Army Regulation 4068

Medical Services

Clinical Quality Management

Rapid Action Revision (RAR) ssue !ate" ## May #00$

%ead&uarters !epartment o' t(e Army )as(ington* !C #6 +e,ruary #004

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SUMMARY of CHANGE
AR 4068 Clinical Quality Management This rapid action revision, dated May 00!""

#sta$lishes speci%ic responsi$ilities %or credentialing %unctions $y Army Reserve Clinical Credentialing A%%airs, &uman Resources Command" 't()ouis, and Active Army units *para +"4h,( Replaces all content in chapter -ith ne- guidance regarding the #.ecutive Committee o% the Medical 'ta%%/ medical sta%% $yla-s/ military treatment %acility committees and %unctions/ and departmental0service organi1ation, structure, and leadership *chap ,( #liminates the re2uirement to su$mit the annual military treatment %acility Quality Management 3rogram 'ummary Report to the 4('( Army Medical Command *previously covered in chap ,( 5denti%ies the American 6urses Association 'tandards o% 6ursing 3ractice or other national pro%essional organi1ations7 standards as the source o% practice e.pectations *para 8"8b*9,,( Relocates in%ormation regarding con%identiality o% 2uality assurance documents %rom paragraph ": to chapter 8 *para 8"9,( Re2uires veterinarians to maintain a current, active, valid, and unrestricted license to practice independently -ithin their de%ined scope o% practice *para 4"4a*+,,( 'peci%ies the educational preparation $y an accredited institution %or military and civilian registered nurses and licensed practical nurses and re2uires the 6ational Council )icensure #.amination" Registered 6urses0 3ractical 6urses %or the military Army 6urse Corps and 68;M60M8 *para 4"6c,( Restates the re2uirement %or an unrestricted license *all Corps, and e.plains the process %or limited -aiver0e.ception *paras 4"6g and 4"9,( Clari%ies the licensure re2uirement %or personal services versus non"personal services contract healthcare personnel *para 4"8a,( 'peci%ies the use o% <A =orms 96:8 and 96:4 %or competency veri%ication o% Army 6urses Corps personnel -ith s>ill identi%ier 8A *Critical Care, and M: *#mergency 6ursing, *para :"+a*+,*$,,( Re2uires currency o% emergency li%e support training at all times *para :" +e,( <eletes the re2uirement %or the advanced practice registered nurse, other than the non"personal services advanced practice registered nurse, to possess and maintain advanced practice licensure *para 9"4b* ,,(

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Restates the colla$orative interaction re2uired $et-een the certi%ied registered nurse anesthetist and anesthesiologist or operating surgeon *para 9"4e*4,*a,"*c,,( Authori1es selected prescription -riting $y occupational therapists *para 9" +8c* ,*a,*6,,( 4pdates pro%essional credentials re2uirements %or physician assistants *para 9"+6b,( Clari%ies Category 5 and 55 privileges %or physical therapists *para 9"+9c,( 3rovides +0 4'C ++0 protection to all documents in the provider credential %ile and the provider activity %ile *paras 8"8b* ,*c, and 8"!a,( 'tipulates that the chairperson o% the credentials committee -ill $e a physician and that he0she -ill vote only in event o% a tie *paras 8":b and 8" :c*:,( 5ndicates that the responsi$ility %or credentials veri%ication %or contracted personnel -ill $e speci%ied in the contract *para 8"6d,( Allo-s use o% the American ?oard o% Medical 'pecialties ;e$ site to veri%y $oard certi%ication *para 8"9d,( #.empts providers outside the continental 4nited 'tates %rom the re2uirement o% a current <rug #n%orcement Agency certi%icate *para 8"9k,( <irects that 2uali%ied healthcare 3rovider 5denti%ier *para 8"9r,( 3rovides *para !" detailed in%ormation c*9,*a,,( providers to o$tain a 6ational procedures

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related

telemedicine

<irects the military treatment %acility credentials o%%ice to maintain the provider credential %ile %or any assigned provider not currently involved in clinical practice *para !"6b,( 3rovides ne- instruction %or 4('( Army Reserve0Army 6ational @uard deployment privileging *para !"8c*4,*d,,( Clari%ies that peer revie- %or an adverse privileging0practice action $e per%ormed $y a panel *para +0"6e* ,*c,,( Re2uires that a physician chair the adverse actions hearing $oard *para +0" 8a, and that he0she -ill vote only in the event o% a tie *para +0"8g,( #liminates the re2uirement %or ver$atim transcript o% the adverse actions hearing $oard *para +0"8e*8,,( 'tates that the voluntary modi%ication o% privileges0practice as a result o% a medical or $ehavioral condition is not an adverse privileging0practice action *para ++"4c,(

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Revises the ris> management content entirety and omits re%erence to the no- dis$anded Consultation Case Revie- ?ranch *paras +8"+ through +8":,( 'peci%ies that any death0disa$ility o% a military mem$er as a result o% medical care -ill $e treated as a potentially compensa$le event *para +8":b,( Revises the layout and contents o% the competency assessment %ile *app C,( Ma>e additional rapid action revision changes *chaps 6, 9, 8, !, +0, ++, +8,+4, and apps #, =, @, &, 5, A,(

%ead&uarters !epartment o' t(e Army )as(ington* !C #6 +e,ruary #004

1Army Regulation 4068

0''ective #6 Marc( #004 Medical Services

Clinical Quality Management

%istory2 This publication is a rapid action revision (RAR). This RAR is effective 29 June 2009. The portions affected by this RAR are listed in the summary of change. Summary2 This consolidated regulation prescribes policies procedures and responsibilities for the administration of the !linical "uality #anagement $rogram. %t includes &'& and statutory policies addressing medical services (uality management re(uirements. %n addition it implements &'& )02*.+,-R &'&& )000.+. and other &'& guidance. Applica,ility2 This regulation applies to the Active Army the Army /ational 0uard of the 1nited 2tates including pe riods 3hen operating in an Army /ational 0uard capacity and 1.2. Army Reserve. This document applies in both the table of distribution and allo3ances and table of organi4ation and e(uipment environments. %t applies to all personnel (Active Army Army /ational 0uard of the 1nited 2tates the 1.2. Army Reserve civilian employees contract personnel and foreign national local hires) 3ho 3or5 3ithin medical department activities medical centers dental activities and organi4ations for 3hich the Army #edical &epartment is the responsible official. This p u b l i c a t i o n i s a p p l i c a b l e d u r i n g mobili4ation. 3roponent and e4ception aut(ority2 The proponent of this regulation is The 2urgeon 0eneral. The proponent has the authority to approve e6ceptions or 3aivers to this regulation that are consistent 3ith controlling la3 and regulations. The pro ponent may delegate this approval authority in 3riting to a division chief 3ithin the proponent agency or a direct reporting unit or field operating agency in the grade of colonel or the civilian e(uivalent. Activities may re(uest a 3aiver to this regulation by providing 7ustification that includes a full analysis of the e6pected benefits and must include formal revie3 by the activity8s senior legal officer. All 3aiver re(uests 3ill be endorsed by the commander or senior leader of the re(uesting activity and for3arded through their higher head(uarters to the policy proponent. Refer to AR 2*-,0 for specific guidance. Army management control process2 This regulation contains management control provisions and identifies 5ey management controls that must be evaluated. (2ee appendi6 J.) S u p p l e m e n t a t i o n 2 2upplementation of this regulation and establishment of command and local forms are prohibited 3ithout prior approval from The 2urgeon 0eneral (&A20-92:) *+09 ;eesburg $i5e <alls !hurch =A 220.+-,2*>. Suggested improvements2 1sers are invited to send comments and suggested improvements on &A <orm 202> (Recom mended !hanges to $ublications and ?lan5 <orms) directly to 'ffice of The 2urgeon 0eneral (&A20-92:) *+09 ;eesburg $i5e <alls !hurch =A 220.+-,2*>. !istri,ution2 This publication is available in electronic media only and is intended for command levels ? ! & and @ for the Active ArmyA ! & and @ for the Army /ational 0uard of the 1nited 2tatesA and ? ! & and @ for the 1. 2. Army Reserve.

Contents

(Listed by paragraph and page number)

C(apter 5 ntroduction* page 1 $urpose B +-+ page 1 References B +-2 page 1 @6planation of abbreviations and terms B +-, page 1

*This regulation supersedes AR 4068, dated 6 !ebruary 004" This regulation supersedes Army Regulation 4068, dated 0 #e$ember %&8&, and Army Regulation 4048, dated ' (o)ember 000" *t res$inds #A !orms +440%'R, +440 'R, and +44% 'R, dated ,une %&&%- and #A !orms +440 6%R, +440 6 R +44%%'R, +44% 6%R, +44% 6 R, and +'+.R, dated ,uly %&8&" (#A !orms +440 6.R and +44% 6.R /ere res$inded in ,une %&&+") This edition publishes a rapid a$tion re)ision"

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Contents6Continued Responsibilities B +-. page 1 C(apter # Medical Sta'' and Military 7reatment +acility Committee Structure and +unctions* page 6 0eneral B 2-+ page 6 #edical staff byla3s B 2-2 page 7 #ilitary treatment facility departmental structure and leadership B 2-, page 7 @6ecutive committee of the medical staff B 2-. page 7 #edical staff participation in performance improvement activities B 2-* page 8 'ther military treatment facility organi4ational functions and committees B 2-) page 8 C(apter 8 7(e Clinical Quality Management 3rogram and 9rgani:ational 3er'ormance mprovement* page 9 The !linical "uality #anagement $rogram B ,-+ page 9 $rocesses and functions re(uiring measurement B ,-2 page 9 $erformance improvement data sources and analyses B ,-, page 9 $erformance improvement activities in the facility8s 3ritten plan B ,-. page 10 <acility accreditation B ,-* page 10 $atient rights and responsibilities B ,-) page 11 !onfidentiality of (uality assurance documents and records B ,-C page 11 C(apter 4 /icensure* Certi'ication* and;or Registration o' %ealt( Care 3ro'essionals* page 11 $olicy B .-+ page 11 2cope of licensure re(uirement B .-2 page 11 ?asic licensure certification registration criteria B .-, page 12 $rofessional disciplines re(uiring license certification andDor registration B .-. page 12 $rofessional responsibility regarding licensure B .-* page 13 0uidance on licensure re(uirements B .-) page 14 @6ceptions to the re(uirement for unrestricted license B .-C page 15 !ontract privileged providers B .-> page 15 %nternational health care graduates B .-9 page 16 <ailure to obtain or maintain a license certification andDor registration B .-+0 page 16 C(apter < Competency Assessment* !elegation* and Supervision o' 3ractice* page 17 !ompetency assessment B *-+ page 17 &elegation B *-2 page 21 2upervision of practice B *-, page 21 C(apter 6 7(e 3eer Revie= 3rocess* page 24 0eneral B )-+ page 24 The peer revie3 function B )-2 page 24 !omposition of peer revie3 board B )-, page 24 The intent of peer revie3 B )-. page 24 !onducting the peer revie3 B )-* page 25 Recommendations and follo3up reporting B )-) page 25 C(apter > 3rivileged %ealt( Care 3roviders* page 25 0eneral B C-+ page 25 !linical practice B C-2 page 26 !linical performance revie3 B C-, page 27 Advanced practice registered nurse B C-. page 27 Audiologist B C-* page 30
ii AR 4068 0 6 !ebruary 004

Contents6Continued ?ehavioral health practitioner B C-) page 30 !hiropractor B C-C page 31 !linical pharmacist B C-> page 32 !linical psychologist B C-9 page 33 !linical social 3or5er B C-+0 page 34 &entist B C-++ page 35 &ietitian B C-+2 page 35 'ccupational therapist B C-+, page 36 'ptometrist B C-+. page 37 $hysician B C-+* page 38 $hysician assistant and specialty physician assistant B C-+) page 38 $hysical therapist B C-+C page 42 $odiatrist B C-+> page 43 $sychological associate B C-+9 page 43 2peech pathologist B C-20 page 44 C(apter 8 Credentials Revie=* page 45 0eneral B >-+ page 45 !redentials authentication for military accessions B >-2 page 45 #ilitary treatment facility authentication of professional credentials B >-, page 46 $rivileged provider credentialing B >-. page 47 #ilitary treatment facility credentials committeeDfunction B >-* page 47 $rovider credentials verification B >-) page 49 $rovider credentials file B >-C page 50 $revious e6perience and reference chec5s B >-> page 52 $rovider activity file B >-9 page 52 The interEfacility credentials transfer brief B >-+0 page 53 The interEfacility credentials transfer brief and 12ARDAR/0 training B >-++ page 53 12ARDAR/0 credentials and privileging for activationDmobili4ation B >-+2 page 54 C(apter $ 7(e 3rivileging 3rocess and Medical Sta'' Appointment* page 55 0eneral B 9-+ page 55 $ractitioners 3ho may be privileged B 9-2 page 56 !ategories of clinical privileges B 9-, page 58 The clinical privileging process B 9-. page 59 #edicalDdental staff appointment B 9-* page 65 $rovider privileging for temporary duty and other actions involving the provider credentials file B 9-) page 67 2eparation of privileged providers B 9-C page 67 12ARDAR/0 privileging procedures B 9-> page 68 C(apter 50 Adverse Clinical 3rivileging;3ractice Actions* page 71 0eneral B +0-+ page 71 !ommand responsibility B +0-2 page 71 !onsultation and coordination regarding adverse privilegingDpractice actions B +0-, page 72 Appropriate use of adverse privilegingDpractice actions B +0-. page 72 'ther considerations related to adverse privilegingDpractice actions B +0-* page 73 %nvo5ing an adverse privilegingDpractice action B +0-) page 74 $rovider hearing rights B +0-C page 78 9earing board procedures B +0-> page 78 Action on hearing recommendations B +0-9 page 80 The appeals process B +0-+0 page 80 !ivilian training B +0-++ page 81

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Contents6Continued 2eparation from <ederal service B +0-+2 page 81 2eparation of a criminally charged provider B +0-+, page 82 Reporting adverse privilegingDpractice action activities B +0-+. page 82 Reportable acts of unprofessional conduct B +0-+* page 83 12ARDAR/0 providerDprofessional adverse privilegingDpractice actions B +0-+) page 83 C(apter 55 Managing Military 7reatment +acility 3ersonnel =it( mpairments* page 94 0eneral B ++-+ page 94 The %mpaired 9ealthcare $ersonnel $rogram B ++-2 page 94 The composition role and function of the impaired healthcare personnel ad hoc committee B ++-, page 95 #anagement of healthcare personnel impaired by medical psychiatric or emotional problems B ++-. page 96 #anagement of healthcare personnel impaired by alcoholDother drug abuseDdependence B ++-* page 96 /otification re(uirements B ++-) page 101 Revie3 of /ational $ractitioner &ata ?an5 (uery and licensing information B ++-C page 101 C(apter 5# 3atient Sa'ety in t(e %ealt(care Setting* page 102 0eneral B +2-+ page 102 2afety associated 3ith patient care B +2-2 page 102 The $atient 2afety $rogram B +2-, page 102 #anagement of an adverse event or close call B +2-. page 103 #anagement of a sentinel event B +2-* page 105 The $2 committeeDfunction B +2-) page 105 $roduct liability and the 2afe #edical &evice Act of +990 B +2-C page 106 $atients 3ho leave the military treatment facility setting prior to completion of care B +2-> page 106 Role of 12A#@&!'# "uality #anagement &ivision B +2-9 page 107 !onfidentiality B +2-+0 page 107 C(apter 58 Ris? Management* page 108 0eneral B +,-+ page 108 #ilitary treatment facility and 1.2. Army #edical !ommand ris5 management activitiesDresponsibilities B +,-2 page 108 The military treatment facility ris5 management committee B +,-, page 108 #anaging the potentially compensable event B +,-. page 109 $eer revie3 of a potentially compensable event B +,-* page 110 #anaging the medical malpractice claim B +,-) page 111 #anagement of medicalDdental records B +,-C page 113 C(apter 54 Reporting and Releasing Adverse 3rivileging;3ractice or Malpractice n'ormation* page 113 0eneral B +.-+ page 113 #ilitary treatment facility responsibilities for providing information B +.-2 page 114 The 2urgeon 0eneral responsibilities in reportable actions B +.-, page 114 The 9ealthcare %ntegrity and $rotection &ata ?an5 B +.-. page 115 Appendi4es

A. ?. !. &. @. <.
i)

References page 117 "uality Assurance ("A) !onfidentiality 2tatute for the &'& page 128 !ompetency Assessment <ile page 130 2pecial <orces #edical 2ergeants8 (+>&) 2cope of $ractice in A#@&& #T<s page 131 $rovider !redentials <ile page 132 $reE2election $rocedures for /onE#ilitary 9ealth !are $ersonnel page 134
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Contents6Continued

0. 9. %. J.

$rovider Activity <ile page 136 %nterE<acility !redentials Transfer ?rief $reparation %nstructions page 137 Reportable Acts of #isconductD1nprofessional !onduct for &'& 9ealth !are $ersonnel page 140 #anagement !ontrol @valuation !hec5list page 141

+igure /ist <igure >-+F 2ample format for re(uest of ne3 accessions credentials from 12AR@! (92&) page 55 <igure 9-+F 2ample format for memorandum notifying provider of clinical privileges and medical staff appointment status page 70 <igure 9-2F 2ample format for provider memorandum ac5no3ledging clinical privileges and staff appointment status page 71 <igure +0-+ ($A0@ +)F 2ample format for memorandum notifying provider of an abeyance or summary suspension page 85 <igure +0-+ ($A0@ 2)F 2ample format for memorandum notifying provider of an abeyance or summary suspensionG !ontinued page 86 <igure +0-2F 2ample format for provider memorandum ac5no3ledging notification of abeyanceDsummary suspension page 86 <igure +0-, ($A0@ +)F 2ample format for memorandum notifying providerDprofessional of a forthcoming peer revie3 page 87 <igure +0-, ($A0@ 2)F 2ample format for memorandum notifying providerDprofessional of a forthcoming peer revie3G !ontinued page 88 <igure +0-. ($A0@ +)F 2ample format for memorandum notifying provider of a proposed adverse privilegingD practice action page 89 <igure +0-. ($A0@ 2)F 2ample format for memorandum notifying provider of a proposed adverse privilegingD practice actionG!ontinued page 90 <igure +0-*F 2ample format for provider memorandum ac5no3ledging notification of proposed adverse privilegingD practice action page 90 <igure +0-) ($A0@ +)F 2ample format for memorandum notifying providerDprofessional of credentialsDother board hearing page 91 <igure +0-) ($A0@ 2)F 2ample format for memorandum notifying providerDprofessional of credentialsDother board hearingG!ontinued page 92 <igure +0-CF 2ample format for provider memorandum ac5no3ledging notification of credentialsDother board hearing page 92 <igure +0->F 2ample format for memorandum notifying provider of hearing board findingsDrecommendations page 93 <igure +0-9F 2ample format for provider memorandum ac5no3ledging receipt of hearing board findingsD recommendations page 94 @lossary

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C(apter 5 ntroduction
552 3urpose This regulation establishes policies procedures and responsibilities for the administration of the Army #edical &epartment (A#@&&) !linical "uality #anagement $rogram (!"#$). 5#2 Re'erences Re(uired and related publications and prescribed and referenced forms are listed in appendi6 A. 582 04planation o' a,,reviations and terms Abbreviations and special terms used in this regulation are e6plained in the glossary. 542 Responsi,ilities a. The Surgeon General. The 2urgeon 0eneral (T20) as the senior medical officer in the &epartment of Army (&A) isD3illG (+) Responsible for the (uality of health care delivered to all categories of beneficiaries. (2) @stablish !"#$ policy to implement &epartment of &efense (&'&) )02*.+,-R other applicable &'&&D &epartment of &efense %nstructions (&'&%s) and current accreditingDregulatory guidance. (,) Responsible for the (uality of care provided in all military treatment facilities (#T<s) 3ithin the A#@&&. 2erves as the governing body (0?) for health care facilities 3orld3ide. (.) The sole authority for reporting adverse privilegingDpractice actions and malpractice claims against providers to 2tate and other regulatory agencies and to the /ational $ractitioner &ata ?an5 (/$&?). (*) &elegate 0? authority to #T< commanders thus ma5ing them responsible and accountable for the (uality of health care provided in their treatment facilities. b. Commander, Un !ed S!a!e" #rm$ %e&ru ! ng Command. The !ommander 1nited 2tates Army Recruiting !ommand (12AR@!) isD3illG (+) @nsure adherence to re(uirements for selection commissioning and accession of health care professionals. (2) Responsible for primary source verification ($2=) of licensure or other authori4ing documents for the A#@&& ne3 accession as 3ell as collecting and for3arding these documents to the appropriate unit of assignment. &. U.S. #rm$ 'ed &al Command (US#')*C+', S!a-- .udge #d/o&a!e. The 1.2. Army #edical !ommand (12A#@&!'#) 2taff Judge Advocate (2JA) 3ill provide legal interpretation of and guidance related to the contents and application of this regulation. d. US#')*C+' 0n"pe&!or General. The 12A#@&!'# %nspector 0eneral (%0) 3ill conduct independent assessE ments of the issues related to the (uality of health care in the A#@&&. e. US#')*C+' 1ual !$ 'anagemen! * / " on "!a--. The 12A#@&!'# "uality #anagement &ivision ("#&) staff 3illG (+) @6ercise broad oversight responsibility for implementation of the A#@&& !"#$ as delegated by T20. (2) Represent T20 as a member of various committees and 3or5ing groups sponsored by the 'ffice of the Assistant 2ecretary of &efense for 9ealth Affairs ('A2&D9A) &epartment of &efense (&'&) and other health care (uality agencies. (,) $rovide corporateElevel clinical (uality management (!"#) guidance 3ithin the A#@&& to include policy on credentialing performanceEbased privileging outcomes management ('#) medical staff appointment and accreditation processes. (.) $rovide corporate guidance administrative andDor clinical advice consultation and education to define andDor clarify standards of care practice and policy. (*) Administer the corporate A#@&& $atient 2afety ($2) and Ris5 #anagement (R#) $rograms that include but are not be limited toF ris5 assessment ris5 avoidance safety practices incident monitoringDmanagement adverse privilegingDpractice actions sentinel events (2@s) and malpractice claims. ()) $rovide policy guidance consultation monitoring and revie3 of 2@s that occur 3ithin the A#@&&. (C) #onitor trends in processes and outcomes of care and report the results to both internal and e6ternal sources as appropriate. (>) !ollect aggregate A#@&& !"# data as re(uired by T20 'A2&D9A or other agencies. (9) 2erve as the corporate repository for select !"#$ data. (+0) %mplement the administrative procedures related to reporting adverse privilegingDpractice actions to appropriate national professional and 2tate licensure certification and registration agencies according to &'& guidance. (++) %mplement the administrative procedures related to reporting providers to the /$&? according to established &'& guidance.

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(+2) #aintain the A#@&& corporate contract 3ith The Joint !ommission (TJ!) or other accrediting agency as approved by the 'A2&(9A) and provide guidance on the accreditation processes. (+,) Responsible for $2= of selected documents as 3ell as collecting and for3arding to their gaining #T< (see chap >) initial credentials documents for deferred medical officers entering active duty (A&). -. Commander" o- ma2or "ubord na!e &ommand". !ommanders of ma7or subordinate commands (e6cept =eterinary !ommand) +>th #edical !ommand and !ommand 2urgeons of the Training and &octrine !ommand <orces !ommand 1.2. Army Reserve !ommand (12AR!) and /ational 0uard ?ureau areD3illG (+) Responsible for administration of this regulationA the effectiveness of the !"# $erformance %mprovement ($%) and R# $rograms in their subordinate unitsA and for tables of distribution and allo3ances (T&A) table of organi4ation and e(uipment (T'@) and modified T'@ units under their command. (2) !ontrol the e6tent of patient care services in those T&A and T'@ treatment facilities in their areas of responsibility. (,) @mploy (ualified %0 assets or sub7ect matter e6perts as necessary to conduct local (ualityEofEcare investigations. (.) @nsure integration of the 1.2. Army Reserve and Army /ational 0uard of the 1nited 2tates (12ARDAR/0) providerDprofessional issuesDactions into all aspects of the organi4ation8s !"#$. (*) Regional #edical !ommand (R#!) commanders 3ill provide input to and recommend modifications or corrections to the support plan as submitted by the T'@ commander for field patient care e6ercises 3ithin the R#! command area (see para (,) belo3) as re(uired. The R#! commander may delegate approval authority to the director of health services (&92). g. 'T3 &ommander". #T< commanders 3illG (+) #eet the appropriate re(uirements related to health care (uality management and (uality assurance as delineated in current published regulations statutes accreditation standards and &'&&sD&'&%s. (2) Approve the a3ard of medical and dental staff appointments for (ualified providers (any discipline) clinical privileges alterations in privileges adverse privileging actions and 3ritten notification of same to all military civilian contract and volunteer health care providers. (,) @nsure that a comprehensive integrated !"#$ is established in compliance 3ith this regulation. (.) Appoint one or more personnel (ualified by education training and e6perience to manage the !"#$ compoE nents as addressed in this regulation. (*) @nsure coordination of actions under appropriate regulations and the 1niform !ode of #ilitary Justice (1!#J) 3hen necessitated by findings under this regulation. ()) @mploy or re(uest from the R#!Dregional dental command (R&!) (ualified sub7ect matter e6perts as necessary to conduct local (ualityEofEcare investigations. (C) &esignate a chairperson for the credentials committeeDfunction. (>) &esignate membership of the committeeDfunction tas5ed to provide support and oversight of impaired health care personnel (%9!$) (previously the %mpaired 9ealthcare $rovider $rogram). (9) @nsure systematic credentials authentication and competency assessment for all health care personnel. This includes $2= of all licensure certification registration andDor other authori4ing documents re(uired for practice prior to employment. (+0) @nsure that interactive collaboration is maintained 3ith civilian agencies involved in e6ternal resource sharing agreements to communicate credentialing and privileging information. (++) @nsure the organi4ation is in continuous compliance 3ith current TJ! standards and other regulatoryDaccreditation re(uirements as appropriate. <or TJ! purposes the medical commander is the delegated authority to represent the 0? at the local level. (+2) @nsure implementation of an integrated $atient 2afety $rogram ($2$) throughout the organi4ation. (+,) $rovide opportunities for integration of 12ARDAR/0 T&A careta5er hospital health care personnel into all aspects of the facilityEspecific !"# processesDfunctions. (+.) A3ard appropriate practice privileges to 12ARDAR/0 providers upon the revie3 of interEfacility credentials transfer briefs (%!T?s) and re(uired privileging documentation from civilian health care organi4ations. !urrent compeE tency in the duty area of concentration (A'!) andDor specialty s5ill must be ensured before granting or rene3ing privileges for 12ARDAR/0 providers 3ho do not currently hold comparable privileges 3ithin their Reserve unit. (+*) As &92 coordinate 3ith the T'@ commander for the provision of health care and services during training e6ercises. (+)) @nsure that an optimal professional relationship e6ists among all healthcare providers in the facility. h. US#% and #%4G S!a!e Surgeon". <or the 12AR Army Reserve !linical !redentialing Affairs (AR!!A) performs the !"#$ procedures noted belo3 for providers in T$1sA 9R!E2t. ;ouis is responsible for these activities for %RR 2oldiersA and for %#A providers assigned to AA units the AA medicalDdental unit performs these functions. <or the AR/0 2tate 2urgeons are responsible for the administration of the policies contained in this regulation. The above named authorities are re(uired to establish $% programs 3ithin their respective commands and 3illG (+) &esignate a !"#$ manager.
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(2) @stablish a credentials committeeDfunction and ensure systematic credentials verification and competency assessE ment for all health care professionals. This includes authentication of all licensure certification registration andDor other authori4ing documents re(uired for practice. (,) @stablish and maintain provider credentials files ($!<s). (.) $rovide complete and current %!T?s for revie3 by the serviced #T<. (*) A3ard privileges (12AR medical unit commandersDAR/0 2tate 2urgeons) to assigned healthcare providers involved in delivering health care to eligible beneficiaries during unitEcontrolled inactive duty training (%&T) and annual training (AT) activities. @6amples of these activities include physical e6aminations immuni4ations dental e6aminations 2oldier readiness processing field e6ercises and medical support missions. !linical privileging for medical treatment provided during %&T is limited to acute and emergent care only. /'T@F 12AR providers 3ho perform %&T or AT at an AA #T< 3ill be privileged by that #T<. . Commander" o- T+) and mod - ed T+) un !". !ommanders of T'@ and modified T'@ units 3illG (+) &uring training e6ercises establish an open dialogue for coordination of health care and services 3ith the &92 for the area of operations. (2) $ropose a scope of serviceDpractice for the unit to the &92 specifying as a minimum the follo3ing elementsF (a) Types and ages of patients served. (b) The appropriateness clinical necessity and timeliness of support services to be provided directly by the hospital or through referral contracts. (c) The availability of necessary staff to provide care. (d) The e6tent to 3hich the level of care or service provided meets patients8 needs. (e) $ractice based on recogni4ed standards of medical care or clinical practice guidelines 3here these are in use. (f) The e6tent to 3hich the facility 3ill be operational and proposed staffing 3hile operational. (,) %n coordination 3ith the &92 establish a plan that includes both the T'@ unit8s scope of services and the professional support and bac5up to be provided by the coElocated T&A unit. (.) <or3ard the plan in (,) above for approval to the R#! commander. 2. +!her 'T3 per"onnel. (+) *epu!$ &ommander -or &l n &al "er/ &e" (*CCS,. The &!!2 isD3illG (a) A privileged physician holding an active appointment to the medical staff and designated as !hief of the #edical 2taff. (b) The principal e6ecutive staff advisor to the commander concerning matters of (uality and scope of medical care and utili4ation of professional resources medical policy and planning. (c) Responsible for and has oversight of the credentialing and privileging process. (d) Act as liaison bet3een assigned members of the medical staff and the commander and as such advocate on behalf of the medical staff and e6ecutive leadership. (e) !hairperson of the e6ecutive committee of the medical staff (@!#2). (%n the absence of the &!!2 this responsibility may be delegated by the #T< commander to another appropriately (ualified individual.) (f) !hairperson of the credentials committeeDfunction or 3ith approval of the commander this responsibility may be delegated. (g) Hith the approval of the commander delegate selected &!!2 responsibilities to a physician 3ith appropriate (ualifications. (h) %ntervene on behalf of the commander to immediately hold in abeyance or suspend privileges 3hen a provider8s conduct threatens the health or safety of any patient employee or other individual until the matter is investigated and resolved according to the provisions outlined in this regulation. (2ee chap 9.) (i) 'rient all medical staff applicants concerning #T< byla3s governing patient care medical staff responsibilities professional ethics continuing education re(uirements privileging adverse privileging actions and due process proceedings. (7) Responsible for ensuring organi4ational $% activities are in place and actively participates in these processes. (5) @nsure that an ongoing proactive program for identifying ris5s to $2 and for reducing medicalDhealth care errors is implemented according to &'&% )02*.+C and 12A#@&!'# guidance. (l) $articipate in the development and implementation of policies and procedures that guide and support the provision of services ensuring that such policies and procedures are integrated into the overall plan for patient care. (m) @nsure an effective peer revie3 program (see glossary) is in place for the organi4ation8s health care professionals. (2) *epu!$ &ommander -or nur" ng (*C4, (or &omparable ! !le,. The &!/ isD3illG (a) A licensed professional registered nurse. (b) The principal e6ecutive staff advisor to the commander on matters concerning the scope of patient care services and clinical policy (specifically related to the provision of nursing care and services and nurse staffing standards) nursing policy and the availability and utili4ation of nursing resources.

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(c) Act as liaison bet3een members of the nursing staff and the commander and as such advocate for the provision of (uality nursing care treatment and services. (d) $articipate in the development implementation and integration into the organi4ation8s overall plan for patient care policies and procedures that guide and support the provision of (uality patient care services. (e) A voting member of the @!#2 (or comparably named committee). (f) @nsure $% activities are in place in all arenas in 3hich nursing care treatment or services are rendered and actively participate in these processes. (g) A voting member of the #T< credentials committee 3ith responsibility for revie3 and concurrence 3ith scope of practice and privileges for nursing personnel. (h) Reduce or appropriately limit the scope of practice of any nursing staff member 3hose competence (uality of care behaviorDconduct threatens the health or safety of any patient employee or other individual until the matter is investigated and resolved according to the provisions outlined in this regulation. (2ee chap 9.) (i) 2upport and actively engage in an ongoing proactive program for identifying $2 ris5s and for reducing nursingD healthcare errors according to &'& )02*.+,-R and 12A#@&!'# guidance. (7) An active participant in the organi4ation8s R# program. (5) @nsure the presence of an effective nursing peer revie3 program (see glossary). (l) @6ecutive staff advisor to the commander for other nonEnursing hospital personnel and services under hisDher supervision and authority 3ith the associated (uality management responsibilities as noted above. (,) Ch e-, depar!men!, "er/ &e, or &l n & and T+) &ommand "urgeon". (References to departments and services include alternate organi4ational structures such as product line teams or multidisciplinary care teams in facilities 3ith these alternative structures.) <or clinical departmentDservicesDclinics 3ith chiefs 3ho are not physicians also see paragraph 2-,. %n hisDher area of responsibility or technical oversight the chiefDcommand surgeon isD3illG (a) Responsible for all clinically related activities. (b) $erform ongoing surveillance of the clinical performance of individuals 3ho are re(uired to hold a license certification or registration for clinical practice. (c) Responsible for ongoing functional !"# activities and their integration as appropriate into the organi4ational $% $rogram. (d) $rovide oversight of and participate in the peer revie3 process. (e) Recommend to the medical staff the clinical privileging criteria that are relevant to the care provided in the departmentDserviceDunit. (f) Recommend privileges for each provider in the departmentDserviceDunit as authori4ed. (g) #a5e recommendation to the relevant hospital authority for needed patient care services not provided by the departmentDserviceDunit or the #T<. (h) %ntegrate the services of the departmentDserviceDunit 3ith the primary functions of the #T<. (i) !oordinate and integrate interDintradepartmental services. (7) $articipate in the development and implementation of policies and procedures that guide and support the provision of services. @nsure that such policies and procedures are integrated into the overall plan for patient care. (5) &etermine the (ualifications and competencies of departmentDserviceDunit health care personnel. (l) @stablish ob7ective (uantifiable methods to continually assess and improve the (uality of care and service provided. 1tili4e 'RIJT# data or li5e data as applicable. (m) #aintain (uality control programs as appropriate and ensure that $2 issues are given high priority and addressed 3hen departmentDserviceDunitElevel processes functions or services are designed or redesigned. (n) $rovide and support orientation inEservice training and continuing education of all personnel in the departmentD serviceDunit. (o) #a5e recommendations for space and other resources re(uired by the departmentDserviceDunit. (p) Recommend a sufficient number of (ualified and competent persons to provide care. (() $articipate in outside source selection for needed services. (.) 5r / leged "!a--. The privileged provider 3illG (a) Ac5no3ledge in 3riting at the time clinical privileges and medical staff appointment (if applicable) are a3arded the intent to abide by applicable byla3s. (b) Hhen appointed a member of the credentials committeeDfunction ma5e recommendations on rene3als reevaluaE tions denials or modifications of privileges of assigned providers. (c) @nsure completion of organi4ation and unitEbased orientation maintain current competency and ability to perform the privileges re(uested andDor according to the A'!s and additional s5ill identifiers (A2%s) a3arded accomplish re(uired training and ensure the currency of all documents and other information contained in hisDher provider files. (d) $articipate in $% (uality control and peer revie3 processes. (*) #ll o!her organ 6a! onal a"" gned per"onnel. $ersonnel other than privileged providers 3illG
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(a) @nsure completion of organi4ation and unitEbased orientation maintain current competency and ability to perform the scope of practice of the assigned position accomplish re(uired training and ensure the currency of all documents and other information contained in hisDher competency assessment file (!A<). (b) $articipate in $T (uality control and peer revie3 processes as applicable. (c) @nsure 5no3ledge of and responsibility for implementing all applicable organi4ational policies and procedures relevant to hisDher 7ob description andDor scope of practice. ()) C1' &oord na!or. The !"# coordinator or similarly titled individual (for e6ample $T coordinator) is tas5ed 3ith overall responsibility for the organi4ation8s !"#$. The individual in this role may be e6pected to e6ercise broad oversight and to collaborate 3ith various 5ey staff to ensure the integration of the (uality functions performed by the organi4ation. This re(uires the incumbent to be an active member of the e6ecutive leadership team. 9eDshe 3illG (a) @nsure that organi4ationE3ide $T is a dynamic process based on ongoing identification of opportunities for change. (b) $rovide leadership and consultative services to departments and sections 3ithin the organi4ation 3ith regard to credentialing and privileging issues accreditation re(uirements !"# and "A regulatory compliance issues $T and R#D$2. (c) $articipate in the development of policies for the organi4ation giving special consideration to the integration of and collaboration bet3een internal administrative and clinical policies. (d) $articipate in the identification of opportunities for $T recommendation of solutions for facility issues and concerns and implementation of plans and follo3up activities related to organi4ational $T. (e) 2erve as sub7ectEmatter e6pert in con7unction 3ith patient administration and the servicing 2taff Judge AdvocateD legal advisor in areas such as accreditation standards for health care documentation and the medicalElegal aspects of health care practice. (f) &irect the collection analyses and dissemination of $T data 3ithin the organi4ation ensuring that basic statistical analyses and comparative processes are included. (g) <acilitate organi4ational efforts to provide prevention 3ellness and specific medical conditionEbased management programs as 3ell as other health management programs as re(uired based on timely #T< data and identified beneficiary need. (h) @nsure that facilityEspecific !"# and $T $rogram changes are identified and implemented as data analyses dictate. (i) Keep organi4ational leadership informed of public policies &'& and &A regulations and guidance and legislative and health care trends that affect various !"# and other related health care initiatives. (7) <acilitate the development and implementation of $T education and training sessions for the #T< staff at all levels. (5) 'versee the preparation of intraE and interEorgani4ational $T reports that demonstrate evidence of collaborative multiEserviceDdepartmental input. (C) Creden! al" manager. The individual in this role 3illG (a) $rovide technical advice and direction to the #T< commander on issues related to health care provider credentialing andDor privileging processes. (b) 2erve as a sub7ect matter e6pert to the #T< staff for appropriate credentialing and privileging procedures guidelines and mandates according to Army regulations (ARs) &'&&s andDor &'&Ts TJ! standards and other regulatory agency re(uirements. #aintain a resource library of such reference materials. (c) $rovide technical oversight and management of the process for verification of all licensure certification registration andDor other authori4ing documents re(uired for practice.
4o!e. At the discretion of the #T< commander responsibility for nonprivileged providers may be assigned to another individual(s).

staff during initial application for medical staff appointment and for biennial reEappointments. (f) 'ffer comprehensive guidance and support to providers during the initial and rene3al privileging processes. (g) @nsure peer and supervisory clinical performance revie3 of health care providers 3ho hold initial medical staff appointment and clinical privileges. (h) #anage and update documents of evidence contained in the $!< relevant to education e6perience licensureD certificationDregistration and training to ensure accuracy and currency of information. (i) !onduct /$&? and other relevant in(uiries and $2= to authenticate credentials of staff members for initial a3ardDbiennial rene3al of clinical privileges and for initial appointmentDbiennial reEappointment to the medical staff.
4o!e. Re(uirements also apply for biennial update of the $!< for 12ARDAR/0 practitioners 3ho are not currently privileged.

(d) $rovide technical oversight and management of all health care provider credentialing and privileging functions. (e) #anage all privileging and medical staff appointment processes. 2erve as a point of contact ($'!) to privileged

(7) Hhen licensure certification or registration is re(uired as a condition of employment ensure that the credentials of all general schedule (02) civilian and contract health care providers have been primary source verified prior to initial employment.
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re(uirements. (2ee chap >.) (p) %n collaboration 3ith the AR!!A and AR/0 unit credentials manager maintain the $!<s and !!"A2 input for privileged providers in those T&A careta5er hospitals for 3hich the #T< is responsible. (() @nsure that %!T?s and mandatory attachments (see paras >-+0 & (AA) and >-++b (12ARDAR/0)) are integrated into the credentials committeeDfunction revie3 process for timely privileging of providers. (r) <acilitate the revie3 of all AAD12ARDAR/0 and other <ederal 2ervice $!<s or %!T?s in compliance 3ith this regulation. (s) <or3ard all re(uests for adverse credentialing and privileging information on individuals previously assigned or employed as privileged <ederal 2ervice providers to the 12A#@&!'# "#& for action. (t) @nsure a process for communicating credentialing and privileging information to civilian agencies involved in e6ternal resource sharing agreements. (>) Ch e-, %' and7or 5S.
4o!e. This may be a single position 3ith combined responsibilities or t3o separate positions 3ith individually defined responsibiliE ties. 2ee chap +2 and +, for additional information.

(5) @stablish and maintain the organi4ation8s !entrali4ed !redentials and "uality Assurance 2ystem (!!"A2). (l) @nsure the !!"A2 database is current and complete. (m) Research and respond as appropriate to in(uiries regarding the status of medical staff membership. (n) #aintain all $!<s according to this regulation. (o) $repare and for3ard $!<s andDor %!T?s for privileged providers to the gaining #T< 3ithin the specified time

The person performing these duties 3illG (a) %ntegrate and coordinate all R#D$2 administrative and management activities 3ithin the medicalDdental facility. (b) !ollaborate 3ith e6ecutive leadership to develop compliance programs for all regulatory and accrediting re(uireE ments associated 3ith R# and $2. (c) @nsure that organi4ational R#D$2 $rograms are supported at all levels. (d) @stablishDmaintain a dedicated program for avoiding adverse events or medical misadventures and improving $2. (e) !ollaborate 3ith e6ecutive leadership and the #T< safety and occupational health manager (comparable title) (&'&% )0**.+) to ensure a comprehensive safety program for all patients employees visitors volunteers and others. (f) Recommend develop monitor and evaluate plans and programs to decrease facility and 0overnment liability andDor financial loss associated 3ith medical misadventures accidents and other unto3ard events. (g) %nitiate actions and processes that 3ill secure preserve and protect evidence related to an 2@. (h) 'versee the investigation of all 2@s to ensure coordination of all data collection activities completion of a thorough and credible root cause analysis (R!A) and reporting through appropriate channels. (2ee para +2-* for more detailed information regarding 2@s.) (i) %nform and coordinate all activities associated 3ith adverse events and 2@s 3ith the !enterD!laimsD!ommand Judge Advocate (!JA). (7) $articipate in structured organi4ational processes to identify potential ris5 analy4e trends and implement $% initiatives to reduce ris5s. (5) !ollaborate 3ith the patient representativeDadvocate and the #T< safety and occupational health manager to identify trends related to customer concerns complaints or incidents and to manage problemsDris5s appropriately. (l) $resent opportunities for improvement related to organi4ational ris5s (including recommended solutions impleE mentation plans and follo3up activities) to the #T< e6ecutive committee for action in support of (uality patient care. (m) $rovide consultative information and ris5 assessmentD$2 reports to the e6ecutive leadership various committees or individuals and all levels of staff on general and specific medical R# issues and events. 8. #')** Cen!er and S&hool &our"e d re&!or". A#@&& !enter and 2chool course directors for all academic programs under the auspices of the A#@&& !enter and 2chool 3ill ensure that their program of instruction contains content relevant to current A#@&& !"# policy and processes health care facility accreditation standards and professional practice standards. !urriculum instruction 3ill highlight each A#@&& member8s responsibility to participate in organi4ational !"# activities.

C(apter # Medical Sta'' and Military 7reatment +acility Committee Structure and +unctions
#52 @eneral The Joint !ommission re(uires an organi4ed selfEgoverning medical staff to provide direction and oversight of the (uality of care treatment and services delivered by privileged providers. The organi4ed medical staffEEreferred to in this publication as the @!#2 or e(uivalent titleEEis also responsible for evaluating the competency of privileged providers on an ongoing basis delineating the scope of privileges that 3ill be granted ensuring a uniform standard of

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care and providing leadership in $% activities 3ithin the organi4ation. The medical staff is accountable to the governing body (T20) as represented by the #T< commander. ##2 Medical sta'' ,yla=s a. The byla3s 3ill be developed adopted and amended by the medical staff and approved by the commander as representative of the governing body. The medical staff 3ill enforce and comply 3ith the byla3s. b. #any of TJ! re(uirements for the medical staff byla3s are contained in this regulation and need not be repeated in #T< medical staff byla3s. c. The #T< medical staff byla3s must meet current re(uirements of TJ!. Those developed by the #T< should e6pand the partial listing provided in this chapter. TJ! re(uires that byla3s include(+) The (ualifications roles and responsibilities of department chiefs. (2ee para +E. 7(,).) (2) The structure function si4e and composition of the @!#2 (or e(uivalent committee) and of the methods for selecting and removing its members and the organi4ed medical staff officers. (,) The empo3erment of the @!#2 to act on behalf of the medical staff. (.) The processes for credentialing privileging and medical staff appointment. (2ee chaps > and 9.) (*) The indications for automatic suspension or summary suspension of medical staff membership or clinical privileges and 3hen these procedures are implemented. (2ee chap +0.) ()) The mechanism for a fair hearing and the appeal process for an adverse privileging action. (2ee chap +0.) #82 Military treatment 'acility departmental structure and leaders(ip The byla3s 3ill describe the (ualifications roles and responsibilities of department chiefs. a. $hysicians or other privileged providers 3ill be appointed as chiefs of medical departmentsDservices by the commander. 2election 3ill be based on (ualifications including clinical and leadership e6perience and ability. %n instances 3here a nonEphysician serves as the chief of a departmentDservice a physician 3ill be selected as the medical director. The medical director 3ill advise the chief and be responsible for practice issues outside the clinical scope of the nonEphysician chief. The medical director 3ill be responsible for peer revie3 and the credentialing and privileging of physicians and other privileged providers. The chief 3ill represent the departmentDservice at the @!#2 and other re(uired meetings. b. Rating schemes 3ill reflect the administrative command and control regardless of the !orps (discipline) of the departmentDservice chief. #42 04ecutive committee o' t(e medical sta'' The @!#2 is authori4ed to carry out medical staff responsibilities and performs its 3or5 3ithin the conte6t of the functions of governance leadership and $%. The @!#2 has the primary authority for activities related to self governance of the medical staff and for $% of the professional services provided by privileged healthcare providers. This committee reports to the e6ecutive committee. /oteF There is currently no re(uirement for an e6ecutive committee of the dental staff (@!&2). Hhere this regulation re(uires informationDaction to route through the @!#2 to the commander it may go directly to the dental commander. a. The ma7ority (at least *+ percent) of voting @!#2 members 3ill be licensed physicians 3ith current privileges and medical staff appointments. b. =oting membership 3ill include the &!!2 (chairperson) the &!/ and chiefs of clinical departments. 'ther members (ualifications for membership and the voting status of members (3ho are not members of the medical staff) 3ill be as delineated in the medical staff byla3s. 'ther members may include senior privileged providers from garrisonE level units and chiefs of administrative divisionsDservices related to patient care (for e6ample patient administration division ($A&) and !"#). c. The @!#2 functions may be conducted by the entire medical staff (committee of the 3hole) concurrently 3ith those of another #T< committee (for e6ample the credentials committee) or by a separate committee. d. The @!#2 acts upon reports of #T< committeesDfunctions clinical departments and subcommittees or 3or5groups designated by the @!#2. %n addition this committee provides recommendations to the commander at a minimum on the follo3ingF (+) The medical staff structure. (2) The process for credentials revie3 and delineation of individual clinical privileges. (,) #edical staff membership and termination of membership. (.) The delineation of privileges for each eligible provider. (%f the @!#2 and the credentials committee are not the same body the privileging recommendations of the credentials committee for each provider 3ill be revie3ed by the @!#2 and for3arded to the commander.) (*) The mechanism for terminating medicalDdental staff membership. ()) The mechanism for adverse actions fair hearing and appeal procedures. (C) The participation of the medical staff in organi4ational $% activities.

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'

#<2 Medical sta'' participation in per'ormance improvement activities a. %e9u red -un&! on". The Joint !ommission re(uires the medical staff to provide leadership in measuring assess E ing and improving processes that primarily depend on the activities of privileged providers as 3ell as participating in organi4ationE3ide $% activities. All committee minutesDreports regarding these activities 3ill be routed through the @!#2 to the commander. As a minimum the follo3ing functions 3ill be evaluated documented trac5ed and reported G (+) #edical assessment and treatment of patients. (2) 1se of medications. (,) 1se of blood and blood components. (.) 'perative and other procedures. (*) Appropriateness of clinical practice patterns. ()) 2ignificant departures from established patterns of clinical practice. (C) 1se of information about adverse privileging decisions. (>) 1se of developed criteria for autopsies. (9) 2entinel event data. (+0) $atient safety data. b. Sugge"!ed -un&! on". 'ther $% functions that may be significant to the organi4ation includeF medical records revie3 tumor boardDcancer conference pain management processes outcomes related to cardiopulmonary resuscitation and services provided to highEris5 populations. #62 9t(er military treatment 'acility organi:ational 'unctions and committees The Joint !ommission re(uires an @!#2 (or committee 3ith a similar function). %n addition TJ! directs the performance of other select functionsA ho3ever a committee need not be dedicated to that purpose. These functions must be accomplished by the organi4ation on a recurring basis 3ith documentation for3arded to the @!#2. The use of minutes or summary reports to document the function is a facilityElevel decision. !ertain other committees (such as ris5 management) are re(uired by agencies other than TJ! as noted belo3. The follo3ing committeesDfunctions are re(uired by this regulationF a. ):e&u! /e &omm !!ee. #embership 3ill include the commander (chairperson) &!!2 deputy commander for administration (&!A) deputy commander for nursing (&!/) or e(uivalents the !ommand 2ergeant #a7or and those !"# staffDother staff designated by the commander. This committee is the conduit for channeling #T< !"# information to the commander 3ho e6ecutes oversight authority. b. 5a! en! "a-e!$ &omm !!ee7-un&! on. $2 activities are designed to maintain and improve healthcare processes and practices reduce the potential for harm to patients and ensure the general safety and security of patients in all settings. #embership of this multidisciplinary committee 3ill be according to guidance from 12A#@&!'# (#!9'-!;-"). The $2 committee reports through the @!#2 to the e6ecutive committee c. % "8 managemen! &omm !!ee7-un&! on. &'& )02*.+,-R re(uires an R# committee. %f these ris5 management duties are not performed by a dedicated committee the medical staff byla3s 3ill specify ho3 this function 3ill be accomplished. 2ee chapter +, for R# and the committeeDfunction. d. Creden! al" &omm !!ee7-un&! on. 2ee chapters >E+0. e. 0mpa red heal!h&are per"onnel &omm !!ee. 2ee chapter ++. f. ;eal!h&are &on"or! um. This forum offers an opportunity for beneficiaries to provide input into healthcare delivery policy and to promote communication bet3een the #T< and its beneficiaries. $articipants 3ill include the commander or designee (as chairperson)A #T< leadershipA and representation from officer enlisted <amily member and retiree beneficiaries. ;ocal policy 3ill define additional parameters of this committee (fre(uency of meetings etc.). %n settings li5e @urope 3here &o& beneficiaries are dispersed over a 3ide geographical area commanders may delegate authority for holding local meetings. To satisfy this re(uirement #T< commanders may attend installation to3n hall meetings. g. +!her -ormal &omm !!ee". =arious committees boards and councils may be established 3ith the approval of the e6ecutive committee to perform the monitoring and evaluation re(uired in paragraph 2E* of this regulation and other relevant guidance (&'& )02*.+,-R) as 3ell as the $% functions as described in the #T< !"# plan. h. Comm !!ee7-un&! on re&ord" and repor!". A 3ritten record of all !"# committeesDfunctions 3ill be maintained by the #T<. The (uality management ("#) office or e(uivalent is the recommended site. The #T< !"# plan 3ill define the process for communicating the results of !"# activities and associated recommendationsDactions 3ithin the organi4ation and to other outside organi4ations.

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C(apter 8 7(e Clinical Quality Management 3rogram and 9rgani:ational 3er'ormance mprovement
852 7(e Clinical Quality Management 3rogram a. The purpose of the A#@&& medical and dental !"#$ is to continuously and ob7ectively assess 5ey aspects of individual and institutional performance 3ith the intent to improve the health care and services provided to eligible &'& beneficiaries and others. b. #ilitary treatment facilityDdental activity (&@/TA!) commanders 3ill establish and resource a !"#$ that coincides 3ith any R#!Dregional dental command (R&!) andDor &'& programs as appropriate and meets the uni(ue needs of the organi4ation. Hhen developing the facilityElevel !"#$ consideration must be given to all accreditation and regulatory re(uirements. A comprehensive program re(uires integration of these criteria that offer evidence of the (uality cost availability and appropriateness of care and services being provided to &'& beneficiaries of all ages. !ritical to the success of the !"#$ is the active involvement and participation of all staff members. c. !linical (uality management 3ill be integrated into the organi4ation8s vision and mission statements and guiding principles. 2uch integration affords #T<D&@/TA! leadership an opportunity to develop an effective strategic plan of action for the delivery and continuous improvement of (uality care. d. @ach #T<D&@/TA! 3ill maintain a single 3ritten plan that includes all departmentsDservicesDfunctions and 3ill define ho3 each of its established !"# processes and $% activities 3ill be implemented. Hhen devising such a plan various !"# models are available including the <indE$lanE&oE2tudyEActD$lanE&oE!hec5EAct (that is <'!12D$&!A) frame3or5 (see glossary and app A). e. %mproving individual and organi4ational performance necessitates the use of various techni(ues tools and methodologies 3ithin a structured frame3or5 to measure and ultimately enhance the (uality and cost efficiency of healthcare delivery. Hhile all healthcare personnel are sta5eholders in the $% process an e6ecutive leadership committed to (uality is crucial to lin5ing organi4ational strategic priorities 3ith "% efforts thereby optimi4ing the impact of improvement activities on organi4ational performance as a 3hole. 8#2 3rocesses and 'unctions re&uiring measurement @ffective $% re(uires the measurement evaluation and comparison over time of a variety of patientEfocused functions organi4ational functions and other activities. 2tandards addressing these activities are found in various TJ! compreE hensive accreditation manuals including those for hospitals ambulatory care behavioral health home care longEterm care laboratory services and others. The facility8s revie3 mechanisms designed to systematically measure and continuously evaluate these activities must be collaborative and multidisciplinary. 882 3er'ormance improvement data sources and analyses a. 2uccessful $% 3ill be based on effective use of both clinical and administrative data from a variety of sources. The #T<D&@/TA! in coordination 3ith the R#!DR&! and 12A#@&!'# 3ill determine 3hich data are appropriate to consider for the purpose of organi4ational improvement. b. =arious activities programs and processes such as those in (+) through (C) belo3 merit consideration as sources of information that may influence the $% $rogram 3ithin the organi4ation. (+) ?eneficiary and health care professional education and feedbac5 sessionsA (2) !$0Ebased condition management programsA (,) $utting $revention into $ractice 9ealthy $eople 20+0 and other illness prevention and health promotion activitiesA (.) 1# activities such as demand and referral management case management and discharge planningA (*) $rovider clinic and clinic team profiling related to morbidity mortality length of stay access disease and prevention program andDor outcomesErelated metrics patient satisfaction and costA ()) &isciplineEspecific standards of care for privileged providersA and (C) American /urses Association (A/A) 2tandards of /ursing $ractice or other nursing specialty organi4ation8s standards of practice (for e6ample the Association of peri'perative Registered /urses or the American Association of !ritical !are /ursing as appropriate) for the delivery of nursing care and recogni4ed practice standards for other healthcare specialties. &. An e6pected conse(uence of effective data analyses related to '#D1# activities is the identification of those clinical practices 3ith significant positive outcomes that are successfully contributing to the organi4ation8s $% ob7ec E tives. At the same time practices that are ineffective in promoting $% ob7ectives (that is result in negative outcomes) may be noted. !areful analysis of the ris5Ead7usted outcomes data 3ill facilitate determination of both best and least effective practices for the organi4ation. 'rgani4ational personnel 3or5ing in small focus groups may be tas5ed to address processes that result in statistically significant positive or negative outcomes. These personnel should carefully evaluate the circumstances resulting in negative patientDorgani4ational outcomes 3ith specific emphasis on recommen E dations for $%. Those circumstances 3ith notably positive outcomes may 3arrant promulgation throughout the organi E 4ation the A#@&& or the &'&.

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d. The commander is responsible for analy4ing the results of #T< studies conducted by e6ternal accrediting agencies as 3ell as &'& or A#@&&Elevel organi4ations. %n addition the results from TJ! and the /ational !ommittee on "uality Assurance metrics monitoring !#2 and 9ealth $lan @mployer and &ata %nformation 2et standardsDmetrics provide useful data. The /ational "uality #anagement $rogram contract reports as applicable and the contractor !"# monitoring of the civilian health care provider net3or5 as stipulated in the TR%!AR@ regional contract should be carefully considered. Actions to improve performance outcomes based on the various data available should be ta5en. 842 3er'ormance improvement activities in t(e 'acilityAs =ritten plan a. The #T<Especific approach to process improvement 3ill be articulated in a plan (see para 2-2 b) that clearly defines ho3 all levels of the organi4ation 3ill address improvement issues. @mphasis on (uantifiable improvements relative to the processes and outcomes of care is essential. The $% plan 3ill provide a systematic approach to $% and 3ill containG (+) An identified scope and focus for measurement (that is 3hat data elements 3ill be assessed). (2) 2tructured processes to assess performance (that is ho3 the data 3ill be assessed). (,) !learly established priorities for improvement. (.) Application of '#D1#D1R information to prioriti4e management and use of limited organi4ational resources. (*) %mplementation of $% activities based on assessment conclusions. ()) %dentified processes to maintain achieved improvements. b. The $% plan 3ill describe all processes procedures and criteria used to evaluate care as 3ell as the functions of the staff responsible for implementation and evaluation of the various 1#D'# activities. A systematic process for considering and acting on recommendations for organi4ational improvement 3ill be clearly identified in the plan. 8<2 +acility accreditation Accreditation of A#@&& #T<s and designated health care programsDfunctions by recogni4ed national organi4ations as re(uired by la3 and &'& guidance is an integral part of the A#@&& !"#$ specifically in support of organi4ational $%. a. 3a& l ! e" re9u r ng a&&red !a! on. %t is &'& policy that all fi6ed hospitals troop medical clinics hospitalE sponsored substance abuse rehabilitation programs and free standing ambulatory care clinics (medical only) 3ill maintain accreditation by the TJ! or other accreditation source approved by the 'A2&(9A). b. #&&red !a! on re9u remen!". All facilities 3ill maintain accreditation under the TJ! standards or other nationally recogni4ed accreditation organi4ation standards as approved by 'A2&(9A) that apply to the services and delivery systems that describe their care. (2ee para ,-2.) c. #&&red !a! on gu dan&e. %nformation related to accreditation standards is contained in various references listed in appendi6 A and 3ill not be duplicated in this regulation. 'n occasion T20 may direct policies and procedures that e6ceed the standards of recogni4ed accrediting agenciesA in these cases appropriate implementing instructions 3ill be issued. %f a conflict e6ists bet3een accrediting agency standards and 1.2. Army policy current Army policy 3ill prevail. The 12A#@&!'# "#& 3ill pursue resolution of any recogni4ed inconsistency in guidance 3ith the accrediting agency. d. #&&red !a! on -und ng. The TJ! Accreditation $rogram for the A#@&& is centrally funded and administered by the 12A#@&!'# "#&. <acilities 3ill complete applications for survey in accordance 3ith current re(uirements of TJ!. The 12A#@&!'# "#& 3ill revie3 the application in consultation 3ith the facility and R#! personnel and provide authori4ation for the #T< to electronically for3ard the application to the TJ!. The 12A#@&!'# "#& is responsible for reimbursement of the triennial TJ! surveys. A copy of each #T<8s application for survey 3ill be maintained on file in con7unction 3ith surveyErelated e6penditures. To ensure correct 0overnment payment to TJ! re(uests for survey date changes or changes in the scope of a scheduled TJ! survey 3ill be made only by the 12A#@&!'# "#&. e. #')** e9u /alen& e" -or T.C "ur/e$. The TJ! recogni4es the follo3ing e(uivalencies 3hen applying TJ! standards to A#@&& #T<s. (+) T20 serves as the 0? for all #T<s 3orld3ide. (2) <ederal la3 &'&&s ARs T20 policies and 12A#@&!'# directivesDpolicies serve as the hospital byla3s. These need not be re3ritten to be included in facilityElevel documents. %n addition #T< commanders may re(uire local policy for issuesDactivities not prescribed by guidance from other sources. 2uch local policies complement higher head(uarters8 re(uirements and are also part of the #T< formal byla3s. (,) The #T<8s mission statement describes its purpose and community responsibilities. (.) The #T< commander serves as the chief e6ecutive officer and represents the 0?. (*) The deputy commander for administration (&!A) or e(uivalent serves as the chief operating officer. ()) The &!!2 or e(uivalent serves as the chief or president of the medical staff. (C) The deputy commander for nursing (&!/) or e(uivalent serves as the nurse e6ecutive.

%0

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(>) The #T< e6ecutive committee formally lin5s the functions of the 0? representative the chief operating officer and the medical and other professional staff 3ith other important aspects of the organi4ation8s operation. f. T.C "ur/e$ repor! "ubm "" on. The #T< commander (medical units only) 3ill submit to the 12A#@&!'# "#& a copy of the preliminary report provided by TJ! surveyors at the completion of the survey regardless of the survey results or disagreement on the part of #T< staff 3ith the survey results. This re(uirement applies to all surveys by TJ!. g. 'T3 a-!er<a&! on repor!". Hithin ,0 days of completion of any TJ! survey (triennial unannounced surveys for cause or focused) the #T< commander 3ill submit through the ne6t higher head(uarters to the !ommander 12A#@&!'# ATT/F #!9'-!;-" 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0 an afterEaction report detailing the survey preparation process (planned surveys) and any lessons learned as a result of the survey process. The 12A#@&!'# "#& 3ill disseminate lessons learned as appropriate. 862 3atient rig(ts and responsi,ilities a. The health care beneficiary is the central focus of all !"# activities. This focus recogni4es the patient as a partner optimi4es patient rights 3ithin the health care system and capitali4es on the value of consumer feedbac5 to effectively improve the processes of care. b. %mplementation of patient rights as defined in &'&& )000.+. current TJ! standards and the 9ealth %nsurance $ortability and Accountability Act of +99) is an important component of the !"#$. These rights include but are not limited toG (+) %nformation disclosure and access and amendment rights. (2) !hoice of providers and health plans. (,) Access to emergency services (military or civilian). (.) $articipation in treatment decisions. (*) Respect and nondiscrimination. ()) !onfidentiality of patientEspecific health information. (C) !omplaints and appeals. &. All health care personnel share in the professional responsibility of ensuring that beneficiaries understand not only their rights but also their responsibility to participate in their o3n health care decisions. $atients 3ill be provided information as to their rights as beneficiaries of the &'& military health system (#92) according to local policy. d. Hritten and verbal beneficiary perceptions of care and services both positive and negative 3ill be incorporated into #T< !"#$ processes as appropriate. 8>2 Con'identiality o' &uality assurance documents and records The /ational &efense Authori4ation Act for fiscal year +9>C ($ublic ;a3 ($;) /o. 99E))+) section ++02 Title +0 (+0 12! ++02) mandates that records created by or for the &'& in a medical or dental "A program are confidential and privileged. $; 99E))+ and subse(uent guidance predicated on this la3 (+0 12! ++02) preclude disclosure of or testimony about any records or findings recommendations evaluations opinions or actions ta5en as part of a "A program e6cept in limited situations. 1nder the provisions of +0 12! ++02 this information is e6empt from release in accordance 3ith @6emption , of the <'%A. Additional detailed information regarding the confidentiality of "A documents and records is contained in appendi6 ?.

C(apter 4 /icensure* Certi'ication* and;or Registration o' %ealt( Care 3ro'essionals

452 3olicy To promote the highest (uality health care for its beneficiaries it is the policy of the 1.2. Army that its employed and contracted health care professionals meet established standards relative to educational preparation professional standing and technical ability. These standards are met in part by the application for and maintenance in good standing of a license certificate andDor registration (as mandated by 2tate la3 <ederal statute 'ffice of $ersonnel #anagement ('$#) Army or &'& (9A) policy) to practice 3ithin the individual8s health care specialty. The re(uirements of this chapter also apply to those 3ho are not classified as employees of the 1.2. Army but are providing patient care services (for e6ample volunteers members of other 2ervices) under the auspices of the military or based on 1.2.D foreign country memorandum of understanding (#'1)Dmemorandum of agreement (#'A)) guidelines (for e6ample nonE1.2. health care personnel in a deployed theater of operations). 4#2 Scope o' licensure re&uirement a. #ilitary civil service contract personnel 3ho re(uire a license certification andDor registration to perform their

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duties must maintain a current active valid and unrestricted license or other authori4ing document such as certification or registration from any 1.2. 7urisdiction (&'& )02*.+,-R). b. ;icensure certification andDor registration re(uirements apply to professionals performing both clinical andDor administrative duties. %ndividuals not assigned to or privileged by an #T< or Armed <orces %nstitute of $athology (A<%$) (for e6ample #edical Research and #ateriel !ommand (#R#!)) 3ill provide evidence of a current active valid and unrestricted license certification andDor registration to the appropriate ne6t higher command that has professional or technical control. 482 Basic licensure* certi'ication* registration criteria a. A license is a grant of permission to a health care professional by a recogni4ed licensing agency of a 2tateA the &istrict of !olumbiaA the !ommon3ealth of $uerto Rico 0uam or the 1nited 2tates (1.2.) =irgin %slandsA or other territory or possession of the 1.2. to provide health care 3ithin the scope of practice for a specific health care discipline. (+) %n lieu of a license 3hen such is not availableDoffered for certain occupations another mechanism such as 2tate certification or registration serves as evidence to support practice 3ithin a specified discipline. (2) %n specialties that are not licensed by the 2tate and the re(uirements of the granting authority for 2tate registration or certification are highly variable there must be validation by a national organi4ation that the individual is professionally (ualified to provide health care in a specified discipline. @6amples of this are the /ational !ommission on the !ertification of $hysicians Assistants (/!!$A) for physician assistants ($As) and the /ational Registry of @mergency #edical Technicians (/R@#T) for emergency medical technicians. (a) 2oldiers (AAD12ARDAR/0) possessing the )>H military occupational specialty (#'2) are re(uired to obtain and maintain certification by the /R@#T. !ertification 3ill be at a minimum at the basic level (emergency medical technicianEbasic). AA )>Hs 3ill be /R@#T certified and meet all other re(uirements for the #'2 by ,0 2eptember 200C (12ARDAR/0 2oldiers by ,0 2eptember 2009). $eriodic recertification as established by the /R@#T is mandatory. 2oldiers 3ho fail to recertify according to /R@#T guidance 3ill immediately be suspended from all duties re(uiring /R@#TEbasic certification. (b) 2oldiers 3ho fail to recertify according to /R@#T guidance 3ill be granted an additional 90 calendar days (for AA) and +>0 calendar days (for 12ARDAR/0) to obtain /R@#TEbasic certificationA 2oldiers 3ill be deemed #'2 (ualified during this period. A 2oldier8s failure to obtain /R@#T certification immediately follo3ing the respective 90E or +>0Eday period 3ill result in hisDher classification as nonE#'2 (ualified and the initiation of an appropriate personnel action (that is mandatory reclassification separation) according to governing regulations. (,) %n the case of health care provided in a foreign country by a providerDprofessional 3ho is not a 1.2. citi4en or national a grant of permission from an official agency of that foreign country 3ill suffice. This authori4es the individual to provide health care 3ithin the specified discipline to &'& beneficiaries in nondeployed settings and in deployed theaters of operation in accordance 3ith established 1.2.Dforeign country #'1D#'A guidelines. b. The license certification andDor registration 3ill be current (not revo5ed suspended or lapsed)A active (character E i4ed by present activity participation practice or use)A valid (the issuing authority accepts and considers professional performance and conduct in determining continued licensure)A and unrestricted (not sub7ect to restriction pertaining to the scope location or type of practice ordinarily granted to all other applicants for similar licensure in the granting 7urisdiction). &. %f a 2tate elects to eliminate the licensure re(uirement for a particular discipline those health care professionals employed by the 1.2. Army (and 3ho are licensed only in that 2tate) must obtain licensure in another 2tate. d. 9ealth care professionals 3ho are attending licensureE (ualifying educational programs must apply for licensure at the earliest available opportunity after having successfully met the (ualifying prere(uisites. e. ;icensed certified andDor registered health care personnel (privilegedDnonprivileged) must immediately notify their supervisor and the appropriate #T< office responsible for authentication of practice credentials that their license no longer meets the re(uirements noted in paragraph b above. /otification 3ill li5e3ise be provided 3hen an authori4ing agency has imposed a restriction on their license certification andDor registration. <ailure of an individual to obtain or maintain the appropriate current active valid and unrestricted credentials (license certification registration) re(uired by this regulation is the basis for immediate suspension of privilegesDpractice andDor other adverse personnel action as referenced in paragraph .-+0. 2uch personnel 3ill be reported to the !ommander 12A#@&!'# (#!9'-!;-") 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0. 442 3ro'essional disciplines re&uiring license* certi'ication* and;or registration a. = &en"e. ;icensure in one8s respective discipline is re(uired for all providersDprofessionals.
4o!e. Advanced practice registered nurses (A$R/s) are given until + July 2009 to meet the re(uirement for 2tate licensure. %f a license is not provided by the individual8s 2tate or 1.2. 7urisdiction the official authori4ing document issued in lieu of a license 3ill be maintained.

(+) The follo3ing health care providersDprofessionals must possess and maintain a current active valid and unrestricted license from a 1.2. 7urisdiction before practicing independently 3ithin the defined scope of practice for

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their specialty (list not all inclusive)F A$R/s audiologists behavioral health practitioners chiropractors clinical pharmacists clinical psychologists clinical social 3or5ers counseling psychologists dental hygienists dentists dieti E tians occupational therapists ('Ts) optometrists physical therapists ($Ts) nonEpersonal services $As physicians podiatrists practicalDvocational nurses (;$/D;=/) psychological associates registered nurses (R/s) substance abuse counselors speech pathologists and veterinarians. The basic (ualifications for a3ard of a medically related military enlisted #'2DA2% are contained in &A $am )++-2+. The '$# has established the minimum (ualification re(uirements for comparable civilian positions by employee classification series and grade level in its "ualification 2tandards 9andboo5 for 0eneral 2chedule $ositions.
4o!e. The information presented in this chapter regarding licensure (or other authori4ing document) of personnel providing directD indirect health services or patient care may change over time as regulatory re(uirements at the 2tate level evolve. Re(uirements related to licensureDcertificationDregistration of A#@&& health care personnel (militaryDcivilian) 3ill at all times comply 3ith current 'A2&(9A) guidance.

(2) 9ealth care personnel (militaryDcivilian) employed by the <ederal 0overnment 3ill abide by the practice re(uirements imposed by their 2tate of licensureDcertificationDregistration to the fullest e6tent possible.
4o!e. !ompliance 3ith 2tate re(uirements shall not interfere 3ith the individual8s performance of assigned dutiesDresponsibilities in the specified discipline 3ithin the <ederal sector.

%ndividuals 3ho provide ancillary health services and 3ho hold licensureDcertificationDregistration (nationalD2tate) in their individual specialty must reveal this authori4ing documentation and are sub7ect to the adverse practice action reporting re(uirements outlined in chapter +.. $rofessional conduct behavior or performance that based on peer revie3 3arrants an adverse practice action 3ill be reported to the appropriate authori4ing agency according to current &'& guidance. b. Cer! - &a! on and7or reg "!ra! on -or "ele&! d "& pl ne". (+) All $As must possess /!!$A (or its successor) certification as a condition of employment (02Dcontract employees) and before being granted clinical privileges (military 02 personal services contact and volunteer). (2) &ietitians must possess and maintain current registration by the !ommission on &ietetic Registration of the American &ietetic Association (A&A) in addition to a current active valid and unrestricted 2tate license. (,) 2ubstance abuse counselors are re(uired to possess and maintain a current active valid and unrestricted license as a social 3or5er or psychologist or if the counselor is prepared at the master8s degree level and is in the 02 +>0-series the license may be as a licensed professional counselor 3ith 2tate or national certification in substance abuse rehabilitation. The deadline for substance abuse counselors to obtain this license 3as ,+ #ay 200,. (.) 2ee chapter C for additional guidance related to scope of practice and other specific professional re(uirements for privileged providers. (*) Although national certification of health care personnel (enlisted civilian) 3ho provide ancillary health services is not mandated e6cept mammography technicians (<ederal &rug Administration L"uality #ammography 2tandardsM) and emergency medical technicians (AR .0-,) it is highly encouraged in any specialty for 3hich it may be available. !ertification andDor registration re(uirements for A#@&& health care personnel (militaryDcivilian) 3ill at all times comply 3ith &'& guidance.
4o!e. 2tate licensure as a (ualified radiology technician and continuing education in mammography may substitute for the certification specified (2+ !<R $art 900 E #ammography).

4<2 3ro'essional responsi,ility regarding licensure %t is the professional and individual responsibility of military and civilian health care professionals and other health care personnel as may be re(uired to obtain and maintain the license certification andDor registration re(uired to practice in a particular health care discipline. &eployment or other e6tended training does not e6empt the military member from this re(uirement. This responsibility includes payment of re(uisite fees and 5no3ledge of and compli E ance 3ith all re(uirements for continuing education and other mandates of the licensing certification andDor registra E tion authority. a. U"e o- appropr a!ed -und" -or pa$men! o- -ee". Appropriated funds may be used to pay professional licensure e6penses for military health care personnel 3ho are re(uired to be licensed in their 2tate of practice in order to participate in a resource sharing agreement 3ith a civilian institution. This entails performance of officially assigned professional duties at an authori4ed location outside the #T< and any military installation. <ederal statute +0 12! +09) allo3s the 2ecretary of &efense to reimburse the military member for up to N*00.00 of the amount of the license fee. This applies only to situations in 3hich the host 2tate or civilian facility refuses to recogni4e the individual8s professional licenseDauthori4ing document despite the licensure portability statute as described in +0 12! +09. and &'&% )02*.+). b. C / l an emplo$ee ! me o--. Hhen in the best interest of the 0overnment and the employee civilian employees may be given brief e6cused absences from duty and official time off for re(uired licensing and certification purposes. $ermissive T&I is authori4ed for military health care personnel ta5ing licensure e6aminations.

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462 @uidance on licensure re&uirements a. $rofessionals directly accessed from a training program 3ho re(uire a license certification andDor registration to practice must obtain such authori4ing documents 3ithin + year of the date 3hen all re(uired didactic and clinical re(uirements are metA 3ithin + year of completion of postgraduate year + ($0I-+) for physiciansA and 3ithin 2 years after a3ard of the doctoral degree for clinical psychologists. The 02 civilian R/ 3ho is appointed to a position pending 2tate licensure may not be e6tended beyond ) months or promoted if licensure has not been attained. (+) ##7US#%7#%4G ph$" & an". To be eligible for licensure physicians must successfully complete 2tep %%% of the 1nited 2tates #edical ;icensing @6amination (12#;@) or !omprehensive 'steopathic #edical ;icensing @6amination (!'#$;@J) as appropriate and complete + year of postgraduate training. $hysicians 3ho choose to be licensed in a 2tate that re(uires more than + year of postgraduate training must first obtain a license from a 2tate that re(uires only + year of postgraduate training. (2) +!her m l !ar$ ph$" & an". #ilitary in deferred status or 12ARDAR/0 physicians in civilian graduate medical education (0#@) training programsGincluding those receiving financial benefits (2pecial Training Assistance $rogram or <inancial Assistance $rogram (<A$))Gmust meet the applicable licensure standards of their civilian training programs. These physicians must possess a current active valid and unrestricted license in a 2tate or other 1.2. 7urisdiction upon successful completion of the training program or upon entering the <A$ at the $0I, level. b. 9ealth care providers 3ho are eligible for privileges but have not ac(uired the appropriate license certification andDor registration 3ill be a3arded supervised privileges and may practice only under a 3ritten plan of supervision. The supervision 3ill be more comprehensive than that afforded a licensed privileged provider of that same discipline. The supervision provided must be from a licensed fully (ualified independently practicing and if appropriate privileged provider of the same or similar specialty. &. <or R/s and ;$/sD;=/s both military and civilian the follo3ing stipulations apply in addition to the re(uirement for a current active valid and unrestricted license from a 2tate 1.2. !ommon3ealth or territoryF (+) #4 o-- &er. The A/ officer 3ho graduated after ,+ &ecember +99C must be a graduate of a nursing program accredited by the American Association of !olleges of /ursing or the /ational ;eague for /ursing. @ffective + 'ctober 20+2 all A/ personnel must have ta5en and passed the /ational !ouncil ;icensure @6amination E Registered /urses (/!;@J-R/) an e6amination developed and administered by the /ational !ouncil of 2tate ?oards of /ursing (/!2?/) (in accordance 3ith 12AR@! guidance). Those individuals 3ho passed an R/ licensing e6amination other than the /!;@J-R/ prior to +2 &ecember +9>) are granted an e6ception to this re(uirement. ?efore 3or5ing 3ithout supervision 3ithin hisDher designated scope of practice the A/ officer must pass the /!;@J-R/. (2) )nl "!ed pra&! &al nur"e. The )>H#) or )>H#, 3ho graduated after ,+ &ecember +99C must be a graduate of a nationally accredited or 2tate approved practical nursing program. @ffective + 'ctober 20+2 the )>H#)D#, must have ta5en and passed the /!2?/8s /ational !ouncil ;icensure @6aminationE$ractical /urses (/!;@J-$/) according to 12AR@! guidance). Those individuals 3ho have passed an ;$/D;=/ licensing e6amination other than the /!;@J-$/ prior to +2 &ecember +9>) are granted an e6ception to this re(uirement. ?efore 3or5ing 3ithout supervision 3ithin hisDher designated scope of practice the )>H#)D#, must pass the /!;@J-$/. (,) C / l an %4. The civilian R/ must be a graduate of an approved professional nursing program as noted above in paragraph (+). !urrent '$# "ualification 2tandards (civilian R/ employment standards) do not include the re(uire E ment for the /!;@JER/. Thus the civilian R/ is e6empt from this re(uirement. The foreign national local hire (</;9) R/ practicing outside the continental 1.2. ('!'/12) must maintain the appropriate 3ritten authori4ation from the country in 3hich heDshe is employed (see para .-9 d). (.) C / l an =54. The civilian ;$/ must be a graduate of an approved practical nursing program as noted in paragraph (2) above. To (ualify for the grade 02-. and above the civilian ;$/D;=/ is re(uired to possess a minimum of ) months of practical nursing e6perience or have successfully completed a program in practical nursing of at least 9 months duration. !urrent '$# "ualification 2tandards (civilian ;$/ employment standards) do not include the re(uirement for the /!;@JE$/. Thus the civilian ;$/D;=/ is e6empt from this re(uirement. (*) 0nd / dual" > !h bo!h %4 and =547=?4 l &en"e". %n instances 3here an individual maintains both an R/ and an ;$/D;=/ license heDshe 3ill be held accountable to the scope of practice of the position for 3hich heDshe 3as hired. ;$/sD;=/s employed by the 1.2. Army 3ho through advanced education (ualify for and obtain an R/ license must maintain an ;$/D;=/ license 3hen employed in an ;$/D;=/ position. ;i5e3ise the R/ 3ho has accepted a position as an ;$/D;=/ must maintain a current active valid and unrestricted license as an ;$/D;=/. The R/ license is not a substitute for a license as an ;$/D;=/. d. 12ARDAR/0 enlisted practical nurses ()>H#)D#,) must be in compliance 3ith the above stated licensure re(uirement. %ndividuals accessed into the 12ARDAR/0 for 3hom an R/ license 3as considered an acceptable substitute for the ;$/D;=/ license or others 3ho through advanced education no3 hold the R/ license must obtain an ;$/D;=/ license from their 2tate of licensure (or other 2tate). Those individuals 3ho have been unsuccessful in documented attempts to obtain dual 2tate licensure 3ill for3ard a re(uest for assistance through 9ead(uarters 12AR! (A<R!-#&) +.0+ &eshler 2treet 2H <ort #c$herson 0A ,0,,0-2000 to the !ommander 12A#@&!'# (#!9'-!;-") 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0. e. !linical psychologists 3ho have not been a3arded their doctoral degree are re(uired to ma5e continual progress

%4

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to3ard completing the doctoral dissertation and meeting 2tate licensure re(uirements throughout the period of their initial contract 3ith the 1.2. Army. &ue to differences in dissertation re(uirements no specific guidelines can be established for all clinical psychologists. The ma7ority of 2tates re(uire + year of postdoctoral supervision before a clinical psychologist is eligible for testing and provisional licensure. &irect accession clinical psychologists must possess a current active valid and unrestricted license upon commissioning (military) or 3hen hired (civilian). -. &entists ne3 dental accessions health professions scholarship program graduates and advanced general dentistry (A0& +2Emonth) residents must hold a current active valid and unrestricted license to practice dentistry in a 2tate or 1.2. 7urisdiction e6cept as noted belo3. (+) Recent dental graduates (up to 90 days after graduation) and A0& +2Emonth selectees must sho3 proof of having passed both $art + and $art 2 of the /ational ?oard &ental @6amination and of having ta5en a licensure e6amination in a 2tate or 1.2. 7urisdiction prior to reporting for A&. Recent graduates must obtain a license 3ithin + year of graduation from dental school. (2) &ental officers 3ith unusual or e6tenuating circumstances may re(uest a 3aiver of the +Eyear timeline to meet licensure re(uirements. Re(uests should be submitted through the chain of command to T20. g. 1nrestricted license specifications for the military are defined belo3. (+) An individual 3ith an unrestricted license has met all clinical financial professional and administrative re(uirements of the issuing 2tateA such license does not differ from the active license of the civilian counterpart. The re(uirement to possess a current unrestricted license 3as established by la3 (+0 12! +09. as amended by section C,. of the 2trom Thurmond /ational &efense Authori4ation Act for <iscal Iear +999 $ublic ;a3 +0*-2)+). (2) <or members of the #edical !orps (#!) &ental !orps (&!) Army /urse !orps (A/) #edical 2ervice !orps (#2) Army #edical 2pecialist !orps (2$) and =eterinary !orps (=!) an unrestricted license (or authori4ing document) is not sub7ect to limitations on the scope of practice ordinarily granted all other applicants for similar specialty in the granting 7urisdiction. (a) The unrestricted license must allo3 the professional unabridged permission to practice in any civilian commu nity in the 7urisdiction of licensure 3ithout having to ta5e any additional action on hisDher license. (b) The re(uirement to hold an unrestricted license also applies to physicians in residency programs 3ho are eligible for licensure as described above. 4>2 04ceptions to t(e re&uirement 'or unrestricted license a. ;egislation does permit 3aiver of the re(uirement for providers to possess an unrestricted license in Lunusual circumstances.M /oteF The payment of a 2tate8s license rene3al fee is not considered an Lunusual circumstanceM and is not sub7ect to 3aiver. (+) T20 has delegated licensure 3aiver authority through the 12A#@&!'# to the #T< commander. The commander may not e6ercise independent 7udgment or decision ma5ing in this activity. %n order to (ualify for approval the 'A2&(9A) must first have identified that the specific re(uirement is eligible for 3aiver. (2) Haiver of licensure re(uirements is not automatic. The provider must submit an application for 3aiver (obtained from the credentials manager). The 3aiver is valid only for the licensure period for 3hich it 3as re(uested. A ne3 application for 3aiver must be submitted for each licensure rene3al period. 2ubmission of subse(uent application for license 3aiver is the responsibility of the provider. (,) %f a 2tate presents an unusual and substantial licensure re(uirement that has yet to be identified this re(uirement and any supporting documentation 3ill be submitted 3ith the 3aiver application. The 3aiver re(uest pac5et is for3arded through the R#! to the !ommander 12A#@&!'# 3ho 3ill submit the re(uest to the 'A2&(9A) for consideration. The approvalDdisapproval from the 'A2&(9A) 3ill be for3arded by 12A#@&!'# through the R#! to the #T< of origination. (.) Approved licensure 3aivers 3ill be placed in 2ection =% of the $!< ne6t to the copy of the provider8s license. b. <or military 02 and personal services contract $As the re(uirement to possess and maintain a current active valid and unrestricted license is 3aived. !urrent /!!$A certification is the recogni4ed authori4ing document in lieu of license. &. The comple6ity of licensure certification andDor registration re(uirements and the changing environment of 2tate licensure policies renders this a dynamic process. 1pEtoEdate guidance 3ill be provided as necessary via conventional and electronic mail and 3ill be posted to the 12A#@&!'# "#& homepage httpFDD333.(mo.amedd.army.milD home.htm. 482 Contract privileged providers All contract employees must maintain a current active valid and unrestricted license or authori4ing document in accordance 3ith paragraphs .-, .-. .-C and a and b belo3. a. $ersonal services contractors and nonEpersonal services contracted providers 3ith duty in nonE1.2. locations may practice under a current active valid and unrestricted license from any 2tate or 1.2. 7urisdiction. 1.2.Ebased nonE personal services contracted providers in all disciplines 3ill be licensed by the 2tate or 7urisdiction in 3hich they are providing services.

