MSCHE/ACOE Self Study

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 third year. An extensive review of the University Eye Center’s (UEC) policies and procedures was conducted during the months of November 2009-February 2010. As a result of this review, 41 policies and procedures had substantive changes and 23 new policies and procedures were developed. These can be found in Appendix G-6. Of the 23 new policies and procedures, 13 of these were specifically in the area of clinical finance. 8.2.2 The program verifies the credentials of faculty members who serve in the clinic. The policy for credentialing in the UEC is in the UEC Policy and Procedure Manual C-12. All faculty members with clinical privileges are required to complete the credentialing process at the time of appointment and every two years thereafter. Submission of original degrees and licenses is required. 8.2.3 The program defines the scope and extent of clinical privileges for each faculty member who serves in the clinic. The credentialing and privileging process has recently been evaluated and enhanced with the result that the amount of paperwork involved for both the practitioner and the credentialing department staff has been reduced significantly. To bring credentialing and privileging files up to date, clinical faculty members have been asked to complete the new credentialing form even if they are in the middle of the credentialing cycle. Providers must request and be granted privileges to provide direct patient care during each credentialing and privileging cycle (P-8 of the UEC Policy and Procedure Manual ). The credentialing and privileging period is two years, and providers must meet certain requirements to be re-credentialed. A faculty member may request a new privilege at any time during the credentialing and privileging cycle. The requested privilege 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) and clinical privileges form (Appendix G-7). Privileging of residents is based on a recommendation by the director of residency programs.

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