.131.52.8.5. Unit staffing and scheduling (including deployment issues).
184.108.40.206.8.6. Requirement to exceed standard productivity.
220.127.116.11.8.7. Design deficiency.
18.104.22.168.8.8. Factors related to the function of the system as a whole.
22.214.171.124.8.9. Corporate culture.
126.96.36.199.8.10. Clarity of existing policy.
188.8.131.52.9. Possible Criminal Behavior. If criminal behavior is potentially involved immediately inform the MTF/CC, who will then consult the SJA for assistance on advisement of rights (Uniform Code of Military Justice (UCMJ), Article 31; or Fifth Amendm
2.9. Sentinel Event Review and Reporting.
2.9.1. Definition (Joint Commission). A sentinel event is defined as an unexpected occurrence involvingdeath or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase "or
2.9.2. Requirements for Joint Commission accredited MTFs:
184.108.40.206. In addition to the accreditation agencies definition and requirements for sentinel events the MTF/CC may define "sentinel event" for its own purposes to identify, report, and manage these events.
220.127.116.11. MTF leadership with staff support will identify and respond to all sentinel events, this includes conducting a timely, .
18.104.22.168. The MTF/CC will assign primary responsibility for implementation of the sentinel event process to a senior physician wh.
22.214.171.124. The JCAHO accredited MTF will submit the JCAHO reviewable sentinel event RCA and action plan to HQ MAJCOM/SG. HQ MAJCOM.
126.96.36.199. The JCAHO accredited MTF will send a
188.8.131.52. The MTF/CC will ensure widest dissemination of sentinel alert bulletins and ensure corrective actions are in place to prevent similar sentinel events from reoccurring at the organization.
184.108.40.206. The MTF will maintain sentinel event documentation in the patient safety/risk management office for a minimum of 10 years.
220.127.116.11. AFMOA/SG3OQ will maintain the AFMS sentinel event database, forward redacted sentinel event information to OASD/HA
18.104.22.168. For those MTFs submitting RCAs to Joint Commission, all feedback from the accrediting agency will be forwarded to HQ MAJCOM/SG.
2.10. Risk Management Program.
2.10.1. Each MTF shall have a risk management program, which focuses on identification, mitigation, and prevention of harmful pa.
22.214.171.124. The effectiveness of the MTF risk management program will be reviewed by the organization's committee responsible for .
126.96.36.199. Each MTF shall designate in writing the SGH or a senior physician to provide professional medical consultation to the .
2.10.2. Risk Management Program Implementation.
188.8.131.52. All serious adverse events shall be promptly investigated by the risk manager and other appropriate staff as necessary.
184.108.40.206. Immediate action shall be taken to ensure the patient is protected from additional injury and to mitigate the untoward.
220.127.116.11. When an adverse event occurs, the person in charge of the clinical area where the event occurred shall ensure notifica.
18.104.22.168. Each adverse event that requires analysis and risk management intervention by a physician or dentist shall include discussion with the chief of the department or clinic involved.
2.10.3. Potentially Compensable Events.
22.214.171.124. When an adverse event is determined to be a potentially compensable event, a formal quality of care review shall be co.
2.10.4. Products Liability Cases.
126.96.36.199. In any actual or potentially products liability cases, the risk manager shall ensure all evidence (for example, needle.
188.8.131.52. When operating room equipment is involved (ambulatory surgery, inpatient operating room), the equipment shall be remov.
2.10.5. Dissemination of Risk Management "Lessons Learned" to the Field.
184.108.40.206. General. A NOTAM will be released to the AFMS by AFMOA/SG3OQ as a means of identifying clinical concerns and lessons l.
220.127.116.11. Responsibilities in NOTAM Dissemination:
18.104.22.168.1.1. Reviews malpractice claims, adverse actions, MIIs, and RCAs to identify lessons learned appropriate for dissemination throughout the AFMS.
22.214.171.124.1.2. Receives request from MTF personnel, HQ MAJCOM/SG, or HQ USAF/ SG3 to submit a NOTAM on a subject.
126.96.36.199.1.3. Drafts NOTAM and coordinates with appropriate subject matter expert(s).
188.8.131.52.1.4. Releases NOTAM electronically to the HQ USAF/SG staff, HQ MAJCOM/ SG quality staff, HQ Corps Chiefs, and the SGN and SGH mail groups.
184.108.40.206.1.5. Posts NOTAM on AFMOA/SG3OQ WWW site at
220.127.116.11.2. HQ MAJCOM/Quality:
18.104.22.168.2.1. Primary point of contact within command for dissemination of NOTAMs.
22.214.171.124.2.2. Upon receipt of NOTAM from AFMOA/SG3OQ, disseminates to the MAJCOM/SG staff and organization/RM point of contact (or designee) within each command.
126.96.36.199.2.3. Participates in the dissemination of lessons learned by submitting NOTAM subjects to AFMOA/SG3OQ, as indicated.
188.8.131.52.2.4. Ensures each MTF within command receives and distributes NOTAM for maximum dissemination.
184.108.40.206.3. MTF Risk Manager/Designee. (Primary point of contact within the organization for NOTAM receipt and dissemination.)
220.127.116.11.3.1. Forwards NOTAM to MTF/CC, executive leadership and ensures widest MTF dissemination possible.
18.104.22.168.3.2. Reviews each NOTAM, evaluates quality assurance suggestions or risk reduction strategies, updates organizational p.
22.214.171.124.3.3. Ensures NOTAM is posted in each work area for staff members and reservists to review before rendering patient care. NOTAM review shall be part of the orientation program for new staff.
126.96.36.199.3.4. Maintains a copy of each NOTAM until it is not longer applicable/clinically current, or is superceded by new clinical practice or NOTAM.
188.8.131.52.3.5. Discusses NOTAM at the next ECOMS, Professional Staff meeting, and other forums as appropriate.
2.10.6. Disclosure and Immediate Actions Following an Unexpected Occurrence Causing Unanticipated Outcomes.
184.108.40.206. The immediate needs of the patient to minimize injury. The event shall be reported IAW this AFI (i.e., SE reporting if applicable, PCE recording, etc).
220.127.116.11. Staff shall seek (time and circumstance permitting), advice, as appropriate, of the Chief of the Medical Staff, Chief .
18.104.22.168. Full disclosure approach includes: (1) the clinical facts known at that time, (2) empathy and education for the patien.
2.10.7. Additional Functions Focusing on Risk Management. Many existing functions focus on managing risk in support and delivery.
2.11. Summary Reports.
2.12. Annual (CY) Evaluation/Report.
Chapter 3 ACCREDITATION, SELF-INSPECTION, COMPETENCY, AND IMPROVING ORGANIZATIONAL PERFORMANCE
Section 3A- Accreditation
3.1. Medical Treatment Facilities Requiring Accreditation.
3.2. Policy Conflict with Accrediting Agencies.
3.3. Governing Body and Other Equivalencies for Use in Accreditation Surveys.
3.3.1. HQ USAF/SG is the governing body for all AF MTFs.
3.3.2. Federal law, DoD and AF directives and instructions, SG policies, MAJCOM directives and policies, and local operating pol.
3.3.3. The MTF's strategic plan describes its purpose, goals, vision, and community responsibilities.
3.3.4. The MTF/CC acts as the chief executive officer and represents the governing body locally.
3.3.5. The MTF/CC designee serves as the chief operating officer (i.e., Deputy MTF/CC or another Executive Committee member).
3.3.6. The chief of the medical staff (SGH) is the president of the medical staff.
3.3.7. The chief nurse (SGN) is the nurse executive.
3.3.8. The MTF administrator (SGA) is the administrator.
3.3.9. The MTF Executive Committee formally links the functions of the governing body representative, the chief operating officer, and the medical staff.
3.3.10. ECOMS monitors medical staff functions and clinical improvement activities.
Section 3B- Self-inspection
3.5. MTF Coordination with Wing Compliance Inspections.
3.6. Self-Inspection Program Manager Appointment.
3.7. New Section Chiefs Self-Inspection Requirements.
3.8. Ongoing Self-Assessment Reports.
3.9. Compliance Oversight.
3.10. Automated Self-inspection Tools.
Section 3C- Competency Assessment
3.11. Staff Competency Assessment.
3.12. MTF Leadership Ensures Appropriate Individual Skill Mix.
3.12.1. Provides an organization wide and unit specific orientation for all new staff.
3.12.2. Assesses and documents current staff competency levels. Competency documentation for all non-privileged staff will be ma.
3.12.3. Identifies the competencies, including age-specific components that each staff member needs to perform the assigned job. NOTE: Specific guidance on competency assessment criteria for enlisted members is found in each career field's Career Field
3.12.4. Informs staff of expectations and objective criteria to perform, improve, or enhance job performance. This includes reviewing job descriptions and performance standards.
3.12.5. Implements programs that enable staff to meet the competencies and performance standards established by the organization.
3.12.6. Completes and presents annual status of the training report to the MTF Executive Committee for evaluation. The annual tr.
3.13. Staff Member Performance Evaluation.
3.14. Staff Orientation and Ongoing Compentency Training.
3.15. Competency Assessment Folder Requirements.
3.15.1. Non-privileged healthcare staff will maintain a CAF, which should be kept by the individual's (officer and enlisted) supervisor and made available to the individual for periodic update and review. See
3.15.2. Privileged Providers. Provider Credentials Files (PCFs) hold credentialing and privileging documents for the privileged provider. The PCF is maintained and secured by the MTF CM. For detailed information on the PCF refer to
22.214.171.124. Competency assessment for initial privileges and biennial renewal is accomplished through the credentialing process and is based on performance measures established by the MTF Credentials Function.
126.96.36.199.1. Initial competency assessment is based on documented training and/or clinical expertise. Evidence of training includes verifiable items in the AF Form 1540/1540A, Application for Clinical Privileges/Medical Staff Appointment/Update; AF Form
188.8.131.52.2. The biennial credentials renewal process integrates output from performance-based determinants collected on an ongoi.
Section 3D- Improving Organizational Performance
3.16. Improving Organizational Performance.
3.17. Performance improvement focuses on clinical, administrative, and cost-of-care issues, as well as actual patient outcomes (results of care).
3.17.1. PI includes evaluating the following attributes: efficacy, appropriateness, availability, timeliness, effectiveness, continuity, safety, efficiency, respect and caring.
3.17.2. The AFMS has developed a process to identify key indicators/metrics for evaluation at the Performance Improvement Board .
3.17.3. The MTF leadership will utilize AFMS benchmarks as a baseline for facility performance improvement. The goal of facility.
3.17.4. Performance improvement activities, based on facility scope of practice and capability, are focused on high-risk, proble.
3.17.5. When determining an appropriate sample size for measuring facility processes rather than an individual practice review, .
184.108.40.206. Sample size of 30 cases for a population size of up to 100 (if the population size is less than 30 cases, sample 100% of available cases).
220.127.116.11. Sample size of 50 cases for a population size of 101 to 500 cases.
18.104.22.168. Sample size of 70 cases for a population size of more than 500 cases.
3.17.6. Data is aggregated and analyzed over time. Statistical tools are used to analyze and display data such as run charts, control charts, bar graphs, etc.
3.17.7. Internal and external comparative analysis is an effective method to identify improvement opportunities. Examples include ORYX and AF/SG AFMS metrics.
3.17.8. Analysis occurs for those topics chosen by leaders as performance improvement priorities and analysis is performed when .
3.17.9. Ongoing, proactive Patient Safety and Risk Management programs are essential in reducing unanticipated adverse events and safety risks to patients and are also a critical part of PI.
Section 3E- Tools and Information Sources
3.18. MTF clinical quality can be assessed by benchmarking nationally recognized measures.
3.19. The Knowledge Exchange (
3.20. P2R2 (
3.21. Population Health Web Site (
3.22. Clinical Practice Guidelines
3.23. AFMOA/SG3OQ WWW Site (
3.24. Centralized Credentials Quality Assurance System (CCQAS) (
3.25. Health Services Inspection (HSI) (
3.26. Accreditation Association for Ambulatory Health Care (AAAHC) (
3.27. The Joint Commission (JC) (
3.28. Surgeons General WWW Sites.
3.28.1. AF, ANG, and AFRC SGs each have dedicated WWW site as follows:
22.214.171.124. Air Force Medical Service (AFMS) (
126.96.36.199. Air National Guard (ANG) (
188.8.131.52. Air Force Reserve Command (AFRC) (
Chapter 4 LICENSURE, CERTIFICATION, AND/OR REGISTRATION OF HEALTHCARE PERSONNEL
Section 4A- Personnel Required to be Licensed, Certified, and/or Registered
4.1. Professional Groups Requiring License, Certification, and/or Registration:
4.1.1. The following healthcare practitioners must possess and maintain an active (characterized by present activity, participat.license from a US jurisdiction before practicing independently within the defined scope of practice for their specialty: a
184.108.40.206. State licensing boards and other national agencies issue and may revoke authorizing documents to practice (licensure, r.
220.127.116.11. Physician Assistants (PAs) must possess and maintain an active, current, valid, andunrestricted nationally recognized certification. In addition, non-personal service contract PAs are required to be licensed in the state of practice.
18.104.22.168.1. PAs (other than non-personal services contract PAs) are exempt from the licensure requirement due to the fact that mo.
22.214.171.124.1.1. Waiver for licensure is not applicable to PAs who are non-personal services contractors (refer to
126.96.36.199. Newly accessed military clinical social workers must, at a minimum, have a Master of Social Work (MSW) level of state l.
188.8.131.52. Certified alcohol and drug abuse counselors (CADAC) must possess and maintain an active, current, valid, and unrestricted nationally recognized certification (refer to paragraph
184.108.40.206. Clinical dietitians must possess and maintain an active, current, valid, and unrestricted nationally recognized registration (refer to paragraph
220.127.116.11. The following advanced practice registered nurses must possess and maintain a current, valid, and unrestricted RN license from a US jurisdiction (as described in paragraphs
18.104.22.168. Refer to
4.2. Scope of Licensure Requirement.
4.2.1. Other Authorizing Documents to Practice. For those whose authorizing document to practice is a national certification (ph.
4.2.2. Deployed personnel must possess and maintain an active, current, valid, and unrestricted license or other required authorizing document to practice (i.e., national certification) and be privileged to practice independently.
4.2.3. Assignment to a position not involving direct patient care within or outside an MTF does not eliminate the requirement to maintain an active, current, valid, unrestricted license and/or authorizing document to practice.
4.2.4. Contract Providers. The type of contract determines the licensure requirement for contract personnel, whether it is a per.
22.214.171.124. Personal services contract employees are managed and supervised as if they are civil service or active duty. For purpos.
126.96.36.199. Non-personal services contract personnel are independent contractors and are required to carry professional liability i.
188.8.131.52. Non-Personal Services Contract Nurses. In 1999, the National Council of State Boards of Nursing (NCSBN) developed the N.
184.108.40.206.1. If a contract nurse is licensed in a state not included in the NLC and is practicing in an MTF he/she must be licensed according to the regulatory requirements of the state in which they are practicing.
4.2.5. Contract providers who practice exclusively outside the MTF are not credentialed or privileged by the MTF. All contract p.
4.2.6. American Citizens Hired Overseas. In order for an MTF located outside the US jurisdiction to hire an American citizen und.
4.3. Obtaining and Maintaining Licenses.
4.3.1. Permissive temporary duty is authorized for military personnel taking license examinations. Civilian employees will be in.
4.3.2. All civilian healthcare personnel considering employment or other affiliation with the AFMS, must obtain and maintain an .
220.127.116.11. When military providers are participating in a resource sharing agreement with a civilian institution that does not recognize the licensure portability statute (described in paragraph
4.3.3. Refer to AFI 41-104, Professional Board and National Certification Examinations, for guidance on circumstances in which a military member may be reimbursed for fees and expenses associated with taking professional board and national certification
4.3.4. The status of individual professional licensure, certification, and/or registration for all health care practitioners will be monitored at the MTF level on a regular basis (see paragraphs
18.104.22.168. Healthcare professionals not required to be entered into CCQAS, but who are required to maintain a license, registration, or certification, will be monitored in accordance with MTF local policy.
4.3.5. The MAJCOMs oversee the quality of data in CCQAS and work directly with the MTF to identify unlicensed providers and provide guidance on resolution.
Section 4B- Management of Licensure Issues
4.4. Guidance on Licensure Requirements:
4.4.1. Those personnel accessed from professional training or who complete other training and require a license, certification, .
22.214.171.124. For physicians to be eligible for licensure, they must successfully complete Step III of the United States Medical Lice.
4.4.2. According to DoD 6025.13-R, healthcare providers who do not yet meet licensure, certification, and/or registration requirements may practice only under a written plan of supervision. Within the AFMS, those healthcare practitioners who do not meet
4.4.3. Licensure Requirements for Clinical Psychologists. Clinical psychologists who have not been awarded their doctoral degree.
4.4.4. Licensure Requirements for Dentists, New Dental Accessions, Health Professions Scholarship Program (HPSP) Dental Graduate.
126.96.36.199. Direct accession new graduates must, at a minimum, show proof of having passed both Part 1 and Part 2 of the National B.
188.8.131.52. Graduates who must serve an active duty service commitment for a health professions scholarship, and other new dental g.
184.108.40.206. Failure to obtain a license within one year of arrival at the first permanent duty station may result in administrative discharge actions IAW AFI 36-3207, Separating Commissioned Officers. (Reference paragraph
4.4.5. Meaning of Unrestricted License:
220.127.116.11. For non-physician professionals who are members of the Biomedical Sciences Corps (BSC) and Dental Corps (DC), an unrest.
18.104.22.168. For Nurse Corps (NC) professionals an unrestricted license is one in which the individual has met all clinical, profess.
22.214.171.124. For the Medical Corps (MC) an unrestricted license is one in which the individual has met all clinical, professional, and administrative requirements.
126.96.36.199.1. The physician must have a license that permits him or her to practice in the state of licensure immediately, seeing non-DoD beneficiaries, without first taking any action (i.e., pay a renewal fee) on that license.
188.8.131.52.2. A physician employed by the military must have a medical license that meets all clinical, professional, and administr.
184.108.40.206.3. This requirement applies to physicians in residency programs, once they become eligible for licensure as described in paragraphs
220.127.116.11.4. This requirement and the effective date were established by United States law, specifically, 10 U.S.C. §1094, Licensure Requirement for Healthcare Professionals, as amended by Section § 734 of the Strom Thurmond National Defense Authorization
4.5. Exceptions to Physician Licensure Requirements:
4.5.1. DoD 6025.13-R outlines the provisions for implementation of 10 U.S.C. §1094 which allows a waiver of the unrestricted sco.
18.104.22.168. If the only administrative requirement is payment of renewal fees, this will not be waived.
22.214.171.124. Waiver of permissible administrative requirements is not automatic. Once determined to be eligible for waiver, each physician must submit an application for waiver (see
126.96.36.199.1. Approved waivers are to be placed in Section VI of the PCF next to the copy of the provider's license and annotated in CCQAS.
188.8.131.52. If a physician has, and intends to maintain, two or more licenses with state-exempted administrative requirements, and .
184.108.40.206. The HQ USAF/SG has delegated waiver authority to MAJCOM/SG who, in turn, may delegate this authority to the MTF/CC. For.
220.127.116.11. If a state has an unusual and substantial administrative licensure requirement, not previously identified by DoD, a waiver request package may be generated by the MTF. This package contains the waiver request memorandum (see
4.5.2. Overseas Local Hire Healthcare Providers Caring for DoD Beneficiaries. Healthcare personnel from jurisdictions other than the US require written practice authorization (permission to practice) to fulfill the requirements in paragraphs
18.104.22.168. Certification by the Educational Commission for Foreign Medical Graduates (ECFMG) (for physicians), certification by the Commission on Graduates of Foreign Nursing Schools (CGFNS) (for nurses), or
22.214.171.124. Demonstration of all of the following:
126.96.36.199.1. Comprehension and proficiency in oral and written use of the English language provided by an external agency.
188.8.131.52.2. Clinical competency documented and assessed by objective performance measures.
184.108.40.206.3. Possession of either a current, valid, unrestricted license, certification, registration, or other authorizing docume.
4.5.3. Foreign National Physicians and Dentists Whose Practice Is Limited to Foreign National Employees of the US at Overseas Locations. These providers are exempt from the requirements of paragraph 4.5.2. but must possess a license or equivalent that w
4.6. Failure to Obtain or Maintain a License, Certification, or Registration.
4.6.1. A healthcare professional who does not obtain an active, current, valid, unrestricted license or other authorizing document will not practice independently (see paragraph
4.6.2. Healthcare professionals who fail to maintain a license, registration or certification will be removed from independent practice and privileged providers will be placed in abeyance. If time
4.6.3. One or more of the following actions will be taken when a healthcare professional fails to obtain or maintain a required license, certification, or registration within the specified time frame:
220.127.116.11. Subject to the needs of the AFMS, the individual may be cross-trained into another career field or revert to previous AFSC, if applicable.
18.104.22.168. MTF/CCs should take action to withdraw the provider's additional special pay and incentive special pay (if applicable). Related references: Medical Officer Specialty Pay Plan, published yearly, and AFI 41-109, Special Pay for Health Professiona
22.214.171.124. Regular and Reserve officers on extended active duty may be involuntarily separated under AFI 36-3206, Administrative Discharge Procedures for Commissioned Officers, or AFI 36-3207, Separating Commissioned Officers, or both.
126.96.36.199. The MTF/CC may request a waiver of the timeline to obtain licensure, certification, and/ or registration.
188.8.131.52.1. The MTF forwards the package containing the MTF/CC's recommendation along with supporting justification for either a waiver of the timeline to obtain licensure, certification, and/or registration (see paragraph
184.108.40.206.2. The MAJCOM/SG forwards the package to AFMOA/SG3OQ who presents the case to the HQ USAF/SGO. If the HQ USAF/SGO's recommendation is for separation/discharge, the package is forwarded to AFPC/DPAM for disposition.
4.6.4. ARC providers who fail to maintain their required license, certification, or registration may be separated under AFI 36-3209, Separation and Retirement Procedures for Air National Guard and Air Force Reserve Members.
4.6.5. Civil service personnel may be terminated under AFI 36-704, Discipline and Adverse Actions. All MTFs will consult with their supporting civilian personnel office for potential actions with civil service or local-hire personnel.
4.7. Clinically Restricted Licenses.
4.8. Portability of State Licensure.
4.8.1. Qualifications. To be eligible for assignment of off-base duties, the healthcare professional will:
220.127.116.11. Have and maintain a current, valid, and unrestricted license or other authorizing document (i.e., certificate or registration, reference paragraph
18.104.22.168. Not be assigned to off-base duties if there is an unresolved allegation, which, if substantiated, would result in an adverse licensing or privileging action.
22.214.171.124. Have current clinical competence to perform the professional duties assigned.
126.96.36.199. In the case of physicians and other privileged providers, current clinical privileges will be granted and maintained IAW
188.8.131.52. In the case of physicians, the following additional qualification requirements apply:
184.108.40.206.1. The physician will have completed at least three years of approved post-graduate training (including completion of PG.
220.127.116.11.2. The physician will have maintained current competence, in that if 10 years or more have passed since completion of the licensing examination, the physician must have ABMS/ AOA specialty board certification.
18.104.22.168.3. The physician will be current with applicable continuing medical education requirements as delineated in AFI 41-117.
22.214.171.124. In all cases in which the off-base duty will be performed in a non-DoD healthcare facility, the healthcare professional will follow the rules and bylaws of such facility; to the extent they are applicable to the professional.
4.8.2. Coordination with State Licensing Boards Prior to Performing Assigned Duty locations. Prior to a healthcare professional .
4.8.3. Investigations and Reports. In the event of any allegation of misconduct on the part of the military healthcare professio.immediately notify their supervisor and MTF senior corps representative when a Federal/state agency or facility, to which
Chapter 5 THE CREDENTIALING PROCESS (APPLIES TO HOSPITALS, CLINICS, AND ARC MEDICAL UNITS)
Section 5A- Centralized Credentialing
5.1. AF/SG's Vision of
5.2. Air Force Centralized Credentials Verification Office (AFCCVO).
5.2.1. AFMOA will identify credentialing and privileging requirements, develop implementation guidance and resolve credential verification issues as they arise.