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b. %n '!'/12 locations the host country must grant a 3aiver to permit an American citi4en (civilian) to be hired under a nonEpersonal services contract. This 3aiver must stipulate that the individual 3ill provide services only on the 1.2. <ederal enclave and 3ill be licensed in any 1.2. 7urisdiction not the host nation. The contracted employee may also obtain a license or other authori4ing document from the host nation via endorsement or reciprocity. $ersonal service contract personnel must be determined to be acting 3ithin the scope of employment to be covered. 4$2 nternational (ealt( care graduates 9ealth care professionals trained in foreign countries are eligible to practice in the A#@&& in their respective disciplines if the appropriate re(uirements are met. (The term LinternationalM replaces the previously used term Lforeign.M) a. 0n!erna! onal med &al gradua!e". 0raduates of foreign medical schools practicing in the 1.2. are re(uired to possess both a medical license and certification by the @ducational !ommission for <oreign #edical 0raduates (@!<#0) or <ifth $ath3ay. %nternational medical graduates participating in 1.2. ArmyEsponsored 0#@ 3ho have more restrictive re(uirements for 0#@ or 3ho encounter administrative obstacles related to meeting licensure re(uirements 3ill not be flagged nor sub7ect to other adverse privilegingDpersonnel action. Their status 3ill be e(ual to that mandated by the 2tate8s re(uirement for individuals of that category. (2ee the glossary for additional details regarding <ifth $ath3ay.) %nternational medical school graduates (including 1.2. citi4ens) 3ho desire <A$ entry must additionally be enrolled full time in or accepted to attend an accredited program in the 1.2. or $uerto Rico for the designated speciali4ed training. They must have completed an accredited $0I-+ program for <A$ entry at the $0I2 level. The speciali4ed training program must be accredited by the Accreditation !ouncil for 0raduate #edical @ducation (A!0#@) for residents. The 0#@ programs must meet the re(uirements of the 0#@ &irectory published by the American #edical Association or Iearboo5 and &irectory of 'steopathic $hysicians published by the American 'steopathic Association as applicable. b. 0n!erna! onal nur"e gradua!e". /urses 3ho are graduates from 7urisdictions other than the 1.2. must possess a current active valid and unrestricted license and certification the <ull @ducation !ourseEbyE!ourse Report by the !ommission on 0raduates of <oreign /ursing 2chools. This certification validates the educational credentials of graduates of international nursing schools and verifies that these individuals are (ualified to practice in the 1.2. c. 0n!erna! onal den!al gradua!e". &entists 3ho are graduates from 7urisdictions other than the 1.2. and !anada are e6pected to meet the criteria of paragraph d belo3 and 3ill be managed by the &! on a caseEbyEcase basis. d. 0n!erna! onal ;eal!h Care Gradua!e" and *+* +C+4US. To fulfill the re(uirements for licensure </;9 health care professionals from 7urisdictions other than the 1.2. 3ho are providing care to &'& beneficiaries '!'/12 re(uire 3ritten authori4ation (grant of permission of an official agency) from the country in 3hich they are practicing or 3here they 3ere trained. /e3ly employed </;9 health care personnel shall practice 3ith supervision for + year. #O@ of the </;98s practice provides evidence of current competence and serves as the basis for continuation of practice. The commander (or designee) 3ill delegate responsibility for conducting and documenting the necessary locally established #O@ activities. (2ee glossary for the definition of #O@.) <or purposes of hiring the </;9 and during the period of #O@ data collection initial authori4ation for the </;9 to provide care to &'& beneficiaries and to subse(uently continue practice must be determined based on the follo3ingF (+) !omprehension of and proficiency in oral and 3ritten use of the @nglish language as demonstrated by e6ternal agency evaluation if available or a personal intervie3 by the selecting official. (2) &ocumented clinical competency assessed by ob7ective performance measures. (,) $ossession of a current active valid and unrestricted licenseA certificationA registrationA or other authori4ing document to practice in the country of employment (host nation) or a license certification andDor registration accepted by the 1.2. as a basis for employment and practice in that country. 4502 +ailure to o,tain or maintain a license* certi'ication* and;or registration All health care personnel must be in full compliance 3ith the stipulations of this chapter. An individual 3ho is re(uired to possess a current active valid and unrestricted license or other authori4ing document and fails to obtain the license or other authori4ing document 3ithin the time frame specified is prohibited from practicing. %n the event the license or other authori4ing document is not obtained by the privileged (privilegesEeligible) individual 3ithin the time frame specified heDshe must re(uest a formal e6tension from the !ommander 12A#@&!'# (#!9'-!;-") 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0. 2aid re(uest 3ill include an e6planation of 3hy the license or authori4ing document 3as not obtained in accordance 3ith this guidance and 3ill address the individual8s specific plan for obtaining the license or authori4ing document. 'nly the !ommander 12A#@&!'# is authori4ed to grant the privileged (privilegesEeligible) provider an e6tension to obtain the license or other authori4ing document. <ailure on the part of the individual to re(uest an e6tension may result in the actions outlined in paragraph a or b belo3. %f an individual fails to maintain the license or other authori4ing document in good standing or allo3s it to lapse for any reason heDshe 3ill be prohibited from practicing. 9ealth care personnel not sub7ect to 1!#J 3ho provide care in violation of this regulation are sub7ect to a civil monetary penalty of not more than N*000.00 (+0 12! +09.). a. The follo3ing applies to military personnel both officer and enlisted 3ho fail to maintain the proper credentials to practice in their clinical A'!D#'2DA2%.
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(+) %ndividuals 3ho are not in compliance 3ith this chapter may have all favorable actions suspended under AR )00>-2. 1nfavorable personnel action (a nontransferable flag) is initiated pending involuntary separationDelimination due to lac5 of 2oldier (ualification. (2) The 2oldier8s obligated status does not e6empt himDher from adverse administrative actions to include early separation from service for loss of professional (ualifications should this be in the best interest of the 1.2. Army. (,) %ndividuals separated prior to completion of obligated service may be sub7ect to recoupment of educational subsidies. (.) 2oldiers (AAD12ARDAR/0) 3ith #'2 )>H#)D#, 3ho fail to maintain a current active valid and unrestric E ted ;$/D;=/ license do not meet the established re(uirements for the #)D#, A2% (#ilitary $ersonnel #essage /umber 0+-2+2). At the discretion of the unit commander AA 2oldiers may be authori4ed 90 calendar days (+>0 calendar days for the 12ARDAR/0) to rene3 their 2tate licensure. 9o3ever during this period of nonlicensure the 2oldier 3ill not be permitted to function as an ;$/D;=/. Hhile the 2oldier is considered non(ualified in the A2% #)D #, heDshe 3ill remain (ualified in the primary #'2 )>H. A 2oldier8s failure to rene3 2tate licensure immediately follo3ing the 90E or +>0Eday interval 3ill result in the unit commander initiating action for removal of #)D#, A2% according to governing regulations. (*) 2ub7ect to the needs of the 1.2. Army the 2oldier may be crossEtrained into another military career field or may revert to a previously held A'!D#'2. ()) Regular ArmyD12AR officers and enlisted 2oldiers 3ho are not in compliance 3ith this regulation may be involuntarily separated from the 2ervice under the provisions of AR )00->-2. AR ),*-200 AR +,*-+C* or AR +,*+C>. The local military personnel office (#%;$') 3ill be consulted for assistance in processing the individual for separationDdischarge from service. (C) 2ervice obligations resulting from receipt of special incentive pays military education (advanced course longterm civilian schooling) acceptance of promotion or resulting from the ,Eyear initial A& obligation incurred upon accession 3ithout 2erviceEsponsored education 3ill be handled as noted above in paragraphs (2) and (.). The appropriate finance office 3ill determine recoupment of any incentive pays or other remuneration. b. %f '$# Army or &'& re(uires a specific license certification andDor registration to (ualify for certain occupations maintenance of that license certification andDor registration is considered a condition of employment. <ailure to meet this condition of employment may result in administrative action to reassign suspend or remove the employee from their civil service position. 02 civilian personnel may be sub7ect to adverse personnel action according to Title * 12! and Title * $art C*2 !ode of <ederal Regulations (!<Rs) as implemented by appropriate &'& policies ARs and applicable labor agreements. The servicing civilian personnel advisory center (!$A!) and 2JA should be consulted for guidance throughout all phases of deprivileging disciplinary or adverse personnel actions against the civilian employee. c. The status of individual professional licensure certification andDor registration for all health care personnel 3ill be trac5ed at the facility level on a regular basis. This information 3ill be 5ept up to date in the !!"A2 or the A#@&&E identified database e(uivalent.
C(apter < Competency Assessment* !elegation* and Supervision o' 3ractice
<52 Competency assessment a. General. !ompetence is the ability of a staff member to apply decisionEma5ing psychomotor and interpersonal s5ills at the level of 5no3ledge e6pected for hisDher current duty position. 9ighly competent performance by members of the organi4ation is predicated on a variety of factors to includeF a carefully structured ne3 employee orientation ongoing education and training opportunities and formali4ed evaluation processes. %n this regulation the 3ord LstaffM refers to all #T< employees those 3ith patient care administrative or other support services responsibilities 3ithin the organi4ation (for e6ample house5eeping maintenance supply and so forth) including both military (AAD12ARD AR/0) and civilian contracted and volunteer personnel. The term Lhealth care personnelM includes all categories of individuals involved in the provision of health care and services (for e6ample laboratory technicians nurses physicians respiratory therapists). (+) !ompetency assessment is re(uired of all members of the staff and is demonstrated by one8s performance in a designated setting. $erformance must meet established standards that are determined in part by the 3or5 setting and the employee8s designated role in that setting. Thus the leaders of an organi4ation must have clearly defined the (ualifications and competencies that staff must possess to accomplish the organi4ation8s mission. (a) To standardi4e criteria for competency s5ills verification throughout the Army forms implemented at the &A level must be used. (b) T3o forms currently re(uired for this purpose are &A <orm C)*, =erification of !linical !ompetencies for

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!ritical !are 25ill %dentifier (2% >A) and &A <orm C)*. =erification of !linical !ompetencies for @mergency /ursing 25ill %dentifier (2% #*). (2) @ach #T< 3ill have in place a mechanism to collect and analy4e individual and group aggregate data from a variety of sources to assess the competence of staff and to identify training needs. (a, An annual report to the #T< e6ecutive committee as re(uired by the TJ! 3ill elaborate levels of competence patterns and trends and competency maintenance activities for all staff. The responsibility for data collection from all departmentsDservices and the preparation of the consolidated #T< report to the e6ecutive committee 3ill be according to local policy. This report should include such data asG +. Total number of personnel (entire organi4ation). 2. $ercentage of ne3 employees 3ho received ne3 employee orientation. ,. $ercentage of total staff 3ho have met AT re(uirements. .. $ercentage of total staff 3ho are competent based on organi4ational criteria to perform the specific re(uirements of their positions. *. 'f those staff for 3hom licensure certification andDor registration is appropriate the percentage of total for 3hom these credentials are current. ). 2pecific education or training needs as identified for all levels of staff. (b, Hhile all staff must be considered in the preparation of this report those 3ho have clinical contact 3ith patients should receive special focus related to identification of training needs and staff development opportunities. ;ocal policy 3ill direct 3ho in the organi4ation is responsible for data collection and preparation of this report. b. %e"pon" b l ! e". (+) +rgan 6a! onal. %mmediate supervisors (officer enlisted civilian) are responsible for assessing maintaining and improving staff competency through an ongoing series of activities. The organi4ation 3illG (a) @nsure all ne3ly assignedDemployed staff receive an orientation to organi4ation and 7obEspecific policies procedures and responsibilities. This orientation is accomplished 3ithin .* days of arrival (military)Demployment start date (civilian). %f military deployment or other select mission re(uirements necessitate e6tension of this time frame an annotation to this effect 3ill be made in the individual8s !A<. (b) %dentify the competencies to include ageEspecific 5no3ledge or s5ills (for health care personnel) that staff must demonstrate to perform in their assigned duty positions. The A/A 2tandards of /ursing $ractice and recogni4ed national nursing specialty organi4ation practice standards provide the professional frame3or5 upon 3hich nursing competency assessment is based. ;i5e3ise for other healthcare disciplines professional specialtyEendorsed practice standards 3ill apply. (c) !onduct initial and periodic competency assessment of staff and document these results. Aggregate data from these assessments should be used to identify competency needs patterns and trends for a given unit or the organi4a E tion. 2pecific training plans and activities at the unit department or organi4ational level 3ill address the staff8s identified learning needs. (d) %nform staff of the e6pectations and ob7ective criteria used to evaluate individual performance and any specific actions re(uired to improve or enhance 7ob performance. This includes revie3ing 7ob descriptions and performance standards. (e) &esign and implement various educational and training programs and an improvement plan as needed to enable staff to successfully meet the competency and performance standards established by the organi4ation. (f) #onitor and evaluate at least annually the formal educational and training programs in place and the response of staff members to these programs. The evaluation performed 3ill assess the overall value of the organi4ation8s programs and the degree to 3hich staff competence has been achieved and maintained relative to these programs. (2) 0nd / dual heal!h &are per"onnel. 9ealth care personnel both privileged and nonprivileged must maintain the re(uisite competencies associated 3ith the 7ob position to 3hich they are assigned 3ithin the organi4ation. <or licensed certified or registered health care personnel failure to maintain current competency may result in formal evaluation of one8s performance through the peer revie3 process. This may include a standard of care (2'!) determination and if applicable recommendation to the commander for adverse action against one8s privilegesDscope of practice or for appropriate disciplinary action. 9ealth care personnel 3illG (a) !omplete department and unit competencyEbased assessment and orientation as appropriate prior to indepenE dently performing duties re(uired of the position. (b) $erform those duties based on individual licensureDcertificationDregistration for 3hich they are competent and those for 3hich competency has been validated or privileges have been a3arded as determined by organi4ationalDunit policy or re(uirements. (c) Re(uest and participate in various training and educational programs as needed to enhance performance s5ills. (d) /otify the appropriate supervisor of assigned duties they are not competent to perform. &. +r en!a! on. All staff are re(uired to orient to and be proficient in the performance of the duties responsibilities e6pectations and components of their 7ob position. Throughout their employment 3ith the organi4ation staff members 3ill receive information and training on confidentiality ne3 e(uipment ne3 procedures or processes ne3 or revised

%8

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policies and ne3 performance e6pectations (that is ageEspecific populationErelated s5ills as appropriate). This training is in addition to that for 3hich an annual update is currently re(uired for e6ample fire and safety infection control basic life support (?;2) and so forth d. )du&a! on and !ra n ng a&! / ! e". %nEservice education as 3ell as formal continuing health professional education and training activities 3ill be made available to assist all staff in ac(uiring maintaining and improving 7obErelated competence. e. )mergen&$ l -e "uppor! !ra n ng. (+) All health care personnel (civilian or military) assigned or sub7ect to reassignment to duties involving the provision of patient care 3ill possess and maintain ?;2 certificate of training. &eployment or other e6tended absence does not e6empt the military member from this re(uirement. 'thers such as partEtime civilian consultants faculty members and so forth may be e6cluded from this re(uirement on a caseEbyEcase basis at the discretion of the #T< commander. 2aid e6ceptions 3ill be documented. (2) As a minimum the anesthesiologists and certified registered nurse anesthetists (!R/As) assigned to the anesthesia departmentDservice 3ill possess and maintain advanced cardiac life support (A!;2) certification. The physicians $As nurse practitioners (/$s) and R/s assigned to the emergency departmentDservice 3ill possess and maintain advanced emergency life support training (for e6ample A!;2 advanced trauma life support (AT;2) and so forth) according to AR .0-,. 'ther health care personnel (medicalDdental) re(uiring A!;2 AT;2 or other advanced life support training are at the discretion of the #T< commander. A!;2 or other advanced life support training is not a substitute for ?;2 training. The demonstrated mastery of life support s5ills is essential. 'nline ?;2 A!;2 pediatric advanced life support ($A;2) or AT;2 courses do not satisfy the re(uirement for this training. @mergency life support training sponsored or endorsed by the American 9eart Association is the only training recogni4ed as acceptable. (,) %n support of a deployed force that 3ill include 2oldiers 3ith a broad spectrum of health care needs &A or &'& civilians and 0overnment contractors $As assigned to all T'@ units are encouraged to obtain and maintain A!;2 certification. !oordination of A!;2 training for divisional assets is a 7oint responsibility bet3een the &ivision 2urgeon and the &92. -. 5er-orman&e e/alua! on. @ach staff member8s performance is evaluated according to Army and '$# (02 civilians) regulatory guidance both periodically (for e6ample (uarterly counseling or as needed) and at regularly scheduled intervals (for e6ample midpoint or annual performance appraisal counseling as re(uired by the Army $erformance Appraisal 2ystem). $erformance evaluation is usually conducted by the person 3ho directly supervises the individual8s dayEtoEday 3or5 performance. These evaluations are analy4ed by the supervisor for patterns or trends related to specific performance issues for 3hich additional training education or more formal corrective action may be re(uired. ?oth individual and aggregate employee data should be considered 3hen determining ho3 best to improve and sustain the s5ills of assigned personnel. %n selected circumstances 3ritten tests may be appropriate to determine the employee8s competency and ability to fulfill specific 7obErelated responsibilities (for e6ample dosage calculations related to potentially highEris5 medications). g. Compe!en&$ -a&!or". The s5ills and abilities that are essential to every staff member8s successful 7ob performance fall into three distinct categoriesF cognitive psychomotor and interpersonal. These factors directly correlate to performance standards and are the basis for employee competency assessment and evaluation. (+) Cogn ! /e or &r ! &al !h n8 ng "8 ll". %dentifying sub7ective and ob7ective data that are relevant to one8s clinical practice and assessing their significance to determine 3hat action if any is 3arranted. (2) 5"$&homo!or or 8no>ledge<ba"ed ph$" &al !a"8 "8 ll". $erforming selected patient care or support functions that re(uire manual de6terityDability and an understanding of 3hat series of steps are re(uired and in 3hat specific order. (,) 0n!erper"onal "8 ll". =arious interactions that ta5e place 3hen meeting establishing rapport intervie3ing and providing care or service to patients <amily members and visitors as 3ell as 3or5ing 3ith other staff. 2uch interactions occur in any and all settings both 3ithin the organi4ation and outside the organi4ation (that is the R#! 12A#@&!'# TR%!AR@ lead agent) and reflect the individual8s ability to function effectively 3ithin an assigned team or 3or5 group. h. Compe!en&$ do&umen!a! on. (+) 4onpr / leged heal!h &are per"onnel. A !A< 3ill be maintained by the first line supervisor for all nonprivileged health care personnel 3or5ing 3ithin the A#@&&. The !A< 3ill be readily available to the employee for updates but protected from general vie3 or public access. <or nonEprivileged 12ARDAR/0 personnel the credentials file main tained by AR!!A contains the documents typically included in the !A<. %n the conte6t of this chapter the terms L!A<M and Lcredentials fileM are interchangeable. (a) The !A< is the repository for a variety of relevant professionally oriented data and information that are accumulated throughout the individual8s tenure 3ith the organi4ation. The !A< should contain information that relates to or may influence clinical performanceA it is not a personnel or counseling folder. !ounselingDdisciplinary records performance appraisals and similar documents 3ill not be retained in the !A<. (b) The !A< is a chronological record that is utili4ed throughout the individual8s employment contract assignment or agreement 3ith the A#@&& during deployment any T&I in support of health careDservice mission and permanent change of station ($!2)Dtransfer. %t 3ill be hand carried by the nonprivileged professional (militaryDcivilian) from one

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place of duty to the ne6t. <or R! the !A< should accompany members during all assigned periods of duty 3ith AA #T<s. 1pon separation from <ederal employment the contents of the !A< 3ill be turned over to the individual in (uestion or destroyed. (c) Jerographic copying of the nursing license certification or registration is permissible. These copies 3ill be protected and secured as specified for $!<D$A< contents (see para >-, b(2)(c)). /either the original nor a copy of the individual8s license (other authori4ing document) 3ill be maintained in the !A<. %nstead an annotation to indicate that the document 3as verified 3ith the primary source 3ill be made in the !A< or other location as specified in local policy. This annotation 3ill includeF date method of verification the $'! contacted and the name of the individual doing the verification. To prevent identity theft social security numbers (22/s) home addresses or other personal identifying informationEEother than the employee8s nameEE3ill not be recorded in the !A<. (d) The nonprivileged professional has a right to revie3 ma5e comment on and receive copies of all materials in hisDher !A<. 9eDshe is responsible for ensuring that all information in the !A< is current. (e) Adverse information 3ill be maintained according to local policy (that is in a unitElevel personnel file main E tained by the firstEline supervisor) and not in the !A<. The individual in (uestion 3ill be provided a copy of any material of an adverse nature (that 3hich reflects negatively on the professional8s conduct condition clinical compe E tence or clinical performance) and offered the opportunity to comment or reclama before it is placed in hisDher personnel file (not !A<). 2tatements by the individual in response to this adverse information 3ill also be included. 1nprofessional conduct or performance that may be grounds to suspend revo5e or restrict a staff member8s license certification andDor registration 3ill re(uire a formal peer revie3 as defined in chapter ). (f) Removal of any adverse information contained in the unitElevel personnel file 3ill be accomplished only if authori4ed by the commander (or designee). (g) &ocuments that reflect the individual8s employment history education and assessment of competence 3ill be maintained in the !A< for a minimum of , years and may be purged according to local policy. <or 12ARDAR/0 members the contents of the !A< that reflect past practiceDcompetency assessment 3ill be maintained for * years. The specific forms to be included in the !A< in 5eeping 3ith the general guidance in appendi6 ! 3ill be at the discretion of the local command. (h) ;ocal policy 3ill address security of the !A< and identify responsibilities for updating its contents. <or 12ARD AR/0 members the !A< 3ill be available during all %&T active duty for training (A&T) and AT periods. Additions and modifications to the 12ARDAR/0 !A< contents are a 7oint responsibility of both the Reserve unit and the AA facility staff. (i) 2ee appendi6 ! for additional information regarding the recommended structure and contents of the employee !A<. (2) 5r / leged heal!h &are pro/ der". %nitial competency assessment is based on documented academic education letters of reference andDor supervised practice and standardi4ed credentials data contained either in the $!< or the provider activity file ($A<). This same information serves as the basis for initial medical staff appointment and clinical practice privileges. The biennial rene3al process as described in chapter 9 integrates findings from a variety of performanceEbased determinants and substantiates privileged provider competency. (,) Spe& al -or&e" med &al "ergean!". The special forces medical sergeant #'2 +>& is a combat arms 2oldier 3ith e6tensive medical education and training in life sustaining s5ills. This individual performs the militaryEuni(ue function of providing primary care medical support to operational units in remote or isolated environments in the absence of a medical officer. (a) The +>&8s responsibility for health care of special forces unit members in operational situations 3orld3ide demands that compassion comfort and care be provided to the utmost of a person8s ability even though the situation may 3ell re(uire s5ills far beyond those of an unlicensed health care giver. %n order to maintain and improve the operational readiness of this Army medical resource the +>& is authori4ed to perform specific clinical tas5s proce dures and interventions as approved by the #T< commander under the direct supervision of a privileged provider. (b) The +>& assigned to an #T< for sustainment training 3ill participate in a structured training program 3ith integrated components of direct handsEon patient care sufficient to ensure competency in the advanced scope of practice as addressed in appendi6 &. %t is e6pected that the +>& in consultation 3ith the supervising privileged provider 3ill participate in the delivery of routine health care perform patient assessments provide initial stabili4ation of acute illnesses and in7uries and manage a variety of health care needs to include comple6 chronic conditions according to the individual8s academic preparation and prior clinical e6perience. (c) The specific guidelines and parameters related to +>& medical proficiency training 3ill be based on the #T<8s scope of services and the availability of appropriate supervisory support. At the conclusion of the sustainment training a performance evaluation 3ill be conducted to evaluate the +>&8s competence and to determine if the identified training ob7ectives 3ere achieved. (d) ?ecause the +>& is a nonmedical #'2 this brief discussion has been provided to ac(uaint the reader 3ith the

AR 4068 0 6 !ebruary 004

nontypical medical proficiency training re(uirements these individuals place on a T&A #T<. <or additional information on career management field )>Eseries clinical competencies (scope of practice) contact the !ommander. 12A#@&!'# ATT/F #!9'-!;-! 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0. <#2 !elegation a. &elegation transfers to a competent individual the authority to perform a selected patient care tas5 in a given situation. Typically delegation involves the licensed or privileged professional allo3ing a specified patient care activity that is 3ithin hisDher o3n scope of practice to be performed by unlicensed assistive personnel (1A$s) an R/D ;$/ or other nonnursing personnel. The authority to perform the tas5 is passed to another but the professional responsibility and accountability for the overall care provided and for associated patient outcomes remains 3ith the delegating individual.
4o!e. %n structured training situations a provider may delegate a privileged tas5 function or process to a competent nonprivileged professional (for e6ample a medical student or +>&. The privileged provider is responsible and accountable for the tas5 function or process that has been delegated and for the patient outcomes. A specific 3ritten plan for supervision of the nonprivileged individual as determined by the assessed level of hisDher competence is re(uired. (2ee para *-, for additional detail regarding types of supervision.)

b. =arious health care personnelGto include )>Eseries career management field 2oldiers nursing assistants and others Gmay be considered and utili4ed to perform delegated tas5s in the delivery of patient care if the individual is competent to perform those tas5s. The +>& is authori4ed to perform an e6tensive variety of clinical tas5s in order to sustain and improve 3artime readiness. Appendi6 & provides an overvie3 (not all inclusive) of the +>&8s advanced scope of practice and outlines the types of clinical e6periences that are critical to his medical s5ills proficiency. The specific guidelines and parameters related to +>& medical s5ills sustainment training 3ill be based on the #T<8s scope of services and the availability of appropriate supervisory support. &. $rofessional 7udgment on the part of the privileged provider or the licensed certified andDor registered individual is re(uired to determine 3hich patient care activities are appropriate to delegate. The determination must ta5e into consideration the safetyDprotection of the patient any patientEuni(ue needs the level of care re(uired by the patient the education and training of the individual to 3hom the tas5 is delegated and the e6tent of supervision re(uired. Any intervention that re(uires independent speciali4ed professional 5no3ledge or s5ill andDor re(uires assessment evaluation and clinical 7udgment 3ill not be delegated. Activities appropriate for delegation are those 3hich meet all of the follo3ing criteriaF (+) <re(uently or routinely reoccur in the daily care of a patient or group of patients (that is vital signs inta5e and output select e6ercisesDactivity routines preparation for or conducting certain diagnostic procedures or tests and so forth). (2) &o not re(uire the individual to e6ercise independent 7udgment. (,) &o not re(uire comple6 andDor multiEdimensional application of the clinical or nursing process. (.) 9ave predictable results and minimal potential ris5 to the patient. (*) 1se an established and unchanging procedure (that is protocol !$0 or standing operating procedure). d. 2elected invasive and highEris5 tas5sDprocedures may be performed by 1A$s and others 3ho have received documented formal trainingA such training may include a certification process. ;ocal policy 3ill direct 3hich highEris5 tas5sDprocedures may be delegated and to 3hom and 3hat level of supervision is re(uired. The privileged providerD professional 3ho is responsible for directDindirect supervision of the 1A$ the +>& or other individual performing a given tas5Dprocedure is also responsible for the immediate postEprocedure evaluation and disposition of the patient. e. %t is the responsibility of local leadership to ensure for all health care personnel to 3hom patient care tas5sD procedures have been delegated that individual competency is assessedA competencyEbased orientation is providedA and utili4ation of personnel is based upon demonstrated 5no3ledge s5ills and technical proficiency. <82 Supervision o' practice To ensure the competence and s5ill of those providing health care and services to every category of A#@&& beneficiaries all health care personnel are provided supervision of their clinical performance as appropriate. This re(uirement based on a concern for public protection and $2 is predicated on $; and reinforced by various 2tate authori4ing agencies. %n addition the supervision of clinical practice is fundamental to both the #T<8s provider privileging and individual performance evaluation processes and it is scrutini4ed by the e6ternal bodiesDorgani4ations that accredit or certify institutional performance. a. #&! / ! e". 2upervisory activities are performed in the conte6t of the relationship that e6ists bet3een supervisor (senior staff member) and employee (subordinate staff member). The assessment and ongoing validation of the employee8s ability to perform various privileged tas5s or patient care activities as applicable substantiates the competency of both privileged and nonprivileged health care personnel. b. T$pe" o- "uper/ " on. (+) The performance of all health care personnel is supervised indirectly or directly and evaluated according to

AR 4068 0 6 !ebruary 004

established AR and '$# guidance. 2pecific re(uirements related to individuals re(uiring direct supervision 3ill be locally determined based on the uni(ue circumstances necessitating this level of supervision. (a) 0nd re&!. The supervisor performs retrospective revie3 of selected records andDor observes the results of the care provided. !riteria used for this revie3 relate to (uality of care (uality of documentation and the staff member8s authori4ed scope of practice. (b) * re&!. &uring the delivery of health care and services the supervisor is involved in the decisionEma5ing process. This may be further subdividedG +. ?erbal. The supervisor is contacted by telephone or by informal consultation before the supervised individual implements or changes a regimen or plan of care. 2. 5h$" &all$ pre"en!. The supervisor is physically present through all or a portion of care.
4o!e. P$hysically presentP 3ill be locally defined and determined on a caseEbyEcase basis given the uni(ue needs of the individual being supervised. This 3ill be addressed in hisDher personali4ed plan of supervision.

(2) %n select circumstances (that is for professionals not yet licensed for novices or those returning to patient care responsibilities 3ho must developDrefine s5ill and competence or for those staff 3hose performance is less than acceptable) supervision is a formal re(uirement. The type of supervision that is 3arranted 3ill be clearly identified and the plan for supervision articulated in 3riting. (a) #T<s 3ith graduate professional health education (0$9@) programs 3ill have a mechanism(s) in place and approved by the medical staff for supervision of program participants in the performance of their patient care responsibilities. 2upervision 3ill be rendered by an appropriately privileged provider ideally in the same discipline 3ho is familiar 3ith the role responsibilities and patient care activities of the 0$9@ program participant. This re(uirement applies to members of all disciplines 3ho are not yet licensedDprivileged but are involved in the provision of patient care.
4o!e. %n the conte6t of this regulation 0$9@ applies to graduate level clinical training for all healthErelated disciplines (all corps).

(b) %ndividuals 3ithout clinical privileges must function 3ithin the 3ritten guidance of a 7ob description specific to the level of care being provided. Job descriptions may be based on the role and need not be traineeEspecific. (2ee glossary for detailed definitions of supervised privileges for providers and enhanced supervision.) &. The plan o- "uper/ " on. The intent of providing appropriate oversight of practice in the conte6t of this regulation is to evaluate and enhance performance of health care personnel in delivering patient care services. 0iven that ob7ective a planned and organi4ed approach to supervision is appropriate. The 3ritten plan of supervision maintained in the $A< (privilegeEeligible provider) or !A< (nonprivileged professional) as appropriate 3ill includeG (+) The !$pe o- "uper/ " on !o be pro/ ded. (2ee para b above.) The type of supervision 3ill be based upon the assessed needs of individually privileged providersDnonprivileged personnel. (2) The name o- !he "uper/ "or. The commander 3ill appointGin 3ritingGa primary and alternate supervisor. This individual (same or similar discipline) 3ill possess the professional e6perience and competence to provide appropriate oversight of the supervised provider8sDprofessional8s practice. The supervisor 3ill ensure that care andDor services provided are consistent 3ith the authori4ed scope of practice or privileges and all approved policies procedures and practice guidelines as applicable. (,) 5er-orman&e e/alua! on". The specific intervals at 3hich performance evaluations 3ill be conducted during the period of supervision 3ill be noted. (a, 5r / leged pro/ der". 2upervisors of privileged providers 3ill complete periodic clinical performance evaluations based on the individual8s e6perience and competency utili4ing &A <orm *..+ (@valuation of !linical $rivileges Anesthesia) and &A <orm *,C. ($erformance Assessment). These are filed initially in the $A< and transferred to the $!< at the time of clinical privileges rene3al $!2 or release from serviceDemployment. A variety of parameters allo3 for revie3 of the appropriateness of care and the privileged provider8s current competence. 'rgani4ations must consider and integrate into the plan for supervision and the evaluation of privileged provider performance current TR%!AR@ and other managed care performance assessment variablesDoutcomes. These address such factors asG +. &iagnostic techni(ues and procedures and associated costs. 2. Therapeutic practice patterns and outcomes of care. ,. !onsultation and referral patterns. .. Availability and productivity. *. &ocumentation of patient care and services. (b, 4onpr / leged per"onnel. 2upervisors of nonprivileged health care personnel 3ill complete periodic clinical performance evaluations as specified in the plan of supervision (narrative format or other locally devised format) that address the individual8s demonstrated abilities and competency to perform the duties responsibilities e6pectations and components of hisDher 7ob position. The individual8s improvement or lac5 of improvement related to hisDher docu mented performance limitationsDinade(uacies 3ill be assessed and addressed in each 3ritten evaluation. d. Unl &en"ed heal!h &are per"onnel. (+) ?oth privileged providers and nonprivileged professionals 3ho re(uire an authori4ing document for practice and 3ho are not licensed certified andDor registered (for e6ample students in health professions8 training graduates
AR 4068 0 6 !ebruary 004

a3aiting licensure e6amination results and so forth) 3ill practice only under the supervision of a properly licensed certified andDor registered (and privileged if re(uired) professional of the same or similar discipline.
4o!e. <oreign military health care personnel or others involved in official e6change student capacity are included in this category.

(2) The level of supervision 3ill be more comprehensive than that provided a licensed individual of the same discipline. At preEdetermined intervals as stipulated in local policy the professional8s performance competence and capabilities in hisDher assigned military or civilian position 3ill be assessed and documented. e. 5r / leged pro/ der". (+) $rivileged providers are responsible to their disciplineEspecific department chief or supervisor for the ongoing assessment of the (uality of care they provide 3ithin their disciplineEspecific scope of practice and defined privileges. The disciplineEspecific chiefDsupervisor 3illG (a, Revie3 and recommend approval of the application for privileges and the $!< prior to submission to the credentials committeeDfunction. (7, #onitor and evaluate the disciplineEspecific scope of practice. (&, !onduct routine peer revie3 of individual practice according to local policy. (2) %n instances of a sole privileged provider in a given setting or the provider is the senior member of hisDher discipline (that is the chief of the department) the provider is responsible to an assigned clinical authority as appropriate to the organi4ation. This individual (from 3ithin the #T< or the R#!) 3ill perform appropriate supervisory functions and provide oversight of the care and services delivered to authori4ed beneficiaries. (a, The individual tas5ed 3ith oversight authority may be of the same discipline a similar discipline or a physician. (7, The individual selected must be (ualified by education and e6perience to provide the appropriate level of supervision and oversight of practice that is re(uired. (,) $hysician supervision of members of another discipline (for e6ample 'Ts $Ts nurses pharmacists) is not re(uired for functions performed that are 3ithin the scope of practice authori4ed by the individual8s license registration certification or privileges. -. +!her &on" dera! on" rela!ed !o "uper/ " on and e/alua! on o- heal!h &are per"onnel. (+) Army policy andDor 2tate licensing la3s re(uire physician supervision of $As privileged to provide patient care and services. 2aid physician supervisor (and an alternate) 3ill be named in 3riting by the #T< commander. (2) 2ignificant variation e6ists among 2tates relative to physician supervision of nonphysician providers. ;i5e3ise variation among 2tates may e6ist regarding supervision andDor the scope of practice of the R/ ;$/ or other licensedD certifiedDregistered professional. The individual nonphysician privileged providerDprofessional is responsible for informE ing hisDher immediate supervisor of any specific 2tateEdirected re(uirements for supervision of clinical practice. %deally this information should be elicited from the employee during orientation and 3ill be documented in hisDher !A<. The immediate supervisor 3ill ensure appropriate coordination to facilitate organi4ational compliance 3herever feasible. (,) Regardless of the oversight andDor supervisory relationship that e6ists provider collaboration and collegial interchange in support of high (uality patient care is the standard in all settings and circumstances. (.) %ndividuals responsible for clinical oversight of privileged or nonprivileged health care personnel need not be responsible for the overall performance evaluation ('@RD@nlisted @valuation ReportDcivilian performance appraisal). &ecisions regarding nonclinical rating schemes must be based on the structure of the organi4ation and other variables that are individual provider and facility specific. (*) A copy of the privileged provider8s clinical performance evaluation (not the '@R or its civilian evaluation e(uivalent) 3ill be for3arded to the #T< credentials committeeDfunction. These documents 3ill be maintained in 2ection %% of the $!< and are the basis for biennial rene3al or revision as needed of clinical privileges. g. Super/ " on o- "&reen ng per"onnel. 2creening personnel (enlisted or civilian) assigned for duty in various clinic settings are permitted to utili4e the algorithmEdirected troop medical care (A&T#!) system (or comparable system) to screen A& 2oldiers during daily sic5 call activities. (!ontact 12A#@&!'# ATT/F #!9'-!;-! for use of this system.) 1se of an algorithmEbased system is mandatory 3hen screening personnel provide evaluation treatment andD or disposition of A& sic5 call patients. #T< commanders 3illG (+) @stablish a local training program in the appropriate use of A&T#!. 2creeners must complete the formal training program prior to being assigned to evaluate treat andDor ma5e disposition of A& 2oldiers 3ho present for care. This training 3ill be documented in the individual8s !A<. (2) @nsure that screeners are provided ade(uate supervision and performance evaluation by a physician $A or other (ualified provider specifically assigned this responsibility. &ocumentation of the care provided by A&T#! screeners &A <orm *+>+ (2creening /ote of Acute #edical !are) or li5e form 3ill be revie3ed on a daily basis. 2creener evaluation 3ill be documented according to instructions from the 12A#@&!'# ATT/F #!9'-!;-!. (,) @nsure that the screener8s scope of practice 3ith regard to evaluating treating andDor determining the disposition of A& sic5 call patients is delineated in 3riting and that it is revie3ed and revised at least annually. (.) Approve the list of selfEcare medications as recommended by the pharmacy and therapeutics ($OT) committee (see AR .0-,) to be dispensed by screeners. 2creeners may be approved to dispense the overEtheEcounter medications

AR 4068 0 6 !ebruary 004

addressed in the screening manual. Additions re(uested for use at the local level are authori4ed only if formal documented training related to the safe and appropriate use of these medications has occurred. (*) Re(uire monthly visits by the appropriate departmentDservice chief to all clinics utili4ing A&T#! to ensure compliance 3ith the above re(uirements. This oversight responsibility may not be delegated.

C(apter 6 7(e 3eer Revie= 3rocess

652 @eneral $eer revie3 of dayEtoEday performance is integral to the $% and competency assessment processes for all licensed certified andDor registered health care personnel both privileged and nonprivileged. This routine revie3 typically focuses on medical records8 contents and direct observation of performance. 9o3ever in the conte6t of a possible adverse privilegingDpractice action the process ta5es on a greater degree of formality and involves fact finding study and analysis of a single incident that resulted in significant harm to a patient or a series of events involving a professional8s performance conduct or condition. %t is conducted in a collegial climate and is focused on obtaining all relevant information about the situation. $rior to any adverse action related to privilegesDscope of practice peer revie3 is re(uired for individuals 3ho are licensed certified andDor registered. ;i5e3ise in the event that an action against an individual8s license (other authori4ing document) may be contemplated a formal peer revie3 3ill be conducted. This chapter presents the basic frame3or5 for a formal peer revie3. Additional specifics associated 3ith peer revie3 and adverse privilegingDpractice actions are contained in chapter +0. $eer revie3 in relation to an 2'! determination for a medical malpractice claim is discussed in chapter +,. 6#2 7(e peer revie= 'unction a. A peer is one 3ho is from the same professional disciplineDspecialty as the individual undergoing revie3. &uring a peer revie3 selected health care personnel (that is peers) evaluate the (uality of the patient care rendered by another professional. These selected health care personnel 3ho are (ualified by education and e6perience 3ill identify opportunities for clinical $% and as appropriate determine 3hether or not given an adverse event or malpractice claim recogni4ed standards of practice 3ere follo3ed or the 2'! 3as met by the individual in (uestion. $rofessional (ualificationsA adherence to established professional standards for the disciplineA the merits of any allegations of substandard s5ill abilities or performanceA and recommendations for adverse privilegingDpractice or administrative action to be ta5en concerning these complaints are also considered.
4o!e. %n circumstances 3here nursing practice is sub7ect to scrutiny in order to determine (uality efficacy or appropriateness the specialtyEspecific A/A 2tandards of !linical /ursing $ractice 3ill apply.

b. @ach #T< 3ill establish peer revie3 processes that are nonadversarial. %deally the peer revie3 should be conducted as soon as possible (3ithin ,0 calendar days) after identification of the incident circumstance or behavior for 3hich a peer revie3 is 3arranted. The results of the peer revie3 shall be made 5no3n to the individual in (uestion as soon as possible follo3ing the conclusion of the peer revie3 activities. 2ee chapter +0 for specific time frames related to notification. The departmentDservice chief is responsible for initiating and coordinating the peer revie3 activities for nonprivileged personnel. <or a privileged provider the peer revie3 is typically coordinated by the credentials or the R# committee. $eer revie3 sub7ects are entitled to due process 3hich includes but is not limited to the right to a hearing and the right to appeal the decision of the #T< commander to the ne6t higher level of command. (2ee para +0-)- for additional detail.)
682 Composition o' peer revie= ,oard $eer revie3 activities may be accomplished either by an established committeeDsubcommittee (that is credentialsDR#) or by an ad hoc peer revie3 panelDcommittee constituted on an asEneeded basis. The formal committeeDsubcommittee structure may perform the peer revie3 function for all categories of personnel or for only privileged staffA the ad hoc committee may be responsible for the nonprivileged personnel. The peer revie3 mechanism that is most appropriate for the organi4ation 3ill be addressed in local policy. The si4e of the #T< and the number and variety of health care personnel for 3hom peer revie3 is appropriate 3ill determine 3hether one or more than one peer revie3 mechanism is established. 'ne option is a single peer revie3 panel 3ith selective membership of an odd number of participants the ma7ority of 3hom are peers of the staff member 3hose practice is being revie3ed. This is a more fle6ible alternative than each departmentDservice assuming responsibility for its o3n ad hoc peer revie3 panel. %n circumstances such as outlying health clinics 3here sufficient staff are not available to conduct peer revie3 the process 3ill be performed at the ne6t level in the chain of command. 642 7(e intent o' peer revie= 2tructured feedbac5 from an individual8s peers (that is a performance assessment (chaps * and 9)) may be used at any time an unbiased e6ternal revie3 of a staff member8s dayEtoEday performance is appropriate. This is considered an
4 AR 4068 0 6 !ebruary 0041RAR 2ay 00&

informal peer revie3. 9o3ever peer revie3 as presented in this chapter is in the conte6t of an adverse privilegingD practice action and is a formal process. A formal peer revie3 is re(uired 3henever an 2'! determination must be made or 3hen the staff member8s performance is such that an adverse practice action (for e6ample limitation of duty or removal from the clinical setting) is considered. The purpose of this revie3 is to e6amine information obtained from the structured unbiased investigationDin(uiry and any other relevant materials. <ollo3ing the revie3 recommendations are presented to the commander regarding the clinical performance competence and liability (medical malpractice case) of the individual. The peer revie3 mechanism is intended toG a. $rotect the rights of the individual (afford due process). b. %dentify systemic issues and refer to appropriate !"# channels for resolution. c. 2eparate professional actions and considerations from administrative or legal considerations. d. $rovide timely reporting to the 12A#@&!'# "#& utili4ing &epartment of &efense <orm (&&) 2.99 (9ealth !are $rovider Action Report) (see chap +0) or && <orm 2*2) (!ase Abstract for #alpractice !laims) (see chap +,) 3hen the need is identified to report a health care privileged provider or nonprivileged professional to a regulatory body. 6<2 Conducting t(e peer revie= a. Hhen a privileged or nonprivileged staff member is removed from all or a portion of hisDher patient care duties the peer revie3 function must be initiated to determine the e6tent of the problem and to ma5e recommendations for further action on the professional issues in the case (for e6ample retraining supervised practice a licensing action). The focus of the peer revie3 is on ho3 the action under revie3 impacts the individual8s ability to practice clinically. b. All procedures related to peer revie3 (notification 3ithdra3al of permission for offEduty employment hearing rights the appeal process) are the same for both privileged and nonprivileged personnel. 2ee chapter +0 for additional guidance associated 3ith peer revie3. 662 Recommendations and 'ollo=up reporting a. %n all cases the recommendations resulting from peer revie3 and subse(uent action by the commander 3ill be for3arded to the supervisor of the staff member 3hose practiceDconduct 3as the sub7ect of the peer revie3 proceedings. %t is the responsibility of the supervisor to ensure that the recommendations from the peer revie3 function and actions ta5en by the commander are implemented. b. The peer revie3 function may recommend reporting the staff member to a licensingDregulatory agency. ;ocal policy 3ill establish 3ho is responsible for preparation of the && <orm 2.99. The #T< commander 3ill for3ard this document to !ommander 12A#@&!'# #!9'-!;-" 20*0 Horth Road <ort 2am 9ouston Te6as C>2,.-)0+0 3ith copy furnished to the R#! or other higher head(uarters as appropriate. The recommendations of the peer revie3 panel and all other information related to the case 3ill accompany the && 2.99 3hen reporting of a privileged provider or nonprivileged professional to a licensing or other regulatory body is re(uired. T20 is the sole reporting authority (para +.-,).

C(apter > 3rivileged %ealt( Care 3roviders

>52 @eneral a. This chapter includes general information and specific professional re(uirements related to each category of privileged provider (military or civilian) listed belo3. The information presented is intended to be a broad overvie3 rather than allEinclusive and 3ill change over time as health care re(uirements evolve. The privileged providers addressed include but are not limited toG (+) A$R/. (a) !ertified nurse mid3ife (!/#). (b) !R/A. (c) !linical nurse specialist (!/2). (d) /$ to include <amily adult pediatric 3omen8s health care acute care geriatric emergency and so forth. (2) Audiologist. (,) ?ehavioral health practitioner. (.) !hiropractor. (*) !linical pharmacist. ()) !linical psychologist. (C) !linical social 3or5er. (>) &entist. (9) &ietitian.
AR 4068 0 6 !ebruary 004 +

(+0) 'T. (++) 'ptometrist. (+2) $hysician. (+,) $A and specialty physician assistant. (+.) $T. (+*) $odiatrist. (+)) $sychological associate. (+C) 2peech pathologist. (+>) 2ubstance abuse counselor.
b. !linical privileges 3hich define the individual8s scope of practice in a specific institution are granted to health care providers based on their credentials clinical competence and the mission and re(uirements of the organi4ation. (+) The privileged provider is authori4ed to ma5e independent decisions related to beneficiary health care manage E ment based on hisDher recogni4ed scope of practice. 9eDshe may supervise coordinate and direct as appropriate the care provided by other members of the health care team. A representative scope of practice by discipline is provided in the pages that follo3. !hanges to the scope of practice for any of the privileged providers presented in this chapter are at the discretion of the #T< commander 3ho is the privilegeEgranting authority.
4o!e. Hhile the specialist in blood ban5ing (2??) may be a3arded clinical privileges in the specialty heDshe does not function independently to diagnose initiate alter or terminate health care treatment regimens. The term Lprovider M as defined in this regulation does not apply to the 2??. (2ee paras 9-+ and 9-2 for additional information regarding the granting of clinical privileges.)

(2) The specific and individual privileges of each provider are delineated on the appropriate &A <orm *..0 &elineation of !linical $rivileges contained in hisDher $!<.
4o!e. 2ee app A for a complete listing of the &A <orms *..0 series.

$roviders 3ith admitting privileges and all physicians 3ill be appointed to the medical staff. <or health care providers 3ho are not authori4ed to admit patients medical staff appointment is optional. The individual8s category of privileges appointment status and authority to admit patients are reflected on &A <orm *..0A Approval of !linical $rivilegesD 2taff Appointment. >#2 Clinical practice a. *e& " on ma8 ng. !linical care decisions and specific therapeutic interventions on the part of the provider are based in part on !$0sA nationally recogni4ed standards of careDpracticeA current professional clinical referencesA and other relevant regimens guidelines or policies as appropriate. These serve as a frame3or5 for practice and are the basis for the specific clinical privileges re(uested by the individual provider and for periodic performance revie3 and evaluation activities. b. Collabora! on. <or privileged providers other than physicians and dentists a designated physician 3ill al3ays be available for consultation and collaboration in person telephonically or by any other means that allo3s personEtoperson e6change of information. !ollaboration reflects both independent and cooperative decision ma5ing based on the professional preparation and ability of each provider. !ollaborative practice implies an open e6change of patient data and information and includes such activities as consultation referral coordination and coEmanagement of patient care. c. 5harma&eu! &al". $rivileged providers are authori4ed to prescribe pharmaceuticals contained in the #T< for E mulary according to the guidance established by the local $OT committee. <or providers other than physicians and dentists the drugs approved for prescription 3riting 3ill be based on the provider8s scope of practice and the beneficiary group(s) served. An open formulary is authori4ed. <acilityEspecific e6ceptions either by category of drug or itemi4ed by name of drug 3ill be noted in 3riting. $rescription 3riting authori4ationGas recommended by the $OT committee revie3ed by the credentials committee and approved by the #T< commanderG3ill be annotated in the $!< as an addendum to the provider8s delineation of clinical privileges. d. 5ro&edure" and d agno"! & !e"! ng. $rivileged providers are authori4ed to perform those procedures for 3hich they have been appropriately trained are properly (ualified and are privileged. /onphysician privileged providers may be authori4ed to perform and document in the medical record minimally comple6 or selected moderately comple6 diagnostic procedures classified as providerEperformed microscopy by the &'& !linical ;aboratory %mprovement $rogram. (2ee A<%$ $am .0-2..) 'ther radiological studies diagnostic testing and procedures authori4ed according to local guidance 3ill be addressed on the disciplineEspecific &A <orm *..0. e. Con! nu ng edu&a! on re9u remen!". $rofessional competency is maintained in part by the ongoing accumulation of advanced 5no3ledge in one8s practice discipline. <or all privileged providers the annual re(uirement for continuing professional education and development is according to AR ,*+-, or as determined by the provider8s 2tate of licensure 3hichever is more stringent. f. %ead ne"" !ra n ng. This is of paramount importance to prepare 1.2. Army privileged providers for mobili4ation in support of the Army8s global mission. ;ocal command decisions 3ill govern the training of assigned personnel. 2uggested training includesG

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(+) #C=S and #T=S or an e9u /alen!. This training ensures that military providers are (ualified in advanced cardiac and trauma management to care for the 3oundedDin7ured on the battlefield or other missionErelated settings. (2) 'ed &al managemen! o- &hem &al, b olog &al, nu&lear, rad olog &al llne""7 n2ur$. The increased ris5 that 3eapons of mass destruction 3ill be employed on the battlefield or in terrorist activity 3orld3ide re(uires that privileged providers as appropriate be prepared to diagnose and appropriately manage the in7uries or diseases that 3ill result from the use of these unconventional agents.
>82 Clinical per'ormance revie= a. 'ngoing professional competency assessment and periodic formal evaluation of performance to include both (uantitative and (ualitative data are re(uired for all privileged providers. This is accomplished at least biennially as part of the privilege reappraisalDprivilege rene3al processes and is documented on &A <orms *,C. and *..+. (2ee app A for a complete listing of &A <orms *..+ series.) An e6ample of professional competency assessment is the periodic peer revie3 in the conte6t of $% of a representative sample of medical records. !ompetency assessment also includes analyses by one8s peers and supervisor of specific outcomesErelated data R# data and patient letters of appreciation or complaints as 3ell as direct observation of performance and verbalD3ritten assessment of clinical 5no3ledgeDs5ills. 'ther performance revie3 criteria as recommended by the TJ! or other accrediting agencies as approved by the 'ffice of the 2ecretary of &efense (9ealth Affairs) ('2&(9A)) may also apply. $erformanceEbased peer revie3 3ill be according to local policy.
4o!e. $erformance revie3 in this conte6t applies to providers 3ith current clinical privileges and other professionals 3ho are actively engaged in the provision of patient care and services.

b. Additional re(uirements for enhanced supervision of the licensed novice or entryElevel provider (or the e6periE enced provider 3ho has returned to clinical practice after a lapse (see glossary) in patient care duties) must be individually determined. This supervision 3ill be provided by a designated individual of the same discipline or by a medical officer 3ith more recent clinical e6perience.
>42 Advanced practice registered nurse a. *e"&r p! on. (+) The A$R/ as a result of master8s or doctoral level education and inEdepth clinical e6perience possesses the advanced 5no3ledge and clinical competency to provide health care in a defined area of speciali4ation. The A$R/ demonstrates e6pertise in the assessment diagnosis and treatment of actual or potential health problemsA the prevention of illness and in7uryA maintenance of 3ellnessA and the provision of comfort to individuals <amilies or communi ties. The A$R/ group includesG (a) !/#s. (b) !R/As. (c) !/2s. (d) /$s. This includes <amily adult pediatric 3omen8s health care and others. (2) !ommunity health nurses (!9/s) function in an e6panded role using !$0s approved by the @!#2 and the &!/. %n this role the !9/ may refill prescriptions or perform other clinical functions of a more comple6 nature but heDshe does not independently initiate alter or discontinue any medical treatment. ;i5e3ise the scope of practice of occupational health nurses ('9/s) typically includes !$0 or protocolEbased patient interventions. %n selected circumstances either the !9/ or '9/ may be assigned duties or functions for 3hich clinical privileges are deemed appropriate. !9/s and '9/s 3ho meet the criteria as an A$R/ may be granted clinical privileges as approved by the #T< commander. b. 5ro-e"" onal &reden! al". (+) )du&a! on. A$R/s 3ho complete their respective specialty programs after ,+ &ecember 200+ must be graduates of an accredited master8s level or doctoral program acceptable to &A that prepares R/s 3ith additional 5no3ledge and s5ills to practice in their clinical specialty. (2) = &en"ure. A$R/s 3ill maintain a current active valid unrestricted R/ license in at least one 1.2. 2tate &istrict of !olumbia !ommon3ealth territory or 7urisdiction (para .-.). (,) Cer! - &a! on. Hithin +2 months of graduation the A$R/ 3ill achieve certification by a nationally recogni4ed certifying body appropriate to the specialty area of practice. !ertification 3ill be maintained for the duration of the individual8s advanced clinical practice. (.) %e" den&$. /e3 graduate A$R/s and those returning to clinical practice after a lapse may be in an intern status 3ith enhanced supervision (see para 9-. e) for a period of +2E2. 3ee5s. The supervision associated 3ith the period of residency is not considered an adverse status. <or specific guidance related to A$R/ residency re(uirements contact #!9'E!;. &. S&ope o- pra&! &e. (+) The A$R/ is a licensed and privileged practitioner and as such coEsignature by a physician or other privileged provider of A$R/ entries in the patient8s medical record prescriptions and so forth is not re(uired.

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(2) As designated by hisDher delineated privileges or scope of practice demonstrated competence and e6perience the A$R/ (independently and collaboratively 3ith other health care professionals) performs a 3ide variety of tas5s or duties based on organi4ational re(uirements and according to local policy. The A$R/ may among other tas5s perform medical e6aminations and document findingsA screen health records (9R@!s) for individuals participating in overseas deployments or other military dutiesA assist in 3ee5ly inspections of confinement facilitiesA e6amine and treat prisoners in confinementA recommend temporary limitedEduty profiles on &A <orm ,,.9 ($hysical $rofile) for A& 2oldiers to include those on flight status (AR .0-*0+)A place patients under hisDher care on (uarters status (AR .0-)))A and perform other duties as authori4ed by the commander. (,) The A$R/ may authenticate temporary limitedEduty profiles for pregnancy and other conditions according to the guidance outlined in AR .0-*0+. d. Cer! - ed nur"e m d> -e. (+) *e"&r p! on. !/#s are R/s 3ith advanced speciali4ed training in mid3ifery. /urseEmid3ifery practice is the independent management of 3omen8s health care focusing particularly on pregnancy childbirth postpartum and ne3born care as 3ell as the <amily planning 3ell 3oman care and the gynecological needs of 3omen. The !/# practices 3ithin a health care system that provides consultation collaborative management or referral as indicated by the health status of the beneficiary. (2) #dd ! onal pro-e"" onal &reden! al". !/#s 3ill demonstrate continued competency through active participation in the !ontinuing !ompetency Assessment $rogram of the American !ollege of /urseE#id3ives. All !/#s 3ill achieve and maintain current !ontinuing !ompetency Assessment $rogram certification. (,) S&ope o- pra&! &e. The !/#G (a) $rovides routine prenatal care labor and delivery management immediate ne3born care and postpartum care. (2ee para (&) belo3.) %n addition they provide 3ellE3oman gynecological services including yearly physical e6ams breast e6ams pap smears <amily planning services preventive health screening and health education. Hith the appropriate training and e6perience the !/# may also be privileged to perform such procedures as colposcopy ultrasound and birth control implant insertionsDremovals and to provide primary care services to adult female beneficiaries. (b) $ractices according to the 2tandards for the $ractice of /urseE#id3ifery as defined by the American !ollege of /urseE#id3ives the A/A 2tandards of !linical /ursing $ractice for /urse #id3ifery and local nurse mid3ifery service guidelines. The #T<Especific guidelines define conditions for 3hich referral or collaborative care (coEmanagement) is appropriate. (c) #ay provide obstetrical care 3ithin hisDher scope of practice and e6pertise using physician consultation andDor coE management to provide comprehensive care for other than lo3Eris5 patients according to #T< guidelines. The !/# may perform outpatient care and be privileged to admit and discharge patients 3hen an obstetrician is on call and is available by telephone to provide medical consultation collaborative management andDor referral 3hen indicated. e. Cer! - ed reg "!ered nur"e ane"!he! "!. (+) *e"&r p! on. !R/As are R/s 3ith advanced speciali4ed training in the administration of anesthesia. /urse anesthesia practice includes the independent administration and management of patient anesthesia to include preopera tive evaluation and preparation perioperative management and postoperative follo3up and evaluation. The !R/A may provide consultation collaborative management or referral to other health care providers as indicated by the health status of the patient. (2) #dd ! onal pro-e"" onal &reden! al". !R/As 3ill maintain current certification by the !ouncil on !ertification of /urse Anesthetists. (,) S&ope o- pra&! &e. The !R/As 3ill be responsible and privileged for the entire anesthetic process. The !R/A 3ill G (a) $erform and document a preanesthetic assessment and evaluation of the patient to include re(uesting consultations and diagnostic studies. (b) @stablish an anesthesia plan and based on the preanesthetic assessment determine that the patient is an appropriate candidate to undergo the planned anesthetic. (c) 'btain informed consent for anesthetic services. (d) 2elect prescribe or administer medications and treatment modalities related to the perianesthetic care of patients. (e) !onduct the preEinduction assessment to determine the patient8s readiness to enter the surgical environment immediately prior to administering the selected anesthetic. (f) 2elect obtain and administer anesthetics ad7unct drugs accessory drugs and fluids necessary to manage the patient in the perianesthetic period to maintain the patient8s physiologic homeostasis and to correct responses to the anesthesia or surgery consistent 3ith the spectrum of anesthesia privileges. (g) @nsure that the patient8s postoperative status is assessed on admission to and discharge from (or bypass of) the postEanesthesia recovery area. (h) Release or discharge patients from the postEanesthesia recovery area.

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( , 'rder and initiate perioperative pain relief therapy. (.) Collabora! on and ane"!he" a<rela!ed de& " on". (a) !R/As routinely provide independent anesthesia care for American 2ociety of Anesthesiologists (A2A) physical status classification + and 2 patients. They are responsible and accountable for determining 3hen a physician (anesthesiologist if available) 3ill be consulted for the delivery of anesthesia care to A2A + and 2 patients. !onsultation 3ill be re(uested as necessary regardless of the patient8s A2A classification. (b) !ollaboration and subse(uent implementation of the specific recommendations provided by the physician does not relieve the !R/A of hisDher overall responsibility to ensure the utmost safety of the patient. At all times the !R/A remains accountable for hisDher decisions and all professional actions associated 3ith the anesthesia care rendered. The consulted physician is accountable for hisDher anesthesiaErelated decisions. (c) <or patients in A2A physical status classification , . * or ) !R/As 3ill collaborate 3ith a physician (anesthesiologist if available) or oral surgeon before induction of anesthesia. This collaboration may be faceEtoEface or by telephone. %n an #T< 3ithout an assigned or available anesthesiologist this collaboration 3ill be 3ith the operating surgeon. The !R/A 3ill document the results of this interaction in the medical record prior to the start of the case. There is no re(uirement for the collaborating physician or oral surgeon to be privileged in the administration or management of anesthetics. (*) Gradua!e nur"e ane"!he! "!". 0raduate nurse anesthetists (0/As) are individuals 3ho have successfully completed a nurse anesthesia program but have not achieved !R/A certification. (a) $rior to !R/A certification the 0/A 3ill be granted supervised clinical privileges. A !R/A or anes thesiologist 3ill supervise the 0/A. (b) The 0/A 3ill not be assigned to unsupervised onEcall duties or emergency procedures nor 3ill heDshe teachD supervise anesthesia nursing students or other anesthesia providers in training. -. Cl n &al nur"e "pe& al "!. (+) *e"&r p! on. !/2s are R/s 3ho have obtained advanced speciali4ed education and certification to practice collaboratively as A$R/s for the purpose of providing specialty care (for e6ample oncology psychiatric cardiovas E cular pulmonary). !/2s participate in the care of both inpatients and outpatients and have primary responsibility for providing clinical e6pertiseA consultationA case managementA disease managementA patientD<amily educationA and re E search application in primary secondary or tertiary health care settings. (2) #dd ! onal pro-e"" onal &reden! al". (a) Cer! - &a! on. !/2s must be certified in their specialty by the American /urses !redentialing !enter or the recogni4ed national nursing certification organi4ation for the specialty (for e6ample 'ncology /ursing 2ociety American Association for !ritical !are /ursing @mergency /urses Association and so forth). (b) +!her. !/2s desiring prescriptive authority must meet the criteria specified by the A/A as 3ell as the privileging re(uirements as described in chapter 9 of this regulation. A !/2 re(uesting prescriptive authority or authori4ation to function beyond the routine !/2 scope of practice may be privileged to provide e6panded services to designated beneficiaries (for e6ample patients re(uiring comprehensive pain management). (,) S&ope o- pra&! &e. !/2s practice independently and collaboratively 3ith other members of the health care team to ensure a comprehensive plan of care for the patient. They function in a variety of practice environments ranging from primary care (as disease manager) to the intensive care setting (as acute care !/2s). 9ealth care activities of the !/2 may include ta5ing initial and interval historiesA performing developmental assessments and screeningsA conduct E ing diagnostic and screening testsA teaching and counseling patientsD<amily members regarding identified problems health maintenance and disease preventionA and initiating and evaluating treatment regimens that may include prescribing and dispensing medication appropriate to the privileged scope of care. g. 4ur"e pra&! ! oner. (+) *e"&r p! on. /$s are R/s 3ith advanced speciali4ed education and clinical competency to provide medicalD health care for diverse populations in a variety of primary acute and longEterm care settings according to their practice specialty. /$s provide nursing and medical services to individuals <amilies and groups. /$ specialties include but are not limited to acute care adult emergency <amily geriatric pediatric psychiatric and 3omen8s health. (2) #dd ! onal pro-e"" onal &reden! al". /$s 3ill maintain current certification by a national certifying body (for e6ample American /urses !redentialing !enterA American Academy of /urse $ractitionersA /ational !ertification ?oard of $ediatric /urse $ractitioners and /ursesA A/AA /ational !ertification !orporation for the 'bstetric 0ynecologic and /eonatal /ursing 2pecialties) as appropriate for their specialty area of practice. (,) S&ope o- pra&! &e. (a) The /$ practices independently and collaboratively 3ith other health care professionals to provide primary care and to diagnose treat and manage the patient8s preventive acute and chronic health problems. 2ervices include but are not limited to ordering conducting and interpreting diagnostic and laboratory testsA prescribing pharmacologic agents and nonpharmacologic therapiesA and teaching and counseling individuals <amilies and groups. (b) The /$ practices according to hisDher specialty the A/A 2tandards of !linical /ursing $ractice for /urse $ractitioners and hisDher individual &A <orm *..0 as determined by the organi4ational mission and scope of care and

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services. #T<Especific guidelines and the individual8s privileges define conditions for 3hich referral or collaborative care is appropriate. ><2 Audiologist a. *e"&r p! on. (+) Audiologists contribute to the operational readiness and (uality of life of the fighting force and other eligible beneficiaries by providing costEeffective hearing health care through audiological services including prevention medical surveillance treatment education and research. (2) Audiologists support the missions of &'& personnel by implementing the Army 9earing !onservation $rogram and preventing noiseEinduced hearing loss to enhance auditory performance in operational environments. Audiologists prevent hearing loss through the provision and fitting of hearing protective devices consultation on the effects of noise on hearing management of hearing conservation programs and presentation of educational programs. Audiologists diagnose and treat hearing deficits of authori4ed beneficiaries by selecting fitting and dispensing amplificationDhearing aids and other devicesA providing aural rehabilitationA and 3hen necessary referring patients for medical intervention. b. 5ro-e"" onal &reden! al". (+) )du&a! on. Audiologists must have a master8s or doctoral degree in audiology from an accredited institution acceptable to &A. (2) = &en"ure. Audiologists 3ill maintain a current active valid and unrestricted audiology license registration or certification from a 1.2. 2tate &istrict of !olumbia !ommon3ealth territory or 7urisdiction. &. S&ope o- pra&! &e. Audiologists follo3 the guidelines published by the American 2peechE;anguageE9earing Association American Academy of Audiology and the /ational 9earing !onservation Association. Audiologists are privileged to provide comprehensive diagnostic and rehabilitative services for all areas of auditory vestibular and related disorders. Those 3ith advanced training and current competence may be privileged to perform special proce E dures such as intraoperative monitoring of the cranial nerves cerumen removal cochlear implant assessments and management posturography and other advanced balance mechanism evaluations. Audiologists 3ill manage hearing conservation programs. 'nce certified as a course director by the !ouncil for Accreditation in 'ccupational 9earing !onservation audiologists 3ill provide certification training for personnel conducting audiometry for hearing conservation programs. >62 Be(avioral (ealt( practitioner a. *e"&r p! on. ?ehavioral health practitioners are trained in behavioral science counseling theories and practical applications of behavior change principles. They may manage numerous behavioral and emotional problems in both general and particular specialty practice levels providing a variety of behavioral health services including screening treatment and consultation. The behavioral health practitioner may develop additional e6pertise in psychometrics industrial psychology substance abuse rehabilitation geriatric care school or health psychology neuropsychology pediatric or adolescent psychology aeromedical psychology and combat stress reactions.
4o!e. The provisions of this section are applicable to 02 +>0Eseries counseling psychologists that do not meet 2tate licensure re(uirements as a doctoralElevel psychologist. These individuals shall be privileged to engage in clinical practice only as defined in this regulation using the title of behavioral health practitioner or psychological associate. (2ee para C-+9.)

b. 5ro-e"" onal &reden! al". ?ehavioral health practitioners must demonstrate appropriate education s5ills training and e6perience to be considered for clinical privileges. The minimum educational and licensure re(uirements for category %-%%% level of privileges includeG (+) Ca!egor$ 0. The individual has earned a master8s degree in counseling psychology fulfilling the re(uirements of a 2Eyear academic program including a minimum of +2 supervised practicum hours in the ma7or specialty. The graduate program must be offered by a collegeDuniversity fully accredited by a 1.2. regional accrediting body. The practitioner performs specialty counseling services and 3or5s under the supervision of a psychologist psychiatrist or clinical social 3or5er licensed in hisDher discipline. The individual must possess either the ;icensed $rofessional !ounselor (;$!) license or a master8s level psychology license such as psychological associate license from a 2tate licensing board.
4o!e. /ot all 2tates offer licenses to master8s level psychologists but all offer the ;$! though some 2tates use a different title for their ;$!Ee(uivalent license. The education and e6perience re(uirements for licensure are the basis for determining e(uivalency.

(2) Ca!egor$ 00. The individual has completed a 2Eyear master8s degree program in counseling psychology at a fully accredited collegeDuniversity including a minimum of +2 semester hours of supervised practicum. The individual possesses the ;$!D;$!Ee(uivalent licensure or a psychological associate (or other master8s level psychology license) available in some states. 9eDshe has a minimum of 2 years8 fullEtime e6perience in the specialty in 3hich services are performed under the supervision of a higher level privileged provider 3ith a license in social 3or5 psychology or psychiatry. (,) Ca!egor$ 000. The individual has completed a postEmaster8s specialty degree from an accredited university and passed a comprehensive e6amination in that specialty. The individual has a ;$!D;$!Ee(uivalent license or a license as a master8s level psychologist from a 2tate licensing body. 9eDshe provides a 3ide range of services in the designated
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specialty and may supervise category %% or % counselors in their provision of services in the specialty. The individual 3ill be supervised by a psychologist psychiatrist or a social 3or5er 3ho is licensed in their respective disciplines and privileged at a higher level (category).
4o!e. %ncumbent Army 2ubstance Abuse $rogram (A2A$) counselors 3ho are already clinically licensed but do not possess the educational (ualifications as noted above are permitted to continue in their present positions (current grade and 02Eseries). 9o3ever they are not eligible for lateral transfer to another position or promotion to a higher grade.

&. S&ope o- pra&! &e. %ndividuals 3ill practice 3ithin the guidelines of their respective 2tate licensing boards as ;$!s (or e(uivalent) or if offered by their 2tate a license for master8sElevel psychology graduates such as psychologi cal associate or licensed mental health provider. ?ehavioral health practitioners adhere to the 2tate ;$! or psychology licensing board8s code of ethics and conduct. 2pecific clinical privileges are granted based upon training e6perience and competency. %n general behavioral health practitioners 3illG (+) !onduct screening evaluations utili4ing information from clinical intervie3s nonpsychometric tests and collatE eral sources as appropriate. (2) &etermine a provisional diagnosis according to the American $sychiatric Association &iagnostic and 2tatistical #anual of #ental &isorders. (,) $rovide individual and group behavioral health treatment 3ithin the scope of practiceDprivileges granted. (.) #anage the behavioral health care of patients and refer those having needs beyond their scope of practice. (*) 2erve as collaborator in human behavioral issues 3ith and consultant to community agencies health care providers and organi4ational leaders. d. Super/ " on. (+) #aster8s level graduates 3ho have recently (3ithin the past year) obtained a master8s level license such as an ;$! or psychological associate license 3ill be fully supervised during their first year of employment as a behavioral health practitioner. (2) ;$!s or psychological associates 3ith 2 or more years8 e6perience (after attaining licensure) 3ill receive general supervision according to the individual8s level of competence as assessed by hisDher supervisor. (,) ;$!s or psychological associates 3ith more than 2 years8 e6perience and 3ith postEmaster8s 3or5 leading to a specialty degree 3ill re(uire supervision in their specialty 3ith difficult highEris5 cases or for cases in 3hich one or more of the patient8s problems fall outside the scope of the counselor8s specialty. >>2 C(iropractor a. *e"&r p! on. !hiropractors provide treatment and care of spineErelated neuromusculos5eletal conditions to eligible beneficiaries. The chiropractor utili4es chiropractic manipulationGalso called chiropractic ad7ustmentGto restore 7oint and related soft tissue function. This treatment may be used 3ith other supporting forms of treatment (physical modalities) depending on the patient8s specific needs. The chiropractic approach to health care is holistic stressing the patient8s overall 3ellEbeing. The natural drugless nonsurgical methods of chiropractic treatment rely on the body8s inherent recuperative abilities to promote healing. b. 5ro-e"" onal &reden! al". (+) )du&a! on. The individual must be a graduate of a chiropractic college accredited by the !ouncil on !hiropractic @ducation or its successor. (2) = &en"ure. A current active valid and unrestricted license to practice chiropractic in a 1.2. 2tate &istrict of !olumbia !ommon3ealth territory or 7urisdiction is re(uired. (,) ):per en&e. To (ualify for clinical privileges the chiropractor must have 2 years8 minimum fullEtime active postE graduate chiropractic e6perience involving the delivery of both diagnostic and treatment services. (.) +p! onal &reden! al". 'ptional credentials include postgraduate credits approved or accredited by an appropriate 2tate licensing board recogni4ed diplomat status formal hospital staff privileges (or evidence of actively see5ing hospital privileges) at a nationally accredited health care facility. &. S&ope o- pra&! &e. At the discretion of the #T< commander clinical privileges may be granted based on the individual8s documented education competence and e6perience. The minimum practice privileges for 3hich the chiropractor is authori4ed includeG (+) $erforming patient history and chiropractic physical e6amination e6cluding vaginal e6amination. (2) 'rdering radiologic e6aminations such as spineDfour vie3s (anteriorEposterior lateral obli(ue spot) and pelvic series. (,) 'rdering standard diagnostic laboratory tests (for e6ample electrolytes glucose urinalysis urine culture and sensitivity complete blood count occult blood and erythrocyte sedimentation rate). (.) $erforming standard osseous and soft tissue procedures consistent 3ith chiropractic care as commonly contained in the core curriculum of !ouncil on !hiropractic @ducationEaccredited chiropractic colleges. (*) 1tili4ing heat and cold modalities electrical stimulation hydrotherapy and ultrasound therapy in patient treatment.

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()) $roviding patient instruction and recommendations pertaining to hygiene nutrition e6ercise sanitary measures lifestyle changes stress reduction and modifications of ergonomic factors. (C) $lacing A& 2oldiers on limited duty profiles not to e6ceed ,0 days according to local policy and on (uarters for a ma6imum of C2 hours. d. Super/ " on. The chiropractor functions under the indirect medical supervision of a physician assigned by the #T<. ?oth clinical supervision and professional evaluation of the individual are integrated into the organi4ation8s current evaluation structure.
>82 Clinical p(armacist a. *e"&r p! on. !linical pharmacists are licensed pharmacists 3ith comple6 clinical s5ills and capabilities ac(uired through advanced education and practical e6perience. !linical pharmacists practice collaboratively in the area of pharmacoeconomics and 3ith patients re(uiring therapy (for e6ample anticoagulant asthma hypertension diabetes hyperlipidemia immuni4ation and oncology nuclear). !linical pharmacists practice in primary care medicine pediat rics geriatrics infectious disease nutrition and pharmacotherapy settings. They provide medication refills. %n many cases the clinical pharmacist 3or5s directly for a physician or group of physicians in a particular specialty or primary care clinic. The pharmacist functions under clinical treatment protocols or !$0s developed in coordination 3ith the medical staff recommended by the $OT committee and approved by the @!#2 or &'&D12A#@&!'#Edeveloped and approved !$0s. !linical pharmacists provide pharmaco5inetic consultation enteral and parenteral nutrition consultation and perform drug therapy management activities on inpatient units and in outpatient clinics. %n all cases communication bet3een pharmacists and physicians is essential for (uality patient care. b. 5ro-e"" onal &reden! al". $harmacists must demonstrate appropriate s5ills training andDor e6perience to be considered for clinical privileges. #inimum re(uirements includeG (+) )du&a! on7&er! - &a! on. $harmacists must haveG (a) A postEbaccalaureate or entry level doctor of pharmacy ($harm&) degree or (b) A master of science degree in pharmacy from a clinically oriented program or (c) ?oard certification in one or more of the pharmacy specialties recogni4ed by the ?oard of $harmaceutical 2pecialties or (d) !ompleted a clinical pharmacy residency or fello3ship accredited by the American 2ociety of 9ealth 2ystem $harmacists or American !ollege of !linical $harmacy or (e) A bachelor of science degree in pharmacy 3ith documentation of appropriate education training andDor continuing education in the practice of clinical pharmacy.
4o!e. The didactic content of current bachelor of science programs is nearly identical to entryElevel $harm& programs. The difference is that $harm& programs have + additional year of clinical e6perience.

(f) Appropriate formal education and clinical training to perform limited physical assessment (that is assessment focused on the specific system under e6amination). This is included in $harm& programs but may not be for bachelor8s and master8s programs. 'ther sources of this training may include the $hysical Assessment @ducation $rogram andDor a formal certification process. (2) = &en"ure. !linical pharmacists 3ill maintain a current active valid unrestricted pharmacy license from a 1.2. 2tate &istrict of !olumbia !ommon3ealth territory or 7urisdiction. &. S&ope o- pra&! &e. $harmacists may be granted clinical privileges to provide clinical treatment protocolD!$0based direct patient care. (2ee para a above.) !ommunication 3ith the patient8s physician through documentation of clinical activities in the patient8s medical record and other verbalD3ritten means is essential to ensure continuity of care. $harmacist privileges may include but are not limited toG (+) Assessing patient8s response to drug therapy and planning drug therapy based on physicianEestablished diagnoses. (2) 'rdering and assessing laboratory tests necessary to evaluate drug therapy effects and therapeutic outcomes. (,) %nitiating modifying or discontinuing medications for ongoing therapy of chronic disease states (for e6ample hypertension hyperlipidemia diabetes asthma and so forth) in cooperation 3ith the medical staff. (.) #onitoring and managing pharmacotherapy re(uiring periodic ad7ustment due to specific or changing pharE maco5inetic characteristics (for e6ample aminoglycosides phenytoin antithrombotics). (*) %nitiating or modifying drug therapy for minor acute conditions such as colds rashes and allergies. ()) Administering prescription or nonprescription drugs according to established treatment protocols or practice guidelines. (C) Assessing metabolic needs and ordering therapeutic enteral or parenteral nutrition products in inpatient and outpatient settings. (>) @valuating medical and medication histories for drugErelated problems and ad7usting drug therapy accordingly. (9) !onsulting 3ith other health care providers (for e6ample physicians dietitians nurses $Ts and so forth) regarding patient pharmacologic treatment needs or options.

