Main

LATE PATIENT/END OF DAY RESPONSIBILITIES *

Effective Date: 
Wed, 01/06/2016
Reviewed: 
Tue, 03/13/2018
Revised: 
Wed, 01/27/2016
Policy: 

In the event that any patients will still be in the building after 5:30pm, the DOC and Charge Nurse will confer to determine the best plan of care for these patients.  

Procedure: 

1.  The DOC will confer with the Charge Nurse at the end of each day to ensure all patients have been discharged from the building prior to leaving work.

 

2.  In the event that patients are still in the building, the DOC or charge nurse will confirm with the treating provider that no assistance is needed from the DOC prior to the DOC departing. The DOC assignment is rotated among career clinicians and has the primary responsibility to stay after 5:30 if needed for patient care.  It is the responsibility of the DOC to arrange physician coverage for this back up responsibility if the DOC departs prior to the last patient leaving.

 

3.  Each day, on a rotating basis one member of the Nursing staff is assigned to stay after 5:30 if needed for patient care. 

 

4.  Anytime patients are still on-site, at a minimum,  two members of staff (1 clinician and 1 nurse) will remain until patient discharge. 

 

5.  The Charge Nurse is responsible for notifying Ancillary Services (Lab, Radiology, Pharmacy) at end of day when all students have been discharged and their services are no longer needed.

 

DIVERSION STATUS

Effective Date: 
Wed, 01/06/2016
Reviewed: 
Tue, 03/13/2018
Policy: 

The Student Health Center will begin to divert students if all of the case management and appointment slots are filled for the day.   

Procedure: 

1.  The charge nurse will make the decision to divert in consultation with the medical director or available manager.

2.  When it has been decided to go on “diversion status” a Broadcast IM to all of the SHS community.  SHOP will be notified by phone.

3.  The Nurse Advice Line will be diverted to the after-hours advice line and the service will be notified of Health Center diversion status by Charge Nurse or Manager.

4.  A sandwich board will be posted at the Health Center main entrance which says:

“The Student Health Center is experiencing higher than normal demand for care.  Please consider returning tomorrow.  If you need to be seen today, our office may assist you to be seen at an off campus site if necessary.”

5.  When the Health Center is on diversion, students will still be evaluated by the triage nurse who will determine the appropriate plan of care in collaboration with the student.   All available staff will assist with triage as able.

 

INTERCOLLEGIATE ATHLETIC VISITS

Effective Date: 
Wed, 11/25/2015
Revised: 
Wed, 12/02/2015
Policy: 

Any registered student is eligible for services at the SHC and can consult with the Triage Nurse at no charge.  

  • Intercollegiate athletes
  • (aka NCAA or Varsity) are required to purchase an "insurance rider" for the health care costs of injuries due to their sport/s, such as advanced imaging and surgery. This does not preclude students with CruzCare or UC SHIP from having an evaluation at the UCSC Student Health Center.   If a student athlete has UC SHIP or CruzCare, we can see them for the initial evaluation at NO charge.  If the student athlete need referrals for specialty care or imaging, then they need to be informed that UC SHIP explicitly excludes coverage for injuries from intercollegiate athletics  whether in a game, practice  or training.

NOTE: There are also sports clubs, both competitive and non-competive (cycling, ultimate frisbee, rugby, lacrosse, judo, dance etc.).  Sports Club students have access to their own "Sports Club" Athletic Trainer