5.2.2. The AFCCVO will complete PSV on provider credentials and conduct appropriate queries for accessions and providers graduat.
5.2.3. The AFCCVO enters the provider's information into CCQAS, maintains the provider credentials documentation and CCQAS file .NOTE: The AFCCVO performs PSVs/queries on behalf of the MTF, therefore, the MTF need not re-accomplish this work.
5.2.4. The AFCCVO performs PSV and applicable queries upon request by the MTF (new contract and civil service employees, providers PCSing to/from MTFs, or providers undergoing annual or biennial review).
5.2.5. During the accession process, the AFCCVO will perform the National Practitioner Data Bank (NPDB)/Healthcare Integrity and.
5.2.6. The AFCCVO will process all FSMB queries. The request for query will be made via CCQAS. On the NPDB/HIPDB/FSMB tab, in the "FSMB Information" section, click the "Request Query" block (reference paragraph
5.2.7. Contact information: AFCCVO, 8626 Tesoro Drive, Suite 205, San Antonio, Texas 78217, commercial telephone number: (210) 826-0242, Fax: (210) 829-4526, electronic mail address:
5.3. Centralized Credentials Quality Assurance System (CCQAS).
5.3.1. The CCQAS database contains QA records created by or for the DoD, as part of the medical QA program. These records are co.
126.96.36.199. The CCQAS electronic PCF will be initiated and updated IAW the CCQAS User's Manual which can be found in the CCQAS "Help" menu.
5.3.2. According to DoD 6025.13-R, the following list of healthcare providers, practitioners, and ancillary personnel must be in.
188.8.131.52. Advanced Practice Nurses
184.108.40.206. Physical Therapists
220.127.116.11. Clinical Dieticians
18.104.22.168. Social Workers
22.214.171.124. Clinical Pharmacists
126.96.36.199. Clinical Psychologists
188.8.131.52. Occupational Therapists
184.108.40.206. Speech Pathologists
220.127.116.11. Physician Assistants
18.104.22.168. Dental Hygienists
22.214.171.124. Mental Health Counselors (to include CADACs)
126.96.36.199. Professional Counselors
188.8.131.52. Marriage and Family Therapists
5.3.3. The CCQAS database is web-based and accessible by MAJCOMs, HQ USAF/SG, and DoD for policy decisions. It is paramount that.
5.3.4. The MTF credentials managers, AFCCVO staff, and graduate education program offices representatives are expected to ensure.
5.3.5. The MTF should fully utilize the report capabilities within CCQAS to effectively manage the credentialing and privileging process and ensure the highest data quality.
Section 5B- Provider Credentials
5.4. Documents Used in the Credentialing Process.
5.4.1. AF Form 1540, Application for Clinical Privileges/Medical Staff Appointment. The provider must complete the AF Form 1540 and be awarded privileges prior to initiating practice in the AFMS. Each provider .Application for Clinical Privileges/Medi
184.108.40.206. The form must be filled in completely, with no time gaps from the date of professional training.
220.127.116.11. Applicants must list all licenses and/or other authorizing documents and narcotics registration(s) they have ever held,.
18.104.22.168. Applicants must provide explanation of any voluntary or involuntary termination or refusal of medical staff appointment.
22.214.171.124. Applicants must provide explanation of any voluntary or involuntary suspension, restriction, or reduction on clinical privileges, including requests for privileges that have been denied or granted with stated limitations or restrictions.
126.96.36.199.1. Section VIII, Question B asks, "Have you ever had a voluntary or involuntary limitation, reduction, revocation, suspe.Chapter 9).
188.8.131.52. Medical Malpractice Documentation. If the answer to Section VIII, Question E is "yes," applicants must advise the AFMS of their entire medical malpractice history and supply the following documentation:184.108.40.206.1. A copy of the complaint and ans
220.127.116.11.1. A medico legal opinion stating the standard of care (SOC) determination, nature of claim, status of claim, and amount.
18.104.22.168.2. Adverse Action Documentation. If there is any evidence of an adverse clinical privileging action at any healthcare facility, the applicant must supply information on that action.
22.214.171.124. If an AF Form 1540 (dated 2004 or later) is not on file for an applicant requesting renewal of privileges, he/she will complete the 2004 AF Form 1540 and include the following information in
Figure 5.1. Additional Questions for Renewal of Privileges.
126.96.36.199. Additional information for ARC personnel:
188.8.131.52.1. When applicant completes AF Form 1540 (dated 2004), Section IV, Present and Military and Civilian Assignments, he/she must include previous and current AD, civilian and ARC assignments.
184.108.40.206.2. For Section VII, References, list individuals most familiar with the provider's professional skills and capabilities. References may be from an individual's previous MTF or a civilian facility in which he or she most recently held privileges.
220.127.116.11.3. For ARC privileging issues see paragraph
5.4.2. AF Form 1540A, Application for Clinical Privileges/Medical Staff Appointment Update (if applicable). This form is completed following a PCS or transfer to an MTF when an AF Form 1540, dated 2004 or later, is already on file for a.
18.104.22.168. The AF Form 1540A will be placed with the previously completed AF Form 1540 and any subsequent AF Forms 1540A completed since the initial application. These documents then become part of the permanent documentation in Section I of the PCF.
5.4.3. Provider's Health Status Documentation:
22.214.171.124. An applicant's physical, mental, and emotional fitness to perform requested privileges must be evaluated. This is accom.
126.96.36.199. For initial privileges and medical staff appointment, health status confirmation may be accomplished by the director of.
188.8.131.52. Refer to AFI 44-102, Medical Care Management, for information on providers with specific infectious diseases.
5.4.4. AF Forms 1562, Credentials Evaluation of Health Care Practitioners:
184.108.40.206. For providers accessed from the civilian sector, three AF Forms 1562 must be completed. Where feasible and as outlined .
220.127.116.11.1. If newly accessed providers are not a member of any hospital's medical staff but are members of a group practice, equivalent individuals in the group who are familiar with the applicants' practice should complete these forms.
18.104.22.168.2. If newly accessed providers are not associated with a group practice, applicants must have peer providers familiar with their practice complete the AF Forms 1562.
22.214.171.124.3. Letters of professional reference are acceptable in lieu of AF Form 1562 if the civilian evaluator adequately address.
126.96.36.199. For providers completing an AFMS training program, one AF Form 1562 must be completed by the training program director .
188.8.131.52. For providers completing civilian training programs the program director and two senior level staff providers must each complete an AF Form 1562.
184.108.40.206. For AD providers PCSing from a DoD MTF, three AF Forms 1562 will be completed by the losing MTF. The provider's clinica.
220.127.116.11.1. For dentists (excluding oral/maxillofacial surgeons), the dental surgeon (SGD) and two other dental peers will comple.
5.4.5. Copies of the following credentials should be provided with applications for privileges; if not available, CMs may work from data supplied in the AF Form 1540 and/or AF Forms 1540A.
18.104.22.168. Qualifying degree, Educational Commission for Foreign Medical Graduates (ECFMG) certificate or Fifth Pathway certificate for individuals who obtained premedical education in the US and received undergraduate medical education abroad. (See
22.214.171.124. Postgraduate training certificates (i.e., internship, residency, fellowship, Aerospace Medicine Primary (AMP) course, or nurse anesthesia, nurse midwifery, nurse practitioner programs). This information must be PSVd as indicated in paragraph
126.96.36.199. All current professional licenses, registrations, and certifications, as well as ones the provider previously held that are now inactive, expired, and/or suspended. These documents must be PSVd.
188.8.131.52.1. The AFCCVO, on behalf of the MTF, must PSV (as indicated in paragraph
184.108.40.206. Specialty board certificates upon certification and recertification, if applicable. This information must be PSVd as indicated in paragraph
220.127.116.11. State Controlled Substance Registration (CRS), if applicable. This information must be PSVd as indicated in paragraph
18.104.22.168. Emergency Resuscitation Training Documentation. Resuscitation training requirements for personnel involved in direct patient care are outlined in AFI 44-102.
22.214.171.124. Continuing Health Education (CHE) Documentation. Continuing education is an adjunct to maintaining clinical skills and .NOTE: CHE that results in awarding specific privileges or that constitutes "Additional Qualifying Training" must be PSVd
126.96.36.199. Prior Clinical Privileges Lists.
188.8.131.52.1. The AFRS (for military accessions) and the MTF (for civilian accessions) will obtain copies of privileges awarded by .
184.108.40.206.2. For newly accessed providers from civilian practice, if the provider had privileges for less than one year at the pri.
220.127.116.11.3. Privileges for ARC personnel are based, in part, upon the applicant's civilian practice. A copy of the privileges lis.
18.104.22.168. Mammography Quality Standards Act (MQSA) Documentation:
22.214.171.124.1. For those MTFs who offer mammography services, radiologists will abide by MQSA requirements and submit appropriate do.Federal Register, Vol. 62, No. 208, Tuesday, October 28, 1997, effective 28 Apr 99). Written documentation that the provid
126.96.36.199. National Provider Identifier (NPI) Registration. The NPI is a unique health identifier for health care providers. Effe.
188.8.131.52. Any Federal Drug Enforcement Administration (DEA) registration(s) and/or the DoD fee-exempt DEA original certificate (reference paragraph
5.4.6. Data Bank Queries:
184.108.40.206. NPDB/HIPDB Queries. NPDB/HIPDB queries will be made by the AFCCVO on behalf of the MTF (reference paragraph
220.127.116.11. Federation of State Medical Board (FSMB) Queries. Effective 1 May 04, FSMB queries are only required one time for physi.
18.104.22.168. Department of Health and Human Services (DHHS) and TRICARE Sanction Provider Listings. DHHS maintains sanction authorit.
22.214.171.124.1. Non-personal service contractors are responsible to review the listing for provider applicants during the hiring process.
126.96.36.199.2. AFCCVO will query the listings for accessions, providers graduating from out-of-service training programs, and other providers at the MTF request.
188.8.131.52.3. The MTF is responsible to review these exclusion lists to ensure there is not a sanction against any provider seeking.
184.108.40.206. Defense Practitioner Data Bank (DPDB) Queries. DPDB queries will be performed by AFMOA/SG3OQ, Risk Management Operation.
5.4.7. Criminal History Background Checks (CHBC). CHBCs are required for all contract and volunteer providers caring for childre.
220.127.116.11. For non-personal service contract personnel, the contractor is responsible for initiating the Federal Bureau of Investi.Criminal History Background Checks on Individuals in Child Care Services.
18.104.22.168. The original or certified copy of the final results of the CHBC is required and must be kept in the PCF for the life of the contract.
22.214.171.124. CHBCs must be repeated every 5 years.
126.96.36.199. CHBCs are to go back as far as possible, to age 18. Prior to age 18, the documents are not accessible.
188.8.131.52. If there has been a break in government service, a complete CHBC must be re-accomplished, even if the individual has had a security clearance and/or recent CHBC.
184.108.40.206. While the DoDI 1402.5 permits DoD to provisionally hire individuals before the completion of the CHBC, it allows the SG.
220.127.116.11.1. Therefore, the MTF/CC will determine what constitutes "close clinical supervision" for individuals whose CHBCs are pe.
18.104.22.168. The MTF/CC may request a CHBC on any personnel in their command at his/her discretion.
5.4.8. Utilizing the ICTB in Lieu of AF Form 1540.
22.214.171.124. The ICTB facilitates transfer of credentials used by the receiving facility/deployed locations when privileging provide.
126.96.36.199. The sending MTF conveys pertinent credentials and privileging information to the gaining MTF using the ICTB. This is now automated via CCQAS. (Refer to CCQAS User's Guide for additional information).
188.8.131.52. The sending MTF/CC, ARC privileging authority, or designee must sign the ICTB.
184.108.40.206. For routine, annual training, or manning assistance, the ICTB package must be received by the gaining MTF at least 60 d.
220.127.116.11. Maintain a copy of the ICTB in Section V of the PCF. When possible, obtain a performance evaluation (i.e., AF Form 22 o.
18.104.22.168. For ongoing, recurrent TDYs, unless the privileges or status change, it is not necessary to generate a new ICTB/AF Form.
Section 5C- Verification of Credentials
5.5. Primary Source Verification (PSV).
5.5.1. Written Confirmation from the Issuing Authority. This confirmation should be included in Section VI of the PCF. In the ca.
5.5.2. Verbal Telephone Confirmation from the Issuing Authority. This confirmation must be annotated on the copy of the document.
5.5.3. The following are considered designated equivalent sources that have been determined to maintain a specific item(s) of cr.
22.214.171.124. The American Medical Association (AMA) Physician Master file may be used for PSV of US medical school graduation and US.
126.96.36.199. The American Osteopathic Association (AOA) Master file may be used as PSV for US medical school and US residency progra.
188.8.131.52. The Educational Commission for Foreign Medical Graduates (ECFMG) for verification of physician's graduation from a foreign medical school. (Refer to paragraph
5.5.4. Internet or WWW. The use of a professional organization's WWW site is permitted for PSV of credentials by a healthcare organization (HCO) or its contracted Credentials Verification Organization (CVO) if:
184.108.40.206. The information is obtained directly from the professional organization's WWW site. Use of the WWW site of another reco.
220.127.116.11. The HCO and, when applicable its CVO, should assure itself that the source WWW site, when not located at, and under the.
18.104.22.168. The information on the WWW site contains all of the information required for the PSV process of the specific credential.
22.214.171.124. The HCO and, when applicable it's CVO, should know the currency of information on the WWW site. Information on the WWW .
126.96.36.199. Any discrepancy between information provided by the applicant and that on the WWW site should be followed up with the professional organization by correspondence or telephone.
188.8.131.52. The fact that adverse information is not presented on the WWW site should not deter the HCO from contacting the profess.
184.108.40.206. The signature block of the person completing verification, along with the date, will be placed on the WWW site printout.
5.5.5. Touchtone Telephone PSV (in which the caller does not speak with an actual person; instead, electronically accesses a dat.
5.6. Credential Document Authentication.
5.7. Actions Following Initial Verification.
5.7.1. Licenses, registrations, certifications must be re-verified as described in paragraph
5.7.2. Credentials which do not expire or require reissue, such as qualifying degree, do not need to be re-verified as long as the practitioner is continually employed by the DoD.
5.8. Inability to Obtain Necessary Credentials PSV.
5.9. Foreign language (excluding Latin) documents must be translated into English.
5.10. Verification of Board Certification.
5.10.1. For the American Board of Medical Specialties (ABMS), the following have been identified and approved as their designate.
220.127.116.11. MTFs will use the AFCCVO services to fully utilize the AFMS subscription for verification of board certification.
18.104.22.168. According to ABMS, the official ABMS Directory of Board Certified Medical Specialists, 37th edition and subsequent pri.
22.214.171.124. According to AOA, the Official Osteopathic Physician Profile Report is recognized as providing primary source informat.
126.96.36.199. Verifications through ABMS or AOA apply only to those specialty boards that are members of the ABMS or AOA. Certification by non-ABMS or AOA boards must be verified directly with the respective board. Reference AFI 41-104, Professional Board a
5.10.2. It is not necessary to delay the award of privileges pending verification of board certification, because board certification is not an AFMS requirement for privileging.
Section 5D- AFRS, AFPC/DPAM, and AFMS Postgraduate Training Program Director Responsibilities for Credentials Documentation
5.11. Provider Accessions through the Air Force Recruiting Service (AFRS).
5.11.1. The ARC accession credential requirements are the same as outlined in paragraph
5.12. Providers Attending Air Force Postgraduate Education Programs:
5.12.1. The director of medical education at the MTF that provides training for an individual will create and maintain a resident medical training record and a CCQAS record at the initiation and throughout the duration of training.
188.8.131.52. The medical training record will contain PSVd copies of all applicable credentialing documents and qualitative perform.
5.12.2. When training is completed, the director of medical education at the MTF prepares a final evaluation to reflect all material in the resident's medical training record. This includes the following:
184.108.40.206. AF Form 1562, Credentials Evaluation of Health Care Practitioners.
220.127.116.11. AF Form 494, Academic/Clinical Evaluation Report. AF Form 494 is completed by the training program director. Program directors for the Residency in Aerospace Medicine (RAM) training may submit an AF Form 475, Education/Training Report in lieu
18.104.22.168. Annotated clinical privileges forms. The training program director will indicate the student's ability to perform trea.
22.214.171.124. An original signed verification (i.e., memorandum, letter, or other document to serve as PSV) of successful training program completion. This includes verification for those persons completing first post-graduate year (PGY-1) training.
5.12.3. The final evaluation documents are filed in the medical training record. The credentials documents in the medical traini.
5.12.4. The training program director or his/her designee at the losing MTF will transfer the CCQAS record to the gaining facili.
5.12.5. Reference Credentials
5.12.6. The training program office will maintain copies of applicable credentialing documents IAW AFI 41-117.
5.13. Deferred Providers Attending Residency, Fellowship, or Other Long-Term Graduate or Other Medical Education Programs in Residence at Civilian Medical Facilities.
5.13.1. Providers in residency programs will be licensed as described in paragraphs
5.13.2. AFCCVO will provide an AF Form 1540, three AF Forms 1562, and the appropriate clinical privileges form(s) to providers for completion. At completion of training, the AFCCVO will PSV credentials IAW paragraph
Section 5E- Provider Credentials File (PCF):
5.14. Handling of the PCF.
5.14.1. The cover of all PCFs must contain the following two statements: 1) "Privacy Act of 1974 governs access to this file," and 2) "This is a Quality Assurance document protected from release by Federal Law, 10 U.S.C., 1102."
5.14.2. PCFs will be maintained in a secure manner. Providers may review their files, but they may not remove them from the control of the CM.
5.15. Content of the PCF.
5.15.1. Section I--Privileging Documents. This section includes the current privileging and medical staff appointment documents. It may include, but is not limited to:
126.96.36.199. The AF Form 1540 (see paragraph
188.8.131.52. Current military clinical privileges list(s) and memoranda regarding privileges.
184.108.40.206. Letters of notification to, and acknowledgment by, the provider regarding the awarded privileges and medical staff appointment at the current MTF.
220.127.116.11. Memoranda designating clinical supervisor and a detailed plan of supervision (see paragraph
18.104.22.168. The current incoming interview and provider's acknowledgement of interview/orientation.
5.15.2. Section II--Performance Data. This section includes documents that reflect relevant and factual performance data. It may include, but is not limited to:
22.214.171.124. AF Form(s) 1562, AF Form 22, AF Form 494, AF Form 475, the most recent NPDB/ HIPDB, and if applicable FSMB and/or DPDB queries, CHBC documentation (if applicable), and results of DHHS and TRICARE sanction queries for the current assignment.
126.96.36.199. For civilian and ARC providers, include current privileges and most recent statement of renewal of privileges from the.
5.15.3. Section III--Medical Practice Review. This section includes adverse privileging action and malpractice claims data. It may include, but is not limited to:
188.8.131.52. DD Form 2499, Health Care Provider Action Report, and supporting documentation of permanent credentials function actions (does not apply to civilian practice).
184.108.40.206. Records of hearings may be kept in a separate folder(s), if too bulky, but must be cross-referenced. The hearing recor.
220.127.116.11. Previously initiated DD Form 2526, Case Abstract for Malpractice Claims. (Does not apply to civilian practice.) Previously initiated forms must be replaced by updated DD Form 2526 as received from reviewing authorities.
5.15.4. Section IV--Continuing Health Education (CHE). This section contains the AF Form 1541, Credentials Continuing Health Education Training Record. It is acceptable to reference the provider's CCQAS file on the AF Form 1541 and attach the printed CC
18.104.22.168. Even if the AF Form 1541 is used to document the provider's continuing education the training must also be documented in the provider's CCQAS record under the Additional Training tab.
22.214.171.124. Copies of training certificates need not be kept in the PCF.
126.96.36.199. AF Form 1541 and CCQAS provider records also captures emergency resuscitation requirements and training [i.e., BLS, Ad.
188.8.131.52. For nurse practitioners, certified registered nurse anesthetists, and certified nurse midwives, the AF Form 2665, Air Force Nurse Corps Education Summary, (continuing education activities) may be used in place of AF Form 1541. If the AF Form 1
5.15.5. Section V--Historical Data. This section is a repository for superseded credentials and privileging documents. It may in.NOTE: Since the most recent NPDB/HIPDB and FSMB queries contain a complete historical record, it is not necessary to maint
5.15.6. Section VI--Credentials. This section contains credentialing documents. It may include, but is not limited to: PSV docum.
5.16. Maintenance of ARC PCFs and CCQAS Database.
5.16.1. Each ARC medical unit commander will appoint, in writing, the most qualified officer or senior non-commissioned officer as the credentials manager/liaison. NOTE: Recommend the MDS/ CC appoint an assistant credentials manager/liaison.
5.16.2. The PCF is established and maintained at the MTF if collocated and at the ARC medical unit of assignment if non-collocat.
5.16.3. Non-collocated ARC medical units will maintain their assigned providers' PCF and associated CCQAS records.
5.16.4. The host MTF of a geographically separated medical reserve unit will maintain the AFRC provider PCF and CCQAS record.
5.16.5. For ANG SMEs, the PCF and CCQAS record is maintained by the host medical unit.
5.16.6. The credentials liaison for the collocated ARC medical units will act as liaison between the AD MTF and the ARC medical unit to ensure appropriate PCF documentation is provided (reference paragraphs
184.108.40.206. The ARC medical unit CC, SGH (or equivalent), unit credentials liaison and provider are responsible for forwarding all required credentials necessary to prepare the PCF for the privileging process to the active duty MTF CM.
220.127.116.11. All supporting credentialing documentation for renewals must be submitted to the MTF CM at least 90 days prior to the .
5.16.7. The AD MTF unit of attachment for Individual Mobilization Augmentees (IMAs) and Participating Individual Ready Reserve (PIRR) providers will create and maintain the assigned provider's PCF and CCQAS record.
Section 5F- Disposition of PCFs/CCQAS Records and Provider Activity Files (PAF)
5.17. Disposition of Active PCFs/CCQAS Records When Providers Transfer.
5.17.1. The losing medical unit sends the PCF by registered, certified or any other accountable mailing source and transfers the CCQAS record to the gaining medical unit to arrive
5.17.2. When a provider is reassigned, the SGH or ARC senior physician designee, clinical supervisor, and one peer at the losing MTF each complete a separate AF Form 1562 (as described in paragraphs
5.17.3. The losing MTF CM may send a request for the AFCCVO (refer to paragraph
5.17.4. Providers assigned to administrative positions (i.e., HQ USAF, HQ MAJCOMS, or other staff positions) that do not request.
18.104.22.168. For providers in administrative positions and those entering re-deferred civilian training programs the CCQAS record i.NOTE: The AFCCVO manages both the CCQAS AFCCVO and AFIT UICs. The losing MTF CM notifies the provider of record location.
5.17.5. PCFs for providers in military post graduate training programs associated with an MTF will be sent to the MTF-specific training program office and the CCQAS record forwarded to the appropriate GME UIC (refer to paragraph
5.17.6. The provider is responsible to provide licensure, registration, certification, CHE, and BLS/ ACLS/ATLS recertification updates to the appropriate office managing their PCF and CCQAS file.
5.18. Disposition of Inactive PCFs, CCQAS Records, and PAFs:
5.18.1. Medical units will maintain inactive PCFs of retired or separated providers IAW Air Force Records Information Management System (AFRIMS), Records Disposition System (RDS), Table 44-7, Rules 3 and 4 (AFMAN 37-139 has been replaced by the AF RDS a
5.18.2. Disposition of the PCF when providers leave employment. When a provider separates, retires, or terminates employment, co.
5.18.3. If a separating or retiring military provider is offered and accepts employment at the same MTF within 30 days, any appr.NOTE: It may be appropriate to change the provider's medical staff appointment based on part time employment status. Howev
5.18.4. If the provider transfers to the ARC, the MTF keeps the file until the ARC requests it and then the CCQAS file is transferred and the PCF is forwarded via the most cost effective accountable mail source to the applicable ARC unit.