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(+0) !onsulting to therapeutically evaluate recommend or modify medication therapy for patients 3ith comple6 medical conditions or difficultEtoEmanageEdisease states. (++) !onducting and coordinating clinical investigation and research (consistent 3ith other health care professionals) approved by a local or regional investigational revie3 board and participating in outcome studies generated by the department of pharmacy and approved by the $OT committee. (+2) $roviding patient educationDcounseling services to enhance compliance and reduce the occurrence of medicationE related problems and adverse drug events. (+,) Applying advanced 5no3ledge of drug therapy to provider and patient education #T< drug formulary analysis and recommendations and serving as preceptor for pharmacy students. d. Super/ " on. (+) !linical pharmacists granted #T< privileges must have a physician available for consultation either in person or by phone 3hen they are performing direct patient care activities. (2) All clinical pharmacists must 3or5 via protocols recommended for approval by the @!#2 and practice 3ith the supervision of a physician preceptor identified in 3riting. The physician preceptor must provide consultation clinical feedbac5 and general oversight of the clinical pharmacist8s practice.
>$2 Clinical psyc(ologist a. *e"&r p! on. !linical psychologists are specialists in the areas of behavioral science psychological processes and behavioral health. !linical psychologists provide comprehensive behavioral health services as independently privileged health care providers. ?ehavioral health services include a variety of evaluation treatment and consultation activities that address behavioral and emotional problems at both the general practice and specialty practice levels. !linical psychologists may develop additional e6pertise in neuropsychology health psychology childDpediatric psychology personnel assessment and selection aeromedical psychology survival evasion resistance and escape (2@R@) psycholE ogy and combat stress control.
4o!e. The provisions of this section are applicable to 02 +>0Eseries counseling psychologists prepared at the doctoral degree level.

b. 5ro-e"" onal &reden! al". !linical psychologists must demonstrate appropriate education s5ills training and e6perience to be considered for clinical privileges. #inimum re(uirements for category %-%= level of privileges areG (+) Ca!egor$ 0. The practitioner has completed predoctoral internship but has not yet completed degree re(uirements for a &octor of $hilosophy ($h.&.) or $sy.&. in clinical or counseling psychology. The graduate program and internship must meet re(uirements of &A $am )++-2+. The practitioner assists in performance of psychological and other services and 3or5s under the supervision of a licensed psychologist. (2) Ca!egor$ 00. The practitioner has a $h.&. or $sy.&. in clinical or counseling psychology but is not yet licensed. The graduate program and internship must meet re(uirements of &A $am )++-2+. The practitioner provides a full range of psychological services as (ualified to deliver by virtue of training. 9eDshe participates in team delivery of services research and teaching and receives (ualified supervision (per licensing criteria) from a licensed psychologist. (,) Ca!egor$ 000. The practitioner has $h.&. or $sy.&. in clinical or counseling psychology and is licensed. 0raduate programs and internships must meet re(uirements of &A $am )++-2+. The practitioner is recogni4ed as possessing a high level of s5ill in psychological assessment intervention and administration of services. 9eDshe delivers psychological services to individuals and treatment teams and may be appointed as supervising psychologist for category % and %% practitioners. (.) Ca!egor$ 0?. The practitioner has a $h.&. or $sy.&. in clinical or counseling psychology and is licensed and board certified by the American ?oard of $rofessional $sychology. 0raduate programs and internships must meet re(uirements of &A $am )++-2+. The practitioner is recogni4ed as possessing the highest level of s5ill in psychologi E cal assessment intervention and administration. 9eDshe may be appointed as a supervising psychologist for category % and %% practitioners. &. S&ope o- pra&! &e. !linical psychologists practice 3ithin the guidelines of their respective 2tate licensing boards and 3ithin the guidelines for providers of psychological services published by the American $sychological Association (A$A). $sychologists adhere to the A$A8s @thical $rinciples of $sychologists and !ode of !onduct. 2pecific clinical privileges are granted based on training e6perience and competency. (+) %n general clinical psychologistsG (a) !onduct psychological evaluations utili4ing information from clinical intervie3s psychological testing and collateral sources as appropriate. (b) @stablish psychiatric diagnoses according to the American $sychiatric Association &iagnostic and 2tatistical #anual of #ental &isorders. (c) $rovide individual and group behavioral health treatments for 3hich the provider holds privileges. (d) %ndependently and collaboratively manage the behavioral health care of patients and refer patients to appropriate providers for health care 3hich falls outside their scope of practice. (e) 2erve as e6pert consultants in human behavior to community agencies health care providers and organi4ational leaders.

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(f) $rovide operational psychological services to include combat stress control aeromedical psychology and 2@R@ psychology. (g) !onduct behavioral research in diverse settings to address the full range of psychological issues that impact individuals groups and military organi4ations. (0 , !onduct personnel assessment and selection for speciali4ed military occupations. (2) !linical psychologists are authori4ed to admit independently and collaboratively treat and collaborate on the discharge of patients from inpatient care to include psychiatric units staffed by psychiatrists. (a) !linical psychologists may admit patients to the #T< only if a physician member of the medical staff to include a psychiatrist in cases re(uiring admission to a psychiatric unit assumes responsibility for performing the admission history and physical (9O$) e6amination. The physician must also be responsible for the patient8s medical problems that e6ist at the time of admission or may arise during hospitali4ation and are outside the psychologist8s scope of practice. (b) !oordination 3ill occur bet3een the admitting clinical psychologist and physician for patient discharge. The clinical psychologist8s discharge recommendation 3ill be documented in the medical record. (c) T h e a p p r o p r i a t e & A < o r m * . . 0 3 i l l c l e a r l y s p e c i f y t h e 3 a r d s D u n i t s t o 3hich the clinical psychologist may admit and discharge patients. d. Super/ " on. (+) $sychology officers 3ho are recent graduates of military psychology residencies and are a3aiting a3ard of their $h.&. or $sy.&. 3ill receive supervision of their clinical activities based on individual needs from a licensed psychologist. (2) 1nlicensed military clinical psychologists 3ho hold a $h.&. or $sy.&. in clinical or counseling psychology but have not yet obtained a 2tate license to practice psychology 3ill be supervised by a licensed psychologist until licensed as specified in the 3ritten plan for supervision. (,) ;icensed clinical psychologists 3ho are privileged in the independent practice of psychology do not re(uire supervision e6cept 3hen engaging in ne3 areas of practice. $sychologists 3ho have not engaged in clinical practice for a period of +2 months or more 3ill re(uire assignment to a +2Emonth period of general supervision. $sychologists 3ill adhere to guidelines of the A$A 3hich re(uire psychologists to receive appropriate training and supervision before engaging in ne3 practice areas. (.) %f another psychologist is not available to provide the re(uired supervision the #T< 3ill coordinate 3ith the R#! senior psychologist before establishing the plan of supervision.
>502 Clinical social =or?er a. *e"&r p! on. The primary mission of Army social 3or5 is to provide comprehensive professional services through a broad range of individual <amily command level and community interventions programs and services to sustain restore or enhance the social 3ellEbeing and functioning of individuals <amilies units and the Army community. 2ocial 3or5ers are members of the health care team most fre(uently 3or5ing in social 3or5 service outpatient mental health clinics <amily Advocacy $rograms (AR )0>-+>) substance abuse treatment services division mental health services combat stress control detachments and correctional facilities. b. 5ro-e"" onal &reden! al". (+) )du&a! on and e:per en&e. !linical social 3or5ers must have a master of social 3or5 (#2H) degree from a school of social 3or5 accredited by the !ouncil on 2ocial Hor5 @ducation. 2ocial 3or5ers practicing in the A#@&& must be (ualified in clinical social 3or5 through the master8s level educational program and postE#2H e6perience. (a) %n order to engage in independent practice clinical social 3or5ers must have completed an #2H have a minimum of 2 years8 postE#2H clinical social 3or5 e6perience and possess the appropriate 2tate licenseDcertification. (%f the 2tate offers a license for independent clinical practice this 3ill be the level of license re(uired. 'ther3ise the license must be at the level appropriate for an #2H social 3or5er 3ith 2 years8 e6perience.) These individuals may be a3arded regular clinical privileges.
4o!e. %ncumbent A2A$ counselors 3ho are already clinically licensed but do not possess the educational (ualifications as noted above are permitted to continue in their present positions (current grade and 02Eseries). 9o3ever they are not eligible for lateral transfer to another position or promotion to a higher grade.

(b) @ntryElevel clinical social 3or5ers may be granted regular privileges 3ith enhanced supervision as described in paragraph 9-. e. A 3ritten plan of supervision 3ill be documented. This applies to the licensed entryElevel clinical social 3or5ers possessing an #2H and less than 2 years8 postE#2H e6perience and to clinical social 3or5ers 3ith greater than 2 years8 postE#2H e6perience that hold a license 3hich does not authori4e independent practice in their 2tate of licensure. (c) 2ocial 3or5ers 3ho are practicing clinical social 3or5 but have only an entryElevel license from a 2tate that offers a higher level of license as described above 3ill be a3arded regular privileges 3ith enhanced supervision until they obtain the necessary level of license. %ndividuals 3ill be given until + 'ctober 200. to meet this independent practice licensure re(uirement. (This allo3s 2 years to meet 2tate clinical e6perienceDsupervision re(uirements plus an

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AR 4068 0 6 !ebruary 004

additional year to obtain the appropriate license. %ndividuals 3ho have already completed the e6perience and supervision re(uirements 3ill be given up to + year to complete the e6amination and licensureDcertification process.) (2) = &en"ure. A current active valid and unrestricted #2H license at any level from a 1.2. 2tate &istrict of !olumbia !ommon3ealth territory or 7urisdiction is re(uired and must be maintained. &. S&ope o- pra&! &e. !linical social 3or5er privileges may include but are not limited toG (+) %ntervie3ing and evaluating patients. (2) &iagnosing mental disorders and formulating appropriate treatment plans. (,) Recommending administrative and medical dispositions. (.) $roviding individual couple <amily and group psychotherapy. d. Super/ " on. !linical social 3or5ers 3ith regular privileges 3ill supervise entry level social 3or5ers. A psychologist or psychiatrist may supervise a social 3or5er (ualifying for an advanced clinical license if a privileged independ ent clinical practice social 3or5er is unavailable and if the supervisor meets the individual8s 2tate licensing authority re(uirements for supervision. >552 !entist a. *e"&r p! on. &entists ensure the optimal oral health of the 2oldier through preservation restoration and replace E ment dental services and they provide dental health care to eligible &'& beneficiaries (AR .0-.00). &entists e6amine diagnose and treat or prescribe courses of treatment for beneficiaries suffering from defects diseases in7uries or disorders of the teeth 7a3s oral cavity and supporting ma6illofacial structures. %n addition dentists support casualty identification through dental forensic identification operations. &ental services are classified as general dentistry or specialty dentistry to include comprehensive dentistry pediatric dentistry periodontics endodontics prosthodontics orthodontics oral and ma6illofacial surgery oral pathology and public health dentistry. b. 5ro-e"" onal &reden! al". (+) )du&a! on. (a) General den! "!. To (ualify as a general dentist an individual must be a graduate of a dental school that is accredited by the American &ental Association or an accepted e(uivalent program and have passed all parts of the /ational ?oard &ental @6amination. (b) Spe& al!$ den! "!. To (ualify as a specialty dentist an individual must meet all (ualifications as a general dentist and be a graduate of a dental specialty training program that is accredited by the American &ental Association or an accepted e(uivalent program. (2) = &en"ure. All dentists 3ill maintain a current active valid and unrestricted license to practice dentistry from a 1.2. 2tate &istrict of !olumbia !ommon3ealth territory or 7urisdiction. &. S&ope o- pra&! &e. The general dentist is re(uired and privileged to perform procedures appropriate to A'! ),A. The specialty dentist is privileged to perform the same procedures as the general dentist in addition to those appropriate to hisDher specialty A'!. &entists in residency training programs 3ill perform specialty procedures as assigned and supervised by their program mentors. >5#2 !ietitian a. *e"&r p! on. &ietitians provide nutrition services to include providing medical nutrition therapy (#/T)A procuring managing and safeguarding all nutrition care division resourcesA supervising food production and service operationsA educating patients health care providers and staffA managing the nutrition component of health promotion programsA and serving as nutrition consultants to the military community.
4o!e. &ietitians 3ho provide #/T must be privileged to perform this therapy.

b. 5ro-e"" onal &reden! al". The minimum criteria for determining an applicant8s ability to provide #/T 3ithin hisD her defined scope of clinical privileges areG (+) )du&a! on. A baccalaureate degree from a 1.2. regionally accredited college or university (or foreign e(uivalent) and completion of specific course 3or5 approved by the !ommission on Accreditation for &ietetics @ducation is re(uired. This course 3or5 must be validated by a verification statement from the !ommission on Accreditation for &ietetics @ducation. (2) %eg "!ra! on. 2uccessful completion of the !ommission on Accreditation for &ietetics @ducationEaccredited supervised practice re(uirements for registration by the !ommission on &ietetic Registration of the A&A is re(uired. (%f the applicant entered the Army as a Lfully (ualifiedM dietitian current registration by the !ommission on &ietetic Registration of the A&A is re(uired. %f the applicant is a graduate of the #ilitary &ietetic %nternship !onsortium registration must be obtained no later than 'ctober of the graduating year.) Registration eligibility must be achieved through one of the follo3ing path3aysF (a) &ietetic internship. (b) Approval of $reprofessional $ractice $rogram. (c) A coordinated undergraduate program in dietetics.

AR 4068 0 6 !ebruary 004

.+

(,) = &en"ure. &ietitians 3ill maintain a current active valid and unrestricted dietetics license or certification from a 1.2. 2tate &istrict of !olumbia !ommon3ealth territory or 7urisdiction. (.) S&ope o- pra&! &e. &ietitians may be granted clinical privileges to provide #/T that include nutrition assessE mentDevaluation counseling ordering laboratory tests and other assessment procedures as 3ell as implementing #/Ts such as enteralDparenteral feedings for inpatients and outpatients and 3riting prescriptions for nutritionErelated pharmaE ceuticals as described in paragraph C-2&. (a) /utrition assessmentDevaluation includes analyses of nutrient inta5eA activity levelA appetiteA inta5e of vitamins minerals nutritional supplements and other complimentary alternative medicine usageA 3eight historyA taste changesA feeding problemsA food intoleranceA foodEdrug interactionsA unhealthy diet behaviorsA socioeconomic and ethnic bac5E groundA documented medical historyA current diagnoses and medical treatment modalitiesA current drug therapyA and clinical signs and symptoms of nutritional deficiencies. $hysiological symptoms that may accompany nutrient inta5e problems may be part of the analyses (for e6ample nausea vomiting diarrhea and constipation). /utrition assessmentD evaluation may also include anthropometric measures (heightA 3eightA s5infold measurementsA midEarm and midEarm muscle circumferencesA elbo3 breadthA 3rist 3aist hip and nec5 circumferences). (b) /utrition counseling includes identifying nutritional inade(uaciesA planning and implementing dietary modificaE tions and interventionsA evaluating and documenting clients8 progress to3ard desired outcomes and goalsA initiating health maintenance nutrition educationA #O@ and documenting individuali4ed #/T plansA and initiating nutrition counseling follo3 up at defined intervals to ensure nutrition goals are met or redefined as appropriate. (c) Advanced specialists 3ith additional certifications may be privileged to order tube feedings parenteral formulas transitional feedings and additional laboratory tests to support nutrition therapy decisions. (d) To support #/T dietitians may refer to other health care providers as needed such as to the diabetes educatorA Homen %nfants and !hildren $rogramA hospiceA home health careA and other community support programs. (*) Super/ " on. %f a dietitian is assigned 3here no other dietitian is available to provide supervision or assessment of the individual8s performance this responsibility is delegated to the senior R#! dietitian or the #T< &!!2. The competency assessment may include periodic revie3 of a representative sample of medical records direct observation of performance or verbalD3ritten assessment of clinical 5no3ledgeDs5ills according to the A&A #anual of !linical &ietetics. !ompetency assessment 3ill be documented and maintained in the dietitian8s !A<. >582 9ccupational t(erapist a. *e"&r p! on. 'Ts contribute to operational readiness and (uality of life by providing costEeffective occupational therapy care to the fighting force and eligible beneficiaries. 'ccupational therapy is the use of purposeful activity or interventions designed to achieve functional outcomes 3hich promote healthA prevent in7ury or disabilityA and 3hich develop improve sustain or restore the highest possible level of independence of any individual 3ho has an in7ury illness cognitive impairment psychosocial dysfunction mental illness developmental or learning disability physical disability or other disorder or condition. %t includes assessment by means of s5illed observation or evaluation through the administration and interpretation of standardi4ed or nonstandardi4ed tests and measurements. 'Ts evaluate treat and consult 3ith individuals 3hose abilities to cope 3ith the tas5s of everyday living are threatened or impaired by physical illness or in7ury psychosocial disability or developmental deficits. The 'T uses goalEdirected activitiesG appropriate to each person8s age and social roleGto restore develop or maintain the ability for independent productive and satisfying lives. b. 5ro-e"" onal &reden! al". (+) )du&a! on and n!ern"h p. The 'T registered must be a graduate of an occupational therapy program that is accredited by The Accreditation !ouncil for 'ccupational Therapy @ducation leading to a degree in occupational therapy. !ompletion of a clinical internship of not less than )Emonths8 duration is re(uired. (This is an occupational therapy certification e6amination prere(uisite that is usually accomplished prior to graduation from an accredited program.) (2) Cer! - &a! on. !urrent certification from the /ational ?oard for !ertification in 'ccupational Therapy (/?!'T) is re(uired. (,) = &en"ure. 'T registered 3ill maintain a current active valid unrestricted occupational therapy license from a 1.2. 2tate &istrict of !olumbia !ommon3ealth territory or 7urisdiction. (.) +!her. The advanced 'T registered clinical specialist in the treatment of upper e6tremity neuromusculos5eletal conditions mustG (a) Attend the 1.2. Army 'ccupational Therapy @valuation and Treatment of 1pper @6tremity !onditions course. (b) !omplete a )Emonth preceptorship under the supervision of an orthopedic physician and be a3arded the C9 designator. &. S&ope o- pra&! &e. (+) Ca!egor$ 0. !ategory % clinical privileges are appropriate for the 'T 3hose activities are limited to the standard scope of practice as defined by hisDher license or certification. The 'T 3ith category % level of practice 3illG (a, 1se guidelines published by the American 'ccupational Therapy Association and the /?!'T.

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AR 4068 0 6 !ebruary 0041RAR

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(b) $rovide occupational therapy evaluation and diagnostic and treatment services for patients seen by providers in the #92 as 3ell as those referred by civilian providers. (c) @valuate and treat deficits in occupational performance components that include motor neuromusculos5eletal cognitive social and psychological dysfunction. Treatment includes individual and groupEbased purposeful activity e6ercise physical agent modalities (used as ad7uncts to purposeful activity) fabrication and training in the use of temporary functional orthotics splints and adaptive devices counseling and education. (d) !onduct ergonomic evaluations and training 3or5 capacity evaluations and 3or5 site analyses. (e) $rovide assessment education and training to 2oldiersDbeneficiaries in the areas of health promotion and diseaseDin7ury prevention to include prevention of psychosocial dysfunction and stress management. (f) $erform combat neuropsychiatric triage. (g) $rovide command consultation on the prevention and management of combat stress casualties. (h) !onduct unit stress and morale surveys and provide consultation and recommendations to command staff. (i) $rovide interventions that enhance communication team building motivation and prevent suicide and misconduct stress behaviors. (7) 2erve as occupational therapy consultant to both #T< and troop commanders. (2) Ca!egor$ 0 !ategory %% clinical privileges are appropriate for the 'T 3ho demonstrates advanced education training andDor board certification as appropriate. (a, The 'T s5illed in the management of upper e6tremity neuromusculos5eletal conditions may be privileged toG +. $rovide direct access (that is no referral re(uired) upper e6tremity neuromusculos5eletal evaluation (/#2@) for acute musculos5eletal and neuromuscular conditions. 2. Re(uest appropriate radiographs and laboratory tests for patients 3ith neuromusculos5eletal conditions for 3hom they are performing primary evaluation and treatment. ,. Assign patients to (uarters not to e6ceed C2 hours. .. Refer patients to appropriate specialty clinics. *. Authenticate temporary limitedEduty profiles according to the guidance outlined in AR .0-*0+. ). Hrite prescriptions for selected medications as described in paragraph C-2 &. (b, The 'T s5illed in the management of patients 3ith occupational performance deficits resulting from psychosocial conditions may be privileged toG +. !onduct critical incident stress debriefings and other crisis intervention or critical incident stress management activities. 2. Assist doctoralElevel mental health care providers in the assessment of patients referred for mental health evaluations by performing psychiatric diagnostic screening intervie3s and mental status e6aminations. (&, The 'T 3ith advanced training in pediatrics may be privileged toG +. !onduct infant and pediatric developmental evaluations and treatment. 2. Assist the radiologist and pediatrician in evaluation of pediatric modified barium s3allo3 studies. d. Super/ " on. The 'T 3ith either category % or %% privileges 3ill be provided supervisionDoversight of hisDher clinical practice by a more e6perienced 'T. %n the absence of a more e6perienced 'T a physician may provide supervisionDoversight.
>542 9ptometrist a. *e"&r p! on. &octors of 'ptometry ('&s) are primary health care providers 3ho e6amine diagnose and treat (or prescribe courses of treatment) for beneficiaries suffering from diseases in7uries or disorders of the visual system the eye and associated structures as 3ell as diagnosisErelated systemic conditions. As primary eye care providers optometrists are part of the health care team and provide an entry point into the health care system. They are s5illed in the coEmanagement of conditions that affect their patients8 eye health and vision and are sources of referral and consultation for other health care professionals. b. 5ro-e"" onal &reden! al". (+) )du&a! on. '&s must have a .Eyear '& degree from an accredited .Eyear college of optometry acceptable to &A. (2) = &en"ure. 'ptometrists 3ill maintain a current active valid and unrestricted optometry license from a 1.2. 2tate &istrict of !olumbia !ommon3ealth territory or 7urisdiction. &. S&ope o- pra&! &e. 'ptometrists may have privileges that include but are not limited toG (+) @6amining diagnosing and treating or prescribing courses of treatment for eligible beneficiaries suffering from diseases in7uries or disorders of the visual system the eye and associated structures as 3ell as diagnosing related systemic conditions. (2) !oEmanaging postEsurgical eye cases and ocular complications of systemic illness in the inpatient and outpatient setting. (,) 2erving as consultant in optometry (primary eye care) for other health care professionals in the #92.

AR 4068 0 6 !ebruary 0041RAR

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(.) $romoting prevention and 3ellness vision conservation education and training activities vision screenings and positive eye and vision health behaviors. (*) $rescribing drugs appropriate for ocular therapy. $rescriptive authority is based on the optometrist8s education and e6perience. 0raduates from 1.2. schools of optometry (+9>* and follo3ing) are deemed to possess the appropriate education. d. Super/ " on. 'ptometrists are licensed independent practitioners and have no re(uirement for physician supervision.
>5<2 3(ysician a. *e"&r p! on. $hysicians are primary or specialty health care providers 3ho e6amine diagnose and treat or prescribe courses of treatment for beneficiaries suffering from diseases in7uries or disorders of any or all of the body8s systems. As either primary or specialty care providers physicians are an integral member of the health care team and participate in most clinical path3ays in the health care system. They are s5illed in the management of acute and chronic conditions that affect their patients and are primary sources of consultation for other health care professionals. b. 5ro-e"" onal &reden! al". (+) )du&a! on. $hysicians must have completed an accredited medical degree program acceptable to &A. (2) = &en"ure. $hysicians 3ill maintain a current active valid and unrestricted ('2&(9A) authori4ed 3aiver) medical or osteopathic medical license from a 1.2. 2tate &istrict of !olumbia !ommon3ealth territory or 7urisdic tion acceptable to &A. (,) @oard &er! - &a! on. $hysicians 3ho have completed re(uirements for training and e6perience meeting the standards of various member boards of the American ?oard of #edical 2pecialties (A?#2) are encouraged to attain board certification in their respective specialties. 9o3ever board certification is not re(uired to practice independently. &. S&ope o- pra&! &e. $hysician privileges may include but are not limited toG (+) @6amining diagnosing and treating or prescribing courses of treatment 3ithin the scope of their training and e6perience for eligible beneficiaries suffering from diseases in7uries or disorders. (2) 2erving as consultants for other health care professionals in the #92. (,) $romoting prevention and 3ellness health and safety education and training activities disease screenings and positive health behaviors. d. Super/ " on. $hysicians are licensed independent practitioners and have no re(uirement for direct supervision. They 3ill act independently in areas of medical and surgical care 3hen they have demonstrated competency 3ithin their delineated privileges. $hysicians in postEgraduate clinical training (interns residents and fello3s) are re(uired to function under the supervision of e6perienced physicians participating in the 0#@ system. A physician returning to practice after a lapse in providing patient care may be re(uired to function for a specified period under the supervision of another more e6perienced physician (that is enhanced supervision as described in para 9-. e) if recommended by the credentials committee and approved by the #T< commander. >562 3(ysician assistant and specialty p(ysician assistant a. *e"&r p! on. $As are health care providers 3ho deliver primary or specialty medical care 3ith physician supervision. Hithin that physicianE$A relationship $As e6ercise significant professional autonomy in medical decision ma5ing and provide a broad range of diagnostic and therapeutic services to all &'& beneficiaries. The clinical role of the $A includes but is not limited to primary care <amily practice and specialty areas such as aviation medicine cardiovascular perfusion emergency medicine occupational medicine and orthopedics. $As deploy to provide medical support during mobili4ation humanitarian assistance and peace5eeping missions. $A practice is centered on the management of illness and in7ury disease prevention and health promotion and may includeGin addition to patient care responsibilitiesGdidactic instruction in a formal setting patient education research and administrative activities.
4o!e. The ma7ority of Army $As are assigned to T'@ combat and combat service support units. #ore detailed e6planation (for e6ample regarding training re(uirements continuing education and so forth) is offered about $As so that nonEA#@&& personnel 3ill better understand the duties and responsibilities of these providers both in garrison and in the field.

+,*-+0+ 3hich stipulates a baccalaureate or master8s degree. All $As must be graduates of a $A training program that is accredited by the Accreditation Revie3 !ommission on @ducation for the $hysician Assistant (or previously recogni4ed accrediting body) and acceptable to the &A. (2) Cer! - &a! on. All $As (AAD12ARDAR/0 and civilian) are re(uired to possess current certification by the /!!$A before regular clinical privileges are grantedDrene3ed. (a, 0n ! al &er! - &a! on. $As 3ho received their training from the %nterservice $hysician Assistant Training $rogram (%$A$) (see AR )0+-20) must ta5e the /!!$A $hysician Assistant /ational !ertifying @6amination ($A/!@) at the first available testing period follo3ing $hase %% of training. The %$A$ graduate must pass the $A/!@ 3ithin +2 months follo3ing completion of the %$A$ $hase 2. %ndividuals 3ho due to circumstances beyond their control are unable to ta5e the $A/!@ 3ithin the +2Emonth interval noted above must re(uest deferment in 3riting from the !hief Army
.8 AR 4068 0 6 !ebruary 0041RAR 2ay 00&

b. 5ro-e"" onal &reden! al". (+) )du&a! on. #ilitary $As must meet the educational criteria for commissioning as a )*& according to AR

#edical 2pecialist !orps prior to the scheduled e6amination date. Any approved deferment 3ill delay the +2Emonth mandatory period to pass the $A/!@. The 2oldier 3ill retain any unused portion of hisDher +2 months for use upon termination of the deferment. %$A$ graduates 3ho are unsuccessful in passing the $A/!@ 3ithin the allotted +2 months 3ill have their privileges revo5ed. This is considered an administrative action not an adverse privileging action. $As 3ith an e6isting A& service obligation for training 3ho fail to complete the $A/!@ 3ithin +2 months 3ill be processed for involuntary branch transfer according to AR )+.E+00. (b) Cer! - &a! on rene>al. All $As 3ill continuously maintain /!!$A certification 3hile employed by the <ederal 0overnment. ?iennial rene3al is mandatory. (c) %e&er! - &a! on. The $A /ational Recertification @6aminationD$ath3ay %% is re(uired every ) years. $As 3ho are unsuccessful in passing this e6amination after t3o attempts 3ill have their privileges revo5ed and are prohibited from practicing in their A'!DA2%. The $A 3ith an e6isting A& service obligation for training 3ill be processed for involuntary branch transfer according to AR )+.-+00. %ndividuals 3ith no A& service obligation may be eliminated from service according to AR )00->-2.. 2ee #@&!'# guidance for additional /!!$A certification re(uirements. (,) = &en"ure. /onEpersonal services contract $As employed by the <ederal 0overnment must be licensed in the particular 2tate in 3hich they are 3or5ing (see para .E> a). All other $As (A& 02 and personal services contract) are granted a 3aiver to the licensure re(uirement by &'&. &. S&ope o- pra&! &e. The $As provide medical care for 2oldiers and eligible beneficiaries in all age groups including children under the age of 2 according to the clinical privileges a3arded by the #T< commander. (+) +u!pa! en! du! e". The $A outpatient duties include but are not limited toG (a) General med &al &are. Hithin the limits of their training and privileges $As provide primary and specialty medical care for the sic5 and in7ured. (b) * agno" ", !rea!men!, and pre"&r p! on. $As may diagnose prescribe for and treat diseases disorders and in7uries. (c) ' nor "urger$ and >ound managemen!. $As may perform minor surgery and 3ound management that re(uire completion of a 'ptional <orm ('<) *22 (#edical RecordERe(uest for Administration of Anesthesia and for $erformance of 'perations and 'ther $rocedures). (2ee AR .0-)) for instructions on the use of this form.) (d) 5a! en!" re!urn ng > !h !he "ame &ompla n!. $As must consult 3ith a physician 3hen a patient presents 3ith the same unresolved complaint t3ice in a single episode of care. $hysician consultation 3ill be documented on either a standard form (2<) )00 (9ealth RecordE!hronological Record of #edical !are) or an 2< *+, (#edical RecordE !onsultation 2heet). (2ee AR .0-)) for instructions on the use of these forms.) This does not apply to patients 3ho are returning for routine follo3 up as directed or for treatment of chronic illnesses previously documented in their medical record. (e) %e-erral and e/a&ua! on. 2ituations re(uiring higher levels of medical diagnosis and treatment 3ill be referred or evacuated. %n the absence of a physician the $A 3ill be the primary source of advice to determine the medical necessity priority and re(uirements for patient evacuation. (f) #u!hen! &a! on o- med &al re&ord en!r e". $As 3ill sign all entries made in the patient8s inpatient treatment record (%TR) or outpatient treatment record ('TR). &ocumentation in the %TR of the patient8s medical history physical e6amination and narrative summary as 3ell as entries on &A <orm .2*) (&octor8s 'rders) (see AR .0-))) re(uire physician countersignature. !ountersignature 3ill be 3ithin 2. hours. @ntries made by a $A in the 9R@! or the 'TR do not re(uire a physician8s countersignature. (2) 0npa! en! du! e". The attending physician is responsible for the health care delivered by the $A. A $A may assist the physician in performing a variety of inpatientErelated duties that may include but is not limited to the follo3ingF (a) Admit patients to an inpatient service in consultation 3ith the onEcallDattending physician. All patients admitted to an inpatient service 3ill have an attending physician. (b) Hrite orders for inpatient care using &A <orm .2*). (c) !omplete the medical histories and perform physical e6aminations. (d) $repare and dictate narrative summaries. (e) &ischarge patients but only at the direction of the attending physician. (f) 2pecific preEoperative counseling is the responsibility of the attending surgeon. $As may not perform a pre E surgical anesthesia evaluation that re(uires completion of a &A <orm C,>9 (#edical RecordEAnesthesia). (2ee AR .0)).) (g) $As may not sign the &A <orm ,).C (%npatient Treatment Record !over 2heet). (2ee AR .0-.00.) (,) 5harma&eu! &al u"age. $As may be privileged to 3rite prescriptions for a 3ide variety of pharmaceuticals as described in paragraph C-2&. (a) $As are authori4ed to prescribe controlled substances (2chedule %%-=). (b) Hhen the $A is providing primary field medical support during a field training e6ercise or deployment heDshe may administer or prescribe any pharmaceutical stoc5ed in the 1.2 Army field medical set 5it or assemblage authori4ed at that level of assignment. This is in addition to the pharmaceuticals authori4ed by addendum to the $A8s delineation of clinical privileges.

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(.) 'ed &al e:am na! on". $As mayG (a) !onduct medical e6aminations follo3ing the guidance in AR .0-*0+ and as deemed appropriate by the supervising physician. (b) $erform medical screening for overseas movement and sign the &A <orm .0,) (#edical and &ental $reparation for 'verseas #ovement). (2ee AR )00->-++.) (*) 5ro- le". $As may authenticate temporary limitedEduty profiles according to the guidance outlined in AR .0*0+. ()) 5er"onnel on -l gh! "!a!u". All $As may assign duty limitations and recommend to an aviation unit commander that an aircre3 member be medically restricted from flight duty. 'nly a flight surgeon (<2) may remove duty limitations on flight personnel. (C) #dd ! onal du! e". $As 3ill not be used in lieu of the professional officerEofEtheEday or for administrative duties for 3hich they have not been trained. &uties such as staff duty officer report of survey officer or AR +*-) investigation officer are not appropriate for the $A 3hose primary responsibility involves dayEtoEday delivery of health care and services. (>) ):panded role". $As 3ith advanced education training e6perience and the appropriate privileges may be used in specialty practice settings such as aviation medicine cardiovascular perfusion emergency medicine occupational health and orthopedics. Additions and deletions of $A specialties 3ill be approved by the !ommander 12A#@&!'# (#!9'-!;-!) 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0. A specialtyEtrained $A may perform the initial patient 3or5Eup or consultation. The consultation prepared by the $A 3ill be revie3ed and countersigned by a physician according to established !"# procedures andDor locally developed scopes of practice. 0uidance for each $A specialty is as follo3sG (a, #/ a! on med & ne. A $A 3ho successfully completes the 1.2. Army <light 2urgeon $rimary !ourse 3ill be designated as aeromedical $A A2% #, and may be assigned to assist the <2 in the practice of aviation medicine. Aeromedical $AsG +. $erform hisDher aviation medicine duties under the supervision of a designated aviationEmedicineEtrained physician ()+/) or resident in aerospace medicine. 2. !ontribute to aviation medicine in the areas of medical e6amination for flight duty and primary health care for aviation personnel and their <amily members. ,. $articipate in the Aviation 2afety $rogram and may supervise the fitting and use of cre3 member personal safety e(uipment. The aeromedical $A 3ill not be a substitute for an <2 in these activities. .. Assist in aircraft accident investigations. The aeromedical $A 3ill neither substitute for the <2 in aircraft accident investigations or flight evaluation boards nor 3ill the aeromedical $A sign reports for these investigations or boards. *. 2ign the &A <orm .+>) (#edical Recommendation for <lying &uty) (see AR .0-*0+) recommending an air cre3 member8s return to flight duty only after consultation 3ith an <2. The name of the consulted <2 3ill be annotated on the &A <orm .+>) according to AR )00-+0) and on 2< )00 filed in the patient8s 9R@!. ). ?e placed on noncre3member flight status by 9ead(uarters &A under the provisions of AR )00-+0). (b, Card o/a"&ular per-u" on. A $A 3ho successfully completes an accredited cardiovascular perfusion training program may be designated as a cardiothoracic perfusion $A. !ardiothoracic perfusion $AsG +. <unction under the supervision of a boardEeligible or boardEcertified cardiothoracic surgeon 3hen assigned duties as a cardiothoracic perfusion $A. 2. 'btain certification (highly encouraged but not re(uired) as a certified cardiovascular perfusionist through the American ?oard of !ardiovascular $erfusion. ,. 'perate e6tracorporeal circulation and autologous blood recovery e(uipment during any situation 3here it is necessary to support or replace a patient8s circulatory or respiratory function. .. Administer blood products anesthetic agents and other medication through the e6tracorporeal circuit according to training guidelines and established protocols. *. 1se ancillary techni(ues such as hypothermia hemoconcentration intraEaortic balloon counterpulsation ventricular assist devices and hemodilution. ). Assist 3ith a variety of surgical or invasive procedures to include saphaneous vein harvesting sternotomy and thoracostomy chest tube insertionDremoval and cannulation of ma7or vessels. (&, )mergen&$ med & ne. A $A 3ho successfully completes a T20Eapproved graduate $A emergency medicine training program may be designated as an emergency medicine $A (@#$A) (A2% #2). @#$AsG +. <unction under the supervision of a board certifiedDeligible emergency medicine physician 3hen 3or5ing in an emergency departmentDservice. 2. %dentify evaluate and initiate appropriate treatment to stabili4e patients presenting to an emergency departmentD service 3ith life threatening or medically urgent in7uries illnesses or conditions. ,. $erform all diagnostic and therapeutic emergency medicine procedures for 3hich heDshe has been properly trained and privileged. .. #aintainDsustain those s5ills and certifications (that is A!;2 AT;2 pediatric advanced life support ($A;2))

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3hich are re(uired as part of the @#$A scope of practice and are necessary in the performance of duties 3ithin an emergency departmentDservice. (d, +&&upa! onal heal!h. A $A 3ho receives a graduate level degree in occupational healthDpublic health may be designated as an occupational health $A ('9$A). The '9$A assists the occupational medicine physician ()0!) or preventive medicine physician ()0&) in occupational and preventive medicine duties for the medical center (#@&!@/) medical department activity (#@&&A!) or T'@ unit areas of responsibility. '9$AsG +. !onduct 7obErelated fitnessEforEduty and healthEmaintenance e6aminations for military and civilian personnel. 2. !onduct occupational and nonEoccupational disease and in7ury prevention and treatment of military and civilian personnel. ,. !onduct illness and in7ury monitoring and investigations. .. 2upervise chronic disease surveillance to include tuberculosis and se6ually transmitted diseases. *. $rovide occupational and environmental health education to 2oldiers and &'& civilian employees. (e, +r!hoped &". A $A 3ho successfully completes a T20Eapproved graduate $A orthopedic training program may be designated an orthopedic $A (A2% #+). 'rthopedic $AsG +. &iagnose treat and appropriately manage musculos5eletal trauma andDor disease. 2. $erform minor orthopedicErelated surgical procedures. ,. $erform orthopedic procedures to include traction pin placement and removal and ad7ustment of e6ternal fi6ation devices. .. <unction as first assistant in the operating room and emergency centerDserviceDdepartment for patients 3ith orthopedic in7uries or problems. *. &irectly assist the physician 3ith reductions of all comple6 fractures and dislocations. ). $erform all diagnostic and therapeutic orthopedic procedures for 3hich heDshe has been properly trained and privileged.
4o!e. 'utpatient procedures by an orthopedic $A should not include any manipulation minor surgery or 3ound management re(uiring other than local or peripheral nerve bloc5 anesthesia.

d. 5r / lege". (+) $As 3ill be a3arded privileges commensurate 3ith their education e6perience competence and the operational needs of the unit to 3hich they are assigned. (2) /e3 graduates of the %nterservice $hysician Assistant Training $rogram may be granted and maintained in a supervised privilege status until they have successfully passed the $A/!@ and are licensed (effective + July 2009). (,) The appropriate T'@ surgeon 3ill participate in the privileging process for $As assigned to T'@ units. e. Super/ " on. #T< commanders must e6ercise the utmost care 3hen selecting physicians to be designated as supervisors for military and civilian $As. These physicians (appointed by name and in 3riting) must demonstrate the ability to provide the re(uired professional supervision guidance and support that is of vital importance in all patient treatment settings. The supervising physician must 3hen needed prescribe standards of good medical practice. The supervisor must be available for consultation in person telephonically by radio or by any other means that allo3s personEtoEperson e6change of information. An alternate physician supervisor must be available during temporary absences of the primary physician supervisor. (+) 1ual - &a! on" and du! e". The physician supervisor 3illG (a) ?e (ualified by education training and privileges to perform any treatment or procedure that heDshe directs a $A to perform. (b) ?e responsible for the $A8s medical practice and the (uality of care rendered. (c) @nsure that the $A8s practice remains 3ithin the scope of hisDher clinical privileges. (d) #onitor the $A8s performance using established outcome criteria for treatment referral and follo3up care. (e) @nsure that performance evaluations are conducted according to established !"# policies. These evaluations may be delayed for $As 3or5ing at geographically remote or inaccessible locations 3ith operationally deployed forces or in units on field training e6ercises. &elayed evaluations 3ill be conducted at the first opportunity and should not be delayed for a period greater than ) months. (The )Emonth ma6imum delay period may be 3aived for deployed forces only if compliance 3ould 7eopardi4e the operational mission of the unit. %n this case the revie3 3ill be completed at the earliest available opportunity.) (f) Revie3 medical treatment records for patients managed by $As according to current unit !"# policies. (g) $articipate in the rating of the $A for 3hom supervision is provided. %n all cases the physician supervisor 3ill be included as either the $A8s rater or senior rater according to AR )2,-,. (2) 4onper"onal "er/ &e" &on!ra&! 5# "uper/ " on. A $A in this status may have supervision re(uirements imposed by hisDher 2tate of licensure that e6ceed 1.2. Army re(uirements. (0iven the variation among 2tates regarding supervision of $As under nonEpersonal services contract to the 0overnment #T<s are encouraged to hire contracted $As via personal services contract.) <or $As 3ho re(uire additional supervision the follo3ing t3o options listed in order of preference may applyG

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(a) The contractor is responsible for providing the additional supervision. %n this case the #T< 3ill cooperate by providing copies of medical records for e6ternal revie3. The number of medical records 3ill be locally determined. (b) The #T< must petition the 2tate board of licensure to honor physician license portability (+0 12! +09.) in order for the #T<Eappointed physician to provide the necessary supervision. %n this case the #T< is obliged to meet the other established supervision re(uirements of the 2tate of licensure. -. C') and !ra n ng. !#@ is critical for sustainment of clinical s5ills necessary for the $A to perform hisDher duties. (+) $As are re(uired to obtain +00 hours of !#@ every 2 years in order to maintain current /!!$A certification. !ommanders are encouraged to provide the time and the necessary funding as appropriate to ensure that all assigned $As remain current in their clinical s5ills. (2) Readiness training is of paramount importance to prepare 1.2. Army $As for their 3artime mission. Recom E mended training for AAD12ARDAR/0 $As includesG (a) #T=S or an e9u /alen!. This training helps ensure that military $As are (ualified in advanced trauma management to meet the doctrinal mission to care for the 3oundedDin7ured on the battlefield. Advanced trauma management sustainment training is re(uired for military $As once every . years. (b) 'ed &al 'anagemen! o- Chem &al and @ olog &al Ca"ual! e" Cour"e. The increased ris5 that 3eapons of mass destruction 3ill be employed in a battlefield scenario re(uires that military $As be able to recogni4e and treat the in7uries or diseases that 3ill result from the use of chemical or biological agents. $As should attend this training as soon as possible follo3ing graduation. (c) Trop &al7global med & ne. The increasing li5elihood of deployments and missions in the tropical and subtropical regions of the 3orld re(uires familiarity 3ith diseases and conditions that are endemic to those areas and 3hich pose a threat to the health and 3ellEbeing of 2oldiers.
>5>2 3(ysical t(erapist a. *e"&r p! on. $Ts ensure operational readiness and (uality of life to the fighting force and other eligible beneficiaries by providing appropriate physical therapy care. This is achieved through physical therapy services that include e6amination evaluation diagnosis prognosis intervention prevention health promotion education and research. b. 5ro-e"" onal &reden! al". (+) )du&a! on. $Ts must be graduates of a physical therapy program accredited by the !ommission on Accreditation in $hysical Therapy @ducation or its e(uivalent. (2) = &en"ure. $Ts 3ill maintain a current active valid and unrestricted physical therapy license from a 1.2. 2tate &istrict of !olumbia !ommon3ealth territory or 7urisdiction. &. S&ope o- pra&! &e. (+) Ca!egor$ 0. !ategory % clinical privileges are appropriate for the $T 3hose activities are limited to the standard scope of practice as defined by hisDher 2tate license. (a) $erform functions in support of physical therapy evaluation and treatment. (b) $rovide physical therapy e6amination evaluation diagnosis prognosis and intervention services for patients seen by providers 3ithin the #92 as 3ell as those referred by civilian providers. (c) 2erve as $T clinical consultant for other health care professionals in the #92 the &'& andDor &epartment of =eteran8s Affairs (=A) facilities concerning patientEspecific treatment approaches. (d) $erform prevention and 3ellness activities education screening and promote positive health behaviors. (2) Ca!egor$ 00. !ategory %% clinical privileges are a3arded to $Ts 3ho demonstrate appropriate education training andDor board certification. These authori4e the $T toG (a, $erform functions in support of physical therapy evaluation and treatment as follo3sF +. Re(uest appropriate imaging studies for patients 3ith neuromuscular disorders for 3hom they are performing primary evaluation and treatment. 2. Assign patients to (uarters for intervals not to e6ceed C2 hours. ,. Refer patients to specialty clinics. .. Authenticate temporary limitedEduty profiles according to the guidance outlined in AR .0-*0+. *. Hrite prescriptions for selected medications as described in paragraph C-2 & for musculos5eletal conditions. (b, $erform and interpret electrophysiologic tests to include nerve conduction studies needle electromyography and somatosensoryEevo5ed potentials. These privileges should only be granted if the $T has met the American ?oard of $hysical Therapy 2pecialties guidelines for the practice of clinical electrophysiologic physical therapy published in !linical @lectrophysiologic $hysical TherapyF &escription of Advanced !linical $ractice (+99*). +. &ocumentation in support of the $T8s re(uest for such privileges includes a summary of postEgraduate professional education (ualifying clinical e6perience and a formal statement by the clinical preceptor and the medical officer attesting the proficiency of the candidate. 2. A (ualified electrophysiologic supervisor as defined belo3 3ill be designated by the #T< commander to be a direct liaison 3ith the $T performing electrophysiologic tests and 3ill serve as the $T8s clinical preceptor for problem

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cases revie3 of cases ascertaining the (uality of practice and to ans3er (uestions concerning ne3 e(uipment or special techni(ues. 3. An ongoing peer revie3 process bet3een the electrophysiologic supervisor and the practicing $T 3ill be established. This should include a (uarterly revie3 of at least a +0 percent sample of patient medical records and reports and a yearly onEsite revie3 of the clinical electrophysiologic testing procedures. A (ualified military or civilian electrophysiologic supervisor shall be a physician certified by the American ?oard of @lectrodiagnostic #edicine a physician holding a !ertificate of Added "ualification in !linical /europhysiology of the American ?oard of $sychiatry and /eurology or a $T certified by the American ?oard of $hysical Therapy 2pecialties as an electrophysiologic certified specialist. (&, $rovide early intervention (that is physical therapy care for highEris5 infants) in the neonatal intensive care unit. d. Super/ " on. The $T 3ith category % privileges 3ill be provided supervisionDoversight of hisDher clinical practice as re(uired by a $T 3ith category %% privileges or in the absence of a category %% privileged $T by a physician. >582 3odiatrist a. *e"&r p! on. &octors of podiatric medicine (&$#) provide comprehensive medical and surgical management of disorders of the foot and an5le. This includes e6amination diagnosis medical and surgical treatment prevention and care of conditionsDfunctions of the foot and related structures. $odiatrists are members of the orthopedicDsurgery service. b. 5ro-e"" onal &reden! al". (+) )du&a! on. $odiatrists 3ill have a &$# degree (.Eyear &$# degree) from an accredited college or university of podiatric medicine acceptable to &A. Hhile completion of a 2.Emonth podiatric surgical residency is preferred completion of a +2Emonth podiatric surgical residency plus a +2Emonth podiatric orthopedicDprimary podiatric medical residency is accepted. (2) = &en"ure. $odiatrists 3ill maintain a current active valid and unrestricted podiatry license from a 1.2. 2tate &istrict of !olumbia !ommon3ealth territory or 7urisdiction. (,) Cer! - &a! on. ?oard certification (not re(uired but encouraged) is via one of t3o certifying boards recogni4ed by the American $odiatric #edical Association8s !ouncil on $odiatric #edical @ducationG (a) American ?oard of $odiatric 2urgery. (b) American ?oard of $odiatric 'rthopedics and $rimary $odiatric #edicine. &. S&ope o- pra&! &e. A &$# may be privileged as any other member of the medical staff in the surgical service. The national standard for &$#s 3ith the appropriate postEgraduate education as stated in b above is the management of all disorders of the anatomic region of the foot and an5le and related structures affecting the foot and an5le. $odiatrists for 3hom residency training included medical history ta5ing and physical e6amination may be privileged to perform the complete 9O$ for A2A patient classification status + and 2 patients in both the inpatient and outpatient settings. The &$# 3ill perform and record the 9O$ on the appropriate medical form(s) for e6ample 2< *0. (!linical Record E 9istory $art %) 2< *0* (!linical Record E 9istory $art %% %%%) and 2< *0) (#edical Record E $hysical @6amination) for the inpatient or 2< )00 (outpatient). $atients classified as A2A patient classification status , and greater 3ill re(uire an 9O$ either all or part of 3hich is performed by a (ualified physician. The podiatric portion of the 9O$ may be performed recorded and signed by the &$#A the remaining medical portion of the 9O$ is the responsibility of the consulting physician. <indings conclusions and assessment of ris5 3ill be confirmed or endorsed by a (ualified physician prior to initiation of any ma7or highEris5 diagnostic or therapeutic intervention. The &$# may be privileged to admit patients only if heDshe is educationally prepared to perform the 9O$. 'ther3ise a privileged physician must admit the patient perform the 9O$ and assume responsibility for the patient8s inpatient medical care during hospitali4ation. d. Super/ " on. $odiatrists are licensed independent practitioners and have no re(uirement for physician supervision. >5$2 3syc(ological associate a. *e"&r p! on. $sychological associates are trained in general psychology psychometric theory psychological testing behavioral science counseling theories and practical applications of psychological principles. The psychologi cal associate may develop additional e6pertise in industrial psychology school or health psychology neuropsychology and pediatric or adolescent psychology.
4o!e. The provisions of this section are applicable to 02 +>0Eseries counseling psychologists that do not meet 2tate re(uirements as a doctoral level psychologist. These individuals shall be privileged to engage in clinical practice only as defined in this regulation using the title psychological associate or behavioral health practitioner. (2ee para C-).)

b. 5ro-e"" onal &reden! al". $sychology associates must demonstrate appropriate education s5ills training and e6perience to be considered for clinical privileges. The minimum educational and licensure re(uirements for category %%%% level of privileges includeG (+) Ca!egor$ 0. The individual has earned a master8s degree in psychology fulfilling the re(uirements of an academic program including a minimum of ) semester hours of supervised practicum in the ma7or specialty. The graduate program must be offered by a collegeDuniversity fully accredited by a 1.2. regional accrediting body.
AR 4068 0 6 !ebruary 004 4.

(2) Ca!egor$ 00. The individual has completed a master8s degree program in psychology at a fully accredited collegeDuniversity including a minimum of ) semester hours of supervised practicum. The individual possesses licensure as a psychological associate or the ;$!D;$!Ee(uivalent licensure (or other master8s level psychology license) available in some states. The individual has a minimum of 2 years8 fullEtime e6perience in the specialty in 3hich services are performed under the supervision of a higher level privileged provider 3ith a license in psychology.
4o!e. /ot all 2tates offer licenses to master8s level psychologists but all offer the ;$! though some 2tates use a different title for the ;$!Ee(uivalent license. The education and e6perience re(uirements for licensure are the basis for determining e(uivalency.

(,) Ca!egor$ 000. The individual has completed a postEmaster8s specialty degree from an accredited collegeDuniversity and passed a comprehensive e6amination in that specialty. The individual is a master8s level psychologist or has an ;$!D;$!Ee(uivalent license from a 2tate licensing body. The individual provides a 3ide range of services in the designated specialty and may supervise category %% or % counselors in the provision of services in the specialty. &. S&ope o- pra&! &e. %ndividuals 3ill practice 3ithin the guidelines of their respective 2tate licensing boards as a licensed psychological associate (if offered by their 2tate) or ;$! (or e(uivalent) or Llicensed mental health provider.M $sychological associates adhere to the 2tate licensing board8s !ode of @thics and !onduct for psychologists or ;$!s. 2pecific clinical privileges are granted based upon training e6perience and competency. %n general psychological associates 3illG (+) !onduct an inta5e intervie3 of assigned patients to include the history of the presenting problem a psychosocial history as 3ell as a mental status evaluation and any relevant behavioral observations. (2) !onduct screening evaluations utili4ing information from clinical intervie3s nonpsychometric tests and collatE eral sources as appropriate. (,) Recommend an assessment strategy sufficient to ans3er the diagnostic (uestion presented. (.) Administer and score all psychological tests used in the assessment and present the data in a format to facilitate evaluation of the data. (*) &etermine a provisional diagnosis according to the $sychiatric Association &iagnostic and 2tatistical #anual of #ental &isorders. ()) $repare under the general supervision of a licensed psychologist a report or evaluation that includes the presenting problem all pertinent historical data information from collateral sources and psychological testing. %ntegrate all data to facilitate conclusions and recommendations. (C) $rovide feedbac5 to patients on the results of the psychological evaluation. d. Super/ " on. (+) #aster8s level graduates 3ill be fully supervised during their first year of employment and 3ill 3or5 under the direct supervision of a licensed psychologist. Thereafter the 3or5 product 3ill be fully revie3ed and general supervision provided by a licensed psychologist according to the individual8s level of competence as assessed by hisD her supervisor. (2) ;icensed psychology associates (or ;$!s) 3ith 2 or more years8 e6perience (after attaining licensure) 3ill receive general supervision by a licensed psychologist according to the individual8s level of competence as assessed by hisDher supervisor. (,) ;icensed psychology associates (or ;$!s) 3ith more than 2 years8 e6perience and 3ith a postEmaster8s specialty degreeGsuch as the @d.2.Gre(uire supervision in their specialty only 3ith difficult highEris5 cases or for cases in 3hich one or more of the patient8s problems fall outside the scope of the associate8s training.
>#02 Speec( pat(ologist a. *e"&r p! on. 2peech pathologists help ensure operational readiness and (ualityEofElife to the fighting force and other eligible beneficiaries by providing costEeffective speech communication health care. 2peech language voice and s3allo3ing services are offered to include prevention medical surveillance education and research. The goal of speech pathology is to support the &'& mission and &'& personnel through implementation of communication enhancement and voice conservation. 2peech pathologists diagnose and treat speech voice and communication deficits of 2oldiers and other beneficiaries by prescribing appropriate treatment and 3hen necessary providing referral for medical intervention. b. 5ro-e"" onal &reden! al". (+) )du&a! on. 2peech pathologists are re(uired to have a master8s or doctoral degree in speech pathology from an accredited institution acceptable to &A. (2) = &en"ure. 2peech pathologists 3ill maintain a current active valid and unrestricted license registration or certification from a 1.2. 2tate &istrict of !olumbia !ommon3ealth territory or 7urisdiction. (,) Cer! - &a! on. A !ertificate of !linical !ompetence from the American 2peechE;anguageE9earing Association is re(uired. &. S&ope o- pra&! &e. 2peech pathologists follo3 the guidelines published by the American 2peechE;anguage9earing Association. They are privileged to provide comprehensive diagnostic and therapeutic procedures of the speech and voice mechanism. Those 3ith advanced training and current competence may be privileged to perform advanced

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procedures such as electrophysiological measures of speech functions acoustic analyses of voice production fiberoptic endoscopic evaluation of s3allo3ing modified barium s3allo3 study dysphagia therapy stuttering treatments and voice therapy. d. Super/ " on. The speech pathologist 3ill be supervisedDprovided oversight of hisDher clinical practice by a more senior or e6perienced speech pathologist as determined by the #T< commander. %n the absence of a senior speech pathologist a physician or other (ualified privileged provider as designated by the &!!2 may provide supervisionD oversight.

C(apter 8 Credentials Revie=

852 @eneral !redentials are those documents presented by the health care professional regardless of the nature of hisDher practice or duty position that constitute evidence of current licensure certification registration or other authori4ing document as appropriate. %n addition professional credentials substantiate relevant education training and e6perienceA current competence and 7udgmentA and the ability to carry out the duties and responsibilities of the assigned position or for the privileged provider to perform the privileges re(uested. 8#2 Credentials aut(entication 'or military accessions a. $rior to selection for military service the appropriate personnel from the respective A#@&& Recruiting &etach E ments 3ill complete $2= of selected military providerDprofessional credentials and these are for3arded to the appropriate branch at 12AR@! (9ealth 2ervices &irectorate (92&)) <ort Kno6 KI. (+) The $2= performed by 12AR@! need not be repeated by the #T< credentials manager if appropriately authenticated provider credentials are available. The methods used to primary source verify credentials are those outlined in paragraph >-)-. (2) The documents and forms re(uired by 12AR@! to apply for military service vary by A#@&& program type. <or privileged provider applicants (direct accessions) the documents that may subse(uently become part of the $!< include but are not limited toG (a) $ersonnel &ata 2heet. (b) $rofessional license and $2= (copy). (c) !urriculum vitae (!=) or resume (copy). (d) &iploma (copy). (e) "ualifying degree official transcripts (copy). (f) !ontinuing medical or health education (copy). (g) #alpractice insurance coverage and $2= (copy). (h) Additional documentsF board certification(s)A /$&? (uery resultsA @!<#0D<ifth $ath3ay certificate (if applica E ble)A and internship residency fello3ship certification or verification as appropriate. b. %n addition to the various documents noted above 12AR@! re(uires an @lectronic $ersonnel 2ecurity "uestionnaire from all individuals 3ho do not currently hold a secret clearance.
4o!e. An /$&? (uery is placed for all privileged providers unless a verified copy of the response from a recent (uery (less than + year old) is available from a civilian organi4ation.

&. 'nce military appointment is accepted all primary source verified documents and other credentials as noted in paragraph a above submitted as part of the application for military appointment 3ill be for3arded by 12AR@! (92&) as follo3sG (+) ## pro/ der"7pra&! ! oner". 12AR@! (92&) 3ill for3ard credentials to the first #T< of assignment as applicable upon receipt of 3ritten re(uest (see fig >-+) from the #T< credentials office. These documents 3ill be for3arded by <ederal @6press (<ed@6) or comparable mail service to the #T< credentials manager. (a, 12AR@! (92&) 3ill process credentials re(uests for the follo3ing categories of AA accessionsF +. 3ull$ 9ual - ed d re&! a&&e"" on appl &an!" n all #')** &orp". !redentials 3ill be for3arded upon re(uest as noted above. 2. #rm$ 'ed &al Spe& al "!" Corp". !redentials for student accessions into the 1.2. ArmyD?aylor $rogram in $hysical Therapy the A#@&& &ietetic %nternship and 'ccupational Therapy <ield3or5 $rograms 3ill be for3arded to the appropriate program directors (no formal re(uest re(uired). ,. 'ed &al Ser/ &e Corp". !redentials for participants of the !linical $sychology and $odiatry Residency $rograms 3ill be for3arded to the appropriate program directors (no formal re(uest re(uired). .. *en!al #G* 12<mon!h appl &an!". &ocuments 3ill be for3arded to the individual program directors at each training site follo3ing the A0& selection board (no formal re(uest re(uired).

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(b, 12AR@! (92&) is not responsible for for3arding credentials on the follo3ing categories of AA accessionsF +. %e! ree re&all". The retiree8s $!< must be re(uested from the 1.2. Army 9uman Resources !ommand (9R!) A9R!-R2A-" + Reserve Hay 2t. ;ouis #' ),+,2-*200. !redentials ac(uired since retirement 3ill be appropri ately verified ($2=) by the credentials office at the unit of assignment. 2. %e"er/e +-- &er Tra n ng Corp" (%+TC, &ade!". The Army R'T! $rogram is an accessions source for generic (nonspeciali4ed) officers primarily A/ and #2. A baccalaureate degree verified by R'T! !adet !ommand from a &AE approved college or university is the single credential re(uired of all R'T! officers. $rior to being assigned to an 'fficer ?asic !ourse class the R'T!Ecommissioned A/ officer must have successfully passed the /ational !ouncil for ;icensure @6aminations Registered /urse and hold a valid unrestricted R/ license as confirmed by R'T! !adet !ommand 3ith the respective 2tate board of nursing. ,. %+TC edu&a! onal dela$ par! & pan!". These individuals are involved in an advanced degree program (most often selfEfunded) in a health care specialty (for e6ample 'T $T and so forth). %f the individual is accessed into the military in a health care A'! credentials from the appropriate source must be re(uested and $2= conducted by the credentials manager at the first unit of assignment. .. ;eal!h 5ro-e"" on" S&holar"h p 5rogram par! & pan!". 1pon graduation from medical school or other professional education program certified true copies of official academic credentials (that is diploma final transcripts and so forth) 3ill be hand carried by the individual to hisDher first year unit of assignment.
4o!e. 'fficial sealed copies of academic credentials are the only credentials that may be hand carried by the individual in (uestion.

these programs 3ill be for3arded in accordance 3ith paragraph 9-. d(+). <or students participating in 0$9@ in civilian deferred status (includes <A$) credentials must be re(uested from the training site. $2= 3ill be conducted by the credentials office at the individual8s first #T< of assignment. (2) US#% pro/ der"7pra&! ! oner". <or3arding instructions 3ill be determined by assignmentDattachment as follo3sF (a) <or providers assigned to troop program units (T$1s) for3ard to the designated unit of assignment. (b) <or providers assigned to a unit but attached to the /ational A#@&& Augmentation &etachment (/AA&) for3ard to !ommander /AA& (A<R!-/A&-"A) +.0+ &eshler 2treet 2H <ort #c$herson 0A ,0,,0-2000. (c) <or providers assigned to the %ndividual Ready Reserve (%RR) (e6cludes 0#@ participants in civilianEdeferred status) or the %ndividual #obili4ation Augmentation $rogram documents 3ill be for3arded to !ommander 9R! (A9R!-R2A-") + Reserve Hay 2t. ;ouis #' ),+,2-*200. (,) 4a! onal Guard pro/ der". <or3ard documents to 2trength #aintenance &ivision (/0?-A2#-2) (A#@&&) 2uite ,.00 +.++ Jefferson &avis 9igh3ay Arlington =A 22202-,2,+. 2trength #aintenance &ivision 3ill for3ard documents to the appropriate 2tate 2urgeonD&eputy 2tate 2urgeon 3ho 3ill for3ard the documents to the designated credentials manager.

*. 3 nan& al #"" "!an&e 5rogram par! & pan!" ("ame a" para 6 belo>,. ). ' l !ar$7& / l an re" den&$, -ello>"h p", or !ra n ng program par! & pan!". !redentials for military trainees in any of

882 Military treatment 'acility aut(entication o' pro'essional credentials a. Revie3 and $2= of the authenticity of credentials for all professional health care personnel is mandatory. %n no instance 3ill an individual be assigned or privileged to perform professional duties unless appropriately (ualified by education training and e6perience. b. =erification of credentials as stipulated in this chapter 3ill be accomplished for all categories of privileged and nonprivileged <ederal employeesF AAD12ARDAR/0 military civil service consultant status </;9 contract or volunteer health care practitioners (includes ne3 medical school graduates and trainees completing 0#@ in civilian deferred status). <or all privileged providers in(uiry 3ill also be made to the /$&? (see para >-C l) prior to the initial granting of clinical privileges 3hen e6panding or adding ne3 clinical privileges and at each biennial rene3al. (+) 4onpr / leged "!a--. =erification of nonprivileged professional credentials is managed by the #T< readiness education and training departmentDservice (or other service) according to local policy. The professional credentials that 3ill be primary source verified and annotated in the individual8s !A< (see chap * and app !) or other locally prescribed training file include but are not limited toG (a) #&adem &. $reEe6isting academic achievement is verified prior to military accession. $reEemployment verifica E tion of academic credentials for civilians (02 personal services contract and volunteer) is the responsibility of the #T<. 9ealthEcareErelated professional degrees attained 3hile employed by the <ederal 0overnment 3ill be verified by the #T<. (b) = &en"ure7&er! - &a! on7reg "!ra! on or o!her au!hor 6 ng do&umen!a! on. <or ne3 military accessions $2= of an e6isting license(s) prior to entry into <ederal service 3ill be accomplished by 12AR@!. ;ocal policy 3ill direct 3ho at the #T< is responsible for $2= of license for recently assigned nonprivileged military accessions and for pre E employment licensure verification for civilians (02 personal services contract and volunteer). The contracting agency 3ill verify licensure 3ith the primary source for nonEpersonal services contract personnel prior to the employee being assigned to the #T< for duty. <or military and civilian employees periodic license rene3al as determined by the issuing 2tateDnational agency 3ill li5e3ise be authenticated 3ith the primary source by the responsible #T< authority.

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The contracting agency is responsible for $2= of licensureDcertificationDregistration rene3al for nonEpersonal services contracted employees. This re(uirement applies to all nonprivileged personnel 3ho possess a license certification or registration as a professional credential. (2ee paras >-)e and f for more information on $2=.) (c) S!a!e or na! onal "pe& al!$ "8 ll" &er! - &a! on. This includes those offered by the A/A or other professional organi4ation mammography s5ills certification for radiology technicians and so forth (d) #u!hen! &a! on o- o!her d "& pl ne<"pe& - & "8 ll or !e&hn &al !ra n ng !o n&lude *+*<"pon"ored !ra n ng. This e6cludes inEservice education and other locally established training re(uirements. (2) 5r / leged "!a--. $rivileged provider credentials are verified updated and maintained during the individual8s tenure 3ith the 1.2. Army by the #T< credentials manager or other responsible authority as designated by the commander. $rofessional information about the privileged provider is contained in both the $!< and the $A<. (a) The $!< is the primary repository of permanent information related to provider credentials and performance. The contents must remain intact and the security of the information ensured at all times. Any re(uest by the sub7ect provider for amendment of information contained in the $!< (for e6ample correction of erroneous or inaccurate information or the removal of improperly filed documents) must be considered under the provisions of the $rivacy Act and AR ,.0-2+. The $!< 3ill be released only to the #T< commander the credentials committee departmentDservice chiefs recogni4ed revie3ing authorities or officially appointed inspectors. The provider may authori4e in 3riting release of hisDher $!< to others but the $!< should be retained in the credentials office 3ith authori4ed access in that secure location. 2ee appendi6 @ for additional information regarding the $!<. (b) The $A< is considered a 3or5ing file that contains a variety of clinical data that are used to profile the provider8s practice to periodically reevaluate performance and to reappraise privileges. 2elected contents of this file (2ee app @ for specific information regarding the contents and organi4ation of the $!<.) are transferred to the $!< according to local procedures for permanent inclusion in the $!<. 'ther contents should be maintained for a minimum of 2 years to allo3 trac5ing and trending of provider clinical performance data and other information considered significant to the organi4ation from a business or clinical perspective. (2ee additional $A< information in para >-9 and app <.) (c) ?oth the $!< and the $A< contain sensitive confidential information. The documents contained in these files (ualify for protection under +0 12! ++02. (2ee app @ for specific information regarding the contents and organi4ation of the $!<.) To protect these files and to maintain the integrity of the contents the $!< and the $A< must be stored in a secure location (for e6ample in a file cabinet des5 dra3er and so forth that can be loc5ed). Access to either file is limited to authori4ed individuals only. The $A< should be retained in the credentials office 3ith authori4ed access only in that secure location. %f either the $!< or the $A< is re(uired outside this area personal delivery by the credentials coordinator (or designated individual) is recommended. The integrity of these files and security of the contents must be maintained at all times. (d) A provider may on re(uest and in the presence of the credentials manager or other command representative be allo3ed to revie3 the contents of hisDher $A< and $!<. 842 3rivileged provider credentialing a. The credentialing process includes a series of activities designed to collect relevant data that serve as the basis for decisions regarding appointment and reappointment to the medicalDdental staff as 3ell as delineation of individual clinical privileges. This information may also be the basis for subse(uent action to e6pand or limit a provider8s privileges. b. Recommendations for the a3ard of clinical privileges and medical staff appointment (if applicable) 3ill be made by the departmentDservice chief acted upon by the credentials committeeDfunction and for3arded through the @!#2 (AA facilities and 12ARDAR/0 units 3herever feasible) to the commander for approval or disapproval. Recommendations from peers 3ho have firsthand 5no3ledge of the applicant8s competence s5ill and ability in the professional discipline are essential to the medicalDdental staff appointmentDreappointment process as 3ell as to the granting rene3ing or revising of clinical privileges. $eer recommendations may include 3ritten feedbac5 fromG (+) The $% committeeDfunction the ma7ority of 3hose members are the provider8s peers. (2) A department or clinical service chief 3ho is a peer. (,) The @!#2 the ma7ority of 3hose members are the provider8s peers. (.) A reference letter or documented telephone conversation about the provider from a peer 3ho is a member of the #T<8s medical staff or 3ho is from outside the organi4ation. $eer recommendations 3ill be maintained in the $!< and are filed 3ith the recommendations by the provider8s department or service chief. 8<2 Military treatment 'acility credentials committee;'unction !entral to the responsibility of assuring (uality care and improving the performance of services rendered by privileged providers are the re(uirements for credentials revie3 delineation of individual clinical privileges for professional staff members appointmentDreappointment to the medical staff and adverse privileging action hearingDappeals processes as appropriate. These functions may be e6ecuted by the @!#2D@!&2 (see glossary) or other group properly constituted to perform this series of activities for e6ample the credentials committee. %f the credentials committee is charged 3ith

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these responsibilities the @!#! must revie3 and concur 3ith all recommendations for actions associated 3ith provider privileging and medical staff appointmentDreappointment prior to their consideration by the commander. a. 5urpo"e. (+) The credentials committeeDfunction revie3s the credentials and the performance of each provider re(uesting clinical privileges and appointment to the medicalDdental staff. 2ubse(uent to this revie3 recommendations for provider privilegingDappointment actions to include those for 12ARDAR/0 providers for 3hom the committee has privileging responsibility are made through the @!#2D@!&2 to the commander. The committee8s recommendations relevant to a provider8s re(uest for privileges are based upon hisDher credentials performance data departmental peer recommendations and the needs and capabilities of the institution. (2) The credentials committeeDfunction 3ill also consider and recommend to the commander 3hether providers in a lessEthanEfully privileged status should be allo3ed to function under clearly defined supervision involuntarily separated or released from A& or civilian employment. (,) /o action recommended by the credentials committeeDfunction is final until it has been revie3ed by the @!#2D @!&2 and approvedDsigned by the commander. b. 'ember"h p and du! e". The #T< commander 3ill designate the &!!2 (or other senior physician) as chairperson and 3ill name the permanent members and a designated alternate for each member of the committee. Alternates 3ill e6ercise all the duties and responsibilities of the permanent voting member 3hom they represent. (+) The chairperson 3ill ensure that all assigned members receive appropriate orientation to assume the duties and responsibilities of this committee. (2) #embership 3ill reflect the diversity of privileged providers practicing 3ithin the facility in outlying patient care settings under the command and control of the #T< and in garrisonElevel T'@ units 3here present. The ma7ority (*+ percent or greater) 3ill be fully appointed members of the medicalDdental staff. (,) /o action on a provider 3ill be ta5en 3ithout the presence of a ma7ority (*+ percent or greater) of the voting membership. (.) The chairperson may re(uest the presence of a legal advisor (nonvoting). (*) The senior nurse e6ecutive (that is the !hief /urseD&!/) is a voting member. ()) At least one voting member of the same discipline if available 3ill be present 3hen clinical privileges for a nonphysician provider are considered. (C) #embers in the same discipline as the provider being evaluated should be present 3hen the committee acts on the credentials of such providers.
4o!e. This is not mandatory for actions on temporary or supervised privileges.

(>) Hhen the credentials of any member of the group are being considered that member 3ill be e6cused from that portion of the meeting. This 3ill be reflected in the minutesDreports. (9) The revie3 of credentials and privileges for the #T< commander and deputy commander 3ill be performed according to paragraph 9-2&. &. 'ee! ng" and repor!". The credentials committee 3ill meet or the function initiated as often as necessary to ensure the timely appraisal of credentials and to prevent the e6piration of privileges. The chairperson 3ill ensure there are 3ritten records of all actions recommendedDta5en by this group. (+) Reports and recommendations of the committee are provided through the @!#2D@!&2 (AA facilities and 12ARDAR/0 units 3herever feasible) to the commander. (2) Announcements of meetings 3ith the e6ception of onEcall meetings 3ill be made no later than * days (no later than ,0 days for 12ARDAR/0 committee meetings) prior to the planned meeting date. (,) Those providers to be considered 3ill receive ,0Edays8 notice ()0 days for 12ARDAR/0 providers) to revie3 and update their credentials as appropriate and to submit a current re(uest for privileges. (.) The chairperson may schedule an onEcall meeting as directed by the commander or as needed toG (a) @valuate provider re(uests for modification (augmentation or reduction) of individual clinical privileges. (b) @valuate the credentials of providers ne3ly assigned (initial &'& assignment follo3ing $!2Dtransfer or T&I). (c) Reevaluate providers 3ho are in initial or restricted categories of professional activities. (d) !onsider or ma5e recommendations to the commander that a provider8s privileges be suspended restricted revo5ed reduced or denied. (*) =oting is by a sho3 of hands or by 3ritten or electronic ballot 3ith either a LyesM or LnoM voteA no abstentions are allo3ed. The chairperson 3ill vote only in the event of a tie.
4o!e. =oting related to routine reprivileging actions may be accomplished by electronic means rather than paper ballot. ;ocal policy 3ill prescribe the application of and any restrictions associated 3ith this method of credentials committee information dissemina tion and balloting.

%n the case of an adverse privileging action against a provider or a controversial issue involving a particular provider the voting may be by secret ballot. %f a member believes heDshe should be dis(ualified from voting for (or against) a

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given individual a re(uest 3ith 7ustification is submitted to the chairperson. %f the re(uest is granted the minutes 3ill reflect by name the member 3ho has recused himDherself from the vote. ()) The minutes 3ill reflect the total LyesM and LnoM votes cast for each action. =oting by nonpermanent members of the committee is restricted to actions or privileges for members of their respective discipline. &is(ualified members 3ill not vote. d. US#%7#%4G &reden! al" managemen! and &reden! al" &omm !!ee7-un&! on. AR!!A manages credentials for the 12ARGe6cept for those managed by 9R!E2t. ;ouis (%RR providers) and those managed by the AA #T< (%#A providers). <or the AR/0 a credentials manager 3ill be appointed on orders. 9eDshe 3ill maintain a complete credentials file and !!"A2 data file for all AR/0 privileged providers 3ithin the 2tate. (+) 2tate 2urgeons 3ill establish a credentials committee (or ensure the function is performed by one of the mechanisms described belo3) to perform the various credentialing and privileging activities as outlined in this regulation. The 2tate 2urgeon 3ill not serve as chairman of the credentials committee. 9eDshe 3ill serve as the approval authority for all privileging actions and 3ill sign in bloc5 9a &A <orm *..0A for both initial privilegesDstaff appointment and for rene3al of privilegesDstaff appointment. (2) A variety of AR/0 unitEspecific circumstances e6ist that influence credentials committee structure and function. (a) The 2tate 2urgeon8s credentials committee serves as the centrali4ed credentialing authority for all AR/0 healthcare providers in the 2tate. The 2tate 2urgeon may delegate this function to another activity if performance is comparable to that of the 2tate 2urgeon8s credentials committee. (b) AR/0 medical units 3ith a minimum of three privileged providers may form a credentials committee. (c) 1nits unable to form a credentials committee due to insufficient providers or other reasons may coordinate to convene a regional credentials committee. An #'1 bet3een the participating 2tates serves as the charter for this committee. (,) The credentials committee 3illG (a) #a5e recommendations to the AR/0 2tate 2urgeonD#T< commander on privileging a unit provider for %&TD A& activities such as those identified in paragraph +-.h(*). (b) Revie3 each provider8s education training and current competencies against regular dutyDmobili4ation A'! re(uirements. All AR/0 providers 3ill be credentialed in both their duty A'! and their civilianEe(uivalent A'!. 9o3ever privileges 3ill be granted in accordance 3ith the AR/0 provider8s duty A'!. (c) !onsider and ma5e recommendations to the 2tate 2urgeon as appropriate that an AR/0 provider8s privileges be denied suspended restricted reduced or revo5ed. 862 3rovider credentials veri'ication $rior to being privileged and a3arded appointment to the medicalDdental staff $2= of those provider8s credentials that re(uire such verification 3ill be accomplished. 'ther credentials as noted belo3 3ill be verified as true and authentic. a. !redentials for 3hich rene3al is not appropriate (diploma certificate of internship and so forth) need only be primary source verified once if the individual maintains continual employment 3ithin the &'&. !redentials that re(uire periodic rene3al 3ill be verified upon rene3al. The privileged health care provider8s license is the only e6ception as described in paragraph >-Cb(2). b. <or military (AAD12ARDAR/0) credentials verification occurs during preEselection processing prior to military commissioning. (2ee para >-2 for more information.) c. <or civil service consultant status </;9 personal services contract or volunteer health care privileged providers credentials verification by the #T< is re(uired. =erification of the applicant8s education training e6perienceA licensureA certification andDor registrationA current competenceA and ability to perform the re(uested privileges or scope of practice is re(uired. The #T< credentials manager (or other as designated by the commander) 3ill ensure that $2= of all credentials has been accomplished prior to position appointmentDplacement of the nonmilitary employeeD volunteer. 2ee appendi6 < for !ivilian $ersonnel 'perations !enter (!$'!)D!$A! dutiesDresponsibilities associated 3ith prospective employee credentials. d. <or the nonEpersonal services contract privileged provider the contract 3ill specify 3ho is responsible for $2= of the provider credentials as noted in paragraph & above. e. The primary source for verification of a credential is the original source of the specific document. The primary source attests to the accuracy of a (ualification. A reasonable effort must be made to verify 3ith the primary issuing authority all documents that re(uire $2=. These documents become part of the $!<. 1nsuccessful attempts made to obtain verification of a credential from the primary source 3ill be documented. f. &ocuments may be primary source verified by one of the follo3ing methods (listed in order of preference)F (+) Ar !!en &on- rma! on d re&!l$ -rom !he ""u ng au!hor !$. (2) ?erbal !elephone &on- rma! on -rom !he ""u ng au!hor !$. A detailed record of the telephone interaction 3ill be made in the $!< to include the name of the individual contacted the dateDtime and the signature of the person responsible for verification. (,) #mer &an 'ed &al #""o& a! on ma"!er- le /er - &a! on o- U.S. med &al "&hool gradua! on and U.S. re" den&$

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program &omple! on. The American 'steopathic Association (A'A) provides a similar service for osteopathic physi cians. $rofile entries in either the A#A or A'A master files are only valid if they have been annotated as L=erified.M (.) Aorld A de Aeb 5S?. 2uch verification is acceptable if the information is obtained directly from the profes E sional organi4ation8s Heb site. The identification of the individual ma5ing the Heb site contact and the date 3ill be annotated on the Heb page printout and this 3ill be entered in the $!<. Any discrepancy bet3een information provided by the applicant and that on the Heb site should be pursued by personal contact 3ith the professional organi4ation. (*) Tou&h<!one !elephone 5S?. @lectronic access by telephone of a database is acceptable only if the other methods listed above are not available. The individual responsible for telephone verification 3ill annotate in the $!< the date time hisDher signature and 3hy this 3as the only verification method available. g. Hhen certificates (for e6ample ?;2 A!;2 specialty board) are rene3ed the credentials manager (or other individual as designated by the commander) must vie3 the original rene3al certificate and annotate on a photocopy of the document L% certify this is a true and valid copy of the original.M The photocopy 3ill be signed dated and entered in the $!<. %f verification documentation from the primary source is available for inclusion in the $!< or other appropriate file (nonprivileged professional) the re(uirement to photocopy the official document(s) does not apply. 8>2 3rovider credentials 'ile The credentials information that originates during the preEemploymentDaccession application period serves as the basis of a comprehensive record (the $!<) that originates at the first unit of assignmentDemployment and is maintained and routinely updated throughout the provider8s entire period of employment 3ith the <ederal 0overnment. The contents of this record are permanentA ho3ever data determined to be either erroneous or inaccurate 3ill be removed in accordance 3ith AR ,.0-2+ and local policy. 2ee appendi6 @ for additional information regarding the $!<. The credentials contained in the $!< include the follo3ingF
4o!e. Those credentials specified in paragraphs a through d and paragraph 2 belo3 3ill be primary source verified.

a. 1ual -$ ng degree", d ploma", )C3'G, 3 -!h 5a!h>a$, or o!her d "& pl ne<"pe& - & &er! - &a!e, a" appropr a!e. (+) %f the @!<#0 certificate is dated prior to +9>) medical school graduation must be verified. ($rior to this date the @!<#0 did not verify graduation from medical school before issue of the certificate.) (2) The #T< 3ill notify the R#!DR&! 3ho 3ill telephonically contact the !ommander 12A#@&!'# (#!9'!;-") 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0 or the !ommander 1.2. Army &ental !ommand (#!&2) 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)00. for guidance and assistance 3henG (a) The medicalDdental diploma 3as issued by a school in a foreign country that has no diplomatic relations 3ith the 1.2. and direct communication to primary source verify the diploma or other credentials is not possible. (b) There are other concerns regarding the diploma or the foreign medicalDdental school. (c) $2= of credentials by a source outside the 1. 2. in a reasonable period of time is not forthcoming. b. S!a!e l &en"e", reg "!ra! on", &er! - &a! on", o!her au!hor 6 ng do&umen!", and &urren! rene>al &er! - &a!e". (+) A list of all licenses ever held 3ill be provided (on &A <orm .)9+ (%nitial Application for !linical $rivileges and 2taff Appointment)) along 3ith an e6planation of any that are not current or that have ever been sub7ected to disciplinary action. The provider8s signature on this form indicates that the list and any related e6planation are complete and accurate. (2) ;icensure of providers 3ill be verified 3ith the primary source by one of the methods described in paragraph >)- at the time ofG (a) 2taff appointment and initial granting of clinical privileges (b) Reappointment or rene3alDrevision of clinical privileges and (c) Rene3al of an e6pired license. &. 5o"!gradua!e !ra n ng &er! - &a!e" (-or e:ample, re" den&$, -ello>"h p, nur"e m d> -er$, nur"e ane"!he" a "&hool,. d. Spe& al!$ board and -ello>"h p &er! - &a!e". 2pecialty board certificates and certificates of rene3al 3ill be sub7ect to $2= 3ith the issuing board or by referencing the A#A or A'A master files. The publication L'fficial American ?oard of #edical 2pecialties (A?#2) &irectory of ?oard !ertified #edical 2pecialtiesM (at Heb site httpFDD 333.abms.org ) is no3 a recogni4ed site for $=2 and may also be used. The A?#2 directory only includes those specialty boards that are members of this organi4ation.
4o!e. %t is not necessary to delay the a3ard of regular privileges pending verification of board certification if all other credentials are in order.

e. # da!ed &urr &ulum / !ae !o a&&oun! -or all per od" o- ! me "ub"e9uen! !o ob!a n ng !he n ! al 9ual -$ ng degree. -. 5roo- o- &urren! (> !h n 1 $ear or mo"! re&en! &l n &al pra&! &e - n an adm n "!ra! /e role, &ompe!en&e. This may include letters of referenceDpeer recommendations from a program or department director or peer describing the scope of practice andDor clinical privileges in the departmentDserviceDsetting in 3hich the applicant is currently practicing. (2ee para 2 belo3 for additional detail.) A copy of the most recent list of privileges 3ith evaluation of the provider8s

+0

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performance related to assigned privileges from the current or previous place of employmentDassignment may be included if available. The e6tent and description of recent clinical privileges 3ill be verified. g. 'alpra&! &e n"uran&e h "!or$ a" re9ue"!ed on *# 3orm 5754 ('alpra&! &e ; "!or$ and Cl n &al 5r / lege" 1ue"! onna re, > !h narra! /e &ommen!", a" appropr a!e. (+) @6planation of any malpractice claims settlements or 7udicial or administrative ad7udication 3ith a brief description of the facts of each claim settled on the behalf of the provider. (2) &ates of malpractice coverage and history of suits and claims verified for the +0 years prior to initial application. (,) =erification 3ith the insurance carrier of all selfEreported suits and claims. h. *e!a led e:plana! on o- ad/er"e &l n &al pr / leg ng and7or d "& pl nar$ a&! on b$ n"! !u! on", S!a!e l &en"ure board", or o!her go/ern ng or regula!or$ agen& e" and !ho"e b$ an$ & / l an med &al or den!al -a& l !$ >here !he pr / leged pro/ der " emplo$ed or pra&! & ng. This 3ill include voluntary or involuntary termination of professional andDor medical staff membership or voluntary or involuntary suspension restriction reduction or revocation of clinical privileges at a hospital or other healthcare delivery setting and any resolved or open charges of misconduct unethical practice or substandard care. The LyesM and LnoM (uestions on &A <orm *C*. 3ith appropriate e6planation capture this providerEspecific information.
4o!e. A lapse bet3een periods of clinical privileges that is less than +>0 days due to $!2 hospitali4ation mobili4ation and so forth is not considered an adverse circumstance or voluntary termination and does not re(uire e6planation as described here.