  • The athletes may allow the athletic trainers to communicate with our clinicians or allow the clincian to communicate with the athletic trainers.  In that case, use HC 560 (attached) for the transfer of that information.  The student athlete is responsible for transporting the form back and forth.  
Procedure: 
  • Student intercollegiate athletes with UC SHIP or CruzCare can be seen in the Same Day Clinic for an  initial evaluation by SHC providers, with X-­rays ordered if indicated for no additional charge. 
  • Students without UC SHIP or CruzCare who elect to see an SHC clinician will be charged for visits and X-­rays  beyond  the Triage Nurse visit
  • Referrals can be made by UCSC SHS clinicians; however, UC SHIP excludes coverage for injuries sustained during  intercollegiate athletics including training.  Therefore, the student athletes must use their other insurance for care  for athletic injuries  
  • UC SHIP referrals do not guarantee authorization for coverage by the health insurance carrier 
  • Students with or without UC SHIP who need follow up, need to see providers in their respective primary insurance  plan; a referral from the SHC can be given, as can a compact disk (CD) of digital X-­rays performed here, if helpful    
  • A referral from the SHC for a student to a specialist does not meet the requirements of their private  insurance plan and does not imply that their private insurance will cover the cost of the visit or  procedure with the specialist.  Final determination of insurance coverage for specialty care is made  by the insurance carrier and cannot be guaranteed

Intercollegiate Athletes

  • Always have outside insurance that is checked by the athletic training department to assure primary coverage for intercollegiate athletic injuries and coverage of up to at  least $90,000.  
  • Always have additional coverage through OPERS, provided by the University as a secondary insurance
  • Kaiser coverage often qualifies as the primary
  • Students may choose to have UC SHIP or CruzCare
  • The athletic trainers recommend waiving UC SHIP ­but SHS recommends that student athletes add on CruzCare for non-sports medical needs 
  • Both UC SHIP and CruzCare may be included in financial aid  
  • Typically, the trainers do NOT send students to the SHC, however, if they do, it is often for X-­rays when the student  athlete cannot get to an Urgent Care Clinic.  Use the attachment if students want the clinician and the trainer to communicate - HC 560 - make a copy to be scanned into the EMR and give the original to the student athlete to bring to the trainer
  • For more information on UCSC Athletics, link to: http://www.goslugs.com/landing/index  
  • Current Intercollegiate Teams o Men’s Basketball o Men’s Cross Country o Men’s Soccer o Men’s Swimming and Diving o Men’s Tennis o Men’s Volleyball o Women’s Basketball o Women’s Cross Country o Women’s Golf o Women’s Soccer o Women’s Swimming and Diving o Women’s Tennis o Women’s Track o Women’s Volleyball 

EXIT CHECKLIST

Form Type: 
HC
Form Number: 
753

EMPLOYEE EXIT POLICY

Effective Date: 
Mon, 11/16/2015
Revised: 
Fri, 04/01/2016
Policy: 

The attached Employee Exit Checklist must be completed for any employee terminating employment with UCSC Student Health Services.  This will be completed by multiple stakeholders and will ensure follow through for all UCSC and UCSC SHS requirements for IT, SHS Administration and SHR actions.

Supervisor Responsibilities:

1.  Upon receipt of notice to terminate/resignation, accept resignation in writing and forward to Student Health Center Staff HR liaison who in turn will notify central Staff HR to initiate process

2.  Initiate and complete HC 753 Employee Exit Checklist

Notify Staff

PERIPHERAL DEVICES

Effective Date: 
Mon, 06/29/2015
Policy: 

The University of California Santa Cruz Student Health Services (SHS) is committed to conducting business in compliance with all applicable laws, regulations and University of California policies. UCSC SHS has adopted this policy to outline the security measures required to protect electronic information systems and related equipment from unauthorized use.

Our objective is to provide an organized approach for handling potential exposure of information from peripheral devices.

Procedure: 

At the University of California Santa Cruz Student Health Services, peripheral devices that store or process confidential or protected information are prohibited except under the approval and direction of the Business and Information Systems Director.

Violations of this policy may lead to disciplinary action up to and including termination under either the Human Resources corrective action process or the HIPAA Sanction policy.

CLINICAL CASE REVIEW *

Effective Date: 
Wed, 06/10/2015
Reviewed: 
Thu, 02/08/2018
Revised: 
Fri, 02/03/2017
Policy: 

Policy: 

In cases where there are questions or concerns about clinical management the Medical Director or appropriate supervisor shall convene a Clinical Case Review committee composed of appropriate licensed professionals who will review the case and make evaluations and/or recommendations concerning the case.  The Clinical Case Review committee is an "ad hoc" committee composed of the Medical Director and/or Executive Director and additional professionals capable of appropriate review the case. 