5.18.5. All ANG medical units will forward the inactive provider PCFs to ANG/SG with a memorandum stating the reason why the PCF.
5.18.6. All AD facilities will maintain a PAF containing cumulative data information on a provider. This data will be used by th.
22.214.171.124. Facilities will maintain PAFs for IMA/ Participating Individual Ready Reserve (PIRR) providers attached to their MTF.
5.19. Closing Medical Units:
5.19.1. Inactive PCFs will be sent by the most cost effective accountable mail source to the medical unit's HQ MAJCOM/SG. PAFs a.
5.19.2. Medical units will attempt to notify providers of the location of their PCFs.
5.19.3. PCFs of active IMA and PIRR providers who have not been reassigned will be sent to HQ ARPC/SG.
5.19.4. HQ MAJCOM/SG will maintain PCFs as described in paragraph
Section 5G- Non-Privileged Medical Professionals
5.20. Primary Source Verification for Non-privileged Medical Professionals.
5.20.1. Non-privileged medical professionals required by the organization, by law, or regulation to practice their profession mu.
126.96.36.199. AFRS will accomplish PSV for all medical accessions requiring licensure, registration or certification IAW paragraph
188.8.131.52. Each MTF shall determine the office responsible for PSV of licensure, registration or certification of non-privileged .NOTE: For professionals hired through a non-personal service contract, the contractor is responsible to perform the PSVs a
184.108.40.206. Non-privileged medical professionals must provide information on all licenses, registrations, or certifications active.
220.127.116.11. For accessions and other employee applicants, any information concerning unfavorable actions against any licenses, reg.
5.21. NPDB/HIPDB queries for RNs/LVNs/LPNs
5.21.1. Effective upon publication of this AFI, AFRS will accomplish a one-time NPDB/HIPDB query for all nurse (RNs/LVN/LPNs) ac.
18.104.22.168. All positive reports will be forwarded through the appropriate clinical chain of command to AFMOA/SG3OQ, to the attention of the Chief Consultant, Nursing Services, for consideration and employment recommendation.
22.214.171.124. HQ AFRC/RS will accomplish a one time NPDB/HIPDB query for all nurse (RN/LVN/ LPN) accessions. All positive reports (i.
Chapter 6 THE PRIVILEGING PROCESS
Section 6A- Considerations in Awarding Privileges
6.1.1. Newly accessed providers who do not have adequate documentation of current clinical competence (i.e., sole practice provi.
6.1.2. The delineation of privileges verified at the MTF should also consider the capabilities of the support staff, equipment, and other resources that may restrict a provider's services.
6.2. General Information:
6.2.1. Privileges must be appropriate to the training, background, and demonstrated current clinical competence of the provider.
6.2.2. Privileges are both individual and MTF/ARC medical unit specific. Military members requesting privileges should hold an A.
6.2.3. Providers referenced in paragraph
6.2.4. Providers who interpret medical data on individual patients must be privileged and privileging should require documentation of some regular or periodic clinical practice, adequate enough to maintain currency.
6.2.5. Privileging is not a disciplinary mechanism and will not be used as punishment for activities unrelated to clinical pract.
6.3. Relationship Among Privileges, Medical Staff Appointment, and Authorization to Admit Patients.
6.4. Master Clinical Privileges List.
6.5. Providers Affected by the Privileging Process.
6.5.1. Audiologists, chiropractors (only contract providers at DoD-designated sites), clinical dietitians, clinical pharmacists,.
6.5.2. The HQ USAF/SG defines the scope of practice for each category of provider to be awarded clinical privileges.
6.5.3. The ASD(HA) establishes which professional groups may be awarded privileges. To seek approval to add another group, submit written request through MAJCOM to AFMOA/SG3OQ who will review and forward to the ASD(HA), if deemed appropriate.
6.5.4. Privileges are not awarded to interns, residents, or advanced practice nurse students in training programs.
126.96.36.199. Fellows and physicians attending a second residency (have completed a previous residency) and fully qualified in a spec.
6.5.5. Dentists who are licensed in a US jurisdiction but undergoing postgraduate training may be granted core privileges. Dentists enrolled in postgraduate training remain subject to supervised practice within the requirements of the residency program.
6.5.6. Privileges are not awarded to social workers in Family Support Centers (FSC), or social workers in family advocacy outrea.
Section 6B- The Credentials Function
6.6. Credentials Function Membership.
6.6.1. Credentials function composition should reflect the diversity of providers practicing within the facility, but, at a mini.
6.6.2. When the credentials function is considering awarding clinical privileges to an allied health provider, the SGH will sele.NOTE: This policy is not required for awarding temporary or supervised privileges.
6.6.3. The chief nurse executive serves as an advisor to the credentials function as a non-voting member.
6.7. Credentials Function Procedures:
6.7.1. The medical staff, through the credentials function, reviews provider requests for privileges and medical staff appointme.
6.7.2. The credentials function should formally meet at least quarterly to maintain appropriate oversight of the entire process.
188.8.131.52. Fast Track Award of Privileges and Medical Staff Appointment. A credentials function consisting of, at a minimum, a pee.
6.7.3. Credentials function proceedings are documented in the summary report that is provided to the ECOMS/Executive Committee of the Professional Staff (ECOPS).
6.7.4. When evaluating a member of the credentials function, the chairperson must excuse the individual from that portion of the meeting or activity. Note his or her absence in the summary report.
6.7.5. The credentials function must not make a privileging recommendation on a provider when less than a majority of the creden.
Section 6C- The Privileging Process within the MTF or ARC medical units:
6.8. Providers who seek privileges will:
6.8.1. Complete and/or review, for currency and accuracy, all of their application forms used for privileges before they are reviewed by the credentials function.
6.8.2. Complete appropriate clinical privileges list(s). The applicant fills out the appropriate privileges list for his or her specialty. General Medical Officers (GMOs) complete the AF Form 2816, Clinical Privileges-Family Practice and Primary Care Ph
184.108.40.206. Instructions for completing privileges list:
220.127.116.11.1. The applicant enters the appropriate code number in the block marked "Requested" for each privilege. This is based on.
18.104.22.168.1.1. NOTE: For those privileges lists that include more than one type of professional (i.e., psychiatry includes clinical psychologists an.
Table 6.1. Codes
22.214.171.124.2. Providers who feel they are no longer competent to perform a specific procedure should enter code "2" or code "4" on .
6.8.3. Comply with MTF by-laws, rules and regulations.
6.8.4. Maintain appropriate documentation of CHE and promptly provide pertinent CHE updates, via copies of specific CHE coursewo.
6.8.5. Review performance data as provided in their provider activity files (PAFs), Composite Health Care System (CHCS), Armed Forces Health Logitudinal Technology Application (AHLTA) (described in glossary) and/or other applicable databases.
6.8.6. Provide updates on credentials maintained in the PCF to the CM or ARC privileging authority for non-collocated medical units as changes occur.
6.8.7. Complete orientation.
6.8.8. Acknowledge by signing the notification letter, once privileges and/or medical staff appointment is granted. A copy of their approved clinical privileges list will also be provided to them (reference
6.9. Clinical Supervisors will:
6.9.1. Meet with the applicant (if possible) to discuss clinical capabilities, expectations, and unique MTF requirements before the provider completes their clinical privileges list(s).
6.9.2. Review the application package.
126.96.36.199. Clinical Supervisors who lack the expertise to adequately evaluate a provider's privileges will ask HQ MAJCOM/SG for th.
188.8.131.52. For senior staff providers, such as the flight commander or chief of the medical staff, applying for privileges and/or .
6.9.3. Complete the clinical supervisor's recommendation on submitted privilege lists. The clinical supervisor reviews the reque.
184.108.40.206. Any discrepancies between the provider requested privileges and those that are verified by the clinical supervisor shal.
220.127.116.11. Verifying specific privileges as code "1" or code "2" is not the same as overall regular or sup8ervised privileges. Refer to Section 6D for a full description of privileges that may be granted.
18.104.22.168. For providers who do not yet have their authorizing document to practice (i.e., license, certification, registration), .
22.214.171.124. It is possible to have a mixture of various codes and still be granted regular privileges. Regular privileges may be gr.
126.96.36.199. The plan of supervision as described in paragraph
6.9.4. Check the appropriate block on the AF Forms 1540 or 1540A (whichever is applicable), signs and dates the form.
6.9.5. Forward application package to the chief of service or the next privileged provider in the clinical chain of command.
6.10. Chiefs of Service/Department Chairperson:
6.10.1. The chief of service or the next privileged provider in the clinical chain of command reviews the application package, checks the appropriate block on the AF Form 1540 or AF Form 1540A, signs and dates the form.
188.8.131.52. Any discrepancies between the provider's requested privileges and those that are recommended for approval must be addressed on the applicable AF Form 1540 or 1540A.
6.10.2. Returns the application package to the CM for routing to the Credentials Function chairperson.
6.11. Credentials Function Chairperson (SGH or the ARC designated senior physician) will:
6.11.1. Ensure all incoming providers complete orientation to include information on applicable DoD, AF, and local instructions,.
184.108.40.206. For civilian providers hired directly by the MTF, the SGH is responsible for interviewing and orienting new civilian h.
6.11.2. Review the application package, check the appropriate block on the AF Form 1540 or 1540A, sign, and date that form, and ensure the package is forwarded to the MTF/CC for approval.
220.127.116.11. Any discrepancies between the provider's requested privileges and those that are recommended for approval must be addressed on the applicable AF Form 1540 or 1540A.
6.12. The MTF/CC (or ARC privileging authority) will:
6.12.1. Consider the recommendations of the credentials function chairperson (or ARC designated senior physician) and take action to award individual provider privileges.
18.104.22.168. Any discrepancies between the provider's requested privileges and those that are recommended for approval must be addressed on the applicable AF Form 1540 or 1540A. NOTE: For initial applications, the privileging authority may limit privileges
6.12.2. Will advise the provider, in writing, of the privileges granted. The provider then has 14 calendar days to acknowledge receipt and accept or appeal the decision of the privileging authority. For the ARC, the provider has
6.13. Revisions and Corrections to Privilege Lists.
6.14. ARC Privileging Process.
6.14.1. ANG Privileging Authority (MDG/CC) for non-collocated medical units.
22.214.171.124. The MDG/CC will review the PCF and recommendations by designated senior physician and award privileges to assigned pro.
126.96.36.199. Each SAS will review the MDG/CCs PCFs (within their state) and award them privileges. In the absence of an SAS, this authority is extended to the ANG/SG.
188.8.131.52. The ANG/SG will review the PCF and award privileges to SASs and is the final privileging authority for the ANG. Forward the PCF to ANG/SG, Attention: Credential Manager, 3500 Fetchet Avenue, Andrews AFB MD 20762-5157.
6.14.2. AFRC Privileging Authority (MDS/CC) for non-collocated medical units.
184.108.40.206. The MDS/CC will review the PCF and recommendations by the SGP or SGH and award privileges to assigned providers. If th.
220.127.116.11. The RSG/SG will review the PCF and award privileges to the MDS/CCs within his or her region. If the RSG/SG is not a ph.
18.104.22.168. The AFRC/SG will review the PCF and award privileges to the RSG/SG, or senior physician, if applicable, and is the final privileging authority for the AFRC.
6.15. ARC Privileging Issues:
6.15.1. ARC providers will complete the AF Form 4318, Clinical Privileges-Air Reserve Components (UTA), and duty AFSC privileges list as applicable.
6.15.2. Awarding of the UTA and duty AFSC privileges are based, in part, upon the provider's civilian work experience and duty specific training.
22.214.171.124. In support of medical readiness, the military duties of ARC personnel should focus on their duty AFSC. For example, ev.
6.15.3. Providers who are assigned to and who provide patient care services in medical units must have a PCF or ICTB and be awarded clinical privileges before beginning practice.
6.15.4. Providers will not be privileged or provide any patient care services without attending UTAs and maintaining training requirements.
6.15.5. Providers will not be privileged or provide any medical services while attending training unless specifically assigned to a support tasking such as support for an operational readiness inspection (ORI), etc.
6.15.6. Privileges awarded to ARC medical providers for UTAs will not apply instead they should be awarded privileges appropriate for their assigned clinical duties when doing AEF training cycle or special assignments at an AD MTF.
6.15.7. When an ARC medical unit is collocated with an active duty MTF, the host AD MTF/CC awards privileges for ARC providers.
6.15.8. If Participating Individual Ready Reserve (PIRR) providers do not participate often enough for the privileging authority.
6.16. Management of Contract Provider Privileges.
6.16.1. Contracts impacting credentialed and/or privileged personnel will be coordinated with the Chief of the Medical Staff and the CM.
6.16.2. Contract healthcare providers should participate in medical staff activities.
6.16.3. Formally assigned and trained Quality Assurance Personnel (QAP), knowledgeable about the Performance Work Statement (PWS) for contractor-provided services, will perform healthcare contract surveillance. NOTE: IAW AFI 41-209, Chapter 4, work stat
6.16.4. According to MTF PI/RM policy, QAP will report issues or incidents involving non-personal services contract healthcare p.
6.17. Privileging in a Field Environment During Peacetime Training or in Support of an Expeditionary/Contingency Mission.
6.17.1. If providers will practice in a fixed MTF, the MTF will review credentials and award appropriate privileges. To expedite.
6.17.2. If providers will not practice in a fixed MTF, the deployed medical commander is responsible for the scope of practice o.
126.96.36.199. The scope of practice of deployed units providing care in an area, which is normally the responsibility of a fixed MTF, must coordinate the level of care provided in the field environment with the fixed MTF/CC.
188.8.131.52. In field locations where a fixed MTF does not have responsibility for care, providers should not exceed the privileges defined by their home MTF/ARC medical unit and the capabilities of the deployed unit itself.
184.108.40.206. Deployed personnel will be familiar with the medical, dental, and ancillary capabilities of the referral MTF and host country healthcare facilities.
220.127.116.11. Privileging actions are not appropriate in the field environment. Privileges are not granted and adverse privileging a.
6.17.3. The MAJCOM/SG responsible for the deployed location should be contacted for further guidance/clarification. Waiver authority for policy related to deployed units is the responsibility of AFMOA/CC or the HQ USAF/SGO.
6.18. Care in Emergency or Wartime Situations.
6.19. Granting Privileges to Short-Term Affiliates using the ICTB.
6.19.1. The ICTB package consists of the ICTB letter which is automated in CCQAS and copies of the provider's current approved c.
18.104.22.168. Simultaneously, the electronic ICTB will be annotated to reflect the date and name of the individual who signed the IC.
6.19.2. Upon receipt of the ICTB letter and applicable privileging lists, the gaining MTF may elect to award privileges in advance to expedite the provider's availability for patient care services.
6.19.3. At the gaining MTF:
22.214.171.124. The CM will request the AFCCVO, on behalf of the MTF, to PSV the provider's license or authorizing document to practice and perform a NPDB/HIPDB query.
126.96.36.199. The credentials function chairperson will sign and date the clinical privileges list and the MTF/CC will grant the privileges at his or her discretion.
188.8.131.52. The MTF/CC may grant clinical privileges after the privileges are delineated on a standardized clinical privileges list and review of the PSV and query results. NOTE: Privileges for ARC personnel are based on their duty AFSC and the provider's
184.108.40.206. The MTF/CC will sign a document containing the following statements and attach it to the provider's ICTB for this purp.
220.127.116.11. No further action is necessary at the time the provider goes to work at the MTF for the duration of the current home-base privileges.
18.104.22.168. Once privileges have been formally awarded, copies of the approved clinical privileges lists should be given to the provider and sent to the appropriate clinical areas.
22.214.171.124. At the completion of the provider's assignment, the clinical supervisor completes an AF Form 1562 or AF Form 22, which is then returned to the parent unit.
6.20. Civilian Consultants.
6.20.1. A current curriculum vitae, a copy of their current civilian privileges list, an original letter from their current inst.NOTE: Civilian consultants must comply with the host state licensure laws.
6.20.2. The AFCCVO, on behalf of the MTF, PSVs the provider's license/authorizing document to practice, obtains a NPDB/HIPDB query and, if applicable, FSMB query and DHHS/TRICARE sanctioned provider listing review (reference
Section 6D- Types of Privileges
6.21. Procedures and Requirements for Specific Types of Privileges:
6.21.1. Regular Privileges. Regular privileges are granted to providers only after full verification and review of credentials.
126.96.36.199. Marking some privileges with a code "2" does not place a provider in the same category as a provider granted supervise.
188.8.131.52. Clinical Pharmacists, PAs, and Physicial Therapists (with prescriptive authority) are required to have a clinical preceptor appointed in writing and may be granted regular privileges according to their scope of practice. NOTE: Physicial Therap
184.108.40.206. APNs no longer require a physician preceptor be identified in writing but must have a physician supervisor available for consultation and collaboration (refer to
6.21.2. Supervised Privileges. Supervised privileges should be granted to providers who lack the necessary licensure or certific.
220.127.116.11. Supervised privileges are awarded in the same manner as regular privileges except that a clinical supervisor with regu.
18.104.22.168. The clinical supervisor determines the required degree of supervision, based on the background, experience, and demonstrated skill of the supervised provider. Degrees of supervision are described in the glossary under "Supervision."
22.214.171.124. All privileges must be marked in the "verified" column with a code "2" indicating all are performed under supervision.
126.96.36.199. Supervision for a "lone specialist" may be provided in several ways different ways (refer to
6.21.3. Temporary Privileges (This is not applicable to the ARC). Temporary privileges are awarded on an emergency basis to meet.
188.8.131.52. Credentials requirements include the following:
184.108.40.206.1. A copy of the provider's license must be obtained and PSVd.
220.127.116.11.2. Verification (documented in the PCF) by the facility where the provider holds regular privileges indicating that the.
18.104.22.168. The credentials function chairperson then recommends granting of temporary privileges to the privileging authority. If he/she is not available, the credentials function chairperson may grant the privileges.
6.21.4. Disaster Privileges. Disaster privileges may be granted when the emergency management plan has been activated and the organization is unable to handle the immediate patient needs. (For additional information for scope of practice see paragraph
22.214.171.124. A current picture hospital ID card OR a current license to practice and a valid picture ID issued by a state, Federal, or regulatory agency OR Identification indicating that the individual is a member of a Disaster Medical Assistance Team (DMA
126.96.36.199. The MTF begins the verification process of the individuals who have received disaster privileges as soon as the immedi.
Section 6E- Medical Staff Appointment (This Section is not applicable to the ANG)
6.23. Types of Medical Staff Appointment.
6.23.1. Initial Medical Staff Appointment. Initial medical staff appointment is granted to a provider during his or her first 12.
188.8.131.52. During this period, the medical staff member's performance will be under close review by clinical supervisor for clini.
184.108.40.206. An initial medical staff appointment leads to an active or affiliate medical staff appointment and should be designate.
220.127.116.11. Before the initial medical staff appointment ends, the Credentials Function must review the provider's performance, bo.NOTE: Professional activities include conduct (behavioral patterns) which may or may not directly affect the provider's a
18.104.22.168. Failure to advance from an initial to active or affiliate appointment shall cause the expiration of (but not termination of) medical staff membership.
22.214.171.124. A provider who is awarded an initial medical staff appointment may later be granted an active or affiliate appointment.
6.23.2. Active Medical Staff Appointment. Active medical staff appointment assigns responsibility to the provider for all functi.
6.23.3. Affiliate Medical Staff Appointment. Affiliate medical staff appointment is for medical staff members whose medical staf.
6.23.4. Temporary Medical Staff Appointment. Temporary medical staff appointment is granted in emergency situations when necessa.
Section 6F- Reprivileging and Reappointment Requirements
6.24. General Information.
6.24.1. The Credentials Function will formally review, and the privileging authority must reconsider, each provider's privileges and medical staff appointment at least
126.96.36.199. If a provider's privileges lapse prior to renewal, the complete privileging process must be re-accomplished because there is no mechanism to extend privileges past the expiration date. Unprivileged providers will not continue to provide patien
6.24.2. The clinical supervisor, department chair/chief of service, credentials function chairperson, and the MTF/CC or ARC privileging authority must review each provider's file and recommend renewal of privileges and medical staff appointment.
6.24.3. If any reviewer does not recommend renewal, the reviewer must provide an explanation to the credentials function chairperson or to the privileging authority.
188.8.131.52. The recommendations are then considered by the credentials function that makes recommendations to the privileging authority.
6.25. Performance-Based Privileging.
6.25.1. Identify performance data needs by provider type.
6.25.2. Determine form of individual data elements (i.e., nominal, ratio, etc.) and the sample size.
6.25.3. Identify data sources for particular data elements.
6.25.4. Identify the frequency of data collection.
6.25.5. Identify responsibilities for data collection.
6.25.6. Integrate with population health activities within the MTF and explicitly identify the relationship to utilization management.
6.25.7. Include a data collection plan.
6.25.8. Refer to
6.26. Provider Activity File (PAF).
6.26.1. Disposition of information within the PAF. The PAF will not accompany the PCF when the AF reassigns the provider to anot.
6.27. Biennial Review Process:
6.27.1. The credentials function chairperson or the ARC privileging authority will notify the provider in writing at least 90 da.
184.108.40.206. Provider completes the AF Form 1540A (reference paragraph
220.127.116.11. Provider reviews clinical privileges list and makes changes if applicable (reference paragraph
18.104.22.168. ARC providers must also provide current privileges from all civilian practice (reference paragraph
22.214.171.124. AF Form 22, Clinical Privileges Evaluation Summary. The AF Form 22 is required when privileges are renewed. The data for the AF Form 22 should include peer review results (reference
126.96.36.199.1. The provider's clinical supervisor will use the PAF, if applicable, to complete an AF Form 22 to summarize all pertinent information on the performance and conduct of the provider during the period of evaluation.
188.8.131.52.2. For ARC, clinical supervisors will complete an AF Form 22 to summarize activities for the privileging period. AF For.
184.108.40.206. Provider submits new CHE information to CM for updating the AF Form 1541 (reference paragraphs
220.127.116.11. The CM or the ARC credentials manager for non-collocated units will re-PSV the provider's license or authorizing document to practice (reference paragraph
18.104.22.168. The provider's clinical supervisor will review the PCF (reference paragraph
22.214.171.124. Once biennial review is accomplished the documentation is consolidated and forwarded to the MTF/CC or ARC privileging authority for awarding privileges.
126.96.36.199. Once privileges have been awarded, copies of the approved clinical privileges lists should be given to the provider (reference paragraph
Section 6G- Miscellaneous Privileging Issues
6.28. Management of Impaired Providers.
6.29. Awarding/Renewing Clinical Privileges to Medical Treatment Facility Commander.
6.30. Providers Assigned to Geographically Separated Units (GSU).
6.30.1. Providers assigned to GSUs must have a PCF and be awarded clinical privileges and medical staff appointment by the host unit which is the privileging authority. NOTE: GSUs units are physically separated from the host unit but are supported by an
6.31. Conscious Sedation for Dentists.
6.33. Interpretive Services Not Covered by Telemedicine Standards.
6.33.1. Interpretative services are services in which a licensed independent practitioner (LIP) provides official readings of im.
6.33.2. For contracted patient care, treatment, and interpretive services, the originating site will use both the credentialing .
188.8.131.52. Specifying in the contract that the contracting entity will ensure that all services provided by the contracted individuals will be within the scope of his or her privileges; or
184.108.40.206. Verifying that all contracted individuals have appropriate privileges by obtaining a copy of their current privileging lists.
220.127.116.11. If the services are obtained from another JCAHO or AAAHC DoD accredited MTF then the originating site obtains an ICTB .
6.33.3. Providers providing these types of services that are not associated with a JCAHO or DoD AAAHC-accredited organization must be fully credentialed and privileged by the MTF.
Section 6H- Applying for Other Documents Used in the Privileging Process
6.34. Applying for National Provider Identifier (NPI).
6.34.1. Providers will apply for and receive only one NPI, which will be a permanent identifier and does not need to be renewed.
6.34.2. At the time of application for privileges, the CMs will query the provider to see if they have obtained an NPI and, if n.