. # "!a!emen! b$ !he appl &an! o- h "7her heal!h "!a!u" (ph$" &al, men!al, and emo! onal heal!h, rela! /e !o h "7her ab l !$ !o pro/ de heal!h&are and !o per-orm !he pr / lege" re9ue"!ed. 2uch a statement is re(uired on page 2 (bloc5 9) of &A <orm *C*.. =alidation by another privileged provider familiar 3ith the individual and hisDher health status 3ill be noted in separate memorandum to the credentials committee or as a comment in 2ection %% &A <orm *..0Eseries by the provider8s supervisor. 2. =e!!er" o- re-eren&e7peer re&ommenda! on". The letters submitted 3ith the application for <ederal service are referred to in this document as letters of reference. These same letters of reference may be used for initial application for privilegesDstaff appointmentA thereafter for rene3al of privilegesDstaff appointment 3ritten input in the form of peer recommendations is re(uired. The individuals providing the letters of reference or peer recommendations should be personally familiar 3ith the sub7ect provider8s clinical professional and ethical performance. This 3ritten input 3ill address the provider8s medical 5no3ledge clinical 7udgment and technical s5ills as 3ell as hisDher interpersonal s5ills communication s5ills and professionalism. (+) =e!!er" o- re-eren&e. A minimum of t3o current letters of reference from appropriate sources in (paras a) through (&) belo3 are re(uired for verification of e6perience and current competence. To best represent the applicant being considered for initial privileges and staff appointment these letters of reference should be dated 3ithin +2 months of submission. (a) A letter from either the chief of the hospital medical staff the clinic administrator the professional supervisor or the department head 3here the appointee has current clinical privileges or is professionally associated. (b) A letter from the director or a faculty member of the appointee8s training program if the appointee 3as in a training program 3ithin the last year. (c) A letter from a provider (in the appointee8s discipline if possible) 3ho is in a position to evaluate the appointee8s professional standing character and ability (for e6ample a peer or a president or secretary of the local professional society). A letter of reference from both a peer and a professional association or society are mandatory if the appointee is selfEemployed. (d) The nonEboard certified physician 3ho alleges to be a specialist re(uires t3o letters of reference attesting to hisD her clinical competence by physicians certified in the specialty in 3hich the nonEboard certified physician is practicing. <or the physician 3ho has not completed hisDher initial period of (ualification for board certification t3o letters attesting to the applicant8s clinical competence are re(uired from board certified specialists 3ho have current 5no3ledge of hisDher clinical practice. (2) 5eer re&ommenda! on". <or providers (AA 12ARDAR/0 civilian volunteer and contracted personnel) 3ith current privileges peer recommendations 3ill be submitted every 2 years as part of the clinical privilegesDstaff appointment rene3al process. 8. # &op$ o- !he pro/ derB" 3ederal nar&o! &" l &en"e > !h &urren! and pr or *rug )n-or&emen! #gen&$ (*)#, or Con!rolled *rug Sub"!an&e (C*S, number", a" appropr a!e. The re(uirement of a current &@A certificate does not apply to providers credentialed by '!'/12 #T<s located in 0ermany Korea and other nonEterritories of the 1.2. l. # &urren! 45*@ repor! on ea&h pro/ der. !onducting an /$&? (uery 3ithin 2. months of the previous (uery is permissible. 9o3ever under no circumstances 3ill a provider8s (uery interval e6ceed 2. months. "uery of the /$&? 3ill occurG (+) ?y the appropriate recruiting agency at the time of application for employment or appointment (military accessions). This report may be used at the initial duty station if dated 3ithin + year. (2) ?y the #T< at the time a provider initially applies for clinical privileges (initial duty station or place of

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employment unless para (+) above applies) 3hen e6panding or adding ne3 clinical privileges and every 2. months thereafter as part of the clinical privileges reappraisal (rene3al) process. (,) %f initial privileging by the provider8s first #T< occurs more than + year after the /$&? (uery for entry on A&. %n this case (uerying the /$&? 3ill be re(uired as part of the initial privileging process. (.) ?y the facility providing training or serving as the site of assignment if necessary for 12ARDAR/0 providers. %f a valid /$&? (uery is present in the provider8s $!< reE(uery is not necessary. m. )/ den&e o- &urren! @=S &er! - &a! on. A!;2 or AT;2 $A;2 or advanced pediatric life support (A$;2) andDor the /eonatal Resuscitation $rogram may be additional performance re(uirements but these are not a substitute for the ?;2 re(uirement. (2ee para *-+e for more specific guidance regarding emergency life support training re(uirements.) n. )/ den&e o- appro/ed &on! nu ng med &al7heal!h edu&a! on. 2uch evidence 3ill be accumulated by the provider for intervals of not less than 2 years and made available to the credentials manager for initial privilegesDappointment and for biennial rene3al. The annual re(uirement for !#@ credits according to AR ,*+-, or as determined by the provider8s 2tate of licensure 3hichever is more stringent. o. Cr m nal h "!or$ ba&8ground &he&8" (C;@C", -or all &on!ra&! and /olun!eer pro/ der" >ho &are -or pa! en!" under !he age o- 18. 'ther providers (AA 12ARDAR/0 and civil service) do not re(uire a !9?! as this security chec5 is routinely performed as part of the ne3 accessionDemployment process. !ontracting agencies are responsible for performing the !9?! on their employees for 3hom this investigation is re(uired. (+) <or nonEpersonal service contract personnel the contractor is responsible for completion of !9?!s and must for3ard results to the gaining #T<. As addressed in local policy the #T< must ensure the !9?! has been completed prior to allo3ing the contracted provider to care for patients under the age of +>. <or personal services contract personnel the #T< is responsible for !9?! completion. (2) $ending completion of the !9?! the provider8s practice 3ill be supervised. The commander 3ill determine the level of supervision that is re(uired. The plan for supervision 3ith designated supervisor noted 3ill be in 3riting. (,) 2ee &'&% +.02.* or Assistant 2ecretary of &efense (<orce #anagement (A2&(<#)) policy sub7ectF !riminal 9istory ?ac5ground !hec5s on 9ealthcare $ersonnel dated 20 April +992 for additional information. p. Spe& al re9u remen!" -or rad olog "!" pro/ d ng mammograph$ "er/ &e. The #ammography "uality 2tandards Act imposes specific re(uirements on radiologists 3ho are involved in providing mammography service. These providers 3ill abide by #ammography "uality 2tandards Act re(uirements and submit the appropriate documentation for inclusion in the $!<. (Refer to &epartment of 9ealth and 9uman 2ervices <ood and &rug Administration 2+ !<R $art 900 "uality #ammography 2tandards <inal Rule published in the <ederal Register =ol. )2 /o. 20> Tuesday 2> 'ctober +99C effective 2> April +999.) The #ammography "uality 2tandards Act can be found on the internet at httpFDD333.fda.govDcdrhDmammographyDfrmamcom2.html. 9. Spe& al re9u remen!" -or ph$" & an" pro/ d ng nu&lear med & ne "er/ &e". The radiopharmaceuticals used in nuclear medicine may only be prescribed by providers 3ho are Lauthori4ed usersM under the facility8s nuclear regulatory commission license. <or regular privileges in diagnostic nuclear medicine the provider must submit documentation that heDshe is an authori4ed user at the facility. <or privileges in therapeutic nuclear medicine there must be specific approval as an Lauthori4ed userM in this capacity as 3ell. Approval by the commander may be for all or selected therapies. r. 4a! onal pro/ der den! - er. The national provider identifier (/$%)EType + is a +0Edigit providerEuni(ue number assigned by !#2 to healthcare personnel both privileged and nonEprivileged 3ho meet established eligibility criteria (9A $olicyF 0*E002). %t is used to identify providers on claims prescriptions referrals and other healthcare related documents. #92 providers 3ere re(uired to obtain and begin using their /$%EType + by 2, #ay 200C. The credentials manager 3ill ensure that the /$% is entered into !!"A2 and that a copy is maintained in the $!<. 882 3revious e4perience and re'erence c(ec?s @very effort should be made to authenticate all provider credentials stated e6perience references and other informa tion contained in the $!< in a timely manner. 0ranting of clinical privileges and medicalDdental staff appointment as appropriate 3ill be 3ithheld until sufficient verified data to document training e6perience and current clinical competence are available. a. %n general reference chec5s should not be limited to only those references noted by the provider on the application form. $roviders 3ill be notified that other individuals may be contacted as necessary. b. Annotated records of each contact made 3ith all personal and professional references 3ill be maintained to include names of all parties to the call the date and a summary of the conversation. !ontacts 3ill be advised that the providers may re(uest and be provided this information. 8$2 3rovider activity 'ile The $A< is the repository for supporting information and data to validate privileging of the provider by the #T<. 2ee appendi6 0 for suggested content of the $A<. =arious $A< criteria definitions are contained in the glossary. a. A $A< 3ill be established and maintained for each privileged provider. The cover of the $A< must bear the

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disclosure statement as noted in paragraph ?-9 of this regulation. %t is a 3or5ing file 3ith contents considered confidential (uality assurance ("A) documents protected by +0 12! ++02. b. #etric performance data both (ualitative and (uantitative and aggregate data from a representative peer group sample are e6amples of the data contained in the $A<. The information and data contained are summari4ed and available for revie3 and evaluation by designated staff (peer level performance assessment) and by the department or service chief for biennial provider reprivilegingDreappointment to the medicalDdental staff. c. Any data included in the $A< that is not re(uired for transfer to the $!< and is greater than 2 years old may be removed and destroyed according to local policy. (The provider 3ill be given the opportunity to 5eep any productivity and computerEgenerated data prior to its destruction.) &ata determined to be either erroneous or inaccurate 3ill be removed from the $A< and in accordance 3ith AR ,.0-2+ and local policy. d. The contents of the $A< may be used by supervisors for administrative purposes (for e6ample counseling evaluation reports preparation of 0$9@ documentation and letters of reference or peer recommendations). 8502 7(e interC'acility credentials trans'er ,rie' a. The %!T? is a computerEgenerated summary of information contained in the $!<. %t is a standardi4ed format (see app 9) for transmittal of privileged provider credentials information across the #92 (9ealth Affairs $olicy 9.-00. and 9ealth Affairs memorandum sub7ectF @6panded 1se of %nterE<acility !redentials Transfer ?rief (%!T?) ++ &ecember +99*). The %!T? may be used for all categories of privileged providers to include uniformed military (AAD12ARD AR/0)A civilian (02 contractors (personal services only) resource sharing)A =AA and nonmilitary uniformed providers (for e6ample $ublic 9ealth 2ervice). This document may be maintained in a temporary $!< created by the gaining facility. b. Hhen a &'& provider is temporarily assigned to another #T< for clinical practice the sending #T< must convey all relevant credentials and privileging information to the gaining #T<. The receiving commander uses this information as the basis for assessing current clinical competence and ma5ing appropriate privileging and staff appointment decisions in a timely manner. (+) /onEpersonal services contract personnel (that is individuals 3or5ing for the 0overnment yet employed by a nonE <ederal agency) are not authori4ed temporary assignment to another #T<. Assignment for duty is only as stipulated in their contract. 1se of an %!T? is not authori4ed. (2) $roviders (AAD12ARDAR/0) mobili4edDactivated in support of covert operations (that is a command structure 3ith privilege granting authority may not be 5no3n or available) do not re(uire an %!T?. Hhile the provider is T&I in this capacity hisDher $!< may be placed in an inactive status at the sending facility. The $!< 3ill be closed out and archived. !redentials committee minutes 3ill reflect those providers 3hose $!< is in an inactive status. 1pon return from deployment the $!< 3ill be reactivated and updated as necessary prior to the provider resuming assigned patient care duties. &. Re(uired attachments to the %!T? for AA providers includeG (+) &isciplineEspecific &A <orm *..0Eseries for privileges being re(uested. (2) &A <orm *..0A 3ith top portion completed. (,) A copy of the current &A <orm *..0Eseries for clinical privileges held at the sending facility. (.) &A <orm *C*.. (*) T3o peer recommendations dated 3ithin 2. months of submission for providers 3ho do not hold current military clinical privileges. (2ee para 9-,a(+0) for additional detail.) ()) Authori4ation for release of information signed by the provider (may be specific to the gaining #T< if provided). d. The %!T? and re(uired attachments accompany the formal application for privileges by the privileged provider. %nformation that appears in the %!T? need not be duplicated on any &A or local privileging forms that contain essentially li5e information. An annotation 3ill be made on these forms as appropriate to L2ee %!T?.M e. Additional information regarding the %!T? is contained in paragraph 9-) & and in appendi6 9. 8552 7(e interC'acility credentials trans'er ,rie' and -SAR;AR.@ training a. The %!T? 3ith appropriate supporting documents 3ill be made available to the facility (training site) by the 12ARDAR/0 credentials manager at least .* days before the scheduled arrival of the 12ARDAR/0 provider. The 12ARDAR/0 privileged provider8s %!T? 3ill be for3arded electronically or by mailA it 3ill not be hand carried by the privileged provider. %f the .*Eday time frame cannot be met direct coordination bet3een the AA and 12ARDAR/0 units is re(uired. b. Re(uired attachments to the %!T? for 12ARDAR/0 providers includeG (+) &isciplineEspecific &A <orm *..0Eseries for privileges being re(uested. (2) &A <orm *..0A 3ith top portion completed. (,) A copy of the clinical privileges currently held (civilian facility and military). (.) &A <orm *C*. signed 3ithin )0 days of %!T? submission.

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(*) T3o peer recommendations dated 3ithin 2. months of submission for providers 3ho do not hold current military clinical privileges. (2ee para 9-,b(+0) for additional detail.) ()) Authori4ation for release of information signed by the provider (may be specific to the gaining #T< if provided). c. 12ARDAR/0 providers 3ill not be accepted for %&T A&T A& for special 3or5 or AT as privileged providers until the AA #T< notifies the provider8s parent unit that privileges have been a3arded. d. AA #T< commanders 3ill ensure that 12ARDAR/0 privileged provider %!T?s are revie3ed e6peditiously and that prompt notice of this revie3 is provided to the 12ARDAR/0 credentials manager. This 3ill allo3 timely processing of personnel actions related to provider training by the unit. &elays in revie3ing the %!T? and notifying the 12ARDAR/0 credentials manager that the documentation is in order could delay the provider8s availability for duty. e. 1pon completion of the re(uired training by 12ARDAR/0 providers the AA #T< 3ill for3ard a &A <orm *,C. and any other specific privileged provider activity data to AR!!A the appropriate unit commander the administrative head(uarters or the credentials manager responsible for custody of the $!<. This information 3ill be for3arded electronically or by mailA it 3ill not be hand carried by the 12ARDAR/0 provider.
85#2 -SAR;AR.@ credentials and privileging 'or activation;mo,ili:ation a. $rivileged providers 3ho are activated on individual orders for a period that is less than ,0 days 3ill have an %!T? generated and for3arded 3ith attachments to the gaining facility. The gaining facility is responsible for granting privileges as appropriate based on the %!T?. b. <or 12ARDAR/0 2oldiers mobili4ed for ,0 days or more the $!< manager 3ill ensure that the $!< is current and complete and 3ill initiate privileging actions by transmitting an %!T? 3ith attachments to the gaining facility or by preparing the $!< for revie3 by the local credentials committee. c. !ommanders of units that are mobili4ed either as a derivative unit or as a total medical asset and designated (typically in a field environment) to function independently of a fi6edEfacility #T< are authori4ed to grant clinical privileges for their assigned providers. The privileging process as described in paragraph 9-)a 3ill be follo3ed. d. #obili4ed providers that are assigned to or 3ithin the area of operations of a fi6edEfacility #T< (AA) 3ill be granted privileges by the commander of that #T<. e. 12ARDAR/0 providers participating in clinical training (prior to arrival in theater) for 3hich privileges are re(uired 3ill be granted privileges for these activities by the facility conducting the training. An %!T? 3ith appropriate attachments 3ill be prepared and transmitted to the gainingDtraining #T<. The commander of the gainingDtraining #T< 3ill grant privileges as appropriate based on the %!T?. f. #edical personnel assigned to nonmedical units 3ill re(uest guidance from their higher head(uarters as to the privilege granting authority in their given situation. %f patient care activities are included in the provider8s description of duties the prescribed credentialing and privileging processes 3ill be follo3ed regardless of the unit of assignment or the mobili4ation assignment. $rivileges should be granted prior to the provider8s arrival in theater. g. <or mobili4ed 12AR privileged providers in T$1s AR!!A 3ill retain control of the $!< during the period of mobili4ationA 9R!E2t. ;ouis 3ill do this for %RR membersA and the AA unit credentials manager 3ill perform this function for %#A providers. The AR/0 unit $!< managers are responsible for the $!< during periods of AR/0 provider mobili4ation. Transfer of the $!< to the 2oldier8s unit of assignment 3ithin the theatre of operations is not authori4ed. h. &uring the period of mobili4ation credentialing actions that can reasonably be completed by the $!< manager should continue. This includes but is not limited to $2= of license and certification rene3als.

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+igure 852 Sample 'ormat 'or re&uest o' ne= accessions credentials 'rom -SAR0C (%S!)

C(apter $ 7(e 3rivileging 3rocess and Medical Sta'' Appointment

$52 @eneral $rivileging is the process 3hereby a specific scope and content of patient care services (delineated clinical privileges) are authori4ed for a healthcare provider by the privileging authority (#T<D12ARDAR/0 unit commanderD2tate 2urgeon). 2uch authority is based on an evaluation of the individual8s credentials performance and the specific needs of the organi4ation. a. The privileging process is directed solely and specifically to the provision of (uality patient care and is not a disciplinary or personnel management mechanism. $rivileging actions may ho3ever accompany actions of an admin E istrative or 7udicial nature or may engender such actions. b. A number of privileging actions both routine and adverse are available to the commander at the recommendation of the credentials committee. The routine privileging actions that are addressed in this chapter include privilege approval (3ith or 3ithout restrictions) privilege reappraisal and privilege rene3al. Adverse privileging actions include

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privilege restriction reduction suspension revocation and denial. These and the nonEadverse privileging action of placing a provider8s privileges in abeyance and summary suspension are discussed in chapter +0. &. $rivileges are facilityEspecific. As such the facility8s characteristics supportive resources and staff are considered in the privileging decisions. d. @ach department or service chief 3ill develop criteria relevant to the a3ard of clinical privileges for the department or service and 3ill identify 3hat privileges are appropriate for the scope of 3or5 in the given setting. &A <orm *..0E series provides basic privileging criteria and other information that are applicable to the practice discipline. The form provides space for comments and privileges to be added as needed based on the #T<8s scope of services the provider8s e6perience and the &'& beneficiary healthcare re(uirements.
4o!e. Hhile the criteria for a3ard of privileges and the specific privileges pertinent to each department are the responsibility of the departmentDservice chief the #T< commander is the clinical privileges approval authority 3ithin the #92.

e. $roviders 3ill be granted clinical privileges appropriate to the settings in 3hich they practice. This includes various departments services clinics and the emergency centerDserviceDdepartment both 3ithin the #T< and in #T< controlled outlying locations. -. Hhere full performance in a given 02 civilian position re(uires the incumbent to be privileged obtaining and maintaining clinical privileges in good standing is deemed a condition of employment. (+) %n this regulation Lgood standingM re(uires that the employee isG (a) /ot in a remedial training program. (b) Able to practice independently. (c) <unctioning 3ith privileges that have not been reduced restricted suspended revo5ed or denied. (2) <or civilian employees 3hose privileges are not in good standing the #T< commander may elect toG (a) Terminate the employee. (b) !hange the employee to a position at a lo3er grade (may be voluntary or involuntary). (c) Reassign the employee to a position for 3hich privileges are not re(uired (may be voluntary or involuntary).
4o!e. Any financial incentives associated 3ith the previously held position shall be terminated.

g. Reappraisal of defined clinical privileges 3ill ta5e place at least every 2. months (prior to the rene3al of privileges) and 3hen a provider is reassigned to a ne3 duty station. (2ee paras 9-. d(2) and 9-. e.) <or 12ARDAR/0 providers see para 9-> d(+).) Rene3al of clinical privileges is based on the provider8s professional (ualifications and demonstrated competence to perform the privileges re(uested. $roviders 3ho are assigned to nonclinical duty positions (for e6ample commander 12AR@! or 'ffice of T20 staff officer or A#@&& !enter and 2chool instructor) 3ho desire medical staff membership or clinical privileges are sub7ect to the same procedures as all other applicants for membership or privileges. These individuals 3ill only be privileged if they are e6pressly engaged in patient care activities appropriate to the discipline in 3hich they are re(uesting privileges. The medical staff byla3s 3ill address ho3 the current competence of providers in administrative positions 3ill be assessed for reappointment and clinical reprivileging. @6amples of criteria that may be considered include but are not limited to departmentDservice chief intervie3A documented continuing educationDtrainingA the acceptable interval bet3een performance of procedures that are identified as comple6 high ris5 or problem proneA available patient outcomes assessment dataA and clinical practice hours per monthDyear. $#2 3ractitioners =(o may ,e privileged a. 9ealthcare practitioners 3ho function independently to initiate alter or terminate a regimen of medical care must be privileged. %n this regulation practitioners 3ho are granted privileges are referred to as providers. $roviders include audiologists behavioral health practitioners chiropractors clinical pharmacists clinical psychologists clinical social 3or5ers dentists dietitians nurse anesthetists nurse mid3ives /$s 'Ts optometrists $Ts physicians $As podiatrists psychological associates speech therapists and substance abuse rehabilitation counselors. Also included are !/2s !9/s and '9/s 3ho in selected circumstances and at the discretion of the commander may be granted clinical privileges (see chap C) and 2??s. b. #embers of the healthcare staff 3ho function under a standard 7ob description in the performance of their duties Gutili4ing practice guidelines or standing policies andDor proceduresGdo not re(uire clinical privileges. &epart E mentDservice chiefs are responsible for the ongoing assessment of the competence of personnel to safely perform assigned duties. <or those 3ho are not privileged an internal certification process may be used to designate selected personnel 3ho have achieved the competence needed to perform specific comple6 highEris5 or problemEprone clinical functions. c. 2pecial privileging considerations are as follo3s. (+) Commander and depu!$ &ommander pr / lege". Approval of privileges (to include periodic privilege rene3al) and appointment to the medical staff for the &!!2 and the commander (and comparable dental positions) 3ill be as follo3s.

+6

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(a) The commanderD&!!2 3ill submit hisDher application for privileges and re(uest for medicalDdental staff appointE ment (&A <orm .)9+-+ (Application for Rene3al of !linical $rivileges and 2taff Appointment)) through the appropriate department chief. (b) The &!!2 is e6cused from the credentials committee meeting (if heDshe is being revie3ed) and the remaining senior member of the credentials committee 3ill act as chairperson. (c) The credentials committee recommendations regarding clinical privileges and medicalDdental staff appointment for the &!!2 (or li5e &! position) 3ill be submitted through the @!#2D@!&2 (AA facilities and 12ARDAR/0 units 3herever feasible) to the local #T< commander for approvalDdisapproval. (d) <or commanders the credentials committee recommendations regarding clinical privileges and medicalDdental staff appointment and all supporting provider documentation 3ill be for3arded by certified return receipt re(uested mail as noted belo3 (by healthcare facility type)G +. 3ree"!and ng ambula!or$7heal!h &l n &, ')**#C, and *)4T#C. &ocuments 3ill be for3arded to the responsible R#!DR&! commander. 2. 121 General ;o"p !al. &ocuments 3ill be for3arded to !ommander +>th #edical !ommand 1nit +*2>+ A$' A$ 9)20*-00*.. ,. ')*C)4, %'C7%*C, and ma2or "ubord na!e &ommand. &ocuments 3ill be for3arded to the !ommander 12A#@&!'# ATT/F #!9'-!;-" 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0 or the !ommander 12A&@/!'# ATT/F #!&2 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)00.. .. 18!h 'ed &al Command. &ocuments 3ill be for3arded to T20 *+09 ;eesburg $i5e 25yline ) Room )>. <alls !hurch =A 220.+-,2*>. (2) )mergen&$ or d "a"!er " !ua! on". 2cope of practice limitations as defined by the clinical privileges granted by the #T< may be ignored only in bona fide emergency circumstances (see glossary) or disaster situations. %n such cases providers are e6pected to intervene and to do everything possible to save the patient8s life or to prevent in7ury or to effectively respond to a significant increase in demand for medical treatment. This includes re(uesting consultation 3ith available medical resources and coordinating care and services as appropriate. (,) The #rmed 3or&e" 'ed &al ):am ner S$"!em. This system as addressed in &'&& *+*..2. authori4es medicoE legal death investigations for all &'& #T<s. The range of support includes onsite autopsies by deputy or regional medical e6aminers telephonic consultations and 3ritten reports. &eputy and regional medical e6aminers hold privi leges granted by the A<%$. &eputy and regional medical e6aminers are authori4ed to perform autopsies upon presentation of their Armed <orces #edical @6aminer credentials to the commanding officer. An application for medical staff appointment 3ith clinical privileges is not re(uired for this service. (.) The +rgan and T ""ue 5ro&uremen! 5rogram and !he #rmed Ser/ &e" 'ed &al %egula! ng S$"!em. 'rgan donation and transplant conducted by organ and tissue procurement teams and the related treatment provided 3ithin #T<s by personnel assigned to the Armed <orces #edical Regulating 2ystem is addressed in &'&& ).)*.,. These personnel are authori4ed to perform their duties in <ederal facilities 3ithout formal credentials revie3 and privileging. 9o3ever the individuals assigned to support these programs 3ill present sufficient documentation (for e6ample official orders assignment letter or identification card) to the #T< commander to establish their authori4ation to perform these services. (*) 'u"&ulo"8ele!al man pula! on". #usculos5eletal manipulations involve palpation and other manual techni(ues used to evaluate and correct somatic dysfunction that impairs or alters function of the somatic systems. These include the s5eletal arthrodial myofascial vascular lymphatic and neural systems. This does not refer to the spinal or peripheral 7oint manipulations commonly used by $Ts that are included in their accepted standard scope of practice as defined by the American $hysical Therapy Association. The follo3ing policy guidance applies to the performance of musculos5eletal manipulation procedures. (a) $rivileged providersGother than doctors of osteopathy $Ts and chiropractors for 3hom manipulation is considered part of their routine scope of practiceG3ith evidence of appropriate education training and e6perience acceptable to the credentials committee may be granted specific privileges to perform musculos5eletal manual manipulations. (b) 'nly specifically privileged physicians (&octor of #edicine or 'steopathy) may perform manipulation procedures using general anesthesia or intravenous medications. An appropriately privileged anesthesiologist or nurse anesthetist 3ill administer the re(uired anesthesia or sedation for these procedures. ()) 5r / leg ng -or ne> med &al pro&edure" and !e&hnolog$. The privileging process remains the same. $articular attention 3ill be focused on provider training e6perience and competence and #T< capabilities in granting privileges for use of recently developed or approved technologies and e(uipment. (a) 4e> pro&edure. $rior to the introduction of a substantially ne3 and innovative procedure into an #T< the commander 3ill ensure that privileging criteria are developed at the departmental level and endorsed by the credentials committee. The criteria 3ill include the specific preparatory training that providers must complete prior to being granted the privilege to perform the ne3 procedure. The privileging process for providers 3ill be accomplished prior to the procedure being performed on eligible beneficiaries. (b) 4e> !e&hnolog$. #T< commanders 3ill ensure that ne3 technology (for e6ample e6cimer lasers) does not
AR 4068 0 6 !ebruary 0041RAR 2ay 00& +'

surpass the staff8s abilities. #T< commanders 3ill establish safety protocols for an instrument8s use and provide for proper privileging procedures prior to the application or use of the ne3 technology. The plan for implementation of ne3 technology must include training of nonprivileged support staff. Adverse patient outcomes involving e(uipment malfunction 3ill be reported according to #T< policy and 3ill include notification of the $2 managerDris5 manager. (2ee para +2-+0.) (C) ' "&ellaneou" pr / leg ng ""ue". (a, Telemed & ne. Telemedicine involves electronic communication or other communication technologies to provide or support clinical care at a distance. +. The medicalDdental staff 3ill determine 3hich clinical services are appropriately delivered via telemedicine lin5. Telemedicine encounters re(uire 3ritten informed patient consent before the use of said technology. All medical information generated in the delivery of telemedicine 3ill be properly documented and archived in the medical record. Any patient information associated 3ith telemedicine in either electronic or paper format is sub7ect to current 9ealth %nsurance $ortability and Accountability Act (9%$AA) standards. 2. $roviders 3ho 3rite orders or direct careDtreatmentDservices via telemedicine must be privileged by the facility receiving this service. The %!T? and a copy of the delineation of privileges 3ill be submitted to the privileging #T<A privileges 3ill be granted for only the services to be rendered via telemedicine. Types of services that re(uire privileges include but are not limited to those 3hich involve videoEteleconference or other direct interactions bet3een patient and provider. ,. $roviders 3ho render official readings of images tracings or specimens or 3ho provide only consultative advice do not re(uire privileges at the receiving #T<. %n such cases the #T< must obtain and maintain a copy of the %!T? and delineation of privileges from the provider8s #T< of assignment but need not privilege the provider. @6amples of these types of services include but are not limited to teleradiology (e6cept mammography for 3hich there are additional re(uirements) teleechocardiography telepathology and storeEfor3ard teledermatology. .. The above paragraphs apply to telemedicine services bet3een #T<s andDor other military organi4ations for e6ample A<%$. Hhen the telemedicine service is provided via contracted services regardless of the type of service in (uestion the providers must be privileged by the receiving #T<. %n instances 3here the contract for services described in paragraph , is 3ith a civilian hospital accredited by TJ! the receiving #T< need not privilege the providers if provider information e(uivalent to that on an %!T? and hisDher delineation of current privileges from the hospital are obtained and maintained on file at the #T<. (b, 'anagemen! o- mpa red pro/ der". A physical or psychological condition that adversely affects (or has the potential to adversely affect) or limits an individual8s ability to safely e6ecute hisDher responsibilities in providing healthcare can be considered an impairment. This includes alcohol or other drug dependencyDabuse or mental health disorders. Typically acute or chronic medical conditions 3ill re(uire a limitedEduty profile or medical evaluation board (#@?) to decide fitness for duty of the military member. !omparable processes e6ist for the civilian employee 3ith duty restrictions related to health problems. 2uch circumstances are managed as medical problems (short or long term) and are not considered impairments. The credentials committeeDfunction 3ill revie3 the performance of privileged providers 3ho are impaired to determine to 3hat e6tent their impairment hampers their ability to safely practice the privileges they have been granted. The provider8s condition or impairment may re(uire modification of hisDher clinical privileges as appropriate. <or further information see chapters +0 and ++. (&, 5ro/ der" a"" gned !o a geograph &all$ "epara!ed un !. The host unit 3ith privileging authority is responsible for maintaining the provider8s $!< and for a3arding clinical privileges and a medical staff appointment if re(uested by the provider. (d, +ral "urgeon". The organi4ation (AAD12ARDAR/0) to 3hich a dental officer is assigned has primary responsiE bility for managing the oral surgeon8s $!< verifying credentials and a3arding clinical privileges and dental staff appointment as appropriate. <or the oral surgeon 3ith duty at a facility other than the dental unit of assignment (that is a #@&&A! or #@&!@/) an %!T? and all appropriate attachments (see para >-+0 b (AA) or >-++b (12ARD AR/0)) 3ill be provided for use by that organi4ation in a3arding clinical privilegesDstaff appointment. (e, *en! "!" adm n "!er ng &on"& ou" "eda! on. As 3ith all procedures the a3ard of specific privileges to a dentist to perform conscious sedation is based upon appropriate education training and e6perience. ?ecause this s5ill is not part of basic dental education specific training in this procedure must be obtained and documented before dentists can be authori4ed to administer conscious sedation. (-, Complemen!ar$ and al!erna! /e med & ne. Application andDor use of these techni(ues and therapies (acupuncture homeopathy massage therapy and so forth) are gaining acceptance 3ithin the #92. Hith the approval of the commander these may be integrated into the broad array of healthcare and services offered to &'& beneficiaries by (ualified providers. $rivileges may be granted follo3ing the guidance relative to ne3 procedures detailed in paragraph ())( a) above. $82 Categories o' clinical privileges !linical privileges define the scope and limits of independent patient care services that a provider may render 3ithin

+8

AR 4068 0 6 !ebruary 0041RAR

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the granting healthcare organi4ation. $rivileges may be granted 3ith or 3ithout an accompanying appointment to the medicalDdental staff. The three categories of clinical privileges that may be a3arded areG a. %egular pr / lege". (+) Regular privileges grant the provider permission to independently provide medical dental and other patient care services in the facility 3ithin defined limits. Regular privileges are granted to providers only after full verification and revie3 of credentials. Regular privileges 3ill not e6ceed a 2.Emonth period 3ithout rene3al. (2) %n granting regular privileges the commander 3ill define the limits of those privileges to include 3hether or not enhanced supervision is re(uired. The nature and e6tent of enhanced supervision 3ill be delineated in 3riting. The commander 3ill also specify limits on regular privileges based upon the #T< mission re(uirements and the ability to support the re(uested privileges. (,) A provider granted regular privileges may be considered for any type of medical staff appointment as discussed in paragraph 9-*d. b. Temporar$ pr / lege". (+) Temporary privileges authori4e a provider to independently provide medical dental and other patient care services on a timeElimited basis to meet pressing patient care needs 3hen time constraints 3ill not allo3 full credentials revie3. The use of temporary privileges should be rare. This category of privileges is appropriate in bona fide patient emergency situations or a declared disaster and is not intended for the administrative convenience of the departmentD service. Temporary privileges 3ill not e6ceed a period of ,0 days and are not sub7ect to rene3al. Any subse(uent re(uest for consecutive privileges should be assessed to determine if regular privileges are more appropriate. (2) ?ecause the #T< has not conducted a thorough credentials revie3 prior to granting temporary privileges there is an added degree of ris5 relevant to the competency of the provider. %n order to minimi4e the ris5 associated 3ith granting temporary privileges the follo3ing actions as a minimum 3ill occur. (a) A copy of the provider8s license 3ill be obtained and verified 3ith the issuing agency. (b) Telephonic contact 3ill be made 3ith the facility 3here the provider has regular privileges to verify that the individual is clinically competent fully (ualified and that the re(uested privileges are 3ithin the individual8s current scope of practice and privileges. The chief of the medical staff department chair or other appropriate authority may provide this information. 'r if available the %!T? may be used for the purpose of granting temporary privileges. (,) A complete thorough credentials revie3 3ill occur during the period of the temporary privileges. (.) Temporary privileges may be granted 3ith or 3ithout a temporary appointment to the medical staff. (*) The use of temporary privileges is authori4ed for all categories of providers. &. Super/ "ed pr / lege". (+) 2upervised privileges are granted to providers 3ho do not meet the re(uirements for independent practice because they lac5 the necessary license certification or other authori4ing document. These providers are not eligible for a medical staff appointment and are unable to practice independently. $roviders 3or5ing under supervised privileges can practice only under a 3ritten plan of supervision 3ith a licensed person of the same or a similar discipline. 2ee paragraph *-, for additional information regarding supervision of practice. (2) This category of privileges 3ill not be granted to licensed providers or providers holding other authori4ing documents even though the defined limits of their privileges include supervision. (,) 2upervised privileges should not be confused 3ith enhanced supervision of practice offered to those privileged providers 3ho for a defined period of time re(uire oversight of their clinical practice. (2ee para 9-. e for additional information regarding enhanced supervision.) (.) 2upervised privileges 3ill be granted for periods not to e6ceed 2. months. $roviders 3ho are re(uired to have a license 3ill obtain that license 3ithin the time frame specified in chapter .. These providers may re(uest regular privileges and a medicalDdental staff appointment once a license is obtained. $42 7(e clinical privileging process a. 3orm" re9u red -or a>ard o- pr / lege". $erformance data and other information (appropriate &A forms) to be considered in the privileging process are maintained in the $A<. These documents are transferred to the $!< as appropriate upon biennial rene3al of the provider8s clinical privileges (see para 9-. &())) $!2 or separation from serviceDemployment. The original 3ill be placed in the $!< 3ith a copy furnished to the provider.
4o!e. $roviders 3ill transition to use of the revised privileging documents addressed belo3 at their ne6t reappraisalDreprivileging opportunity.

(+) *# 3orm 4691. &A <orm .)9+ provides a synopsis of the provider8s education and e6perience at the time of initial application for clinical privileges and medical staff appointment (if applicable). %t includes professional education postgraduate training previous clinical assignments specialty board certification professional society membership and credentials action history. <or the provider 3ith continuous <ederal service &A <orm .)9+ is completed only once at the provider8s first military duty station or place of &'& employment. <or all categories of providers 3ith noncontinuous <ederal service (that is there is a lapse in clinical privilegesDstaff appointment 3ithin the &'&) this form must be completed if the interval bet3een periods of service is greater than +>0 days. %nitial clinical privileges

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+&

and medical staff membership are valid for a period of + year. &uring this +2Emonth period regularly scheduled evaluation of the provider8s performance is re(uired. (2) *# 3orm 4691C1 (ne>,. &A <orm .)9+-+ is used by providers 3ith continuous <ederal service or a lapse in periods of service of less than +>0 days to re(uest rene3al of clinical privileges and medical staff reappointment. %nformation entered on this form relates to the provider8s professional activities (for e6ample education e6perience professional recognition and so forth) since the previous application for clinical privileges and medical staff appointment. (,) *# 3orm 5374. This form contains providerEspecific performance data both (ualitative and (uantitative. %t is used to evaluate the provider8s demonstrated clinical performance according to established standards and compared to that of hisDher peers. %n con7unction 3ith &A <orm *..+Eseries this t3oEpage assessment contains evidence of the individual8s competence s5ills and abilities and provides ob7ective and sub7ective data upon 3hich to base a3ardD rene3al of clinical privileges and appointmentDreappointment to the medical staff. (.) *# 3orm 5440. The appropriate disciplineEspecific &A <orm *..0 (as delineated in app A) 3ill be used to document the re(uest by the provider for clinical privileges and the recommendation for approval by the departmentD service chief and the credentials committee. Any variance bet3een the privileges re(uested by the provider and the privileges recommended for approval by the supervisor should be discussed prior to submission of the &A <orm *..0. Any unresolved discrepancies must be e6plained in 2ection %% !omments for consideration by the credentials committee. These forms may contain categorical (patient ris5 and provider training re(uirements) and itemi4ed disease and procedureEbased privileging information by discipline. The diseaseErelated and procedural content of this form 3ill be individuali4ed to address the current competency of the provider re(uesting privileges as 3ell as the needs and capabilities of the #T<. The re(uirements for residency training and board certification as stated on the &A <orm *..0 cannot be changed at the local level. The entire &A <orm *..0Eseries is available in the A#@&& @lectronic <orms 2upport 2ystem and at httpFDD333.apd.army.milD12A$AQforms$1?formrangeQf.asp for printing andDor local reproducE tion on >+R2E by ++Einch paper. (*) *# 3orm 5440C22 (*el nea! on o- Cl n &al 5r / lege",. This blan5 form is used as a continuation sheet for those providers completing their disciplineEspecific &A <orm *..0 and for e6panded role functions or practice specialties not other3ise included in the &A <orm *..0 series (for e6ample endocrinology adolescent psychiatry). This form is available for customi4ed use as needed. ()) *# 3orm 5440#. &A <orm *..0A is used to record e6ecutiveElevel medical staff recommendations and decisions by the commander concerning the clinical privileges and medicalDdental staff appointment (if applicable) of all privileged providers. (C) *# 3orm 5441. The disciplineEspecific &A <orm *..+ 3ill be used to evaluate the provider8s competence and s5ill in the performance of hisDher clinical privileges. Appendi6 A contains a listing of forms in the *..+Eseries. The content of this document corresponds to the privileges of the specialty as outlined on the &A <orm *..0. (>) *# 3orm 5753 (US#% or #%4G #ppl &a! on -or Cl n &al 5r / lege" !o 5er-orm #&! /e or 0na&! /e *u!$ Tra n ng,. This form is obsolete and is replaced by revised &A <orm .)9+ (for initial privileges) or &A <orm .)9+-+ (for privilege rene3al) 3hich are used for clinical privileging by both AAD12ARDAR/0. (9) *# 3orm 5754. All privileged providers 3ill complete a &A <orm *C*.. &A <orm *C*. provides information on licensure malpractice clinical privileges and conditions that may impact the individual8s ability to deliver care. The form is completed as part of the initial application for clinical privileges and at each subse(uent rene3al of privileges. b. 0n ! al appl &a! on -or pr / lege". (+) 1pon arrival at the first duty station or place of &'& employment the provider must submit a re(uest for initial clinical privileges. The re(uest 3ill include the follo3ingF (a) &A <orm .)9+. (b) The appropriate &A <orm *..0 3ith the provider completing the column on the left side of the form by properly coding the specific category of privileges re(uested if applicable and each individually listed privilege. (c) <or the ne3ly graduated provider re(uesting privileges for the first time &A <orms *..0 *..+ and *,C. if available (prepared by the clinical directorDfaculty) document hisDher competence s5ill and ability in the training setting. (2ee para h(,) belo3.) <or providers currently involved in civilian practice or those 3ith a lapse in privilegesD staff appointment in the &'& of greater than +>0 days the most current evaluation of clinical performance (&A <orms *..+ and *,C.) and peer recommendations contained in the $!< 3ill substitute. (d) &A <orm *C*. completed and signed by the provider. (e) All verifiedDvalidated credentials and other documents as re(uired in paragraph >-C. (f) @vidence that a !9?! has been initiated as per the !rime !ontrol Act of +990 (.2 12! +,0.+) and AR )0>-+0 for individuals (contractDvolunteer) 3ho provide healthcare or other services for children under the age of +> years. (Also see para >-Co.) (2) The re(uest 3ill be revie3ed by the department or service chief 3ho 3ill properly code each category if applicable and privilege in the appropriate column of the &A <orm *..0. The recommendation by the department or service chief for the a3ard or the limitation of privileges re(uested 3ill include specific rationale or 7ustification of
60 AR 4068 0 6 !ebruary 004

same in the L!ommentsM area (2ection %%). The re(uest 3ill then be for3arded to the #T< credentials committeeD function for revie3. (,) The provider8s validated credentials (para >-C) and the completed &A <orms .)9+ and *..0Eseries serve as the basis for the granting of clinical privileges. The credentials committeeDfunction 3ill for3ard its recommendation for clinical privileges and medicalDdental staff appointment (if applicable) through the @!#2D@!&2 (AA facilities and 12ARDAR/0 units 3herever feasible) to the facility commander. (.) The commander is the approving authority for the a3ard of clinical privileges and medicalDdental staff appointment. The commander8s signature on &A <orm *..0A authori4es clinical privileges and staff appointment if appropriate based on the individual provider8s licensure education and training e6perience and hisDher demonstrated professional competence. (a) &A <orm *..0A 3ill be used to record the e6ecutive level medical staff recommendations and the commander8s decision concerning the clinical privileges and medicalDdental staff appointment of providers. !redentials committeeD function minutesDreports 3ill reflect deliberations made by this committee regarding both privileging and appointment status for each provider. (b) The type of medicalDdental staff appointment if applicable 3ill be recorded in ?loc5 )b &A <orm *..0A. (c) ?loc5 )c of &A <orm *..0A 3ill reflect the current recogni4ed privileging category. ?loc5 )d notes admitting privileges. (d) 2ignature by the departmentDservice chief and the chairperson of the credentials committee affirms that a revie3 3as made of the provider8s primaryEsourceEverified licensure education and training e6perience capability to perform the re(uested privileges and documented current competence. Age groups for 3hom the provider 3ill render healthcare services are indicated in bloc5 )g. Any age or patient populationEspecific comments 3ill be included in bloc5 C. (e) <or providers 3ho are assigned to one departmentDserviceDclinic and re(uest privileges in another the disciplineE specific &A <orm *..0s 3ill be submittedA the appropriate chiefs in both departmentsDservicesDclinics 3ill be named and 3ill sign the &A <orm *..0A. ?loc5 C may be used for the additional signatures. (f) Hhen privileges are modified from those re(uested the reason 3ill be stated in bloc5 C. (@6amples of such reasons include lac5 of technological resources lac5 of support staff privileges unauthori4ed by the A#@&& lac5 of provider credentials lac5 of demonstrated competency or lac5 of professional performance.) (*) The authenticated copies of &A <orms *..0 and *..0A serve as notification to the provider of the a3ardD rene3al of hisDher clinical privileges and medical staff appointment. A cover memorandum to the provider may also be prepared. (2ee fig 9-+.) The provider must ac5no3ledge receipt of these documents by signed memorandum returned to the $!< manager. (2ee fig 9-2.) The original &A <orms *..0 *..0A .)9+ and *C*. 3ill be maintained in the provider8s $!< 3ith copies returned to the provider. &. 5er od & reappra "al and rene>al o- pr / lege". (+) $rovider performance 3ill be continuously monitored through facilityEspecific ongoing performance assessment activities to ensure that (uality patient care is rendered. $roviders are responsible for submitting !#@ continuing dental education or documentation of other disciplineEspecific professional education licensure rene3als ?;2 certification rene3als and other certification rene3als or credential updates to the $!< manager in a timely manner. (2) !linical privileges are in effect for a period not to e6ceed 2. months from the date granted. %t is the responsibility of each provider to re(uest the rene3al of hisDher clinical privileges and medicalDdental staff appointment (if applicable) every 2 years. The re(uest for rene3al 3ill be submitted far enough in advance to permit an evaluation of current clinical privileges and performance. <ailure to re(uest rene3al in a timely fashion may result in the e6piration of the provider8s privileges. (,) <or clinical privileges rene3al &A .)9+-+ 3ill be submitted. Appropriate attachments include a ne3 &A <orm *..0 and *C*. completed and signed by the provider and &A <orms *..+ and *,C. prepared by the individual8s departmentDservice chief. (.) &A <orm *..+ documents the assessment of the provider8s performance of currently assigned privileges and hisD her professional performance according to established standards. Reappraisal and rene3al of clinical privileges are based on provider performance facility capabilities and the needs of the beneficiaries. (2ee app A for a complete listing of the &A <orms *..0 and *..+ series.) (a) The Lprivileges performedM and evaluated on &A <orm *..+ must be identical to the Lprivileges delineatedM as re(uested on &A <orm *..0. (b) Hhen privileges are to be modified because of the performance reappraisal the reason 3ill be stated under L!ommentsM on &A <orm *..+. (c) &A <orm *,C. 3ill be used to evaluate professional clinical and interpersonal s5ills. %t 3ill be completed by the departmentDserviceDclinic chief and 3ill include both (ualitative and (uantitative performance data. The assessment 3ill address the individual8s clinical and technical s5ills based on locally determined performance criteria as 3ell as a comparative analysis of the provider8s performance in relation to aggregate data from a representative peer group sample. The comparative analysis that is performed should contain both intraE and interEfacility data. (*) A revie3 of provider credentials 3ill be conducted. $rivilege reappraisal and subse(uent rene3al 3ill be based
AR 4068 0 6 !ebruary 004 6%

on education training e6perience clinical performance evaluations provider activity profile data professional conduct $% activities and the provider8s capability to perform the re(uested privileges (formerly called health status). ()) %f the provider8s performance is deemed to be substandard or not current enhanced supervision may be re(uired for a period of time as specified by the commander (see para e belo3) or remedial training may be 3arranted (para belo3). (C) At the time of privilege reappraisalDrene3al other than current data may be removed from the $A< and destroyed (or given to the provider). This 3ill ta5e place only after it has been determined based on credentials committee criteria that this information is reflected accurately and completely in the current performance appraisal and other privilege delineation information contained in the $!<. (>) The authenticated &A <orms *..0 and *..0A serve as notification to the provider of the rene3al of hisDher clinical privileges and medical staff appointment. A cover memorandum to the provider may also be prepared. (2ee fig 9-+.) The provider must ac5no3ledge receipt of these documents by signed memorandum returned to the $!< manager. (2ee fig 9-2.) The original &A <orms *..0 *..0A *..+ .)9+-+ and *C*. 3ill be maintained in the provider8s $!< 3ith copies returned to the provider. d. #ppl &a! on -or rene>al o- pr / lege" -ollo> ng 5CS or permanen! !ran"-er. (+) 1pon notification of the provider8s impending $!2Dtransfer to another #T< the losing unit 3ill complete ne3 &A <orms *..+ and *,C.. The biennial appraisal 3ill be considered current if it 3as completed 3ithin ) months of departure. The credentials manager of the losing #T< 3ill for3ard these forms together 3ith the $!< and the provider8s !!"A2 file by certified return receipt re(uested mail to the receiving unit. The files 3ill be for3arded far enough in advance to ensure arrival at the receiving facility at least +* days prior to the provider8s reporting date. Any documents that have not been included in the $!< prior to its release 3ill be for3arded at the earliest possible opportunity. %f the gaining facility has not received these documents upon the provider8s arrival immediate action should be ta5en to locate these sensitive files. (2) The gaining #T< 3ill use this documentation as the basis for initiating clinical privileging and medicalDdental staff appointment actions. The $!< 3ill include the most recent clinical performance appraisals (&A <orms *..+ and *,C.) even if the provider transfers to a leadership or administrative position involving no clinical practice or to student status (see para 9-*). (,) Hith the release of !!"A2 version 2.) the data contained in this restrictedEaccess data baseGin con7unction 3ith &A <orms *,C. and *..+G3ill facilitate the privileging of ne3ly assigned providers. $reliminary revie3 of credentials for privileging and medical staff appointment can begin in advance of the provider8s actual arrival or the facility8s receipt of hisDher $!<. (.) @lectronicDtelephonic communication bet3een facility credentials managers regarding providers in transit is li5e3ise encouraged. The information documented as a result of these interactions may serve in place of the actual forms in the privileging process. Any credentialingDprivileging action ta5en by the credentials committee based on other than actual documents in the $!< 3ill be annotated in meeting minutesDreports. =erification of receipt of the document(s) in (uestion and that it is in order 3ill be noted in subse(uent meeting minutesDreports. (*) 1pon arrival at the ne3 duty station or place of employment the provider 3ill submit a re(uest for rene3al of clinical privileges and if applicable medicalDdental staff appointment. The re(uest 3ill include the documents noted above. Transfer bet3een A#@&& facilities is considered continuous &'& service under the same 0? (T20) and provided the stipulations of paragraph a(+) above are met rene3al of provider privileges and professional staff reappointment are appropriate. ()) The provider (AAD12ARDAR/0) 3ill apply for privileges immediately but in no case later than * duty days (+0 duty days for '!'/12 providers) follo3ing arrival. The 12ARDAR/0 privileged provider 3ill meet 3ith the unit credentials manager as soon as possible to submit hisDher credentials for revie3 and to apply for unitElevel privileges if appropriate. All providers must be privileged prior to being involved in or assigned to patient care activities. e. )nhan&ed "uper/ " on -or pro/ der". (+) @nhanced supervision is not an adverse privileging action against a provider. %t does not alter the individual8s medicalDdental staff appointment status nor does it reduce the provider8s category of privileges as a3arded by the institution. (2) @nhanced supervision for up to ) months (3ith e6tension granted on an individual basis) may be re(uired 3hen in the best interest of (uality patient care the privileged provider8s performance 3arrants closer attention or scrutiny. 2ome e6amples includeG (a) <ollo3ing a $!2 move or during a T&I to ensure full clinical competence. (b) Hhen privileges for a ne3 procedure or technology are considered. (c) <or providers returning to clinical practice follo3ing an e6tended absence from patient care responsibilities. (d) <or the novice provider 3ho is developing hisDher clinical practice s5ills. (,) Although only the initial category of medicalDdental privilegesDstaff appointment specifically re(uires revie3 of the medicalDdental staff member8s performance this does not preclude enhanced supervision or performance revie3 of providers in an active affiliate or temporary appointment status or providers 3ho do not have a medicalDdental staff appointment.
6 AR 4068 0 6 !ebruary 004

(.) Routine ongoing performance assessment is the basis for all $% activities and is essential for providers 3ith all types of medicalDdental staff appointments and all categories of privileges. The credentials committeeDfunction 3ill recommend for the commander8s approval the specific enhanced supervision re(uirements based upon the provider8s needs. (a) The re(uirement for enhanced supervision 3ill be indicated in bloc5 )e of &A <orm *..0A. The provider8s performance 3ill be revie3ed by the credentials committee upon completion of the specified time period for the supervision. %f it is determined that the supervision is no longer re(uired a ne3 annotation 3ill be made in bloc5 C. The appropriate credential committeeDfunction minutesDreport 3ill reflect this decision. The provider8s privileging period 3ill not change. (b) The re(uirement for supervision to determine or monitor the clinical competence of ne3ly assigned providers those 3ho practice infre(uently or those re(uesting ne3 privileges is not considered adverse and does not re(uire reporting. (c) %f the period re(uired for enhanced supervision is greater than +2 months remedial training for the privileged provider should be considered. (d) %n contrast to the above re(uirements for supervision resulting from an adverse privileging action (for e6ample restriction of privileges) 3ill be reported as adverse according to the procedures outlined in paragraph +0-) -(*). -. 3ormal remed al !ra n ng program. (+) Hhen a provider 3ith clinical privileges fails to maintain re(uired proficiency levels to practice in hisDher specialty at the discretion of the commander a remedial training plan designed to enhance proficiency levels may be implemented. The decision to implement a formal remedial training program must be based on the individual circumstances of the provider and any additional unitErelated considerations. (2) The formal remedial training program as addressed here is appropriate for A& serviceEobligated providers 3ho have had their privileges either suspended or restricted by the facility commander. (2ee para +0-) -(*).) $roviders 3ho have had their privileges reduced or revo5ed are not eligible for remedial training. (,) The uni(ue nature of each situation necessitates an individuali4ed approach to determining the length of the formal training the location and other specifics. (.) %n the interest of the privileged provider this training is best accomplished after $!2 to a ne3 assignment or during a period of T&I. (*) Re(uests for remedial training 3ill be initiated by the provider8s current #T< commander and for3arded through the ne6t higher head(uarters to !ommander 12A#@&!'# (#!9'-!;-") 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0. Re(uests concerning dentists 3ill be for3arded to the !ommander 12A&@/!'# (#!&2) 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)00.. 2pecific criteria defining the e6pected trainee outcomes 3ill be included as part of the re(uest. ()) The goals duration and location of remedial training 3ill be addressed in recommendations to T20 by the !ommander 12A#@&!'# (#!9'-!;-") 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0 or the !omE mander 12A&@/!'# (#!&2) 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)00. in consultation 3ith the appropriate specialty consultant to T20. (a) The decision 3ill be coordinated 3ith the #T< commander or designee the #T< commander or designee at the training site and if necessary the 9ealth 2ervices &ivision 9R! (TA$!-#2R) 200 2tovall 2treet Ale6andria =A 22,,2-0002. (b) The respective corps chief or designee has final approval of the remedial training plan. (c) The !hief "#& 12A#@&!'# (#!9'-!;-") 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0 3ill be 5ept informed of the privileged provider8s progress in the remedial program and the ultimate outcome. (C) 0enerally an individual identified as needing remedial training 3ill be assigned to an #T< that is at >* percent or higher fill against the authori4ations in hisDher specific A'! or as determined by the T20 consultant in the A'!D A2%. At the time the provider in remedial training returns to full practice heDshe may be slotted against a valid authori4ation. The provider may be retained at the facility that provided the training returned to hisDher original unit or reassigned to a ne3 duty station. !oordination for reassignment 3ill be accomplished by 9R! in con7unction 3ith the appropriate T20 specialty consultant. (>) $roviders 3ho do not successfully complete remedial training may be processed for separation under the provisions of AR )00->-2. or AR +,*-+C* as appropriate. (9) %n contrast to formal remedial training informal training may be utili4ed for any categoryDdiscipline of providerD professional at any time. This is coordinated at the local level by the individual8s chain of command. The 12ARD AR/0 provider 3ho 3ishes to reEestablish clinical competency may re(uest through hisDher chain of command an AT opportunity for s5ills enhancement purposes. g. 'od - &a! on o- pr / lege" a! !he re9ue"! o- !he pro/ der. (+) %f a provider re(uests modification of hisDher clinical privileges for the upcoming period a ne3 &A <orm *..0 3ill be prepared 3ith the specific privileges to be modified appropriately coded. The re(uested modification may be for augmentation or reduction of privileges. %f the re(uest is for an augmentation of privileges documentation of appropriate education training and e6perience to support the additional privileges is re(uired. $roviders 3ho re(uest
AR 4068 0 6 !ebruary 004 6.

privileges substantially less than those of members of their specialty A'! or s5ill identifier (2%) 3ill re(uire careful evaluation and subse(uent action by the credentials committee. (2) %f the modification reduces the provider8s privileges 3ritten 7ustification 3ill be submitted 3ith the &A <orm *..0. The credentials committee 3ill determine ifG (a) The re(uest is 3arranted and 3hat accommodations are appropriate considering the individual8s special needs associated 3ith a medical condition or other documented situation related to performance deficit(s). (b) The privileged provider 3ill undergo a period of structured training. %f the training is approved (does not include the formal remedial training described above) the temporary modification of privileges if ,0 days or less 3ill not result in an adverse privileging action. (c) A recommendation should be made to change the provider8s A'! or 2% and terminate any special pay. (d) 2eparation in a lessEthanEfullyEprivileged status should be recommended. (,) A privileged provider cannot voluntarily re(uest a modification of privileges in order to avoid an adverse privileging action. A voluntary surrender or restriction of privileges 3hile under investigation for possible professional incompetence or unprofessional conduct or as part of an agreement 3ith the organi4ation for not conducting an investigation or professional revie3 action 3ill be reported to the !ommander 12A#@&!'# ATT/F #!9'-!;" 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0. 2uch actions may re(uire subse(uent reporting to the /$&? according to paragraph +0-+2 a(+). h. G5;) par! & pan!". (+) Super/ " on. (a) $hysician and dental providers 3ith regular privileges in the same A'! or 2% and an active appointment on the medicalDdental staff 3ill supervise #!D&! graduate level clinical residency and fello3ship program participants. /onphysician privileged providers in graduate clinical training programs 3ill be supervised by a provider 3ith the same or similar A'!D2% and regular privileges or by a physician. (b) The degree of supervision (direct or indirect) afforded the provider in student status 3ill be appropriate to the individual8s level of progress the ris5 of the procedure and the seriousness of the patient8s illness. (2ee para *-,b(2)(a) for additional information regarding supervision of 0$9@ trainees.) !oncurrent consultation 3ill be obtained for any patient for 3hom a substantial ris5 is implied or the diagnosis is obscure. This consultation 3ill be documented on 2< *09 (#edical RecordE$rogress /otes) on 2< *+, or on 2< )00. (2ee AR .0-)) for instructions on the use of these forms.) 2ituations that re(uire mandatory direct supervision 3ill be identified by the program directorGin 3ritingGand documentation of such 3ill be provided to all those involved. (2) 5r / lege"7"!a-- appo n!men! -or el g ble !ra nee". <ello3s and other privileged providers involved in a second residency may apply for regular privileges in their primary specialty (for e6ample fello3s in plastic surgery 3ho are eligible for regular privileges in otolaryngology may apply for otolaryngology privilegesA eligible pediatricians in endocrinology fello3ships may apply for pediatric privileges). These providers may be granted either an active or affiliate appointment according to their e6pected participation in medical staff activities or an initial appointment if they have not held a medical staff appointment in a &'& facility during the past +>0 days. (,) Tra n ng &reden! al" - le" (TC3",. A T!< and a $A< 3ill be developed and maintained during 0$9@ for interns residents and other trainees (all disciplines) in military training programs for 3hom a $!< has not yet been established. The T!< 3ill be initiated during the first year of training and 3ill contain verified copies of diplomas licenses clearing house reports training certificates practice e6perience documents curriculum vitae and other documents as appropriate. T!<s and $A<s 3ill be maintained by the 0#@ director or as indicated by the commander. $erformance assessments 3ill be conducted at least every ) monthsA on an annual basis the department chief 3ill provide a 3ritten recommendation to approveDdisapprove matriculation to the ne6t year8s training level. All such assessments 3ill be filed in the $A<. 'ther documentation such as letters of appreciation patient complaints and other reports that may lend themselves to trending or profiling the trainee8s performance 3ill also be filed in hisDher $A<. (.) Cl n &al per-orman&e e/alua! on. $rior to completion of the clinical training program trainees 3ill submit the appropriate disciplineEspecific &A <orm *..0 through their service and department chiefs to the 0$9@ committee (military setting) or to their faculty advisorDpreceptor (civilian setting). The trainee based on a selfEappraisal is attesting to hisDher current level of competence related to privileges appropriate to hisDher specialty. (a) 'ne month prior to completion of the training the trainee8s clinical supervisor 3ill complete and the 0$9@ committee (or committee 3ith comparable professional oversight authority) 3ill authenticate &A <orms *..+ and *,C.. These documents address the trainee8s professional s5ills abilities and competence and reflect recommendations for clinical privileges at the provider8s subse(uent duty assignment based on hisDher performance during training. &A <orms *..0 *..+ and *,C. 3ill become a permanent part of the T!<. The information contained in the T!< becomes the basis for the $!<. (b) The 0$9@ committee 3ill decide 3hich if any of the interval performance assessments and other data accumulated during the training period 3ill remain in the T!<. %n instances 3here an #T< 0$9@ committee does not e6ist a comparable line of academic authority must be locally established based on the availability of professional resources. The #T< commander 3ill delegate responsibility for the duties performed by the 0$9@ officeDcommittee for academicDclinical oversight and for documentation of the trainee8s clinical competence as appropriate. The T!<

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3ill be for3arded by certified return receipt re(uested mail to the credentials coordinator at the gaining facility to arrive +* days prior to $!2. %n the absence of 0$9@ committee as a minimum &A <orms *..0 *..+ and *,C. 3ill be for3arded by the supervisor through the credentials committeeDfunction to the trainee8s ne6t unit of assignment. (&, &A <orms *..0 *..+ and *,C. are available at Heb site httpFDD333.apd.army.milD. @ach corps 3ill ensure that instructions for proper completion authentication and transmittal to the first unit of assignment are provided to military and 02 civilian trainees enrolled in civilian 0$9@DlongEterm health education and training clinical programs. The trainee 3ill ensure that the completed documents are mailed by the authori4ed supervisor (program directorDfaculty memberDpreceptor) to the trainee8s first unit of assignment (ATT/F #T< !redentials 'ffice). These documents 3ill not be relin(uished to the trainee. The performance data contained on the &A <orms *..+ and *,C. serve as the basis for a3ard of initial clinical privileges and professional staff appointment. !linical performance evaluation is in addition to and does not substitute for the academic evaluation report that is re(uired in accordance 3ith AR )2,-,. (*) 3a lure !o &omple!e. %n the case of a provider8s failure to complete hisDher training program or heDshe is removed from a program for lac5 of competence or for disciplinary reasons the details 3ill be documented in the individual8s T!<. ()) %epor! ng. The administrative management and reporting of providers 3ho fail to complete or are removed from a training program for substandard performance or unprofessional conduct 3ill be made according to paragraphs 9-C +0+, and +0-+*. . 3ormal on<!he<2ob !ra n ng (+.T,. 'JT programs involve formal structured training designed to provide 5no3l E edge and technical e6pertise to providers 3ho are e6pected to receive privileges in a given A'! or 2% or for augmentation of clinical privileges associated 3ith ne3 technology or a ne3 procedure(s). The commander 3ill re(uire a 3ritten program of instruction specific learning ob7ectives and clearly identified training outcomes for the 'JT program. (+) $roviders 3ith defined privileges in the same A'! or 2% 3ill supervise 'JT trainees. The degree of supervision 3ill be appropriate to each trainee8s level of progress the ris5 of the procedure and the seriousness of the patient8s illness. The trainee 3ill obtain concurrent consultation for any patient for 3hom a substantial ris5 is implied or the diagnosis is obscure. 2ituations re(uiring mandatory direct supervision 3ill be identified in 3riting by the 'JT program directorDcoordinator and documentation of this re(uirement 3ill be provided to all those involved. (2) %ndividuals progressing unsatisfactorily in a formal 'JT program 3ill be managed according to established training program procedures. (,) 'ne month prior to completion of training the preceptor 3ill complete &A <orms *..+ and *,C. 3hich 3ill reflect those clinical privileges 3arranted at the individual8s #T< of assignment based on performance during training. These forms 3ill be for3arded through the 0$9@ committee if one e6ists other3ise through the credentials committee to the gaining facility. They 3ill be for3arded by certified return receipt re(uested mail to the credentials coordinator at the gaining facility to arrive +* days prior to $!2. The gaining facility 3ill use this information as the basis for granting clinical privileges. These forms become a permanent part of the individual8s $!<. $<2 Medical;dental sta'' appointment a. Appointment to the medicalDdental staff is a process distinct from that of granting clinical privileges. Hhile similar data are considered for these concurrent procedures they are separate recommendations to the commander by the credentials committee and must be reflected as such in the credentials committee minutes. &A <orm .)9+ or &A <orm .)9+-+ signed by the privileged provider and submitted to the credentials committee is utili4ed to re(uest clinical privileges and medicalDdental staff appointment if desired. b. A medicalDdental staff appointment reflects the provider8s relationship 3ith the medicalDdental staff and the degree to 3hich the provider participates in medicalDdental staff surveillance and revie3 as 3ell as (uality improve ment activities related to the governance of the medicalDdental staff. (+) An appointment to the medicalDdental staff can be granted only to licensed certified or registered providers and it must be accompanied by the granting of clinical privileges. (2) A medical staff appointment is re(uired for privileged providers to admit patients to inpatient services. (,) #edical staff membership is not re(uired of individually privileged nonphysician providers 3ho do not admit patients but they may re(uest membership if desired. (.) /o provider 3ith regular or temporary privileges is precluded from membership on the medical staff solely because of hisDher professional discipline or specialty. &. The applicant for medical staff appointment 3ith accompanying privileges 3ill be oriented to pertinent 1.2. Army and #T< procedures policies and regulations governing patient care and medicalDdental staff responsibilities and e6pectations. The applicant 3ill ac5no3ledge in 3riting hisDher intention (an attestation) to abide by these standards. The #T< is responsible for providing each privileged provider 3ho is a member of the medicalDdental staff copies of any significant revisions to the rules and regulations governing their practice. d. The type of appointment 3ill vary depending upon the clinical privileges granted the availability of the provider to the facility and the defined role of the provider in the delivery of healthcare by the #T<. There are five categories of medical staff appointment.

AR 4068 0 6 !ebruary 004

6+

(+) 0n ! al appo n!men!. (a) An initial medicalDdental staff appointment is granted to a provider 3hen heDshe is first assigned or employed in a &'& #T<. 'r if the provider (AAD12ARDAR/0) has not held a medical staff appointment in a &'& #T< during the previous +>0 days an initial appointment is the only appointment that 3ill be granted. This is in the best interest of (uality patient care and is not intended to reflect negatively on the individually privileged provider. The initial appointment 3ill not e6ceed a +2Emonth period. (b) &uring the initial appointment period the privileged staff member8s performance 3ill be under revie3 by the responsible departmentDserviceDclinic chief(s) to determine clinical competence and to evaluate the provider8s 5no3l edge and conduct 3ith respect to the medicalDdental staff byla3s policies procedures regulations and code of professional conduct. The commander 3ill determine specific supervisory re(uirements for the provider 3hen an initial appointment is granted. (c) A provider may subse(uently be granted either an active or an affiliate medical staff membership depending upon hisDher type of employment or relationship 3ith the medicalDdental staff. Advancement from initial to active or affiliate appointment status is discretionary and is not a right of the appointee. Advancement 3ill depend upon the appointee8s (ualifications performance and the needs of the facility. Hhen an appointee is not advanced because of changing needs of the facility the medicalDdental staff appointment 3ill e6pireA this is not considered an adverse occurrence. (2) #&! /e appo n!men!. (a) An active appointment is granted to a provider e6ercising regular privileges and meeting all (ualifications for membership on the medicalDdental staff according to the needs of the 0overnment after successfully completing the initial appointment period. A provider 3ho has completed an initial appointment period at another #T< and has not had a lapse of greater than +>0 days may be granted an active appointment upon arrival at the ne3 duty station. Active appointments 3ill not e6ceed a 2.Emonth period 3ithout rene3al. (b) #edicalDdental staff members 3ith active appointments 3ill participate fully in appropriate activities of the medicalDdental staff. Active members 3ill agree to abide by all byla3s rules regulations policies and procedures of the medical staff and are responsible for being 5no3ledgeable of the same. (,) #-- l a!e appo n!men!. (a) An affiliate appointment is granted to a provider e6ercising regular privileges and meeting all (ualifications for membership on the medicalDdental staff according to the needs of the 0overnment after successfully completing the initial appointment period. A provider 3ith an affiliate appointment due to conditions of employment is neither assigned organi4ational responsibilities of the medicalDdental staff nor e6pected to be a full participant in activities of the medicalDdental staff. Affiliate appointments 3ill not e6ceed a 2.Emonth period 3ithout rene3al. (b) The category of affiliate member 3as created to relieve certain medicalDdental staff members of the re(uirement to serve on medicalDdental staff committees including the @!#2D@!&2. Affiliate members may therefore be precluded from membership on the @!#2D@!&2 and may be relieved of the re(uirement to participate in other medicalDdental staff committees and activities. Affiliate members ho3ever 3ill be encouraged to participate in departmentDserviceDclinic and medicalDdental staff meetings and $% activities. Affiliate members 3ill agree to abide by all byla3s rules regulations policies and procedures of the medicalDdental staff and are responsible for being 5no3ledgeable of the same. The #T< 3ill 5eep affiliate members informed of changes to the byla3s rules regulations policies and procedures of the medicalDdental staff. (c) Affiliate status may be considered for contracted staff consultants e6perts staff in a T&I status resource sharing personnel partEtime staff 12ARDAR/0 providers performing individual duty for training (for e6ample monthly drills) at the #T< and individual mobili4ation augmentees (%#As). Also included are providers 3ho are not nationals of the 1.2. but are rendering care to &'& beneficiaries under an established 1.2.Dforeign country #'1D #'A. (.) Temporar$ appo n!men!. A temporary appointment is granted in emergency or disaster situations 3hen time constraints 3ill not allo3 full credentials revie3 but 3hen there are pressing patient care needs and a temporarily privileged provider 3ill be admitting patients. The use of temporary appointments should be rare. The temporary appointment 3ill be time limited and 3ill not e6ceed ,0 days. A complete thorough credentials revie3 3ill occur during the period of the temporary appointment. (*) 4o appo n!men!. $roviders 3ithout a license or other authori4ing document or 3ho have not been granted clinical privileges 3ill not be appointed to the medicalDdental staff. These providers do not share medicalDdental staff responsibility to the 0? for medicalDdental staff surveillance revie3 and (uality improvement activities 3ithin the #T<A they are not authori4ed admitting privileges. e. Hhen a provider is privileged and appointed to the medicalDdental staff if applicable the commander 3ill advise the providerGin 3ritingGof their defined privileges and the medical staff appointment that has been granted. &A <orm *..0A 3ill be utili4ed for this purpose 3ith or 3ithout a cover memorandum (see fig 9-+). The provider 3ill ac5no3ledge receipt of the privileges and professional staff appointment if applicable by signed memorandum.

66

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$62 3rovider privileging 'or temporary duty and ot(er actions involving t(e provider credentials 'ile a. 5ro/ der !emporar$ du!$. (+) <or providers on T&I for clinical practice to another #T<Dunit the information conveyed in the %!T? is the basis for ma5ing appropriate medical staff appointment and privileging decisions in an e6peditious manner. The sending #T< commander or designee 3ill ensure that all information communicated in the %!T? is accurate and 3ill sign the document. The commander8s signature imparts their recommendation for subse(uent privileges. 9o3ever the gaining institution retains full responsibility and authority for ma5ing privileging decisions. (2) The %!T? 3hich serves in place of documents contained in the $!< is 7oined 3ith the formal application for privileges (&A .)9+ or &A <orm .)9+-+) and supplants sections of these forms containing essentially li5e informa tion. @very effort must be made to avoid unnecessary duplication of information in the privileging of temporarily assigned providers. (2ee app 9 for guidance on the preparation of the %!T?.) (,) Hhen privileges are re(uested other than those granted at the sending facility additional documentation 3ill be provided supporting these ne3 privileges (for e6ample training documentation or privileging and evaluation documen E tation from another hospital). The gaining facility 3ill revie3 this documentation in addition to the %!T? to evaluate the provider8s competencies and to determine 3hat privileges 3ill be granted. (.) After customary departmentalDserviceDclinic and credentials committee revie3 and recommendation and considE eration of the facility8s capability the gaining #T< commander may grant privileges 3ith or 3ithout modifications based on the approved privilege list from the sending #T<Dunit. The gaining facility 3ill use &A <orm *..0A for notifying providers of their clinical appointments and for documenting the same. $rivileges applied for but not granted due to facilityEbased limitations are not adverse privileging actions. (*) The %!T? becomes invalid upon e6piration of the clinical privileges and professional staff appointment (sending facility) on 3hich it is based. %f the provider is assigned temporarily for several brief periods to the same location the %!T? remains valid over the duration of the combined periods provided the clinical privileges and medicalDdental staff appointment (if applicable) at the sending #T< remain active. %f other credentials have e6pired in the interim telephonic or message confirmation of the rene3al of the credential(s) 3ith the facility holding the $!< 3ill suffice. A ne3 %!T? is not re(uired. A record of the telephone call or the message confirmation 3ill be maintained in the $!< at the gaining facility. The sending facility 3ill 5eep an accurate record of each #T< to 3hich an %!T? is sent to ensure updates on provider status are for3arded as re(uired. The sending #T< 3ill provide a ne3 %!T? 3henever the provider8s privileges change (for e6ample rene3al of privileges adverse privileging actions and so forth). ()) $erformance appraisals received by the provider 3hile practicing under the authority of an %!T? 3ill be maintained in the $A< and incorporated into hisDher clinical privileges reappraisal process. The #T< (sending facility) credentials committeeDfunction 3ill accept provider performance appraisalsDevaluations submitted on the other 2ervices8 forms. b. #dm n "!ra! /e a"" gnmen!. %f the privileged provider is assigned to a position outside an #T< involving no clinical practice (for e6ample 12A#@&!'# #R#! A#@&& !enter and 2chool) or attends a civilian or military school (other than 0$9@ or other graduate level training for 3hich clinical privileges are re(uired) the $!< and !!"A2 provider file 3ill be for3arded to the !ommander 12A#@&!'# (#!9'-!;-") 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0 for other than &! providers. &ental officer files 3ill be sent to !ommander 12A&@/!'# (#!&2) 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)00.. These files 3ill be held until re(uested. %f the provider applies for privileges at a local #T< 3hile in an academic or administrative position the facility credentials manager 3ill re(uest the $!< for clinical privileging and medical staff appointment if appropriate. The $!< for the individual assigned to an #T< 3ho is currently not involved in clinical practice 3ill be retained in the local credentials office and the !!"A2 file 3ill be maintained in active status at the #T<. &. #&adem & a"" gnmen!. <or those attending military graduate medicalDdental education or other graduate level professional health education the $!< and !!"A2 provider file 3ill be for3arded to the military facility conducting the internship residency or fello3ship training. <or those attending civilian graduate medical or dental education the losing facility 3ill send a copy of the $!< by certified return receipt re(uested mail to the civilian institution and the original along 3ith the provider8s !!"A2 file to the appropriate command as identified in paragraph a above. $>2 Separation o' privileged providers a. ' l !ar$. AA officers 3ho e6perience a loss of professional (ualifications 3ill be processed for elimination in accordance 3ith the provisions of AR )00->-2.. b. C / l an. A civilian provider8s failure to attain or to maintain the re(uired proficiency may be the basis for separation from <ederal service. !ommanders 3ill consider separation under one of the follo3ing three options each of 3hich re(uires close coordination and consultation 3ith the servicing !$'!D!$A! as appropriateF (+) Separa! on dur ng proba! on. %f the 02 provider is serving as a ne3 &'& employee under a probationary appointment (initial competitive appointment typically a ,)*Eday period) heDshe may be separated under the provi sions of 2ection ,+*.>0. Title * !<R. 2uch an action should be completed before the end of the last duty day prior to the provider8s ,)*th day follo3ing appointment. <or providers 3ho are in a probationary status this is the preferred

AR 4068 0 6 !ebruary 0041RAR

2ay 00&

6'

course of action. !lose scrutiny of employees during their first year of employment is encouraged to identify potential clinical practice problems. (2) Separa! on ba"ed on per-orman&e. This option is based on poor performance of one or more critical elements in a provider8s performance plan and need not include a loss of privileges. This action is ta5en under the provisions of Title * $art C*2 !<R. 'rgani4ational leadership must be a3are of significant employee rights to include rights to notice opportunity to improve and opportunity to see5 e6ternal revie3. (,) Separa! on ba"ed on lo"" o- 9ual - &a! on". This alternative is based on the fact that the provider is no longer (ualified to perform the duties of the position to 3hich heDshe 3as appointed or 3hen misconduct or malfeasance is the issue. This option may also be e6ercised if provider misconduct or malfeasance is the issue. (The misconduct must be related to the individual8s ability to perform the duties of the position that is the Lne6usM re(uirement.) %n this instance there are significant employee rights to notice hearing representation and appeal beyond the agency. $82 -SAR;AR.@ privileging procedures a. 5r / leg ng a! !he un !<le/el. The clinical privileging process for 12ARDAR/0 privileged providers 3ill meet all the re(uirements addressed in this chapter. $rivileging of 12ARDAR/0 commanders 3ill be coordinated 3ith the ne6t higher medical head(uarters or the 2tate 2urgeon8s office as appropriate. (+) 12ARDAR/0 providers 3ill complete &A <orm .)9+ at the time of initial application for unitElevel privileges and submit it to their unit8s credentials committee or other appropriate credentials committee. (2ee para >-* d(+).) #embers of the %RR 3ill submit &A <orm .)9+ at the time of initial application to !ommander 9R! ATT/F A9R!-R2A-" + Reserve Hay 2t. ;ouis #' ),+,2-*200. (2) 'ther appropriate privileging documents as outlined in paragraphs 9-. a through & 3ill be used to re(uest privileges at the unit level. 1nitElevel privileges 3ill be based on mission andDor medical tas5ings from higher head(uarters. The e6tent to 3hich privileges are granted may differ based upon type and length of duty performed. <or privileged providers assigned to the %RR 3ho re(uest duty at an AA #T< 9R! "uality #anagement &irectorate 3ill coordinate completion of the appropriate privileging documents 3ith the AA #T<. (2ee para b belo3.) (,) The originals of each privileging forms (&A <orm .)9+ .)9+-+ *..0 *..0A and *C*.) are maintained in the $!< 3ith a copy furnished to the 12ARDAR/0 provider. b. 5r / leg ng -or US#%7#%4G !ra n ng or du!$ a! ## 'T3". (+) The provider documentation that 3ill be for3arded to the AA #T< includes an %!T? generated by the unit and the attachments as specified in paragraph >-++ b. The 12ARDAR/0 unit commanderD2tate 2urgeon 3ill recommend privileges to be granted by the AA #T< based on recommendations by the unit8s credentials committee. The AA credentials committeeDfunction 3ill integrate the %!T? 3ith attachments provided by the 12ARDAR/0 unit into its routine privileging process. (2) 0iven the organi4ational structure and mission of 9R! and the /AA& traditional credentials committee function is not practical. Thus the &irector "uality #anagement &irectorate 9R! 9ealth 2ervices and the !ommander /AA& may recommend that privileges be granted based upon direct revie3 of the $!< 3ithout the preliminary action (revie3 and recommendations) by a credentials committee. (,) 12ARDAR/0 providers 3ho cannot supply documentation to support current clinical competence may be sub7ect to an evaluative AT period of duty. This is not considered an adverse privileging action. There 3ill be coordination bet3een the unit of assignmentDattachment and higher head(uarters to identify the facility that 3ill accommodate the healthcare provider for the evaluative period. At no time 3ill this period of evaluation be less than +. days. (.) A current %!T? and other supporting documentation are re(uired for each period of AT A&T or %&T e6cept in situations 3here 12ARDAR/0 provider training occurs at the same AA facility and hisDher clinical scope of practice remains the same. %n these situations the period of clinical privileges may be up to +2 months if no professional staff appointment has been granted and up to 2. months if the provider holds a professional staff appointment. (*) %f the 12ARDAR/0 provider8s scope of privileges is limited due to the inability of the AA #T< to support specific practices the limitations 3ill be annotated in the L!ommentsM section of &A <orm *..0A. This is not considered an adverse privileging action and does not re(uire reporting. ()) %f an 12ARDAR/0 provider8s privileges are denied or if in the performance of duty hisDher privileges are restricted due to professional incompetence or misconduct the !ommander 12A#@&!'# (#!9'-!;-") 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0 3ill be notified according to paragraph +0-+) b. The 12A#@&!'# 3ill then notify the follo3ing as appropriateF (a) 0%% and 0'# member". !ommander 9R! (A9R!-R2A-") + Reserve Hay 2t. ;ouis #' ),+,2-*200. (b) US#% T5U member". Through !ommander 12AR! (A<R!-#&) +.0+ &eshler 2treet 2H <ort #c$herson 0A ,0,,0-2000 to the commander unit of assignmentDattachment. (c) #%4G. Through the AR/0 Readiness !enter (/0?-AR2) +++ 2outh 0eorge #ason &rive Arlington =A 2220.-+,>2 to The Ad7utant 0eneral ATT/F 2tate 2urgeon and #%;$' of the applicable 2tate. (C) 12ARDAR/0 providers 3ith recurrent duty at the same AA #T< are eligible and may re(uest an appointment to the professional staff as described in paragraph 9-*.

