Assuring Quality in Medical Staff Membership

Refer to: OQ

1. Purpose.

   The purpose of this circular is to provide temporary Indian Health Service (IHS) licensing requirements for health care providers and medical staff, establish more stringent oversight of exceptions to the licensure policy, and provide guidance on addressing credentialing and privileging of impaired providers. Current policy is found in the Indian Health Manual (IHM) Part 3, Chapter 1, Medical Credentials and Privileges Review Process , which will be updated at next issuance to incorporate the requirements expressed herein and the use of newer Agency-wide technology for credentialing and privileging.

   Credentialing and privileging of health care practitioners for medical staff membership is one of the most critical tasks of the Agency and is directly related to the quality of healthcare provided at IHS facilities. A strong credentialing and privileging policy and process decreases the potential for patient harm by verifying the training, competence, character, and ongoing successful clinical performance of medical staff.

2. Clarification of General Licensure Requirements.

   I am relying on the full support of all IHS Area Directors and all Area Chief Medical Officers to ensure that all facilities and medical providers and staff, including temporary staff contractors or locums, adhere to the IHS policy, as established in the Indian Health Manual (IHM) Part 3, Chapter 1, Medical Credentials and Privileges Review Process , Section 3-1.4.C (5). Specifically, I want to emphasize the policy statement that in general, providers with any restrictions on any State license, certification, or registration will not be granted medical staff membership or privileges (emphasis added) except in very limited circumstances.

3. Granting Exceptions for Licensure Restrictions.

   Medical staff with restricted licenses will only be granted membership or privileges in rare cases. If determined necessary, exceptions will be granted at the time of initial credentialing, re-credentialing, or with any change in licensure status. An exception to the requirement that all licenses held by a provider must be unrestricted may only be made upon recommendation and tentative approval of the Medical Executive Committee or its equivalent, and the Governing Body. This matter must be forwarded to the IHS Quality Assurance Risk Management Committee for endorsement, prior to final Governing Board action.

4. Impaired Providers.

   The medical staff and facility Governing Board have an obligation to protect patients, its members, and other persons present in the facility from harm. Area medical staff must establish a process that recognizes, facilitates, and addresses the rehabilitation of licensed independent practitioners who suffer from a potentially impairing condition.

   The purpose of an established process is to ensure proper patient care and safety. If it is determined at any time during the diagnosis, treatment, or rehabilitation phase of an established process that a practitioner is unable to safely perform their responsibilities, the matter will be resolved using appropriate corrective action, including adherence to any relevant mandated reporting requirements. Finally, communication and coordination will be made with the appropriate Area Office of Human Resources, Office of Equal Employment Opportunity, and/or Office of the General Counsel, when necessary.

5. Supersedure. None.
6. Effective Date. This circular becomes effective on the date of signature.
/Michael D. Weahkee/
RADM Michael D. Weahkee, MBA, MHSA
Assistant Surgeon General, U.S. Public Health Service
Director, Indian Health Service