Case Review Committee responsibilities include: 
1. Providing additional review of cases identified in the peer review process as having possible quality of care problems
2. Reviewing clinical incident reports
3. Participating, as appropriate, in resolution of quality of care issues involving clinician staff.

Depending on the outcome of the review, results may be summarized as an Incident Report and reported to the QM committee.  Some clinical case reviews may result in verbal or written feedback to the individual clinician and others may not warrant any feedback if the care and documentation meet community standards.

 

 

 

 

 

 

Procedure: 

Procedure: 

1. When questions about specific clinical care are identified and an analysis of the situation indicated a Case Review Committee shall be convened.

2. The committee is under the direction of the Executive Director or the Medical Director and includes professional staff appropriate to evaluate the clinical situation.

3.  Case Review committee evaluations and recommendations are summarized as Incident Reports and shared with the appropriate staff and the QM committee as appropriate. 

Key Points: 

Key Points: 

The SHS has in place a process for the objective evaluation of clinical situations. 

VERIFICATION OF OTHER HEALTH CARE PROVIDERS (OHP) *

Effective Date: 
Sun, 07/01/2012
Reviewed: 
Thu, 02/08/2018
Revised: 
Wed, 11/01/2017
Policy: 

To assure that patients receive care by qualified staff, each  Other Healthcare Provider (OHP) (Certified Medical Assistant, Certified Optician, Certified Pharmacy Technician, Certified Phlebotomy Technician, Certified Radiology Technician, Clinical Laboratory Scientist, Licensed Vocational Nurse, Registered Dietitian, Registered Nurse) is verified  prior to being hired.  The verification process by the Credentials Verification Organization (CVO) includes verification of current licensure/certification in good standing, NPDB and OIG.

Procedure: 

Initial Verification Prior to Hiring:

Candidate Applies—Hiring Supervisor receives and reviews applications and selects candidates for Interview

Interview, References and Livescan—Hiring Supervisor completes reference checks, employment verification, interview and refers select applicants for Livescan background check.

After successful Livescan is returned to Hiring Supervisor and all references are deemed acceptable, Hiring Supervisor notifies Credentialing Specialist to initiate the verification process.

Begin Verification Process—Credentialing Specialist contacts selected applicant and starts them on the online  application process with Medversant CVO. The CVO will verify the following: Current license/certification (except Registered Dietitian, Certified Medical Assistant and Certified Optician which are not State of California issued), NPDB and OIG.

      All license/certifications serve as primary source verification for applicable education, with the exception of Registered Nurse (RN). The CVO will do primary source verification of Registered Nurse education/training.  Certified Medical Assistant, Certified Optician and Registered Dietitian, will provide verification of their registration from their applicable certifying agencies.

Once verified profile is completed and returned by the CVO— Credentialing Specialist reviews and audits all pertinent paperwork. If additional information is required, Credentialing Specialist will obtain prior to presenting to the Medical Director for sign off.  If there are any discrepancies or other information the Credentialing Specialist will discuss with the Medical Director and hiring supervisor as applicable.

Medical Director reviews the audited file and if acceptable and clear signs off on the applicants file.  This is the approval  to proceed with hiring.

Credential Specialist notifies Health Center HR staff member and hiring supervisor that applicant has been approved and the final steps can be taken to move forward to Staff HR for the formal job offer.

SHR On-boarding—after formal offer is accepted, SHR sets up the date  for Campus SHR                       On-boarding.

SHS Orientation—New hire comes to SHC for Orientation. Confidentiality, HIPAA and other topics are covered. Staff must provide copy of CPR card and other credentials as required.

 

Maintaining Licenses/Certifications and Other Credentials

All state issued licenses/certifications are monitored monthly by the CVO for expiration dates and any adverse actions. The Credentialing Specialist uses this report in conjunction with other reports to track license/certification, CPR and other trainings for expiration.