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&. %emo!e " !e !ra n ng, med &al " !e "uppor!, and !a&! &al e:er& "e "uppor!. (+) Remote sites are defined as 12ARDAR/0 training sites 3ith troop medical clinics physical e6amination sites Army #ateriel !ommand depots semiEactive <ederal sites medical readiness and training e6ercises and field sites 3hen conducting unit training. (2) <or remote sites that are under the command and control of an AA #T< the #T< commander as the &92 is the privileging authority for all assigned providers. At sites located a3ay from an AA #T< 12ARDAR/0 providers may be granted privileges by the 12ARDAR/0 unit commander or 2tate 2urgeon to perform unit integrity re(uire E ments as identified in paragraph +-. h(*). These 12ARDAR/0 providers are sub7ect to credentials revie3 and privileging according to chapters > and 9. (,) The standard scope of practice for providers at these sites 3ill be based on the appropriate &A <orm *..0. (.) $rivileges may be granted by the appropriate 0? (or designee) based upon the recommendation of the credentials committee. <or R! this responsibility is delegated to the unit medical or dental commander. There are four possible scenariosG (a) The 2tate 2urgeon8s credentials committee provides centrali4ed credentialing for all healthcare providers in the 2tate and recommends approval of privileges to the 2tate 2urgeon. The 2tate 2urgeon is the privileging authority. (b) The participating 12ARDAR/0 medical unit has sufficient #! staff to form its o3n credentials committee. The committee revie3s the provider8s $!< and ma5es recommendations to the unit commander 3ho is the granting authority for clinical privileges. (c) The credentials committee of the medical unit at the ne6t level in the 12ARDAR/0 chain of command (if the unit does not have its o3n committee) revie3s the provider8s $!< and ma5es recommendations for privileges to the unit commander 3ho is the granting authority for clinical privileges. (d) <or deployment to a theatre of operation 12ARDAR/0 providers 3ill be privileged by the AA #T< privileging authority at or responsible for the deployment site. This 3ill be accomplished using the %!T? 3ith re(uired attachments provided by the AR!!A or the individual 2tate 2urgeon8s office. A copy of the %!T? and delineation of privileges granted by the #T< 3ill be presented to the commander of the medical unit to 3hich the individual is assigned. (e) %f the 12ARDAR/0 provider 3ill be delivering healthcare at or under the supervision of an AA #T< the #T< credentials committee 3ill revie3 the individual8s %!T? and ma5e recommendations to the #T< commander 3ho is the privilege granting authority. (*) <or informational purposes copies of the 12ARDAR/0 provider8s privileges granted by the 12ARDAR/0 commander any other relevant clinical privileging documentation and the %!T? 3ill be for3arded to the &92 3ithin 3hose area the site is located or the e6ercise ta5es place. d. )/alua! on o- US#%7#%4G pro/ der"7a&! / ! e". (+) Reappraisal and rene3al or modification (augmentation or restriction) of clinical privileges 3ill follo3 the guidance in this chapter. @valuations 3ill normally be performed during AT or follo3ing each A& period of * or more days. (2) The appropriate &A <orm *..+ 3ill be used to evaluate each A& training period. <or 12ARDAR/0 providers 3ho participate in an inactive duty status evaluation 3ill be conducted follo3ing the completion of a minimum of 2. nonconsecutive inactive duty days. &A <orm *,C. 3ill be used to evaluate periods of %&T. This process allo3s the evaluation of performance to be completed giving consideration to current policies regarding fragmented training or e6cused absences from training. The original copy of &A <orms *..+ or *,C. 3ill be included in the $!<. %f the $!< is maintained by the 12ARDAR/0 unit these forms 3ill be for3arded by the AA #T< credentials manager as soon after completion as possible. A copy may be attached to the %!T? maintained by the AA #T<. A copy 3ill also be furnished to the 12ARDAR/0 privileged provider. (,) @6cept for evaluations follo3ing each A& period of five or more consecutive days evaluation of providers is re(uired only once annually. (.) <or evaluation of medical or dental care providers at remote sites the &92 may defer to the 12ARDAR/0 LonE siteM medical unit commander. The medical unit commander may be re(uired to certify by letter at the completion of AT that healthcare (as assessed by current established ob7ective criteria) met the re(uired standards. %n other training units 3here the medical unit commander is unable to personally verify the (uality of care being provided the &92 has the follo3ing optionsF (a) !onduct site visits using various staff representatives from the #T<. (b) Accept certification by the onEsite clinical officer in charge that the (uality of care provided by hisDher 12ARD AR/0 unit or privileged providers meets established performance re(uirements mandated by provider credentials scope of practice and current professional standards of care. This certification re(uires a medical or dental staff of three or more officers to conduct a (ualityEofEcare revie3 at the 12ARDAR/0 treatment facility. (c) Re(uire a retrospective medical record revie3 by the &92 representative. A representative sample of medical records 3ill be revie3ed for (uality medical necessity and appropriateness of care.

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(*) &A <orm *,C. and the appropriate &A <orm *..+ 3ill be used to record individual clinical performance evaluations based on type of duty as discussed above. ()) 2tateEo3ned and 2tateEoperated AR/0 facilities 3ill undergo periodic site evaluation visits from the area &92 (or representative) to enable the R#! commander to fulfill hisDher technical oversight responsibility (AR +0->C).
+igure $52 Sample 'ormat 'or memorandum noti'ying provider o' clinical privileges and medical sta'' appointment status

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+igure $#2 Sample 'ormat 'or provider memorandum ac?no=ledging clinical privileges and sta'' appointment status

C(apter 50 Adverse Clinical 3rivileging;3ractice Actions

5052 @eneral This chapter describes the management of adverse privilegingDpractice actions for privileged providers and other professionals. The process has four stepsF investigation professional peer revie3 hearing and appeal. The term LproviderM is used for individuals granted clinical privileges. %n select instances information contained in this chapter may also apply to the nonprivileged professional. %n those instances the term LprofessionalM 3ill be used. (2ee chap ) for adverse practice action and peer revie3 information regarding nonprivileged personnel.) 50#2 Command responsi,ility a. Action ta5en on the part of the commander against a provider8s privileges (professional8s scope of practice) may be 3arranted based on performance suspected or deemed not to be in the best interest of (uality patient care. These actions include holding in abeyance denying suspending restricting reducing or revo5ing clinical privilegesDpractice. The action ta5en may be immediate (summary) in the event of a critical incident or as a result of the credential committee8s deliberation (routine) on information made available through !"# reporting channels. b. The commander8s prerogative to hold in abeyance to deny or to summarily suspend clinical privilegesDpractice is e6ercised 3hen there is reasonable cause to doubt the individual8s competence to practice or for any other cause affecting the safety of patients or others. Reasonable cause includesG (+) A single incident of gross negligence. (2) A pattern of inappropriate prescribing. (,) A pattern of substandard care.

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disorder that is not responsive to treatment. (C) 2ignificant unprofessional conduct. &. The specific intent of all those involved in any adverse action against a provider8s privileges (adverse practice action for the professional) should beG (+) To protect the safety and 3ellEbeing of all patients for 3hom healthcare is provided. (2) To safeguard the (uality and efficiency of care delivered 3ithin the A#@&&. (,) To protect the rights of the individual(s) in (uestion (afford due process). (.) To ensure timely resolution of the issues related to providerDprofessional performance. (*) To separate the professional actions and considerations from any associated administrative or legal considerations. ()) To allo3 timely reporting of individuals to professional regulatory agencies if re(uired. d. Hhen an #T< closes careful attention 3ill be given to the disposition of adverse privilegingDpractice action information. Records 3ill not be destroyed. The credentials manager at the closing facility 3ill for3ard all files reports and adverse privilegingDpractice actions information (archived and active) to the R#!DR&!. The R#!DR&! assumes responsibility for the resolution of any pending adverse action cases (privilegingDpractice or administrative) and the maintenance of all records files and reports.

(.) An act of incompetence or negligence causing death or serious bodily in7ury. (*) Abuse of legal or illegal drugs or diagnosis of alcohol dependence. (2ee chap ++.) ()) &ocumented alcohol or other drug impairment and the individual refusesDfails rehabilitation or a psychiatric

5082 Consultation and coordination regarding adverse privileging;practice actions a. A !h legal &oun"el. $rior to proceeding 3ith any adverse privilegingDpractice action addressed in this chapter coordination should occur 3ith the servicing 2JA. This includes actions of abeyance summary suspension of clinical privileges investigationsDin(uiries removal of the providerDprofessional from patient care and any letters of notification. 2JA coordination 3ill help ensure that appropriate due process and legal rights are afforded from the outset of any action that may be ta5en. $rompt coordination 3ith the local 2JA is also encouraged to help ensure that the legal guidance regarding the action(s) under3ay is follo3ed throughout. b. A !h !he %'C7%*C and o!her". (+) #ll &a!egor e" o- emplo$ee". The R#!DR&! 3ill be notified early in the adverse privilegingDpractice action process for guidance on procedures and to discuss a plan of action. As the primary $'! for subordinate units on policies and procedures related to an adverse privilegingDpractice action the R#!DR&! is responsible for oversight of the process. <or providersDprofessionals assigned to #T<s 3ithin the region the R#!DR&! 3ill conduct the appeal of the commander8s decision regarding an adverse privilegingDpractice action unless the #T< is a #@&!@/. <or #@&!@/ and R#!DR&! staff the 12A#@&!'#D12A&@/!'# 3ill provide oversight and 3ill conduct the appeal. (2) C / l "er/ &e (GS, emplo$ee". !onsultation 3ith the appropriate !$'!D!$A! employee relations specialist should occur prior to any adverse privilegingDpractice action (nonprivileged professional) being considered related to civil service employees. This consultation 3ill help ensure that all established 02 civilian employee guidelines are met. (,) Con!ra&! emplo$ee". %f an adverse privilegingDpractice action is being considered on a contract employee the contract officer must be contacted before proceeding according to the provisions of the contract in place. &. All adverse privilegingDpractice actions 3ill be revie3ed by the 12A#@&!'# 'ffice of the 2JA for legal sufficiency prior to final action by T20. 5042 Appropriate use o' adverse privileging;practice actions a. Adverse privilegingDpractice actions addressed in this chapter and any related administrative or legal actions must be handled separately. #T< and R#!DR&! commanders must ensure that 3hen appropriate adverse privilegingD practice action is ta5en and that the associated procedures are managed in a timely manner. b. An adverse privilegingDpractice action is considered appropriate 3hen there is evidence of incompetence unE professional conduct or impairment and the providerDprofessional refuses to voluntarily modify or relin(uish hisDher privilegesDscope of practice. <or e6ample evidence may include deficits in medical 5no3ledge e6pertise or 7udgment (competence)A unprofessional unethical or criminal conduct (serious misdemeanor or felony) (conduct)A or mental health disorders or alcoholDdrug impairment (condition) that reduce or prevent the individual from safely e6ecuting hisD her responsibilities in providing healthcare. c. %f an acute or chronic medical problem mental health condition or alcoholDdrug impairment interferes 3ith the provider8sDprofessional8s performance of clinical duties the individual 3ill submit a re(uest to appropriately modify hisDher privileges or scope of practice. This is considered an administrative action not an adverse privileging/practice action. The re(uest 3ith supporting evidenceDinformation and the appropriate &A <orm *..0 reflecting the modified privileges 3ill be submitted according to local privileging procedures. The &A <orms *..+ and *,C. 3ill be processed in the same manner as any other re(uest for change of clinical privileges. 2ee chapter ++ for further information regarding privileging actions and impairments.
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d. Actions that do not meet these stated criteria may 3arrant authori4ed administrative or legal attention and action as appropriate. e. %f 3arranted adverse privilegingDpractice action must be ta5en regardless of the individual8s affiliation 3ith the organi4ation (for e6ample contracted employee volunteer) or duty status 3ithin the #T<. f. 2evering the employment relationship (to include $!2 separation or retirement) in lieu of ta5ing the adverse privilegingDpractice action that is indicated is not appropriate. g. %n situations involving illegal activity (for e6ample narcotics pilfering physicalDse6ual abuse of a patient and so forth) the !JA 3ill be notified and an adverse privilegingDpractice action initiated as soon as possible follo3ing initiation of the !riminal %nvestigation &ivision (!%&) investigation. !oncurrent action by the !%& and the #T< 3ill facilitate timely notification to outside agencies of those individuals for 3hom such notice is 3arranted. /o reporting to regulatory agencies by the 12A#@&!'# 3ill occur until final resolution of the !%& investigation and all relevant information concerning the incident is available to T20.
50<2 9t(er considerations related to adverse privileging;practice actions a. 0nd / dual" pro/ d ng mpl &a! ng n-orma! on. The A#@&& 3ill ma5e all reasonable efforts to protect the identity of persons 3ho offer information that may result in an adverse privilegingDpractice action against another provider or professional. <or e6ample the name of the individual providing information 3ill be protected unless the due process rights of the providerDprofessional 3ho is the sub7ect of the action re(uire disclosure or if disclosure is deemed appropriate pursuant to a re(uest under the <'%A. /o disciplinary action punishment or any form of retaliatory action 3ill be ta5en against a person 3ho submits information concerning a providerDprofessional unless it is later determined that the information 3as false and the person providing the information acted maliciously. b. #llega! on" n/ol/ ng pro/ der"7pro-e"" onal" "epara!ed -rom "er/ &e. Any allegations of substandard performance or misconduct reported to have occurred prior to an individual8s separation from <ederal service must be investigated even though the individual in (uestion is no longer on A& or employed by the <ederal 0overnment. The responsibility for investigating these situations 3hich may result in a providerDprofessional adverse privilegingDpractice action 3ill remain 3ith the #T< in 3hich the alleged substandard performance or misconduct occurred 3ith assistance as necessary from the R#!DR&!. The #T< 3ill notify the providerDprofessional of the allegations under revie3 and 3ill afford the individual the opportunity to supply information on hisDher behalf. %f the #T< is no longer operational the R#!DR&! 3ill assume these responsibilities. &. #llega! on" n/ol/ ng !he 'T3 &ommander. Hhen information arises on a privileged commander8s clinical performance conduct or condition that may bear on hisDher suitability for professional practice the &!!2 (or dental e(uivalent) 3ill notify the R#!DR&! 3ho in turn 3ill notify the !ommander 12A#@&!'# ATT/F #!9'-!;-" 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0 or !ommander 12A&@/!'# ATT/F #!&2 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)00.. The R#!DR&! is responsible for any adverse privilegingDpractice actions involving its subordinate #T< commanders e6cept #@&!@/ commanders. The 12A#@&!'# "#& or 12A&@/!'# is responsible for any adverse privilegingDpractice action involving R#!D R&! or #@&!@/ commanders. d. U"e o- ! me l ne". Time lines 3ill be specified both in calendar days for actions re(uired of the command and in duty days (that is actual 3or5ing days) for the individual involved 3hen corresponding actions are re(uired of the providerDprofessional. The time lines are established to allo3 the individual in (uestion ade(uate time to prepare for and sufficiently participate in the proceedings and to facilitate timely resolution of the adverse privilegingDpractice action. Hhile it is important that the time limits reflected in this regulation are met no rights 3ill accrue to the benefit of an affected providerDprofessional in an other3ise proper action based solely on the organi4ation8s failure to meet such time limits. e. A !hdra>al o- perm "" on !o engage n o--<du!$ emplo$men!. (+) The commander (or designee) must 3ithdra3 any permission for the military providerDprofessional to engage in clinically related offEduty civilian employment until the privilegeDpractice action under revie3 is resolved. The commander must also notify any #T< (or civilian treatment facility) 3here the individual (military or civilian) is employed of a summary suspension of clinical privilegesDpractice. !oordination 3ith the !JA is encouraged to ensure the $rivacy Act rights of the providerDprofessional are not violated in the notification of offEduty employers. (2ee AR .0-+ para +-> for guidance regarding offEduty civilian employment.) (2) /otification in response to abeyance of privilegesDpractice is at the commander8s discretion. (,) The commander must revo5e permission for offEduty healthEcareErelated employment if an individual has been indicted or titled for any of the acts of unprofessional conduct listed in appendi6 %. (.) The contractor 3ill be notified for contract employees. (*) Any ne3 application for offEduty employment submitted during an adverse privilegingDpractice action revie3 3ill not be approved until the privilegesDpractice duties of the individual have been restored. -. 0n-orma! on !o S!a!e and o!her regula!or$ agen& e". @very effort must be made at the local level and by appropriate 12A#@&!'# "#& staff to assist in the investigation of the incident(s) by 2tate boards or other

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regulatory agencies. %nformation made available to licensingDregulatory bodies 3ill be provided only by the 12A#@&E !'# "#&. 5062 nvo?ing an adverse privileging;practice action Hhen a provider8s conduct condition or performance re(uires action to protect the health or safety of patients hisDher clinical privilegesDpractice 3ill be placed in abeyance or suspended 3hile a thorough and impartial investigation is conducted. The factEfinding period allo3s time to gather and carefully evaluate additional information regarding the situation prior to initiation of an adverse privilegingDpractice action if deemed appropriate. a. #be$an&e. (+) An abeyance is not an adverse privilegingDpractice action. 9o3ever the individual is formally placed Lon noticeM that scrutiny of hisDher practice has begun 3hich may result in an adverse privileging action or other administrative action. The commander &!!2 or department chief may ta5e this action against a providerDprofessional. (2) An abeyance action is ta5en by the appropriate authority 3hen an evaluation of performance appears 3arranted but information is insufficient to suspend privilegesDpractice or the potential ha4ard to patients or patient care is not 3ell defined. %n any case prudence dictates that the individual not be permitted to render patient care. &uring the period of abeyance the provider is assigned to nonclinical duties until the investigation is complete. && <orm 2.99 3ill be initiated and for3arded (for informational purposes only) to the 12A#@&!'# "#& 3ith copy furnished to the R#! or other higher head(uarters as appropriate. (,) An abeyance is valid for +* calendar days and may be e6tended by the commander if re(uired provided the total period of abeyance does not e6ceed ,0 calendar days. 'n the ,+st day if the abeyance is not closed the action automatically becomes a summary suspension of clinical privilegesDpractice. This is a temporary action. 'nce the case is closed all documentation associated 3ith an unfounded abeyance action 3ill be destroyed. (.) An abeyance that is not resolved 3hen the individual terminates hisDher relationship 3ith the #T< (that is resigns hisDher position or is released from A&) automatically becomes a suspension of privileges. This is considered a final action and the suspension of the provider8s privilegesDpractice 3ill be reported as outlined in chapter +.. b. Su"pen" on. There are t3o types of suspension associated 3ith clinical privilegesF summary suspension (a temporary action) and suspension (a final privileging action). (+) 2ummary suspension of clinical privilegesDpractice is a temporary removal of privileges (full or partial) that is used to limit a provider8sDprofessional8s practice 3hile the investigation and due process procedures are conducted or 3hile performance reevaluation targeted training or rehabilitation is completed. (a) As noted in paragraph a(,) above a summary suspension is automatically imposed follo3ing ,0 calendar days of abeyance if the factEfinding procedures and related actions have not been completed. @very effort must be made to conclude the investigation in a timely manner in order to reinstate the individual8s privilegesDpractice if 3arranted or to proceed 3ith other appropriate interventions or an adverse privilegingDpractice action. (b) %n cases 3here the individual8s misconduct professional incompetence or negligence is obvious and this poses a clear and evident threat to the safety of patients or the 3ellEbeing of others instead of an abeyance a summary suspension of clinical privilegesDpractice should be the initial course of action. (2) The commander 3ill invo5e the summary suspension of clinical privilegesDpractice. This immediately details the individual in (uestion to nonclinical duties. 2pecific instructions to the providerDprofessional related to hisDher duty 3ill be included in the commander8s 3ritten notification of suspension. A summary suspension of privilegesDpractice 3ill last only as long as needed for other definitive adverse privilegingDpractice action (that is restriction reduction suspension denial or revocation) to be ta5en. Hhile these actions if longer than ,0 days in duration are reportable to the /$&? (see para +.-, b) summary suspension of clinical privileges 3ithin the &'& is not reported to the /$&?. && <orm 2.99 3ill be initiated (informational purposes) and for3arded to the !ommander 12A#@&!'# (#!9'-!;-") 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0 3ith copy furnished to the R#! or other higher head(uarters as appropriate. At the conclusion of the period of summary suspension if the case is unsubstantiated or unfounded all documentation associated 3ith this action 3ill be destroyed. /o information concerning this incident 3ill be entered into the $!<. (,) A suspension of privileges (final determination) is an adverse privileging action and therefore must be identified as such. 2uspensions must be disclosed 3hen applying for future privileges licensureDcertificationDregistra E tion or malpractice insurance. The suspension must be disclosed even if subse(uent action results in reinstatement. @6planation of the reasons for the suspension and its final outcome may be offered by the providerDprofessional at the time of disclosure. &. 4o! - &a! on pro&edure". (+) $rivileged provider or professional. (a, The individual 3ill be notified in 3riting 3ithin +. calendar days that hisDher clinical privilegesDpractice have been placed in abeyanceDsummary suspension. The memorandum (see fig +0-+)Gdelivered in person or by certified return receipt re(uested mailG3ill state the basis for the abeyanceDsummary suspension the duration of the action that a "A investigation 3ill be conducted and that the results of the process 3ill be revie3ed by the credentials committee.

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(b) %f only a portion of the provider8s clinical privileges or professional8s scope of practice are being placed in abeyanceDsummary suspension the notification letter must state this. (c) %n addition the notification must state that an abeyance not resolved 3ithin ,0 calendar days 3ill become a summary suspension. (d) The notification letter should also e6plain the implications of leaving military service or <ederal employment 3hile a privilegeDpractice action is under3ay. (2ee para a(.) above.) The provider 3ill ac5no3ledge receipt of this notification by signed memorandum. (2ee fig +0-2.) %f the provider refuses to sign the memorandum a responsible official may indicate Lrefused to signM 3here the signature 3ould normally appear. (2) R#!DR&! and 12A#@&!'#D12A&@/!'# notification. (a) The #T< commander 3ill notify the 12A#@&!'# and the ne6t higher head(uarters 3hen a provider8s privilegesDprofessional scope of practice have been either placed in abeyance or summarily suspended. /otification utili4ing && <orm 2.99 3ill be made 3ithin , 3or5ing days. (b) 'ther available information regarding any egregious situation of a sensitive or a potentially notorious nature any incident of gross negligence and any act of incompetence or negligence causing death or serious bodily in7ury (an 2@) or allegations thereof 3ill be transmitted electronically to the !ommander 12A#@&!'# (#!9'-!;-") 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0 3ith copy furnished to the R#! or other higher head(uarters as appropriate. (c) The 12A#@&!'# "#& is responsible for relaying information to T20 as appropriate. <ollo3up documentaE tion on && <orm 2.99 3ill be according to the re(uirements of paragraph +0-+.. d. The C1' 1# n/e"! ga! on. (+) %n cases of abeyance or summary suspension of clinical privilegesDpractice there 3ill be an immediate and rigorous investigation to collect the relevant facts and information. @very effort must be made to ensure a thorough fair honest and unbiased revie3 of the matter(s) under investigation. (a) The #T< commander (designee) 3ill appoint an officer (a disinterested third party) pursuant to the authority of this regulation to conduct the investigation and to report the results to the credentials committee or for nonprivileged individuals to the departmentDservice chief. (b) The investigating officer may testify at any hearing conducted follo3ing the investigation and may be re(uired to provide clarifying information or respond to (uestions from the credentials committee as appropriate. 9o3ever if the individual is a member of the credentials committee heDshe is dis(ualified from any formal committee vote on this matter. (c) To ensure a comprehensive independent revie3 of the event the #T< commander may re(uest that a providerD professional 3ith the appropriate specialty bac5ground and credentials be made available from the ne6t higher head(uarters or from another 2ervice to conduct the investigation. (d) To ma6imi4e the ob7ectivity of the process a recogni4ed unaffiliated civilian specialist may be re(uested if practical to actively participate in the investigation. (2) The investigation may include voluntary consultation 3ith the individual in (uestion revie3 of any relevant documents or discussions 3ith other individuals having 5no3ledge of the situation. (a) Hhen the investigation is complete the report submitted by the investigating officer 3ill present the factual findings 3ith appropriate 7ustification or details and may include the investigating officer8s conclusions or recommendations. (b) %n select circumstances the commander need not 3ait until the conclusion of the investigation to return the provider to clinical duties. %f the early phases of the investigation clearly indicate the absence of substandard performance or other problems the credentials committee should meet revie3 the preliminary details of the investigation and advise the commander of such 3ithout delay. %n situations 3here provider misconduct or malfeasance may be apparent or suspected the commander 3ill be notified immediately. 'ther action (for e6ample Article ,2 or AR +*-) investigation) on the part of the commander may be appropriate. The servicing Judge Advocate shall be consulted.
4o!e. <or nonprivileged professionals information regarding the !"# "A investigation is returned to the departmentDservice chief. The credentials committee is involved in direct management of privileged providers only. 2ee chapter ) for information regarding nonprivileged professional peer revie3 mechanisms.

e. Creden! al" &omm !!ee a&! on. (+) At the conclusion of the investigation the credentials committee 3ill revie3 and carefully consider the investiga E tive officer8s report. The report along 3ith other information collected is the basis of the peer revie3 that may be 3arranted and subse(uent recommendations to the commander for adverse privileging action against the provider. (2) After revie3ing the !"# "A investigation report andDor other pertinent information the credentials committee chairperson may recommend to the commander thatG (a) /o further action be ta5en (that is the evidence available did not 3arrant a privileging action) and the provider8s clinical privileges in abeyance be fully reinstated. (b) The provider8s clinical privileges currently held in abeyance be summarily suspended pending a formal peer revie3.

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(c) A peer revie3 panel be convened to evaluate the available information and to determine if the 2'! 3as met. This function may be conducted under the auspices of the credentials committee or other committee as is customary for the organi4ation and according to local policy. The appropriate authority according to local policy 3ill ensure that the provider receives 3ritten notification of the forthcoming peer revie3 (see fig +0-,) and is advised of hisDher rights to due process. (d) 'ther actions (administrative personnel civil or criminal) be ta5en. -. The pr / leged pro/ der peer re/ e> pro&e"". (2ee chap ) for peer revie3 information pertinent to nonprivileged professionals.) (+) The n!en!. Hhen a provider8s privileges have been summarily suspended (or other3ise adversely affected) a peer revie3 panel (internal or e6ternal) 3ill be conducted to evaluate the provider8s performance conduct or condition to determine the e6tent of the problem(s) and to ma5e recommendations through the credentials committee to the commander. (a) To avoid the possibility of bias those individuals 3ho are involved in the peer revie3 (for 2'! determination or evaluation of the provider8s conduct condition or competence) should not participate as voting members for subse(uent credentials or R# committee actions involving the named provider. (b) The professional revie3 by a committee of the provider8s peers must focus on ho3 the action under revie3 impacts the provider8s ability to practice clinically. (c) The provider in (uestion does not have the right to be present during the proceedingsA ho3ever heDshe shall have the opportunity to provide a 3ritten statement regarding the events under revie3 to appear before the committee and ma5e a verbal statement to clarify issues in the case as needed to as5 (uestions and to respond to (uestions from the committee. (d) The provider is encouraged to consult 3ith legal counsel at any step in an adverse privileging actionA ho3ever the peer revie3 is not a legal proceeding. (2) 5ro/ der no! - &a! on o- a "&heduled peer re/ e>. The individual in (uestion 3ill ac5no3ledge receipt of notification of forthcoming peer revie3 using a format similar to the memorandum ac5no3ledging notification of abeyanceDsummary action. (2ee fig +0-2.) The 3ritten notification to the provider 3ithin +. calendar days of the decision to conduct the peer revie3 3ill containG (a) The date time and location of the peer revie3. (b) A statement of the alleged facts events conduct or omissions sub7ect to revie3. To maintain the confidentiality of any patients 3ho may be associated 3ith the evaluation of the individual8s conduct or performance the patient8s hospital admission number or initials 3ill be used. (c) 9isDher rights regarding participation in the peer revie3 proceedings as noted in paragraph (+)( & ) above. (d) A $'! (name address telephone and facsimile numbers) to receive any 3ritten correspondence or providerE supplied information. (e) Reference to the #T< peer revie3 policy for additional guidance. (,) 5eer re/ e> panel &ompo" ! on. The provider peer revie3 panel must be comprised of an odd number of members e6cept as noted in paragraph (.) belo3. (a) 'ne person 3ill be designated as the chairpersonDfacilitator. (b) The members 3ill be of similar bac5ground 3henever possible and in the same professional disciplineDspecialty as the provider in (uestion. $anel members may be brought in from other #T<s to meet this re(uirement (that is to conduct an internal peer revie3) or the case file and all supporting documentation may be for3arded to another #T< (military or civilian) for an e6ternal peer revie3 to be performed. ;ocal policy 3ill stipulate the circumstances under 3hich an e6ternal peer revie3 is re(uired. The peer revie3 panel may also be convened by audioDvideoEteleconference if there are insufficient (ualified providers in a given location to perform this function. (c) @6cept in cases of an unfounded or unsubstantiated abeyance action or summary suspension of a provider8s privileges the credentials manager 3ill maintain an administrative file containing the peer revie3 documentation associated 3ith an adverse privileging action for possible future reference. The Army Records %nformation #anage E ment 2ystem (AR%#2) retention schedule at httpsFDD333.arims.army.milDspecifies the period of time this record may be 5ept at the #T<. &ocuments retained in this file may includeF list of references usedA list of documents revie3edA list of personnel intervie3edA inventory of documents revie3ed and returnedA a confidentiality statement to be signed by each of the panel participantsA or the commander8s letter of appointment to the peer revie3 for each member. All documentation associated 3ith an unfounded abeyance action or summary suspension 3ill be destroyed. (.) 0mpar! al !$ o- !he peer re/ e> par! & pan!". This revie3 process is a function of the provider8s peers. $ersonnel participating in this process must be able to impartially revie3 the case and render an ob7ective decision at the conclusion of deliberation. The follo3ing individuals should not be voting participants in the peer revie3 of the provider in (uestionF (a) The individual8s direct supervisor. (b) $roviders for 3hom the individual is the supervisor to include immediate or senior rater for '@Rs or endorsing official for civilian performance appraisals.

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(c) The individual 3ho suspended the provider8s privileges or 3ho recommended administrative or legal action against the provider in this case or previous cases. (d) Any person 3ho investigated the case. (e) Any person 3hose testimony plays a significant part in the case. (f) Any member 3ho is participating or has participated in other administrative proceedings (courtsEmartial board or administrative revie3 board) involving the provider in (uestion. (g) Any member 3ho is revie3ing or has revie3ed the provider8s actions under consideration by the credentials committee. (h) The credentialsDR# committee chairperson. (*) %e&ommenda! on" regard ng &l n &al pr / lege". The conclusions reached should be readily supported by rationale that specifically addresses the issues for 3hich the peer revie3 3as conducted. #inority opinions and vie3s of the peer revie3 panel 3ill be considered and appropriately entered into the record of the panel8s activities. %f additional information is re(uired the case may be referred bac5 for further action to the individual(s) 3ho conducted the in(uiry. The peer revie3 panel considers the information from the !"# "A investigation and any other relevant facts and ma5es recommendations to the credentials committee regarding the provider8s clinical privileges. 'ne of the follo3ing recommendations may be madeF (a) %e n"!a!emen!. The return of privileges to the original privilege state. Reinstatement may include provisions for provider #O@ 3ith stipulations as to the nature and duration of the #O@. This is not an adverse privileging actionA it is not reportable to regulatory agencies and no hearing or appeal is offered. %f #O@ e6ceeds ,0 days this is deemed a conditional reinstatement of privileges and 3ill be reported by the 12A#@&!'# "#& to the appropriate 2tateD regulatory agencies. (b) Su"pen" on. The temporary removal of all or a portion of a provider8s privileges resulting from incompetence negligence or unprofessional conduct. (2ee para b(,) above.) (c) %e"!r &! on. A temporary or permanent limit placed on all or a portion of the provider8s clinical privileges. The provider may be re(uired to obtain concurrence before providing all or some specified healthcare procedures 3ithin the scope of hisDher license certification or registration. The restriction may re(uire some type of supervision. (d) %edu&! on. The permanent removal of a portion of the provider8s clinical privileges. The reduction of privileges may be based on misconduct physical impairment or other factors limiting a provider8s capability. (e) %e/o&a! on. The permanent removal of all clinical privileges and termination of the provider8s patient care duties. %n most cases this action 3ill be follo3ed by administrative procedures to terminate the individual8s &'& services. This action can only be ta5en after the provider has been afforded hearing rights. (2ee para +0-C.) $rior to the hearing the #T< may decideDnotifyDrefer to this only as an intent to revo5e clinical privilegesDpractice. (f) *en al. Refusal of a re(uest for privileges due to substandard performance professional misconduct or impairE ment. This may occur at the time of initial application for privileges or 3hen rene3al of privileges is re(uested. ()) Creden! al" &omm !!ee re&ommenda! on" !o !he &ommander. Hithin C calendar days of completing the peer revie3 process the panel8s recommendation(s) along 3ith the case evidence 3ill be for3arded to the credentials committee. <ollo3ing any additional revie3 of the facts of the case the credentials committee 3ill include its recommendation(s) 3hich may or may not coincide 3ith those of the peer revie3 panel and the entire case file 3ith recommendations is for3arded to the commander. (C) #&! on b$ !he &ommander. (a) The commander has +. calendar days from receipt of the recommendation(s) to revie3 and to decide 3hat privileging action to ta5e based on the facts provided. The commander is not bound by the recommendations of the credentials committee or the peer revie3 panel. (b) The commander 3ill provide 3ritten notification to the provider of the privileging action to be ta5en and the 7ustification for this action addressing all specified allegations (see fig +0-.). %f the provider is a contractor a copy of the notification is for3arded to the responsible contracting office and a letter documenting these actions is provided to the contractor at the address of record. (c) %f the proposed action is to deny suspend restrict reduce or revo5e the provider8s privileges the commander must advise the provider in 3riting of hisDher hearing and appeal rights. The commander must address in the notice to the provider the specific allegations that constitute grounds for the hearing and 3ill include relevant dates and copies of patient records that are pertinent to the hearing. (d) <or providers 3hose privileges have been restricted to the e6tent that they are no longer performing the full range of normal duties in their specialty practice follo3Eon administrative action may be re(uired. +. The #T< commander may consider separation from service in a lessEthanEfully privileged status (military) or ta5e appropriate action through the civil service system or the employee8s contracting agency for failure to maintain conditions of employment (civilianDcontract). 2. %f the provider is to be retained on A& appropriate personnel or administrative action 3ill be ta5en to change hisD her A'! or 2% and discontinue specialty pay. The #T< commander 3ill ma5e hisDher recommendation through the R#! through the !ommander 12A#@&!'# (#!9'-!;-") 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0 to 9R! (TA$!-'$9) appropriate career branch) 200 2tovall 2treet Ale6andria =A 22,22-0.+C. The
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&T< commander 3ill ma5e hisDher recommendations through the R&! through !ommander 12A&@/!'# (#!&2) 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)00. through the !ommander 12A#@&!'# (#!9'-!;-") 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0 to 9R! (TA$!-'$9) appropriate career branch) 200 2tovall 2treet Ale6andria =A 22,22-0.+C. 2ee paragraph +0-+)e for guidance regarding 12ARDAR/0 personnel. g. +!her &reden! al" &omm !!ee a&! on". (+) %n the case of suspected drug or alcohol involvement a member of the impaired healthcare personnel committee (%9!$!) 3ill be appointed to the ad hoc group that 3ill conduct the peer revie3. (2ee chap ++.) (2) The credentials committee 3ill ensure that peer revie3 findings are considered 3hen providerEspecific creden E tialing and privileging decisions are rendered and as appropriate in the organi4ation8s $% processes. 2ummary peer revie3 conclusions 3ill be trac5ed over time and any $% actions based on these conclusions 3ill be monitored for effectiveness. (,) The credentials committee is responsible for e6ecutive oversight and analysis of aggregate data related to all adverse privilegingDscope of practice actions 3ithin the organi4ation. $rivileged provider data are contained in credentials committee minutes. <or the nonprivileged healthcare professional a copy of the !"# "A investigation peer revie3 activity and the subse(uent recommendations for action provided to the commander 3ill be for3arded by the appropriate department chief to the credentials committee. 50>2 3rovider (earing rig(ts a. Ar !!en no! &e o- hear ng r gh!". /otification of the commander8s decision for action against a provider8s privileges 3ill be delivered to the provider either in person or by certified return receipt re(uested mail (see fig +0-.). The notification 3ill be made as soon as is practical but in no case later than +. calendar days after the recommenda tions are made by the credentials committee to the commander. The same 3ritten notification re(uirement and time line e6ist 3hen the !"# "A investigation suggests reasonable cause. Hhen the commander8s proposed action is to deny suspend restrict reduce or revo5e the provider8s privileges the follo3ing re(uirements apply. (+) The 3ritten notice to the provider 3ill specify the deficiencies substantiated by the peer revie3 process the proposed adverse privileging action to be ta5en by the commander and the right of the provider to re(uest and to be present at a formal hearing. (2) ?y signed memorandum the provider ac5no3ledges hisDher receipt of this notification. (2ee fig +0-*.) 2hould the provider refuse to ac5no3ledge receipt of 3ritten notice a memorandum for record to ma5e note of the refusal 3ill be prepared. b. 5ro/ der par! & pa! on. %f the provider 3ishes to re(uest a hearing heDshe 3ill have +0 duty days from date of receipt of the notification of recommended adverse privileging action to respond in 3riting to the credentials committee chairperson. (+) $rior to the hearing the provider 3ill have access to all information that 3ill be presented for consideration at the hearing. (2) The provider may voluntarily 3aive hisDher right to a hearing. This decision is final and not sub7ect to appeal. (,) %f the provider 3aives hisDher right to a hearing recommendations from the credentials committee (and peer revie3 panel if this revie3 3as conducted) 3ill be for3arded to the #T< commander for revie3 and decision. A copy of the commander8s decision regarding the adverse privileging action and the provider8s notice of said action 3ill be filed in the $!<. (.) Haiver of hearing and appeal rights 3ill result in a report to the /$&? according to paragraph +.-, b . (*) <ailure on the part of the provider to re(uest a hearing or failure to appear at the scheduled hearing (absent good cause) constitutes 3aiver of hearing and appeal rights. At the re(uest of the provider the commander 3ill determine the e6istence of good cause. ()) %f the provider is unable to appear in person at the hearing due to unusual or urgent circumstances alternate means of obtaining hisDher personal participation 3ill be offered (for e6ample 3ritten deposition telephone conference call). 5082 %earing ,oard procedures a. The &!!2 (or other physician designated by the commander) 3ill chair the hearing board. #embers of the hearing board shall be individuals 3ho 3ere not involved in the peer revie3 of the provider in (uestion. (+) The hearing is administrative in nature. Therefore the rules of evidence prescribed for trials by courtsEmartial or for proceedings in a court of la3 are not applicable. <or further guidance see AR +*-) paragraph ,-). %f criminal misconduct is suspected the president of the board 3ill see5 the advice of the servicing 7udge advocate before proceeding. (2) The committee 3ill be fully informed of the facts to allo3 an intelligent reasonable good faith 7udgment. The committee may (uestion 3itnesses and e6amine documents as necessary to collect pertinent information. (,) <or procedural guidance on ho3 to conduct the hearing AR +*-) may be consulted but its provisions are not mandatory. b. The chairperson of the hearing board 3ill advise the provider in 3riting (fig +0-)) delivered in person 3ith
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provider receipt ac5no3ledged by signed memorandum (fig +0-C) or by certified return receipt re(uested mail of the follo3ingF (+) The adverse privileging action under consideration that is the grounds for the hearingA any specific dates factsA and all pertinent documents applicable to the case. (2) The time and location of the hearing. The hearing should convene 3ithin +0 duty days (not less than * days but not more than +0 days) from the provider8s receipt of the hearing notification unless e6tended for good cause by the hearing board chairperson. <or 12ARDAR/0 providers the hearing 3ill be convened 3ithin ,0 calendar days of provider notification. (,) The names of the 3itnesses 3ho 3ill be called to testify at the hearing. (.) 9isDher right to be present to submit evidence to (uestion 3itnesses called and to call 3itnesses on hisDher behalf. The provider should be advised that heDshe is responsible for arranging the presence of hisDher 3itnesses and that failure of such 3itnesses to appear 3ill not constitute a procedural error or basis for delay of the proceedings. (*) The right to consult legal counsel. $roviders 3hose personnel status entitles them to receive legal assistance may contact their servicing office of the 2JA for legal advice if desired. ;egal representation in this matter is not an entitlement but may be provided sub7ect to resource limitations as determined by the supervisory 7udge advocate in the office of the 2JA or Trial &efense 2ervice. $roviders may obtain advice or representation from civilian counsel at no e6pense to the 0overnment. To determine if a provider is eligible to receive legal assistance consult AR 2C-,. &. The provider is encouraged to consult 3ith legal counsel or any other representative. !ivilian counsel obtained by the provider 3ill be at no e6pense to the 0overnment. 2uch representatives may attend the hearing but their participation is limited to advising the provider only. They 3ill not be permitted to as5 (uestions respond to (uestions on behalf of the provider call or (uestion 3itnesses or see5 to or enter material into the record. d. &uring a hearing involving a civilian provider the e6clusive representative of the appropriate bargaining unit (union or contract agency) has the right to be present if re(uested by the provider under the follo3ing conditionsF (+) Hhen a civilian provider as a member of the bargaining unit is the sub7ect of the proceedings or a re(uested 3itness. (2) Hhen the civilian provider reasonably believes that the investigation could lead to disciplinary action. 1nless specifically re(uired by the collective bargaining agreement there is no re(uirement to advise the employee that the representative could be present under these circumstances. (a) %f the civilian provider re(uests the presence of the e6clusive representative a reasonable amount of time 3ill be allo3ed for this to be accomplished. The servicing !$'!D!$A! as appropriate and labor union counselor 3ill be consulted before denying such a re(uest. (b) The role of the e6clusive representative is not 3holly passive although heDshe 3ill not be permitted to ma5e the proceedings adversarial. (c) 2ub7ect to the discretion of the hearing board chairperson the e6clusive representative may be permitted to e6plain the employee8s position in this matter (if the employee agrees) or to persuade the employee to cooperate in the proceedings. e. The hearing board 3ill revie3 all the material presented including that submitted by the provider. The chairperson 3ill arrange for the orderly presentation of information and 3ill rule on any ob7ections made by the provider. (+) %f criminal misconduct including dereliction of duty is 5no3n or suspected the chairperson of the hearing board 3ill advise the provider of hisDher rights using &A <orm ,>>+ (Rights Harning $rocedureDHaiver !ertificate). (2ee AR +90-,0 for instructions on the use of this form.) (2) %f an investigating officer 3as designated (see para +0-) d(+)) heDshe may be called before the hearing committee to ans3er (uestions or to provide additional information. 9o3ever the investigating officer 3ill not participate in the hearing board deliberations and heDshe may not vote. (,) The hearing 3ill be documented in summari4ed minutes that reflect all the salient details of the proceedings. The hearing is considered a "A activity covered by +0 12! ++02 and as such no recording devices other than that used by the designated recorder to prepare the record 3ill be permitted in the hearing room. -. <ollo3ing the presentation of all evidence and relevant information the provider being e6amined 3ill be e6cused and the hearing board 3ill determine its findings and recommendations.
4o!e. @ach of the board8s findings must be supported by a preponderance of the evidence. @ach finding must be supported by a greater 3eight of evidence than supports a contrary conclusion that is evidence 3hich considering all evidence presented points to a particular conclusion as being more credible and probable than any other conclusion.

Recommendations may include but are not limited toG (+) Reinstatement of privileges. (2) %dentification of specific provider deficiencies that re(uire improvement and the establishment of re(uirements such as consultation 3ith other providers or specialists related to patient care management. (The board should not ma5e recommendations involving the reassignment of a provider.) (,) 2uspension reduction or restriction of clinical privileges for a specified length of time. The hearing board may recommend that a provider be released from A& or <ederal employment.

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#embers of the hearing board 3ill cast a vote either LyesM or Lno.M /o abstentions are permitted. =oting 3ill be by secret ballot. h. The hearing board must be a3are of the gravity of its responsibilities and the need to clearly document its findings and recommendations. 2pecifically identified incidents or situations 3ill support general statements by the board. !opies of pertinent medicalDdental records or specific case histories to substantiate the findings of the board 3ill be included in the record of the proceedings. These and any other attachments 3ill be tabbed as e6hibits to the record. i. 2elected members of the credentials committee may serve as the hearing board or the entire credentials committee may perform this function as determined locally. Any credentials committee member 3ho has acted as investigating officer or member of the peer revie3 panel should recuse themselves from any subse(uent proceedings in 3hich a vote is re(uired. A privileged provider from the same discipline as the provider in (uestion should be a voting member of the hearing board. 7. The hearing 3ill be closed to the publicA ho3ever the provider may re(uest that observers be permitted. The chairperson 3ill normally grant the re(uest but may limit the number of observers and may e6clude anyone 3ho is disruptive. 5. The hearing board may obtain advice concerning legal (uestions from the servicing 2JA office. The provider should be advised of any legal (uestions as they arise and the ans3ers that 3ere provided by legal counsel. 50$2 Action on (earing recommendations a. The record of the hearingGincluding findings and recommendationsG3ill be revie3ed by the @!#2 prior to being for3arded to the #T< commander. (+) The hearing board recordGto include findings and recommendationsGshall be available for revie3 by all (ualified members of the @!#2 prior to the case file being for3arded to the commander. (2) All (ualified members of the @!#2 (e6cluding any hearing board members or any member that acted as the investigation officer) may either concur by endorsement 3ith the recommendations or submit separate recommendations. (,) %f a member of the @!#2 is absent (for e6ample through T&I or illness) 3hen the hearing board report is for3arded such absence 3ill be noted and the case for3arded to the commander 3ithout action by the absent member. b. The servicing 2JA (or &A civilian attorney) 3ill revie3 the record including credentials committeeDpeer revie3 panel findings and recommendations and any input from the provider in (uestion for legal sufficiency prior to action by the commander. &. The commander 3ill revie3 the hearing record (including credentials committeeDpeer revie3 panel findings and recommendations and any input from the provider in (uestion) and ma5e a decision regarding the provider8s privileges. (+) The findings and recommendations contained in the hearing record are advisory only and not binding on the commander. (2) Hritten notice of the commander8s decision 3ith the date of delivery annotated on it 3ill be furnished to the provider either in person or by certified return receipt re(uested mail. The signed receipt ac5no3ledges the provider8s receipt of the commander8s decision. %f the decision includes denial suspension restriction reduction or revocation of the individual8s privileges the notice should advise the provider of hisDher right of appeal. The notice should also advise the provider that upon re(uest heDshe 3ill be provided a copy of the hearing record. (,) A copy of this notice 3ill be placed in the individual8s $!<. The appropriate department service or clinic chiefs 3ill also be advised of the decision. 50502 7(e appeals process a. Hhen the #T< commander decides to suspend restrict reduce revo5e or deny clinical privileges the provider 3ill be granted +0 duty days (e6tendable in 3riting by the commander for good cause) to submit a re(uest for reconsideration to the #T< commander. (+) %f the provider does not re(uest reconsideration the adverse privileging action and all information pertaining to the case 3ill be submitted to the 12A#@&!'# "#& 3ith copy furnished to the ne6t higher head(uarters for reporting to the /$&?. (2ee chap +..) (2) %f the provider elects to appeal the commander8s decision heDshe 3ill submit a formal re(uest for reconsidera tion that identifies the errors of fact or procedure that form the basis of the re(uest. The burden is on the provider to specify the grounds for reconsiderationDappeal. b. The #T< commander is granted +. calendar days to consider the re(uest. %f heDshe denies the re(uest in 3hole or in part the action 3ill automatically be endorsed to T20 as an appeal. T20 is the final appellate authority for denying suspending restricting reducing or revo5ing clinical privileges. &. The 3ritten appeal and all information pertaining to the case 3ill be submitted through the appropriate R#!D
80 AR 4068 0 6 !ebruary 0041RAR 2ay 00&

(.) Revocation of clinical privileges. (*) To reconvene the hearing after appropriate notice to the provider to consider additional relevant evidence. g. &ecision of the hearing board is by ma7ority vote. The chairperson of the board 3ill vote only in the event of a tie.

R&! commander using certified return receipt re(uested mail. The R#!DR&! commander 3ill revie3 the pac5et to ensure that all necessary information is included prior to for3arding the case to the appropriate staff office that 3ill conduct the appeal. d. The 12A#@&!'# "#& 3ill convene the appeals board for those appeals involving #@&!@/DR#!DR&! providers or commandersA the R#!DR&! is responsible for any adverse privileging action appeal from its subordinate #T<s. %n either case the appeals board 3ill convene as soon as possible follo3ing receipt of all materials related to the adverse privileging action. e. The appeals board 3ill consist of a minimum of three privileged providers one of 3hom 3ill serve as the chairperson. The chairperson of the appeals board is a voting member. This may be the &!!2 at the R#! level (comparable R&! position) or the &irector "#& at the 12A#@&!'# level or other senior officer as deemed appropriate. %t is recommended that at least one member be of the same discipline and specialty as the provider 3hose appeal is being considered. (+) %f the provider is a dentist 3ith no medical facility privileges the appeals board 3ill consist of three dental officers. (2) %f the dentist has medical facility privileges and these privileges are sub7ect to revie3 the committee 3ill include one privileged physician and t3o dental officers. %deally one of these &! officers shall hold medical facility privileges. %f action is being considered against a dental officer 3ith hospital privileges yet the action involves only the provider8s dental privileges the composition of the appeals board 3ill be as described in paragraph (+) above. The dental provider 3ill be afforded the same opportunity to submit 3ritten input for consideration by the appeals board. -. The appeals board 3ill revie3 all information furnished by the provider as 3ell as the hearing record and all findings and recommendations in light of the provider8s alleged basis for appeal. After considering the information and evaluating the merit of the appellant8s appeal the appeals board 3ill advise the commander (12A#@&!'#D 12A&@/!'# or R#!DR&!) of its findings and recommendations for disposition and 3hether it finds substantial evidence to support the #T< commander8s adverse privileging action. <or R#!Elevel appeals the findings and recommendations of the board 3ill be endorsed by the R#! commander and all documents considered by the board 3ill be for3arded by certified return receipt re(uested mail to the 12A#@&!'# for revie3 and approval by the appellate authority (T20). The findings and recommendations of the appeals board are advisory in nature and do not bind the appellate authority. T20 is the sole authority responsible for provider notification of the final decision associated 3ith an appeal. To remove any potential conflict no other parties 3ill have input into the final decision by the appellate authority. There 3ill be no deviation from this regulation in the revie3 process. g. The appellate authority 3ill notify the provider by certified return receipt re(uested mail as soon as possible follo3ing ad7ournment of the appeals board of the decision concerning the appeal. The R#! or #T< commander as appropriate 3ill also be notified in 3riting. The appellate authority 3ill provide clear guidance as to 3hat actions the #T< is e6pected to ta5e regarding the future utili4ation of the provider. h. 'nly adverse privileging actions may be appealed under these procedures. &enial of a re(uest for privileges for reasons unrelated to the abilities (ualifications health or s5ills of the provider is not considered an adverse privileging action. . Administrative action to separate the provider as a result of an adverse privileging action under paragraph +0-+2 3ill be deferred pending appeal resolution. $roviders 3ho voluntarily separate prior to resolution of their appeal 3ill be informed in 3riting that the process 3ill be completed as though they 3ere still on A& or employed in a civilian capacity. 2pecial considerations such as e6tensions of time for appeal 3ill not be granted. 50552 Civilian training %f subse(uent to an adverse privileging action the provider is not separated from <ederal service and heDshe see5s remedial training at a civilian institution that institution 3ill be notified of the adverse privileging action. Any remedial training must be approved by the #T< commander. 505#2 Separation 'rom +ederal service a. An A#@&& provider8s loss of license or clinical privileges or a professional8s loss of license is the basis for separation from military or civilian service. (2ee AR )00->-2. and AR +,*-+C* (for officers) or AR ),*-200 and AR +,*-+C> (for enlisted).) Hhen the clinical privileges of a military or civilian provider are denied suspended restricted reduced or revo5ed a local command administrative revie3 3ill be held to determine 3hether personnel action to separate the provider from <ederal service should be initiated. (+) <or a providerDprofessional 3ho separates from <ederal service (military or civilian) in a lessEthanEfully privileged status or 3ith lessEthanEfull scope of practice information relative to the adverse privilegingDpractice action 3ill be reported. 'nly T20 is authori4ed to report A#@&& healthcare personnel to the appropriate professional regulating authorities. The providerDprofessional 3ill be informed of the conse(uences of leaving <ederal service in a lessEthanEfullyE privileged statusDfull scope of practice (that is that a report 3ill be filed 3ith the /$&? the <ederation of 2tate #edical ?oards 2tate licensing board and other regulatory agencies).

AR 4068 0 6 !ebruary 0041RAR

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8%

(2) <or a providerDprofessional 3ith a service obligation consideration must then be given to branch transfer or reclassification action or as an e6ception to policy elimination from the 2ervice. b. The facility that initiated the adverse privilegingDpractice action 3ill be responsible for finali4ing all details associated 3ith the action. This includes follo3up administrative procedures for a providerDprofessional 3ho has been detailed to another facility for evaluation and found unfit for duty. %n this instance the individual 3ill also be advised of hisDher rights of due process. 50582 Separation o' a criminally c(arged provider %n accordance 3ith AR )00->-2 flags 3ill be submitted 3hen an unfavorable action or investigation (formal or informal) is started against a 2oldier by military or civilian authorities. 2oldiers 3ill not automatically be held beyond their e6piration term of service (@T2) e6piration of service agreement (@2A) or mandatory release date (#R&) pending completion of an investigation or privilegeDlicensing action even if they are flagged. All investigations or privilegeDlicensing actions must be completed prior to @T2D@2AD#R& or authority must be obtained from the 0eneral !ourtE#artial !onvening Authority or 9ead(uarters &epartment of the Army (9"&A) to e6tend the @T2D@2AD#R&. %n accordance 3ith AR )00->-2. paragraph +-+) an officer under investigation or pending courtEmartial 3ill not be separated 3ithout 9"&A approval. %n the case of civilian personnel the management employee relations specialist at the servicing !$A! should be contacted for guidance. 50542 Reporting adverse privileging;practice action activities a. The && <orm 2.99 is used to report actions ta5en against a provider8s privileges or the licensedDcertifiedD registered professional8s scope of practice. (+) At the conclusion of the adverse privilegingDpractice action proceedings documentation supporting the && <orm 2.99 to include credentials committee minutes hearing board record of proceedings results of investigation appeal response letter and any other pertinent information 3ill be for3arded if the #T< has not already done so 3ith the && <orm 2.99 to the 12A#@&!'#D12A&@/!'#. A copy of these documents 3ill also be furnished by the #T< to the ne6t higher head(uarters. (2) The #T< commander 3ill sign and date the && <orm 2.99 in the bottom right hand corner of the Lremar5s section M (bloc5 +2) belo3 any annotations contained in this section of the form. (,) The date the && <orm 2.99 is mailed to the 12A#@&!'# 3ill be annotated in the top right corner of the form. b. The follo3ing activities 3ill be reported through the chain of command as indicatedF (+) C1' 1# n/e"! ga! on". $roviderDprofessional !"# "A investigations being conducted 3ill be reported to the ne6t higher head(uarters (for informational purposes) 3ithin C calendar days of initiation. Appropriate documentation (that is && <orm 2.99 and other supporting materials) 3ill follo3 as stipulated belo3 if the evidence from the investigation supports an adverse privilegingDpractice action. (2) Cl n &al pr / lege"7pra&! &e a&! on". Hhen the commander suspends restricts reduces revo5es or denies (for other than facilityEspecific reasons) a provider8s privileges or a professional8s practice or the individual voluntarily surrenders all privilegesDpractice 3hile under investigation or to avoid investigation a && <orm 2.99 3ill be submitted 3ithin C calendar days follo3ing the action. (a) #T< commanders 3ill for3ard the && <orm 2.99 to !ommander 12A#@&!'# ATT/F #!9'-!;-" 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0 3ith copy furnished to the ne6t higher head(uarters. (b) &T< commanders 3ill for3ard the && <orm 2.99 through the !ommander 12A&@/!'# ATT/F #!&2 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)00. 3ith copy furnished to the ne6t higher head(uarters. 12A&@/!'# subse(uently for3ards the report to 12A#@&!'# (#!9'-!;-"). (c) The R#!s and R&!s are responsible for administrative revie3 to ensure completeness of the && <orm 2.99 and all enclosures and other guidance as appropriate. (d) !opies of all supporting documentation related to the adverse privilegingDpractice action 3ill accompany the && <orm 2.99. (,) S!a!u" repor!". $roviderDprofessional status changes using && <orm 2.99 3ill be reported to the 12A#@&!'# (#!9'-!;-")D12A&@/!'# (#!&2) 3ith copy furnished to the ne6t higher head(uarters. Reports 3ill be submitted every ,0 days until final action has been completed and so indicated on the final && <orm 2.99. (.) %e n"!a!emen! o- &l n &al pr / lege"7pra&! &e. Hhen the #T< commander approves total or partial restoration of clinical privilegesDpractice that had previously been removed && <orm 2.99 3ill be submitted to 12A#@&!'# (#!9'-!;-") 3ith copy furnished to the ne6t higher head(uarters. (*) #dm n "!ra! /e or 2ud & al a&! on a--e&! ng pr / lege"7pra&! &e. %f an individual is the sub7ect of an administrative or 7udicial action (for e6ample a courtEmartial) a && <orm 2.99 3ill be submitted reflecting the modified status of the individual8s privileges. &. %n the event of a suspension restriction reduction revocation or denial of clinical privileges for a military provider 3ith permission to engage in remunerative professional employment at a civilian medicalDdental healthcare institution the civilian employer 3ill be notified of adverse privileging actions as they occur by the #T< commander.

AR 4068 0 6 !ebruary 0041RAR

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The same re(uirement to report applies to nonmilitary providers 3or5ing at civilian facilities. This is the only e6ception to T20 as the informationEreleasing authority. 505<2 Reporta,le acts o' unpro'essional conduct a. 9ealthcare providers 3ho are involved in any of the unprofessional actsDactivities listed in appendi6 % or similarly unprofessional actions 3ill be evaluated by the credentials committee (by the peer revie3 panel and departmentDservice chief for nonprivileged) and appropriate adverse privileging or practice recommendations 3ill be made to the commander. Although the credentials committee is not a criminal investigative body it can and 3ill consider all evidence from such investigations in its deliberations. Hhenever a reportable activity is identified a && <orm 2.99 3ill be submitted (see para +0-+.b) noting any adverse privilegingDpractice actions that have been ta5en. b. An unprofessional act is deemed to have LoccurredM 3hen the individual is indicted or titled for an offense (if applicable) or after completion of applicable investigative proceedings and command action. The commander 3ill notify any civilian facilities in 3hich the individual is engaged in offEduty healthEcareErelated employment of the aforementioned. (2ee para +0-*e.) c. A && <orm 2.99 3ill be submitted on privileged providers and other nonprivileged healthcare personnel 3hether licensed or pending licensure 3ho are convicted plead guilty plead nolo contendere receive a discharge in lieu of courtsEmartial receive a discharge in lieu of criminal investigation or a less than honorable discharge for unprofessional conduct. Reporting 3ill occur 3ithin C days of the date that formal charges 3ere filed or the date of discharge 3hichever comes first. 50562 -SAR;AR.@ provider;pro'essional adverse privileging;practice actions a. 12ARDAR/0 providersDprofessionals are sub7ect to denial suspension restriction reduction or revocation of clinical privilegesDpractice according to paragraph +0-.b. b. %f a military agency initiated the adverse privilegingDpractice action that agency 3ill for3ard the && <orm 2.99 to !ommander 12A#@&!'# ATT/F #!9'-!;-" 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0 or !ommander 12A&@/!'# ATT/F #!&2 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)00. 3ith copy furnished to the R#! or ne6t higher head(uarters as appropriate. The 12A#@&!'# 3ill notify the appropriate regulatory authorities medical commands and the ma7or Army commands to 3hich the individual is assigned. %nitiation of adverse privilegingDpractice actions 3ill be based on individual unit assignmentDattachment and type of training as follo3sG (+) <or all 12ARDAR/0 members performing duty (regardless of type) in an #T< the commander of that facility 3ill initiate the actions. (2) <or Active 0uard Reserve members not assigned to a T$1 the actions 3ill be initiated by the commander of the unit to 3hich they are assigned or attached. 'ther Active 0uard Reserve members are covered by the provisions of subparagraph ()) or (C) belo3. (,) <or %#A members the commander of the unit to 3hich they are assigned 3ill initiate the actions. (.) <or %RR members not attached to a unit and assigned to the 9R! (not performing duty) the 9R! commander 3ill initiate the actions. (*) <or %RR members attached to or performing duty at a T$1 if the individual is in a medical unit the actions 3ill be initiated by the unit commander. %f the individual is not in a medical unit the ne6t higher medical command or the command having medical authority 3ill initiate the actions. ()) <or AR/0 members assigned to a medical unit the unit commander 3ill initiate the action. %f the individual is not assigned to a medical unit the 2tate 2urgeon or ne6t higher command having a medical authority 3ill initiate the action. (C) <or 12AR members assigned or attached to a medical T$1 the unit commander 3ill initiate the actions. %f the individual is not assigned to a medical T$1 the ne6t higher command having medical authority 3ill initiate the actions. &. <or purposes of initiating adverse privilegingDpractice actions processing appeals and other appropriate follo3up action if the ne6t level of command is not a medical unit (or is a medical unit 3ithout sufficient medical assets assigned to convene the re(uired committees) the higher commander having a medical authority 3ill direct the appropriate assets from 3ithin hisDher command to provide the necessary support. d. Hhen the 12A#@&!'# is notified by a regulatory authority to include the <ederation of 2tate #edical ?oards or other sources that an action 3as ta5en against an 12ARDAR/0 member the 12A#@&!'# (#!9'-!;-") 3ill automatically notify the individual8s unit of assignmentDattachment. Additionally the /ational 0uard ?ureau 12AR! andDor 9R! 3ill be notified of adverse privilegingDpractice information relevant to their assigned personnel. %nformation from the regulatory authorities 3ill be provided to the appropriate commands for revie3 and action according to chapter +. of this regulation andDor AR +,*-+C* if appropriate. e. A 12ARDAR/0 providerDprofessional 3ill be considered for reclassification branch transfer or separation if an adverse privilegingDpractice action 3as ta5en 3hich resulted in a permanent restriction or revocation of clinical

AR 4068 0 6 !ebruary 004

8.

privilegesDscope of practice. 12ARDAR/0 commanders 3ill revie3 such assigned members and recommend disposi tion according to appropriate regulations dependent upon the nature and merit of each case. -. 9earing rights and the appeals process 3ill be as described in paragraphs +0-> and +0-+0. T20 is the final appeal authority.

84

AR 4068 0 6 !ebruary 004

(34ALT3 5AR4 !A5*L*T6 Letterhead) 7!!*54 86297L (640:%0e) (#ate)

2427RA(#;2 !7R ((ame, <rade, and Address o= >ro)ider1 >ro=essional) 8;9,45T? (oti$e o= Abeyan$e (8ummary 8uspension) o= 5lini$al >ri)ileges1>ra$ti$e

+. 4==e$ti)e immediately (all) (a portion) o= your $lini$al pri)ileges1pra$ti$e at (in$lude =a$ility name and lo$ation) ha)e been (pla$ed in abeyan$e) (summarily suspended)" This a$tion is being ta@en as a result o= (state the spe$i=i$1alleged de=i$ien$ies in)ol)ed, and the s$ope o= the a$tion being ta@en" *n$lude the spe$i=i$ pri)ileges1s$ope o= pra$ti$e that are1is e==e$ted and /hat is eApe$ted o= the pro)ider1pro=essional in terms o= his1her $lini$al duties and responsibilities)" 2. The period o= (abeyan$e is =or a period o= (spe$i=y number) days (may not eA$eed .0) (summary suspension is inde=inite, pending $on$lusion o= due pro$ess pro$eedings, as appropriate, asso$iated /ith this a$tion)" A$tion related to your $lini$al pri)ileges1pra$ti$e and sta== appointment, i= /arranted, /ill be initiated by the $redentials $ommittee at its meeting s$heduled =or (date)" 4)ery e==ort /ill be made to $on$lude the pro$eedings related to this matter in a timely manner" ,. An abeyan$e that is not $losed /ithin .0 days /ill automati$ally be$ome a summary suspension o= $lini$al pri)ileges" 8ummary suspension /ill be in e==e$t /hile due pro$ess pro$eedings are under/ay" 8ummary suspension in the #o# is not reportable" .. 6ou are hereby noti=ied that a $lini$al Buality management (5C2) Buality assuran$e (CA) in)estigation /ill be $ondu$ted $on$erning the allegations spe$i=ied abo)e in paragraph %" *=, based on this in)estigation, there is substantial $ause to pro$eed, a peer re)ie/ under the auspi$es o= the $redentials $ommittee (other $ommittee) /ill be $ondu$ted to $olle$t the ne$essary =a$ts bearing on this matter" 8hould a peer re)ie/ be /arranted, you /ill re$ei)e /ritten noti=i$ation o= su$h and instru$tions as to your rights and responsibilities related to the peer re)ie/ pro$ess as detailed in AR 40:68, $hapter %0" *. 8hould you ele$t to terminate your (military) (!ederal) ser)i$e prior to resolution o= these matters, your (abeyan$e) (summary suspension) /ill be$ome a suspension o= pri)ileges1pra$ti$e" This is $onsidered a =inal a$tion and a report to the (>#9 and1or other 8tate or regulatory agen$ies /ill be =iled"
+igure 50C5 (3A@0 5)2 Sample 'ormat 'or memorandum noti'ying provider o' an a,eyance or summary suspension

AR 40-68 D #6 +e,ruary #004

8<

+igure 505 (3A@0 #)2 Sample 'ormat 'or memorandum noti'ying provider o' an a,eyance or summary suspension6

Continued +igure 50#2 Sample 'ormat 'or provider memorandum ac?no=ledging noti'ication o' a,eyance;summary suspension

86

AR 4068 0 6 !ebruary 004

(34ALT3 5AR4 !A5*L*T6 Letterhead) 7!!*54 86297L (640:%0e) 2427RA(#;2 !7R? ((ame, <rade, and Address o= >ro)ider) 8;9,45T? >ro)ider1>ro=essional (oti=i$ation o= >eer Re)ie/ (#ate)

+. This is to in=orm you that on (date), the ($redentials $ommittee) (a $redentials hearing board or other $ommittee) /ill $ondu$t a peer re)ie/ to e)aluate your per=orman$e, $ondu$t, or $ondition that /as the subDe$t o= a re$ent 5C2 CA in)estigation" This $ommittee /ill re)ie/ the nature o= the $ir$umstan$es surrounding the e)ents in Buestion, determine the )alidity o= any allegations, and ma@e re$ommendation to the $ommander, as appropriate" The peer re)ie/ may ad)ersely a==e$t your $lini$al pri)ileges1pra$ti$e" 6our sta== appointment, as appropriate, may li@e/ise be a==e$ted" 2. The allegations to be re)ie/ed are (state the nature o= the allegations $onstituting the grounds =or the peer re)ie/ in su==i$ient detail" *n$lude the date, identity, and lo$ation o= the re$ord(s) o= all a$ti)ities or the $ases that are in)ol)ed in the allegations, so that the indi)idual /ill be =ully apprised o= the matters to be $onsidered during the peer re)ie/") ,. The peer re)ie/ /ill be $ondu$ted at (hour) on (date) at (lo$ation) (/ithin %4 $alendar days o= noti$e to indi)idual)" Ehile you do not ha)e the right to be present during the pro$eedings, you may present a /ritten statement regarding the e)ents under re)ie/" *n addition, you may be reBuired to appear be=ore the peer re)ie/ panel to ma@e a )erbal statement, to $lari=y issues as needed, to as@ Buestions, and to respond to Buestions o= the panel" .. 6ou are en$ouraged to see@ legal $ounsel at any step in the ad)erse pri)ileging1pra$ti$e a$tion pro$ess" 3o/e)er, the peer re)ie/ is not a legal pro$eeding, and a la/yer is not permitted to a$ti)ely parti$ipate during the peer re)ie/" (As a $i)ilian employee, you may be entitled to bargaining unit representation") *. A point o= $onta$t =or you as you prepare =or the peer re)ie/ pro$ess is (state >75 name, address, telephone, and =a$simile numbers)" 3e1she is a)ailable to assist you and to a$$ept any =orth$oming /ritten $orresponden$e =rom third party sour$es or any additional in=ormation that you may /ish to pro)ide" ). 8hould you ha)e any Buestions, or need =urther guidan$e, you may a$$ess AR 40:68, 5lini$al Cuality 2anagement, in the (o==i$e o= the 5redentials 2anager) (other lo$ation)" ((ote any other lo$al re=eren$es that may be use=ul to the pro)ider")
+igure 50C8 (3A@0 5)2 Sample 'ormat 'or memorandum noti'ying provider;pro'essional o' a 'ort(coming peer revie=

AR 40-68 D #6 !ebruary 004

8'

+igure 508 (3A@0 #)2 Sample 'ormat 'or memorandum noti'ying provider;pro'essional o' a 'ort(coming peer revie=6

Continued

88

AR 4068 0 6 !ebruary 004

(34ALT3 5AR4 !A5*L*T6 Letterhead) 8? (8uspense date) 7!!*54 86297L (640:%0e) 2427RA(#;2 !7R ((ame, <rade, and Address o= *ndi)idual) 8;9,45T? (oti$e o= >roposed Ad)erse 5lini$al >ri)ileging1 >ra$ti$e A$tion by the 5ommander +. 6ou are hereby noti=ied o= my de$ision to (state ad)erse pri)ileging1pra$ti$e a$tion proposed) your $lini$al pri)ileges1pra$ti$e at (!A5*L*T6? 8tate name and lo$ation)" 4==e$ti)e (date) your $lini$al pri)ileges1pra$ti$e /ill be (state limitation) =or improper (state spe$i=i$ally the per=orman$e, $ondu$t, beha)ior under re)ie/ and the rationale =or the a$tion addressing all allegations)" The period o= this ad)erse pri)ileging1pra$ti$e a$tion is to be (inde=inite) (temporary, =or a period o= (state number o= days), =rom (date) to (date))" 2. 2y de$ision is based upon re$ommendations =rom the ($redentials1other $ommittee) that met (date) to re)ie/ all the =a$ts and e)iden$e pertinent to the 5C2 CA in)estigation and peer re)ie/ that /ere $ondu$ted" As a result, (must spe$i=y /hat pri)ileges1pra$ti$e are a==e$ted and /hat is eApe$ted as =ar as the pro)iderFs $lini$al duties and responsibilities)" ,. *n addition to this proposed ad)erse a$tion related to your $lini$al pri)ileges, your sta== appointment to this =a$ility (/ill) (/ill not) be a==e$ted" ((ote proposed $hange to appointment status, as appropriate") .. 6ou are ad)ised that you ha)e the right, upon reBuest, to ha)e the $redentials hearing board $ondu$t a hearing to re)ie/ this a$tion $on$erning your pri)ileges" The hearing pro$edures and your hearing rights are detailed in AR 40:68, $hapter %0" *. *n order =or this hearing to be $ondu$ted, you must ma@e a /ritten reBuest =or su$h to the $hairperson o= the $redentials $ommittee /ithin %0 duty days =rom the date you re$ei)e this noti$e" *= you =ail to ma@e the reBuest /ithin that time =rame, or i= you =ail to appear at the s$heduled hearing, you /ai)e your right to the hearing and also /ai)e your right to appeal to higher medi$al or dental authority"
+igure 50C4 (3A@0 5)2 Sample 'ormat 'or memorandum noti'ying provider o' a proposed adverse privileging;practice action

(#ate)

AR 40-68 D #6 !ebruary 004

8&

+igure 504 (3A@0 #)2 Sample 'ormat 'or memorandum noti'ying provider o' a proposed adverse privileging;practice action6

Continued

+igure 50<2 Sample 'ormat 'or provider memorandum ac?no=ledging noti'ication o' proposed adverse privileging;practice action

&0

AR 4068 0 6 !ebruary 004

(34ALT3 5AR4 !A5*L*T6 Letterhead) 8? (8uspense date) 7!!*54 86297L (640:%0e) (#ate)

2427RA(#;2 !7R ((ame, <rade, and Address o= *ndi)idual) 8;9,45T? >ro)ider1 >ro=essional (oti=i$ation o= 5redentials 5ommittee17ther 5ommittee 3earing %" (The $redentials $ommittee) (a $redentials hearing1other $ommittee) /ill $ondu$t a hearing, at your reBuest, $on$erning allegations that may ad)ersely a==e$t your $lini$al pri)ileges1pra$ti$e" 6our sta== appointment, as appropriate, may li@e/ise be a==e$ted" " The allegations to be re)ie/ed are (state the nature o= the allegations $onstituting the grounds =or the hearing in su==i$ient detail" *n$lude the date, identity, and lo$ation o= the re$ord o= a$ti)ities or the $ases that are in)ol)ed in the allegations, so that the pro)ider1pro=essional /ill be =ully appraised o= the matters under in)estigation") ." The $ommittee /ill hold the hearing at (hour) on (date) at (lo$ation)" 6ou ha)e the right to be present, to present e)iden$e and $all /itnesses in your behal=, to $ross:eAamine /itnesses $alled by the $ommittee, to $onsult legal $ounsel, and to be ad)ised by legal $ounsel at the hearing" *t is your responsibility to arrange =or the presen$e o= any /itnesses you desire" 6ou may $onta$t the 7==i$e o= the 8ta== ,udge Ad)o$ate =or legal ad)i$e" Legal representation in this matter is not an entitlement, but may be pro)ided subDe$t to resour$e limitations as determined by the appropriate super)isory ,udge Ad)o$ate" 6ou may retain a $i)ilian attorney at your o/n eApense" a. !ailure to appear at the hearing /ill $onstitute a /ai)er o= the rights listed here and your right to appeal" b. ;pon your /ritten reBuest, the time and pla$e o= the hearing may be $hanged by the $hairperson o= the hearing board be=ore the indi$ated suspense date, i= your reBuest is based on good $ause" i= any") c. The hearing board /ill $all the =ollo/ing /itnesses? (list o= /itnesses,

4" Any $losed (not pending re$onsideration or appeal) ad)erse $lini$al pri)ileging1pra$ti$e a$tion /ill be reported to the (>#9 and to other 8tate or regulatory agen$ies, as appropriate"
+igure 50C6 (3A@0 5)2 Sample 'ormat 'or memorandum noti'ying provider;pro'essional o' credentials;ot(er ,oard (earing

AR 40C68 D #6 +e,ruary #004

$5

+igure 506 (3A@0 #)2 Sample 'ormat 'or memorandum noti'ying provider;pro'essional o' credentials;ot(er ,oard (earing6

Continued

+igure 50>2 Sample 'ormat 'or provider memorandum ac?no=ledging noti'ication o' credentials;ot(er ,oard (earing

&

AR 4068 0 6 !ebruary 004

+igure 5082 Sample 'ormat 'or memorandum noti'ying provider o' (earing ,oard 'indings;recommendations

AR 4068 0 6 !ebruary 004

&.

+igure 50$2 Sample 'ormat 'or provider memorandum ac?no=ledging receipt o' (earing ,oard 'indings;recommendations

C(apter 55 Managing Military 7reatment +acility 3ersonnel =it( mpairments

5552 @eneral 9ealth statusGto include the physical and emotional 3ellEbeing of individuals providing care and other services to patientsGis an important consideration in the ongoing assessment of professional competence and performance. This chapter establishes policies and procedures for healthEfocused assessment and support activities provided by the #T< for its assigned personnel. The follo3ing guidance applies to #T< employeesGboth military and civilian (02 and personal services contract)Gor employees 3ho function in an administrative or ancillary services support capacity. 55#2 7(e mpaired %ealt(care 3ersonnel 3rogram a. @ach facility 3ill establish an %mpaired healthcare $ersonnel $rogram (%9!$$) or comparably titled program to address the multidisciplinary needs of its military and civilian healthcare personnel 3ith physical limitations emotional or psychiatric conditions or alcoholDother drug abuse problemsDdependency. These limitations or conditions result in social or occupational dysfunction of the individual in (uestion or place the patient or others at ris5. The program 3ill meet all the provisions of AR )00->*. (2ee &A $am )00->* for additional instruction and procedural guidance.) #edical and dental facilities that are coElocated are encouraged to develop a single program that includes all eligible #T< participants. b. The %9!$$ is designed to provide support assistance and rehabilitation to those healthcare personnel 3ho suffer from a condition that negatively influences or has the potential to negatively influence optimal performance. <or purposes of this chapter the term LimpairmentM applies to the manifestations of emotional or psychological conditions and alcohol or other drug useDabuse problemsDdependency. $hysical limitations are considered impairments 3hen the individual8s physical condition places the safety of patients or others in 7eopardy. These medical problems may be associated 3ith alcohol or other drug useDabuse a coEe6isting emotionalDpsychological disorder or there may be physical conditions that the individual is un3illing to ac5no3ledge or for 3hich treatment is refused. c. The ob7ectives of the %9!$$ are toG (+) $romote the 3ellEbeing of healthcare personnel through education and minimi4e factors that contribute to impairment associated 3ith alcohol and other drug useDabuse.