18.104.22.168. For ANG providers, the CM submits a copy of the NPI to ANG/SG, Attention: Credential Manager, 3500 Fetchet Avenue, Andrews AFB MD 20762-5157.
6.35. DoD Fee-Exempt DEA Certification.
Chapter 7 PROFESSIONAL SCOPE OF PRACTICE FOR ALLIED HEALTH PROFESSIONALS
Section 7A- Allied Health Providers (BSC, NC, and Civilian-Equivalent Privileged Providers)
7.1. Allied Health Provider List:
7.1.1. Audiologists (paragraph
7.1.2. Certified Nurse Midwives (paragraph
7.1.3. Certified Registered Nurse Anesthetists (paragraph
7.1.4. Chiropractors (paragraph 7.5.)
7.1.5. Clinical Dietitians (paragraph
7.1.6. Clinical Pharmacists (paragraph
7.1.7. Clinical Psychologists (paragraph
7.1.8. Clinical Social Workers (paragraph 7.9.)
7.1.9. Family Nurse Practitioners (Includes Adult and Primary Care) (paragraph
7.1.10. Occupational Therapists (paragraph
7.1.11. Optometrists (paragraph
7.1.12. Pediatric Nurse Practitioners (paragraph
7.1.13. Physical Therapists (paragraph
7.1.14. Physician Assistants (paragraph
7.1.15. Physician Assistants Specialty (paragraph
7.1.16. Podiatrists (paragraph
7.1.17. Psychiatric/Mental Health Nurse Practitioners (paragraph
7.1.18. Speech Pathologists (paragraph
7.1.19. Women's Health Nurse Practitioners (paragraph
7.1.20. Certified Alcohol/Drug Abuse Counselors (CADACs) = Substance Abuse Counselors (paragraph
7.1.21. Independent Duty Medical Technicians (IDMTs) (paragraph
7.1.22. Licensed Practical/Vocational Nurses (LPN/LVN) (paragraph
7.1.23. Medical Technicians Utilized in Ambulance Services (paragraph
7.1.24. Registered Dental Hygienists (paragraph
7.2.1. Background. Deliver state-of-the-art audiological services, including prevention, medical surveillance, education, and research.
22.214.171.124. Support the flying mission of DoD personnel by implementing the AF Hearing Conservation Program to prevent noise-induced hearing loss and enhance auditory performance in operational environments.
7.2.2. Education/Licensure/Certification Requirements:
126.96.36.199. Graduation from an accredited master's or doctoral degree from an accredited program acceptable to the HQ USAF/SG.
188.8.131.52. Licensure from a US jurisdiction.
184.108.40.206. National certification (Certificate of Clinical Competence from the American Speech-Language-Hearing Association) or American Board of Audiology (ABA) certification.
7.2.3. Scope of Practice. Audiologists:
220.127.116.11. Practice IAW the guidelines published by the American Speech-Language-Hearing Association, American Academy of Audiology, and the National Hearing Conservation Association.
18.104.22.168. Audiologists are privileged to provide comprehensive diagnostic and therapeutic procedures of the hearing and balance m.
22.214.171.124. May act independently in areas of demonstrated competency within their designated scope of practice, as indicated by code "1" on their clinical privileges list.
126.96.36.199. As with any privileged provider, an ongoing, proactive peer review process (as outlined in
7.3. Certified Nurse Midwives (CNM):
7.3.1. Background. CNMs are registered nurses who have obtained advanced education, training, and certification in midwifery. Nu.
7.3.2. Education/Licensure/Certification Requirements:
188.8.131.52. Graduation from an accredited baccalaureate degree program in nursing (BSN) acceptable to the HQ USAF/SG.
184.108.40.206. Completion of an approved course in nurse midwifery acceptable to the HQ USAF/SG.
220.127.116.11. Master's degree from accredited program in specialty is required.
18.104.22.168. Licensure as an RN from at least one US jurisdiction.
22.214.171.124. CNMs are not required to be licensed to the advanced practice level by a US jurisdiction but are encouraged to obtain the same. EXCEPTION: CNMs hired as non-personal service contractors must be licensed according to the regulatory requirements
126.96.36.199. National certification in specialty (Certification by the American College of Nurse Midwives Certification Council. Prior to 1990, certification was via the American College of Nurse Midwives).
7.3.3. Scope of Practice. Certified Nurse Midwives:
188.8.131.52. Practice IAW the Standards for the Practice of Nurse Midwifery, as defined by the American College of Nurse Midwives (ACNM). MTF-specific protocols define conditions for which referral or collaborative care (co-manage) is appropriate.
184.108.40.206.1. Management of newborns outside the delivery suite or birthing room requires specific privileges.
220.127.116.11. Provide routine prenatal care, labor and delivery management, immediate newborn care, and postpartum care. In addition,.
18.104.22.168. May act independently in areas of demonstrated competency within their designated scope of practice, as indicated by code "1" on their privileges list.
22.214.171.124. May perform outpatient care and have admission and discharge privileges when an obstetrician is on call and available by phone to provide for medical consultation, collaborative management, or referral.
126.96.36.199. May provide obstetrical call within their scope of practice and expertise utilizing physician consultation and/or co-management to provide comprehensive care for the high-risk patient according to MTF protocols.
188.8.131.52. CNMs granted MTF privileges must have physician (privileged to the same scope of practice) consultation available either in person or by phone when they are performing direct patient care activities.
184.108.40.206. As with any privileged provider, an ongoing, proactive peer review process (as outlined in Chapter 8) is required. Periodic review of performance is required at least biennially as part of the competency-based privileging proces.
7.4. Certified Registered Nurse Anesthetists (CRNA):
7.4.1. Background. CRNAs are registered nurses who have obtained advanced education, training, and certification in administrati.
7.4.2. Education and Certification Requirements:
220.127.116.11. Graduation from an accredited baccalaureate degree program in nursing (BSN) acceptable to the HQ USAF/SG.
18.104.22.168. Completion of an approved course in nurse anesthesia acceptable to the HQ USAF/SG.
22.214.171.124. Master's degree from an accredited program in specialty is required.
126.96.36.199. Licensure as an RN from at least one US jurisdiction.
188.8.131.52. CRNAs are not required to be licensed to the advanced practice level by a US jurisdiction but are encouraged to obtain the same. EXCEPTION: CRNAs hired as non-personal service contractors must be licensed according to the regulatory requirement
184.108.40.206. National certification in specialty (Certification by the Council on Certification of Nurse Anesthetists).
7.4.3. Scope of Practice. Certified Registered Nurse Anesthetist:
220.127.116.11. Are authorized to provide anesthesia services independently (without clinical supervision or direction) and collaborati.
18.104.22.168.1. Any American Society of Anesthesiologists (ASA) Classification 1 or 2 patient including obstetric care.
22.214.171.124.2. Any ASA 3 patient where Monitored Anesthesia Care (MAC) is the planned anesthetic approach.
126.96.36.199.3. Any ASA 1 patient who is a child under 2 years old where MAC is the planned anesthetic approach.
188.8.131.52. CRNAs will always consult with an anesthesiologist for all other patients.
184.108.40.206.1. In MTFs with anesthesiologists present for patients not identified in paragraph
220.127.116.11.2. In MTFs where no anesthesiologist is present for patients not identified in paragraph 18.104.22.168., consultation with an anesthesiologist will be documented by the CRNA in the medical record. This consultation may be verbal or.
22.214.171.124.3. EXCEPTION: Cases in which the operating surgeon and CRNA determine that a delay for consultation will be detrimental to the outcome.
126.96.36.199. Anesthesia departments at MTFs without an assigned anesthesiologist must formalize a consultant relationship with another MTF (e.g., MOU) that does have an anesthesiologist on staff.
188.8.131.52. Provide anesthesia "on-call" within their scope of practice and expertise, utilizing consultation and/or shared responsibility for patient care, to provide comprehensive anesthetic care for the high-risk patient.
184.108.40.206. CRNAs are accountable for the preoperative assessment of all patients for whom they are the primary anesthesia provider.
220.127.116.11. The CRNA remains responsible and accountable for determining when consultation with a physician specialist (e.g., anest.
18.104.22.168. CRNAs granted MTF privileges must have physician consultation available either in person or by phone when they are performing direct patient care activities.
22.214.171.124. There will be a dedicated "back-up" provider available in the event of an emergency. This back-up provider must be another anesthesia provider, physician, or oral surgeon capable of immediately diagnosing and treating a medical emergency.
126.96.36.199. As with any privileged provider, an ongoing, proactive peer review process (as outlined in
7.5.1. Background. The practice of chiropractic focuses on the relationship between structure (primarily the spine) and function.
7.5.2. Education/Licensure/Certification Requirements:
188.8.131.52. Graduation from a chiropractic college accredited by the Council on Chiropractic Education or its successor.
184.108.40.206. Licensure as a Doctor of Chiropractic in the state in which he or she will be hired and practice (if a non-personal service contractor).
220.127.116.11. Member in good standing with the State Board of Chiropractic Examiners in the state in which he or she practices.
18.104.22.168. A minimum of 2 years full-time active chiropractic experience in which he or she has consistently administered both diagnostic and treatment services.
7.5.3. Scope of Practice. Chiropractors:
22.214.171.124. Provide chiropractic diagnosis and treatments, excluding vaginal examinations, and consistent with current chiropractic.
126.96.36.199. Serve as consultants in chiropractic for other healthcare professionals in the military healthcare system.
188.8.131.52. Are involved in prevention and wellness activities, screening, and promotion of positive health behaviors.
184.108.40.206. Provide neuromusculoskeletal evaluation for musculoskeletal and neuromuscular conditions which may include the privileg.
220.127.116.11. May act independently in areas of demonstrated competency within their designated scope of practice, as indicated by code "1" on their privileges list.
18.104.22.168. As with any privileged provider, an ongoing, proactive peer review process (as outlined in Chapter 8) is required. Periodic review of performance is required at least biennially as part of the competency-based privileging proces.
7.6. Clinical Dietitians or Nutrition Program Managers (contract providers):
7.6.1. Background. Registered Dietitians provide nutrition services to include: providing medical nutrition therapy (MNT); procu.
7.6.2. Education and Registration Requirements: The minimum criteria for determining an applicant's ability to provide MNT within the scope of clinical privileges are:
22.214.171.124. Completion of at least a baccalaureate degree from an accredited college or university AND completion of a didactic pro.
126.96.36.199. Successful completion of one of the following Commission on Accreditation of Dietetics Education-approved supervised practice programs:
188.8.131.52.1. Dietetic internship with generalist or military emphasis or a
184.108.40.206.2. Coordinated program in dietetics with generalist emphasis.
220.127.116.11. Current registration by the Commission on Dietetic Registration of the ADA or proof of eligibility to take the ADA regi.
7.6.3. Scope of Practice. Clinical Dietitians:
18.104.22.168. May be granted clinical privileges to provide MNT which includes nutrition assessment and evaluation, counseling, order.
22.214.171.124. Advanced specialists with additional certifications may be privileged to order tube feedings, parenteral formulas, transitional feedings, and additional laboratory tests to support nutrition therapy decisions.
126.96.36.199. May refer to other healthcare providers as needed to support MNT, such as diabetes educator; women, infants, and children (WIC) program; hospice; home health care; and other community support programs.
188.8.131.52. May act independently in areas of demonstrated competency within their designated scope of practice, as indicated by code "1" on their privileges list.
184.108.40.206. As with any privileged provider, an ongoing, proactive peer review process (as outlined in Chapter 8) is required. Periodic review of performance is required at least biennially as part of the competency-based privileging proces.
7.7. Clinical Pharmacists:
7.7.1. Background. Clinical pharmacists are licensed pharmacists with advanced training or acquired clinical skills through prac.
7.7.2. Education/Licensure/Certification Requirements: Pharmacists must demonstrate appropriate skills, training, and/or experience to be considered for clinical privileges. Minimum requirements include:
220.127.116.11. Valid pharmacy license as described in this instruction and
18.104.22.168. PharmD degree, or
22.214.171.124. Master of science (MS) degree in pharmacy from a clinically oriented program, or
126.96.36.199. Board certification in one or more of the pharmacy specialties recognized by the Board of Pharmaceutical Specialties, or
188.8.131.52. Completion of a clinical pharmacy residency or fellowship accredited by the American Society of Health System Pharmacists or American College of Clinical Pharmacy, or
184.108.40.206. Bachelor of science (BS) degree in pharmacy with documentation of appropriate education, training, and/or CME in the practice of clinical pharmacy.
220.127.116.11. To perform limited physical assessment (i.e., assessment focused on specific system under examination), one must have documentation of appropriate education, training, and/or CME. NOTE: This course work is included in PharmD programs but may no
7.7.3. Scope of Practice: Pharmacists may be granted clinical privileges by the MTF commander to provide direct patient care und.
18.104.22.168. Assessing patient's response to drug therapy and planning drug therapy based on physician-established diagnoses.
22.214.171.124. Ordering and evaluating laboratory tests necessary to evaluate drug therapy effects and outcomes.
126.96.36.199. Initiating, modifying, or discontinuing medications for ongoing therapy of chronic disease states (e.g., hypertension, .
188.8.131.52. Monitoring and managing pharmacotherapy requiring periodic adjustment due to specific or changing pharmacokinetic characteristics (e.g., aminoglycosides, phenytoin, anticoagulants).
184.108.40.206. Initiating or modifying drug therapy for minor acute conditions such as colds, rashes, and allergies.
220.127.116.11. Administering prescription or non-prescription drugs according to established agreements or protocols.
18.104.22.168. Assessing metabolic needs and ordering therapeutic enteral or parenteral nutrition products in the inpatient setting in consultation with the attending physician.
22.214.171.124. Evaluating medical and medication histories for drug-related problems and adjusting drug therapy accordingly.
126.96.36.199. Consulting with other healthcare providers (e.g., physicians, dietitians, nurses, physical therapists, etc.) about patient treatment needs or options.
188.8.131.52. Conducting and coordinating clinical investigations and research (consistent with other healthcare professionals) appr.
184.108.40.206. May act independently in areas of demonstrated competency within their designated scope of practice, as indicated by code "1" on their privileges list.
220.127.116.11. Clinical pharmacists granted MTF privileges must have physician consultation available, either in person or by phone, when they are performing direct patient care activities.
18.104.22.168. All clinical pharmacists must work via protocols approved by the ECOMS and practice with the supervision of a physician.
22.214.171.124. As with any privileged provider, an ongoing, proactive peer review process (as outlined in
126.96.36.199. Psychologists who have not met all doctoral requirements, meaning not yet completed dissertation (all but dissertation [ABD]):
188.8.131.52.1. Cannot be privileged.
184.108.40.206.2. Must obtain a recommended scope of practice from the training director for his or her AF clinical psychology internship program. The recommended scope of practice will be submitted to the MTF credentials function for approval.
220.127.116.11.3. Must practice with a basic written plan of supervision and a designated preceptor.
18.104.22.168.4. Must have written medical documentation co-signed by a mental health provider.
22.214.171.124.5. Regardless of degree status, supervision of psychological testing work must be done by a psychologist.
126.96.36.199. If at all possible, other clinical psychologists will supervise entry level psychologists. Most states require this type of supervision.
188.8.131.52. When a psychologist granted "supervised privileges" needs to make a recommendation regarding a patient in a special dut.
7.9. Clinical Social Workers:
7.9.1. Background. AF social workers facilitate individual, family, and corporate health. Clinical social workers are key member.
7.9.2. Education/Licensure/Certification Requirements:
184.108.40.206. An MSW degree from an accredited school of social work.
220.127.116.11. Experience in clinical social work, either through a master's-level practicum or 2 years post-MSW experience.
18.104.22.168. License/certification from a US jurisdiction. Effective 1 Oct 98, state licensure/certification at any MSW level became the qualifying document, while national certification became optional. Social workers on active duty or employed by the Air
22.214.171.124. Entry level clinical social workers are individuals who have been awarded a state license/ certification available to m.
126.96.36.199.1. NOTE: Clinical social workers with more than 2 years of post-MSW experience will also be considered entry level if they hold a license which would not authorize them to practice without supervision in their state of licensure.
188.8.131.52. Fully qualified clinical social workers are individuals who have completed an MSW, a minimum of 2 years post-MSW social.
184.108.40.206.1. NOTE: Those AF social workers, who are practicing clinical social work with a license that would require supervision for the practice.
220.127.116.11.2. NOTE: The issue of licensure for clinical social workers is complicated by the fact that US jurisdictions have such varied approaches.clinical social work without supervision." The license must allow the full scope of clinical practice, inc
7.9.3. Scope of Practice. Clinical Social Workers:
18.104.22.168. Conduct clinical interviews and evaluate patients.
22.214.171.124. Diagnose mental disorders and formulate diagnosis and treatment plans.
126.96.36.199. Recommend administrative and medical dispositions.
188.8.131.52. Provide individual, couple, family, and group psychotherapy; hypnosis (refer to AFI 44-102); formal sex therapy (refer .
184.108.40.206. Admit, treat, and discharge patients, with physician oversight, to/from inpatient substance abuse treatment programs.
220.127.116.11. Perform risk assessments and determine degree of danger posed by the patient.
18.104.22.168. Screen records and personnel for security clearances and make administrative recommendations.
22.214.171.124. Perform commander-directed mental health evaluations (CDEs); PhD required.
126.96.36.199. Serve as behavioral health consultant to commanders, first sergeants, and medical personnel.
188.8.131.52. Serve on aircraft mishap investigation boards (must have completed appropriate training program such as Air Force Aircraft Mishap Investigation and Prevention Course).
184.108.40.206. Serve on family advocacy command assistance teams (must have completed training required by AFMOA/SGOF).
220.127.116.11. May act independently in areas of demonstrated competency within their designated scope of practice, as indicated by code "1" on their privileges list.
18.104.22.168. Generally, other clinical social workers will supervise entry-level social workers, if at all possible. In order to mee.
22.214.171.124. As with any privileged provider, an ongoing, proactive peer review process (as outlined in
7.10. Family Nurse Practitioners (Includes Adult and Primary Care):
7.10.1. Background. Family Nurse Practitioners (FNP) are registered nurses who have obtained advanced education, training, and c.NOTE: Adult and Primary Care Nurse Practitioners have the same role as FNPs; however, their scope of practice does not inc
7.10.2. Education/Licensure/Certification Requirements:
126.96.36.199. Graduation from an accredited baccalaureate degree program in nursing (BSN) acceptable to the HQ USAF/SG.
188.8.131.52. Completion of an approved nurse practitioner program acceptable to the HQ USAF/SG.
184.108.40.206. Master's degree from accredited program in specialty.
220.127.116.11. Licensure as an RN from at least one US jurisdiction.
18.104.22.168. FNPs are not required to be licensed to the advanced practice level by a US jurisdiction but are encouraged to obtain the same. EXCEPTION: FNPs hired as non-personal service contractors must be licensed according to the regulatory requirements
22.214.171.124. National certification in specialty (i.e., certification by the American Nurses Credentialing Center [ANCC] or the American Academy of Nurse Practitioners [AANP]).
7.10.3. Scope of Practice. Family Nurse Practitioners:
126.96.36.199. FNPs practice independently and collaboratively with physicians in providing primary healthcare for well and sick indi.
188.8.131.52.1. Obtaining comprehensive and episodic health histories and performing physical examination.
184.108.40.206.2. Ordering, conducting, and interpreting appropriate screening studies, tests, and diagnostic procedures.
220.127.116.11.3. Diagnosing and managing acute episodic and chronic illnesses, minor traumas, and behavioral/psychological problems.
18.104.22.168.4. Initiation and evaluation of treatment regimens which may include prescribing and dispensing medications appropriate for privileged scope of care.
22.214.171.124.5. Performing therapeutic procedures as defined and approved on the provider privileges list.
126.96.36.199.6. Teaching, counseling, and advising patients and families about current health status, illness(es), and health promotion and disease prevention activities appropriate for patient age and condition.
188.8.131.52.7. Collaborating with and/or referring to other healthcare providers, as appropriate.
184.108.40.206.8. May act independently in areas of demonstrated competency within their designated scope of practice, as indicated by code "1" on their privileges list.
220.127.116.11.9. May pull PCM primary call and work as sole provider in extended-hours clinics with physician consultation available as described below if these specific privileges have been granted as code "1" on the privileges list.
18.104.22.168. FNPs granted MTF privileges must have physician (privileged for the same scope of practice) consultation available, ei.
22.214.171.124. Supervision of FNPs in the Emergency Services Department (ESD):
126.96.36.199.1. FNPs may augment the medical staff of the ESD when additional manpower assistance is required to meet access standards.
188.8.131.52.2. FNPs will work in this area only when deemed necessary and based on the individual's skills and competencies.
184.108.40.206.3. If the FNP is required to see patients in the ESD, the ESD physician must be present in the facility and be immediately available by two-way voice communication.
220.127.116.11.4. The ESD physician reviews the medical record of each patient under the care of the FNP prior to the patient's departure from the ESD.
18.104.22.168. As with any privileged provider, an ongoing, proactive peer review process (as outlined in
7.11. Occupational Therapists:
7.11.1. Background. Occupational therapists provide services to include prevention, health promotion, ergonomics, wound care, an.
7.11.2. Education and Certification Requirements:
22.214.171.124. Master of science/art or entry level master's degree in OT (Master of Occupational Therapy) from an accredited OT program acceptable to the HQ USAF/SG.
126.96.36.199. Certification by the National Board for Certification in Occupational Therapy, Inc.
188.8.131.52. Completion of 6 months of clinical internship. (This is usually accomplished prior to graduation and must be done in order to be eligible to take the certification exam).
184.108.40.206. License from a US jurisdiction.
220.127.116.11. Occupational Therapy Doctoral (OTD) is the advanced degree.
7.11.3. Scope of Practice. Occupational Therapists:
18.104.22.168. Provide evaluation and treatment services under the guidelines of the American Occupational Therapy Association.
22.214.171.124. Serve as consultants in occupational therapy for other healthcare professionals.
126.96.36.199. OT privileges may include, but are not limited to, assessing patient's functional status and planning therapy, based upon physician-established diagnosis.
188.8.131.52. Advanced degree in clinical specialty may include hand therapy and/or ergonomics.
184.108.40.206. May act independently in areas of demonstrated competency within their designated scope of practice, as indicated by code "1" on their privileges list.
220.127.116.11. As with any privileged provider, an ongoing, proactive peer review process (as outlined in
7.12.1. Background. Doctors of optometry are primary eye care professionals who provide comprehensive management of disorders an.
7.12.2. Education/Licensure/Certification Requirements:
18.104.22.168. Doctor of optometry degree from an accredited 4-year college of optometry approved by the HQ USAF/SG.
22.214.171.124. Licensure from a US jurisdiction.
126.96.36.199. The AFMS recognizes Fellowship in the American Academy of Optometry (FAAO) as board certification for optometrists. Board certification is encouraged but is not required.
7.12.3. Scope of Practice. Optometrists:
188.8.131.52. Provide comprehensive eye care services including evaluation/diagnosis of diseases and disorders of the eye, associate.
184.108.40.206. Co-manage post surgical eye cases and ocular complications of systemic disease. Refer to higher levels of care when indicated.
220.127.116.11. Serve as eye care consultants for other healthcare professionals in the military healthcare system.
18.104.22.168. Promote operational readiness, prevention and wellness, vision conservation/safety, and education and training activities.
22.214.171.124. May act independently in areas of demonstrated competency within their designated scope of practice, as indicated by code "1" on their privileges list.
126.96.36.199. As with any privileged provider, an ongoing, proactive peer review process (as outlined in
7.13. Pediatric Nurse Practitioners (PNP):
7.13.1. Background. PNPs are registered nurses who have obtained advanced education, training, and certification to practice ind.
7.13.2. Education/Licensure/Certification Requirements:
188.8.131.52. Graduation from an accredited baccalaureate degree program in nursing (BSN) acceptable to the HQ USAF/SG.
184.108.40.206. Completion of an approved nurse practitioner program acceptable to the HQ USAF/SG.
220.127.116.11. Master's degree from accredited program in specialty. (See paragraph
18.104.22.168. Licensure as an RN from at least one US jurisdiction.
22.214.171.124. PNPs are not required to be licensed to the advanced practice level by a US jurisdiction but are encouraged to obtain the same. EXCEPTION: PNPs hired as non-personal service contractors must be licensed according to the regulatory requirements
126.96.36.199. National certification in specialty (i.e., certification through the National Certification Board of Pediatric Nurse Practitioners and Nurses [NCBPNP/N] or the American Nurses Credentialing Center [ANCC]).