It is each staff member’s responsibility to renew their license/certifications/CPR in a timely manner and give a copy to the Credentialing Specialist prior to the expiration of the old one.No staff member may work with an expired license/certification.Current California license/certification in good standing is required as a special condition of employment for all OHP staff.

Every 3 years, OHP staff members, at the discretion of the Credentialing Committee/Governing Board, will complete the online application through the CVOfor DisclosureQuestions and Attestation.

Key Points:

The Student Health Center is required to verify Initial and Continued licensure/certification of OHP staff.

It is the employee’s responsibility to provide copies of current licensure/certification and CPR as applicable.

 

CREDENTIALING AND PRIVILEGING OF ALLIED HEALTH PROFESSIONALS (AHP) - PA, NP, RPh, LMFT, LCSW, OD *

Effective Date: 
Sun, 07/01/2012
Reviewed: 
Thu, 02/08/2018
Revised: 
Thu, 02/08/2018
Policy: 

In order to ensure patients/clients receive care by qualified clinical staff, all Allied Health Professionals (PA, NP, RPh, LMFT, LCSW, OD ) must meet the credentialing requirements of the Student Health Services prior to hiring and approval of clinical privileges. The credentialing process includes, but is not limited to, verification of applicable education, training, licensure, certification, reference checks, background checks and other required verifications per UCOP regulations.

 

Procedure: 

Initial Credentialing Procedure prior to hiring:

Candidate Applies—Hiring Supervisor receives and reviews applications and selects candidates for Interview

Interview, References and Livescan—Hiring Supervisor completes 3 reference checks, interviews and refers select applicants for Livescan background check.

After successful Livescan is returned to Hiring Supervisor and all references are deemed acceptable, Hiring Supervisor notifies Credentialing Specialist to initiate the Credentialing Process.

Begin Credentialing Process—Credentialing Specialist contacts selected applicant and starts them on the onlineapplication process with Medversant CVO.Once application is completed and submitted, the CVO will verify the following:

Education, training and experience:Relevant education and training are verified, the applicant’s experience is reviewed for continuity, relevance and documentation of any interruptions in that experience.

Three (3) Peer References:Current competence is verified and documented.

Board Certification, if applicable.

Current hospital affiliation, if applicable.

Employment history.

State license(s): The primary and California state licenses held during the past five (5) years shall be verified and documented at the time of credentialing including current, unrestricted California license

Drug Enforcement Administration (DEA) registration, if applicable, for location address.

Proof of current medical liability coverage meeting Governing Body requirements, if any.

Information obtained from the National Practitioner Data Bank (NPDB).

Information obtained from the Office of Inspector General (OIG).

Once verified profile is completed and returned by the CVO— Credentialing Specialist reviews, audits and analyzes all pertinent reports. If adverse actions or incomplete information is received, the Credentialing Specialist will consult with the Credentialing Committee/Governing Board prior to convening them for approval.  Once the file is in order and all information has been satisfactorily verified, the Credentialing Specialist will convene the Credentialing Committee/Governing Board.  The Credentialing Specialist will then present the applicant’s file for review, discussion and approval/denial.  The Credentialing Committee/Governing Body may at their discretion provisionally approve the applicant pending specific follow up as will be documented in the file.  In this event, the Credentialing Specialist will track follow up requirements and reconvene the Credentialing Committee/Governing Body when they have been completed.

 

Credential Specialist notifies Health Center HR staff member and hiring supervisor that applicant has been approved and the final steps can be taken to move forward to Staff HR for the formal job offer.

SHR On-boarding—after formal offer is accepted, SHR sets up the datefor Campus SHR On-boarding.

SHS Orientation—New hire comes to SHC for Orientation to include: Confidentiality, HIPAA, I2P2and other relevant topics. Staff must provide copy of CPR card, Immunization records and other credentials as required. Physicians Assistants and Nurse Practitioners will sign the Statement of Approval for the SHC Standardized Procedures and Protocols for Midlevel Providers.  Physician assistants will operate under the delation of authority agreement.