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AR 4068 0 6 !ebruary 004

personnel 3ith an identified impairment. (.) $rovide a mechanism for treatment or other appropriate remedial actions and subse(uent return to clinical practice (3hen feasible) for impaired personnel 3ho have been successfully rehabilitated. (*) $rovide a mechanism for ongoing monitoring of rehabilitated personnel. ()) $rovide a mechanism for ensuring compliance 3ith &'&& ).90.+ 3hen a mental status evaluation is recommended. d. Key participants in the process of identification treatment and the successful rehabilitation of healthcare personnel 3ith an impairment include the R#!D#T< commander the %9!$$ members alcohol and other drug rehabilitation counselors medical resource personnel supportive <amilyDfriends and the individual confronting and attempting to effectively deal 3ith hisDher impairment. 5582 7(e composition* role* and 'unction o' t(e impaired (ealt(care personnel ad (oc committee The %9!$! or comparably titled committee as a formal committee or subcommittee of another body (for e6ample credentials committee) serves to ensure effective assistance and rehabilitation and to aid the employee in retaining or regaining optimal professional functioning. %n addition the %9!$! facilitates implementation of the guidelines set forth in AR )00->* in a healthcare setting. This committee is charged 3ith the identification treatment and return to service of healthcare personnel 3ith alcoholDother drug problemsDdependency and medical psychiatric or emotional conditions. a. The committee members 3ill be designated by the commander and should 3hen possible include at leastG (+) The alcoholDother drug abuse clinical director andDor the clinical consultant. (2) Representatives from the departments of psychiatry and nursing (a !/2 if available). (,) A recovering impaired staff member of comparable position 3ith at least 2 years in recovery if available. b. The %9!$! chairperson 3ill ensure that all assigned members receive an orientation to the duties and responsibil E ities of this committee. &. The %9!$! 3ill meet as needed to accomplish the follo3ing functionsF (+) Recommend to the #T< commander a plan for management of healthcare personnel impaired by alcoholDother drug abuseDdependence as 3ell as psychiatric problems including emotional and behavioral disorders. (a) &esign a staff development plan that incorporates elements of impairment prevention education about healthcare personnel impairment and 3ellEbeing issues. (b) Recommend facilityEspecific procedures for management of %9!$s. Recommendations 3ill be consistent 3ith all re(uirements contained in both &'&& ).90.+ and &'&% ).90.. 3hen a mental status evaluation is considered for a healthcare provider regardless of the reason for the evaluation. (c) @valuate any healthcare staff member reported or self referred for alcoholDother drug abuseDdependence for evidence of impairment. (d) Recommend restrictions on the clinical privilegesDpractice of %9!$s. Recommendations for privileged providers 3ill be for3arded through the credentials committee and the @!#2D@!&2 to the commander. Recommendations for all others 3ill be provided through the individual8s department chief to the commander 3ith copy furnished to the credentials committee. Recommendations are routed throughDto the credentials committee to ensure the committee is a3are of all staff members 3ith an identified impairment. $eriodic status reports on #T< staff being follo3ed by the %9!$$ may be submitted to the commander. (e) #onitor the progress of impaired individuals during treatment through aftercare until the completion of the ongoing monitoring phase. (f) Recommend an individuali4ed plan for the gradual return to full clinical practice for each impaired staff member 3ho has completed treatment. <or privileged providers 3ho are retiring or separating from <ederal service 3hile still enrolled in an %9!$$ the %9!$! 3ill address 3hether to recommend full reinstatement of privileges or continuation of the monitored status by the 2tate licensing board. (2) Hhen an impaired staff member from a particular department is discussed the department chief may be re(uested to attend the meeting if this direct participation is deemed beneficial to the individual in (uestion. 'neEonE one coordination as re(uired may also occur bet3een %9!$! chairperson or committee member and the appropriate department chief. (,) Hhen impairment is due to alcohol or other drugs the %9!$! 3ill revie3 input from the alcoholDother drug abuse clinical staff the duty supervisor and the involved healthcare staff member8s department chief as appropriate. (.) %n cases of medical or psychiatric impairment the %9!$! 3ill revie3 statements of progress and recommendations from the impaired individual8s physician and duty supervisor and recommend appropriate actions. (*) %f as the result of a physical conditionDdisorderDproblem an #@? recommendation results in a duty limitation or recommendation for separation from service the #@? ruling 3ill be revie3ed for its impact on the individual8s

(2) %dentify impairment of healthcare personnel as early as possible in order to promote recovery and ensure $2. (,) $rovide a mechanism for appropriately limiting the clinical practice of privileged or nonprivileged healthcare

AR 4068 0 6 !ebruary 004

&+

privileges or scope of practice. %f the provider is unable to fully perform hisDher granted privileges or scope of practice appropriate modification of the individual8s privilegesDscope of practice 3ill be recommended to the commander. 5542 Management o' (ealt(care personnel impaired ,y medical* psyc(iatric* or emotional pro,lems Any staff member involved in the delivery of healthcare (medical or dental) 3ho is 5no3n or suspected of having an acute or chronic medical psychiatric or emotional problem that impairs (or could potentially impair) clinical perform E ance 3ill be reported to the %9!$!. ;i5e3ise any staff member 3ho recogni4es that a potentialDactual problem e6ists may selfEreport. a. The commandEdirected mental health evaluation is an evaluation directed by a 2oldier8s commander as an e6ercise of the commander8s discretionary authority. (+) The re(uirements restrictions and specific procedures associated 3ith this type of evaluation are addressed in &'&& ).90.+ &'&% ).90.. and current 12A#@&!'# (#!9'-!;-9) guidance. (2) The #T< commander 3ill ensure that fully trained personnel and the necessary safeguards and performance revie3 processes in support of the above mentioned guidance are in place 3ithin hisDher organi4ation. b. The %9!$! 3ill re(uest the follo3ingF (+) A statement of diagnosis prognosis and implications for clinical performance from a physician (preferably the primary physician treating the providerDprofessional). A mental health evaluation should be included in the assessment of the health status of %9!$ as appropriate. (2) A statement concerning current clinical performance from at least one immediate supervisor or professional peer. The statement must focus on ho3 the medical or psychological condition reduces or prevents the individual8s ability to safely e6ecute hisDher responsibilities in providing or supervising the delivery of healthcare. Any recogni4ed deficits in medical 5no3ledge technical ability performance or 7udgment associated 3ith the identified medical or psychological condition should also be addressed. (,) Recommendations from the departmentDservice chief regarding the impaired staff member8s scope of clinical privilegesDpractice. These may be provided directly to the %9!$! or through other locally established channels (for e6ample via the credentials committee). The providerDprofessional in (uestion may be actively involved in the process of revie3 and recommendations for modification if 3arranted of hisDher clinical privilegesDscope of practice. &epart E mentDservice chief recommendations must ta5e into consideration the best interest of (uality care and $2. &. The %9!$! 3ill revie3 the information in paragraph b above and recommend modifications to clinical privileges or practice as necessary. %f the impaired staff member has privileges these recommendations 3ill be submitted through the #T< credentials committee and @!#2D@!&2 to the commander. 'ther3ise the recommenda E tions 3ill be made through the department chief to the commander. The voluntary modification of clinical privileges or practice as a result of medical or behavioral health related problems is not to be construed as an adverse privilegingD practice action. %f due to other e6tenuating circumstances the commander decides to invo5e an adverse privilegingD practice action notification of this action 3ill be made according to paragraph +0-) -(C). d. !urrent status reports from the individual8s attending physician and hisDher clinical supervisor (or a designated professional peer) 3ill be re(uired for the individual 3ith a chronic or debilitating disease. These reports are re(uired at the time of privilege reappraisal and rene3alDperformance evaluation or if a change occurs in the health of the impaired staff member. <or privileged providers these reports 3ill be maintained in the $A<. 'ther3ise the reports 3ill be maintained in a confidential temporary "A file (see app ?) that 3ill be destroyed 3hen the staff member is successfully returned to full clinical practice. %f a $!2 occurs prior to the return to full practice this "A file and all supporting documentation 3ill be for3arded to the gaining facility in the same manner as the $!< (by certified return receipt re(uested mail). %n addition the credentials coordinator at the gaining #T< 3ill be telephonically notified that an impaired healthcare individual is being transferred to the facility. e. 1pon report of the staff member8s recovery separation or retirement from <ederal service the %9!$! 3ill again re(uest and revie3 statements from the attending physician at least one immediate supervisor or a professional peer and the departmentDservice chief. (+) ?ased on the above feedbac5 the committee 3ill ma5e recommendations through the credentials committee and @!#2D@!&2 to the commander regarding the removal of limitations on clinical practice. %f the recommendation is to remove the limitation(s) the committee may recommend an appropriate follo3up period of monitoring. (2) <or those %9!$s separating or retiring from service due to a medical or psychological condition the committee 3ill ma5e a recommendation regarding the need to continue in a monitored status versus a return to full privilegesD practice 3ithout monitoring. %f continued monitoring is recommended the staff member 3ill be reported on && <orm 2.99 to 12A#@&!'# (#!9'-!;-") 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0. (,) The 12A#@&!'# "#& 3ill report these %9!$s to appropriate licensing authorities. Any privileged provider 3ho fails to complete the rehabilitation program in 3hich heDshe is enrolled 3ill be reported to the /$&?. 55<2 Management o' (ealt(care personnel impaired ,y alco(ol;ot(er drug a,use;dependence a. #bu"e and dependen&e. AlcoholDother drug abuseDdependence as described in the current &iagnostic and 2tatistical #anual of #ental &isorders may lead to impairment and the subse(uent need for rehabilitation.

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AR 4068 0 6 !ebruary 0041RAR

2ay 00&

b. %epor! ng o- mpa red per"onnel. All healthcare personnel (military and civilian) 5no3n or suspected of having an alcoholDother drug abuseDdependence problem 3ill be reported or may selfEreport to the %9!$!. c. *rug and al&ohol rehab l !a! on program &omponen!". The provisions of AR )00->* apply fully to healthcare personnel impaired by alcoholDother drug abuseDdependence. The eight program components related to management of the individual 3ith this type impairment includeF prevention caseEfinding intervention treatment aftercare reEentry ongoing monitoring and program termination. (+) 5re/en! on. (a, ?ecause healthcare personnel 3or5 in a milieu that is often highly stressful overuse of alcohol by some may be problematic. ;i5e3ise ready access to habitEforming drugs presents an enticement that may lead to misuseDabuse. All #T<s 3ill develop a prevention and identification plan in con7unction 3ith the alcoholDother drug abuse clinical director. The plan 3ill incorporate elements of alcohol and drug deglamori4ation 3idespread publicity education and various "A activities to identify staff member performance or behavior that is substandard or that has deteriorated over time. +. @ducational programs 3ill place special emphasis on the susceptibility to drug abuse for those 3or5ing 3ith pharmaceuticals of addictive potential. %n addition all #T<s 3ill have in place standardi4ed policies and procedures for storing handling dispensing and accounting for controlled drugs throughout the organi4ation (that is parent unit and outlying clinics). These policies and procedures 3ill be revie3ed periodically and 3ill comply 3ith all applicable 1.2. Army and TJ! standards. 2. Hhen drug diverting or illegal use has occurred this general problem 3ill be addressed 3ithin the #T< !"# structure. ;essons learned that may benefit others 3ill be for3arded through the ne6t higher head(uarters to 12A#@&!'# (#!9'-!;-") 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0. (%t should be noted that drug diversion and abuse is criminal misconduct and la3 enforcement involvement is appropriate.) (b, All healthcare providersGespecially those in psychiatry <amily practice primary healthcare and emergency medicineG3ill be educated in all aspects of alcoholDother drug abuseDdependence as part of an ongoing educational program. All personnel 3ith patient care contact should 3hen feasible participate in a didactic and e6periential orientation at a residential treatment facility (RT<). (&, <ormal educational programs for #T< healthcare personnel 3ill emphasi4eG +. The vulnerability of healthcare personnel to alcoholDother drug abuseDdependence despite their bac5grounds education training and e6perience. 2. The importance of healthy coping mechanisms in dealing 3ith the stresses that often contribute to the develop ment of alcoholDother drug abuseDdependence among healthcare personnel. ,. The R# and $2 implications of providing or supervising patient care 3hile impaired. .. The impact on decisionEma5ing s5ills and the ris5s associated 3ith the use and misuse of alcohol andDor other drugs. *. The role of denial relative to alcoholDother drug abuseDdependence and that this is compounded by the silence of colleagues supervisors and even patients. ). The early behavioral and 7obErelated performance indicators of alcoholDother drug abuseDdependence. C. The principles of effective intervention and the various treatment programs available to %9!$ and their <amilies. >. The responsibility of peers and supervisors to report the individual 3ho abuses or is dependent on alcohol or other drugs to the %9!$!. 9. The specific procedures for selfEreferral according to local policy. +0. The threat to the career health and life if the impairment is allo3ed to continue. ++. The statistics related to effective treatment and successful return to full clinical practice especially 3hen abuseD dependence is identified early. (d, @ncourage %9!$s 3ho have been through treatment and have been in recovery for at least + year to volunteer as resource personnel to assist in teaching or conducting educational programs. (e, #echanisms to solicit employee feedbac5 concerning recogni4edDperceived staff problems 3ith alcohol or other drugs should be considered. Revie3 of specific unit policies or stressful 3or5 environments that may be contributing to the use of alcohol or other drugs by #T< staff is appropriate. (2) Ca"e<- nd ng. Techni(ues such as anonymous employee surveys and %0 sensing sessions may help identify personnel 3ith real or potential problems. #anagement must be sensitive to the signs and symptoms of alcoholDother drug abuseDdependence in order to facilitate early recognition and ultimate treatment of such problems. A change in a staff members8 clinical performance and behavior as noted by the clinical supervisor may be among the first signs of an impending problem. (a, All #T< personnel are re(uired to notify the %9!$! (or the &!!2 if this is more practical) of individuals (including contract personnel) 3hose clinical practice is impaired. This notification may be either verbal or in 3riting. An open door policy on the part of the %9!$! 3ill encourage selfEreferral as 3ell as identification of suspected or potential impairment. /onEpersonal services contract personnel 3ill be brought to the attention of the contracting agency for management and appropriate follo3up according to 2tate licensing board re(uirements. All 3ho are

AR 4068 0 6 !ebruary 004

&'

involved 3ith healthcare personnel 3ho are either being evaluated for or 3ho have been determined to have an impairment must be mindful of the confidentiality of information shared in the conte6t of the %9!$$ and the individual in (uestion8s right to privacy. /o disciplinary action punishment or any form of retaliatory action 3ill be ta5en against a person 3ho submits information concerning an impaired providerDprofessional unless it is later determined that the information 3as false and the individual providing the information acted maliciously. (b) The department chief 3ill revie3 the report and inform the committee 3hether monitoring or confrontation 3ill be employed. %n either case the alcohol and drug abuse clinical director 3ill be notified and heDshe 3ill be involved in the process. (c) <or civilian staff in addition to the A2A$ clinic civilian program coordinator the managementEemployee relations representative from the servicing !$'!D!$A! and the bargaining unit (union) representative 3ill be informed. !oordination to ensure the appropriate management of this sensitive situation is essential. (d) 'ne of the follo3ing courses of action 3ill be ta5en if performance does not meet the supervisor8s e6pectations as a result of actual (or suspected) alcoholDother drug abuseDdependenceF +. 'on !or ng or enhan&ed "uper/ " on. This action is used only 3hen there is no clear evidence 3ith 3hich to confront potential impairment. %f monitoring or enhanced supervision is the course of action selected a memorandum for record describing the circumstances and specifying the type of monitoring to be conducted 3ill be for3arded to the %9!$!. 2. Con-ron!a! on. This course of action is recommended if evidence of impairment e6ists. The supervisor 3ill present the ob7ective documented evidence of the staff member8s deteriorating 7ob performance. The supervisor 3ill not discuss any suspicion of alcoholDother drug abuse but 3ill focus only on the deteriorating 7ob performance. The supervisor should offer assistance for any problem that may be contributing to the deteriorating 7ob performance. %t is also appropriate to advise the staff member that heDshe 3ill be referred to another professional (for e6ample a mental health professional an addiction specialist or an employee assistance specialist) for supportDassistance and to the A2A$ clinic or other appropriate service for a full evaluation. The supervisor must not attempt to diagnose the problem but should outline hisDher e6pectations relative to acceptable future employee performance. The potential conse(uences to the employee if heDshe fails to meet these e6pectations should be stressed. A memorandum for record 3ill be for3arded to the %9!$! describing the evidence presented in the confrontation the stated future e6pectations and the staff member8s response. 1nder no circumstance 3ill a staff member be (uestioned about hisDher impairment or the cause thereof 3ithout appropriate legal advice concerning the staff member8s Article ,+ 1!#J andDor other employee rights as appropriate. (,) 0n!er/en! on. (a, %ntervention involves confrontation as a first step to3ard the %9!$ entering treatment. %ntervention is used 3hen the behavior that impairs (or potentially impairs) clinical performance is clearly related to alcoholDother drug abuseD dependence. Hhen intervention is electedG +. The alcoholDother drug abuse clinical director 3ill be notified so that the therapist can provide consultation and assistance. The alcoholDother drug abuse clinical staff 3ill process enrollment and admission to an appropriate treatment program if appropriate. 2. A medical evaluation is necessary prior to admission to any inpatient or partial treatment program. The medical staff 3ill develop criteria and include these criteria in their byla3s for determining 3hen a medical evaluation is re(uired for referral to outpatient and all other treatment programs. ,. The #T< commander 3ill initiate direct enrollment of an AA 2oldier into a treatment program if participation on the part of the involved individual is not voluntary. %f the impaired staff member is a civilian employee the civilian program coordinator of the alcoholDother drug abuse clinical program the managementEemployee relations representative from the servicing !$'!D!$A! and the bargaining unit (union) representative 3ill be notified prior to the intervention. !oordination to ensure the appropriate management of this sensitive situation is essential. !onse(uences to the civilian or military member for refusal to enter treatment 3ill be determined in advance and the employee so advised. .. 12ARDAR/0 healthcare personnel identified by virtue of urinalysis blood alcohol level direct observation alcohol breath analysis device or 7ob performance 3ill be counseled according to AR )00->*. A counseling statement 3hich includes the follo3ingF L$ursuant to AR ,.0-2+ chapter , % hereby consent to release of information by the Army concerning my alcoholDdrug abuse to the 2tateEcertified ArmyEapproved substance abuse counseling and treatment center of my choice. % further consent under applicable 2tate and <ederal la3 to the release of information concerning my treatment and rehabilitation by the substance counseling and treatment center to my commander.M 3ill be signed by the 2oldier involved. 2hould the individual elect not to sign the statement heDshe is sub7ect to immediate separation. (b, The clinical practice parameters of the impaired individual 3ill be revie3ed by the %9!$! in coordination 3ith the credentials committee 3hen appropriate. The impaired staff member 3ill be removed from direct patient contact if deemed necessary. %n an effort to be supportive of the impaired individual and to protect the safety of patients and the (uality of care provided decisions regarding professional privilegesDpractice must be made on a caseEbyEcase basis. %f a privileged provider is involved hisDher privileges may re(uire summary suspension (see para +0-) b) until the

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AR 4068 0 6 !ebruary 004

credentials committee determines that the problem has been resolved. %9!$s re(uiring inpatient treatment 3ill have their clinical privilegesDpractice reevaluated upon return to duty. (&, !are 3ill be ta5en to ensure that healthcare personnel 3ho have been confronted have an ade(uate support system regardless of 3hether the individual remains at home and receives treatment as an outpatient or is hospitali4ed. (.) Trea!men!. (a, 4eed -or !rea!men!. The need for treatment is based both on the type of drug and ho3 it is being used. Apart from the legal ramifications drug abuse can range from simple e6perimentation to psychological or physical depend ence. All identified abusers 3ill immediately be referred to the A2A$ clinic for evaluation. 12ARDAR/0 personnel 3ill see5 assistance from area civilian agencies or if eligible through the =A. Assessment of the need for treatment and the level of treatment 3ill be made by the A2A$ clinic staff independent of any administrative or legal concerns. (b, T$pe" o- !rea!men!. +. %npatient (residential) treatment of AA healthcare personnel 3ill be offered in an Army RT< if the individual has potential for retention on A&. Treatment may be offered through the =A if 2oldiers are separated from military service. 2. %f deto6ification is necessary it 3ill be accomplished per established local medical deto6ification protocols. ,. 'utpatient treatment and education 3ill be available from the alcoholDother drug abuse clinical staff to all military and civilian %9!$s. .. !ivilians may elect to be treated in civilian outpatient or residential programs through the <ederal @mployee8s 9ealth ?enefits $rogram other commercial insurance programs or 2tate board of licensing rehabilitation programs. *. 12ARDAR/0 personnel may elect to enroll or may be directed by their 2tate board of licensure to participate in a 2tate %9!$ treatment program. The program may be inpatient outpatient or residential. The 2tate board 3ill stipulate the parameters of the impaired individual8s practice. (&, Coord na! on o- !rea!men!. +. Treatment 3ill be coordinated by the alcoholDother drug abuse clinical staff for AA and civilian personnel. 12ARDAR/0 personnel 3ill comply 3ith the treatment plan established by their 2tate8s %9!$$. Activities 3ill be monitored and supported by a physician or other clinical staff members participating in the treatment plan. @very effort 3ill be made to ensure that the <amilies of %9!$s are included in the development and implementation of treatment plans. 2. Administrative or legal charges that may interfere 3ith treatment should be resolved prior to admission to an RT<. <or those 3ho do not enter an RT< and those a3aiting the decision of administrative or legal charges a binding outpatient treatment plan 3ill be developed according to the re(uirements in (*) belo3. (*) #-!er&are. Aftercare for AA personnel is the program of activities that ta5es place during the remainder of the +E year enrollment follo3ing residential or outpatient treatment. The program is designed to promote longEterm recovery. The aftercare plan 3ill be developed prior to discharge from the RT< or completion of an outpatient treatment program. The alcoholDother drug abuse therapist 3ill coordinate a rehabilitation team meeting as soon as the staff member returns to duty. The #T< commander supervisor involved staff member and %9!$! 3ill be provided a copy of the plan. The aftercare plan 3ill be binding and the conse(uences to the impaired staff member of not follo3ing the plan 3ill be clearly documented. (a, The aftercare plan 3ill include the provision that the impaired staff member demonstrates evidence ofG +. Attendance at Alcoholics Anonymous /arcotics Anonymous !ocaine Anonymous or other approved support group at least three times 3ee5ly. 2. Appropriate use of Antabuse if prescribed. ,. $articipation in the A2A$ groups educational classes and individual sessions as described in the aftercare plan. .. !ompliance 3ith random testing for illegal drug use. %9!$s 3ith problems involving illegal drug use 3ill submit to urine testing conducted by the installation biochemical testing coordinator. The samples 3ill be tested for the specific drug of abuse if possible. 2uch testing 3ill be performed 3ee5ly for the first ) months and t3ice a month for the ne6t ) months. %n the second year of aftercare the #T< commander in coordination 3ith the alcoholDother drug abuse staff 3ill ensure that monthly drug testing is accomplished. The test results 3ill be reported to the %9!$!. (b, @vidence of compliance 3ith the above re(uirements 3ill be submitted to the %9!$! monthly for the first year follo3ing entry into treatment and at least (uarterly for the second year. (&, %n the event of a relapse (return to alcohol or other drug use) the impaired staff member 3ill have hisDher clinical duties suspended immediately. A full reevaluation 3ill be made to include an assessment of progress to this point and the circumstances surrounding the individual8s relapse (that is precipitating factors and the staff member8s use of recovery coping s5ills). The report of assessment 3ill contain a recommendation for processing the staff member for release from <ederal service or for continued treatment. %f a second admission to an RT< is recommended approval must be granted by the commander according to established managed care criteria and policies. (d, Tours of duty for A& %9!$s 3ill be stabili4ed for at least +2 months from the date of admission to the RT< or initiation of outpatient treatment according to AR )+.-*. @6ceptions may be made by R#! commanders in cases 3here the community is lac5ing sufficient aftercare resources or levels of staffing are insufficient and replacement of

AR 4068 0 6 !ebruary 004

&&

the recovering provider is necessary to support the patient care mission. #a7or leadership positions and solo practices are to be avoided. %n these cases a re(uest for e6ception to policy 3ill be initiated to ensure the impaired professional is appropriately reassigned. (e) Routine re(uests by %9!$s for leave generally 3ill not be approved until )0 days after discharge from an RT< to allo3 time for transition into the aftercare phase of rehabilitation. (f) Aftercare for 12ARDAR/0 %9!$s participating in 2tate treatment programs 3ill be according to established guidelines of the specific 2tate treatment program. 2tate programs vary significantly and 12ARDAR/0 unit contact 3ith the individual agency 3ill be necessary to facilitate achievement of all associated program re(uirements. #ost 2tates re(uire that a contract of agreement to participate be signed by the impaired individual. This contract describes the sanctions that 3ill be imposed if the %9!$ is not compliant 3ith aftercare treatment e6pectations. +. The R! provider is re(uired to notify hisDher employer(s) of enrollment in a treatment program. This re(uirement includes notification of hisDher R! unit of assignmentDattachment. 2. A copy of the signed contract bet3een the impaired 12ARDAR/0 member and the civilian treatment facility 3ill be provided to the 12ARDAR/0 unit of assignmentDattachment. A $'! 3ill be identified on this document to facilitate future coordination bet3een the 12ARDAR/0 unit and the civilian agency. ,. 2pecific contractual re(uirements 3ill be noted and supported by the 12ARDAR/0 unit. .. !opies of progress reports from the coordinator of the treatment program 3ill be obtained and included in the $!<Dcase file for nonprivileged personnel. *. #ost contracts include as a minimumF attendance at or participation in A2A$ groups or meetingsA random unannounced urinalysis if applicableA restriction of healthcare personnel to the 2tate in 3hich treatment is being monitored unless prior 2tate approval is granted. ()) %e<en!r$. ReEentry refers to the return to duty and reEentry into clinical practice of recovering %9!$s. Reinstatement to full clinical practice 3ill normally be a gradual process. Return to full practice depends upon the circumstances of the individual case and the staff member8s response to treatment and aftercare. The commander ma5es reEentryEinto practice determinations based on recommendations from the %9!$! in coordination 3ith the credentials committee 3hen appropriate. The 12ARDAR/0 unit commander may designate a (ualified unit member 3ho is familiar 3ith the 2tate8s re(uirements related to healthcare personnel 3ith impairments to determine the appropriate level of return to practice of the impaired 12ARDAR/0 providerDprofessional. These recommendations are for3arded to the 12ARD AR/0 commander for hisDher decision. (a) The privileged healthcare provider 3ho has abused controlled drugs is generally restricted from prescribing or administering controlled drugs upon initial return to duty after treatment. (b) %f progress is satisfactory the healthcare staff member should eventually be returned to full clinical practice in the role previously held. The individual8s return to practice the capacity in 3hich practice 3ill resume and the specifics of the ongoing monitoring of practice must be determined on a caseEbyEcase basis. (c) %f in the opinion of the department chief the %9!$! credentials committees the involved therapists and the individual concerned a return to the previously held practice specialty is not appropriate a recommendation for change of A'!D#'2Dduty position 3ill be initiated. The appropriate corps chief is the final approval authority. <or civilian healthcare personnel coordination for a change in duty position 3ill occur among the #T< leadership the !$'!D !$A! representative the bargaining unit and the individual employee. (d) %n no case 3ill the recovering staff member participate as a spea5er for an #T< inEservice or other presentation on alcoholDother drug abuseDdependence during the first +2 months follo3ing the onset of treatment. (e) 12ARDAR/0 members 3ill be allo3ed to perform duty 3ithin AA #T<s 3hile participating in or follo3ing completion of an %9!$$ unless their practice has been restricted. The 2tate impaired personnel program in 3hich the individual has participated (either voluntarily or by orderDstipulation) establishes criteria related to return to practice. A copy of all 2tate ordersDstipulations should be obtained and revie3ed by the 12ARDAR/0 unit to facilitate a clear understanding of the 12ARDAR/0 member8s probation and any limitations or restrictions to practice that may have been imposed. !ontact 3ith the 2tate board for clarification of terms definitions or other e6pectations is 3arranted. 2tate treatment program re(uirements must be follo3ed to facilitate and support the impaired 12ARDAR/0 member8s return to hisDher clinical environment. The 12ARDAR/0 provider 3ill furnish proof of employer notification to hisDher 12ARDAR/0 unit of assignmentDattachment. &ocumentation related to current delineation of privileges from each civilian agency 3here the impaired 12ARDAR/0 provider is privileged 3ill be submitted to the AA #T< at the time of re(uest for privileges. (C) +ngo ng mon !or ng. 'ngoing monitoring for AA personnel includes the observations reports and meetings re(uired over a 2Eyear period to assess the progress of %9!$s 3ho have returned to duty. This 2Eyear period begins from the day the individual completes treatment as an outpatient or is discharged from a residential setting. The A2A$ clinic is involved in monitoring during the first year of aftercare. The supervisor department chief and %9!$! 3ill continue monitoring for the second year. The committee 3ill revie3 the progress of each impaired staff member monthly for the first , months of treatment and at least (uarterly thereafter until 2 years from the last date of treatment. Re(uirements related to ongoing monitoring of 12ARDAR/0 members 3ho are participating in 2tate treatment programs vary dramatically. 2tate impaired personnel programs are inconsistent in monitoring re(uirements and the

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AR 4068 0 6 !ebruary 004

period of monitoring may be any3here from *-+0 years in length. &irect coordination 3ith the 2tate treatment program or organi4ation providing monitoring is necessary. 2tate programs or agencies that 3ill not support 1.2. Army8s impaired personnel reporting re(uirements 3ill be identified to the 12A#@&!'# "#& for coordination efforts. (a, %nformation pertinent to re(uired reports is contained in paragraphs 1 through 3 belo3. +. The A2A$ clinic staff 3ill submit monthly 3ritten reports to the %9!$! for the first , months and (uarterly thereafter 3hile %9!$s are in aftercare. These reports 3ill state for each case as a minimum the status of compliance 3ith the aftercare plan current progress and prognosis. The reports 3ill be for3arded to the credentials committee for privileged 9!$s. 2. The immediate supervisor or designated peer 3ill submit monthly reports to the A2A$ regarding the staff member8s duty competence during the first , months and (uarterly thereafter until completion of aftercare monitoring. ,. Reports for3arded to the credentials committee 3ill be maintained in the $A<. Reports on nonprivileged staff members 3ill be maintained in a confidential protected "A file (see app ?) 3hich 3ill be destroyed 3hen the staff member is successfully returned to full practice. %f a $!2 occurs prior to the individual8s return to full practice these files 3ill be transferred to the gaining facility follo3ing the guidelines for transfer of a $!<. (2ee para 9-. d(+).) (b, %ndividuals involved in monitoring the impaired staff member 3ill notify the appropriate supervisor and therapist immediately upon signs of relapse or failure to follo3 the aftercare plan. $rompt intervention 3ill be initiated for the good of the staff member as 3ell as the safety of hisDher patients. (&, The confidentiality re(uirements of AR )00->* apply to all reports committee minutes and discussions pertaining to %9!$s in the 1.2. Army8s A2A$. !ivil penalties apply for unauthori4ed disclosure. (2ee app ?.) (>) 5rogram !erm na! on. (a) 5ro-e"" onal n/ol/emen!. The A2A$8s role in the staff member8s recovery program ends + year after the date treatment 3as completed. The role of all others generally ends after the second year. At this time the %9!$! 3ill recommend termination of monitoring unless findings based on revie3 of the case or relapse necessitate further involvement. (b) 5ro&e"" ng -or "epara! on. %n accordance 3ith AR )00->* all AA and 12ARDAR/0 2oldiers 3ho are identified as illegal drug abusers 3ill be processed for administrative separation. 5562 .oti'ication re&uirements a. /otification to the 12A#@&!'# 3ill be made regarding all healthcare personnel (officer enlisted civilian and contracted) 3ho are involved in the %9!$$. && <orm 2.99 3ill be utili4ed for this purpose. Reports 3ill be sent through the ne6t higher head(uarters to !ommander 12A#@&!'# (#!9'-!;-") 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0. @ach AA #T< 3ill provide a copy of the && <orm 2.99 to their A2A$ clinical offices. 12ARDAR/0 units 3ill for3ard a copy of the && 2.99 to their respective Regional 2upport !ommand or 2tate Army 12ARDAR/0 9ead(uarters 2urgeon8s 'ffices. b. Hhile the 12A#@&!'# is notified of all healthcare personnel involved in the %9!$$ only those meeting any of the criteria in (+) through (*) belo3 are reported to professional regulating authorities. The providerDprofessional 3hoG (+) 9as hisDher clinical privilegesDpractice denied suspended restricted reduced or revo5ed. 12ARDAR/0 units are not responsible for reporting clinical privilegesDpractice actions ta5en against 12ARDAR/0 personnel by civilian agenciesDfacilitiesA this is the responsibility of the civilian employer. 9o3ever privileges denied suspended restricted reduced or revo5ed by the 12ARDAR/0 unit of assignmentDattachment 3ill be reported. (2) $ossesses prescribes sells administers gives or uses any drug legally classified as a controlled substance for other than medically acceptable therapeutic purposes. (,) 2eparates from A& or <ederal service 3ith lessEthanEfull privileges or lessEthanEfull scope of clinical practice for nonprivileged personnel. (.) 9as an unauthori4ed absence at any time for any reason during the 2Eyear monitoring period (AA only) follo3ing alcohol or other drug rehabilitation. (*) 9as been enrolled in the %9!$$. Reporting by the 12A#@&!'# to the /$&? 3ill occur only if the impaired individual fails to successfully complete the program. &. T20 is the reporting authority for %9!$s (AAD12ARDAR/0) to all professional regulating authorities. 55>2 Revie= o' .ational 3ractitioner !ata Ban? &uery and licensing in'ormation a. 12ARDAR/0 %9!$s are reported to the /$&? by both the civilian healthcare facility and by the 2tate licensing board 3hen an adverse privilegingDpractice action associated 3ith impairment has been ta5en against the individual8s license. Reporting of the impaired 12ARDAR/0 member occurs despite the individual being actively engaged in and complying 3ith all the re(uirements of a rehabilitation program. b. ?ecause an adverse privilegingDpractice action report to the /$&? is filed by the facility and licensing board it is not unusual for more than one adverse privilegingDpractice action to be noted on an 12ARDAR/0 member8s report from the /$&?. This is in contrast to the AA provider8s /$&? report 3hich 3ill not reflect an adverse privilegingD practice action related to an impairment unless one of the conditions in paragraph ++-) b is met.
AR 4068 0 6 !ebruary 0041RAR 2ay 00& %0%

c. All adverse reports from the /$&? re(uire revie3 by the credentials committee. 9o3ever if multiple reports of the same impairment are on record this should be ta5en into consideration 3hen recommendations for initial privileges or rene3al of privileges are made. d. A 12ARDAR/0 member 3ho is involved in a civilian %9!$$ may have an unfavorable action ta5en by the 2tate licensing board that places the license on probation but does not restrict the individual8s practice. The probation period is for a specified length of time that varies from 2tate to 2tate.
C(apter 5# 3atient Sa'ety in t(e %ealt(care Setting
5#52 @eneral a. $2 in the healthcare setting involves a variety of clinical and administrative activities that organi4ations underta5e to identify evaluate and reduce the potential for harm to beneficiaries and to improve healthcare (uality. @ffective $2 initiatives see5 to control unto3ard events before they occur and as such elements of ris5 assessment ris5 identifica tion and ris5 reduction or containment are involved. %n the past this frame of reference has been associated almost e6clusively 3ith R# at the facility level. b. The #T< leadership plays a critical role in the facilityEbased $2$ given the influence that leaders e6ert on activities directly associated 3ith this program such as $% environmental safety and R#. Although the beneficiary is the central focus of $2 it is difficult to create an organi4ationE3ide $2 initiative that e6cludes staff <amily members and others. #any of the activities implemented to improve $2 (for e6ample security fire safety e(uipment safety infection control falls prevention) encompass staff and others as 3ell as patients. $2 is a critical component of a T&A organi4ation8s comprehensive safety efforts. As such $2 activities and processes must be effectively integrated 3ith those of the e6isting #T< 2afety $rogram. c. $2 and the reporting of adverse events especially 2@s are li5e3ise important in the T'@ environment. Hherever practical efforts must be made by T'@ leadership to emphasi4e $2 and to minimi4e patient harm associated 3ith the provision of healthcare to 2oldiers. 5##2 Sa'ety associated =it( patient care a. $2 activities are proactive and focus on reducing or avoiding misadventures during the delivery of medicalD healthcare. &eliberate attention is re(uired to improve medical systems and processes in order to prevent harm related to medicalDhealthcare interventions and to modify reduce or eliminate beneficiary e6posure 3herever possible. b. %n order to sustain a culture of safety 3ithin the A#@&& enhanced responsibility and accountability for $2 at all levels of the organi4ation is essential. ;eadership must establish an atmosphere of trust and confidence that encourages all staff to report actual and potential medicalDhealthcare errors in order to protect patients to learn from the ha4ardous situations identified and 3herever possible to prevent future recurrences. c. Active participation is re(uired on the part of all staff members to avoid unto3ard medical care outcomes and to improve $2. As a minimum organi4ations 3illG (+) Appropriately report adverse events (including 2@s) and close callsDnear misses according to &'& and 12A#@&!'# $2$ re(uirements and TJ! guidance. (2) <ocus on system and process factors rather than the performance of the individual(s) involved 3hen analy4ing a $2 event to determine its cause. (,) %dentify the underlying cause(s) and the associated process changes that may reduce the potential for recurrence. (.) %mplement healthcare service delivery system redesigns that 3ill reduce the li5elihood of harm and promote $2. (*) &ocument $2 issues and lessons learned for dissemination internally and throughout the A#@&& and the #92 as appropriate. 5#82 7(e 3atient Sa'ety 3rogram a. @ach #T< commander 3ill establish and implement a $2$ according to 12A#@&!'# guidance as an integral part of the "AD$% processes of the organi4ation according to &'& policy (&'&% )02*.+C). The specific components of $2 include the assessment identification classification management analysis and reporting as appropriate of medicalDhealthEcareEassociated adverse events (to include 2@s). $2 addresses incidents involving both potential harm (close call) to patients as 3ell as those in 3hich actual in7ury occurred (adverse event). b. @ach #T< 3ill demonstrate evidence of $2$ activities that meet current &'& and 12A#@&!'# guidance as 3ell as applicable TJ! standards. c. The #T< commander 3ill ensure integration of the various $2 functionsGas defined in 3ritingGinto both the #T< 2afety $rogram and the organi4ation8s !"#$. 9eDshe 3ill designate a (ualified individual as $2 manager to effectively coordinate the organi4ation8s interdisciplinary $2 activities and initiatives.

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AR 4068 0 6 !ebruary 004

d. The facilityElevel $2$ 3ill be based on current &'& and 12A#@&!'# guidance and 3ill include as a minimumG (+) The roles and responsibilities of all personnel to include the medicalDdental staff relative to $2. (2) @ducation of staff and patients regarding $2 emphasi4ing opportunities to reduce ris5 and minimi4e harm to patients. (,) !learly defined standardi4ed processes for reporting revie3ing and analy4ing ris5 and other $2 data and initiating corrective measures to reduce and prevent future occurrences. (.) 2tandardi4ed methods for identifying classifying trac5ing trending and evaluating all near miss and adverse events (to include 2@s). (*) A standardi4ed method for conducting an R!A of 2@s and other adverse events. ()) %dentified process metrics relative to $2 (see 12A#@&!'# guidance for re(uired and recommended metrics). (C) A mechanism for providing prompt feedbac5 to staff 3ho report adverse events including close calls. <eedbac5 of a nonconfidential nature that addresses actions ta5enDactions pro7ected as a result of the staff member8s report is appropriate. This communication ac5no3ledges the importance of the staff member8s efforts to participate actively in organi4ational $%. (>) The re(uirement for reporting $2$ data to the 12A#@&!'# and other agencies as re(uired by 'A2&(9A) and an annual evaluation of the overall effectiveness of the integrated $2DR# activities. (9) An evaluation (utili4ing the standardi4ed survey tool provided by 12A#@&!'#) of the organi4ation8s corporate culture as it affects the reporting of adverse events and close calls. (+0) @stablishment of an interdisciplinary $2 revie3 function. e. The annual !"#$ report that is submitted to the #T< @6ecutive !ommittee 3ill summari4e the organi4ation8s significant $2 issues and activities (for e6ample reportable adverse events 2@s system issues and steps ta5en to rectify problems and any lessons learned). These data are e6tracted from the #T< annual $2$ report. Reporting re(uirements associated 3ith the $2$ are dynamic and may vary from year to year based on &'& guidance. The 12A#@&!'# "#& 3ill provide current upEtoEdate guidance as re(uirements change. A copy of the #T<8s annual $2$ report 3ill be provided to 12A#@&!'# ATT/F #!9'-!;-" 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0. 5#42 Management o' an adverse event or close call a. T$pe" o- n& den!". %n the conte6t of patient safety incidents involving patients are classified as either adverse events or close calls. (2ee glossary definitions.) (+) The person in charge of the activity 3here the adverse eventDclose call has occurred 3ill ensure that the $2 manager (or designee) is notified 3ithin .> hours of its detection. (2) The $2 manager is responsible for revie3 of the facts associated 3ith either type of event and for ensuring that an appropriate evaluation is performed as re(uired by &'& and 12A#@&!'# guidance. (,) The !JA 3ill be informed and appropriate coordination 3ill occur throughout the management of adverse events that are identified as potentially compensable events ($!@s) and 2@s. b. *o&umen!a! on. (+) &A <orm .+0) (%ncident Report) or e(uivalent report 3ill be completed. &A <orm .+0) is used to document all types of incidents or unanticipated events to include patient safety events that occur in the #T<. This document provides the initial report of a situation that based on Army or 12A#@&!'# guidance or local policy may re(uire more detailed documentation. 1pon revie3 by the designated authority ($2 manager ris5 manager #T< safety and environmental health manager and so forth) if it is determined that the incident has "ADR# implications this document is considered protected under +0 12! ++02. The specific type of incident (hospital safety $2 R# and so forth) 3ill determine 3hat additional documentation if any is necessary and 3ho is responsible for follo3up action. &A <orm .+0) contains concise factual ob7ective and complete details about the event. Hhile an e6planation of the situation is appropriate to include precipitating circumstances or reasons speculation about the cause of the incident should be avoided. (2) The completed &A <orm .+0) 3ill be for3arded through appropriate supervisory channels to the designated authority as soon as possible but not later than .> hours after the occurrence. Reports of adverse eventsDclose calls or other incidents occurring on the 3ee5end or holidays 3ill be submitted on the first duty day follo3ing the incident. (,) 1pon submission &A <orm .+0) or electronic e(uivalent 3ill be maintained in a central location (for e6ample the $2DR# office) as determined by local policy. %n accordance 3ith the AR%#2 record retention schedule information relating to involvement of a patient in an unusual occurrence or accident in an #T< is destroyed after C years. %nformation relating to medical incidents for 3hich a claim andDor suit has been filed have the follo3ing disposition scheduleF cutoffF after final resolution of the caseA transferF to the <ederal Records !enter , years after cutoff. &A <orm .+0) 3ill not be included in the beneficiary medicalDdental recordA it 3ill not be duplicated and maintained at the department or service level. (.) All factual data related to a $2 adverse event 3ill be entered in the patient8s medicalDdental record on 2< *09 or other appropriate medical records form (for e6ample 2< )00 2<)0,D)0,A (&ental 9ealth Record)). The entry should
AR 4068 0 6 !ebruary 004 %0.

describeGin detailGe6actly 3hat occurred any evidence of in7ury to the beneficiary and the immediate action(s) initiated in response to the event. %n addition all the facts surrounding the adverse event must be fully disclosed to the patientD<amily member by the provider. A statement by the primary care provider or attending physician documenting the circumstances surrounding the adverse event as relayed to the beneficiary or <amily member 3ill be entered (&'&% )02*.+C) in the patient8s medicalDdental record. The annotation in the medicalDdental record 3ill not conclude that an adverse event or accident occurred using those specific terms nor 3ill it indicate that a &A <orm .+0) 3as completed. "uestions related to disclosure and documentation of information associated 3ith an unanticipated patient outcome or adverse event should be referred to the #T< !JA. &. #""e""men! o- !he ad/er"e e/en!. (+) The adverse event assessment and 3eighted scoring (that is safety assessment code (2A!) or comparable &'&E sanctioned methodology) may be by a designated individual (for e6ample the $2 manager) or by an interdisciplinary group. A multidisciplinary approach ensures that a broad ob7ective perspective is maintained in the revie3 process. ?oth clinical and nonclinical e6perts provide valuable input to the decisions that result and the subse(uent actions ta5en regarding adverse eventsDclose calls. (2) %f there is a lo3 priority accorded the event based on the standardi4ed $2 severity assessment performed (that is 2A! score (see 12A#@&!'# $2$ guidance for event scoring directions)) the decision may be to ta5e no action other than trac5ing trending and subse(uent aggregate revie3 analysis of the adverse event according to &'& and 12A#@&!'# guidance. The action may include reporting the event to 12A#@&!'# A<%$ andDor the TJ!. %f 3arranted an R!A 3ill be performed and a corrective action plan developed in accordance 3ith 12A#@&!'# $2$ guidance. Adverse events or incidents involving physical safety issues or ha4ardous conditions 3ill be revie3ed and referred for corrective action to the individual(s) responsible for managing the #T< 2afety $rogram or other appropri ate facility personnel. %ncidents classified as $!@s 3ill be referred to R# for appropriate action. (,) %f in the course of investigation the evidence suggests that the incident presumed to be an adverse event is the result of an intentional unsafe act the incident 3ill immediately be referred to the #T< commander for appropriate action. %ntentional unsafe acts are not 3ithin the defined scope of the $2$. R# is responsible for notifying the !JA of such alleged incidents as 3ell as all coordination and follo3up action. <indings of intentional unsafe acts that result from gross negligence or possible criminal activity shall be reported to the !%&. 0iven the implications of these acts they 3ill be addressed 3ith all due attention through legal administrative and disciplinary channels. (.) <or incidents that appear to be both an adverse event and an intentional unsafe act that is deliberate administra E tion of a potentially lethal dose of a medication primary authority and responsibility are outside the $2$. The $2 manager may proceed 3ith a revie3 of the incident to include an R!A if applicable of any facility systems and processes implicated in the actualDpotential intentional safe act. 9o3ever given the medical malpractice implications a separate R# investigationD2'! determination 3ill be conducted on the matter of culpability of the individual(s) involved in the act. This is in addition to any criminal investigation that may ensue. (*) 1nintentional human error 3ill occur despite the most diligent efforts on the part of healthcare personnel. These must be dealt 3ith in an atmosphere of supportive concern. 9o3ever criminal actions and errors due to gross negligenceDrec5less behavior substance abuse andDor patient abuse 3ill not be tolerated. %ndividuals implicated in such actions 3ill be referred for action to the fullest e6tent possible through established R# provider action channels or administrative channels for the nonprivileged healthcare professional. d. 0n/e"! ga! ng and !ra&8 ng. (+) %n order to maintain an accurate accounting of occurrences 3ith potential $2 implications all adverse events (including close calls) 3ill be entered into the organi4ation8s registry of adverse events. Re(uirements for reporting the data that are collected 3ill be according to current &'& and 12A#@&!'# guidance. (2) <or events 3ith minimal harm to the patient and close calls an aggregate revie3 and analysis of data may be appropriate. <alls and medication errors are t3o e6amples of events for 3hich an aggregate revie3 is authori4ed. (,) An R!A is mandatory for all 2@s and for other adverse events as designated by &'& and 12A#@&!'# policy. (.) Any adverse event that is classified as a $!@ 3ill also be entered into the R# #O@ database (that is !!"A2 or replacement system). 0iven the potential medical malpractice implications a peer revie3D2'! determination 3ill be conducted on the matter of culpability of the individual(s) significantly involved in the $!@. (2ee para +,-. b for additional guidance.) Hhen scrutini4ing professional behavior and competence the medical malpractice peer revie3 that is conducted 3ill rely to the ma6imum e6tent possible on other revie3 systems and processes outside the $2$. e. %epor! ng !o !he US#')*C+'. Adverse events that according to 12A#@&!'# guidance re(uire "#& notification 3ill be reported to the 12A#@&!'# (#!9'-!;-") 20*0 Horth Road <ort 2am 9ouston TJ C>2,.)0+0 3ithin C2 hours of identification. #T<s 3ill also inform the 12A#@&!'# of any situation in 3hich the ne3s media is involved or may be involved and the coverage may reflect negatively on the #92. <acilityElevel $2$ aggregate data 3ill be electronically submitted to the 12A#@&!'# "#& on a regularly scheduled basis (that is (uarterly) according to current 12A#@&!'# guidance.

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AR 4068 0 6 !ebruary 004

5#<2 Management o' a sentinel event An 2@ is an une6pected occurrence involving death or serious physical or psychological in7ury or ris5 thereof. 2uch adverse events are called LsentinelM because they signal the need for immediate impartial investigation and response by the organi4ation. Hithin the conte6t of this general definition each organi4ation may further define for its o3n purposes the specific parameters of the term Lsentinel event.M As a minimum the organi4ation8s 3ritten 2@ policy 3ill include those events that are sub7ect to revie3 according to TJ! and 12A#@&!'# guidance. a. %epor! ng o- an S). (+) To !he T.C. Any incident that meets the current TJ! definition of a revie3able 2@ must be reported directly to the TJ! 3ithin * days of its identification. 2ee Heb site 333.TJ!.org for specific reporting criteria and other guidelines. /either beneficiary nor caregiver identifiers may be used 3hen reporting 2@s to the TJ!. (2) To US#')*C+'. All 2@s reported to the TJ! must also be reported through the R#! (or through the R&! and the 12A&@/!'#) to the 12A#@&!'# (#!9'-!;-") 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0 3ithin C2 hours of identification. (2ee para +2-.d.) b. 3a& l !$<le/el -ollo>up a&! on". The $2DR# 3ill notify the !JA of an 2@ as soon after identification as possible. As an integral part of its established process for $2 analysis each #T< 3ill have in place and in 3riting a mechanism for performing an R!A reporting and other appropriate follo3up activities related to 2@s that are consistent 3ith current TJ! &'& and 12A#@&!'# guidance. (+) An R!A must be conducted using thorough and credible processes to determine the basic or causal factor(s) that contributed to or may have contributed to an 2@Dpossible occurrence of an 2@. %n an attempt to be impartial and fully accountable the R!A 3ill focus primarily on organi4ational systems or processes not individual performance. (2) A detailed R!A action plan must be developed that enumerates the ris5 reduction strategies that the organi4ation intends to implement as a result of the R!A to prevent the recurrence of similar events in the future. The specific content of the #T< action plan 3ith follo3up evaluation of the effectiveness of the R!A action plan 3ill be according to 12A#@&!'# guidance. &. %C# and a&! on plan re/ e>. (+) @$ !he T.C. Revie3 by the TJ! of the #T< R!A and action plan 3ill be according to current TJ! guidance. Timelines established by the TJ! for submission of the R!A and action plan 3ill be follo3ed. 2ee the TJ! Heb site as noted in paragraph +2-*a(+) for additional information. (2) @$ US#')*C+'. A copy of the R!A and action plan for all 2@s 3ill be provided through the chain of command to the 12A#@&!'# "#& according to the guidance and timelines established for reporting to the TJ!. These documents 3ill be for3arded to the !ommander 12A#@&!'# (#!9'-!;-") 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0. !ommercial overnight delivery service is authori4ed for this purpose. d. 'ed a re9ue"!". Any and all communication 3ith the media concerning an 2@ an adverse event or significant $2 issues 3ill be coordinated by the local public affairs office ($A') 3ith the !JA. $ress in(uiries and other mediaErelated issues 3ill be referred by the local $A' as appropriate to the 12A#@&!'# $A' 12A#@&!'# (#!$A) 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)000. (2ee AR 2C-.0.) e. %e9ue"!" -or med &al7den!al n-orma! on. The 9ealth %nsurance $ortability and Accountability Act of +99) ($; +0.-+9+) re(uires that release of 9R@!s 3ill be in compliance 3ith appropriate statutory and regulatory authority to protect 3ithin the guidelines of those la3s and regulations the sanctity of the records. Re(uests from claimants or potential claimants (or their attorneys or representatives) for medical or dental information related to an 2@ or any adverse event 3ill be referred to the chief patient administration division ($A&) for medical records or the &T< commander for dental records. %n these cases $A& or the &T< commander 3ill coordinate 3ith the $2Dris5 manager 3ho 3ill follo3 the legal guidance provided by the !JA. #T< personnel 3ill not deal directly 3ith claimants or potential claimants (or their attorneys or representatives) 3ithout prior coordination 3ith the $2Dris5 manager. 5#62 7(e 3S committee;'unction a. %ntegration of all organi4ational $2 and ris5Erelated issues and processes under the auspices of the #T< safety committeeDfunction reduces duplication of effort and enhances overall program efficiency. The #T< revie3 process for $2Erelated issues 3ill be multidisciplinary to include representatives of the #T< e6ecutive leadership (for e6ample the &!!2 &!A &!/)A selected department chiefsA ancillary services representatives (for e6ample pharmacy logistics nutrition care)A the "#D$% coordinatorA the $2Dris5 managerA the #T< safety and occupational health managerA the !JAA enlisted representativesA and others as deemed appropriate. b. <or dental clinics the $2 committee membership 3ill be at the discretion of the dental commander. %t 3ill be multispecialty composed of general and specialty dentists and others as appropriate. c. The $2 committeeDfunction minutes or reports 3ill summari4e activities to include as a minimum analysis of the results of adverse eventsDclose callsD2@ process measures analysis of the results of #T<Especific occurrence screens and recommendations to the #T< leadership for improvements to specific $2 processes $2 initiative(s) and other organi4ational changes as appropriate. $2 committeeDfunction minutesDreports 3ill be maintained according to AR 2*.00-2.

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5#>2 3roduct lia,ility and t(e Sa'e Medical !evice Act o' 5$$0 The $2 function 3ill incorporate (uality control procedures and processes for medical materiel complaints and 2afe #edical &evice Act (2#&A) identification and reporting. a. The chief logistics division (or comparable title) in both T&A and T'@ healthcare facilities is responsible for dissemination of medical materiel (uality control messages under the provisions of AR .0-)+. The chief logistics division 3ill ensure that the $2Dris5 manager and appropriate departmentDservice chiefs are promptly notified of all product liability complaints to include 2#&A events. A follo3up mechanism to ensure that appropriate action is ta5en on a complaint and that $2 is achieved 3ill be established by the chief logistics division. b. %n actual or potential product liabilityD2#&A cases the $2Dris5 manager 3ill ensure that evidence is carefully preserved. Representative cases include adverse events in 3hich medical e(uipment or appliances are involved in une6pected in7ury drug overdose drug reaction or an improper prescription. @very effort 3ill be made to preserve the actual e(uipment (for e6ample needles sponges) supplies drugs or any 2#&AElisted items along 3ith relevant maintenance and purchase records and manufacture8s literature. (2ee AR 2C-20.) The list of documentary evidence that should be preserved in actualDpotential product liabilityD2#&A cases includes all manufacturer <ood and &rug Administration (<&A) and 1.2. Army #R#! notices regarding the drug product medical e(uipment or appliance and any documentation of remedial action ta5en by the #T<. c. %n situations that involve malfunctioning (actual or suspected) medical e(uipment (for e6ample respirator suction e(uipment or devices controlling the administration of intravenous fluids) the e(uipment in (uestion 3ill immediately be removed from service. A (ualified 0overnment employee 3ill inspect the e(uipment to determine 3hether there has been a malfunction or a design fla3 and to determine 3hether an independent appraisal is necessary. d. AR .0-)+ outlines procedures for reporting incidents that relate to medical materiel complaintsDproblems to include 2#&A events. The supplier and manufacturer 3ill be notified and provided an opportunity to inspect (under the observation of a (ualified 0overnment employee) the actual e(uipment and e(uipment parts involved. The !JA 3ill be notified prior to any inspection by 0overnment employees contractors or suppliers. The e(uipment 3ill be repaired and returned to service prior to contractor or supplier inspection only 3hen in the opinion of the commander medical necessity re(uires its immediate use. Any defective parts removed and replaced 3ill be secured for possible evidentiary use by the chief logistics division. All original maintenance and purchase records as 3ell as any photographs ta5en of the malfunctioning e(uipment 3ill also be maintained in a secure manner. e. 2#&A incident identification trac5ing and reporting procedures 3ill be described in the facility safety plan. The plan 3ill address those devices identified under 2#&A 3hich result in a reportable death or serious in7ury or illness. 2< ,>0 (Reporting and $rocessing #edical #ateriel !omplaintsD"uality %mprovement Report) 3ill be used to submit incidents according to AR .0-)+ guidelines. f. %n cases (2@s) involving death associated 3ith or suspected to be the result of the use of a medical device or e(uipment immediate attention 3ill be given to determine 3hether an autopsy 3ould aid in determining cause of death. The autopsy should attempt to consider all life shortening conditions present. Hhere necessary consultation 3ith the &epartment of ;egal #edicine A<%$ is encouraged. These cases 3ill be handled as 2@s according to paragraph +2-*. 5#82 3atients =(o leave t(e military treatment 'acility setting prior to completion o' care a. Term na! on o- heal!h&are. $atientsDprospective patients being provided healthcare or 3aiting for care in either the inpatient or the outpatient setting may on occasion elect to terminate the healthcare providerEbeneficiary relationship before definitive care is complete. The decision to terminate inpatientDoutpatient care by other than a privileged provider presents valid $2 concerns. Three different scenarios are associated 3ith the termination of healthcare in this conte6t. (+) The nonEA& patient for 3hom diagnostic or definitive care has been initiated may refuse additional treatment and depart against medical advice (A#A). (2) The patient for 3hom diagnostic or definitive care has been initiated may depart the care setting 3ithout the prior 5no3ledgeDconsent of the healthcare staff (that is an elopement). (,) The individual presenting for care and for 3hom diagnostic treatment by a privileged provider (or designee) has not yet begun may leave 3ithout being seen by the provider.
4o!e. %n the conte6t of this paragraph privileged provider may include residents (referred to here as designee) as established in local policy.

b. 5a! en! r "8. The decision by other than a (ualified privileged provider (or designee) to terminate care (that is to leave A#A leave 3ithout being seen or elope) may pose a real or potential ris5 to the safety of the patient andDor others. Thus specific intervention on the part of the #T< staff is appropriate. 0iven any of the termination of care situations presented both counseling (patientDlegal representative) if feasible and documentation of the event in the medical record (%TRD'TRD9R@!Dcivilian employee medical record (!@#R)) is re(uired. &. Term na! on o- &are #'#. (+) The attending privileged provider (or designee) 3ho is managing the patient8s care is responsible for counseling the patient or hisDher legal representative. This counseling 3ill include as a minimum the natureDpurpose of the
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treatment the material ris5s associated 3ith the treatment the li5elihood of success alternatives to the proposed treatment and the prognosis 3ithout the treatment or the medical or surgical intervention. (2) %f the mentally competent patient is intent on leaving A#A despite efforts of the healthcare staff to convince himDher other3ise &A <orm *009 (#edical RecordERelease Against #edical Advice) 3ill be completed by the attending privileged provider (or designee). The patientDlegal representative should be as5ed to sign the &A <orm *009 to ac5no3ledge that the counseling 3as performed and the ris5s associated 3ith the decision to terminate care 3ere presented. 2hould the patientDlegal representative refuse to sign the &A <orm *009 this 3ill be annotated on the form or in the patient8s medical record on 2< *09 (inpatient) or 2< )00 (9R@! 'TR !@#R). (,) The attending privileged provider (or designee) 3ill document in the %TRD'TRD!@#R a summary of the counseling that 3as provided to the patientDlegal representative and an assessment of the patient at the time of this counseling. %n addition any specific instructions (for e6ample 3hat to do in case of bleeding continuedDincreased pain fever and so forth) and recommended follo3up outpatient care 3ill also be noted. (.) &A <orm .+0) 3ill be completed according to paragraph +2-. a of this regulation to document this incident. 'ther documentation related to the inpatientDoutpatient treatment 3ill be completed as appropriate to close out the medical record for that episode of care. (*) A& 2oldiers are not authori4ed to refuse medical care e6cept as noted in AR )00-20. A& 2oldiers 3ill not sign out A#A. 2ee AR )00-20 and consult the local office of the 2JA for additional guidance regarding 2oldiers 3ho refuse medical care. d. 5a! en! elopemen!. (+) 1nli5e an A#A departure from the #T< the patient 3ho elopes has terminated the beneficiaryDprovider relationship 3ithout advance notice to the healthcare staff and 3ithout benefit of the counseling described in paragraph &(+) above. @lopement is often discovered some time after the patient has departed the treatment setting. (2) The incident 3ill be documented in the %TRD'TR as appropriate to close out the medical record for that episode of care and a &A <orm .+0) 3ill be completed. (,) ;ocal policy 3ill address appropriate actions for contacting the individual 3ho has eloped (hisDher legal representative) to determine the patient8s health status at the time of contact and to provide instruction for further follo3up or emergency careDtreatment as re(uired. A privileged provider (or designee) or other professionally (ualified individual 3ill initiate contact 3ith the patientDlegal representative. The contact made 3ith the patient any current symptoms or complaints heDshe describes and the instructions provided by the staff member 3ill be documented in the %TRD'TRD9R@!. e. The per"on >ho lea/e" > !hou! be ng "een. (+) This individual (AAD12ARDAR/0D<amily member) has presented for care in the outpatient setting but decides to leave 3ithout being seen by the privileged provider (or designee). This person may have been triaged and evaluated by nursing personnel but no definitive care has been initiated. (2) ;ocal policy 3ill determine 3hat follo3up actions are re(uired for contacting this individual (hisDher legal representative) and other procedures to ensure the 3ell being of the patient. -. Cogn ! /e a""e""men! o- !he bene- & ar$. (+) %f in the opinion of the privileged provider or psychiatrist the patient 3ho has elected to depart the #T< A#A or to elope is mentally incompetent to fully understand the ramifications of such a decision the medical record entry 3ill clearly annotate the patient8s inability to understand the potential conse(uences of hisDher actions. (2) ;ocal policy 3ill direct other actions to be ta5en by #T< staff. As a minimum the 2JA 3ill be contacted as early in the situation as possible to provide legal guidance. ;a3 enforcement authorities should be notified of the mentally incompetent patient8s elopement if the <amilyDsignificant other has no 5no3ledge of hisDher 3hereabouts. g. Term na! on o- &are b$ !he 'T3. 'n rare occasion medical care may be terminated by the healthcare provider for failure on the part of the patientD<amily member to comply 3ith the established plan of care established regulations #T< policy or as the result of other irregularities. %n these instances the stipulations noted above in paragraphs &(+) through (.) 3ill apply. %n accordance 3ith current managed care policy coordination of necessary follo3Eon care and any other arrangements 3ill be made by #T< staff 3ith another appropriate healthcare facility. Termination of care under these circumstances 3ill be according to the legal guidance provided by the servicing 2JA. 5#$2 Role o' -SAM0!C9M Quality Management !ivision The role of the 12A#@&!'# "#& in facilitating effective $2 processes is consultative educational and supportive. The "#& staff 3ill provide policy guidance and educationA gather maintain and disseminate 1.2. ArmyE3ide clinically focused $2 dataA and provide consultation and support about 2@ analysisA provide feedbac5 on best practicesA and report information as appropriate to outside agencies as directed by 'A2&(9A). 5#502 Con'identiality As 3ith other medical "A documents any information records reports minutes and other documents directly

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associated 3ith $2 activities are protected under +0 12! ++02 and &'& )02*.+,-R. 2ee appendi6 ? for more information concerning the confidentiality of !"# "A documents.

C(apter 58 Ris? Management

5852 @eneral Ris5 management involves a variety of activities designed to prevent the loss of human materiel or financial resources and to limit the negative conse(uences of adverse or unanticipated events that occur in a healthcare setting. !ompreE hensive processes to effectively identify and reduce the occurrence of potentially compensable events ($!@s) and to manage medical malpractice claims against the 1.2. 0overnment are critical to an organi4ation8s R# activities. The importance of collaboration among organi4ational staff members 3ho are responsible for R# $2 #T< safety and occupational health cannot be overemphasi4ed. 58#2 Military treatment 'acility and -2S2 Army Medical Command ris? management activities; responsi,ilities @ach #T< 3ill demonstrate evidence of R# activities that meet current &'& and 12A#@&!'# guidance. a. The #T< !"# plan for R# 3ill include such facilityEspecific activities asG (+) The responsibilities of #T< personnel relative to R#. (2) @ducational re(uirements for identified staff members regarding R#. (,) !learly defined processes related to ris5 reductionDris5 mitigation activities. (.) The management of all $!@sDmedical malpractice claims. /oteF The term $!@ refers to in7ury to all categories of #92 beneficiary including in7ury 3ith subse(uent death or disability of a military member (see &'& )02*.+,ER). (*) 9o3 opportunities for changeDimprovement in healthcare and services that are identified during the malpractice claims revie3 3ill be integrated into the organi4ation8s $% processes. b. The #T< commander 3ill ensure that R# processes as defined in 3riting in the !"# plan are in place and that an individual is designated to serve as the organi4ation8s ris5 manager and as the clinical advisor as appropriate. &. The #T< ris5 manager 3illG (+) %dentify and (uantify healthcare related ris5. (2) $articipate in the ris5 analysis process. (,) !oordinate the $!@ and malpractice claims management processes (.) &evelop and revise ris5 management policies and procedures. (*) @ducate staff (all levels all disciplines) concerning ris5 reductionDmitigation. ()) $rovide data on a periodic basis to #T< senior leadership concerning R# issues and trends. To avoid redundancies due to the comparable processes related to ris5 and patient safety the information reported to the #T< e6ecutive committee or @!#2 at defined intervals should reflect an integration of effort 3herever possible (see para +2E)). d. The R# clinical advisor is a senior physician or dentist appointed to provide oversight of the R# program in healthcare settings 3here the designated R# is other than a physician or a dentist. 9eDshe is responsible for providing professional medicalDdental consultation to 5ey $2DR# staff and the medical !JAD2JA. Among other R# duties the clinical advisor 3illEE (+) Assist in the revie3 and analysis of all patientErelated adverse events 3ith particular attention to those identified as $!@s. (2) @nsure that coordination is made for participation as re(uired by (ualified military or civilian medicalDdentalD other specialists in any peer revie3 activities related to a $!@. (,) @nsure that medicalDdental malpractice claims information is collected collated and reported in a timely manner. e. The 12A#@&!'# "#& is responsible for collecting #T<Elevel data associated 3ith medical malpractice claims and healthcare related death or in7ury to military members for (uarterly reporting to the &'& R# committee. 2aid data are li5e3ise revie3ed and analy4ed for A#@&&E3ide trends and opportunities for improvement. %n addition #@&!'# conducts the senior A#@&& revie3 of paid malpractice claims and provides recommendations to T20 for reporting of licensed certified or registered healthcare personnel to the /$&?. 5882 7(e military treatment 'acility ris? management committee a. The #T< R# committee provides impartial oversight and revie3 of all $!@s and medical malpracticeDdisability claims management activities as described in this chapter. (+) This group is multidisciplinary 3ith representation from each clinical departmentDservice the ris5 manager the medical !JAD2JA and other designated (ad hoc) participants as needed.

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(2) The ris5 manager and !JAD2JA are nonEvoting members. (,) The chairperson 3ill vote only in the event of a tie.
b. The R# committee 3ill revie3 the facts of the case ($!@ or claim) consider any departmentDservice level peer revie3 findings and recommendations concerning the events in (uestion and categori4e the care related to the $!@D claim asF 2'! L#et M L/ot #e tM or L%ndeterminate.M (+) All significantly involved healthcare providers (any discipline) associated 3ith the care deemed to have caused patient harmDin7ury 3ill be considered and 2'! determination made for each healthcare provider.
4o!e. This information must be entered in the L2tandard of !areM and LAttribution of !auseM fields of !!"A2 3hich are re(uired fields for both a $!@ and a claim.

(2) The specific rationale for an 2'! determination of L/ot #etM and L%ndeterminateM 3ill be addressed.
4o!e. 2'! may be deemed L%ndeterminateM for any number of reasons for e6ample unavailability of the medical record contents or the provider8s involvement in the medical care in (uestion is not clear.

&. The R# committee minutes 3ill summari4e the committee8s activities to includeF the 2'! vote for each involved providerA specific follo3Eup actions related to systems or process issuesA any apparent trends 3ith recommendations for improvementA and the status of any pending claims and $!@s. Recommendations to the credentials committee for privilegeDprofessional practice related actions 3ill be clearly stated. (+) #inutesDreports 3ill be for3arded through the appropriate "# channels to the commander. <or accurate identification of the individual(s) involved in an adverse event ($!@ claim) the significantly involved providers (any discipline) 3ill be identified by name. (2) $ractitionerEspecific findings 3ill be reported to the credentials committee andDor department chief (nonEprivileged professional) according to local policy. (,) The R# minutesDreports are confidential "AEprotected documents. @very effort must be made to ensure that the privacy of the contents is maintained at all times. (.) 2ensitive information not included in the minutesDreports 3ill be maintained in the ris5 manager8s office. 5842 Managing t(e potentially compensa,le event Any adverse event (to include those involving military members) that meets the definition of a $!@ as contained in this regulation 3ill be documented trac5ed revie3ed and analy4ed to determine if the adverse event could have been avoided. Any identified trends 3ill be reported through established "# channels and organi4ational changes 3hich may be 3arranted to prevent the reoccurrence of an event must be openly addressed. !lose coordination 3ill occur among the #T< ris5 manager the clinical advisor and the !JAD2JA throughout the $!@ identification and management process. a. &A <orm .+0) %ncident Report or e(uivalent 3ill be used to document all R# events that occur in the #T<. Typically this document originates at the point of care (adverse event) and is the initial report of the situation. 9o3ever information related to a $!@ may come to light via 3ritten or verbal statements from the patient a <amily member or healthcare staff. Additional documentation investigation and follo3Eup action by the ris5 manager and others is re(uired. (2ee para +2E. for instructions on the use of &A <orm .+0).) b. All $!@s 3ill be promptly prioriti4ed and investigated by the ris5 manager (&'& )02*.+,ER). All $!@s 3ill be peer revie3ed and information related to the event 3ill be entered into the R# module of !!"A2. c. !opies of documents in $!@ files maintained by the ris5 manager 3ill be for3arded to the !JAD2JA for revie3 as mandated by AR 2C-20. The $!@ case files contain $rivacy Act data and 3ill be secured and maintained in accordance 3ith AR ,.0-2+ and AR 2*-.00-2. d. 1se of the !!"A2 R# module. (+) !!"A2 electronic data entry 3ill be initiated for every identified $!@. (2) These electronic data document descriptive information regarding the incident the healthcare personnel involved all relevant patient information the clinical details of the incident and the departmentDR# committee professional peer revie3 assessments. (,) &uring the early phases of information gathering related to the $!@ partially completed !!"A2 data entries at the facility level are acceptable. %ncremental submission by the R# staff of information associated 3ith the $!@ is as follo3sG (a) %nitial !!"A2 data entry 3ithin C days of $!@ identification. (b) %nterim data entry 3ith supporting documentation of facilityElevel action such as the departmentDservice peer revie3 results R# committee activityDdecisions or referral to credentials committee for an adverse privileging action as these are available. (c) 2hould a medical malpractice claim against the 1.2. 0overnment be filed the data contained in the $!@ module 3ill be electronically imported into the !!"A2 claims management module (.) %nformation contained in !!"A2 and other supporting documentation associated 3ith the $!@ or claim help to establish a factual and accurate data base for future reference. !!"A2 data are pass3ord protected as Lcontrolled

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access onlyM information. $aper case files ($!@ and claim) 3ill be secured and maintained by the ris5 manager according to local policy for +0 12! ++02 protected information. 58<2 3eer revie= o' a potentially compensa,le event $eer revie3 in the conte6t of ris5 management is different than that 3hich is conducted 3hen an adverse privilegingD practice action is being considered. a. The initial peer revie3 of a $!@ is most often conducted at the departmentDservice level. %t is performed by an individual (a peer as defined by this regulation) 3ho has not been involved 3ith the case in (uestion. The primary reason for the R# peer revie3 is to render an 2'! determination 3hich is for3arded to the R# committee for action. The clinical facts and circumstances surrounding the adverse event are e6amined to determine if practice 3as or 3as not according to accepted practice standards (medical nursing and so forth.). %n addition responsibility (attribution) for the event is assigned based on the investigation of the circumstances and an unbiased revie3 of the evidence available.
4o!e. ;ocal policy 3ill dictate the 3or5 flo3 related to $!@ revie3 and analysis and the degree of involvement by the R# committee 3ith identified $!@s.

b. A peer revie3 (internal to the #T< or e6ternal) 3ill be initiated as soon as possible (ideally 3ithin ,0 days) after the $!@ is identified. The peer revie3 process for a $!@ and for a malpractice claim is identical and 3ill include every case involving death or disability of a military member as a result of medical or dental care. (+) An immediate investigation of the $!@ ensures timely access to the healthcare personnel involved and the availability of all medical record documentation. %n addition involved personnel can provide accurate detail concerning the $!@ 3hich enhances the validity of the peer revie3 findings. (2) %n instances 3here the #T< lac5s sufficient personnel to conduct an impartial and unbiased peer revie3 andDor R# committee functional oversight the R#! 3ill assist in coordinating for these e6ternal peer revie3 services 3ith another #T<. (,) 2ignificantly involved healthcare providers (all disciplines)Gincluding those no longer assigned to the #T<G 3ill be notified of the forthcoming R# peer revie3 and afforded the opportunity to participate or to 3aive participation in the peer revie3 process. (a) The notice to the individual(s) involved 3ill be in person or by certified return receipt re(uested mail. (b) #edical records and redacted copies of other documents associated 3ith the case 3ill be made available to the healthcare provider(s) in (uestion prior to the peer revie3. (c) $articipation by significantly involved personnel in the peer revie3 process is typically by 3ritten statement. 9o3ever local policy may allo3 inEperson presentation of information by the provider.
4o!e. 2ignificantly involved personnel 3ill not be present for nor participate in the R# committee deliberations related to the $!@ being considered.

(d) 1nli5e the adverse privilegingDpractice action process R# peer revie3 is not a formal proceeding therefore due process procedures in this conte6t do not apply. (.) The departmentDserviceEspecific peer revie3 process must includeDconsider all significantly involved providers and professionals as defined by this regulation and 3illG (a) %dentify each individual by name. (b) !onsider all information pertinent to the $!@ to include any 3ritten statements regarding the providerDprofes E sional8s involvement in the case and the rationale for hisDher clinical interventions and decisions associated 3ith the care in (uestion. (c) Render an 2'! determination for the case as a 3hole and for each of the healthcare providersDprofessionals significantly involved. (*) The peer revie3 documentation 3ill include the revie3 of care findings 3ith 2'! determination assignment of responsibility and the rationale in support of this decision and any input from each provider involved unless heDshe has elected to 3aive this opportunity. ()) All healthcare personnel 3ho 3ere significantly involved in the case 3ill be documented in !!"A2 according to &'& )02*.+,-RG (a) Regardless of 2'! determination (that is met not met or indeterminate). (b) Regardless of the professional discipline or duty status of the healthcare provider (that is regular staff (fullDpartE time) attending supervising or trainee). (c) Regardless of the peer revie3 determination that a system management facility or e(uipment failure 3as the cause of the harm. (C) %f the peer revie3 identifies a nonElicensed nonEregistered or nonEcertified individual (not re(uired to be licensed registered or certified and not a trainee) as responsible the individual involved 3ill also be documented in !!"A2.
4o!e. Hhile said individuals are not reportable to the /$&? their names 3ill be noted in !!"A2 to complete the data entry.

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(>) A peer revie3 may also be 3arranted for $% purposes as a proactive response to any adverse event or series of events regardless of the apparent severity. This is at the discretion of the ris5 manager in consultation 3ith the $2 manager and the clinical advisor. A peer revie3 should not be construed as an adverse or punitive action against a providerDprofessional. Rather it is an opportunity for fact finding data collection and clarification of the circumstances related to the event. c. Coord na! on > !h !he C.#7S.#. !oordination is re(uired among the $2 manager ris5 manager #T< safety and occupational health manager and the !JAD2JA to ensure effective communication e6ists regarding all adverse incidents involving beneficiaries <amily members visitors volunteers #T< personnel and others. d. 5C) - le ma n!enan&e. !!"A2 data related to a $!@ are maintained permanently. $aper or electronic (nonE !!"A2) case files associated 3ith a $!@ should be retained (AR 2*-.00-2) for , years beyond the date that the beneficiary 3as made a3are of the incident (adult) or for a $!@ involving a minor follo3ing the individual8s age of ma7ority or the date the malpractice claim 3as resolved 3hichever is greater. e. US#')*C+' o/er" gh! o- !he 5C). The 12A#@&!'# "#& is responsible for corporate trac5ing and trending as directed by T20 of all $!@ related data. 5862 Managing t(e medical malpractice claim The management of medical malpractice claims is a multidisciplinary process involving legal clinical and "# administrative staff members 3ho are responsible for R# and for the privileging of healthcare providers. a. 4o! - &a! on o- a &la m. The 1.2. Army !laims 2ervice (12AR!2) or the 'ffice of the !JAD2JA at 3hich the medical malpractice claim 3as submitted 3ill provide a copy of 2< 9* !laim for &amage %n7ury or &eath (or any other 3riting constituting a claim) alleging substandard care to the #T< commander of the facility against 3hich the claim has been filed 3ith a copy furnished to the 12A#@&!'# "#&. To maintain a high level of a3areness regarding all active malpractice claims the #T< ris5 manager 3ill reconcile the status of all claims 3ith the servicing !JAD2JA on a monthly basis. b. %e"pon" b l ! e" o- !he 'T3 &ommander. The commander 3ill ensure that a mechanism is in place to conduct a comprehensive revie3 of each malpractice claim as 3ell as cases involving healthcare related death or medical disability of a military member. The #T< commander 3illG (+) /otify the ne6t higher head(uarters (R#! other) according to current guidance particularly for cases of command or media interest. (2) @nsure electronic data entry into !!"A2 (claim management module) 3ithin C days of notification of a claim having been filed. This !!"A2 data entry serves as the #T< notification of the claim to the 12A#@&!'#. %nitial !!"A2 claims data entry should include as much information as possible 3ith follo3Eup data provided as it becomes available. %f the event has already been entered in the L%ncident #oduleM of !!"A2 as a $!@ it can be readily lin5ed to the ne3ly received claim. The claim management module of !!"A2 3ill be utili4ed 3henG (a) The ris5 manager is notified by the local !JAD2JA that a claim alleging negligence or substandard care has been filed. (b) The ris5 manager is notified by the local !JAD2JA that a monetary a3ard has been granted. %n this instance the claim 3as settled either by the 12AR!2 or the host nation (%nternational !laims 2ettlement Act claims) or 3as a litigation case settled or ad7udicated by the &epartment of Justice. (c) The case has been settled and a monetary payment 3as made or payment 3as denied. &ata entry to the !!"A2 claim management module 3ill occur for all malpractice claims regardless of the 2'! determination associated 3ith the case. (d) /e3 data are available to update the !!"A2 file. (,) %nitiate the peer revie3 process under the auspices of the R# committee 3ithin ,0 days of notice that a malpractice claim has been filed to render both 2'! and attribution determinations. %ncluded in this re(uirement is every claim of alleged malpractice filed under the <ederal Tort !laims Act the #ilitary !laims Act the %nternational !laims 2ettlement Act or the <oreign !laims Act relating to healthcare provided by a &o& facility or practitioner. /oteF %f the event 3as previously peer revie3ed as a $!@ and all specifications of para +,E* aEb above 3ere met the process need not be repeated. (a) <or every malpractice claim responsibility for the act or omission cited on the 2< 9* (or any other 3riting constituting a claim) or implied based on the facts of the case 3ill be assigned for each providerDprofessional named (or other3ise determined to be involved). (b) $rompt action is imperative to allo3 final 2'! determination by T20 no later than +>0 days follo3ing notification of the malpractice claim payment (see &'& )02*.+,-R). (.) $rovide the local !JAD2JA all clinically pertinent information relevant to a claim to include a legible copy of medical records 3ithin 20 3or5ing days of notification. The !JAD2JA is responsible for for3arding all re(uired documentation to the 12AR!2. (*) @nsure that all malpractice claims documentation is secured as determined locally and for3arded to the 12A#@&!'# upon re(uest. 1pon compilation of all claim related documentation at the 12A#@&!'# the #T< may dispose of the medical malpractice case file according to AR 2*-.00-2. At this point the 12A#@&!'# "#&

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becomes the case file custodian. !ase files are maintained by the 12A#@&!'# "#& for a period of +0 years follo3ing administrative closure. &. #alpractice claim documentation. At a minimum the #T< case file that is for3arded to 12A#@&!'# 3ill includeG (+) An 2< 9* (or any other 3riting constituting a claim). (2) An electronically generated && <orm 2*2) !ase Abstract for #alpractice !laims from the !!"A2 ris5 management module. The && <orm 2*2) (paper version) is no longer in use. %t 3ill not be substituted for !!"A2 claim management data entry in its entirety. (,) The departmentDservice peer revie3 minutesDreport supporting the 2'!Dattribution determinations and associated R# committee meeting minutesDreports. (.) 2tatements from the significantly involved healthcare personnel. (*) A copy of pertinent patient medical records as directed by 12A#@&!'# "#&. ()) !urrent addresses (mail eEmail) for the involved personnel if available. (C) 12AR!2 or Army ;itigation &ivision notice of legal settlement or disposition if available. d. 3ollo>up a&! on". Hithin ,0 days of notification by the !JAD2JA that a claim has been settled (paid or denied) the commander 3ill ensure thatG (+) All relevant information has been entered into !!"A2 claim file and it is electronically transferred that is LReleased to 'T20M for access by 12A#@&!'# "#&. (2) The entire case file as described above is on file 3ith the !ommander 12A#@&!'# (#!9'-!;-") 20*0 Horth Road <ort 2am 9ouston TJ C>2,.E)0+0. (,) 1pon re(uest copies 3ill be furnished to the R#! or other higher head(uarters. e. R#! staff participation. $articipation by the R#!DR&! staff to facilitate speedy but thorough processing of medical malpractice cases in preparation for 12A#@&!'# special revie3 is essential. The level of involvement by the R#!DR&! 3ith medical malpractice claims management and duties appropriate to the respective staff members 3ill be coordinated 3ith the 12A#@&!'# and as directed by the R#!DR&! commander. -. Responsibilities of 12A#@&!'# "#&. The 12A#@&!'# "#& serves as the office of record for medical malpractice claims data and is responsible for corporate oversight of the medical malpractice processes 3ithin the A#@&&. 2pecific duties include coordinationDoversight ofEE (+) The &l n &al e:per! re/ e>. The disciplineDspecialty revie3er provides T20 e6pert clinical revie3 related to the (uality of care associated 3ith a malpractice claimDdeath or disability of a military member. This revie3 3hich replaces the revie3 previously performed by the !onsultation !ase Revie3 ?ranch (!!R?) may be provided in a 3ritten report of findings or via participation as a member of the special revie3 panel (2R$). %f a 3ritten report is submitted it 3ill include an 2'! determination for significantly involved providers of the same discipline. %n instances 3here a provider is deemed to have L/ot #etM 2'! or L%ndeterminateM is selected the rationale for said determination 3ill be e6plained.
4o!e. &ue to the disbanding of the "#& !!R? malpractice cases processed by the 12A#@&!'# after + July 200) do not re(uire !!R? revie3.