7.13.3. Scope of Practice. Pediatric Nurse Practitioners:
188.8.131.52. PNPs practice independently and collaboratively with physicians providing healthcare for well and sick children from b.
184.108.40.206. Pediatric nurse practitioner practice is focused on:
220.127.116.11.1. Obtaining comprehensive and episodic health histories and performing physical examinations.
18.104.22.168.2. Ordering and conducting and interpreting appropriate screening studies, tests and diagnostic procedures.
22.214.171.124.3. Diagnosing and managing acute episodic and chronic illnesses, minor traumas, and behavioral/psychological problems.
126.96.36.199.4. Initiation and evaluation of treatment regimens which may include prescribing and dispensing medications appropriate for privileged scope of care.
188.8.131.52.5. Collaborating with and making appropriate referral for specialty evaluation and care.
184.108.40.206.6. Conducting appropriate developmental assessments and screenings referring to specialty care as appropriate.
220.127.116.11.7. Performing therapeutic procedures as defined and approved on the provider privilege list
18.104.22.168.8. Teaching, counseling and advising patients and parents about current health status, illnesses, and health promotion and disease prevention appropriate for child's age and condition.
22.214.171.124. PNP scope and standards of practice guidelines are published by the National Association of Pediatric Nurse Practitioners (NAPNP).
126.96.36.199. PNPs may act independently in areas of demonstrated competency within their designated scope of practice, as indicated by code "1" on their privileges list.
188.8.131.52. PNPs may pull pediatric PCM primary call and work as sole provider in extended-hours pediatric clinics with physician consultation available as described below if these specific privileges have been granted as code "1" on the privileges list.
184.108.40.206. PNPs granted MTF privileges must have physician (privileged for the same scope of practice) consultation available either in person, by phone, or electronic means when they are performing ambulatory clinic direct patient care activities.
220.127.116.11. As with any privileged provider, an ongoing, proactive peer review process (as outlined in
7.14. Physical Therapists:
7.14.1. Background. Physical therapists provide services including prevention, health promotion, ergonomics, wound care, comprehensive physical rehabilitation and research.
7.14.2. Education/Licensure/Certification Requirements:
18.104.22.168. Entry level physical therapists must be graduates of a physical therapy program acceptable to the HQ USAF/SG, and accredited by the American Physical Therapy Association (APTA) Commission on Accreditation in Physical Therapy Education.
22.214.171.124. Licensure from a US jurisdiction.
126.96.36.199. Advanced clinical specialists in physical therapy must meet the following requirements:
188.8.131.52.1. Advanced clinical specialty board certification; or post entry-level residency, master's, or doctorate; or over 4000 hours in physical therapy practice; and
184.108.40.206.2. Completion of USAF Advanced Course; US Army Neuromusculoskeletal (NMS) Evaluation Course; civilian-sponsored neuromu.
7.14.3. Scope of Practice. Physical Therapists:
220.127.116.11. Practice according to the guidelines published by the APTA.
18.104.22.168. Provide physical therapy evaluation and diagnostic/treatment services for patients.
22.214.171.124. Serve as consultants in physical therapy for other healthcare professionals.
126.96.36.199. Provide direct access to prevention and wellness activities, screening, and promotion of positive health behaviors.
188.8.131.52. Advanced clinical specialists in physical therapy are those with post entry-level education and/or training. They may be privileged to perform advanced specialty clinical practice including, but not limited to:
184.108.40.206.1. Providing direct access (i.e., no referral needed) neuromusculoskeletal evaluation for acute musculoskeletal and neu.
220.127.116.11.2. Performing needle insertion for electrodiagnostic testing.
18.104.22.168.3. Evaluating and treating infants in the neonatal intensive care unit.
22.214.171.124.4. Neurodevelopmental evaluation and treatment.
126.96.36.199. May act independently in areas of demonstrated competency within their designated scope of practice, as indicated by code "1" on their privileges list.
188.8.131.52. As with any privileged provider, an ongoing, proactive peer review process (as outlined in
184.108.40.206.1. PTs who have prescription privileges must have a physician preceptor identified in writing for oversight of the clin.
7.15. Physician Assistants (PA):
7.15.1. Background. PAs are health professionals whose practice is centered on patient care and disease prevention and may inclu.
7.15.2. Education and Certification Requirements:
220.127.116.11. Graduation from a physician assistant education program accredited by the Accreditation Review Commission for Physician Assistant Education, Inc. (ARC-PA) or its predecessors, and acceptable to the HQ USAF/SG.
18.104.22.168. PAs must obtain initial certification by the National Commission on Certification of Physician Assistants (NCCPA) within 12 months of graduation. NOTE: Civilian accessions should be certified prior to entering active, or ARC duty.
22.214.171.124. Refer to paragraph
126.96.36.199.1. For non-personal service contractor PAs a state license from the state they are practicing is required along with the national certification.
188.8.131.52. PAs are required to maintain NCCPA certification. Certification is maintained by meeting NCCPA continuing medical education and re-examination requirements as outlined in the NCCPA recertification process.
184.108.40.206. Specialty PAs must complete an additional residency or fellowship program acceptable to the HQ USAF/SG. Reference paragraph
7.15.3. Scope of Practice. Physician Assistants:
220.127.116.11. Are credentialed through the MTF and privileged as any member of the staff of the particular service in which they practice.
18.104.22.168. Diagnose patient medical conditions and plan therapy appropriate for the diagnosis to include performing procedures, o.
22.214.171.124. May cover PCM primary call and work as sole provider in extended-hours clinics with physician consultation available a.
126.96.36.199. PAs may work in the ESD managing patients, consistent with their training and experience. Refer to paragraph
188.8.131.52. PAs who are privileged to assist with inpatient care may admit patients to the admitting physician's service after fir.
184.108.40.206. May act independently in areas of demonstrated competency within their designated scope of practice, as indicated by code "1" on their privileges list.
220.127.116.11. A physician preceptor must be identified, in writing, for each PA. This information will be placed in Section I of the PA's PCF.
18.104.22.168. Preceptor must be a physician who provides consultation, clinical feedback, and general oversight of the PA's practice.
22.214.171.124. PAs must have physician consultation available either in person, by phone, or electronic means when they are performin.
126.96.36.199. As with any privileged provider, an ongoing, proactive peer review process (as outlined in
7.15.5. Supervision of PAs in the Emergency Services Department (ESD).
188.8.131.52. The ESD physician must be present in the facility and be immediately available by two-way voice communication.
184.108.40.206. The ESD physician reviews the medical record of each patient under the care of the PA prior to the patient's departure from the ESD (except for Emergency Medicine Specialty Physician Assistants as described in paragraph
7.16. Physician Assistants (Specialty):
7.16.1. Background. Specialty Physician Assistants (SPAs) are physician assistants who have met all of the definitions and requirements of physician assistants described in paragraph 7.15.2. and have received subsequent additional training in a medical
7.16.2. Education and Certification Requirements.
220.127.116.11. In addition to the education requirements listed in
18.104.22.168. Specialty PAs are trained at approved sites within the Air Force, DoD, or at accredited civilian institutions. Most AF PA specialty training programs award an AFSC specialty shred out upon completion.
7.16.3. Scope of Practice. Specialty Physician Assistants:
22.214.171.124. Is consistent with the scope of practice defined in paragraph
126.96.36.199. May cover primary specialty call with specialty physician consultation available as described in paragraphs
188.8.131.52. Supervision requirements outlined in paragraph
184.108.40.206.1. Emergency Medicine SPAs practicing within their approved scope of practice in the ESD are exempt from having the ESD physician review the medical record of each patient prior to the patient's departure from the ESD.
220.127.116.11. SPAs may be assigned to MTFs where there is no physician of the same specialty assigned. In such cases, a staff physic.
7.17.1. Background. Doctors of podiatric medicine (DPM) provide comprehensive medical and surgical management of disorders of th.
7.17.2. Education/Licensure/Certification Requirements:
18.104.22.168. Doctor of Podiatric Medicine (4-year DPM degree) from an accredited college or university of podiatric medicine acceptable to the HQ USAF/SG.
22.214.171.124. Completion of a minimum 24-month podiatric surgical residency required. Completion of a 12-month podiatric surgical, plus a 12-month podiatric orthopedic/primary podiatric medical residency, accepted.
126.96.36.199. Licensure from a US jurisdiction.
188.8.131.52. Board certification (not required but encouraged) is via one of the following two certifying boards recognized by the American Podiatric Medical Association's Council on Podiatric Medical Education:
184.108.40.206.1. American Board of Podiatric Surgery.
220.127.116.11.2. American Board of Podiatric Orthopedics and Primary Podiatric Medicine.
7.17.3. Scope of Practice. Podiatrists:
18.104.22.168. The national standard for podiatric medical doctors with appropriate postgraduate education, as stated above, is the anatomic region of the foot and ankle as well as related structures affecting the foot and ankle.
22.214.171.124. May admit patients as necessary, to include performing complete H&P examination. If the podiatrist's educational progr.
126.96.36.199. May act independently in areas of demonstrated competency within their designated scope of practice, as indicated by code "1" on their privileges list.
188.8.131.52. As with any privileged provider, an ongoing, proactive peer review process (as outlined in
7.18. Psychiatric/Mental Health Nurse Practitioners (P/MHNP):
7.18.1. Background. P/MHNP are registered nurses who have obtained advanced education, training, and certification to practice i.
7.18.2. Education/Licensure/Certification Requirements:
184.108.40.206. Graduation from an accredited baccalaureate program in nursing (BSN) acceptable to the HQ USAF/SG.
220.127.116.11. Completion of an approved nurse practitioner program acceptable to the HQ USAF/SG.
18.104.22.168. Master's degree from accredited program in specialty is required.
22.214.171.124. Licensure as an RN from at least one US jurisdiction.
126.96.36.199. P/MHNPs are not required to be licensed to the advanced practice level by a US jurisdiction but are encouraged to obtain the same. EXCEPTION: P/MHNPs hired as non-personal service contractors must be licensed according to the regulatory requir
188.8.131.52. National certification in specialty (i.e., certification by the ANCC).
7.18.3. Scope of Practice. Psychiatric/Mental Health Nurse Practitioners:
184.108.40.206. Take, evaluate, and record histories on all inpatient/outpatient mental health units for patients between 18 and 65 ye.
220.127.116.11. Analyze and interpret data, formulate problem lists, and establish plans for solution of clinical problems.
18.104.22.168. Treat problems within his/her scope of competence and exercise judgment on problems requiring consultation, referral, or evaluation by a physician.
22.214.171.124. Order and interpret appropriate laboratory studies, X-rays, electrocardiograms, and other special examinations relevant to the management of health care during acute and chronic phases of mental disorders.
126.96.36.199. Initiate consultation requests to specialists and other health professionals to include physical therapists, occupational therapists, dietitians, health and wellness training, biofeedback, etc.
188.8.131.52. Perform ongoing collaborative consultation with mental health providers to include psychiatrists, psychologists, social workers, and nurse practitioners.
184.108.40.206. Prescribe therapeutic agents within the scope of practice, licensure limitations, level of individual competence.
220.127.116.11. Recognize and manage a wide range of psychiatric disorders, to include, but not limited to:
18.104.22.168.1. Complications and untoward reactions to medication.
22.214.171.124.2. Crisis oriented care for individuals, identified as needing immediate psychiatric therapeutic intervention.
126.96.36.199.3. Preventative care on a daily basis for clients as an alternative to inpatient hospitalization.
188.8.131.52.4. Inpatient/outpatient care for patients requiring continual therapy and the initiating of psychopharmacological medications and/or refills.
184.108.40.206.5. Follow-up care for continuity and prevention of relapse for patients with chronic psychiatric problems, or selected clients who have recently been discharged from inpatient hospitalization.
220.127.116.11. Perform psychotherapy for individuals, couples, and families.
18.104.22.168. Perform psychotherapy groups that address issues common to adults and families.
22.214.171.124. Educate and counsel patients (individuals, families, and groups) in mental health issues, use of medication, expected effects of treatment, diet, and other health maintenance matters.
126.96.36.199. Serve as a consultant and liaison to other units/clinics in the hospital, and target appropriate psychiatric interventions for patients receiving care in these areas.
188.8.131.52. Provide teaching and consultation to paraprofessionals assigned to mental health.
184.108.40.206. Provide mental health and wellness information, as requested, to military and community organizations.
220.127.116.11. May act independently in areas of demonstrated competency within their designated scope of practice, as indicated by code "1" on their privileges list.
18.104.22.168. P/MHNPs granted MTF privileges must have a physician (privileged for the same scope of practice) consultation available either in person, by phone, or electronic means when they are performing ambulatory clinic direct patient care activities.
22.214.171.124. As with any privileged provider, an ongoing, proactive peer review process (as outlined in
7.19. Speech Pathologists:
126.96.36.199. Speech pathologists ensure operational readiness and quality-of-life to the fighting force and eligible beneficiaries .
7.19.2. Education/Licensure/Certification Requirements:
188.8.131.52. Master's or doctoral degree from an accredited institution acceptable to the HQ USAF/ SG.
184.108.40.206. Licensure from a US jurisdiction.
220.127.116.11. National certification (Certificate of Clinical Competence from the American Speech-Language-Hearing Association).
7.19.3. Scope of Practice. Speech Pathologists:
18.104.22.168. Follow the guidelines published by the American Speech-Language-Hearing Association.
22.214.171.124. Are privileged to provide diagnostic and therapeutic procedures for speech, language, and voice. Those with advanced t.
126.96.36.199. May act independently in areas of demonstrated competency within their designated scope of practice, as indicated by code "1" on their privileges list.
188.8.131.52. As with any privileged provider, an ongoing, proactive peer review process (as outlined in
7.20. Women's Health Nurse Practitioners (WHNP):
7.20.1. Background. WHNPs are registered nurses who have obtained advanced education, training, and certification to practice in.
7.20.2. Education/Licensure/Certification Requirements:
184.108.40.206. Graduation from an accredited baccalaureate degree program in nursing (BSN) acceptable to the HQ USAF/SG.
220.127.116.11. Completion of an approved nurse practitioner program acceptable to the HQ USAF/SG.
18.104.22.168. Master's degree from accredited program in specialty is required. (See paragraph
22.214.171.124. Licensure as an RN from at least one US jurisdiction.
126.96.36.199. WHNPs are not required to be licensed to the advanced practice level by a US jurisdiction but are encouraged to obtain the same. EXCEPTION: WHNPs hired as non-personal service contractors must be licensed according to the regulatory requiremen
188.8.131.52. National certification in specialty (i.e., certification through the ANCC for the obstetric, gynecologic, and neonatal nursing specialties).
7.20.3. Scope of Practice. Women's Health Nurse Practitioners:
184.108.40.206. May be granted clinical privileges to provide primary ambulatory health care to both obstetrical and gynecological patients. Clinical privileges include:
220.127.116.11.1. Obtaining medical histories, performing physical exams, and establishing medical diagnoses.
18.104.22.168.2. Ordering and interpreting diagnostic studies.
22.214.171.124.3. Initiating appropriate treatment, to include drug therapy, within privileged scope of care.
126.96.36.199.4. Performing comprehensive family planning counseling, cancer screening, STD care, procedures (such as vulvar, cervical, endometrial, and shave biopsies), cryotherapy, IUD insertion, and diaphragm fittings).
188.8.131.52.5. May perform additional skills such as colposcopy, ultrasound, and birth control implant insertions/removals, based on appropriate education and training.
184.108.40.206. May act independently in areas of demonstrated competency within their designated scope of practice, as indicated by code "1" on their privileges list.
220.127.116.11. May work as sole provider in WH extended-hours clinics with physician consultation available as described below if these specific privileges have been granted as code "1" on the privileges list.
18.104.22.168. WHNPs must have physician (privileged for the same scope of practice) consultation available either in person, by phone, or electronic means when they are performing ambulatory clinic direct patient care activities.
22.214.171.124. As with any privileged provider, an ongoing, proactive peer review process (as outlined in
7.21. Certified Alcohol and Drug Abuse Counselors = Substance Abuse Counselors:
7.21.1. Background. Mental health technicians serve in clinical roles as certified alcohol and drug abuse counselors (CADAC) or .Alcohol and Drug Abuse Prevention and Treatment (ADAPT) Program, for further information.
7.21.2. Education and Certification Requirements:
126.96.36.199. Must meet the following requirements:
188.8.131.52.1. Have a minimum of 270 hours didactic instruction and 6,000 hours within the 12 core functions of substance abuse cou.
184.108.40.206.2. Have a signed agreement to practice under strict USAF ethical guidelines. NOTE: Ethical guidelines are state/board specific.
220.127.116.11.3. Demonstrate competency in the 12 core function/46 global criterion areas in front of a board of trained evaluators. NOTE: Each core function has global criteria that outline the area.
18.104.22.168.4. Pass a recognized written examination administered by the USAF.
22.214.171.124.5. Obtain nationally recognized certification from the ICRC.
126.96.36.199. Recertify every 3 years by obtaining 60 hours continuing professional education within the behavioral sciences, as outlined by the AF Substance Abuse Counselor Certifying Handbook.
188.8.131.52. NOTE: The Air Force Substance Abuse Counselor Certification program issues the certification and has the authority to revoke certification for cause.
7.21.3. Scope of Practice/Supervision. Certified Alcohol and Drug Abuse Counselors:
184.108.40.206. Perform the 12 core functions independently as directed by the ADAPT program manager. Supervision by another fully qua.
220.127.116.11. Provide treatment planning, crisis intervention, and group treatment under the supervision of a privileged provider. F.
18.104.22.168. The ADAPT program manager is responsible for the clinical practice of CADACs and is familiar with the training needs o.
22.214.171.124. Non-certified mental health technicians who are in training may conduct the 12 core functions only when directly super.
7.22. Registered Dental Hygienists:
7.22.1. Background. Dental hygienists are licensed professionals who work as members of healthcare delivery teams. Hygienists us.
7.22.2. Education/Licensure/Certification Requirements:
126.96.36.199. Dental hygienists must demonstrate appropriate skills, training, and experience to be authorized to practice. Minimum educational requirements include:
188.8.131.52.1. Completion of a dental hygiene certificate program accredited by the Commission on Dental Accreditation of the Ameri.
184.108.40.206. License to practice dental hygiene from a US jurisdiction.
220.127.116.11. Successful challenge of the National Board Dental Hygiene Examination.
7.22.3. Scope of Practice. Registered Dental Hygienists:
18.104.22.168. Current dental hygiene practice encourages patient treatment that should be approached as a continuous process of care.
22.214.171.124.1. Complete an evaluation of every patient and formulate a dental hygiene diagnosis and treatment plan, in collaboration with the dentist and patient.
126.96.36.199.2. Complete preventive treatment and education to promote the values of oral and general health and wellness to support.
188.8.131.52.3. Provide specialized treatment designed to achieve and maintain oral health. Specialized treatment includes scaling a.
184.108.40.206.4. Provide community oral health services in a variety of settings, depending on the local mission, resources, and oppo.
220.127.116.11. Dental hygienists function under the indirect or general supervision of a dentist, as defined by the American Dental A.
18.104.22.168. Indirect supervision requires the dentist to be in the clinic or treatment facility and to be physically available to .
22.214.171.124. The degree of supervision required varies with the nature of the procedure and the medical and dental history of the patient. Appropriate levels of supervision must be chosen that will not jeopardize the systemic or oral health of the patient.
126.96.36.199. As with any healthcare professional, an ongoing, proactive peer review process and periodic review of performance is r.
7.23. Licensed Practical/Vocational Nurses:
7.23.1. Background. Licensed Practical/Vocational Nurses (LPN/LVN) have completed education, training, and certification in prac.
7.23.2. Education/Licensure/Certification Requirements:
188.8.131.52. The active duty 4N0 LPN/LVN must meet all the requirements for and hold the 4N051 or 4N071 AFSC to include NREMT basic certification
184.108.40.206. Graduation and certificate of completion from accredited LPN/LVN training program acceptable to the HQ USAF/SG.
220.127.116.11. Licensure as a practical/vocational nurse from at least one US jurisdiction.
7.23.3. Scope of Practice. Licensed Practical/Vocational Nurses:
18.104.22.168. Performs all relevant care within the LPN/LVN job description and specialty competencies IAW 4N0X1 CFETP and applicable state practice act.
22.214.171.124. Provides patient care according to the nursing process to selected and assigned patient populations.
126.96.36.199. Provides ongoing education to patients and families.
188.8.131.52. Leads and assesses a team of 4N0s to care for a group of assigned patients.
184.108.40.206. Direct supervision will be the enlisted or officer rater, as assigned.
220.127.116.11. Oversight of LVN clinical practice will be by an RN.
7.24. Independent Duty Medical Technician (IDMT):
7.25. Medical Technicians Utilized in Ambulance Services:
7.25.1. All medical technicians assigned to the ambulance service either as a full time job or occasionally to assist with patie.
7.25.2. Composition of Ambulance Crews: Ambulance crews consist of at least two NREMT-Basics.
7.25.3. Prehospital Emergency Care: Prehospital emergency medical care personnel follow physician-approved protocols and keep continuous two-way voice communication with physicians. NOTE: Every AFMS ambulance service must use the standardized and approv
18.104.22.168. MTFs who have a paramedic-level ambulance service must use EMT Paramedic protocols which have been approved by the Med.
7.25.4. Alternative to CFETP. For clinical (patient care) tasks not outlined in the CFETP, consult the MAJCOM/SG.
22.214.171.124. When the MTF executive management team determines there is need for enlisted personnel to perform tasks clearly beyond.
126.96.36.199. In all cases, training for additional clinical tasks will be formally certified on AF Form 797, Job Qualification Standard Continuation/Command JQS, and maintained in the individual Enlisted Training and Competency Record. Training references
188.8.131.52. Waiver requests will include the following:
184.108.40.206.1. Rationale for expanding practice to include who and their location within the MTF.
220.127.116.11.2. Training protocol.
18.104.22.168.3. Procedures for competency validation/verification.
22.214.171.124.4. Guidelines for maintaining proficiency.
126.96.36.199.5. Procedures for sustaining the expanded practice within the MTF (i.e., sustainment of EMT-Paramedics).
7.26. Medical/Dental Student Documentation in Medical Records
7.26.1. Medical/dental students must indicate their status when signing an entry by indicating the year of training. For example, sign "MS-3" for a third-year student and "MS-4" for a fourth-year student.
7.26.2. Supervising physician must countersign all patient record entries written by medical students
7.26.3. Before orders written by medical/dental students can be executed, the supervising physician must review and sign.
188.8.131.52. Medical/dental students are prohibited from giving verbal orders.
7.26.4. The H&P examination must be countersigned by the attending physician or senior resident before it becomes part of the medical record.
7.26.5. Medical/dental students may not obtain informed consent.
7.26.6. For the ANG, reference ANGI 41-102, Early Appointment Program for Physicians, for further guidance regarding third and fourth-year medical students.
Chapter 8 PEER REVIEW
Section 8A- Peer Review Process
Figure 8.1. Peer Review Process
8.2. Proactive review.
8.2.1. Comparable Data Analysis is the use of performance-based metrics and data to compare the practice of a provider to peers .
8.2.2. There is no set number of charts to review. The number should be adequate to compare providers, as determined by the SGH .
8.2.3. Clinical Skills Review is routine and not administrative in nature. It is clinical and must be performed by a peer. A pee.
184.108.40.206. Criteria must be clinical and defined by current standard of practice/care (i.e., Clinical Practice Guidelines on asthm.
220.127.116.11. For facilities that have single providers practicing a specialty (i.e., one man ENT shop) clinical skills review can be.
