ACOE_Self-Study

8.2.1 The program must publish and make available to staff, student clinicians, residents and faculty, a clinic manual which includes all clinic policies and procedures. There has been a concerted effort to be green with the voluminous UEC Policy and Procedure Manual (just under 700 pages) ( Appendix VIII-6 ) and not print unnecessary copies. The complete manual is available to faculty and staff via the Office 365 email system in the Sharepoint SUNY OPT Home Page under the document header of College – UEC policies & procedures . The appendices to the manual incorporate documents such as the Clinical Management Protocols, Bylaws, Tables of Organization and the Credentialing Standards. The Sharepoint document also contains a summary of 2018 changes to the UEC manual (see below). For students, the manual and list of changes are available electronically via the Sharepoint SUNY OPT Home Page. In addition, each clinical floor (Floors 5, 6, 7 and 8) has a CD with the aforementioned files in the rare occurrence that the network is down and not available. All new employees (faculty and staff) are provided with information on how to access these electronic documents. Students are informed during their orientation immediately preceding their entry into the clinics. An extensive review of the University Eye Center’s (UEC) policies and procedures was last conducted between February and April 2018. As a result of this review, 82 policies/procedures were modified (approximately 25% of these were substantial changes). Appendix VIII-7 summarizes the changes. Two new policies/procedures were developed in the areas of operations and patient care . 8.2.2 The program must verify credentials of faculty members who serve in the clinic. The policy for initial and re-credentialing in the UEC is in the UEC Policy and Procedure Manual C- 12 ( Appendix VIII-6 ). All faculty members with clinical privileges are required to complete the credentialing process at the time of initial appointment and every two years thereafter. A number of specific items are required to be submitted for the initial and re-credentialing and privileging process, including original degrees and licenses. A detailed listing of these items is included in the above-mentioned policy and procedure. Providers must request and be granted privileges to provide direct patient care during each credentialing and privileging cycle. The policy is section P-8 of the UEC Policy and Procedure Manual ( Appendix VIII-6 ). The credentialing and privileging period is bi-annual, and providers must meet certain requirements to be re-credentialed and maintain privileges. A faculty member may request a new privilege at any time during the credentialing and privileging cycle. The requested privilege or change in privileges requires approval by a service chief. Delineation of the scope and extent of each faculty member’s clinical privileges are determined with the credentialing policy ( UEC Policy and Procedure Manual C-12 in Appendix VIII-6 ) and clinical privileges form ( Appendix VIII-8 ). Moreover, the approval process ensures review at the service- specific and organizational level with the Chief Medical Officer granting the final approved 8.2.3 The program must define the scope and extent of clinical privileges for each faculty member who serves in the clinic.

98