(2) The e:!ernal peer re/ e>. The 12A#@&!'# "#& ensures that the e6ternal revie3 (&'& )02*.+,-R) is conducted utili4ing the peer revie3 organi4ation designated by the 'A2&(9A). (,) The S%5. The 12A#@&!'# 2R$ comprised of senior military clinicians is convened to revie3 paid medical malpractice claims as 3ell as medically related disabilities and deaths involving military members. g. The 12A#@&!'# 2R$ procedures and functions. (+) 5anel &ompo" ! on. The 2R$ 3ill consist of at least three privileged providersA a senior military physician 3ill serve as the chairperson. The panel 3ill include a minimum of one member of the same specialty (privileged healthcare provider under revie3) or discipline (nonEprivileged healthcare provider under revie3). All participants 3ill vote unless for some reason an individual elects to recuse himDherself. %n lieu of actual 2R$ participation a 3ritten revie3 by a clinical e6pert of the same specialty or discipline as described in paragraph +,-*e(+) 3ill suffice. (2) %e/ e> pro&edure". (a) The 2R$ activities are administrative in natureA therefore rules of evidence prescribed for trials by courtsEmartial or for civil court proceedings are not applicable (see para .-9b(,)(b)). (b) A file that includes the investigative andDor fact finding report(s) the various peer revie3s (#T< clinical e6pert &'& e6ternal) the summary of the administrative claim ad7udication andDor litigation disposition documents and any relevant clinical records is compiled for each 2R$ member. (c) The significantly involved healthcare provider under revie3 3ill be notified of the forthcoming 2R$ and afforded time (usually +* duty days) to submit additional information on hisDher behalf to 9ead(uarters 12A#@&!'# (#!9'-!;-") 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0. (d) The 2R$ 3ill revie3 all documents presented and any 3ritten comments submitted for consideration by the involved provider and the results of all 2'! revie3s to date and render its determination. (e) According to &'& )02*.+,ER T20 may delegate /$&? reporting authority to a senior 12A#@&!'#
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physician revie3er. %n cases 3here there is consensus for reporting among lo3er level revie3s (#T< clinical e6pert or other agency as designated by 'A2&(9A)) the 2R$ 3ill render the final 2'! determination. The report to the /$&? in this instance is made at the direction of the 2R$. (-, %n cases for 3hich there is disagreement for reporting among lo3er level revie3s the 2R$ 3ill document its 2'! determination and recommendation to T20 for provider reporting to the /$&? as appropriate. The case 3ill be evaluated by the 12A#@&!'# 2JA for legal sufficiency to support a report to the /$&? or other regulatory agencies. All relevant case documents are then for3arded for final revie3 and decision by T20. 58>2 Management o' medical;dental records !omplete and accurate medical records are the best defense in the event of patient careErelated litigation. #edical records management is a critical factor in loss prevention and medical malpractice claims resolution. a. %n all situations identified as $!@s or malpracticeDdisability claims original medicalDdental records 3ill not be released directly to the beneficiary or hisDher authori4ed representative. The !JA or 12AR!2 as appropriate may release copies of the records. This does not apply to cases in 3hich the claim is being filed 3ith an individual or agency outside the 1.2. 0overnment. (2ee AR .0-)) for additional medicalDdental records management information.) b. 'riginal records andDor other documents 3ill not be released unless re(uested by a 1.2. 0overnment attorney defending the 1. 2. in a malpractice la3suit. The recordsDdocuments 3ill be released only per AR ,.0-2+ AR 2*-** and AR 2C-20. Any re(uest for medicalDdental records must be in 3riting and must specify the treatment dates and the names of the #T<s involved. Release of medicalDdental records is limited to records defined in AR .0-)). c. 'ther records reports and any specimens maintained by #T< departments services and clinics (for e6ample 6E rays 3et tissue paraffin bloc5s microscopic slides surgical and autopsy specimens tumor and death reports and fetal monitoring strips) 3ill be released only upon re(uest by the ;itigation &ivision of the 'ffice of the Judge Advocate 0eneral ('TJA0) or 12AR!2. 0ranting of re(uests for records by the beneficiary or hisDher representative 3ill be at the discretion of the !JA or 12AR!2. d. Hhen medicalDdental records are re(uired by another healthcare facility for beneficiary treatment purposes copies or appropriate e6tracts 3ill be furnished. The 1nited 2tates Army ;egal 2ervices Agency ;itigation &ivision (JA;2;TT) 90+ /orth 2tuart 2treet ?allston 2uite .00 Arlington =A 2220,-+>2+ 3ill be consulted prior to the disposition of these records to the /ational $ersonnel Records !enter 12AR!2 or ;itigation &ivision. e. 2pecial handling 3ill be provided to medicalDdental records involved in litigation or ad7udication to ensure accuracy and correlation of evidential documentation. There 3ill be strict adherence to the follo3ing practices. (+) $rior to any action (for e6ample photocopyA release to local !JAA transmittal to ;itigation &ivision 'TJA0A or response to subpoena) the original medicalDdental record 3ill be revie3ed for completeness by $A& or the &@/TA! and assembled as prescribed in AR .0-)). (2) #edicalDdental records involved in litigation or ad7udication re(uire special safeguarding by $A& or by the &T< commander. %f practical they 3ill be maintained separately from other medicalDdental records. <or accountability purposes portions of records (for e6ample reports of special e6amination) that may be in another location 3ill be crossE referenced by an annotation in the basic record (for e6ample on 2< )00 as prescribed in AR .0-))). (,) $A& is the only location in the #T< (dental commanders 3ill designate 3ho has responsibility for this function) 3here an authenticated photocopy of a medicalDdental record 3ill be made for purposes cited in this regulation. There 3ill be a legible photocopy page to correspond to every original page in the medicalDdental record. All pages of the medicalDdental record 3ill be numbered consecutively prior to photocopying. (.) Hhen medicalDdental records are released to the !JA or to 12AR!2 $A& or the &T< commander (designee) 3ill append the appropriate staff signatureDinitial verification list to the record. (*) !opies of all correspondence concerning the case 3ill be appended to the record. !opies of this same corre E spondence 3ill also be maintained by the !JA.

C(apter 54 Reporting and Releasing Adverse 3rivileging;3ractice or Malpractice n'ormation

5452 @eneral A variety of national agencies and clearinghouses e6ist to 3hich the A#@&& must report information such as malpractice payments licensure disciplinary actions adverse clinical privileging actions and unfavorable actions affecting professional society membership. Adverse professional peer revie3 actions ta5en against any healthcare personnel must be reported. %n addition 2tate regulatory agencies responsible for licensure certification or registration re(uire notification of the follo3ingF substantiated unprofessional conduct or behavior (see app %) any actions ta5en to restrict or other3ise constrain the professional privilegesDscope of practice of healthcare personnel and malpractice settlements on behalf of healthcare personnel.

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54#2 Military treatment 'acility responsi,ilities 'or providing in'ormation a. %e9ue"!" -or rou! ne n-orma! on. #T<s often receive re(uests for information involving an application for employment andDor clinical privileges at a civilian facility by currently or previously assigned providersDprofessionals. The #T< may reply to nonE&'& re(uests for information from a provider8sDprofessional8s records only if the individual in (uestion has authori4ed disclosure of said information to the re(uesting civilian agencyDinstitution by signed and dated release according to AR 2*-** and AR ,.0-2+. %f the #T< no longer has information on file regarding a provider or professional 3ho has retiredDseparated from military service the re(uest and the individual8s authori4ation for release of information may be for3arded to !ommander A9R!-2t. ;ouis (9uman Resources !ommand) (A9R!-R2A-") + Reserve Hay 2t. ;ouis #' ),+,2-*200. b. %e9ue"!" -or ad/er"e pr / leg ng7pra&! &e a&! on or malpra&! &e h "!or$ n-orma! on. Re(uests to the #T< from outside agencies for release of adverse privileging information including (ueries from 0$9@ programs or malpractice history information 3ill be for3arded directly to the !ommander 12A#@&!'# (#!9'-!;-") 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0 for response. %ndividuals 3ho are the sub7ect of any information released under this regulation are entitled to a copy of that same information. The providerDprofessional must authori4eGin 3ritingGthe release of adverse privilegingDpractice action information or malpractice history by the "#& to prospec tive employers or insurers. 5482 7(e Surgeon @eneral responsi,ilities in reporta,le actions The 2urgeon 0eneral is the sole reporting authority to the /$&? 2tate regulatory authorities the <ederation of 2tate #edical ?oards andDor other appropriate central clearinghouses. T20 is responsible for reporting malpractice history information and adverse privileging actions unprofessional conduct or behavior and any legal charges for 3hich the providerDprofessional is found guilty pleads guilty pleads nolo contendere or re(uests discharge from the military in lieu of courtsEmartial. T20 3ill not report to professional regulatory agencies or to any other agencies adverse privileging actions malpractice payments or any civilian court actions involving a 12ARDAR/0 provider8s behavior or conduct 3hich occurs during other than hisDher military duty. #T< documentation in support of reports to the /$&? 2tate regulatory agencies the <ederation of 2tate #edical ?oards or other bodies 3ill be for3arded directly to !ommander 12A#@&!'# (#!9'-!;-") 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0. a. 'alpra&! &e &la m" repor!ed !o !he 45*@. (+) $; 99-))0 (The 9ealthcare "uality %mprovement Act of +9>)) provides for reporting to the /$&? malpractice claims resulting in monetary settlements and certain professional revie3 actions. 9ealthcare providersDprofessionals 3ill be reported 3hether licensed or pending licensure. $rotection is ensured (+0 12! ++02) for those submitting information to a professional revie3 body the /$&? or other regulatory agency unless such information is false and the person providing the information had 5no3ledge that it 3as false. (2) %n a malpractice case the follo3ing criteria 3ill be used by the 12A#@&!'# "#& 2R$ to support a recommendation to T20 to report the provider in (uestion to the /$&? or to the &efense $ractitioner &ata ?an5 (&$&?) for events involving personal in7ury or death of a military member as a result of medical care.
4o!e. The &$&? is composed of the various dataDreports released to &'& via the !!"A2 ris5 management module.

omission that 3as the cause of a harm that gave rise to payment. (c) %n instances involving a healthcare trainee hisDher act(s) of omission or commission 3ere not reasonably foreseeable by the supervisor or the trainee acted outside hisDher established scope of practice. (d) %n instances involving a healthcare trainee the supervising provider failed to meet reasonable standards of supervision. (,) The 2R$ recommendation to T20 based on a ma7ority vote and any supporting comments including the recommendations of the clinical e6pert participants 3ill be prepared by the 12A#@&!'# "#&. The 12A#@& !'# 2JA 3ill be consulted for legal sufficiency before /$&? or &$&? reporting. (.) The individual 3ill be provided 3ritten notification that a report 3as or 3as not submitted to the /$&? or &$&?. (*) The reporting of healthcare personnel (privileged or nonEprivileged) is an administrative processA therefore full due process procedures are not applicable. ()) A copy of the /$&? report 3ill beG (a) <or3arded to all 2tates of 5no3n providerDprofessional licensure. (b) #aintained on file by the 12A#@&!'# "#&. (c) <or3arded by certified return receipt re(uested mail to the individual involved. b. #d/er"e pr / leg ng7pra&! &e a&! on" repor!ed !o !he 45*@ or !o S!a!e regula!or$ agen& e". (+) $rivileged providersDprofessionals 3ill be reported to the /$&? or to a 2tate regulatory agency 3ithin ,0 calendar days of approval 3hen any of the follo3ing occurG (a, !linical privileges have been denied due to lac5 of (ualifications or a restriction reduction suspension or

(a) The providerDprofessional or trainee deviated from the 2'! in the act of commission or omission. (b) #onetary payment 3as made and the providerDprofessional or trainee 3as responsible for an act of commission or

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revocation for substandard performance impairment 3ith refusal to see5 treatment or unprofessional conduct has occurred. Any adverse privileging action longer than ,0 days in duration 3ill be reported. 9o3ever a report to the /$&? 3ill not occur until the individual8s appeal if re(uested is completed. (b) The providerDprofessional voluntarily surrenders hisDher clinical privileges or voluntarily re(uests a limitation of scope of practice 3hile under investigation for issues of competence or conduct. (c) The providerDprofessional 3ith an adverse privileging action in effect or limited scope of practice elects to separate from military service retire or terminate hisDher employment (02 or contract) or volunteer service rather than to contest the adverse privilegingDpractice action. (d) The provider 3ith suspended privileges or the professional 3ith a limited scope of practice 3ho is enrolled in rehabilitation for alcohol or other substance abuse fails to satisfactorily complete the program or electively leaves <ederal service prior to completing the rehabilitation program. (This does not preclude reporting to other professional regulating authorities as noted in para c belo3.) Any adverse privilegingDpractice action ta5en against the providerD professional in rehabilitation for professional incompetence patient endangerment or unprofessional conduct 3ill be reported. (2) A copy of the /$&? report of an adverse privilegingDpractice action 3ill be for3arded toG (a) 2tates of 5no3n providerDprofessional licensure. (b) The individual involved at hisDher last 5no3n address. (,) #aintenance of the /$&? report of adverse privilegingDpractice action 3ill be as follo3sF (a) A copy of the report to the /$&? 3ill be included in the $!< or for the nonprivileged individual in the confidential counseling file maintained by the first line supervisor. (b) !opies of && <orms 2.99 and 2*2) associated 3ith the /$&? report 3ill also be included in the $!< or the nonprivileged individual8s confidential counseling file. &. #dm n "!ra! /e a&! on" repor!ed !o S!a!e regula!or$ agen& e". %n addition to reporting adverse privilegingDpractice actions noted above administrative actions may be reported by T20 to 2tate regulatory agencies. A privileged providerDprofessional 3ill be reported if heDsheG (+) %s separated under any administrative discharge authority. (2) %s separatedDremoved from medical care responsibilities follo3ing appropriate due process procedures for physical or mental limitations that affect hisDher ability to provide (uality patient care. (,) 9as a medical condition that affects hisDher ability to render safe patient care (includes individuals 3ho voluntarily limit their practice for medical reasons). (.) %s found guilty pleads guilty or nolo contendere separates from the 2ervice in lieu of further administrative or legal action or separates follo3ing a voluntary 3ritten confession or admission of any of the reportable acts of misconduct listed in appendi6 % or similar unprofessional actions. (*) !ommits any other act not other3ise covered by the provisions of this regulation 3hich is reportable according to 2tate licensing statutes or regulations. 5442 7(e %ealt(care ntegrity and 3rotection !ata Ban? The 9ealth %nsurance $ortability and Accountability Act of +99) established the 9%$&? as a fraud and abuse data collection program for the reporting and disclosure of certain final unfavorable actions ta5en against healthcare providers suppliers or practitioners. The A#@&& is re(uired to report to the 9%$&? a broad range of Ladverse privilegingDpractice actionsM affecting &'& healthcare personnel as 3ell as members of the civilian provider community involved in TR%!AR@. a. %epor! ng re"pon" b l !$. 9ealth Affairs #emorandum &'& $articipation in the 9%$&? ,+ 'ctober 2000 outlines the follo3ing reporting responsibilities by T20 and other <ederal agencies. (+) T20 is responsible for reporting to the 9%$&? adverse privilegingDpractice or administrative actions ta5en against healthcare providers suppliers or practitioners providing healthcare services to A& members or any other #92 beneficiaries in #T<s or as part of any military unit. !linical privileging actions against physicians and dentists are e6cluded from this reporting re(uirement. These actions are reportable to the /$&? as noted in paragraph +.-, b. The follo3ing 3ill be reported to the 9%$&?F (a) #d/er"e pr / leg ng7pra&! &e a&! on". Adverse privilegingDpractice actions against healthcare practitioners other than physicians and dentists. (b) UC'. a&! on". Adverse convictions under the 1!#J as approved by the courtsEmartial convening authority (or final non7udicial punishment under the 1!#J) of a healthcare provider supplier or practitioner in a case in 3hich the acts or omissions of the member convicted 3ere related to the delivery of a healthcare item or service. (c) +!her ad2ud &a!ed a&! on" or de& " on". The follo3ing actions are reportable if they are against a healthcare provider supplier or practitioner based on acts or omissions that affect the payment provision or delivery of a healthcare item or serviceF 1. #d/er"e per"onnel a&! on" a--e&! ng m l !ar$ member". Any administrative action resulting in separation reduction in grade involuntary military occupational specialty classification or other administrative action.

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personal services or nonEpersonal services contractor. (2) Reports to the 9%$&? by T20 3ill also be for3arded to the &epartment of ;egal #edicine of the A<%$. (,) &esignated debarring officials of the military departments and the &efense ;ogistics Agency are re(uired to report to the 9%$&? any contract debarments or suspensions arising from any &'& healthcare program contracts 3ith any healthcare provider supplier or practitioner. b. 'e!hod" and pro&edure" -or ;05*@ repor!". %n filing reports 3ith the 9%$&? the methods and procedures 3ill be according to those described on Heb siteF 333.bhpr.hrsa.govDd(a.

2. #d/er"e & / l an per"onnel a&! on". Any adverse personnel action under !hapter C* or Title * 12!. ,. Con!ra&! !erm na! on -or de-aul!. A contract termination for default ta5en by an #T< or medical command against a

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Appendi4 A Re'erences
Section Re&uired 3u,lications Army regulations are available online from the A$& Heb site at httpFDD333.apd.army.mil. $ublic la3s may be accessed at httpFDD333.gpoaccess.govDpla3sDinde6.html. &'& directives and instructions are available at httpFDD 333.dtic.milD3hsDdirectives. &'& 9ealth Affairs policies are available at httpFDD333.ha.osd.milDpoliciesDdefault.cfm. AR 156 $rocedures for %nvestigating 'fficers and ?oards of 'fficers (!ited in paras C-+) &(C) +0-)d(2)(b) +0->a(+) (,) and ?-,.) AR 2555 The &epartment of the Army <reedom of %nformation Act $rogram (!ited in paras +,-) b +.-2 a .) AR 254002 The Army Records %nformation #anagement 2ystem (AR%#2). (!ited in paras +2-) & +,-.a(2) -*b(*) and @-*d(+).) AR 4066 #edical Record Administration and 9ealthcare &ocumentation. (!ited in paras C-.&(2) C-+)&(+)(&) C-+)&(+)(d) C+)&(+)(-) C-+)&(2)(-) 9-.h(+)(b) +,-)a +,-)b +,-)e(+) and +,-)e(2).) AR 40501 2tandards of #edical <itness. (!ited in paras C-.&(2) C-.&(,) C-+,&(2)(a)* C-+)&(.)(a) C-+)&(*) C-+)&(>)(a)* and C-+C&(2)(a)..) AR 135175 2eparation of 'fficers. (!ited in paras .-+0 a ()) 9-. - (>) +0-+2 a and +0-+) d .) AR 135178 @nlisted Administrative 2eparations. (!ited in para .-+0 a()) and +0-+2 a.) AR 34021 The Army $rivacy $rogram. (!ited in paras >-, b(2)(a) >-C >-9& ++-*&(,)(a). +,-.a(2) +,-)b +.-2a and @-+.) AR 3513 $rofessional @ducation and Training $rograms of the Army #edical &epartment. (!ited in paras CE2 e and >-C n.) AR 60082 2uspension of <avorable $ersonnel Actions (<lags). (!ited in paras .-+0 a (+) and +0-+,.) AR 600824 'fficer Transfers and &ischarges. (!ited in paras .-+0 a ()) C-+) b (2)( &) 9-. - (>) 9-C a +0-+2 a and +0-+,.) AR 60085 Army 2ubstance Abuse $rogram. (!ited in paras ++-2 a ++-, ++-*& ++-*&(,)(a). ++-*&(C)(&) and ++-*&(>)(b).) AR 60810 !hild &evelopment 2ervices. (!ited in para 9-. b(+)( - ).) AR 614100 'fficer Assignment $olicies &etails and Transfers. (!ited in paras C-+) b (2)( a) and C-+)b (2)( &).) AR 6233 @valuation Reporting 2ystem. (!ited in para C-+) e(+)( g).) AR 635200 Active &uty @nlisted Administrative 2eparations. (!ited in paras .-+0 a()) and +0-+2 a .)

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DA a! 60085 Army 2ubstance Abuse $rogram !ivilian 2ervices. (!ited in para ++-2 a .) DA a! 61121 #ilitary 'ccupational !lassification and 2tructure. (!ited in paras .-. a (+) and C-9 b(+) through (.).) D"D 6025#13R !linical "uality #anagement $rogram (!"#$) in the #ilitary 9ealth 2ervices 2ystem (#922). (!ited in paras +-. a(2) +-.2(2)(i) 2-)&andg .-2a +2-+0 +,-2a(.) +,-.b +,-*b()) +,-)b(,)(b) +,-)-(2) and +,-)g(2)(e).) D"D$ 1332#38 $hysical &isability @valuation. (!ited in para +,-. b (+).) D"D$ 1402#5 !riminal 9istory ?ac5ground !hec5s on %ndividuals in !hild !are 2ervices. (!ited in paras >-C o(,) <-,d(.) and <..) D"D$ 6025#16 $ortability of 2tate ;icensure for 9ealthcare $rofessionals. (!ited in para .-* a .) D"D$ 6055#1 &o& 2afety and 'ccupational 9ealth (2'9) $rogram. (!ited in para +-. 2 (C)( e ).) ) D"D$ 64%0#4 Re(uirements for #ental 9ealth @valuations of #embers of the Armed <orces. (!ited in paras ++-, &(+)(b) and ++.a(+).) &ealt' A((airs olic) 05002 9ealth %nsurance $ortability and Accountability Act /ational $rovider @numeration $olicy for #ilitary 9ealth 2ystem %ndividual (Type +) 9ealthcare $roviders 2) January 200*. (!ited in para >-C r.) (Available at httpFDD333.ha.osd.milD policiesDdefault.cfm.) &ealt' A((airs olic) 00000% &o& $articipation in the 9ealth %ntegrity and $rotection &ata ?an5. (!ited in para +.-..) 'btain online at httpFDD 333.ha.osd.milDpoliciesDdefault.cfm. &ealt' A((airs *e!orandu! Additional 0uidance Regarding &o& $olicy on $hysician ;icensure 2> 2eptember +999. (!ited in para .-) g.) 'btain online at httpFDD333.ha.osd.milDpoliciesDdefault.cfm. &ealt' A((airs *e!orandu! @6panded 1se of %nterE<acility !redentials Transfer ?rief (%!T?) ++ &ecember +99*. (!ited in para >-+0 a.) 'btain online at httpFDD333.ha.osd.milDpoliciesDdefault.cfm. &ealt' A((airs olic) %4004 &o& %nterE<acility !redentials Transfer and $rivileging. (!ited in para >-+0a.) 'btain online at httpFDD333.ha.osd.milD policiesDdefault.cfm. &ealt' A((airs olic) %8015 $olicy for $rovider &irectories. (!ited in para 2-. a(C).) 'btain online at httpFDD333.ha.osd.milDpoliciesDdefault.cfm. &ealt' A((airs olic) %%007 &o& $olicy on $hysician ;icensure. (!ited in paras .-) g(+) and .-Ca.) 'btain online at httpFDD333.ha.osd.milD policiesDdefault.cfm. "((ice o( ersonnel *anage!ent "ualification 2tandardsA 0eneral 2chedule $ositions. (!ited in para .-. a(+).) ('btain at httpFDD333.opm.govD (ualificationsDinde6.html.)

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+'e ,oint -o!!ission *anuals !omprehensive Accreditation #anual for 9ospitalsF Ambulatory !are #anual 9ome !are #anual ;ong Term !are #anual 9ealthcare /et3or5s #anual ?ehavioral 9ealth #anual $athology and !linical ;aboratory #anual. (!ited in paras ,-2 ,-)b(2) and J-.b.) (The current editions of the seven publications listed above may be obtained from TJ! 'ne Renaissance ?oulevard 'a5broo5 Terrace %; )0+>+.) Section Related 3u,lications A related publication is a source of additional information. The user does not have to read a related reference to understand this publication. The $ublic ;a3s and the 1.2. !ode are available at httpFDD333.gpoaccess.govDinde6.html. &'& directives are available online at httpFDD333.dtic.milD3hsDdirectives. Ar!ed .orces /nstitute o( at'olog) 0A./ 1 a!p'let 4024 Technical %nstructions for the &o& !linical ;aboratory %mprovement $rogram. ('btain at httpFDD333.afip.orgD'!;A?D formsD$A#.0E2.2002.pdf.) AR 151 !ommittee #anagement AR 201 %nspector 0eneral Activities and $rocedures AR 273 The Army ;egal Assistance $rogram AR 2720 !laims AR 2740 ;itigation AR 401 !omposition #ission and <unctions of the Army #edical &epartment AR 403 #edical &ental and =eterinary !are AR 4061 #edical ;ogistics $olicies AR 40400 $atient Administration AR 135101 Appointment of Reserve !ommissioned 'fficers for Assignment to Army #edical &epartment ?ranches AR 1%030 #ilitary $olice %nvestigations AR 38510 The Army 2afety $rogram AR 600811 Reassignment AR 60020 Army !ommand $olicy AR 600106 <lying 2tatus for /onrated Army Aviation $ersonnel

AR 4068 0 6 !ebruary 004

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AR 60120 %nterservice $hysician Assistant Training $rogram AR 60818 The Army <amily Advocacy $rogram -linical 2lectrop')siologic ')sical +'erap)3 Description o( Advanced ractice Ale6andria =AF American $hysical Therapy Association (+99*). ('btain at httpFDD333.apta.orgD@ducationDspecialistD A?$T2!ertDdscptQadvancedQclnQprt.) Diagnostic and 4tatistical *anual o( *ental Disorders (This publication may be obtained from The American $sychiatric Association +C00 +>th 2treet /H Hashington &! 20009.) D"DD 5154#24 Armed <orces %nstitute of $athology (A<%$) D"DD 6000#14 $atient ?ill of Rights and Responsibilities in the #ilitary 9ealth 2ystem (#92) D"DD 6025#13 #edical "uality Assurance (#"A) in the #ilitary 9ealth 2ervice (#92) . #ay 200.. D"DD 6465#3 'rgan and Tissue &onation D"DD 64%0#1 #ental 9ealth @valuations of #embers of the Armed <orces /-D%-* %nternational !lassification of &iseases (%!&)E/inth RevisionE!linical #odification. (!opies of this ,Evolume set may be obtained from the 2uperintendent of &ocuments 0overnment $rinting 'ffice Hashington &! 20.02-9,2*.) *anual o( -linical Dietetics American &ietetic Association. ('btain at httpFDD333.eatright.org .) "ut o( t'e -risis &eming H.@. !ambridge #AF #assachusetts %nstitute of Technology. ('btain at httpFDD333.deming.edu .) 5 %%660 The 9ealthcare "uality %mprovement Act of +9>) 5 %%661 The /ational &efense Authori4ation Act for <iscal Iear +9>C 5 10162% 2afe #edical &evices Act of +990 5 101647 !rime !ontrol Act (!!A) of +990 5 1041%1 The 9ealth %nsurance $ortability and Accountability Act of +99) +itle 56 -ode o( .ederal Regulations Administrative $ersonnel. ('btain at httpFDD333.access.gpo.govDnaraDcfrD.) +itle 216 -ode o( .ederal Regulations <ood and &rugs. ('btain at httpFDD333.access.gpo.govDnaraDcfrD.)

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AR 4068 0 6 !ebruary 004

Section 3rescri,ed +orms @6cept 3here other3ise indicated belo3 the follo3ing forms are available as follo3sF &A forms are available on the Army $ublishing &irectorate8s (A$&) Heb site (httpFDD333.apd.army.mil)A && forms are available on the 'ffice of the 2ecretary of &efense Heb site (httpFDD3eb+.3hy.osd.milDicdhomeDicdhome.htm). DA .or! 4106 %ncident Report. ($rescribed in paras +2-. b (+) (2) (,) (.)A +2-> &(.)A +2-> d (2)A and +,-. a (2).) DA .or! 46%1 %nitial Application for !linical $rivileges and 2taff Appointment. ($rescribed in paras >-C b(+)A 9-.a(+) (>)A 9-.b(+)(a)A 9-.b(,) (*)A 9-*aA 9->a(+) (,)A @->a(+)A and 0-,a.) DA .or! 46%11 Application for Rene3al of !linical $rivileges and 2taff Appointment. ($rescribed in paras 9-2 &(+)(a)A 9-.a(2) (>)A 9.&(,) (>)A 9-)a(2) (,)A and @->a()).) DA .or! 500% #edical RecordGRelease Against #edical Advice. ($rescribed in para +2-> &(2).) DA .or! 5374 $erformance Assessment. ($rescribed in paras ,-)b(2)(e)A *-,&(,)(a)A C-,aA >-++bA 9-.a(,)A 9-.b(+)(&)A 9-.&(,)A 9.&(,)(&)A 9-.d(+) (2) (,)A 9-.h(.)(a)A 9-. (,)A 9->d(2) (*)A +0-.&A @-)(2) (,)A @->b(+)A @->eA 9-,a(>)) DA .or! 5440 4eries &elineation of !linical $rivilegesG (/oteF <orms included in this series begin 3ith &A <orm *..0 and end 3ith &A <orm *..0-*> as listed belo3.) ($rescribed in paras C-+b(2)A C-2dA C-.g(,)(b)A C-9&(2)A >-C A >-+0&(+) (,) A >++b(+)A9-+dA 9-.a(.) (*) (C)A9-.b(+) through (*)A 9-.&(,) (.) (>)A 9-.g(+) (2)A 9-.h(.)A 9->a(,)A 9->&(,)A +0-.&A @>a(2)A @->eA <-,aA 0-,aA and 9-,&(+). ) DA .or! 5440A Approval of !linical $rivilegesD2taff Appointment. ($rescribed in paras C-+bA >-*d(+)A >-+0&(2)A >-++b(.)A 9-.a())A 9.b(.) (*)A 9-.&(.) (>)A 9-.e(.)A 9-.h(.)A 9-*eA 9-)a(,)A 9->b(*)A 9->a(,)A @->a(,)A and 9-,&(.).) DA .or! 5440 &elineation of !linical $rivilegesGAnesthesia. ($rescribed in para 9-. a(.).) DA .or! 54401 &elineation of !linical $rivilegesG&entistry. ($rescribed in para 9-. a(.).) DA .or! 54402 &elineation of !linical $rivilegesG<amily $ractice. ($rescribed in para 9-. a(.).) DA .or! 54403 &elineation of !linical $rivilegesG%nternal #edicine. ($rescribed in para 9-. a (.).) DA .or! 54404 &elineation of !linical $rivilegesG/eurology. ($rescribed in para 9-. a(.).) DA .or! 54405 &elineation of !linical $rivilegesG'bstetrics and 0ynecology. ($rescribed in para 9-. a(.).) DA .or! 54406 &elineation of !linical $rivilegesG'ptometry. ($rescribed in para 9-. a(.).) DA .or! 54407 &elineation of !linical $rivilegesG$athology. ($rescribed in para 9-. a(.).) DA .or! 54408 &elineation of !linical $rivilegesG$ediatrics. ($rescribed in para 9-. a(.).)

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DA .or! 5440% &elineation of !linical $rivilegesG$odiatry. ($rescribed in para 9-. a(.).) DA .or! 544010 &elineation of !linical $rivilegesG$sychiatry. ($rescribed in para 9-. a(.).) DA .or! 544011 &elineation of !linical $rivilegesG$sychology. ($rescribed in para 9-. a(.).) DA .or! 544012 &elineation of !linical $rivilegesG&iagnostic Radiology. ($rescribed in para 9-. a(.).) DA .or! 544013 &elineation of !linical $rivilegesG0eneral 2urgery. ($rescribed in para 9-. a(.).) DA .or! 544014 &elineation of !linical $rivilegesG/urse Anesthetist. ($rescribed in para 9-. a(.).) DA .or! 544015 &elineation of !linical $rivilegesG!ertified /urse #id3ife. ($rescribed in para 9-. a(.).) DA .or! 544016 &elineation of !linical $rivilegesG/urse $ractitioner. ($rescribed in para 9-. a(.).) DA .or! 544018 &elineation of !linical $rivilegesG$hysician Assistant. ($rescribed in para 9-. a(.).) DA .or! 54401% &elineation of !linical $rivilegesG&ietetics. ($rescribed in para 9-. a(.).) DA .or! 544020 &elineation of !linical $rivilegesG'ccupational Therapy. ($rescribed in para 9-. a(.).) DA .or! 544021 &elineation of !linical $rivilegesG$hysical Therapy. ($rescribed in para 9-. a (.).) DA .or! 544022 &elineation of !linical $rivileges. ($rescribed in para 9-. a(.).) DA .or! 544023 &elineation of !linical $rivilegesG@mergency #edicine. ($rescribed in para 9-. a (.).) DA .or! 544024 &elineation of !linical $rivilegesGAerospace #edicine. ($rescribed in para 9-. a(.).) DA .or! 544025 &elineation of !linical $rivilegesG0eneral #edical 'fficer. ($rescribed in para 9-. a(.).) DA .or! 544028 &elineation of !linical $rivilegesG2ocial Hor5. ($rescribed in para 9-. a (.).) DA .or! 54402% &elineation of !linical $rivilegesGAllergyD%mmunology. ($rescribed in para 9-. a(.).) DA .or! 544030 &elineation of !linical $rivilegesE/ephrology. ($rescribed in para 9-. a(.).) DA .or! 544031 &elineation of !linical $rivilegesE!hiropractic. ($rescribed in para 9-. a(.).)

AR 4068 0 6 !ebruary 004

DA .or! 544032 &elineation of !linical $rivilegesE&ermatology. ($rescribed in para 9-. a(.).) DA .or! 544033 &elineation of !linical $rivilegesE1rology. ($rescribed in para 9-. a(.).) DA .or! 544034 &elineation of !linical $rivilegesG?ehavioral 9ealth $ractitioner. ($rescribed in para 9-. a (.).) DA .or! 544035 &elineation of !linical $rivilegesG$sychological Associate. ($rescribed in para 9-. a(.).) DA .or! 544036 &elineation of !linical $rivilegesEAudiology. ($rescribed in para 9-. a(.).) DA .or! 544037 &elineation of !linical $rivilegesG2peech $athology. ($rescribed in para 9-. a(.).) DA .or! 544038 &elineation of !linical $rivilegesG!linical $harmacy. ($rescribed in para 9-. a(.).) DA .or! 54403% &elineation of !linical $rivilegesG/uclear #edicine. ($rescribed in para 9-. a (.).) DA .or! 544040 &elineation of !linical $rivilegesGTherapeutic Radiology. ($rescribed in para 9-. a(.).) DA .or! 544041 &elineation of !linical $rivilegesG$hysical #edicine and Rehabilitation. ($rescribed in para 9-. a(.).) DA .or! 544042 &elineation of !linical $rivilegesE!ardiology. ($rescribed in para 9-. a(.).) DA .or! 544043 &elineation of !linical $rivilegesE'phthalmology. ($rescribed in para 9-. a(.).) DA .or! 544044 &elineation of !linical $rivilegesE'tolaryngology. ($rescribed in para 9-. a(.).) DA .or! 544045 &elineation of !linical $rivilegesE!ardiovascular 2urgery. ($rescribed in para 9-. a(.).) DA .or! 544046 &elineation of !linical $rivilegesG$ulmonary &isease. ($rescribed in para 9-. a(.).) DA .or! 544047 &elineation of !linical $rivilegesG$reventive #edicine. ($rescribed in para 9-. a(.).) DA .or! 544048 &elineation of !linical $rivilegesG 'ral O #a6illofacial 2urgery. ($rescribed in para 9-. a (.).) DA .or! 54404% &elineation of !linical $rivilegesG$lastic 2urgery. ($rescribed in para 9-. a(.).) DA .or! 544050 &elineation of !linical $rivilegesG=ascular 2urgery. ($rescribed in para 9-. a(.).) DA .or! 544051 &elineation of !linical $rivilegesE/eurosurgery. ($rescribed in para 9-. a(.).)

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DA .or! 544052 &elineation of !linical $rivilegesG!ritical !are #edicine. ($rescribed in para 9-. a (.).) DA .or! 544053 &elineation of !linical $rivilegesG'ccupational #edicine. ($rescribed in para 9-. a(.).) DA .or! 544054 &elineation of !linical $rivilegesGThoracic 2urgery. ($rescribed in para 9-. a(.).) DA .or! 544055 &elineation of !linical $rivilegesG'rthopaedic. ($rescribed in para 9-. a(.).) DA .or! 544056 &elineation of !linical $rivilegesG?lood 2ervices. ($rescribed in para 9-. a (.).) DA .or! 544057 &elineation of !linical $rivilegesG$sychiatric Advanced $ractice /urse. ($rescribed in para 9-. a(.).) DA .or! 544058 &elineation of !linical $rivilegesG2ubstance Abuse Rehabilitation. ($rescribed in para 9-. a(.).) DA .or! 5441 4eries @valuation of !linical $rivilegesG . (/oteF <orms included in this series begin 3ith &A <orm *..+ and end 3ith &A <orm *..+-*> as noted belo3.)($rescribed in paras *-,&(,)A C-,aA 9-.a(,) (C)A 9-.b(+)A 9-.&(,) (.) (>)A 9-.d(+) (2) (,)A 9-.h(.)A 9-. (,)A 9->d(2) (*)A +0-.&A @-)A @->a(.)A @->eA 9-,a(9)A and 9-,b(9).) DA .or! 5441 @valuation of !linical $rivilegesGAnesthesia. ($rescribed in para 9-. a(C).) DA .or! 54411 @valuation of !linical $rivilegesG&entistry. ($rescribed in para 9-. a(C).) DA .or! 54412 @valuation of !linical $rivilegesG<amily $ractice. ($rescribed in para 9-. a(C)).) DA .or! 54413 @valuation of !linical $rivilegesG%nternal #edicine. ($rescribed in para 9-. a (C).) DA .or! 54414 @valuation of !linical $rivilegesG/eurology. ($rescribed in para 9-. a(C).) DA .or! 54415 @valuation of !linical $rivilegesG'bstetrics and 0ynecology. ($rescribed in para 9-. a (C).) DA .or! 54416 @valuation of !linical $rivilegesG'ptometry. ($rescribed in para 9-. a(C).) DA .or! 54417 @valuation of !linical $rivilegesG$athology. ($rescribed in para 9-. a(C).) DA .or! 54418 @valuation of !linical $rivilegesG$ediatrics. ($rescribed in para 9-. a(C).) DA .or! 5441% @valuation of !linical $rivilegesG$odiatry. ($rescribed in para 9-. a(C).) DA .or! 544110 @valuation of !linical $rivilegesG$sychiatry. ($rescribed in para 9-. a(C).)

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AR 4068 0 6 !ebruary 004

DA .or! 544111 @valuation of !linical $rivilegesG!linical $sychology. ($rescribed in para 9-. a(C).) DA .or! 544112 @valuation of !linical $rivilegesG&iagnostic Radiology. ($rescribed in para 9-. a(C).) DA .or! 544113 @valuation of !linical $rivilegesG0eneral 2urgery. ($rescribed in para 9-. a(C).) DA .or! 544114 @valuation of !linical $rivilegesG/urse Anesthetist. ($rescribed in para 9-. a(C).) DA .or! 544115 @valuation of !linical $rivilegesG!ertified /urse #id3ife. ($rescribed in para 9-. a(C).) DA .or! 544116 @valuation of !linical $rivilegesG/urse $ractitioner. ($rescribed in para 9-. a (C).) DA .or! 544118 @valuation of !linical $rivilegesG$hysician Assistant. ($rescribed in para 9-. a(C).) DA .or! 54411% @valuation of !linical $rivilegesG&ietetics. ($rescribed in para 9-. a (C).) DA .or! 544120 @valuation of !linical $rivilegesG'ccupational Therapy. ($rescribed in para 9-. a(C).) DA .or! 544121 @valuation of !linical $rivilegesG$hysical Therapy. ($rescribed in para 9-. a(C).) DA .or! 544122 @valuation of !linical $rivileges. ($rescribed in para 9-. a(C).) DA .or! 544123 @valuation of !linical $rivilegesG@mergency #edicine. ($rescribed in para 9-. a(C).) DA .or! 544124 @valuation of !linical $rivilegesGAerospace #edicine. ($rescribed in para 9-. a(C).) DA .or! 544125 @valuation of !linical $rivilegesG0eneral #edical 'fficer. ($rescribed in para 9-. a(C).) DA .or! 544128 @valuation of !linical $rivilegesG2ocial Hor5. ($rescribed in para 9-. a (C).) DA .or! 54412% @valuation of !linical $rivilegesGAllergyD%mmunology. ($rescribed in para 9-. a(C).) DA .or! 544130 @valuation of !linical $rivilegesE/ephrology. ($rescribed in para 9-. a(C).) DA .or! 544131 @valuation of !linical $rivilegesE!hiropractic. ($rescribed in para 9-. a(C).) DA .or! 544132 @valuation of !linical $rivilegesE&ermatology. ($rescribed in para 9-. a(C).) DA .or! 544133 @valuation of !linical $rivilegesE1rology. ($rescribed in para 9-. a(C).)

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DA .or! 544134 @valuation of !linical $rivilegesG?ehavioral 9ealth $ractitioner. ($rescribed in para 9-. a (C).) DA .or! 544135 @valuation of !linical $rivilegesG$sychological Associate. ($rescribed in para 9-. a(C).) DA .or! 544136 @valuation of !linical $rivilegesGAudiology. ($rescribed in para 9-. a(C).) DA .or! 544137 @valuation of !linical $rivilegesG2peech $athology. ($rescribed in para 9-. a(C).) DA .or! 544138 @valuation of !linical $rivilegesG!linical $harmacy. ($rescribed in para 9-. a(C).) DA .or! 54413% @valuation of !linical $rivilegesG/uclear #edicine. ($rescribed in para 9-. a (C).) DA .or! 544140 @valuation of !linical $rivilegesGTherapeutic Radiology. ($rescribed in para 9-. a(C).) DA .or! 544141 @valuation of !linical $rivilegesG$hysical #edicine and Rehabilitation. ($rescribed in para 9-. a(C).) DA .or! 544142 @valuation of !linical $rivilegesE!ardiology. ($rescribed in para 9-. a(C).) DA .or! 544143 @valuation of !linical $rivilegesE'phthalmology. ($rescribed in para 9-. a(C).) DA .or! 544144 @valuation of !linical $rivilegesE'tolaryngology. ($rescribed in para 9-. a(C).) DA .or! 544145 @valuation of !linical $rivilegesG!ardiovascular 2urgery. ($rescribed in para 9-. a(C).) DA .or! 544146 @valuation of !linical $rivilegesG$ulmonary &isease. ($rescribed in para 9-. a(C).) DA .or! 544147 @valuation of !linical $rivilegesG$reventive #edicine. ($rescribed in para 9-. a(C).) DA .or! 544148 @valuation of !linical $rivilegesG'ral O #a6illofacial and 2urgery. ($rescribed in para 9-. a (C).) DA .or! 54414% @valuation of !linical $rivilegesG$lastic 2urgery. ($rescribed in para 9-. a(C).) DA .or! 544150 @valuation of !linical $rivilegesG=ascular 2urgery. ($rescribed in para 9-. a(C).) DA .or! 544151 @valuation of !linical $rivilegesE/eurosurgery. ($rescribed in para 9-. a(C).) DA .or! 544152 @valuation of !linical $rivilegesG!ritical !are #edicine. ($rescribed in para 9-. a (C).) DA .or! 544153 @valuation of !linical $rivilegesG'ccupational #edicine. ($rescribed in para 9-. a(C).)

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DA .or! 544154 @valuation of !linical $rivilegesGThoracic 2urgery. ($rescribed in para 9-. a(C).) DA .or! 544155 @valuation of !linical $rivilegesG'rthopedics. ($rescribed in para 9-. a(C).) DA .or! 544156 @valuation of !linical $rivilegesE?lood 2ervices. ($rescribed in para 9-. a(C).) DA .or! 544157 @valuation of !linical $rivilegesE$sychiatric Advanced $ractice /urse. ($rescribed in para 9-. a (C).) DA .or! 544158 @valuation of !linical $rivilegesEArmy 2ubstance Abuse Rehabilitation. ($rescribed in para 9-. a (C).) DA .or! 5754 #alpractice 9istory and !linical $rivileges "uestionnaire. ($rescribed in paras >-C g,h, A 9-.a(9)A 9-.b(+) (*)A 9-.&(,) (>)A 9->a(,)A @->a(*)A and 0-,a.) DA .or! 7653 =ertification of !linical !ompetencies for !ritical !are 25ill %dentifier (2A >A). ($rescribed in para *-+ a (+).) DA .or! 7654 =ertification of !linical !ompetencies for @mergency /ursing 25ill %dentifier (2% #*). ($rescribed in para *-+ a (+).) DD .or! 24%% 9ealth !are $rovider Action Report. ($rescribed in paras )-.dA )-)bA +0-*-A +0-)a(2)A +0-)b(2)A +0-)&(2)(a) (&)A +0+.aA +0-+.b(+) through (*)A +0-+*a +0-+*& +0-+)b ++-.e(2) ++-)a and +.-,b(2) (b).) DD .or! 2526 !ase Abstract for #alpractice !laims. ($rescribed in paras )-.d +,-.a(+) +,-.b(.) +,-.& +,-.e +,-*b(+) (,) (*) +,-*&(+) (2) +,-)&(2) and +.-,b(,) Section E Re'erenced +orms DA .or! 112R #anagement !ontrol @valuation !ertification 2tatement DA .or! 200 Transmittal Record DA .or! 2028 Recommended !hanges to $ublications and ?lan5 <orms DA .or! 334% $hysical $rofile DA .or! 3647 %npatient Treatment Record !over 2heet DA .or! 3881 Rights Harning $rocedureDHaiver !ertificate DA .or! 4036 #edical and &ental $reparation for 'verseas #ovement DA .or! 4186 #edical Recommendation for <lying &uty

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DA .or! 4256 &octor8s 'rders DA .or! 5181 2creening /ote of Acute #edical !are DA .or! 5753 12AR or AR/0 Application for !linical $rivileges to $erform Active or %nactive &uty Training. (This form is obsolete but if previously completed it 3ill be 5ept for historical purposes in individual files.) DA .or! 738% #edical Record-Anesthesia DA .or! 7653 =erification of !linical !ompetencies for !ritical !are /ursing 25ill %denitifer (2% >A) DA .or! 7654 =erification of !linical !ompetencies for !ritical !are /ursing 25ill %denitifer (2% #*) ". 522 #edical Record-Re(uest for Administration of Anesthesia and for $erformance of 'perations and 'ther $rocedures 4. %5 !laim for &amage %n7ury or &eath 4. 380 Reporting and $rocessing #edical #ateriel !omplaintsD"uality %mprovement Report 4. 504 !linical Record E 9istory $art % 4. 505 !linical Record E 9istory $art %% and %%% 4. 506 #edical Record E $hysical @6amination 4. 50% #edical RecordE$rogress /otes 4. 513 #edical RecordG!onsultation 2heet 4. 600 9ealth RecordG!hronological Record of #edical !are 4. 603 9ealth RecordG&ental 4. 603A 9ealth RecordG&ental-!ontinuation

Appendi4 B Quality Assurance (QA) Con'identiality Statute 'or t(e !9!

B52 Statute overvie= The /ational &efense Authori4ation Act for fiscal year +9>C ($;99-))+) as contained in +0 12! ++02 provides that records created by or for the &'& in a medical or dental "A program are confidential and privileged. This la3 precludes disclosure of or testimony about any "A records or findings recommendations evaluations opinions or

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actions ta5en as part of a "A program e6cept in limited situations. (2ee para ?-).) <urther guidance is provided in &'& )02*.+,-R. The statutory privilege addressed in these documents is designed to improve the (uality of medicalD dental care by encouraging thorough and candid "A evaluation revie3 and reporting processes. B#2 Statute provisions The statuteG a. @stablishes the confidential and privileged nature of "A information. b. $rohibits disclosure of records and testimony concerning the records e6cept in those circumstances as defined in +0 12! ++02 and &'& )02*.+,-R and implemented by this regulation. c. @stablishes penalties for unauthori4ed disclosure. d. $rovides immunity from civil liability for anyone 3ho in good faith participates in or provides information to a person or body engaged in creating or revie3ing medicalDdental "A records. The la3 does not limit access to information in a record created and maintained outside a medicalDdental "A program even though it may be presented to a peer revie3 body and is subse(uently incorporated into a "A record (for e6ample a patient8s medicalDdental record). B82 nclusion as con'idential or privileged To receive coverage under this statute "A activities as 3ell as those documents that (ualify as "A records 3ill be clearly identified. <or e6ample a commander8s investigation under AR +*-) is not normally a "A function 3hile a "A investigation using the format for an AR +*-) investigation 3ould be a "A function. 2imilarly an %0 survey in(uiry or investigation under AR 20-+ is not routinely a "A activity 3hile an %0 survey in(uiry or investigation designated by the commander as a "A survey in(uiry or inspection 3ould be protected as a "A activity. B42 !e'initions speci'ic to &uality assurance a. A Lmedical "A programM is defined in +0 12! ++02 as Lall activities carried out before on or after +. /ovember +9>) by or for the &'& to assess the (uality of medical care.M The statute specifically includes any activity designed to assess the (uality of medical care by individualsA #T<D&T< committees or other revie3 bodies responsible for "A credentials infection control patient care assessment outcomes (including treatment procedures blood drugs and therapeutics)A medicalDdental recordsA health resource management revie3A and identification and prevention of medicalDdental incidents and ris5s. b. A Lmedical "A recordM is defined in +0 12! ++02 as Lthe proceedings records minutes and reports that emanate from "A program activities and are produced or compiled by the &'& as part of a medical "A programM (no3 considered a subset of the !"#$). B<2 7(e QA record as part o' anot(er record "A records do not lose their protected status because they are included as part of other records or reports. <or e6ample 3hen "A records are included as part of %0 !%& or other reports the "A records 3ill not be released under the <'%A or other formal re(uest for information e6cept as specifically outlined in this regulation. "A records 3ill be removed from the report(s) 3hen %0 !%& or other reports are released if disclosure of said "A records is not authori4ed. The investigation record(s) or reports 3ill be annotated that "A contents have been removed pursuant to +0 12! ++02. B62 Aut(ori:ed disclosure or testimony The statute and &'& guidance allo3 for disclosure of a "A record or testimony in connection 3ith such a record only as follo3sF a. A <ederal e6ecutive agency or private organi4ation if the medical "A record(s) or testimony is needed to perform licensing or accreditation functions related to &'& health care facilities or to perform monitoring as re(uired by la3 of &'& health care facilities. b. An administrative or 7udicial proceeding initiated by a present or former &'& health care provider concerning the termination suspension or limitation of hisDher clinical privileges. c. A 0overnment board or agency or a professional health care society or organi4ation if the medicalDdental "A records or testimony is needed to perform licensing credentialing or monitoring of professional standards of any health care providerDprofessional 3ho is or 3as a member contractor contracted employee or an employee of the &'&. d. A hospital #@&!@/ or other institution that provides health care services if the medicalDdental "A records or testimony is needed to assess the professional (ualifications of any health care provider 3ho is or 3as a member or employee of the &'& and 3ho has applied for or has been granted authority or employment to provide health care services in or on behalf of such institution. e. An officer employee or contractor of the &'& 3ho has need for said records or testimony to perform official duties. f. A criminal or civil la3 enforcement agency or instrumentality charged under applicable la3 3ith the protection of

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the public health and safety if a (ualified representative of said agency or instrumentality ma5es a 3ritten re(uest that the records or testimony be provided for a purpose authori4ed by la3. g. An administrative or 7udicial proceeding initiated by a criminal or civil la3 enforcement agency or instrumentality referred to in subparagraph - above but only 3ith respect to the sub7ect of said proceeding.

?-C. Secondary disclosure

The records of the "A activity or testimony given concerning the "A process remain confidential and further disclosure may be made only as specifically provided. This e6tends to any person or entity having possession of or access to "A records or testimony.

?->. Release o' in'ormation

%n no instance 3ill "A records or information be released to anyone other than A#@&& personnel in the performance of their duties 3ithout the 3ritten approval of the #T< commander or T20. Release of "A information outside the &'& re(uires the approval of T20 or his designee. T20 has delegated to the 12A#@&!'# "#& sole responsibility for reporting "AEspecific information to the /$&? and national professional and 2tate licensing certification and registration agencies. #T< commanders should consult 3ith the 2JA or civilian legal adviser concerning (uestions of disclosure of information.

?-9. !isclosure statement

The follo3ing 3ill be included on all "A documents prior to transmittalF L"uality Assurance &ocument under +0 12! ++02. !opies of this document enclosures thereto and information therefrom 3ill not be further released under penalty of the la3. 1nauthori4ed disclosure carries a statutory penalty of not more than N, 000 in the case of a first offense and not more than N20 000 in the case of a subse(uent offense. %n addition to these statutory penalties unauthori4ed disclosure may lead to unfavorable actions under the 1!#J andDor adverse administrative action including separation from military or civilian service.M

?-+0. 3enalty provisions

The penalty provisions specified in the disclosure statement above apply to any person 3ho 3illingly ma5es an unauthori4ed disclosure of protected "A information.

?-++. !eletion o' names 'rom t(e record

All names included in a "A record e6cept the name of the sub7ect of a "A action 3ill be deleted from the record before disclosure outside &'&. The re(uirement to delete names does not apply to information released to the individual 3ho is the sub7ect of a "A action ($rivacy Act * 12! **2a). <ormal minutes (e6cept for the credentials committee) or other "A documents 3ill not refer to a case in a 3ay that 3ill allo3 identification of the patient involved or any health care personnel attending to the patient (for e6ample 22/ registration number provider8s name). A reference number or code to allo3 for trac5ing 3ill be used. "A records should not contain third party 22/s or third party home addresses. %f such information is contained in a record it must be e6punged before release of the record to anyone including the individual 3ho is the sub7ect of a "A action.

?-+2. -se o' t(e +9 A re&uest

Hhile "A records are specifically e6empt from access under the <'%A (* 12! **2a) the processing of a <'%A re(uest is re(uired for authori4ed disclosure of information in any of the circumstances outlined in paragraph ?-). The <'%A re(uest 3ill be for3arded 3ith legible copies of the re(uested "A records to the appropriate initial denial authority. The initial denial authority for "A records is T20.

Appendi4 C Competency Assessment +ile

!-+. !escription
The !A< is used as the repository for information related to individual competence for all nonEprivileged healthcare personnel. 2ee paragraph *-+h for additional information related to competency documentation and use of the !A<.

!-2. Contents and organi:ation

All information contained in the !A< 3ill be filed chronologically 3ith the most recent on top. &ue to the sensitive nature of such information as 22/ address and so forth this personal information should not be included in the !A<. Any counseling or disciplinary records performance appraisals and the li5e should be maintained in the individual8s personnel folder. The !A< 3ill be assembled as follo3sF

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a. Se&! on 0. Job description (ualifications and performance standards for all staff (military 02 contract and volunteer). b. Se&! on 00. ;icense verification and certifications. (+) @vidence of verification of all 2tate licenses 2tate or national certifications andDor registrations. %f said verification is maintained in a centrali4ed location 3ithin the #T< a reliable and confidential mechanism to transmit these data to the !A< manager 3ill be addressed in local policy. ?ecause of the potential for inappropriate use of this sensitive document the individual8s licenseDother authori4ing document 3ill not be 6erographically copied for mainte E nance in the !A< or comparable file. (2) @vidence of mandatory certifications (for e6ample ?;2 A!;2 AT;2 $A;2) as re(uired. (,) @vidence of any national specialty certifications (for e6ample !ertified @mergency /urse) or facilityEspecific certifications (for e6ample chemotherapy administration suturing). &. Se&! on 000. 'rientation and training. (+) @vidence of facility level orientation. (2) @vidence of unit level orientation. (,) @vidence of initial and annual medical readiness training as re(uired and other training according to 12A#@& E !'# TJ! 'ccupational 2afety and 9ealth Administration and other local guidelines. (.) 'ther professional achievements (for e6ample published articles and boo5s committee membership community service). d. Se&! on 0?. %nitial and ongoing competency assessment. (+) )/ den&e o- n ! al &ompe!en&$ a""e""men!. A standardi4ed format 3ith multiple e6amples of competency assessment tools are available for local modification and use at httpsFDDa5m.amedd.army.milDcompetency or httpFDD a5m.amedd.army.milDcompetency. Hhile this format is recommended it is not re(uired for use at the #T< level. (2) )/ den&e o- ongo ng &ompe!en&$ a""e""men!. A standardi4ed format for this re(uirement is li5e3ise available at the Heb sites noted above. Hhile this format is recommended its use at the #T< level is not mandatory. (,) )/ den&e o- age<"pe& - & &ompe!en&$ a""e""men!, - nd &a!ed. AgeEspecific competency tools are available at the Heb sites noted above. These should be used to complement the ongoing training documentation. (.) +!her. 'ther institutionEspecific forms as specified in local policy. e. Se&! on ?. !ontinuing education. (+) @vidence of professional education military and readiness training inservice education related to clinical competence or civilian continuing education unit producing programsDcourses. (2) <or employees 3ith patient care responsibilities evidence of ongoing education related to such topics asF pain management recognition of abuse and neglect patient safety and topics pertinent to the patientEspecific care setting. -. Se&! on ?0. #iscellaneous information. This section may be used for facilityE or unitEspecific re(uirements as specified in local policy. @6amples includeF the individual8s curriculum vitae letters of appreciationDrecognition professional publications and so forth.

Appendi4 ! Special +orces Medical SergeantsA (58!) Scope o' 3ractice in AM0!! M7+s
!52 @eneral The 2pecial <orces #edical 2ergeant (+>&) must maintain a variety of medical s5ills for application in 3orld3ide operational environments 3here no medical officer is available. &uring structured sustainment training in an A#@&& #T< the +>& is authori4ed to perform the follo3ing procedures under the supervision of a privileged providerF a. Air3ay management including intubation and emergency air3ay procedures. b. ?agEvalveEmas5 or bagEvalveEtube ventilatory support. c. $atient immobili4ation and transport. d. $lacement of urinary tract catheter. e. $lacement of nasogastric or orogastric tube. f. #inor surgical procedures for 3ound debridement to drain an abscess or to control hemorrhage. g. Hound suturing. h. @mergency needle and tube thoracostomy. i. Administration of topical inhalation oral subcutaneous intravenous or intramuscular medications. 7. Administration of local regional and intravenous anesthesia for the primary purpose of providing sufficient analgesiaDamnesiaDsedation to allo3 completion of a re(uired surgical or manipulative procedure.

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!#2 3atient assessment training and management s?ills &uring structured sustainment training in an A#@&& #T< the +>& is authori4ed to perform the follo3ing patient assessment and management s5ills under the supervision of a privileged providerF a. $erform assessment of patients and document 9O$ e6amination. b. Triage patients and recommend disposition of patients. &. $erform basic interpretation of plain radiographs of e6tremities chest abdomen spine and pelvis. d. $erform basic interpretation of urinalysis complete blood count 0ram8s stain blood smears and K'9 and saline slide preparations. e. Assess and manage diseases of the mouth and teeth to include uncomplicated dental caries and emergency management of ma6illofacial and dental trauma. -. %nitial management ofG (+) =arious types of 3ounds (lacerations burns blunt in7ury crush in7uries head trauma) and traumatic amputations. (2) <ractures and soft tissue in7uries to include bandaging splinting and casting. (,) 2hoc5 (cardiogenic hemorrhagic septic) to include intravenous access and fluid management. (.) =arious medical emergencies including cardiac pulmonary gastroenterologic neurologic to6icologic metabolic and ophthalmologic diseases heatDcold in7ury and altitudeDdecompression sic5ness. g. %nitial assessment and management ofG (+) #edical diseases including infectious disease gastroenterology cardiovascular endocrine pulmonary neurology otolaryngology nephrology musculos5eletal and dermatology. (2) 1ncomplicated emotional psychological and psychiatric conditions. (,) Acute uncomplicated pediatric illness and infectious disease. h. #anage uncomplicated gynecological diseases and perform uncomplicated obstetrical care to include management of pregnancy labor delivery and care of the ne3born and emergency childbirth 3ith normal presentation.

Appendi4 0 3rovider Credentials +ile

052 ndividuals re&uiring a 3C+ A $!< 3ill be established for all privileged providers per paragraph >-, b(2)(a). @ither paper or electronic files (that is !!"A2) may be maintained. Any re(uest by the sub7ect privileged provider for amendment of information contained in the $!< must be considered under the provisions of the $rivacy Act and AR ,.0-2+. 0#2 !uration o' use The $!< 3ill be maintained for the entire service career of the military provider to include active and inactive service in the R!. <or civilians (02 and contract) the $!< 3ill be maintained for the entire period of employment 3ith the <ederal 0overnment. 082 Maintenance o' t(e 3C+ <or the various categories of A#@&& providers the responsibility for $!< maintenance is as follo3sF a. <or AA military and civilian (02 and contract) the credentials office of the #T< 3ho e6ercises command or e6ecutive authority over the provider is responsible for the $!<. <or AA privileged providers attending nonclinical postgraduate or specialty training advanced military training or changing duty stations to a nonclinical assignment the $!< 3ill be for3arded to !ommander 12A#@&!'# ATT/F #!9'-!;-" 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0. b. <or AR/0 the respective 2tate Ad7utant 0eneral or the AR/0 2tate 2urgeon 3ho is the Ad7utant 0eneral8s designee for !"# 3ill be responsible. c. <or 12AR T$1 privileged providers AR!!A is responsible. &uplicate files 3ill not be maintained by the unit of assignmentDattachment. d. <or %RR members and retired providers (12ARDAR/0 retired and dischargedDseparated AA) the 9R! is responsible. e. <or %#As the credentials office of the facility to 3hich the provider is assigned is responsible. 4o!e. Any
credentialing processes performed at other than AA medical or dental units 3ill be to the same level of (uality and detail as that of the AA #T< credentials committee.

042 Security o' t(e 3C+ The $!< manager 3ill maintain all $!<s in a secure manner (for e6ample cabinetDcontainer that can be loc5ed) in a

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limited access area. $roviders may revie3 the contents of their $!< in the presence of the credentials manager. At no time 3ill the $!< be removed from the control of the $!< manager. a. The contents of the $!< are protected by the $rivacy Act of +9C.. Thus the cover of the $!< must contain the follo3ing statementF L$rivacy Act of +9C. governs access to this file.M b. All contents 3ithin the $!< are deemed confidential and privileged "A information. As such the contents of the $!< are protected under +0 12! ++02. The cover of the $!< 3ill bear the disclosure statement as noted in paragraph ?-9 of this regulation. c. The $!< 3ill be released only to the #T< commander the credentials committee departmentDservice chiefs and revie3ing authorities or officially appointed inspectors. The contents must be intact and the security of the information ensured at all times. The provider may authori4e in 3riting release of hisDher $!< to others. The $!< 3ill be retained in the credentials office 3ith authori4ed access by others in that secure location. 0<2 !isposition o' t(e 3C+ a. The $!< transfer from facilityEtoEfacility 3ill be by certified mail return receipt re(uested. Accompanying the $!< 3ill be a &A <orm 200 (Transmittal Record). A $!< 3ill never be hand carried by the individual provider. b. <or AA providers 3ho have separated in good standing 3ith defined privileges the original $!< 3ill be for3arded immediately to !ommander 9R! ATT/F A9R!-R2A-" + Reserve Hay 2t. ;ouis #' ),+,2-*200. A copy of the order of separation discharge or assignment to the %RR 3ill be included 3ith the $!<. A copy of the $!< and a copy of the separation order 3ill be held at the #T< for + year and then destroyed. &. 1pon discharge or retirement from the Army the $!< (all military providers) 3ill be for3arded to 9R! "uality #anagement &irectorate for maintenance. <or those A& providers transferring to the R! the entire $!< 3ill be for3arded to the unit of assignmentDattachment or to !ommander 9R! ATT/F A9R!-R2A-" + Reserve Hay 2t. ;ouis #' ),+,2-*200 for for3arding to the T$1 of assignment. d. &isposition of the $!< after the provider ends hisDher military service (separates is discharged or retires) 3ill be according to AR 2*-.00-2. (+) 9R! 3ill store in a retired status the $!<s of all retired privileged providers as stipulated in AR 2*-.00-2. (2) $ertinent data from the $!<s of all retired privileged providers 3ill be entered into the !!"A2 databaseA the $!<s are then catalogued and stored according to established trac5ing procedures. (,) Retirees in 12A#@&!'#Edesignated critically short A'!s 3ill have their $!<s maintained by 9R! for a period as specified in 12A#@&!'# guidance. (.) The $!<s of privileged providers separating from the military 3ill be entered into the !!"A2 database identified by a trac5ing number and for3arded to the designated "# holding area at 9R!. (*) The $!<s and credentials data of privileged providers discharged from A& roles and transferred to the %RR 3ill be maintained by 9R! until these individuals retire or separate from the %RR. e. The $!< of civilian providers (02 and contract) 3ill be retained for * years by the last #T< of employment and then destroyed. -. At the time of provider discharge or separation a copy of both the $!< and the $A< that contain any permanent adverse privileging actions or information 3ill be for3arded directly to !ommander 12A#@&!'# ATT/F #!9'!;-" 20*0 Horth Road <ort 2am 9ouston TJ C>2,.-)0+0. 062 3CS* retirement* separation 'rom Service Hhen the provider $!2s separates or retires from the 2ervice an updated copy of &A <orms *,C. and *..+ 3ill be included in the $!< prior to the file being for3arded as indicated in paragraphs @-*b and &. 0>2 CCQAS data entry $rimaryEsourceEverifiedEcredentials information contained in the $!< 3ill be entered and maintained in the &'& Triservice !!"A2 data base or subse(uent &'& designated replacement system by the credentials manager of the $!<. !!"A2 data entry is re(uired for all privileged providers regardless of discipline or category of employment (that is military (AAD12ARDAR/0 1.2.Dforeign national) or civilian (02 contract </;9 volunteer)). 12A#@& E !'# instructions 3ill direct the for3arding of !!"A2 information as re(uired to the 12A#@&!'# andDor bet3een #T<s. 082 3C+ contents and organi:ation The $!< is a si6Esection folder (/ational 2toc5 /umber C*,0-00-990->>>.) 3ith li5e documents grouped together filed in reverse chronological order 3ith the most current data on top. %nformation entered into the $!< 3ill be permanently maintained as follo3sG a. Se&! on 0. (+) &A <orm .)9+. (2) &A <orm *..0 (current). (,) &A <orm *..0A (current).
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&A <orm *..+ (current). &A <orm *C*.. &A <orm .)9+-+. ReleaseEofEinformation statement signed by the provider (local document). Rene3al re(uired every t3o years. %!T? for the current period if applicable. b. Se&! on 00. (+) &A <orm *,C. (current). (2) $A< data as determined by the credentials committee and commander (para >-C). (,) !redentials and privileges granted (scope of practice) from civilian facilities 3here the member is employed or practicing (for 12ARDAR/0 practitioners). (.) <or 12ARDAR/0 providers t3o peer recommendations attesting to the competence and professional capabilities of the named provider. These letters must be rene3ed every 2 years. &. Se&! on 000. &ocuments of adverse privileging action by Army #T<sF (+) ;ettersDmemorandum of notification. (2) ;ettersDmemorandum of ac5no3ledgment. (,) 9earing summary or minutes. (.) %nvestigation results. (*) /$&? andDor 9%$&? reports E current (3ithin 2 years) and previous. ()) ;etters of decision (2'! determination final adverse privileging action). (C) #alpractice claims together 3ith the peer revie3 2'! determinations (#T< !!R? or 12A#@&!'# as appropriate). (>) !opies of any other unfavorable information. 2uch information 3ill be placed in the $!< only after revie3 by the credentials committee and at the direction of the #T< commander. (The 12ARDAR/0 $!< 3ill include copies of any adverse privileging actions ta5en by civilian agencies if available). (9) !opy of !9?! result (3hen applicable) (see para >-C o). (+0) !opy of the provider8s current malpractice insurance policy for AA providers engaged in offEduty civilian employment and for 12ARDAR/0 providers. d. Se&! on 0?. (+) !ontinuing education (!@) summary 3hich includes a ,Eyear history of courses sponsors locations (city and 2tate) dates (startDend) and !@ hoursDunits. &ocumented proof of attendance at approved !@ offerings is re(uired. (2) ;ectures given papers published and special activities (for e6ample research). (,) !urriculum vitae or biographical summary that is revised dated and resubmitted every 2 yearsGideally 3ith other privilege rene3al documents. e. Se&! on ?. All past and previous &A <orms *..0 *..+ and *,C.A %!T?s from previous #T<sA privileges granted at civilian agencies if applicableA and any historical data associated 3ith clinical privileges. -. Se&! on ?0. (+) !opies of diplomasDcertificates (for e6ample medical school residencies fello3ships). (2) !opies of licenses certifications and other authori4ing documents.
4o!e. &ue to the security provided the $!< copies of the provider8s license (other authori4ing documents) may be 5ept on file in the $!< according to local policy.

(.) (*) ()) (C) (>)

forth).

(,) 2pecialty board certification. (.) $rimary source verification of credentials documentation (para >-)). (*) @mergency resuscitation training data (?;2 A!;2 AT;2 $A;2DA$;2 neonatal resuscitation program and so ()) &@AD!&2 and /$%-Type + documentation. (C) $rovider ac5no3ledgement of &'& physician licensure policy re(uirements (#! only).

Appendi4 + 3reCSelection 3rocedures 'or .onCMilitary %ealt( Care 3ersonnel

+52 @eneral a. #ppl &ab l !$ and heal!h &are per"onnel addre""ed. This appendi6 applies to servicing !$'!sD!$A!s procurement offices and commanders or directors of A#@&& activities. These provisions cover personnel 3ho are ma5ing initial application for <ederal service positions in the follo3ing occupations and their </;9 e(uivalents (list not all inclusive)G medical officer 02-0)02A dentist 02-0)>0A veterinarian 02-0C0+A nurse 02-0)+0A podiatrist 02-0))0A $A 02-0)0,A clinical psychologist 02-0+>0A optometrist 02-0))2A $T 02-0),,A 'T 02-0),+A social 3or5er

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02-0+>*A dietitian 02-0),0A pharmacist 02-0))0A speech pathologist 02-0))*A psychologist 02-0+>0A audiologist 02-0)),A medical technologist 02-0)..A emergency medical technician 02-0)99A paramedic 02-0)99A ;$/ 020)20A and dental hygienist 02-0)>2. The re(uirements contained in this appendi6 are also relevant to applicants for volunteer and personal services contract positions to include chiropractors. b. 5re<"ele&! on /er - &a! on. $reEselection $2= of education training clinical e6perience licensure and certification or registration before appointment andDor placement into selected civil service consultant and e6pert contracted and </;9 positions is re(uired. 'nly certified true copies of professional credentials 3ill be accepted. <or internal placement or transfer of inEservice applicants a thorough revie3 of the individual8s (ualifications for the position in (uestion shall be conducted. !urrent inEservice <ederal employees see5ing to transfer into positions or functions identified above are addressed in chapters > and 9 of this regulation. Hith a release of information signed by the providerDprofessional in (uestion information as specified by the individual related to clinical performance (or other information) from the $!<D$A<D!A< may be provided to prospective employers in either the <ederal or civilian sectors. 2ee paragraph +.-2 b for e6ceptions to the release of adverse information. The responsibility for procurement and appointment of highly (ualified candidates for all health care positions is a responsibility shared 7ointly by the !$'!D!$A! and the #T<. +#2 3reCselection tas?s a. <or civilian (02) healthEcareErelatedEoccupations applicants (para <-+a) consultants and e6perts and </;9s the servicing !$'!D!$A! and employing A#@&& activity 3ill perform data collection preEselection credentials revie3 and authentication. The commander 3ill designate an individual(s) to perform these re(uired preEemployment activities. b. <or personal services contracted employees the #T< 3ill perform the data collection preEselection credentials revie3 and authentication. <or nonEpersonal services contracted employees the contracting office provides for data collection revie3 and authentication. (2ee para <-..) c. The A#@&& activity commanderDdirector (or designee) is responsible for the preEselection validation or verificaE tion of professional credentials including resolution of any issues that bear on the employment of the individual in (uestion. Appointment to any A#@&& healthEcareErelated position may be made only after receipt of the A#@&& commander8sDdirector8s (or designee8s) 3ritten approval of the candidate8s acceptability. +82 3rocedures 'or civil service* consultant and e4pert* and 'oreign national local (ire (ealt( care personnel a. Cand da!e" >ho re9u re pr / lege". 1pon selection the ne3EtoE<ederalEservice applicant 3ill submit to the #T< credentials manager (or designee) the appropriate privileging documents (for e6ample &A <orms .)9+ *C*. and the *..0 appropriate to hisDher discipline). These documents and the re(uired letters of reference supplement the profes E sional credentials compiled by the servicing !$'!D!$A! and are necessary for initial clinical privileging and professional staff appointment if applicable. (2ee para >-C for a listing of re(uired credentials.) b. Cand da!e" no! re9u r ng pr / lege". /e3 applicants for <ederal service employment for 3hom privileges are not re(uired 3ill submit to the !$'!D!$A! or the #T< $'! tas5ed 3ith coordinating the hiring action the appropriate documentation of professional credentials. @6amples include official transcripts and diploma from an accredited institution of higher learning re(uired licenseDcertificationDregistration evidence of current continuing educationD e6perience and ?;2 and other certification if available. &. Ser/ & ng C5+C7C5#C. The servicing !$'!D!$A! is responsible for determining the ne3 applicant8s basic (ualifications according to the '$# (ualification standards and for referring to the #T< individuals 3ho meet the established '$# (ualifying criteria. %f paper3or5 for a !9?! has not already been submitted for a ne3ly hired employee (02 personal services contract volunteer) the security office 3ill initiate this action. The servicing !$'!D !$A! performs data collectionA the employing A#@&& #T< is responsible for credentials revie3 and authentication as appropriate. A !$'!D!$A! official 3illG (+) 'btain certified copies of the follo3ing from the applicantF (a) "ualifying official transcripts (or e(uivalent documents) and diplomas to include postEgraduate training fello3E ships and board certification as applicable. (b) $rofessional license(s) registration certification or other authori4ing documents as applicable. A list of all health care licenses ever held 3ill be obtained along 3ith an e6planation of any licenses that are not current have been voluntarily relin(uished or have been sub7ected to disciplinary action. (c) @!<#0 certificate for the physician trained in other than a 1.2. territory or !anada. (2) @stablish an official civilian personnel file on all (ualified applicants. (,) %nitiate a national agency chec5 3ith in(uiry. d. The #')** -a& l !$. The appropriate #T< staff memberDaction officer 3illG (+) Authenticate the educational and other credentials from medical facilities andDor institutions 3here the applicant 3as enrolled andDor employed. (2) 2ecure at least t3o letters of reference on behalf of the ne3EtoE<ederalEservice applicant 3ho 3ill be re(uesting initial privileges. (2ee para >-C.)

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(,) 'btain a current report from the /$&? for all privileged providers unless a valid report less than 2 years old is available from another hospitalDhealth care institution. (.) @nsure that a !9?! has been initiated in compliance 3ith the !rime !ontrol Act of +990 and &'&% +.02.* for staff 3ho 3ill be 3or5ing 3ith children under +> years of age. (*) =alidate certificates of completed !#@ or other !@ as applicable to include the category type. This informa tion must cover , years or from the time the applicant obtained the (ualifying degree if less than , years. ()) &etermine if any of the applicant8s licensesDregistrationsDcertifications have been or are currently being challenged. (C) &etermine if the applicant has been involved in any medical malpractice actions and 3hether the provider has had hisDher medical organi4ation membership cancelled or professional staff appointment terminated. (>) 'btain and verify a history of clinical privileges as applicable and determine if any adverse action has been ta5en against the individual8s privileges by any hospitalDhealth care institution. (9) /ote currency of &@A or !&2 status as appropriate. (+0) !onduct $2= of the credentials re(uiring this authentication. (++) /otify the !$'!D!$A! that credentials verification is complete on the selected candidate so that an employment start date can be established. (+2) Return any documentation regarding the applicant as appropriate either electronically or in the selected individual8s file to the servicing !$'!D!$A!. (+,) !omplete the privileging process as described in chapter 9.
+42 3rocedures 'or contracted services The contracting office 3ill accomplish the preEselection verification (para <-+ b) for nonEpersonal services contract personnel and provide documentation of such upon re(uest by the A#@&& activity. The contracting office 3ill ensure that a !9?! has been initiated as re(uired by the !rime !ontrol Act of +990 and &'&% +.02.*.

Appendi4 @ 3rovider Activity +ile

@52 !escription o' t(e 3A+ The $A< contains various data to include metric performance data and other information to support the granting of provider clinical privileges. #aintenance and security of this 3or5ing file is typically the responsibility of the credentials manager. The $A< 3ill be 5ept in a secure location and filed 3ith but not part of the $!<. a. The contents of the $A< are protected by the $rivacy Act of +9C.. Thus the cover of the $A< must contain the follo3ing statementF L$rivacy Act of +9C. governs access to this file.M b. &ocuments maintained in the $A< are protected under +0 12! ++02. The cover of the $A< 3ill bear the disclosure statement as noted in paragraph ?-9 of this regulation. <or additional information regarding ++02 protection of individual documents see paragraph @-> and appendi6 ? or consult the local 2JA for more specific guidance. @#2 Contents o' t(e 3A+ A suggested listing (not allEinclusive) of data that may be contained in the $A< is provided belo3. There is no specific re(uirement for 3hich items are to be filedA nor is there a set format for the organi4ation of the $A< or ho3 data are to be presented. @ach clinical departmentDservice must determine 3hich parameters are most useful to assess the performance of its providers. 2ome performance parameters evaluated 3ill have economicDutili4ation implicationsA others must be considered for their clinical performance implications. At least every 2 years at the time of clinical privileges rene3al and at $!2D@T2 information contained in the $A< 3ill be revie3ed for transfer to the $!< as permanent provider data. %nformation relevant to the provider8s competence performance and conduct 3ill be considered for inclusion in the $!<. %nformation not transferred to the $!< may be turned over to the provider or destroyed in accordance 3ith local policy. a. @a"el ne n-orma! on and me!r & da!a. (+) #ll pro/ der". $rovider identification number re(uired professional staff meeting attendance number of duty days clinical time (that is percentage of time spent on clinical activities administration and so forth) percentage of time deployed. (2) +u!pa! en! pro/ der". Average dailyDmonthly patient load total annual visits number of impaneled patient visits for emergency services. (,) 0npa! en! pro/ der". /umber of admissions discharges procedures by category (for e6ample deliveries surgerE ies and so forth) special care admissions. (.) )mergen&$ pro/ der". /umber of visits admissionsDspecial care admissions special procedures (for e6ample thoracotomies and so forth).

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(*) Super/ "ed pro/ der". $eriodic performance reports as re(uired name of clinical supervisor. b. +u!&ome" da!a. $roviderEspecific data on mortality morbidity and other clinical performance parameters (for e6ample surgical cases transfusion therapy and drug usage revie3s that reflect notable variances) should be maintained. %nclude cases of superior care and cases of substantiated substandard care each 3ith appropriate documentation. &. U! l 6a! on re/ e> da!a. These data reflect the medical necessity and appropriateness of care. !onsider useDnonuse of approved !$0s and other relevant data for specific diagnoses (high volume high ris5 or high cost). %nclude appropriate data on usage of high cost resources such as computeri4ed tomography scan magnetic resonance imaging medications durable and nondurable medical e(uipmentDsupplies and blood product utili4ation. As computerEbased 1# data in support of current business practices become more readily available information on lengths of stay by %nternational !lassification of &iseases (%!&) manual (current edition) code and other meaningful utili4ation data should be identified and maintained. d. % "8 managemen! da!a. 2ynopses of negative incident reports 2@s malpractice claims and applicable peer revie3 materials should be included. e. 5a! en!73am l$<genera!ed da!a. !ommendationsDcomplaints 3ith relevant revie3s attached. -. #dm n "!ra! /e &on!en!". (+) $rovider profile reports highlighting e6piration dates of current 2tate license(s) ?;2 AT;2 and A!;2 training certificatesA date of last clinical privileges reappraisalA and date(s) of recent professional training (coursesDprograms offering certificates of completion and number of hours or units of !@ a3arded by professional organi4ations societies or associations). (2) Reports on medicalDdental record deficiencies and delin(uencies. As a minimum the follo3ing medicalDdental record deficiencies 3ill be identified and recordedF (a) 9O$ not performed 3ithin 2. hours of admission. (b) 'perative report not dictated 3ithin 2. hours of completion of surgery. (c) /arrative summary not dictated 3ithin . 3or5ing days of patient discharge. g. Comm !!ee a&! on". 'ngoing peer revie3 (that is minutes recommendations counseling and sanctioning documents for any case leading to investigation or adverse privileging actions of the provider). h. +!her n-orma! on. ;etters of appointment to staff positions and committee duties participation in activities of benefit to military medicine teaching activities and other information as deemed appropriate by the credentials committee or the departmentDservice chief.

Appendi4 % nterC+acility Credentials 7rans'er Brie' 3reparation nstructions

9-+. 3urpose
The %!T? has been authori4ed by &'& for credentials transfer and privileging 3hen &'& health care providers are temporarily assigned to medical or dental treatment facilities for clinical practice.

9-2. CCQAS
The !!"A2 is a HebEbased application that maintains and stores provider credentialing information on a central secure server. The %!T? is generated electronically from 5ey data elements of information stored 3ithin !!"A2. <or users 3ith !!"A2 access rights basic information regarding the use of this realEtime credentials data collectionD management system is available at Heb site httpsFDDcc(as.mont.disa.mil.
4o!e. %nstructions for use of this system are located in the 9elp menu on the !redentials $rovider 2earch 2creen.

9-,. Active Army C7B and -SAR;AR.@ C7B

The !!"A2 generates t3o different %!T?sF an AA %!T? or a 12ARDAR/0 %!T?. The AA %!T? is to be used by military or fullEtime civilian providers assigned to AA military facilities e6cept nonpersonal services contract employees. The %!T? supports privileging re(uirements for temporary assignment of providers bet3een #T<sDunits (AAD 12ARDAR/0). The 12ARDAR/0 %!T? is used by the 12ARDAR/0 providers 3hen re(uesting privileges in an AA facility. The %!T? may be prepared using the !!"A2 (current version) or by typing the information as specified belo3.
4o!e. The screen content of the !!"A2 %!T? 3ill vary slightly from the manually prepared version.

a. The contents of the manually prepared %!T? for AA providers are as follo3sF (+) 5aragraph 1. $rovider data. !omplete name grade (or rating if 02 provider) corps branch of service 22/ date of birth gender and clinical specialty (A'!). (2) 5aragraph 2. @ducationDtraining. /ote the school or facility name. ;ist (ualifying degree internship residency fello3ship and other (ualifying training as appropriate. %nclude the completion date of each level of training and

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indicate presenceDabsence of $2= in the credentials file.

4o!e. $2= of all documents associated 3ith educationDtraining is re(uired.

(,) 5aragraph 3. ;icensureDregistrationDcertification. ;ist all currently held 2tate licenses registrations and certificaE tionsA authori4ing 2tate and document number (for e6ample license number)A status (for e6ample active inactive)A e6piration dateA and $2= status.
4o!e. $2= is re(uired.

(.) 5aragraph 4. 2pecialty or board certificationDrecertification. ;ist all applicable specialtyDboard certificationsDreE certificationsA certificationDrecertification date(s)A and e6piration date(s).
4o!e. $2= is re(uired.

(*) 5aragraph 5. !ontingency training. ;ist all applicable life support training (?;2 A!;2 AT;2 and so forth) any readiness training as documented in !!"A2 and e6piration dates. ?;2 certification is a re(uirement for all personnel 3ho are involved in the provision of patient care. (2ee para *-+e(+) for additional information.) ()) 5aragraph 6. &@AD!&2 authori4ing document. /ote document type number e6piration date and $2= status. (C) 5aragraph 7. !urrent staff appointmentDclinical privileges. ;ist the type of professional staff appointment currently held by the provider and the e6piration date of the appointment. %dentify the privilege category.
4o!e. Attach a copy of the current list(s) of privileges to the %!T?.