8.3. Responsive Review.
8.3.1. Individual Practice Review (IPR) is a peer review of a provider's practice through records, on-site interviews and observation or TDY of a provider to another location (see paragraph 18.104.22.168. for M&E). A peer is defined as the same AFSC or a high
22.214.171.124. IPR can also be used as a result of an credentials function recommendation. This most often takes the form of Monitorin.
8.3.2. Standard of Care Review (SOC) review is a peer review of a specific case. It is initiated in response to a concern about .
8.3.3. Expert review is an external peer review of a specific case in preparation for a malpractice case against the government. The regional MLC directs expert reviews.
Chapter 9 ADVERSE CLINICAL AND ADMINISTRATIVE ACTIONS RELATED TO THE PROVISION OF HEALTHCARE
Section 9A- Clinical Adverse Actions
9.1.1. This chapter will separately explain the clinical adverse action due process for privileged and non-privileged providers. Administrative adverse action is reported to the HIPDB and is addressed in Section 9G.
9.2.1. To protect our patients.
9.2.2. To enhance the quality of care and protect the integrity of the AFMS.
9.2.3. To protect the rights of the provider(s) in question (afford due process).
9.2.4. To ensure timely resolution of the issues.
9.2.5. To differentiate clinical versus administrative actions.
9.2.6. To allow timely reporting of individuals to professional regulatory agencies if required.
9.3. Consult with Legal Counsel.
9.4. Coordination with MTF Executive Leadership.
9.5. Early Notifications:
9.5.1. HQ MAJCOM:
9.5.2. Civil Service Employees:
9.5.3. Contract Employees:
9.5.4. Host Nation Providers:
9.6. Roles and Responsibilities:
9.6.1. Credentials Function Chairperson (Privileged Provider Actions):
126.96.36.199. Provides oversight of adverse actions for privileged providers. Initiates inquiry of incidents that may lead to adverse privileging action.
188.8.131.52. Invokes abeyance or summary suspension action on privileged providers.
184.108.40.206. Appoints members to conduct credentials function reviews and/or hearing procedures.
220.127.116.11. Provides guidance (on due process, substance matters) to the MTF/CC and consults with MAJCOM, as needed.
18.104.22.168. Communicates abeyance, summary suspension, and/or hearing notifications to provider.
22.214.171.124. Ensures involved providers are informed of their due process rights, to include all required written notifications are completed as specified in this AFI.
126.96.36.199. Coordinates with senior corps representative for actions involving respective corps providers.
9.6.2. Senior Corps Representative (Non-Privileged Provider Actions):
188.8.131.52. Provides oversight of adverse actions taken on non-privileged providers. Initiates inquiry of incidents that may lead to adverse practice action.
184.108.40.206. Invokes initial removal of non-privileged provider from patient care.
220.127.116.11. Appoints members to conduct Non-Privileged Provider Review Function and hearing procedures.
18.104.22.168. Provides guidance (on due process and substance matters) to the MTF/CC and consults with MAJCOM as needed.
22.214.171.124. Communicates initial removal from patient care and hearing recommendations to non-privileged provider, to include all required written notifications are completed as specified in this AFI.
126.96.36.199. Ensures involved non-privileged providers are informed of their due process rights as specified in this chapter.
188.8.131.52. Appoints primary point of contact for adverse actions policy.
184.108.40.206. Directs Credentials Function Chairperson (SGH) or senior corps representative to conduct inquiry procedures into privileged or non-privileged provider's actions or misconduct.
220.127.116.11. Proposes adverse actions on privileged and non-privileged providers.
18.104.22.168. Takes final action on provider's privileges/non-privileged provider's practice, following hearing procedures.
9.6.4. Risk Manager/Quality Manager:
22.214.171.124. Primary POC for adverse actions policy and procedures within the MTF. Supports Credentials Function Chairperson (SGH) and Senior Corps Representative with due process procedures.
126.96.36.199. Ensures due process and notification procedures are appropriately completed for adverse actions. Coordinates documentation requirements with credentials manager (CM).
188.8.131.52. Establishes/maintains adverse action system of files with all required documents. The risk manager shall coordinate and.NOTE: The provider is not allowed to have possession of the file.
9.6.5. HQ MAJCOM/SG Office:
184.108.40.206. Communicates with/advises MTF during the adverse action process.
220.127.116.11. After consultation with AFMOA/SG3OQ approves extension of summary suspension actions lasting longer than
18.104.22.168. Forwards case file to AFMOA/SG3OQ for appeal and/or reporting to regulatory agencies. May provide comments to AF/SG for consideration.
9.6.6. MLCs, Judge Advocates and Civilian Air Force Attorneys:
22.214.171.124. Advise the MTF/CC, Credentials Function Chairperson, senior corps representative and staff regarding legal aspects of adverse actions.
126.96.36.199. Ensure legal requirements are met for hearing procedures.
188.8.131.52. Participate in hearing procedures.
184.108.40.206. Coordinates and prepares Adverse Action case for final AF/SG review.
220.127.116.11. Considers appeals of adverse privilege/practice actions through the Medical Practice Review Board (MPRB), to include expert peer review of the clinical substance of the case and legal review for due process procedures.
18.104.22.168. Reports final actions to the NPDB, states of known licensure, and/or other regulatory agencies
22.214.171.124. Communicates AF/SG decision and action to involved provider, the MTF/CC and HQ MAJCOM/SG.
126.96.36.199. Releases information regarding adverse actions to regulatory agencies and/or credentialing agencies, when requested.
188.8.131.52. Maintains a database of adverse actions for the AFMS. Provides lessons learned from adverse actions to HQ MAJCOM/SG personnel annually.
184.108.40.206. Submits reports to DoD Risk Management Committee IAW DoD 6025.13-R.
9.7. Differentiate Clinical and Administrative Adverse Actions.
9.7.1. An adverse clinical action must be taken when appropriate, regardless of the individual's contract or other duty status w.
9.8. Providers Ending Affiliation with the Air Force Medical Service After Initiation of an Abeyance or an Adverse Action.
9.8.1. The MTF/CC must inform (in writing) individuals who separate or end affiliation with the AFMS while under an abeyance or .
9.8.2. The provider may ask that due process procedures be continued after the change in his or her status with the AFMS or MTF.
9.8.3. If the provider chooses not to continue the adverse action due process, the MTF/CC's decision becomes the final action and is forwarded to AFMOA/SG3OQ via the MAJCOM/SG for review and reporting as indicated.
9.8.4. Adverse actions may be considered for up to 12 months following cessation of a provider's affiliation with an MTF for iss.
9.9. Air Reserve Components (ARC).
9.10. Theater of Operations.
9.11. Actions Involving the Medical Group Commander.
9.12. Use of Timelines.
Section 9B- Clinical Adverse Actions for a Privileged Provider
9.13.1. While under abeyance or summary suspension of all clinical privileges, the provider will not be reassigned to other clinical duties (another clinic seeing patients, etc) or PCS'd to another MTF. In cases of abeyance or summary suspension of a po
9.14. Withdrawal of Permission to Engage in Off-Duty Employment.
9.15. Invoking an Abeyance.
9.15.1. Provider Notification. The provider is notified, in writing, by the Credentials Function Chairperson, that his or her pr.
9.15.2. Inquiry Procedures. When more information on the provider's professional and clinical performance, professional conduct,.Chapter 8, Peer Review) to determine if there are clinical practice deficits that are or may affect patient safety. The in
9.15.3. Disclosure of Abeyance. Since abeyance is not an adverse action, providers may not be required to disclose a period of a.
9.16. Invoking a Summary Suspension.
9.16.1. Provider Notification. The provider will be notified, in writing, by the Credentials Function Chairperson, that their cl.
9.16.2. Disclosure of Summary Suspension. A summary suspension is a clinical adverse action and, therefore, it may be necessary .
9.17. Notification to HQ MAJCOM/SG.
9.17.1. Notification to AFMOA/SG3OQ. HQ MAJCOM/SG should notify AFMOA/SG3OQ about adverse actions of a sensitive or potentially notorious nature. AFMOA/SG3OQ will be responsible for providing information to HQ USAF/SG leadership, as appropriate.
9.18.1. Contract (including Host Nation contract) Providers. If the provider is a member of a contract group, the Credentials Fu.
9.18.2. GS Civilian Providers. If the provider is a GS provider, the Credentials Function Chairperson shall provide a copy of th.
9.19. Command Directed Evaluations.
9.20. Credentials Function Review Process.
9.21. Composition of the Credentials Function.
9.22. Ensuring Impartiality in Credentials Function.
9.22.1. The individual's direct supervisor.
9.22.2. Subordinates of the provider under review.
9.22.3. The individual who summarily suspended the provider's privileges or who recommended the provider's discharge from active duty.
9.22.4. Inquiry/Investigation officers.
9.22.5. Any person whose testimony plays a significant part in the case.
9.22.6. Any officer/member who is participating, or has participated, in other administrative proceedings (court-martial board or administrative review board) regarding the provider under review.
9.22.7. Any member who is reviewing, or has reviewed, the provider's actions under consideration by the credentials function.
9.22.8. The Credentials Function Chairperson.
9.23. Credentials Function Recommendations.
9.23.1. Reinstatement. The return of unsupervised privileges or no action taken to limit or revoke the provider's privileges. Re.
220.127.116.11. Monitoring and Evaluation (M&E). M&E is a well-defined, time-limited, well documented plan of intensified peer review .NOTE: M&E is not a substitute for retraining. It is not reportable to the NPDB. Providers shall acknowledge the conditions
9.23.2. Restriction. A temporary or permanent limit placed on all or a portion of the provider's clinical privileges so the prov.
9.23.3. Reduction. The permanent removal of a portion of a provider's clinical privileges. Reduction of privileges is reportable to the NPDB.
9.23.4. Revocation. Member is permanently removed from all patient care duties. Revocation of privileges is reportable to the NPDB.
9.23.5. Denial of clinical privileges. Refusal to grant provider-requested privileges. This could occur at initial application f.NOTE: Refer to paragraph
9.24. Credentials Function Forwards Recommendations to the MTF/CC.
9.25. MTF/CC Action on Credentials Function Recommendations.
9.25.1. The MTF/CC has
9.25.2. The MTF/CC then gives written notification to the provider of his or her intent to take action, identifies the proposed action, and the reasons for the action
9.25.3. If the proposed action is to deny, reduce, restrict, or revoke the provider's privileges, then the MTF/CC must advise the provider of his or her hearing and appeal rights (reference
9.26. Hearing Rights and Responsibilities.
9.26.1. If no hearing request is received in
9.26.2. If the provider fails to appear for a scheduled hearing, the MTF/CC may choose to proceed with a hearing or act on the provider's privileges as intended in the Notice of Proposed Adverse Action Letter (reference
9.27. Provider Notification of Hearing.
9.27.1. The date, time, and location of the hearing, which must be no sooner than 30 calendar days from the date of the notification, but scheduled
9.27.2. The provider's right to be present, to present evidence, and to call witnesses. The provider must arrange for the presence of his or her witnesses at his or her own expense.
9.27.3. The names of MTF's witnesses to be called to testify at the hearing. The provider shall disclose the names and contact information for all witnesses testifying on his or her behalf
9.27.4. The right to cross-examine these witnesses.
9.27.5. The right to have a military counsel (Area Defense Counsel) appointed to assist the provider (if the provider is military) and/or the right to hire a civilian attorney at the provider's expense.
9.27.6. The provider may request a delay of the hearing for good reason. The credentials function chairperson evaluates the requ.
9.28. Hearing Panel Composition.
9.28.1. If the MTF/CC is the provider being evaluated, or is disqualified from acting in the case, the HQ MAJCOM/SG will appoint a senior physician to act as the MTF/CC for the case. The personnel listed below shall not serve on the hearing committee:
18.104.22.168. The individual's direct supervisor.
22.214.171.124. Subordinates of the provider under review.
126.96.36.199. The individual who summarily suspended the provider's privileges or who recommended the provider's discharge from active duty.
188.8.131.52. Inquiry/Investigation officers.
184.108.40.206. Any person whose testimony plays a significant part in the case.
220.127.116.11. Any officer/member who is participating, or has participated, in other administrative proceedings (court-martial board or administrative review board) regarding the provider under review.
18.104.22.168. Any member who is reviewing, or has reviewed, the provider's actions under consideration by the credentials function.
22.214.171.124. The Credentials Function Chairperson.
9.29. Legal Advisor.
9.30. Obtaining Court Reporting Services.
9.31. Hearing Overview.
9.31.1. Roles and Responsibilities.
126.96.36.199. Chairperson. The chairperson of the hearing panel shall preside over the proceeding, and must consult with the appoint.
188.8.131.52. Legal Advisor. Once appointed, the legal advisor may rule on any procedural issues that are raised prior to or during .
9.31.2. Hearing Proceedings. These proceedings are not bound by formal rules of evidence or a strict procedural format. The chairperson and legal advisor to the hearing panel may use the hearing script at
9.31.3. Presentation of New Information at Hearing. Additional information relevant to the allegations contained in the notifica.NOTE: New information that rises to the level of a new allegation requires adherence to the notification provisions outlin
9.31.4. Hearing Panel Findings and Recommendation. The hearing panel findings must be supported by a preponderance of the eviden.
9.31.5. Timeliness of Findings and Recommendations. The panel should notify the provider of its findings and recommendations imm.
9.31.6. Hearing Transcription. A verbatim record of the proceedings prepared by a qualified court reporter is required. In order.
9.31.7. Forward Recommendations. The hearing transcript shall be completed and all copies provided to the Credentials Function Chairperson within 30 calendar days of the hearing. If this cannot be accomplished within
184.108.40.206. The credentials function meets to review the hearing transcript, evidence, and committee findings and recommendations. They can submit additional comments or recommendations to the MTF/CC.
9.31.8. The Credentials Function Chairperson gives a copy of all hearing panel findings and recommendations, additional recommen.
9.32. Provider Statement of Exceptions and Corrections.
9.32.1. Upon receipt of the provider's statement of exceptions and corrections, the Credentials Function Chairperson forwards the case file to the MTF/CC for a final decision.
9.33. Commander's Decision and Provider Notification.
9.33.1. The MTF/CC must provide written notification to the provider of the final decision (reference
9.34. Provider's Appeal.
9.34.1. A provider who fails to appeal the MTF/CC's decision waives any further appeal rights. If the provider waives his/her ri.
9.35. Forward Documentation to HQ MAJCOM/SG.
9.35.1. Specialty pays withheld.
9.35.2. Promotions halted.
9.35.3. Pending administrative discharge/separation procedures or retirement.
9.35.4. Medical Evaluation Board/Physical Evaluation Board (MEB/PEB) pending.
9.35.5. Referral OPRs.
9.35.6. Provider resigned commission.
9.35.7. Related UCMJ action.
9.35.8. Removal of AFSC.
9.35.9. Contract Status (if applicable).
9.36. Appeals Review Process.
9.37. AF/SG Review and Final Action.
9.38. AFMOA/SG3OQ Notifications.
Section 9C- Documentation Requirements Related to Adverse Actions
9.39. Abeyances and Summary Suspensions Documentation.
9.39.1. Abeyance Leading to Reinstatement. Notification of abeyance and reinstatement of privileges will be kept in the PAF sinc.
9.39.2. Summary Suspension Leading to Reinstatement. Notification of summary suspension and reinstatement of privileges will be .
9.39.3. Abeyance and Summary Suspension Action Leading to Adverse Action. Action that leads to restriction, reduction, or revoca.
9.40. Monitoring and Evaluation (M&E) Documentation.
9.40.1. M&E Leading to Reinstatement. If no adverse action is recommended, the M&E documents are filed in the PAF. Regular written and verbal feedback must be given to the provider during the period of M&E.
9.40.2. M&E Leading to Adverse Action. If the M&E documents become evidence in an adverse action proceeding, these documents must be placed in the PCF. The AF Form 22 may be used to summarize the provider's performance during the M&E period.
Section 9D- Non-Privileged Providers Clinical Adverse Actions Process
9.41.1. Notification. The non-privileged provider will be notified, in writing, by the Senior Corps representative that an inquiry is being conducted (see
9.41.2. Civil Service Employees. Consultation with the employee relations specialist at the CPO shall occur prior to any adverse.
9.41.3. Contract (including host nation contract employees). If an adverse action is being considered on a contract employee, co.
9.42. Withdrawal of Permission to Engage in Off-Duty Employment.
9.43. Inquiry Procedures.
9.44. Notification to Non-Privileged Provider.
9.45. Notification to HQ MAJCOM/SG.
9.46.1. Non-Privileged Provider Review Function Process. When a Non-Privileged Provider Review Function is convened, it must det.
9.46.2. Composition of Non-Privileged Provider Review Function. The Non-Privileged Provider Review Function must be composed of .
9.46.3. Non-Privileged Provider Review Function Recommendations. The Non-Privileged Provider Review Function considers the infor.
220.127.116.11. Reinstatement. Return the non-privileged provider back to full duty or change of assignment within the MTF that does n.
18.104.22.168.1. M&E. M&E is a well-defined, time-limited, well documented plan of intensified peer review to confirm that a non-privileged provider .NOTE: M&E is not a substitute for retraining. The provider will be notified in writing and acknowledge the
22.214.171.124. Reduction. Permanent removal of a portion of the non-privileged provider's patient care duties. (Example: Obstetric nu.
126.96.36.199. Restriction. A temporary or permanent limit placed on all or a portion of the non-privileged provider's clinical pract.
188.8.131.52. Revocation. Permanent removal from all direct patient care duties. This is an adverse action that is reportable to regulatory agencies.
9.47. Forward Recommendations to the MTF/CC.
9.47.1. The MTF/CC has
9.48. Non-Privileged Provider Notification.
9.48.1. If the proposed action is to permanently reduce, or revoke the non-privileged provider's practice, then the MTF/CC's must advise the individual of his or her hearing and appeal rights (see
9.49.1. If the non-privileged provider fails to appear for a scheduled hearing, the MTF/CC may choose to proceed with a hearing.
9.50. Hearing Procedures.
9.50.1. Hearing Panel Recommendations. The recommendation options are the same as those for the Non-Privileged Provider Review Function listed above in paragraph
9.50.2. Forward Recommendations. The hearing transcript shall be completed and copies provided to the Senior Corps Representative within
9.50.3. The Senior Corps Representative reviews the hearing panel findings and recommendations. He/she may submit additional comments or recommendations to the MTF/CC.
9.50.4. The Senior Corps Representative gives a copy of all hearing panel findings and recommendations, additional recommendatio.
9.51. Non-Privileged Provider Statement of Exceptions and Corrections.
9.51.1. Upon receipt of the provider's statement of exceptions and corrections, the Senior Corps Representative forwards the case file to the MTF/CC for a final decision.
9.52. Commander's Decision and Provider Notification.
9.52.1. The MTF/CC must provide written notification to the provider of the final decision (see
9.53. Non-Privileged Provider's Appeal.
9.53.1. When a non-privileged provider chooses not to appeal the MTF/CC's decision this waives any further appeal rights. If the.
9.54. Forward Documentation to HQ MAJCOM/SG.
9.54.1. Promotions halted.
9.54.2. Pending administrative discharge/separation procedures or retirement.
9.54.3. Medical Evaluation Board/Physical Evaluation Board (MEB/PEB) pending.
9.54.4. Referral OPRs/EPRs.
9.54.5. Provider resigned commission.
9.54.6. Related Uniform Code of Military Justice (UCMJ) action.
9.54.7. Removal of AFSC.
9.54.8. Contract Status (if applicable).
9.55. Appeals Review Process.
9.56. Senior Corps Chief Review and Final Action.
9.57. AFMOA/SG3OQ Notifications.
9.58. Non-Privileged Provider Documentation Requirements.
9.59. Removing Nurses from the Nurse Transition Program.
9.60. Removing Technicians from Clinical Practice.
9.60.1. Peer review will be by technician providers who are of similar grade and experience, and who hold the same certification as the one in question. At least two peers must be used in the review.
9.60.2. There is no clinical due process requirement for technicians who do not require a certification to perform their clinical duties.
9.60.3. Decertification procedures for Independent Duty Medical Technicians is found in AFI 41-103.
Section 9E- Management of Impaired Privileged/Non-Privileged Providers
9.62. Alcohol or Drug Impairment:
9.62.1. Voluntary Self-disclosure. A provider may self-disclose an alcohol or drug impairment and request treatment. The treatme.
9.62.2. Determining If Adverse Action Is Needed. The MLC will provide guidance to the MTF on professional adverse actions relate.
184.108.40.206. The Credentials Function Chairperson or Senior Corps Representative must initiate an inquiry into reports of provider impairment IAW paragraphs
9.62.3. Any alcohol or drug event that occurs while a provider is on duty or on call must be considered for adverse privilege/pr.Section 9B (privileged providers) and Section 9C (non-privileged providers).
9.62.4. Returning to Practice Following Treatment. Upon anticipated return to clinical duties following treatment, the credentia.
9.62.5. Evidence of Relapse. Any identified relapse will be reported immediately to the credentials function or Senior Corps Rep.
9.62.6. Actions Involving Civilian Personnel. The supervisor of civil service providers/employees will contact the Civilian Personnel Office, Employee Relations Branch, for advice prior to questioning the employee.
9.62.7. Actions Involving Contract Providers. The supervisor of contract staff will contact the QA personnel assigned to the con.
9.63. Physical/Mental Impairments:
9.63.1. Temporary Impairments. Temporary impairments (i.e., broken arm or leg, pregnancy, scratched cornea, medication use which.
9.63.2. Permanent and Long-Term Impairments. Permanent or long-term impairments shall be reviewed by the Credentials Function fo.
9.63.3. Voluntarily Restricting Practice Related to a Medical Condition. A provider may voluntarily restrict his or her practice.adverse action to any state regulatory agency. The Credentials Function/Senior Corps Representative must approve the volun
9.63.4. Determining if Adverse Action is Needed. The Credentials Function or Senior Corps Representative in consultation with th.
9.63.5. Medical Evaluation Board/Physical Evaluation Board (MEB/PEB). The MEB/PEB process is not designed to decide if a person .
9.63.6. Reassessment of Impairment Status. Impairment status should be reviewed periodically. The credentials function/senior co.
9.64. Management of Individuals with Communicable Diseases that Could Affect Patient Safety:
9.64.1. Determining Extent of the Exposure Risk. The credentials function or senior corps representative must review the scope o.
9.64.2. Voluntary Restriction of Practice. The individual may voluntarily restrict his or her practice related to medical condit.
9.64.3. Restriction of Practice. If the MTF/CC determines that the individual's practice must be restricted, reduced, or revoked.
Section 9F- Other Management Issues Related to Adverse Actions
9.65. Simultaneous Adverse Action and UCMJ Action.
9.65.1. If there is a conflict between the MTF and other investigating agencies regarding the continuation of an adverse action process, the base SJA will decide whether the adverse action will be postponed.
9.66. Administrative Denial of Privileges.
9.67.1. Refresher Program. Needed for individuals to "get back up to speed." Basic fund of knowledge intact; fundamentals, skill.
9.67.2. Skills Enhancement. Adding focused knowledge, a few skills, or core competencies to a sound foundation. Lets a provider .
9.68. Removing Residents from Patient Care Responsibilities.
Section 9G- Reporting and Releasing Adverse Information to National and Regulatory Agencies
9.69. Responding to Written Requests for Information.
9.70. Disposition of Reports and Actions When MTFs Close.
9.71. AFMOA/SG3OQ Responsibilities in Reportable Actions.
9.72. NPDB Reporting of Adverse Actions.
9.72.1. Privileged providers will be reported to the NPDB within
220.127.116.11. Clinical privileges have been denied, restricted, reduced, or revoked for substandard performance, impairment, or unprofessional conduct.
18.104.22.168. A provider voluntarily surrenders clinical privileges while under investigation for issues of incompetence or misconduct, or in return for not conducting such an investigation or proceedings.
22.214.171.124. Provider separates, retires, moves PCS, or terminates employment, contract, or volunteer services with their privileges summarily suspended.
9.72.2. A copy of the NPDB report will be sent to states of known licensure, the FSMB for physicians, and/or the American Association of Dental Examiners (AADE) for dentists, and other regulatory/professional organizations IAW DoD directives.
9.72.3. The following agencies will receive a notification of final adverse action: HQ AFPC/DPAM, ANG/SG, HQ AFRC/SG, HQ ARPC/SG, HQ MAJCOM/SG, MTF/CC, and to the subject of the action at his or her last known address.
Section 9H- Reporting to the Healthcare Integrity and Protection Data Bank (HIPDB)
9.74.1. The AF/SG is responsible for reports regarding reportable adverse actions taken against healthcare providers, suppliers,.
9.74.2. AFMOA/SG3OQ provides oversight and consultation for HIPDB reporting. Risk Management Operations processes these actions for review and reporting and notifies in writing the MTF/CC, MAJCOM, and the individual of the final action.
9.74.3. HQ MAJCOM/SG offices are responsible for reviewing cases for substance, completion of required process, and forwarding to AFMOA/SG3OQ.
9.74.4. The MTF Commander will receive reports on actions for final determination as to whether they should be forwarded for rep.
9.74.5. SQ/CC and supervisors of medical personnel are responsible for identifying, and reporting to the MTF/CC, actions that may potentially be reported to the HIPDB (Article 15, Court Martial, Termination for Default, etc.).
9.74.6. Contractor Quality Assessment Personnel will serve as the liaison between the MTF and the contractor, and will monitor the process to ensure the requirements outlined in the contract are fulfilled.
9.74.7. The MTF Civilian Personnel Liaison is responsible for working with the Civilian Personnel Office to ensure that local bargaining obligations have been met.
9.74.8. The MLC and SJA are responsible for providing legal consultation to the MTF.
9.74.9. The Credentials Function Chairperson will be the functional reporter to the MTF Commander for privileged providers. This.
9.74.10. The Senior Corps representative will be the functional reporter to the MTF/CC for actions involving non-privileged prov.
9.74.11. The First Sergeant will be the functional reporter for actions involving enlisted members. This individual is responsib.
9.75. Reportable Actions:
9.75.1. Military Personnel: Reportable actions are court-martial convictions (once approved by the court-martial convening autho.
9.75.2. Civilian Personnel: Reportable actions include adverse personnel actions related to misconduct, based on acts or omissio.
9.75.3. Contract Personnel: Reportable actions include contract termination for default taken by an MTF or medical command against a personal services or non-personal services contractor.
9.76.1. Upon imposition of an adverse administrative action, the appropriate authority (SQ/CC, functional reporter) must notify the individual in writing within
9.76.2. The individual involved has
9.76.3. The SQ/CC (or designee) will make a preliminary determination as to whether the act or omission did or could have a potential to adversely effect the provision of healthcare. The functional reporter will complete a DD Form 2499, Healthcare Pract
9.76.4. The MTF/CC will make the final determination as to the effect on healthcare and whether the individual shall be considered for reporting to the HIPDB. He/she must notify the individual in question in writing within
9.76.5. Forward the case file to HQ MAJCOM/SG Quality Office. Case files must contain:
126.96.36.199. Commander's final letter to recommend reporting to the HIPDB and how the member's action effected on the provision of healthcare.
188.8.131.52. For military members, AF Form 3070, Record of Non-Judicial Punishment, or copy of court-martial order announcing the convening authority's initial action; for civilian employees, a copy of the decision letter and Standard Form 50, Notice of Pe
184.108.40.206. DD Form 2499, Healthcare Practitioner Action Report.
220.127.116.11. Individual's written statement, or memorandum stating none was submitted.
18.104.22.168. Initial letter of notification to individual of potential to report to the HIPDB.
9.77. HQ MAJCOM/SG Review.
9.77.1. If the case involves a Court-Martial or civilian adverse action, and the individual intends to appeal, the HIPDB reporti.
Chapter 10 MEDICAL MALPRACTICE CLAIM MANAGEMENT
Section 10A- Medical Malpractice Claims.
10.1.1. DoD is required to report to the NPDB when a medical malpractice payment is made for the benefit of a healthcare practit.
10.2. Medical Malpractice Claim Processing Responsibilities:
10.2.1.1. Provides oversight for medical malpractice claim process within the MTF.
10.2.1.2. Directs a quality of care review (including SOC determinations) be completed on all malpractice claims involving their MTF.
10.2.1.3. Ensures all significantly involved providers are notified of their involvement in the medical malpractice claim (see
10.2.2. SGH, or Designee Responsibilities:
10.2.2.1. Facilitates identification of providers who are significantly involved in the allegation of the claim. May consult wit.
10.2.2.1.1. Significantly Involved Provider is one who actively delivered care (based on clinical record entries) in either primary or consultative roles during the episodes of care that gave rise to the allegation, regardless of SOC determination. Addi
10.2.2.2. Assist MTF/CC and risk manager with initial notification to significantly involved providers. (See
10.2.2.3. Review medical malpractice data and lessons learned at professional staff meetings. Inform MTF/CC if a provider has mo.
10.2.3. MTF Risk Manager/Designee Responsibilities:
10.2.3.1. Upon notification of a medical malpractice claim (Standard Form 95), secures all medical records, evidence, documents .NOTE: The original medical records remain sequestered, a certified copy is placed in records administration for appointmen
10.2.3.2. Organizes a Quality of Care review (including SOC determinations) on every medical malpractice claim to identify lesso.
10.2.3.3. Submits requested documents and evidence to the base legal office. Prepares DD Form 2526 on all significantly involved.
10.2.3.4. Documents sent to the base legal office include (but are not limited to):
10.2.3.4.1. MTF Quality of Care review to include SOC determinations on significantly involved provider(s), also include any medical literature used to support the standard of care determinations.
10.2.3.4.2. List of significantly involved providers and their SOC reviews.
10.2.3.4.3. DD Form 2526 on each significantly involved provider.
10.2.3.4.4. Provider statement of sequence of events (if submitted).
10.2.3.4.5. Witness locator list (to include a permanent address, phone number, DEROS and/ or separation date, if applicable).
10.2.3.4.6. Applicable medical records (certified copies) and relevant evidence (x-rays, consultation reports, etc), and relevant wing/medical group instructions, policies, and/or protocols.
10.2.3.4.6.1. For outpatient records, number the pages on the bottom right hand side from the earliest entry to the latest.
10.2.3.4.6.2. For inpatient records, numbered on the bottom right hand side, from the latest entry to the earliest. (This numbering is opposite from the outpatient record, the most recent inpatient record would be on the bottom.)
10.2.3.5. Risk manager shall assemble the medical records in the following manner:
10.2.3.5.1. Certified copy.
10.2.3.5.2. Copied on only one side.
10.2.3.5.3. Placed in medical record folders as the original.
10.2.3.6. The MTF Risk Management office will ensure the CCQAS database is utilized for medical malpractice claim management and.
10.2.3.7. Maintain data within CCQAS on medical malpractice claims to include, but not limited to; claimant(s) name, claim numbe.
10.2.3.8. Provide all Significantly Involved Providers a redacted copy of the MLC expert peer review (SOC determination). If the.
10.2.3.9. Provider response should address the facts of the incident of care that gave rise to the allegation of the claim, thei.
10.2.3.10. Significantly involved providers must notify the MTF/CC, in writing, of their intent to respond, within
10.2.3.11. The risk manager will transmit the provider's intent to respond, by facsimile, to AFMOA/SG3OQ, (Attention: Chief, Risk Management), within
10.2.3.11.1. The provider's response is reviewed and given full consideration by the final expert peer reviewer in preparation for the MPRB and is forwarded with the case to the AF/SG for final SOC determination.
10.2.3.11.2. If the provider elects not to respond to the claim, AFMOA/SG3OQ will proceed with the malpractice claim review following final legal closure.
10.2.3.12. Notify all Significantly Involved Providers of legal and clinical closure of a claim, to include a final copy of thei.
10.2.3.13. Providers found to be not significantly involved shall be notified that they have been removed from the claim. Ensure.
10.2.3.14. Risk manager shall brief MTF/CC and executive staff (ECOMS) on MTF medical malpractice claims status report (semi-ann.
10.2.4. HQ MAJCOM/SG Responsibilities:
10.2.4.1. Examine the MTF Quality of Care review, preliminary SOC determinations, and expert peer reviews received from the MLC.
10.2.4.2. Submit recommendations for AF policy changes to AFMOA/SG3OQ, based on analysis of malpractice case reviews, including system problems and lessons learned.
10.2.5. Base Legal Office Responsibilities:
10.2.5.1. Notify the MTF risk manager of the newly filed claim and send a copy of each claim form [Standard Form (SF) 95] to the MTF.
10.2.5.2. Coordinate Significantly Involved Provider witness interviews with SGH, SGN, and risk manager.
10.2.5.3. Investigate each claim and forward documents to the MLC. Serve as liaison between MLC and MTF risk manager for malpractice claim management. Notify MTF risk manager when additional documents/interviews, etc., are needed for legal proceedings.
10.2.5.4. Notify the MTF risk manager of legal outcome of claims.
10.2.5.5. Is a member of the MTF Risk Management Committee.
10.2.6. MLC Responsibilities:
10.2.6.1. Contact Expert Review Manager (ERM) at AFMOA/SG3OQ to coordinate necessary expert peer reviews for each claim. Provide.
10.2.6.2. Complete medical-legal review of the claim.
10.2.6.3. Forward appropriate documentation to the MTF, HQ MAJCOM/SG, AFMOA/SG3OQ, and the base legal office.
10.2.6.4. Forward redacted MLC expert SOC determinations to the MTF including recommendations of all Significantly Involved Provider.
10.2.6.5. Forward copy of the claim and medical records to AFMOA/SG3OQ Risk Management Operations.
10.2.7. AFMOA/SG3OQ Expert Review Manager (ERM) Responsibilities:
10.2.7.1. ERM shall coordinate all expert peer reviews for AFMS medical malpractice claims.
10.2.7.2. Maintains current list of AFMS clinical consultants and expert peer reviewers for each clinical specialty.
10.2.7.3. Coordinates requests for expert reviews from the MLCs.
10.2.7.4. Contacts expert reviewers in coordination with the appropriate clinical consultant and establishes a suspense date for the review(s).
10.2.7.5. Provides the MLC with the expert reviewer(s) contact information, MLC forwards the claim file to the expert peer reviewer.
10.2.7.6. ERM monitors (via a database) each claim to ensure the expert reviews are completed by the suspense date. If the exper.
10.2.7.7. Notifies appropriate AFMOA/SG3OQ consultant when expert reviewers are unable to complete the reviews by suspense date since this may compromise the legal adjudication of the claim.
10.2.8. Expert Medical Reviewer Responsibilities:
10.2.8.1. Prepares written expert peer review(s) based upon available evidence and standards of care applicable at the time of the incident. Cites relevant professional standards and literature to support their SOC determination.
10.2.8.2. Identifies significantly involved providers, renders SOC determinations within their clinical specialty with rationale and supporting justification, and identifies system problems and opportunities to improve care (lessons learned).
10.2.8.2.1. SOC determinations include: SOC met (what the reasonable prudent provider with similar training and experience would.
10.2.8.2.2. Validates the individual(s) identified by the MTF is/are significantly involved.
10.2.8.2.3. Prepares a written review according to format requested by the MLC.
10.2.8.2.4. Sends SOC written report to the MLC by agreed suspense date. If unable to meet the suspense date, the reviewer must coordinate an extension with the MLC/ERM prior to suspense date.
10.2.9. AFMOA/SG3OQ Responsibilities:
10.2.9.1. Chief, Risk Management Operations will provide oversight and daily guidance for malpractice claims management.
10.2.9.2. Maintain malpractice claim data using CCQAS risk management module. Release all AFMS malpractice data to AFIP, Department of Legal Medicine, and DoD Risk Management Committee as required.
10.2.9.3. Establish criteria for expert medical reviewer(s). At a minimum, expert peer reviewers should have a minimum of four y.
10.2.9.4. Provide claim information to significantly involved providers, MTF risk manager (and other MTF personnel), base claims.
10.2.9.5. Provide medical malpractice claim histories on AFMS healthcare professionals to State licensing agencies, credentialing agencies, and liability carriers as appropriate.
10.2.9.6. Convene the Medical Practice Review Board (MPRB), which is chartered to review all paid medical malpractice claims whe.
10.2.9.7. Based upon claim analysis, the MPRB suggests policy initiatives and clinical NOTAMS.
10.2.9.8. Communicate final SOC determination and claim status via DD Form 2526 to the MTF via HQ MAJCOM/SG. If MPRB determines .
10.2.9.9. Management of SOC Indeterminate. If the expert review of the claim finds SOC indeterminate for a provider, AFMOA/SG3OQ will manage the case in the following manner:
10.2.9.9.1. AFMOA/SG3OQ will attempt to obtain necessary documents (i.e., medical records, radiographs, etc.) to facilitate the .
10.2.10. HQ AFLOA/JACC Responsibilities:
10.2.10.1. Report all closed claims and litigation results to AFMOA/SG3OQ monthly. Reports will include claim name, claim number.
10.2.10.2. Respond to requests for additional information from AFMOA/SG3OQ regarding settlement of a malpractice claim.
10.3. External Agency (Civilian) Review of Medical Malpractice Claims.
10.3.1. AFMOA/SG3OQ will forward a copy of each paid claim, where an SOC is deemed to be met or a system problem is identified, to an external agency for review IAW DoD 6025.13-R.
10.3.2. AFMOA/SG3OQ will receive a written report from the external agency with a SOC determination on each significantly involv.
10.3.3. The malpractice claim will be processed through the MPRB. The AF/SG will review these claims and maintains responsibility for final decision on SOC determination and reporting to the NPDB.
10.4. Management of DD Form 2526, Case Abstract for Malpractice Claims:
10.4.1. AFMOA/SG3OQ will annotate claim status and final SOC determination on the DD Form 2526. This form will be forwarded via CCQAS to the MTF risk manager, with final SOC reviews and legal closure documents.
10.4.2. The base claims officer will notify the MTF/RM or designee of final settlements when received.
10.4.3. The MTF/CC or designee will inform the significantly involved providers of final SOC determination, the claim outcome, a.
10.4.4. File the DD Form 2526 in the provider's credentials folder. Send non-privileged healthcare professional DD Form 2526 to .
10.5. NPDB Reporting.
10.5.1. Reports are made to the NPDB when the SG determines that a claim was paid on behalf of a healthcare provider for failure to meet an acceptable SOC. The following conditions require reporting to the NPDB:
10.5.1.1. SOC is not met, and payment was made on behalf of an individual provider. A payment is considered on behalf of a provi.
10.5.1.2. Malpractice payment reporting to the NPDB applies to all privileged and non-privileged providers within the AFMS.
10.5.1.3. All healthcare workers reported to the NPDB will be notified by AFMOA/SG3OQ of the report and will receive a copy of t.
10.6. Reporting Healthcare Trainees and Clinical Supervisors to the NPDB.
10.6.1. If the SG determines that a payment was made for the benefit of a healthcare trainee, the attending practitioner responsible for the delivered care shall be reported to the NPDB. In such cases, the trainee will not be reported.
10.6.2. If the SG makes a specific finding that the attending practitioner clearly met all reasonable standards of supervision a.
10.7. Reports to State Boards of Licensure.
10.8. Provider Rights Related to Medical Malpractice Claims
10.8.1. Right to Notification. The MTF/CC and MTF risk manager will make reasonable attempts to ensure all significantly involved providers are informed of the status of a claim. Provider notifications should be accomplished at the following intervals:
10.8.1.1. Upon identification and involvement in a potentially compensable event (reference paragraph 22.214.171.124.)
10.8.1.2. When a malpractice claim is filed.
10.8.1.3. When the SOC not met determination is sent to the MTF/CC by the MLC.
10.8.2. Right to Notification of Final Outcome. The MTF/CC or designee will notify providers of the final outcome of malpractice.
10.9. MTF Actions When Providers Separate While a Malpractice Case is Under Review:
10.9.1. Separating providers with malpractice claims pending must provide the credentials manager with a permanent address (home of record), phone number, and all active/inactive state license numbers. This information shall be maintained in CCQAS.
10.9.2. If the base closes under BRAC, the MTF/CC or designee must ensure the entire claim file is sent to the HQ MAJCOM/SG with the current address, phone number, and states of licensure of the healthcare worker.
10.10. Provider Responsibility for Notifying Future Employers of Malpractice Claims.
10.11. Non-Personal Services Contract Providers.
10.12. Air Force Medical Residents Working in Civilian/Department of Veteran Affairs (VA) Institutions.
10.13. Reporting Feres-barred Cases.
10.13.1. When a determination is made that disability system or other payments shall be made because of personal injury or death.
10.13.2. In any case of specific, credible evidence that a report should be made, a presumption is created that a report is required. This presumption becomes conclusive in
10.13.3. Specific credible evidence exists when the following occur:
10.13.3.1. A Medical Evaluation Board (MEB) reports to the AFMOA/SG3OQ Risk Management that a member whose medical impairments r.
10.13.3.2. A medical examiner designated by the Armed Forces Medical Examiner determines that a member may have died as a result.
10.13.3.3. When an AD member has died as a result of medical care provided in a MTF and the provider was found to not meet the SOC. A DPDB report shall be entered for that provider.
10.13.3.4. AFMOA/SG3OQ Risk Management otherwise becomes aware of circumstances indicating that the disability system shall be u.
10.13.4. The process for the AF/SG to make the final determination discussed in paragraph
10.13.5. When a healthcare trainee is a significantly involved provider subject to a report, the attending provider responsible .
10.13.6. Confidentiality of External Peer Review Opinion. External peer review reports under paragraph
10.14. Annual Summary Report.
Attachment 1 GLOSSARY OF REFERENCES AND SUPPORTING INFORMATION
Attachment 2 CONTENTS OF COMPETENCY ASSESSMENT FOLDER (CAF)
Table A2.1. BSC/MSC/NC Officer, Civilian, and Volunteer Non-Privileged Personnel- Competency Assessment Folder
Table A2.2. Privileged Personnel Competency Assessment Folder
Attachment 3 APPLICATION FOR WAIVER OF ADMINISTRATIVE LICENSURE REQUIREMENTS
Attachment 4 SAMPLE LETTER - COORDINATION WITH STATE LICENSING BOARDS -DEPARTMENT OF DEFENSE HEALTH CARE PROFESSIONALS PRACTICING IN CIVILIAN HEALTH CARE FACILITIES
Attachment 5 CREDENTIALS TABLES
Table A5.1. Credentials Required for Fully Qualified Active Duty Providers
Table A5.2. Credentials Required for AD Providers Who Enter the AFMS and Proceed to and Then Graduate from an AFMS Training Program.
Table A5.3. Credentials Required for Providers Who Enter the AFMS and Proceed to Civilian Training in Sponsored and Non-Sponsored Programs.
Table A5.4. Credentials Required for Civilian Providers (Non-Personnel Service Contract Providers, Civil Service Employee, Personnel
Attachment 6 FORMAT FOR TRANSFER BRIEF MEMORANDUM
A6.1. Paragraph 1.
A6.2. Paragraph 2.
A6.3. Paragraph 3.
A6.4. Paragraph 4.
A6.5. Paragraph 5.
A6.6. Paragraph 6.
A6.7. Paragraph 7.
A6.8. Paragraph 8.
A6.9. Paragraph 9.
A6.10. Paragraph 10.
A6.11. Paragraph 11.
A6.12. General Comments:
A6.12.1. Paragraphs applicable to healthcare providers from Reserve or Guard components: Pro vide the current civilian position,.
A6.12.2. The Transfer Brief will be valid until expiration of the privileges upon which it is based. If the practitioner is assi.
A6.12.3. The Transfer Brief is joined with the formal application for privileges and supplants sec tions of applicable Military .
A6.12.4. Credentials Functions in DoD MTF/DTFs will accept healthcare provider performance appraisals on other Service's forms as their own.
A6.12.5. MTF/DTF commanders may grant privileges based on the approved privileges list from the sending MTF/DTF by approving it .
Attachment 7 CONTENTS OF PROVIDER ACTIVITY FILE (PAF)
A7.1. The PAF is the principal repository for supporting information and data to validate privileging of the provider at the ins.
A7.2. Listed below is data which may be included in the PAF. There is no specific format on how the PAF is to be organized, what.
A7.2.1. Baseline information and metric data:
A126.96.36.199. For all providers:
A188.8.131.52.1. Facility specific provider identification number
A184.108.40.206.2. Attendance at required professional staff meetings
A220.127.116.11.3. Data on number of duty days, clinical time (i.e., percentage of time spent on clinical activities, administration, etc.)
A18.104.22.168. For outpatient providers:
A22.214.171.124.1. Average daily/monthly patient load
A126.96.36.199.2. Total annual visits
A188.8.131.52.3. Number of emergency visits
A184.108.40.206. For inpatient providers:
A220.127.116.11.1. Number of admissions
A18.104.22.168.2. Number of discharges
A22.214.171.124.3. Number of procedures by category (i.e., deliveries, surgeries, etc.)
A126.96.36.199.4. Number of special care admissions
A188.8.131.52. For emergency providers:
A184.108.40.206.1. Number of visits
A220.127.116.11.2. Number of admissions/special care admissions
A18.104.22.168.3. Number of special procedures (i.e., Thoracotomies)
A22.214.171.124. For supervised providers
A126.96.36.199.1. Periodic performance reports as required.
A7.2.2. Outcome data on mortality, morbidity, and clinical monitoring data on performance parameters which may be used to support the AF Form 22 should be maintained and expressed in rates when possible. Further items to consider are:
A188.8.131.52. Transfusion data
A184.108.40.206. Medication usage
A220.127.116.11. Department specific
A7.2.3. Utilization data. Include appropriate data on usage of high cost resources such as CT, MRI, high cost medications, bloo.
A7.2.4. Risk management data. Synopsis of mortality and morbidity reviews, incident reports, serious events, malpractice claims, and applicable peer review materials should be included.
A7.2.5. Patient generated data. Commendations/complaints with relevant reviews attached.
A7.2.6. Other information:
A18.104.22.168. Letters of appointment to staff positions/committee duties
A22.214.171.124. Copy of curriculum vitae including any publications
A126.96.36.199. Administrative data: rate of chart delinquency, documentation deficiencies, etc.
A188.8.131.52. Participation in activities of benefit to military medicine
A184.108.40.206. Teaching activities
A7.3. The specific clinical service needs to determine which parameters are most useful to assess the provider's performance. So.
A7.4. The PAF must be kept secure (locked drawer/room, same as PCF). Providers may review the information in their PAF only unde.
Attachment 8 LETTER FORMAT FOR INFORMING AN INDIVIDUAL OF IMPLICATIONS OF SEPARATING OR CHANGING DUTY STATIONS WHILE UNDER REVIEW
Attachment 9 REPORTABLE ACTIONS OF MISCONDUCT FOR DOD HEALTHCARE PRACTITIONERS
A9.1. The following misconduct actions shall be reported, as appropriate, to the Surgeon General, the Federation of State Medica.
A9.1.1. Misconduct Actions to be Reported After Due Process, Command Action, and Completion of Applicable Appeal Procedures
A220.127.116.11. Fraud or misrepresentation involving application for enlistment, commission, employment, or affiliation with DoD service that results in removal from service;
A18.104.22.168. Fraud or misrepresentation involving renewal of contract for professional employment, renewal of clinical privileges, or extension of Service obligation;
A22.214.171.124. Proof of cheating on a professional qualifying examination; and
A126.96.36.199. Abrogation of professional responsibility through any of the following actions:
A188.8.131.52.1. Deliberately making a false or misleading statement to patients as regards clinical skills or clinical privileges;
A184.108.40.206.2. Willfully or negligently violating the confidentiality between practitio ner and patient except as required by civilian or military law;
A220.127.116.11.3. Being found impaired by reason of drug abuse, alcohol abuse, or alco holism;
A18.104.22.168.4. Intentionally aiding or abetting the practice of medicine or dentistry by obviously incompetent or impaired persons;
A22.214.171.124.5. Commission of an act of sexual abuse or exploitation related to clini cal activities, or non-clinically related indi.
A126.96.36.199.6. Prescribing, selling, administering, or providing controlled substances as defined by 21 U.S.C. 801-977 [reference (.