(>) 5aragraph 8. /$&?D9%$&? (uery. ;ist the date of most recent /$&?D9%$&? (ueries and include the information contained in these reports. (9) 5aragraph 9. $urpose of T&I. %nclude a statement of the nature or purpose of the temporary assignment and re(uest performance appraisals as appropriate from the gaining facility. 2pecify the date that the evaluationDappraisal is due. &A <orms *,C. and the *..+ 3ill be used for evaluationDappraisal of providers performing duty in an #T<. 9o3ever any of the 2ervices8 clinical performance appraisalDevaluation forms 3ill be accepted by the sending facility. 1pon completion of provider8s temporary assignment the evaluationDappraisal forms should be for3arded by the gaining facility to the facilityDunit initiating the %!T?. (+0) 5aragraph 10. 2tatement of (ualifications. This paragraph contains a brief statement (may be e6tracted or summari4ed from an actual peer recommendation) from an individual personally ac(uainted 3ith the provider8s professional and clinical performance through direct observation or revie3. The individual providing this information may be a training program director for ne3 providers or a peer (military or civilian) from a present or prior duty assignmentDemployment. 2pecific reference should be made to current and pro7ected practice. The statement should describe the provider8sG (a) Actual clinical performance 3ith respect to the privileges granted at the sending facility (b) The discharge of hisDher professional obligations as a medical staff member and (c) 9isDher ethical performance. (d) 2hould direct contact 3ith the person (peer) providing the statement of (ualifications be re(uired include the name title or position held address and telephone number(s) both office and facsimile 3here this individual at the sending facility may be reached prior to the provider reporting for duty. The names and contact information of the t3o staff members 3ho provided the peer recommendations if re(uired may be noted.
4o!e. <or AA providers not currently holding military privileges t3o peer recommendations dated 3ithin 2. months of %!T? submission are re(uired attachments to the %!T?. These supplement the contents of paragraph +0. $2= of peer recommendations is re(uired

(++) 5aragraph 11. =erification of %!T? contents. %nclude a statement attesting to the fact that the $!< 3as revie3ed and is accurately reflected in the brief as of the date the %!T? 3as prepared. This paragraph must contain a statement indicating the presenceDabsence of other relevant information in the $!<. 'f particular importance is supplemental information accompanying $2= of training and licensure unprofessional conduct during training or in previous practice settings investigations conducted or limitations imposed by 2tate licensing boards adverse privileging actions malpractice cases and so forth. Three possible statements that may be applicable are as follo3s. (a) The $!< contains no additional information relevant to the privileging of the provider. (b) The $!< contains additional relevant information regarding status of the current license. !ontact this command for further information before ta5ing appointing and privileging action. (c) The $!< contains additional relevant information that may reflect on the current competence of the provider. !ontact this command for further information before ta5ing appointing and privileging action. (+2) 5aragraph 12. 'ther comments. /ote any additional remar5s pertinent to the provider8s credentials andDor other privilegeErelated information. (+,) 5aragraph 13. !redentials coordinator8s signature. /ote the name telephone and facsimile numbers and electronic mail address of the #T< credentials coordinator. (+.) 5aragraph 14. !ommanders8s signature. The signature of the privileging authority (that is the commander or

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designee) and date are re(uired. ?y signing heDshe is attesting to the accuracy and the completeness of the information provided. An individual designated on an additional duty appointment may sign for the commander if so authori4ed. b. The contents of the manually prepared %!T? for 12ARDAR/0 providers are as follo3sF (+) 5aragraph 1. $rovider data. !omplete name grade (or rating if 02 provider) corps branch of 2ervice 22/ date of birth gender and clinical specialty (A'!). (2) 5aragraph 2. @ducationDtraining. /ote the school or facility name. ;ist (ualifying degree internship residency fello3ship and other (ualifying training as appropriate. %nclude the completion date of each level of training and indicate presenceDabsence of $2= in the credentials file.
4o!e. $2= of all documents associated 3ith educationDtraining is re(uired.

(,) 5aragraph 3. ;icensureDregistrationDcertification. ;ist all currently held 2tate licenses registrations and certificaE tionsA authori4ing 2tate and document number (for e6ample license number)A status (for e6ample active inactive)A e6piration dateA and $2= status.
4o!e. $2= is re(uired.

(.) 5aragraph 4. 2pecialty or board certificationDrecertification. ;ist all applicable specialtyDboard certificationsDreE certificationsA certificationDrecertification date(s)A and e6piration date(s).
4o!e. $2= is re(uired.

(*) 5aragraph 5. !ontingency training. ;ist all applicable life support training (?;2 A!;2 AT;2 and so forth) any readiness training as documented in !!"A2 and e6piration dates. ?;2 certification is a re(uirement for all personnel 3ho are involved in the provision of patient care. (2ee para *-+e(+) for additional information.) ()) 5aragraph 6. &@AD!&2 authori4ing document. /ote document type number e6piration date and $2= status.
4o!e. $2= is re(uired.

(C) 5aragraph 7. !urrent medical staff appointmentDclinical privileges. ;ist the type of professional staff appointment(s) currently held by the provider at the #T<Dcivilian institution(s) and the e6piration date of the appointment(s). The provider 3ho is privileged at the 12ARDAR/0 unit level normally 3ill not have an #T< staff appointment. %dentify the privilege category.
4o!e. Attach a copy of the current list(s) of privileges (civilian and military) to the %!T?.

. (>) 5aragraph 8. /$&?D9%$&? (uery. ;ist the date of most recent /$&?D9%$&? (ueries and include the information contained in these reports. %f no (uery has been made so state. (9) 5aragraph 9. $urpose of T&I. %nclude a statement of the nature or purpose of the temporary assignment and re(uest performance appraisals as appropriate from the gaining facility. 2pecify the date that the evaluationDappraisal is due. &A <orms *,C. and the *..+ 3ill be used for evaluationDappraisal of providers performing duty in an #T<. 9o3ever any of the 2ervices8 clinical performance appraisalDevaluation forms 3ill be accepted by the sending facility. 1pon completion of a provider8s temporary assignment the evaluationDappraisal forms should be for3arded by the gaining facility to the facilityDunit initiating the %!T?. (+0) 5aragraph 10. 2tatement of (ualifications. This paragraph contains a brief statement (may be e6tracted or summari4ed from an actual peer recommendation) from an individual personally ac(uainted 3ith the provider8s professional and clinical performance through direct observation or revie3. The individual providing this information may be a training program director for ne3 providers or a peer (military or civilian) from a present or prior duty assignmentDemployment. 2pecific reference should be made to current and pro7ected practice. This paragraph must contain a statement indicating the presenceDabsence of other relevant information relating to the provider8s clinical competence. The statement should describe the provider8sG (a) Actual clinical performance 3ith respect to the privileges granted at the sending facility (b) The discharge of hisDher professional obligations as a medical staff member and (c) 9isDher ethical performance. (d) 2hould direct contact 3ith the person (peer) providing the statement of (ualifications be re(uired include the name address and telephone number(s) both business and facsimile 3here this professional $'! may be reached prior to the 12ARDAR/0 provider reporting for duty. The names and contact information of the t3o staff members 3ho provided the peer recommendations if re(uired may be noted.
4o!e. <or 12ARDAR/0 providers not currently holding military privileges t3o peer recommendations dated 3ithin 2. months of %!T? submission are re(uired attachments. These supplement the contents of paragraph +0 of the %!T?.

(++) 5aragraph 11. $rivileging sitesDactivities and contact information. (a, %nclude the provider8s current civilian position place(s) of employment or facility(ies) 3here privileges are held and the specialty(ies) in 3hich the individual is privileged. A $'! at each facility (including name title address telephone number facsimile number and so forth) should be included in the event there are (uestions related to current

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civilian privileges. !ivilian facilities should receive a release of information signed by the provider and should be advised that this information 3ill be used for privileging the provider 3hile heDshe is on A&. (b) %f the provider is selfEemployed provide the individual8s office address telephone number and facsimile number. (c) %f privileges are held at several civilian facilities provide the name and location of the place(s) 3here the ma7ority of the provider8s practice is conducted. (+2) 5aragraph 12. $rovider contact information. %nclude demographic information on ho3 to reach the 12ARD AR/0 provider by mail or telephone prior to the individual reporting for T&I. (+,) 5aragraph 13. 12ARDAR/0 training data. %nclude a listing of recent Reserve training dates locations and type of training performed. (+.) 5aragraph 14. =erification of %!T? contents. %nclude a statement attesting to the fact that the 12ARDAR/0 provider8s $!< 3as revie3ed and is accurately reflected in the brief as of the date of the %!T?. A statement indicating the presenceDabsence of other relevant information in the $!< 3ill also appear here. (This is a prompt by the computer at the time the %!T? is generated and is referring to Ladverse informationM that might be found 3ithin the $!<.) %nclude any additional information that is relevant to the privileging of the 12ARDAR/0 provider as noted above in paragraph ( 11) for the %!T?. (+*) 5aragraph 15. 'ther comments. /ote any additional remar5s pertinent to the provider8s credentials andDor other privilegeErelated information. (+)) 5aragraph 16. 1nit credentials $'!. %ndicate a primary $'! 3ho has responsibility as the 12ARDAR/0 unit credentials manager and can address issues or concerns if a problem arises. %nclude both telephone and facsimile numbers and electronic mail address if available. %f the credentials manager is not available on a fullEtime basis note an alternate $'! (that is a fullEtime individual 3ho is authori4ed access to !!"A2 and can ans3er (uestions during 3ee5day duty hours). (+C) 5aragraph 17. !ommander8s signature. The privileging authority (that is the 12ARDAR/0 hospitalDunit commander or designee) 3ill sign and date this document. ?y signing heDshe is attesting to the accuracy and the completeness of the information provided. The chief of professional services or an individual designated on an additional duty appointment may sign for the commander if so authori4ed. This signature serves as the !ommander8s recommendation that the provider be granted privileges. &. The follo3ing documents are mandatory attachments to the %!T? for both AA and 12ARDAR/0F (+) A copy of all clinical privileges currently held both military and civilian (that is &A <orm *..0Eseries andDor civilian privileging document(s)). (2) %n instances 3here the provider does not hold current military privileges t3o professional peer recommendations dated 3ithin 2. months of submission. (,) A completed &A <orm *..0 (specific to individual8s A'!). (.) A completed &A <orm *..0A the top portion only (bloc5s +-*). (*) A completed &A <orm *C*. (signed 3ithin )0 days of %!T? submission). ()) An authori4ation document for release of information. This may be specific to the gaining facility if available.
4o!e. <or the 12ARDAR/0 contact is encouraged 3ith the specific AA facility 3here the individual is to report for duty. The 12ARDAR/0 credentials manager may submit the forms noted above to the AA facility either prior to the %!T? being generated or 3ith the %!T? once it is prepared. %f previously submitted to the gaining facility these forms are not mandatory attachments at the time the %!T? is for3arded.

d. The %!T? should be sent to the gaining facility no later than .* days prior to the start date of duty. This allo3s the AA facility sufficient time to conduct the re(uired privileging activities (for e6ample to process the privileging forms conduct the /$&?D9%$&? (ueries and integrate the %!T? into the AA facility8s regularly scheduled privileging process).

Appendi4 Reporta,le Acts o' Misconduct;-npro'essional Conduct 'or !9! %ealt( Care 3ersonnel 52
Acts re&uiring reporting 'ollo=ing command action Acts of misconduct or unprofessional conduct or similarly unprofessional actions 3ill be reported to the <ederation of 2tate #edical ?oards (physicians and dentists) /ational !ouncil for 2tate ?oards of /ursing (R/ and ;$/D;=/) and the appropriate 2tate agency or national professional certifying body for all health care personnel as appropriate follo3ing command action and completion of applicable appeal procedures in compliance 3ith &'& guidance (&'& )02*.+,-R). The follo3ing 3ill be reported upon conviction by courtEmartial or civilian court or upon other final disposition ad7udication or administrative actionF a. <raud or misrepresentation involving application for enlistment commission employment or affiliation 3ith &'& service that results in removal from 2ervice.

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b. <raud or misrepresentation involving rene3al of contract for professional employment application for or rene3al of clinical privileges or e6tension of a 2ervice obligation. &. $roof of cheating on a professional (ualifying e6amination. d. @ntry of guilty nolo contendere plea or re(uest for discharge in lieu of courtsEmartial 3hile charged 3ith a serious misdemeanor or felony. e. Abrogating professional responsibility through any of the follo3ing or similarly unprofessional actionsF (+) &eliberately ma5ing false or misleading statements to patients regarding clinical s5ills andDor clinical privilegesD practice. (2) Hillfully or negligently violating the confidentiality bet3een practitioner and patient e6cept as re(uired by civilian or military la3. (,) ?eing impaired by reason of alcoholDother drug abuse and refusing to participate in or failing to complete rehabilitation. (.) %ntentionally aiding or abetting the practice of medicine or dentistry by obviously incompetent or impaired persons. -. !ommission of an act of se6ual abuse misconduct or e6ploitation related to clinical activities or nonEclinically related indications of se6ual misconduct. @6amples include promiscuity bi4arre se6ual conduct indecent e6posure rape contributing to the delin(uency of a minor or child molestation. 2uch activities in the commander8s 7udgment impair the individual8s overall effectiveness and credibility 3ithin the health care system or 3ithin hisDher professional or patient communities. g. $rescribing selling administering giving or using any drug legally classified as a schedule %% controlled substance as defined by 2+ 12! >0+-9CC intended for use by the practitioner or a <amily member of the practitioner 3ithout an e6ception to policy and the e6pressed 3ritten permission of the #T< commander or admitted misuse of such substances by the providerDprofessional. h. !ommission of any offense that is punishable in a civilian court of competent 7urisdiction by a fine of more than N+ 000 or confinement for over ,0 days for an offense(s) related to professional practice or 3hich impairs the practitioner8s credibility 3ithin the health care system or 3ithin hisDher professional community. . Any violation of the 1!#J for 3hich the individual 3as a3arded non7udicial punishment 3hen the offense is related to the practitioner8s ability to practice hisDher profession or 3hich impairs the practitioner8s credibility 3ithin the health care system or 3ithin hisDher professional community. 2. <raud under dual compensation provisions of <ederal statutes relating to directly or indirectly receiving a fee commission rebate or other compensation for the treatment of patients eligible for care in a &'& #T<. 8. <ailure to report to the privileging authorityG (+) Any disciplinary action ta5en by professional or governmental organi4ation reportable under this regulation. (2) #alpractice a3ards 7udgments or settlements occurring outside &'& facilities. (,) Any professional sanction ta5en by a civilian licensing agency or health care facility. l. Re(uest for administrative discharge in lieu of courtsEmartial or administrative discharge 3hile charged 3ith any of the offenses noted above. #2 Acts reported 'ollo=ing courtsCmartial or indictment The follo3ing 3ill be reported upon referral for trial by courtsEmartial or indictment in a civilian court and upon final verdict ad7udication or administrative dispositionF a. 'ffenses punishable by a fine of more than N* 000 or confinement in e6cess of + year by the civilian 7urisdiction in 3hich the alleged offense occurred. b. 'ffenses punishable by confinement or imprisonment for more than ,)* days under the 1!#J. c. @ntry of a guilty or nolo contendere plea or a re(uest for discharge in lieu of courtsEmartial 3hile charged 3ith an offense designated in a or b above. d. !ommitting an act of se6ual abuse or e6ploitation in the practice of medicine dentistry nursing or other practice of health care. e. %nappropriately receiving compensation for treatment of patients eligible for care in &'& #T<s. f. $ossessing or using any drug legally classified as a controlled substance for other than acceptable therapeutic purposes.

Appendi4 F Management Control 0valuation C(ec?list

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J-+. +unction
The function covered by this chec5list is !"# administration.

J-2. 3urpose
The purpose of this chec5list is to assist local commanders and the 12A#@&!'# "#& in evaluating the 5ey management controls listed belo3. %t is not intended to address all controls.

J-,. nstructions
Ans3ers must be based on the actual testing of 5ey management controls (for e6ample document analysis direct observation intervie3ing data sampling or simulation). Ans3ers that indicate deficiencies must be e6plained and corrective action indicated in supporting documentation. These 5ey management controls must be formally evaluated at least once every * years. !ertification that this evaluation has been conducted must be accomplished on &A <orm ++-2-R (#anagement !ontrol @valuation !ertification 2tatement).

J-.. 7est &uestions

a. Cl n &al 1ual !$ 'anagemen! 5rogram. @ach #T< has established a comprehensive integrated !"#$ that is in compliance 3ith current accreditingDregulatory guidance. (+) %s there a comprehensive integrated !"#$ in place in the #T<S (2) %s the #T< !"#$ supported by a 3ritten !"# planS (,) 9o3 are providersDprofessionals being educated about the #T<8s (uality issues and initiativesS (.) 9o3 are (uality or (ualityEprocess issues that are identified by staff or beneficiaries brought to the attention of the #T< leadersS (*) Are !"# data collected analy4ed and utili4ed by #T< leadership to improve organi4ational performanceS ()) Are !"#$ summary reports prepared and submitted according to applicable regulatory guidanceS (C) Are "A documents and records maintained according to <ederal la3 and applicable &'& guidanceS b. #&&red !a! on program. !ompliance 3ith TJ! accreditation standards is evaluated during the triennial TJ! survey process. The standards are outlined in the current TJ! manual as applicable to the site being surveyed. The survey results are submitted to the 12A#@&!'# "#&. (+) &id the #T< commander ensure compliance 3ith TJ! accreditation standards as evidenced by a score of C0 percent or better during its triennial accreditation surveyS (2) &id the #T< submit its TJ! survey preliminary report and a TJ! survey afterEaction report to the 12A#@&!'# "#&S &. 5a! en! r gh!" and re"pon" b l ! e". @ach #T< has established processes that ensure patient rights and responsibilities are addressed according to TJ! standards and &'& re(uirements. (+) &oes the #T< revie3 and incorporate the facilityEspecific information from &'&Esponsored beneficiary surveys into its programs and processesS (2) Has the #T< in compliance 3ith current TJ! patient rights standards during its latest TJ! surveyS (,) &id the #T< commander designate at least one person to be responsible for e6plaining to beneficiaries their rights and responsibilitiesS (.) %s a health care consumer council in place and functioning in the organi4ationS &o the #T< leaders participate in the activities of this councilS Hhat has changed in the organi4ation as a result of this council8s actionsS (*) &id the #T< commander include the status of patient rights implementation in the annual !"#$ 2ummary ReportS ()) %s an #T< report card posted or visibly displayedS Hhat data are provided and ho3 often is this data updatedS d. U! l 6a! on managemen!7ou!&ome" managemen!. @ach #T< establishes 1#D'# processes to meet TJ! &'& and 12A#@&!'# re(uirements. (+) &id the #T< 1#D'# plan describe the functions of the staff responsible for 1#D'# 3ithin the organi4ation as 3ell as all processes procedures and criteria used to evaluate health care and servicesS (2) &id the #T< demonstrate (uantifiable improvements in the processes and outcomes of care as reflected in the annual !"#$ 2ummary Report to the commanderS (,) &id the #T< provide evidence of the use of !$0s andDor clinical path3ays in the annual !"#$ 2ummary Report to the commanderS e. % "8 'anagemen!75a! en! Sa-e!$ 5rogram(",. @ach #T< establishesEeither as an individual program or integrated into the #T< 2afety $rogramEan R#D$2 $rogram(s) to meet TJ! &'& and 12A#@&!'# re(uirements. (+) Has a comprehensive #T< 2afety $rogram in place for all beneficiaries employees visitors volunteers and othersS (2) &id the #T< perform rigorous ris5 assessment ris5 evaluation and ris5 reductionDcontainment activities to reduce the potential for harm to beneficiaries and othersS

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(,) &id the #T< demonstrate process measures for identifying evaluating and reporting $2 events that are according to regulatory and accrediting guidanceS (.) &id the #T< commander report 2@s according to current 12A#@&!'# guidanceS (*) &id the #T< commander conduct an R!A for each 2@ reportedS ()) &id the @!#2 (or e(uivalent group) demonstrate oversight and revie3 of the #T< R#D$2 $rogram(s) according to regulatory guidanceS (C) Here $!@s and medical malpractice claims identified trac5ed and systematically managed according to regulatory guidanceS -. = &en"ure, &er! - &a! on, or reg "!ra! on. &'& has established re(uirements for the licensure certification or registration of health care personnel 3or5ing 3ithin the #92. (+) Are all health care practitioners 3ho are re(uired to possess a license certification or registration in compliance 3ith applicable &'& guidanceS (2) %f a provider is unable to obtain the re(uired license certification or registration in the time frame indicated by this regulation is a formal re(uest for e6tension submitted to the !ommander 12A#@&!'#S (,) Hhat action is ta5en 3hen a provider8sDprofessional8s license has lapsedS g. Compe!en&e a""e""men!, "uper/ " on, and peer re/ e>. (+) Here organi4ational and unitEbased orientation processes and procedures in place and re(uired for all privileged and nonprivileged health care personnelS (2) Has there evidence of initial and ongoing competence assessment of all members of the organi4ation8s health care staffS (,) <or those individuals 3ho re(uire supervision of clinical practice 3as a plan of supervision established and in 3ritingS (.) Hhat process is in place for dealing 3ith a physician for 3hom a health care (uality or ethics issue aroseS <or a nonphysician providerDprofessionalS (*) Has there evidence of a viable peer revie3 process for both privileged and nonprivileged practitionersS ()) Has peer revie3 conducted prior to any adverse action against a privileged provider8s privileges or a nonE privileged professional8s scope of practiceS h. Creden! al" re/ e>, &l n &al pr / leg ng, and pro&eed ng". (+) &id #T< TJ! survey results document compliance 3ith current TJ! medical staff standardsS (2) Has there evidence of systematic credentials verification for all privileged providers and nonprivileged professionalsS (,) &id the #T< demonstrate evidence of performanceEbased decision ma5ing relevant to clinical privileging and appointment to the medical staffS (.) Has a $!< established for each privileged provider and 3ere these $!<s maintained according to regulatory guidanceS (*) %s the !!"A2 in place and utili4ed according to &'& guidanceS ()) Are provider privileging or professional scope of practice actions managed and reported to regulatory and 2tate licensing agencies as appropriateS (C) Here adverse privilegingDpractice actions reported directly to the 12A#@&!'# "#&S . 0mpa red ;eal!h Care 5er"onnel 5rogram. (+) Has there evidence of an #T< %9!$$ that is functional and incorporated into the !"#$ processes as appropriateS (2) Here both privileged and nonprivileged members of the staff 3ith alcoholDother drug impairments or medical psychiatric or emotional conditions included in the #T< %9!$$S J-*. Supersession
There 3as no previous chec5list on this sub7ect.

J-). Comments
9elp ma5e this a better tool for evaluating the !"# processes. !omments regarding this chec5list should be addressed toF !ommander 12A#@&!'# (#!9'-!;-") 20*0 Horth Road 2uite +0 <ort 2am 9ouston TJ C>2,.-)0+0.

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@lossary
Section A,,reviations AA Active Army A7*4 American ?oard of #edical 2pecialties A-8*2 Accreditation !ouncil for 0raduate #edical @ducation A-54 advanced cardiac life support AD active duty ADA American &ietetic Association AD+ active duty for training AD+*algorithmEdirected troop medical care A./ Armed <orces %nstitute of $athology A8D Advanced 0eneral &entistry (+2 month) A*A against medical advice A*2DD Army #edical &epartment A9 Army /urse !orps A9A American /urses Association A"area of concentration (formerly 22%) A A American $sychological Association A 54 advanced pediatric life support A R9 advanced practice registered nurse AR Army regulation

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AR--A Army Reserve !linical !redentials Activity AR/*4 Army Records %nformation #anagement 2ystem AR98 Army /ational 0uard A4A American 2ociety of Anesthesiologists A4A Army 2ubstance Abuse $rogram A4D0&A1 Assistant 2ecretary of &efense for 9ealth Affairs A4/ additional s5ill identifier A+ annual training A+54 advanced trauma life support 754 basic life support -A. competency assessment file --:A4 !entrali4ed !redentials "uality Assurance 2ystem --R7 consultation case revie3 branch -D4 controlled drug substance -DR"* compact dis5Eread only memory -2 continuing education -2*R civilian employee medical record -.R !ode of <ederal Regulation -&7criminal history bac5ground chec5s -&9 community health nurse

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-/D !riminal %nvestigation &ivision -,A claims 7udge advocate (#@&&A!) center 7udge advocate (#@&!@/) command 7udge advocate ('!'/12) -*2 continuing medical education -*4 !enters for #edicare O #edicaid 2ervices (previously 9!<A) -9* certified nurse mid3ife -94 clinical nurse specialist - Acivilian personnel advisory center - 8 clinical practice guideline - "civilian personnel operations center -:* clinical (uality management -:* !linical "uality #anagement $rogram -R9A certified registered nurse anesthetist DA &epartment of the Army D&ental !orps D-A deputy commander for administration D--4 deputy commander for clinical services D-9 deputy commander for nursing DD &epartment of &efense form D2A &rug @nforcement Agency D29+Adental activity

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D&4 director of health services D"D &epartment of &efense D"DD &epartment of &efense &irective D"D/ &epartment of &efense %nstruction D D7 &efense $ractitioner &ata ?an5 D * &octor of $odiatric #edicine D+. dental treatment facility 2-D4 e6ecutive committee of the dental staff 2-.*8 @ducational !ommission for <oreign #edical 0raduates 2-*4 e6ecutive committee of the medial staff 2* A emergency medicine physician assistant 2 4: @lectronic $ersonnel 2ecurity "uestionnaire 24A e6piration of service agreement 2+4 e6piration of term of service .A <inancial Assistance $rogram .DA <ood and &rug Administration .95& foreign national local hire ."/A <reedom of %nformation Act .4 flight surgeon 87 governing body

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8*2 graduate medical education 89A graduate nurse anesthetist 8 &2 graduate professional health education 84 general schedule &-.A 9ealth !are <inancing Administration (no3 referred to as !enters for #edicare O #edicaid 2ervices) &/ D7 9ealthcare %ntegrity and $rotection &ata ?an5 &; history and physical &:DA 9ead(uarters &epartment of the Army &R1.2. Army 9uman Resources !ommand &R2health record &4D 9ealth 2ervices &irectorate /-D international classification of diseases /-+7 interEfacility credentials transfer brief /D+ inactive duty training /8 inspector general /&impaired health care personnel /&- impaired health care personnel committee /&%mpaired 9ealth !are $ersonnel $rogram /*A individual mobili4ation augmentee / A %nterservice $hysician Assistant Training $rogram

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/RR %ndividual Ready Reserve /+R inpatient treatment record 5 licensed professional counselor 5 9/5<9 licensed practical nurseDlicensed vocational nurse *#edical !orps *;2 monitoring and evaluation *27 medical evaluation board *2D-29 #edical center *2DDAmedical department activity (Army) *&4 military health system */5 " military personnel office *9+ medical nutrition therapy *"A memorandum of agreement *"4 military occupational specialty *"= memorandum of understanding *:A medical (uality assurance *RD mandatory release date *R*(1.2. Army) #edical Research and #ateriel !ommand *4 #edical 2ervice !orps *4> master of social 3or5

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*+. military treatment facility 9AAD /ational A#@&& Augmentation &etachment 97-"+ /ational ?oard for !ertification in 'ccupational Therapy 9-- A /ational !ommission on !ertification of $hysician Assistants 9-52? 9 /ational !ouncil ;icensure @6aminationE$ractical /urse 9-52?R9 /ational !ouncil ;icensure @6aminationERegistered /urse 9*42 neuromusculos5eletal evaluation 9 nurse practitioner 9 D7 /ational $ractitioner &ata ?an5 9 / /ational $rovider %dentifier 9R2*+ /ational Registry of @mergency #edical Technicians "A4D/&A 'ffice of the Assistant 2ecretary of &efense for 9ealth Affairs "-"9=4 outside continental 1nited 2tates "D doctor of optometry "2R officer evaluation report "&9 occupational health nurse "& A occupational health physician assistant ",+ onEtheE7ob training "* outcomes management " * 'ffice of $ersonnel #anagement

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"+ occupational therapist "+,A8 'ffice of The Judge Advocate 0eneral "+R outpatient treatment record A physician assistant AD patient administration division A. provider activity file A54 pediatric advanced life support A9-2 $hysician Assistant /ational !ertifying @6amination A" public affairs office -2 potentially compensable event -. provider credentials file -4 permanent change of station D-A/ D4A plan do chec5Dstudy act 8@ postgraduate year '#D# doctor of philosophy 'ar!D doctor of pharmacy / performance improvement 5 public la3 "point of contact 4 patient safety

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4 $atient 2afety $rogram 4< primary source verification + physical therapist ;+ pharmacy and therapeutics :A (uality assurance :*D "uality #anagement &ivision R-A root cause analysis RDregional dental command R* ris5 management R*regional medical command R9 registered nurse R"+Reserve 'fficer Training !orps R+. residential treatment facility 4Asafety assessment code 477 specialist in blood ban5ing 42 sentinel event 42R2 survival evasion resistance and escape 4. standard form 4/ s5ill identifier (formerly A2%) 4,A staff 7udge advocate

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4*DA 2afe #edical &evice Act 4R special revie3 panel 449 social security number 4"standard of care 4 Army #edical 2pecialist !orps +-. training credentials file +DA table of distribution and allo3ances +D@ temporary duty +,The Joint !ommission +"2 table(s) of organi4ation and e(uipment + = troop program unit +48 The 2urgeon 0eneral =A unlicensed assistive personnel =-*, 1niform !ode of #ilitary Justice =* utili4ation management =R utili4ation revie3 =#4# 1nited 2tates =4AD29-"* 1.2. Army &ental !ommand =4A*2D-"* 1.2. Army #edical !ommand =4AR 1.2. Army Reserve

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%+.

=4AR-4 1.2. Army !laims 2ervice =4AR21.2. Army Recruiting !ommand =41nited 2tates !ode =4*52 1nited 2tates #edical ;icensing @6amination <A &epartment of =eteran8s Affairs <=eterinary !orps >>> Horld Hide Heb Section 7erms Abe)ance The temporary assignment of a provider from clinical duties to nonclinical duties 3hile an internal or e6ternal peer revie3 or "A investigation is conducted. An abeyance is valid for ,0 calendar days. %t is not an adverse clinical privileging action and need not be reported. Accreditation A formal process by 3hich an agency or organi4ation evaluates and recogni4es an institution or program of study as meeting certain predetermined standards. Accreditation -ouncil (or 8raduate *edical 2ducation An agency that accredits 0#@ programs. #embership is composed of national association <ederal 0overnment public sector and resident physician representatives. Action plan The end product of an R!A that identifies the ris5 reduction strategies the facility intends to implement to prevent the recurrence of similar adverse events in the future. Advance directive A document or documentation that allo3s an individual to provide direction about future medical care or to designate another person(s) to ma5e medical decisions if the individual loses hisDher capacity for decisionEma5ing. Advance directives may include living 3ills durable po3ers of attorney doEnotEresuscitate orders right to die or similar documentation e6pressing the individual8s preferences as specified in the $atient 2elfE&etermination Act. Adverse event An occurrence or condition associated 3ith the provision of care or services that caused harmDin7ury to the beneficiary. Adverse events may be due to acts of commission or omission. Adverse privileging/practice action The denial suspension restriction reduction or revocation of clinical privilegesDpractice based upon misconduct professional impairment or lac5 of professional competence.
4o!e. The termination of staff appointment based upon conduct incompatible 3ith continued professional staff membership may also result in an adverse privileging action.

Advocate A person 3ho represents the rights and interests of another individual as though they 3ere the person8s o3n in order

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to reali4e the rights to 3hich the individual is entitled obtain needed services and remove barriers to meeting the individual8s needs. Aggregate To combine standardi4ed data and information collected over time. Aggregate data An accumulation of data that is used by the organi4ation to measure performance. Aggregate revieA The process of analy4ing recurring incidents events or close calls (near misses) for trends and patterns. This information is utili4ed by the organi4ation for process improvement interventions. Alco'ol abuse The nondependent use of alcohol to an e6tent that it has an adverse effect on the user8s health or behavior <amily community or &'&. Alco'ol dependence or alco'olis! $sychological andDor physiological reliance on alcohol as defined by the current &iagnostic and 2tatistical #anual. Alco'ol and Drug Abuse revention and -ontrol rogra! /o3 referred to as the Army 2ubstance Abuse $rogram (A2A$). A!erican 7oard o( *edical 4pecialties A nonprofit organi4ation 3hose mission is to maintain and improve the (uality of medical care by assisting member boards to develop and use professional and educational standards for the evaluation and certification of physician specialists. Ancillar) services Those services that participate in the care of patients principally by assisting and augmenting the talents of attending health care providers in diagnosing and treating human ills. Ancillary services generally do not have primary responsi E bility for the clinical management of patients. Appoint!ent to t'e !edical/dental sta(( A designation by the 0? that stipulates the provider8s relationship to the medicalDdental staff and the degree to 3hich the provider participates in medialDdental activities related to the governance of said staff. Appropriate The determination that the service being provided is suited for the condition that is present and that it is suitable for a particular person condition occasion andDor place. Appropriateness The e6tent to 3hich a particular procedure treatment test or service is effective is clearly indicated is not e6cessive is ade(uate in (uantity and is provided in inpatient outpatient home or other settings best suited to the patient8s need given the current state of 5no3ledge. Appropriateness criteria !riteria that represent the clinical circumstances that support a decision to perform a diagnostic therapeutic or surgical procedure. Ar!) 4ubstance Abuse rogra! The Army8s official program for prevention identification treatment and management of personnel 3ith alcohol and drugErelated problems. A4A p')sical status classi(ication A system used to classify the physical status of the patient prior to the administration of anesthesia. $atients are classified along a continuum $+ through $) or as an emergency (e).
4o!e. The L$2M before each number refers to Lphysical status.M

a. $2+ E A normal healthy patient. b. $22 E A patient 3ith mild systemic disease. c. $2, E A patient 3ith severe systemic disease.

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d. e. f. g.

$2. E A patient 3ith severe systemic disease that is a constant threat to life. $2* E A moribund patient 3ho is not e6pected to survive 3ithout the operation. $2) E A declared brainEdead patient 3hose organs are being removed for donor purposes. @ E A patient for 3hom an emergency operation is re(uired.

Assess To transform data collected as part of the measurement activity into information through analysis. Assess!ent The follo3ing appliesF a. The systematic collection and revie3 of beneficiaryEspecific data as it applies to $% activities. b. <or the purpose of beneficiary assessment the process established by an organi4ation for obtaining appropriate and necessary information about each individual see5ing entry into a health care setting or service. Attending p')sician The physician 3ith defined clinical privileges having primary responsibility for diagnosis and treatment of the patient. Audiologist An individual (ualified by graduation from an accredited college or university 3ith a master8s or doctoral degree in audiology. 9eDshe possesses national certification from either the American ?oard of Audiology or the American 2peech ;anguage 9earing Association and is licensed to practice audiology in a 2tate !ommon3ealth territory or 7urisdiction. Aug!entation The addition of clinical privileges not previously held by the provider based upon additional professional training sustained superior performance or correction of previously demonstrated deficiencies. Aut'enticate Authenticate isG a. A method to denote authorship of an entry made in a patient8s medical or dental record by means of a 3ritten signature identifiable initials a computer 5ey or a personally used rubber stamp. b. The process of certifying machineEgenerated copies as genuine. Availabilit) The degree to 3hich appropriate careDservice is present to meet an individual8s needs. 7ene(iciar) Anyone eligible to receive health promotion illness prevention inpatient and outpatient health care and services 3ithin the military health system. 7oard certi(ied A term applied to a physician or other health care professional 3ho has passed an e6amination given by a professional specialty board and has been certified by that board as a specialist in that sub7ect or discipline. 7)laAs A governance frame3or5 that establishes the roles and responsibilities of a body and its members. -are The provision of accommodations comfort and treatment to an individual. %n all services provided to include habilitation rehabilitation or other programs instituted by the organi4ation for the individual the responsibility for safety is implied. -aretaBer 'ospital A 12AR hospital that provides total replacement (that is bac5fill) of deployed A& $R'<%2 assets of an active T'@ hospital that is embedded in a T&A #T<. -entraliCed -redentials :ualit) Assurance 4)ste! The &'& database maintained by each #T< that assists the credentials manager 3ith control of credentials managing the credentialingDprivileging processes reports letter generation preparing provider $!2 paper3or5 and the %!T?.

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%nformation is available to managers at all levels for generating &'& and other reports personnel management and for planning purposes. -erti(ication 'fficial recognition of an individual by a national agency or association that is intended to assure the public that the health care professional has successfully completed an approved educational program and evaluation. This includes a formal e6amination designed to assess the 5no3ledge e6perience and s5ills re(uisite to the provision of high (uality patient care in that specialty. -erti(ied nurse !idAi(e An R/ 3ho has graduated 3ith a master8s or doctoral degree from an accredited school of mid3ifery. 9eDshe has passed the national certification e6amination by the !ontinuing !ompetency Assessment $rogram of the American !ollege of /urseE#id3ives. The mid3ife is (ualified to diagnose determine initiate alter or terminate defined regimens of mid3ifery care andDor nursing treatment provided to a patient on a routine or occasional basis. -erti(ied registered nurse anest'etist An R/ 3ho has graduated 3ith a master8s degree from an accredited school of nurse anesthesia and 3ho has passed the national certification e6amination by the !ouncil on !ertification of /urse Anesthetists. 9eDshe is (ualified to diagnose determine initiate alter or terminate anesthesia care andDor nursing treatment provided to a patient on a routine or occasional basis. -'iropractor An individual (ualified by graduation from an accredited chiropractic college 3ith a minimum of a baccalaureate degree and 3ho possesses a current license to practice chiropractic in a 1.2. 2tate !ommon3ealth territory or 7urisdiction. -ivilian netAorB 'ealt' care providers %ndependent contractors of the 0overnment (or other independent entities having business arrangements 3ith the 0overnment). @ach civilian net3or5 provider must have ade(uate professional liability insurance and must agree to indemnify the 1.2. 0overnment for any liability that may be assessed against the 1.2. 0overnment that is attributable to any action or omission of the provider. -linical co!petence The 5no3ledge s5ills and abilities of a health care providerDprofessional that contribute to effective intervention in illness or in7ury. The health care individual8s demonstrated capability to perform in 5eeping 3ith defined e6pectations. -linical consultant A professional practitioner (3ho has interest and special 5no3ledge training and e6pertise in a professional field of endeavor) appointed by T20 or in select instances by the #T< commander to serve as the sub7ect matter e6pert in support of the A#@&&D#T< mission. -linical nurse specialist An R/ 3ho has graduated 3ith a master8s degree 3ith emphasis as a !/2 from an accredited school of nursing and 3ho has passed the national certification e6amination by the American /urses !ertification !orporation or the recogni4ed national nursing certification for hisDher particular specialty. %n select circumstances the !/2 may be (ualified to diagnose determine initiate alter or terminate health services management of identified populations of patients andDor the nursing treatment provided to patients on a routine or occasional basis. The !/2 possesses a current license to practice in a 2tate !ommon3ealth territory or 7urisdiction. -linical practice guidelines 2ystematically developed diseaseDdiagnosisEbased statements to assist provider and patient decisions about appropriate health care for specific clinical conditions or circumstances. -linical p'ar!acist An individual (ualified by graduation from an accredited college or university pharmacy program 3ith a baccalaureate master8s or doctoral degree and clinical pharmacy e6perienceDtraining. 9eDshe may possess certification by the ?oard of $harmaceutical 2pecialties and is licensed to practice pharmacy by a 2tate !ommon3ealth territory or 7urisdiction. -linical privileging The process 3hereby a health care provider is granted based on peer and department head recommendations the permission and responsibility to provide specified or delineated health care 3ithin the scope of his or her license

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certification or registration. !linical privileges define the scope and limits of practice for individual providers and are based on the capability of the health care facility the provider8s licensure relevant training and e6perience current competence health status and 7udgment. -linical social AorBer An individual (ualified by graduation from an accredited college or university social 3or5 program 3ith a master8s in social 3or5 and appropriate licenseDcertification to practice social 3or5 from a 2tate !ommon3ealth territory or 7urisdiction. -lose call An event or situation that could have resulted in harm to the patient but did not either by chance or through timely intervention. The event 3as identified and resolved before reaching the patient. 2uch events are also referred to as Lnear missM incidents. An e6ample of a close call is a surgical procedure almost performed on the 3rong patient but caught before the surgery 3as initiated. -o!!ittee o( t'e A'ole %n smaller less comple6 hospitals the entire medical staff comprises a committee that performs the activities and functions of the @!#2. -o!!unit) 'ealt' nurse An R/ 3ho has successfully completed the 1.2. Army nonEdegree producing course $rinciples of #ilitary $reventive #edicine ()A-<*) or 3ho holds a master8s degree in public health nursing. The individual possesses e6perience related to providing <amilyEcentered nursing services to individuals <amilies and groups in the community to include epidemiological and health promotion support. -o!petence The ability to perform the duties functions and re(uirements of a particular discipline 7ob or duty position as measured by meeting the follo3ing conditionsF a. Authori4ed to practice a specified scope of care under a 3ritten plan of supervision at any time 3ithin the past 2 yearsA or completed formal graduate professional education in a specified clinical specialty at any time 3ithin the past 2 years or privileged to practiceDauthori4ed to provide a specified scope of care at any time 3ithin the past 2 years. b. Actively pursued the practice of his or her discipline 7ob or duty position 3ithin the past 2 years by having encountered a sufficient number of clinical cases or variety of e6periences to represent a broad spectrum of the privileges re(uested or scope of care authori4edA and c. 2atisfactorily practiced the discipline as determined by the results of professional staff #O@ relative to the (uality and appropriateness of patient care. -o!pliance ?ehavior that is consistent 3ith stated re(uirements such as standards la3s and regulations. -o!plication A condition that arises follo3ing the initiation of inpatient or outpatient health care or treatment and alters the course of the patient8s illness or the medical care re(uired. -on(identialit) !onfidentiality isG a. Restriction of access to data and information to individuals 3ho have a need a reason and permission for such access. b. An individual8s right 3ithin the la3 to personal and informational privacy including his or her health care records. -onsultation case revieA branc' A#@&& activity that provides a legal andDor clinical opinion concerning the standard of patient care in a malpractice claim case. -ontinuing education @ducation beyond initial academic or professional preparation that is relevant to the type of care or service delivered in an organi4ationA courses of study that provide current 5no3ledge relevant to an individual8s field of practice or service responsibilitiesA and that update and enhance the 5no3ledge s5ills and e6perience of health care personnel.

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-ontinuit) o( care The process for providing the ongoing appropriate level of care as the patient moves through the health care continuum from the most acute and intensive to the least acute and intensive. -redentialing The process of obtaining assessing and verifying the (ualifications of a health care provider to render beneficiary careDservice in or for a health care organi4ation. -redentials The documents that constitute evidence of (ualifying education training licensure certification or registration e6perience current competence health status and other (ualifications of health care personnel. -redentials revieA The process by 3hich the health care professional8s credentials are determined to be appropriate for the position re(uested or held prior to being granted clinical privileges or assigned patient care responsibility. %t is based on the follo3ing four core criteriaF current licensureA relevant education training or e6perienceA current competenceA and ability to perform the re(uested privileges or scope of practice (nonprivileged personnel). !redentials revie3 is conducted on health care personnel prior to selection and procurement for military service or civilian employment. %t is repeated for licensed certified or registered health care personnel at the time of authori4ing document rene3alA and for health care providers prior to medicalDdental staff appointment and a3ard of clinical privileges. Thereafter the revie3 is due at the time of biennial staff reappointment and rene3al of privileges. -redentials6 veri(ied $rofessional documents for 3hich confirmation of authenticity has been obtained from the primary (issuing) source by the military service or representative of the military service. !onfirmation independent of the practitioner is a 5ey criterion. 'nce verified confirmation of authenticity 3ith the primary source need not be repeated during subse(uent credentials revie3 (e6cept for provider license) for the length of the individual8s continuous employment by the <ederal 0overnment. -riteria @6pected levels of achievement or specifications against 3hich performance or (uality may be compared. Data #aterial facts or clinical observations that have not been interpreted. Delegation To entrust to another competent individual the authority to perform a selected tas5(s) in a selected situation(s). Denial o( privileges Refusal to grant re(uested privileges to a provider at the time of initial application or rene3al due to professional or clinical concerns or due to facilityEspecific limitations. &enial of privileges due to professional incompetence or misconduct is an adverse privileging action that is reportable to the /$&?. &enial of privileges due to facilityErelated constraints is not an adverse privileging action and is not reported to the /$&?. Dentist An individual (ualified by a degree in dental surgery or dental medicine and licensed by a 2tate !ommon3ealth territory or 7urisdiction to practice dentistry. Dietitian An individual (ualified by graduation from a college or university 3ith a ma7or in foods or nutrition or institution management and possessing either a baccalaureate or a master8s degree and registered by the A&A. Direct supervision 2ee 2upervision. Disaster A natural or manEmade event 3ithin the facility or in the nearby community that significantly disrupts the #T<8s environment of care or its ability to provide patient care and treatment. The event results in sudden significantly changed or increased demands on the organi4ation8s services and typically 3ill re(uire activation of the organi4ation8s @mergency #anagementD$reparedness $lan.

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Docu!entation The process of recording information in the health care beneficiary8s medical record or the recording of information inD on another source document. Drug abuse The use or possession of illegal drugs or the nonmedical use of prescription or overEtheEcounter drugs. Drug dependence $sychological andDor physiological reliance on a psychoactive drug as defined by the current &iagnostic and 2tatistical #anual American $sychiatric Association of #ental &isorders. Due process The manner in 3hich proceedings are conducted according to established rules and procedures in order to protect the individual8s *th amendment right to notice of a hearing and +.th amendment right to a fair hearing. Durable !edical eDuip!ent #edical e(uipment that is not disposable (that is is used repeatedly) and is related only to care of a medical condition. 2ducational -o!!ission (or .oreign *edical 8raduates A nonprofit organi4ation that assesses the readiness of graduates of foreign medical schools to enter residency programs in the 1.2. that are accredited by the A!0#@. 2((ectiveness The degree to 3hich action(s) achieve the intended health or dental result under normal or usual circumstances. 2((icac) The degree to 3hich the care of the individual has been sho3n to accomplish the desired or pro7ected outcomes. 2((icienc) 'ptimal allocation of goods or services. %n health or dental care it is ma6imi4ing the units of effective care delivered for a given unit of resources e6pended. 2!ergenc) A condition in 3hich life is in imminent danger andDor permanent in7ury may result if treatment is delayed. %n a larger conte6t this may be a natural or manEmade event that severely ta6es the resources and capability of a health care organi4ation re(uiring activation of the @mergency #anagementD$reparedness $lan. (2ee &isaster.) 2rgono!ics The field of study that see5s to fit the 7ob to the person rather than the person to the 7ob. %ncludes the evaluation and design of 3or5places environments 7obs tas5s e(uipment and processes in relationship to human capabilities and interactions in the 3or5place. 2valuation Analysis of collected compiled and organi4ed data pertaining to important aspects of care. &ata are compared 3ith predetermined clinically valid criteriaA variations from criteria are determined to be 7ustified or un7ustifiedA and problems or opportunities to improve care are identified. 2Eecutive co!!ittee o( t'e !edical/dental sta(( A group comprised of physicians and other members in leadership positions 3ithin the organi4ation that is responsible for activities related to selfEgovernance of the medical staff and $% of the professional services provided by individuals 3ith clinical privileges. A ma7ority (at least *+ percent) of voting members of this committee must be fully licensed and privileged physician members of the medical staff actively practicing in the hospitalDor privileged dentists on the dental staff. .acilit) A designated unit organi4ation institution or physical structure either military (AAD12ARDAR/0) or civilian. As used in this AR facility infers and applies to entities engaged in the delivery of health care and services. (2ee definition of #T<.)

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.i(t' pat'Aa) A program to facilitate entry into 0#@ in the 1nited 2tates for individuals 3ho obtain their undergraduate medical education abroad. The <ifth $ath3ay is a period of supervised clinical training for students 3ho haveF a. !ompleted in an accredited 1.2. college or university undergraduate premedical studies of a (uality acceptable for matriculation into an accredited 1.2. medical schoolA b. Received undergraduate education abroad at a medical school listed in the Horld 9ealth 'rgani4ation Horld &irectory of #edical 2choolsA c. !ompleted all formal re(uirements of the foreign medical school e6cept internship andDor social service and passed 2tep + of the 12#;@. (Those 3ho have completed all the re(uirements of the foreign medical school are /'T eligible.)
4o!e. After successful completion of a year of clinical training that is postEgraduate year one ($0I-+) sponsored by a 1.2. medical school accredited by the ;iaison !ommittee on #edical @ducation and having passed 12#;@ 2tep 2 the candidate receives a <ifth $ath3ay certificate and is eligible to enter residency training ($0I-2 and beyond) as an international medical graduate.

."-=4 D-A/ D4A A process improvement methodology to-<ind a process to improveA 'rgani4e an effortA !larify current 5no3ledge of the processA 1nderstand the sources of variationA and 2elect the process improvement. %n addition those involved must-$lan the improvement and data collectionA &o the improvement data collection and analysisA !hec5 or 2tudy the resultsA Act to hold the gains and continue improving the process. .ocused revieA Revie3 that concentrates on a perceived problem area that may be a specific diagnosis procedure practitioner(s) patient(s) or other limited scope topic. %t may be performed in place of or preliminary to a more comprehensive revie3. .or!al education and training progra! A planned program of instruction that is based on individually assessed learning needs of the participants. 2pecific learning ob7ectives provide a structure to the academic andDor technical content that is presented. A preE andDor posttest may be administered to assess student comprehension and mastery of the material presented. 8overning bod) The individual group or agency that has ultimate authority and responsibility for the overall operation of the organi4ation. <or the A#@&& this is T20. 8raduate pro(essional 'ealt' education 2tructured disciplineEspecific professional health care related training that is accredited by a national body (for e6ample the A!0#@ /ational ;eague for /ursing and so forth) approved by &A and obtained after the appropriate basic professional degree. !ompletion of the educational re(uirements associated 3ith this training may lead to the a3ard of a master8s or doctoralElevel academic degree. &aCard Any real or potential condition that can cause in7ury illness or death to patients personnel or other individuals or damage to or loss of e(uipment or property mission degradation or damage to the environment. &aCardous condition Any set of circumstances 3hich increases the li5elihood of in7ury or harm. &ealt' -are .inancing Ad!inistration The <ederal Agency that oversees all aspects of health care financing for #edicare and for the 'ffice of $repaid 9ealth !are 'perations and 'versight (no3 referred to as !enters for #edicare and #edicaid 2ervices). &ealt' care personnel %ndividuals involved in the direct or indirect delivery of health services or patient care. &ealt' care pro(essional #ilitary (AAD12ARDAR/0) and civilian (02 and those 3or5ing under contractual or similar arrangement) personnel 3ho have received advanced education or training beyond the technical level in a recogni4ed health care discipline and 3ho are licensed certified or registered by a 2tate 0overnment agency or professional organi4ation to provide

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specific health services in that field. This includes those involved in the provision of diagnostic therapeutic or preventive care ancillary services and administration. &ealt' care provider #ilitary (AAD12ARDAR/0) and civilian (02 and those 3or5ing under contractual or similar arrangement) personnel granted privileges to diagnose initiate alter or terminate health care treatment regimens 3ithin the scope of hisDher license certification or registration. &ealt' care services The services intended to directly or indirectly contribute to the health and 3ellEbeing of patients. /!paired 'ealt' care personnel A privileged provider or nonprivileged individual 3ho by reason of alcohol or drug abuse or dependence medical condition or emotional disturbance has e6hibited unprofessional conduct substandard medical practice or professional incompetence 3hich is or has the potential to be detrimental to $2 or to the proper delivery of (uality patient care. /!portant aspects o( care !linical activities that involve a high volume of patients that entail a high degree of ris5 for beneficiaries or that tend to produce problems for patients. 2uch activities are deemed important for the purpose of #O@. /ndicator A defined measurable dimension (variable) of the (uality or appropriateness of an important aspect of care. %ndicators specify the patient care activities events occurrences or outcomes that are to be monitored and evaluated over time in order to determine 3hether those aspects of patient care conform to current acceptable standards of practice. /ndirect supervision 2ee 2upervision. /n(ection control progra! or process An organi4ationE3ide program or process to include policies and procedures for surveillance prevention and control of infection to minimi4e the ris5 of infection to patients and medical or dental treatment staff. /n(or!ation An interpreted set(s) of data that can assist in decision ma5ing. /nFservice education 'rgani4ed educational opportunities designed to enhance staff member 5no3ledge and s5ills or to teach ne3 5no3ledge and s5ills relevant to their particular responsibilities and disciplines. /ntentional unsa(e act Any alleged or suspected deliberate act or omission by a provider staff member contractor trainee or volunteer pertaining to a patient that involves a criminal actA a purposefully unsafe actA patient abuseA or an event caused or affected by drug or alcohol abuse. %ntentional unsafe acts are matters for military andDor civilian la3 enforcement the military or civil service disciplinary systems or an administrative investigation and are significant R# issues. 2aid acts are not 3ithin the definition of adverse events for 3hich the $2$ has authority. /nternational -lassi(ication o( Diseases 0/-D1 A manual that classifies medicalDsurgical diseasesDdisorders based on severity and comple6ity. This universally ac cepted threeEvolume publication is revised periodically. @ach ne3 revision is numbered se(uentially. !opies may be obtained from the 2uperintendent of &ocuments 0overnment $rinting 'ffice Hashington &! 20.02-9,2*. /nternational !edical graduate A physician 3hose basic medical degree or (ualification 3as conferred by a medical school located outside the 1nited 2tates !anada or $uerto Rico. 5apse A period of nonclinical duty that has diminished or has the potential to diminish the clinical s5illsDabilities of the provider. Typically this is an interval of +2 months or more but must be determined on a caseEbyEcase basis.

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AR 4068 0 6 !ebruary 004

5icense A grant of permission by an official agency of a 2tate the &istrict of !olumbia or a !ommon3ealth territory or possession of the 1nited 2tates to provide health care 3ithin the scope of practice of a specified discipline. a. Curren!. Active not revo5ed suspended or lapsed in registration. b. #&! /e. !haracteri4ed by present activity participation practice or use. c. ?al d. The issuing authority accepts investigates and acts upon "A information such as practitioner professional performance conduct and ethics of practice regardless of the practitioner8s military status or residency. d. Unre"!r &!ed. /ot sub7ect to limitations on the scope of practice ordinarily granted all other applicants for similar specialty in the granting 7urisdiction. 5icensed practical nurse/licensed vocational nurse An individual 3ho is specifically prepared in the techni(ues of nursing 3ho is a graduate of an accredited school of practicalDvocational nursing and 3hose (ualifications have been e6amined by a 2tate board of nursing and 3ho has been legally authori4ed to practice as an ;$/D;=/. 5i!itation o( privileges 2ee Restriction. *alpractice A dereliction of professional duty incorrect or negligent treatment failure of professional s5ill or learning as 3ell as illegal or immoral conduct by any providerDprofessional responsible for health care that results in death in7ury loss or damage to the health care beneficiary. *easure To collect (uantifiable data about a function or process. *easure!ent The systematic process of data collection repeated over time or at a single point in time. *edical eEa!ination A process of inspection or investigation performed by a (ualified individual specifically as a means of diagnosing disease illness or dysfunction. *edical nutrition t'erap) The assessment of patient nutritional status follo3ed by therapy ranging from diet modification and counseling to the administration of speciali4ed nutrition therapies such as enteral or parenteral feedings. *edical readiness training certi(ication A process that verifies the preparation of health care providers for operational re(uirements. The commander8s revie3 and verification of individual collective and unit medical readiness training education and e6periences is a critical element of the process. *edical sta(( An organi4ed body of fully licensed individuals (physician and others 3ith the appropriate appointment) 3ithin the #T< 3ho hold regular privileges and 3ho are characteri4ed by primary responsibility to the 0? for the (uality of patient care 3ithin the #T<. *edical sta(( appoint!ent A status that reflects the relationship of a given privileged provider to the medical staff. At the time clinical privileges are granted or rene3ed the provider may also be granted a medical staff appointment 3hich runs concurrently 3ith the privileges. Hhile privileges may be granted 3ith or 3ithout a staff appointment a medical staff appointment may not be made in the absence of granting privileges. A medical staff appointment may be revo5ed 3ithout affecting the provider8s clinical privileges. An appointment to the medical staff is re(uired in order for a provider to admit patients. There are four medical staff appointment categoriesF a. 0n ! al. 0ranted to a provider 3hen heDshe is first assignedDemployed in a &'& #T< or if the provider has a lapse of greater than +>0 days since holding a medicalDdental staff appointment in a &'& #T<. b. #&! /e. 0ranted to a provider e6ercising regular privileges and meeting all (ualifications for medicalDdental staff membership after successful completion of the initial appointment period. c. #-- l a!e. 0ranted to a provider e6ercising regular privileges and meeting all (ualifications for medical staff membership. This applies after successful completion of the initial appointment period 3hen due to conditions of

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%6.

employment the provider is neither assigned organi4ational responsibilities of the medicalDdental staff nor e6pected to fully participate in activities of the medicalDdental staff. d. Temporar$. 0ranted to a provider in emergency or disaster situations 3hen there are urgent beneficiary care needs but the time constraints 3ill not allo3 full credentials revie3. *edicare The <ederal health insurance program for people )* years of age or older certain younger people 3ith disabilities and people 3ith endEstage renal disease. *ilitar) 'ealt' s)ste! The combination of military and civilian medical systems used to provide health care to &'& medical beneficiaries. The #92 incorporates all aspects of health services for the &'&. *ilitar) treat!ent (acilit) 0*+.1 As used in this AR #T< infers and applies to T&A and T'@ medical and dental facilitiesDunits both AA and R!. *onitoring The systematic and ongoing collection compilation and organi4ation of data pertaining to indicators for the (uality and appropriateness of important aspects of care in order that problems or opportunities to improve care can be identified. *onitoring and evaluation #O@ of care denotes actions ta5en to ensure a provider or nonprivileged professional understands and renders appropriate care. This action is not reportable to the /$&? or regulatory agencies and may includeG a. @lements of indirect supervision such as retrospective or concurrent revie3 of medical records. b. Revie3ing verbally 3ith the providerDprofessional the diagnosisDassessment treatment options and decisions for care rendered by the providerDprofessional on a sample of cases or on particular types of cases. c. 'bserving at least t3o significant demonstrations of technical s5ill if appropriate. 9ational ractitioner Data 7anB The agency designated by the &epartment of 9ealth and 9uman 2ervices to receive and provide data on substandard clinical performance and conduct of physicians dentists and other licensed health care practitioners including data on malpractice claims payment made on behalf of those practitioners. 9ational rovider /denti(ier A standard providerEuni(ue +0Edigit number assigned by !#2 to eligible heathcare personnel. The /$% is used throughout the 1nited 2tates healthcare system to identify providers 3ho furnish billable healthcare services or those 3ho may initiate andDor receive referrals. 9ear !iss 2ee !lose call. 9etAorB The combination of the #T< and other civilian preferred providers (for e6ample individual and group practitioners other <ederal and nonE<ederal hospitals clinics and so forth) 3ho have agreed to accept &'& and 1niformed 2ervices beneficiaries enrolled in the #92 #anaged !are (TR%!AR@) $rogram provide care at negotiated rates adhere to "A and 1# procedures and follo3 other re(uirements of the TR%!AR@ $rogram. 9eEus A connection or lin5 bet3een individual events circumstances or facts. The fundamental core or center of a given situation (that is the heart of the matter). 9urse practitioner An R/ 3ho has graduated 3ith a master8s degree as an /$ in a given specialty from an accredited school of nursing and 3ho has passed the national certification e6amination by the American /urses !ertification !orporation or the recogni4ed national nursing certification for hisDher particular specialty. The /$ is (ualified to diagnose determine initiate alter or terminate health services management of identified populations of patients andDor the nursing treatment provided to patients on a routine or occasional basis. The /$ possesses a current license to practice in a 2tate !ommon3ealth territory or 7urisdiction.

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AR 4068 0 6 !ebruary 004

9ursing plan o( care Any 3ritten documentation of the nursing process as it applies to an individual patient. 9utritional care services Those activities related to the provision of comprehensive nutritional care to include nutritional assessment and #/T of beneficiaries nutrition education and health promotion administration and operation of a hospital food service and applied research. "bligated status Active duty service obligation(s) resulting from entry into the Army participation in the various subsidi4ed accession programs (for e6ample 9ealth $rofessions 2cholarship $rogram 1niformed 2ervices 1niversity of the 9ealth 2ci ences R'T!) or from participation in inEservice or 2erviceEsponsored professional education programs that include an active duty obligation. "ccupational 'aCards 9a4ards directly related to the 3or5 environment. "ccupational and environ!ental 'ealt' nursing 'ccupational and environmental health nursing is the specialty practice that provides for and delivers health and safety programs and services to 3or5ers. The practice focuses on promotion of health prevention of illness and in7ury and protection from 3or5 related and environmental ha4ards. 'ccupational and environmental health nurses have a combined 5no3ledge of health and business that they blend 3ith healthcare e6pertise to achieve the re(uirement for a safe and healthful 3or5 environment. "ccupational t'erapist An individual (ualified by graduation from an accredited school of occupational therapy 3ith either a baccalaureate or master8s degree 3ho has passed a national certification e6amination given by the /ational ?oard for !ertification in 'ccupational Therapy %nc. A license to practice from a 2tate !ommon3ealth territory or 7urisdiction is re(uired. "pto!etrist A person (ualified by graduation from an accredited school of optometry and licensed to provide independent primary eye care in a 2tate !ommon3ealth territory or 7urisdiction. "R@?+* A TJ! proprietary initiative that integrates health care organi4ational outcomes and other performance measurement data into the accreditation process. "t'er aut'oriCing docu!ent 'ther authori4ing document isG a. A mechanism such as registration and certification by 3hich a 2tateA the &istrict of !olumbiaA or a !ommonE 3ealth territory or possession of the 1nited 2tates grants authority to provide health care in a specified disciplineA or b. %n specialties not licensed and 3here the re(uirements of the granting authority for registration or certification are highly variable the validation by a national organi4ation that a practitioner is professionally (ualified to provide health care in a specified disciplineA or c. %n the case 3here health care is provided in a foreign country by any person 3ho is not a national of the 1nited 2tates a grant of permission by an official agency of that foreign country for that person to provide health care in a specified discipline. "utco!es The result of performance (or nonperformance) of a function process or series of processes. 2tates or conditions of individuals and populations attributed or attributable to antecedent health care. They can include adverse or beneficial results of care shortE or longEterm results of care complications or occurrences and are the product of the perform ance (or nonperformance) of one or more functions or processes. atient care 9ealth care interventions or services provided to a designated beneficiary in a health care home or other setting that are diagnostic preventive or therapeutic in nature. $atient care may be classified as either direct or indirect. a. * re&! pa! en! &are. 9ealth care interventions services or activities that engage the providerDprofessional in face to face contact 3ith the beneficiary andDor <amily memberDsignificant other. @6amples of direct care include assisting 3ith activities of daily livingA conducting a patient assessmentA ta5ing an 6ErayA performing an 9O$ e6aminationA patient teachingA and the collecting reporting and documenting data related to these activities.

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b. 0nd re&! pa! en! &are. 9ealth care related activities that complement or augment direct care but typically do not involve immediate contact 3ith the beneficiary andDor <amily memberDsignificant other. @6amples of indirect care include performing a procedure on a specimen in the laboratoryA processing or interpreting radiological filmsA revie3 ing data contained in a medical recordA preparing pharmaceuticals or intravenous solutionsA and the collecting reporting and documenting data related to these activities. atient care evaluation $rocesses performed either concurrently or retrospectively 3hich assess in depth the (uality andDor nature of the utili4ation of an aspect of health or dental careDservice. This often is accomplished by observation or medical record revie3. !orrective action is ta5en 3here indicated and a subse(uent analysis (follo3up) is made of the corrective actionDeffect. atient 'ar! $ersonal in7ury or damage to a patient of a physical or psychological nature as a result of a patient safety event. atient sa(et) event An incident or error that occurred (actual event) or almost occurred (close callDnear miss) that caused or had the potential to cause harm to the patient. eer An individual from the same professional disciplineDspecialty to 3hom comparative reference is being made. eer reco!!endation Hritten feedbac5 from an individual (a peer) 3ho has firsthand 5no3ledge of the professional performance of the provider in (uestion. The document 3ill be current (that is for initial staff appointmentDa3ard of clinical privileges less than +2 months oldA less than 2. months for appointmentDprivileges rene3al). The content of the recommendation should address the provider8s professional 5no3ledge clinical 7udgment and technical s5ills interpersonal s5ills communication s5ills and professionalism.. %n instances 3here these documents are not available or are not current another method (for e6ample telephonic intervie3 3ith documentation included in the $!<) of obtaining peer recommendation 3ill be employed. This course of action should be ta5en only in e6treme circumstances (that is emergencyDdisaster) and is valid for a temporary period of time according to local policy pending receipt of 3ritten peer recommendations. eer revieA The process by 3hich health care providersDprofessionals of the same discipline evaluate the care of a fello3 providerD professional and ma5e determinations about the (uality of that care. %n addition a decision is made regarding 3hether in a given clinical situation(s) the professional 2'! 3as met or not met by the individual in (uestion. $rivilegesD practice are at ris5 of being adversely affected. er(or!ance i!prove!ent The continuous study and adaptation of a health care organi4ation8s functions and processes to increase the probability of achieving desired outcomes and to better meet the needs of individuals populations and other users of services. ')sical t'erapist An individual (ualified by graduation from an accredited school of physical therapy 3ith either a baccalaureate or master8s degree and licensed by a 2tate !ommon3ealth territory or 7urisdiction to practice physical therapy. ')sician An individual possessing a degree in medicine or osteopathy and licensed by a 2tate !ommon3ealth territory or 7urisdiction to practice medicine. ')sician assistant An individual 3ho has graduated from an accredited $A education program and is granted privileges to determine initiate alter or terminate regimens of medical care under the supervision of a licensed physician. lan o( supervision A commandEapproved arrangement to provide supervision specific to a practitioner that includesF the scope of care permitted level of supervision identity of supervisor evaluation criteria and fre(uency of evaluation.

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odiatrist An individual (ualified by graduation from an accredited school of podiatric medicine and licensed to practice podiatry by a 2tate !ommon3ealth territory or 7urisdiction. otentiall) co!pensable event An adverse event that occurs in the delivery of health care or services 3ith resulting in7ury to the patient. %t includes any adverse event or outcome 3ith or 3ithout legal fault in 3hich the patient e6periences any unintended or une6pected negative result. %t pertains to all patients regardless of beneficiary status (for e6ample A& retired family member civilian emergency and so forth). ractice or procedure variance Any deviation from the accepted standards of care practice or performance. rescriptive aut'orit) $ermission granted by an authori4ing 2tate agency to prescribe pharmacologic agents based on specific clinical indicators including the results of diagnostic tests and laboratory results and the patient8s health status or needs. ri!ar) source veri(ication The process utili4ed to authenticate the accuracy of a specific credential or (ualification as reported by an individual health care provider or professional. The primary source is the institution agency or body that is the original source of the credential or (ualification. rivileges 0clinical1 $ermission to provide specified medical and other beneficiary health care services in the granting institution 3ithin defined limits based on the individual8s education professional license e6perience competence ability health and 7udgment. The three categories of clinical privileges includeG a. %egular. $ermission to independently provide medical and other beneficiary health care services as described above. Regular privileges shall be granted for periods not to e6ceed 2. months. b. Temporar$. 0ranted in situations 3hen time constraints 3ill not allo3 full credentials revie3. Temporary privileges are valid for periods not to e6ceed ,0 days. 0ranting of temporary privileges should occur infre(uently and then only to fulfill pressing patient care needs. Temporary privileges may be granted 3ith or 3ithout a temporary appointment to the medical staff. c. Super/ "ed. %dentifies the status of nonlicensedDnoncertified providers 3ho may neither be appointed to the medical staff nor practice independently. 2upervised privileges may be granted for periods not to e6ceed 2. months. (2ee 2upervised privileges for more detail.) rivileging The process 3hereby the privileging authority upon recommendation from the credentials committee grants to individuals the authority and responsibility for ma5ing independent decisions to diagnosis initiate alter or terminate a regimen of medical or dental care. rocess A goalEdirected interrelated series of actions events mechanisms or steps. ro(essional 2ee 9ealth care professional. ro(essional i!pair!ent A condition that may adversely affect the ability of health care personnel to render (uality care. $rofessional impairment may include deficits in medical 5no3ledge e6pertise or 7udgmentA unprofessional unethical or criminal conductA and any medical condition that reduces or prevents the individual from safely e6ecuting his or her responsibil E ities in the provision of health care. ro(essional revieA process The process by 3hich providersDpersonnel of a li5e or similar discipline conduct an investigation and peer revie3 to evaluate the (uality of patient care of another health care providerDprofessional. Recommendations are subse(uently made to the commander regarding adverse privileging action or limitation of practice. The credentials committeeD function is involved in the evaluation of the privileged providerA a designated peer revie3 panel evaluates the nonprivileged health care professional.

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ro(essional sta(( appoint!ent 2ee #edical staff appointment. rotocol A 3ritten procedure providing basic guidelines for the management (diagnosis and treatment) of specific types of medical or dental patient care in specified circumstances. rovider 2ee 9ealth care provider. rovider activit) (ile A file containing temporary providerEspecific information and performance data used to support the privilege rene3al process. %t contains R# data to include pending adverse privilegingDpractice action information and potential data pending resolution. %t is an e6tension of the $!< and contains active "A documents protected from disclosure by +0 12! ++02. $A< criteria include but are not limited toG a. /umber of patients LdischargedM identifies the total number by patients discharged and transferred to the responsibility of the attending practitioner (e6cluding administrative transfers 3hen the patient 3as not admitted for treatment). This includes inpatient deaths but e6cludes patients for 3hom only medical records responsibility is assumed. b. /umber of patient Ldeaths (failed criteria)M identifies deaths that may have been contributed to by provider failure delay or inappropriate diagnosis or treatment. c. /umber of patients 3ith Lnormal tissue (failed criteria)M identifies surgical cases 3ith normal tissue found unacceptable by surgical cases revie3 function. d. /umber of medical record LdeficienciesM is determined by the medical record revie3 function. e. /umber of medical record Ldelin(uenciesM identifies documented instances of a provider8s failure to complete records 3ithin prescribed time limits that is in no instance longer than ,0 days from patient discharge for total record completion. f. /umber of Ltransfusion variationsM identifies instances of inappropriate blood use as determined by transfusion revie3 or other "AD(uality improvement revie3 function. g. /umber of Ldrug use variationsM identifies instances of inappropriate drug use as determined by revie3 of the $OT committeeDfunction or other "AD(uality improvement revie3. h. /umber of Lvalidated complaintsM identifies providerEdirected beneficiary complaints revie3ed and found 7ustified. i. /umber of Lvalidated occurrencesM identifies occurrences that have been attributed to a provider8s act of commission or omission. rovider credentials (ile A file containing a variety of professional credentialing and privileging documents that substantiate the provider8s licensure education training e6perience current competence health status and medical practice revie3s. %nformation related to provider performance permanent adverse privileging actions and malpractice cases is contained. %t is maintained in a secure manner and is protected from disclosure by +0 12! ++02. :ualit) The degree of adherence to generally recogni4ed contemporary standards of good practice and the achievement of anticipated outcome for a particular service procedure diagnosis or clinical problem. :ualit) assurance A formal and systematic monitoring and revie3ing of medical care delivery and outcomesA designing activities to improve health care and overcome identified deficiencies in providers facilities or support systemsA and carrying out follo3up steps or procedures to ensure that actions have been effective and no ne3 problems have been introduced. :ualit) i!prove!ent An approach to the continuous study and improvement of the processes of providing health care services to meet the needs of individuals and others. 2ynonyms include continuous (uality improvement continuous improvement organiE 4ationE3ide $% and total (uality management. :ualit) !anage!ent A systematic organi4ed multidisciplinary approach to the ongoing assessment monitoring evaluation and modification of the processes of health care and services to enhance (uality. These activities are associated 3ith incremental and focused processes or $%s to meet the health care needs and e6pectations of eligible beneficiaries.

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:ualit) !anage!ent progra! A structured series of coordinated activities and procedures that emphasi4es leadership commitment to (uality performance regardless of the practice site (including operational platforms) a supportive organi4ational culture and the evaluation of the effectiveness of clinical $% activities. These activities include structured processes that design measure assess and improve the health care status and the (uality of health care services provided to individuals and populations. :ualit) o( care The degree to 3hich health care and services for individuals and populations increase the li5elihood of achieving desired health outcomes and are consistent 3ith current professional 5no3ledge. &imensions of performance relative to (uality of care includeF the perspective of the beneficiaryA safety of the care environmentA and accessibility appropriateness continuity effectiveness efficacy efficiency and timeliness of care. Reduction o( privileges/practice The permanent removal of a portion of a provider8s clinical privileges or a nonprivileged professional8s scope of practice. The reduction may be based on misconduct physical impairment or other factors limiting the individual8s capability. Reduction of privilegesDscope of practice is reportable to the /$&? and to 2tate and other regulatory agencies as appropriate. An opportunity for a hearing 3ill be afforded the individual. Re(erral The practice of directing a patient to another program or practitioner for services or advice that the referring source is not prepared or (ualified to provide. Registered nurse An individual 3ho is specifically prepared in the scientific basis of nursingA is a graduate of an accredited school of nursingA has successfully completed the /ational !ouncil ;icensure @6amination for Registered /ursesA and possesses a license to practice as an R/ in a 2tate !ommon3ealth territory or 7urisdiction. Reinstate!ent o( privileges/practice A revision to an adverse privileging action that restores all or a portion of the provider8sDnonprivileged professional8s privileges or scope of practice. Reinstatement may include provisions for #O@ of the individual involvedA the nature and duration of #O@ 3ill be clearly established in 3riting. Reinstatement of privileges is reportable to the /$&?. Representative sa!ple A sample inclusive of the personnel or procedures under revie3 in sufficient number to create statistically significant data. Residential treat!ent (acilit) The inpatient rehabilitation element of the Army 2ubstance Abuse $rogram (formerly 5no3n as the Alcohol and &rug Abuse $revention and !ontrol $rogram (A&A$!$)) 3hich provides an intensive structured treatment program for eligible personnel in designated Army #T<s. Restriction o( privileges/practice A temporary or permanent limit is placed on all or a portion of a provider8s clinical privileges or the nonprivileged professional8s scope of practice based on incompetence unprofessional conduct or other factors affecting the activities restricted. The individual may be re(uired to obtain concurrence before providing all or some specified care andDor may re(uire some type of supervision. This action may be permanent or for a specified period of time. Restriction of privilegesDscope of practice is reportable to the /$&? and to 2tate and other regulatory agencies as appropriate. An opportunity for a hearing 3ill be afforded the individual. Revocation o( privileges/practice The termination of all clinical privilegesDpractice of a given providerDprofessional and permanent removal of the individual from all patient care duties. %n most cases such action is follo3ed by action to terminate the provider8sD nonprivileged professional8s &'& service. Revocation of privilegesDscope of practice is reportable to the /$&? and to 2tate and other regulatory agencies as appropriate. An opportunity for a hearing 3ill be afforded the individual. RisB The chance of an adverse outcome or negative conse(uence such as in7ury illness or loss.

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RisB Assess!ent A structured process to proactively identify and evaluate safety and healthErelated ha4ards in order to minimi4e the li5elihood of the event occurring. RisB !anage!ent !linical and administrative activities that organi4ations underta5e to identify evaluate and reduce the ris5 of in7ury to patients staff and visitors and the ris5 of financial loss to the organi4ation. %t involves identifying ris5 potential prevention of ris5 e6posure and the management of real or potential adverse incidents and medical malpractice claims. Root cause anal)sis A process for identifying the basic or contributing causal factor(s) associated 3ith an adverse event or close call. The revie3 is interdisciplinary and includes those 3ho are closest to the process. %t focuses on systems and processes not individual performance. The analysis as5s L3hatM and L3hyM until all aspects of the process are revie3ed and all contributing factors have been determined. %t identifies changes that could be made in systems and processes that 3ould improve performance and reduce the ris5 of adverse events or recurrence of close calls. 4a(et) assess!ent code A ris5 assessment score that is assigned to an adverse or near miss event based on the severity of the incident and the probability of its recurrence. 4cope o( care or services The activities performed by governance managerial clinical or support staff. 4entinel event An une6pected occurrence involving death or serious physical or psychological in7ury to a patient or the ris5 thereof that is not related to the natural course of the patient8s illnesses or underlying condition. 2erious in7ury specifically includes loss of limb or function. 4igni(icantl) involved provider/sta(( !e!ber %ndividuals 3ho (based on medical record entries) actively delivered care in primary or consultative roles during the episode(s) of care that gave rise to the allegation(s) of malpractice regardless of the 2'! determination. 4peec' pat'ologist An individual (ualified by graduation from an accredited college or university 3ith a master8s or doctoral degree in speech pathology. 9eDshe possesses a !ertificate of !linical !ompetence from the American 2peechE;anguageE9earing Association and license to practice speech pathology from a 2tate !ommon3ealth territory or 7urisdiction. 4tandard o( care 9ealth care diagnostic or treatment 7udgments and actions of a providerDprofessional generally accepted in the health care discipline or specialty involved as reasonable prudent and appropriate. 4tandard o( per(or!ance @6pected level of performance based on education level of e6perience and criteria of current position re(uirements. 4tandard o( practice %dentified levels of care that focus on health care personnel and serve as guidelines to assess their competence e6perience and education. 4tandards $rofessionally developed e6pressions of the range of acceptable variation in (uality of care generally 3ith respect to specific services. 4ubstandard !edical practice or care #edical care rendered to a patient that fails to meet the 2'!. 4u!!ar) suspension o( clinical privileges The temporary removal of all or a portion of a provider8s privileges. This action ta5en prior to the completion of due process procedures is based on peer assessment or command decision that the action is necessary to protect patients or the integrity of the command. 2ummary suspension results in the individual8s temporary removal from patient care duties based on allegations of incompetence negligence unprofessional conduct physical (alcohol or other drug related) or professional impairment and may continue until due process procedures are complete. This action may ta5e

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AR 4068 0 6 !ebruary 004

place follo3ing a period of abeyance or as an initial action in response to the performance conduct or behavior of the provider in (uestion. 2ummary suspension of clinical privileges 3ithin the &'& is not reportable to the /$&? or to 2tate or other regulatory agencies. 4upervised privileges $rivileges granted to a provider 3ho does not meet the re(uirements for independent practice because heDshe lac5s the necessary license or certification to practice independently. 9o3ever all minimal educational re(uirements must be met in order to (ualify for supervised privileges. a. The procedure for a3arding supervised privileges is the same as for regular privileges e6cept that a clinical supervisor must be named in 3riting at the time privileges are a3arded. A 3ritten plan for supervision and a schedule for periodic reporting of the provider8s progress must also be outlined. The supervisor must be an #T< provider 3ith regular privileges in a scope of practice that meets or e6ceeds that of the provider being supervised. The degree of supervision re(uired is determined by the clinical supervisor and must be appropriate to the bac5ground e6perience and demonstrated s5ill of the provider being supervised. b. 2upervised privileges may be granted for periods not to e6ceed 2. months. 4upervision The process of revie3ing monitoring observing and accepting responsibility for assigned personnel. The three types of supervision areG a. 0nd re&!. The supervisor performs retrospective revie3 of selected records. !riteria used for revie3 relate to (uality of care (uality of documentation and the authori4ed scope of privilegesDpractice of the individual in (uestion. Revie3s may also include countersignature or authentication of medical entries reports or orders prescribed by another. b. * re&!. The supervisor is involved in the decisionEma5ing process. This may be further subdivided as follo3sF (+) =erbal-the supervisor is contacted by telephone or informal consultation before implementing or changing a regimen of careA and (2) $hysically present-the supervisor is present physically through all or a portion of care. c. )nhan&ed "uper/ " on. 2upervision afforded a provider 3ith regular privileges for 3hom the need to assess competence and performance has been identified. This may be appropriate follo3ing a $!2 move or a provider8s return to patient care responsibility from an administrativeDnonclinical assignment during a period of temporary duty or 3hen privileges for a ne3 procedure are granted. This is not an adverse privilegingDpractice action. 4upervisor 0clinical1 'ne 3ho provides professional oversight of the clinical activities of another. This may be the departmentDservice chief or a senior staff member of li5e specialty or service 3ho revie3s and ma5es medical policy and ensures that the medical staff revie3 functions are performed 3ithin the service. <or purposes of evaluating performance and recommending clinical privileges the clinical supervisor is a peer (if possible) 3ho is an appointed member of the medical staff and is the individual best (ualified on the basis of bac5ground and training to 7udge the practice of the provider under revie3. 4upport services Those activities in a health care facility that are re(uired to sustain patient care and the environment in 3hich care is provided. @6amples include medical maintenance house5eeping medical supply and materiel activities information management resources management and the medical library. 4uspension o( privileges/practice The temporary removal of all or a portion of a provider8s privileges or a nonprivileged personnel8s scope of practice based on incompetence negligence unprofessional conduct or other factors that do or may affect the appropriateness of the provider8s privilegesDpractice. 2uspension of privilegesDscope of practice is reportable to the /$&? and to 2tate and other regulatory agencies as appropriate. An opportunity for a hearing 3ill be afforded the individual. 4)ste!s anal)sis The analysis of a se(uence of activities or management operations to determine 3hich activities or operations are necessary ho3 they can best be accomplished and ho3 successful processes can be perpetuated. +ele!edicine The use of telecommunication and information technologies to provide health services. Typically this involves live videoEteleconference bet3een a beneficiary and the primary care provider (at a remote site) and a consultant or specialist in another location. The consultant revie3s relevant medical or other data before the sessionA conducts an actual live assessment and consultationA and subse(uently provides a 3ritten report to the provider re(uesting this service.

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+'res'olds $reEestablished levels or points 3hich 3hen reached 3ill trigger intensive evaluation. =npro(essional conduct !onduct that is beyond or outside of professional re(uirements for rendering beneficiary care and 3hich negatively affects or has the potential to negatively affect the professional relationship or contract 3ith the beneficiary. =tiliCation !anage!ent A series of processes by an organi4ation to e6amine evaluate and determine if utili4ation of its resources is appropriate. These processes include planning organi4ing directing and controlling the delivery of medical or dental service in a manner that is costEeffective 3hile maintaining acceptable performance and practice standards. =tiliCation revieA The retrospective and concurrent evaluation of an individual provider8s practice to determine the medical necessity and appropriateness of the care delivered. <eri(ied credentials &ocuments for 3hich confirmation of authenticity has been obtained from the primary source. Section Special A,,reviations and 7erms This section contains no entries.

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AR 4068 0 6 !ebruary 004

-.C/ASS + 0!

3 . 066$$4000

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