A188.8.131.52.7. Failure to report to the privileging authority any disciplinary action taken by professional or governmental organizations;
A184.108.40.206.8. Failure to report to the privileging authority any malpractice awards, judgments, or settlements occurring outside of DoD facilities;
A220.127.116.11.9. Failure to report to the privileging authority any professional sanction taken by a civilian licensing agency or healthcare facility;
A18.104.22.168.10. Any violation of the Uniform Code of Military Justice [reference (e)] for which the member was awarded non judicial.
A22.214.171.124.11. Commission of any offense that is punishable in a civilian court of competent jurisdiction by a fine of more than $.
A9.1.2. Administrative Discharge. Discharge instead of court-martial or administrative dis charge while charged with an offense designated in this enclosure after command action and com pletion of applicable appeal procedures.
A9.1.3. Misconduct to be Reported Upon Referral for Trial by Courts-Martial or Indictment in a Civilian Court and Upon Final Verdict Adjudication or Administrative Disposition.
A126.96.36.199. Offenses punishable by a fine of more than $5,000 or confinement in excess of 1 year by the civilian jurisdiction in which the alleged offense occurred;
A188.8.131.52. Offenses punishable by confinement or imprisonment for more than 1 year under 10 U.S.C 801-940 (reference (e));
A184.108.40.206. Entry of a guilty or nolo contendere plea, or request for discharge instead of court-martial while charged with an offense designated in subsection A9.1.1. above.
A220.127.116.11. Committing an act of sexual abuse or exploitation in the practice of medicine, dentistry, nursing, or other professional practice of healthcare as may be designated by the ASD(HA);
A18.104.22.168. Inappropriately receiving compensation for treatment of patients eligible for care in DoD hospitals and,
A22.214.171.124. Possessing or using any drug legally classified as a controlled substance for other than acceptable therapeutic purposes.
Attachment 10 LETTER FORMAT FOR NOTIFICATION OF ABEYANCE OF CLINICAL PRIVILEGES
Attachment 11 LETTER FORMAT FOR NOTIFICATION OF CLINICAL PRIVILEGES SUMMARY SUSPENSION
Attachment 12 LETTER FORMAT FOR NOTIFICATION OF PROPOSED ADVERSE ACTION
Attachment 13 LETTER FORMAT FOR NOTIFICATION OF ADVERSE ACTION HEARING
Attachment 14 SAMPLE HEARING SCRIPT
Attachment 15 LETTER FORMAT FOR NOTIFICATION OF HEARING RECOMMENDATIONS
Attachment 16 LETTER FORMAT OF FINAL DECISION BY MEDICAL TREATMENT FACILITY COMMANDER
Attachment 17 ARRANGEMENT OF ADVERSE ACTION CASE FILE
Attachment 18 LETTER FORMAT NOTIFICATION FOR REMOVAL FROM PATIENT CARE DUTIES
Attachment 19 LETTER FORMAT FOR NOTIFICATION TO AFMOA/SG3OQ OF REPORTABLE ACTION
Attachment 20 LETTER FORMAT FOR NOTIFICATION TO INDIVIDUAL OF POTENTIAL HIPDB REPORT
Attachment 21 LETTER FORMAT FOR NOTIFICATION OF STANDARD OF CARE MET
Attachment 22 LETTER FORMAT FOR NOTIFICATION OF STANDARD OF CARE NOT MET
BUMED INSTRUCTION 6320.66E CHANGE TRANSMITTAL 5
From: Chief, Bureau of Medicine and Surgery
M. L. NATHAN
BUMED INSTRUCTION 6320.66E
From: Chief, Bureau of Medicine and Surgery
Table of Contents
CLINICAL PRIVILEGES FOR PHYSICIANS
BUMEDINST 6320.66E CH-5
11 Mar 2013
Allergy and innunolgy
BUMEDINST 6320.66E CH-5
BUMEDINST 6630.66E CH-5
CLINICAL PRIVILEGES FOR DENTISTS
BUMEDINST 6320.66E CH-5
BUMEDINST 6320.66E CH-5
CLINICAL PRIVILEGES FOR ALLIED HEALTH SPECIALISTS
CLINICAL PRIVILEGES FOR ADVANCED PRACTICE NURSES
(b) Evidence of competence and performance excellence as noted in recent performance recommendation for employer reflects.
(c) Evidence of continuous training in specialty area.
(d) Recommendation from relevant specialty leader.
(5) As educational systems evolve, some universities are not granting degrees specifically titled "nursing." Where these programs are not so titled, the relevant specialty leader will review and evaluate course content.
BUMED INSTRUCTION 6320.66E
From: Chief, Bureau of Medicine and Surgery
Credentialing as a Prescribing
Psychologist in the Military:
A Resource Manual
Fairleigh Dickinson University
M.S. Program in Clinical Psychopharmacology
We are grateful to a number of individuals who contributed to the completion of this manual. The views expressed in this publication are those of the authors and do not reflect the official policy of position of the Department of the Army, Department of the Air Force, Department of the Navy, Department of Defense, Public Health Service, Indian Health Service, the United States Government, or any other agency for which the authors are employed. The final content is the sole responsibility of the Fairleigh Dickinson University M.S. Program in Clinical Psychopharmacology.
Robert McGrath, Ph.D. Director, M.S. Program in Clinical Psychopharmacology School of Psychology Fairleigh Dickinson University Teaneck NJ 07666 Copyright 2014 Fairleigh Dickinson University
The first step in the process of getting credentialed to prescribe in the military, whether as a
civilian employee or active duty officer, is to familiarize yourself with the regulations governing
credentialing of prescribing psychologists in your branch. Attached to this document are the
Air Force psychologists should read p. 105 of Air Force Instruction 44-119 (Appendix A).
Army psychologists should read the February 13, 2009 memorandum for commanders of
MEDCOM Regional Medical Commands titled "Policy and Procedures for Credentialing and
Privileging Clinical Psychologists to Prescribe Medications" (Appendix B).
Navy psychologists should read p. G-7 of BUMED Instruction 6320.66E (Appendix C).
The Credentials Committee determines who gets credentialed to provide clinical services in a
medical treatment facility. The Medical Treatment Facility (MTF) Commander signs off on all
proposed actions of a Credentials Committee. The Credentials Committee for a military facility
is comprised of primarily physicians with representatives from the different specialties.
Frequently, the membership is comprised of department chiefs from the facility. For behavioral
health, there are some facilities that only have Psychiatry as a behavioral health voting member
of the Credentials Committee, while at other facilities the position may rotate among disciplines
or include representatives from the different behavioral health specialties. At times, some
behavioral health specialists may be allowed to attend and participate in the Committee, but do
not serve as voting members. The work of the Credentials Committee includes routine
presentation and approval of privileges for all providers in the facility and also reviews and takes
action on the privileges of providers whose actions have raised concerns. As such, Credentials
Committees have a responsibility for making the decision regarding whether and how a clinician
will practice in the MTF.
It is a good idea to connect with a supportive voting member of the Credentials Committee. The
first contact to be made is likely with your facility's senior psychologist. That senior
psychologist can then work to advocate for you. In the Marine Corps, that role is filled by a local
administrator responsible for gathering input for the committee. You want to ensure that this
contact understands and supports your request for privileges. (Share the appropriate document
from Appendices A-C.) If you will be working with a psychiatrist or social worker, you will
likely need to provide them with additional information on prescribing psychologists. If your
facility has not recently credentialed a psychologist for prescribing privileges it is highly
recommended that contact also be made with the Chair of the Credentials Committee
beforehand. (This should be through your identified contact. Remember, you always need to
work through your Chain of Command.) The Chair needs to understand that prescription
privileges are an established, appropriate privilege for appropriately trained psychologists.
Appendix D provides an Information Paper that you may use or modify as a means of
introducing relevant staff to the activities of the prescribing psychologist. This should be shared
widely. Each branch can have its own guidelines regarding formularies. Review the regulations
specific to your branch so that you can understand what is required. Appendix E provides an
example of a formulary that may be helpful to your during the credentialing process based on
Once you are credentialed at one facility, the path tends to be easier at subsequent placements.
Once you are credentialed at an MTF, when you go on to work at another facility your
Credentials file, with your privilege delineations, is transferred to the new facility. For this
reason, some people who have had trouble getting credentialed at their home facility have gotten
themselves credentialed during deployment to another facility, and this has eased the process
upon return to the original facility.
Some sites have refused to support application for a DEA number, instead insisting on obtaining
a DEA number through licensure as a prescribing psychologist at the state level. You will need
to talk with your credentialing point of contact with regard to current policy and practices for
obtaining a DEA certificate.
What can help the process more than anything else is consultation with others who have gone
through the process before. Appendix F provides a list of all prescribing psychologists and
psychologists who have undergone training to become a prescribing psychologist we have
identified in the military, including service, current facility, and all facilities in which they have
obtained credentialing. To help others in the future, if you find ANY errors in this document,
please bring it to our attention.
Air Force Instruction 44-119, p. 105
BY ORDER OF THE
AIR FORCE INSTRUCTION 44-119
SECRETARY OF THE AIR FORCE
24 SEPTEMBER 2007
MEDICAL QUALITY OPERATIONS
COMPLIANCE WITH THIS PUBLICATION IS MANDATORY
ACCESSIBILITY: Publications and forms are available for downloading or ordering on the
e-Publishing website at: .
RELEASABILITY: There are no releasability restrictions on this publication.
OPR: AFMOA/SG3OQ Certified
(Col Lawrence M. Riddles)
Supersedes AFI44-119, 4 June 2001
This instruction implements AFPD 44-1, Medical Operations, DoDD 6025.13-R, Clinical Quality Man-agement Program(CQMP) in the Military Health Services System (MHS), which incorporated DoDD6025.14, Department of Defense Participation in the National Practitioner Data Bank (NPDB), DoDI6040.37, Confidentiality of Medical Quality Assurance (QA) Records, DoDI 6025.15 Implementation ofDepartment of Defense Participation in the National Practitioner Data Bank; DoDI 6025.16, Portabilityof State Licensure for Health Care Professionals; DoDI 6025.17, Department of Defense (DoD) PatientSafety Program (PSP).
It outlines medical treatment facility (MTF) roles and responsibilities in the area of clinical performance
improvement (PI), explains patient safety and risk management (RM) programs, PI/accreditation/
self-inspection requirements, credentials and privileging processes, and scope of practice in order to pro-
vide optimal healthcare delivery. This instruction applies to all Air Force Medical Service (AFMS) per-
sonnel to include units of the Air Reserve Components (ARC) with the exception that the ARC are
exempt from the requirement for Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) accreditation and the annual PI/RM Summary. ARC Aeromedical Evacuation Squadrons
(AES) participating in actual patient care will comply with applicable ARC guidance. The reporting
requirement in paragraph 2.8.7. is exempt from licensing in accordance with (IAW) paragraph 2.11.12. of
AFI 33-324, The Information Collections and Reports Management Program; Controlling Internal, Pub-
lic, and Interagency Air Force Information Collections. This instruction directs collecting and maintain-
ing information protected by the Privacy Act of 1974 authorized by Title 10, United States Code (U.S.C.),
Section 8013, Secretary of the Air Force. Privacy Act system notice F044 AF SG K, Medical Professional
Staffing Records, applies. Ensure that all records created as a result of processes prescribed in this publi-
cation are maintained in accordance with AFMAN 37-123 (will convert to AFMAN 33-363), Manage-
ment of Records, and disposed of in accordance with the Air Force Records Disposition Schedule (RDS)
ed to be forwarded to higher
headquarters for review and coordination before publishing. Refer recommended changes and questions
about this publication to the Office of Primary Responsibility (OPR) using the AF IMT 847, Recommen-
AFI44-119 24 SEPTEMBER 2007
7.8. Clinical Psychologists:
7.8.1. Background. Clinical psychology is the discipline of professional psychology dedicated to thescientific understanding of factors operating in the etiology, maintenance, and potential change ofhuman behavior, habits, and lifestyles. Clinical psychologists are trained in providing health and men-tal health promotion programs for individuals and groups experiencing ongoing mental and physicalproblems.
7.8.2. Education and Licensure Requirements: Clinical psychologists must demonstrate appropriateskills, training, and experience to be considered for clinical privileges. Minimum educational require-ments include:
126.96.36.199. A doctor of philosophy (PhD) or a doctor of psychology (PsyD) degree in clinical, coun-seling, or combined professional-scientific psychology from a program accredited by the Ameri-can Psychological Association (APA). Waiver of this requirement (i.e., for graduates of regionallyaccredited universities or schools of professional psychology) must be staffed through AFMOA/SG3OQ.
188.8.131.52. An APA-accredited predoctoral internship in professional psychology (This 1-yearinternship is part of an APA-accredited doctoral program. The AF accepts this internship from anyAPA-accredited site including designated AF sites).
184.108.40.206. An optional postdoctoral fellowship allows for subspecialization in Operations/Aviationpsychology, child/adolescent psychology, health psychology, or neuropsychology.
220.127.116.11. Valid license to practice psychology from a US jurisdiction.
7.8.3. Scope of Practice. Clinical Psychologists:
18.104.22.168. Conduct clinical interviews and interpret psychological tests/assessments.
22.214.171.124. Diagnose mental disorders and formulate treatment plans.
126.96.36.199. Provide individual and group psychotherapy, hypnosis (See AFI 44-102), formal sextherapy (See AFI 44-102), and biofeedback (chief of the medical staff should review the pro-vider's credentials with the consultant for clinical psychology if they are unfamiliar with the cre-dentials requirements).
188.8.131.52. Recommend administrative and medical dispositions.
184.108.40.206. Perform neuropsychological screening.
220.127.116.11. Perform comprehensive neuropsychological evaluations (must have postdoctoral fellow-ship training as described above).
18.104.22.168. Admit, treat, and discharge patients (with physician oversight) to/from inpatient unitswith mental health capability.
22.214.171.124. Admit/discharge patients to/from substance abuse rehabilitation centers.
126.96.36.199. Makes recommendations to medical evaluation boards when requested.
188.8.131.52. Determine the degree of impairment for military service and for civilian social andindustrial adaptability due to mental disorders.
184.108.40.206. Perform safety and risk assessments.
AFI44-119 24 SEPTEMBER 2007
220.127.116.11. Serve on competency and sanity boards.
18.104.22.168. Certify stability for the sensitive duty programs such as PRP, security clearances, andspecial access.
22.214.171.124. Assess for mental competency when administrative or legal matters arise.
126.96.36.199. Perform commander-directed mental health evaluations (CDEs) and act as behavioralhealth consultants to commanders and first sergeants.
188.8.131.52. Serve on aircraft mishap investigation boards (must have completed appropriate trainingprogram such as Air Force Aircraft Mishap Investigation and Prevention Course).
184.108.40.206. Those clinical psychologists designated by the HQ USAF/SG, who participated in theDoD Psychopharmacology Demonstration Project (PDP) and were thereby granted prescriptiveauthority, may continue to have prescriptive authority for the remainder of their tenure with theAFMS. Prescriptive authority may also be granted to fully qualified psychologists who have com-pleted a Master's Degree in clinical psychopharmacology, successfully passed the Psychopharma-cology Exam for Psychologist (PEP), and who have received a minimum of one yearof documented supervision. Supervision must be provided by a psychiatrist or a psychologist withprescriptive authority.
220.127.116.11. May act independently in areas of demonstrated competency within their designatedscope of practice, as indicated by code "1" on their privileges list.
18.104.22.168. As with any privileged provider, an ongoing, proactive peer review process (as outlined performance is required at least biennially as part ofthe competency-based privileging process. Examples of competency assessment include periodicreview of a representative sample of medical records, direct observation of performance, and ver-bal/written assessment of clinical knowledge/skills.
22.214.171.124. Unlicensed clinical psychologists who have completed their doctorate:
126.96.36.199.1. May be granted supervised privileges.
188.8.131.52.2. Are supervised by a fully qualified licensed provider who will establish a plan ofsupervision based on the unlicensed psychologist's skills and needs. As a minimum, the super-visor will meet with the unlicensed psychologist for at least one hour every week.
184.108.40.206.3. Supervision can be obtained from any one of the following (listed in order of pref-erence):
220.127.116.11.3.1. A privileged mental health provider at the MTF, including a reservist, ifassigned, or
18.104.22.168.3.2. A licensed provider at a nearby VA facility or a nearby MTF, or
22.214.171.124.3.3. A licensed civilian psychologist in the local community.
126.96.36.199.4. NOTE: As described in , the clinical supervisor must be a provider who
has regular privileges in the scope of practice for which he or she is supervising. EXCEP-
TION: A VA provider or civilian psychologist shall have full credentials review as a consult-
ant, as described in paragraph
Policy and Procedures for Credentialing and Privileging
Clinical Psychologists to Prescribe Medications
Navy BUMED Instruction 6320.66E, p. G-7
BUMEDINST 6320.66E CH-5
(5) Approval to perform LA as "physician extenders" under a defined scope of
practice shall be granted to licensed acupuncturists encompassing those disorders associated with their practice and treatable by acupuncture as per Navy Medicine policy on approved indications as detailed above in Section E, paragraph 6c, "Criteria for supplemental privileges for physician medical acupuncture."
(6) The following acupuncture techniques are authorized for performance by
licensed acupuncturists (as long as the technique(s) falls within the scope of practice of their state license): neurofunctional acupuncture, electroacupuncture, dry needling, and auricular acupuncture. Licensed acupuncturists may apply for approval to perform additional acupuncture techniques.
(7) Ongoing assessment of practitioner performance is a requirement in
continued granting of approval/certification to perform LA. Practitioner-specific data required for the assessment includes results of peer review activities. For the purpose of peer review for a licensed acupuncturist, any physician acupuncturist currently privileged and practicing in the Navy may serve as a peer reviewer. Additional peer review by a licensed acupuncturist currently privileged and practicing in the Navy is desirable. 7. Additional requirements for clinical psychologists. The following must be documented before granting the indicated supplemental privileges:
a. To prescribe and dispense psychotropic medications. Requires completion of
five of the American Psychological Association (APA) recommended training in psycho-harmacology. Successful passage of the Psychopharmacology Examination for Psychologists from the APAs College of Professional Psychology. This privilege allows the psychologist to prescribe and dispense psychotropic and adjunctive medications.
b. The admission of patients
(1) Clinical psychologists may admit patients to the hospital only if a physician
member of the active medical staff conducts or directly supervises the admitting medical history and conducts the physical examination. All patients admitted for care by clinical psychologists shall receive the same basic medical appraisal as patients admitted to other departments or services.
(2) The physician assumes responsibility for the care of the patient's medical
problems which are outside the psychologist's scope of practice both at the time of admission and during hospitalization.
Sample Information Paper on
14 September 2014
SUBJECT: Prescribing Psychologists 1. Purpose: To provide information about the education, training, and practice of prescribing psychologists. 2. Facts: a. Postdoctoral trained psychologists have been successfully prescribing for approximately 20 years. The states of New Mexico, Louisiana, and Illinois have requirements for certifying and licensing prescribing psychologists. Psychologists are also currently prescribing within the Indian Health Service and U.S. Public Health Service. b. Doctoral level clinical psychologists with prescribing privileges have advanced education and training that addresses the indications, contraindications, side effects, potential drug interactions and dosage parameters associated with psychotropic medications. c. Prescribing psychologists typically have completed a postdoctoral master's degree in psychopharmacology, engaged in psychopharmacological practice under the supervision of a physician, and passed a national qualifying examination. d. The Air Force, Army, and Navy have official guidance regarding the education, training, and credentialing of prescribing psychologists
1. Air Force Instruction 44-119;
2. Army MEDCOM Memo, 13 FEB 2009, Policy and Procedures for Credentialing and
Privileging Clinical Psychologists to Prescribe Medications;
3. Navy BUMED Instruction 6320.66D.
e. Psychologists are currently prescribing in all branches of the military and there are mechanisms in place allowing for credentialing of these specialty providers. 3. Discussion: Prescribing psychologists have been providing pharmacological services to civilians and service members safely and effectively for the past two decades. Their unique perspective on behavioral health issues allows them to use psychiatric medications when indicated and discontinue medications when non-medication treatments are determined to be the appropriate first-line intervention.
JOHN DOE, PH.D. Clinical Psychologist, 1st Clinic
Sample Army Formulary
MEMORANDUM THRU Director, XXXXX FOR Chief, Department of Pharmacy SUBJECT: Authorized Medication List for XXXX Psychologist to Prescribe 1. IAW AR 40-68, 7-2c and MEDCOM Memo, 13 FEB 2009, Policy and Procedures for
Credentialing and Privileging Clinical Psychologists to Prescribe Medications, Clinical Psychologists may write prescriptions for drugs approved by the XXXX Pharmacy and Therapeutics Committee. The drug classes typically prescribed by Clinical Psychologists are found in enclosure one and include: antidepressants, antipsychotics, anticonvulsants used for psychiatric conditions, benzodiazepines, ADHD/narcolepsy drugs, and miscellaneous drugs. Additional classes of medications to augment enclosure one as requested by Dr. XXXXX, a Clinical Psychologist privileged as "fully competent" to prescribe psychotropic medications, are found in enclosure two and include: sedative hypnotics (e.g., zolpidem, eszopiclone, ramelteon), anxiolytics (e.g., buspirone, hydroxyzine), mood stabilizers (e.g., lithium) and other miscellaneous drugs commonly used off-label in psychiatric practice.
2. Clinical Psychologists with prescribing privileges have advanced education and training that
addresses the indications, contraindications, potential drug interactions and dosage parameters associated with each of the above drug classes. At a minimum, clinical psychologists with prescribing privileges have a postdoctoral masters degree in psychopharmacology from a regionally accredited university, passed the Psychopharmacology Examination for Psychologists, and completed one year of supervision from a board-certified Psychiatrist or Psychologist with prescribing privileges. In addition, case and peer review and a portion of continuing education specific to psychopharmacology are required.
3. POCs for this action are Drs. XXXX and XXXX, XXXXX and can be reached at xxx-xxx-xxxx.
Insert Army Memorandum Here (see Appendix B)
Enclosure 2: Augmentation to Prescribing Psychologist Formulary
Drugs by Class:
Sedative hypnotics (e.g., zolpidem, eszopiclone, ramelteon)
Anxiolytics (e.g., buspirone, hydroxyzine)
Mood stabilizers (e.g., lithium)
Other medications commonly used off-label in psychiatric practice, to include, but not limited to:
These individuals either are in training to become prescribing psychologists, have completed training, or have been credentialed as prescribing psychologists in the military. PLEASE NOTE: We cannot guarantee the currency of this information.
COL Debra Dunivin
Dr. Alan Hopewell
Dr. David Shearer
Dr. Laurence Perotti
Dr. Bret A. Moore
MAJ David R. Miller
Dr. Brian Seavey
CAPT Shamecca Scott
MAJ Michelle Miller
[email protected] Bethesda, MD
CAPT Robert Younger
CDR Roderick Bacho
CDR Julie Miller
LCDR Adeline Ong
Naval Medical Center, San Diego
LT COL Ruth Roa-Navarrete [email protected]
COL Rob Rottschafer
MAJ Mikel Merritt
CAPT Rafael Salas
LCDR James Tyson
MAJ Jill E. Breitbach
CDR Bithiah Reed
CDR Michael Tilus
LCDR Sharyl Trail
US Naval Academy
CDR Anthony Tranchita
CAPT Kevin McGuinness
Qualtrics Survey Software ROTARY RESPONSIBLE BUSINESS AWARD Default Question Block Submission Deadline: Friday 29 July In keeping with the international community's current conversation about the need for inclusive economic development and in recognition of the important role that businesses play in advancing economic conditions around the world, Rotary will honor six individual Rotary members and two business partners with our first Rotary Responsible Business Award during Rotary Day at the United Nations on Saturday 12 November 2016.
In silico Docking Study of Active Constituents Identified in Morinda Citrifolia Linn as Enzyme targets of Alzheimer's Disease J. Srikanth1, S. Kavimani2, and C. Uma Maheswara Reddy1 1Department of Pharmacology, Faculty of Pharmacy, Sri Ramachandra University, Porur, Chennai – 600 116, Tamil Nadu, India