      New hire will complete the request for specific privileges at this time.  The Credentialing Specialist will convene the Credentialing Committee/Governing Body to meet, discuss and approve/deny the request for specific privileges.  A copy of the privilege form will be given to the provider for reference. New privileges may be granted by the Credentialing Committee/Governing Body upon written request documenting satisfactory training and experience. The copy of the updated privilege form will be given to provider for their records.

For Physicians Assistants and Nurse Practitioners, initial review of clinical work is done on a minimum of 30 cases within the first 30 days of the initial assumption of duties.  Additional chart review may be deemed appropriate at the discretion of the Medical Director or Psychiatry Director.  The Medical Director or designees will use the standard peer review format in reviewing cases.  Results of this initial review are evaluated by the Medical Director or Psychiatry Director, who will hold a conference with the staff member regarding the results.

Documentation pertaining to the AHP credentialing is maintained in confidential files in the Credentialing Specialist office.It is the responsibility of the AHP staff to notify the Credentialing Specialistof any changes or updates in credentials or licensure.

Appointment and privileges for AHP staff are granted for a maximum of 3 years.

 

Procedure for Re-Credentialing

All state issued licenses/certifications are monitored monthly by the CVO for expiration dates and any adverse actions. The Credentialing Specialist uses this report in conjunction with other reports to track license, certifications, CPR and other trainings for expiration.

It is each staff member’s responsibility to renew their license/certifications/CPR in a timely manner and give a copy to the Credentialing Specialist prior to the expiration of the old one.No staff member may work with an expired license/certification. Current California license in good standing is required as a special condition of employment for all AHP staff.

Every 3 years, the AHP staff members will go through re-credentialing which consists of updating their online application through the CVO (verifying demographics, expiration dates, hospital affiliation if applicable, liability coverage, disclosure questions and attesting and signing) and completing a new privilege form.

Once the credential profile is completed and returned from the CVO— the Credentialing Specialist reviews and audits all pertinent paperwork. The file is presented along with updated privilege form to the Medical Director, Psychiatry Director or CAPS Director, as applicable, to review prior to committee.

The Medical Director, Psychiatry Director and CAPS Director will evaluate the  AHP staff’s professional performance, judgment, patterns of patient/client care, and when appropriate, technical skill (through direct observation or consultation with other UCSC Student Health Center practitioners  who have observed the candidate). The evaluation shall also include the AHP’s specific performance improvement and patient/client safety data (peer review). They will sign a form recommending or not-recommending the staff member for reappointment.

Credential Committee/Governing Body convenes to review re-credential packet (credential file, updated privilege form and recommendation from Medical, Psychiatry or CAPS Director) and discuss any relevant issues as applicable. After any discussions, the Credentialing Committee/Governing Bodythen approves the file, or if applicable defer or place conditionspending further information before final approval. The Credentialing Committee/Governing Body signs off and approves

re-appointment for 3 more years.

Credential Specialist sends letter to staff members with copy of updated Privilege form and notice of re-appointment.

 

 

 

CREDENTIALING AND PRIVILEGING OF LICENSED INDEPENDENT PRACTITIONERS (LIP) - MD, DO & PhD/PsyD *

Effective Date: 
Sun, 07/01/2012
Reviewed: 
Thu, 02/08/2018
Revised: 
Wed, 11/01/2017
Policy: 

In order to ensure patients/clients receive care by qualified clinical staff, all Licensed Independent Practitioners (MD, DO and PhD/PsyD) must meet the credentialing requirements of the Student Health Services prior to hiring and approval of clinical privileges. The credentialing process includes, but is not limited to, verification of applicable education, training, licensure, certification, reference checks, background checks and other required verifications per UCOP regulations.

 

Procedure: 

Initial Credentialing Procedure prior to hiring:

Candidate Applies—Hiring Supervisor receives and reviews applications and selects candidates for Interview

Interview, References and Livescan—Hiring Supervisor completes 3 reference checks, interviews and refers select applicants for Livescan background check.

After successful Livescan is returned to Hiring Supervisor and all references are deemed acceptable, Hiring Supervisor notifies Credentialing Specialist to initiate the Credentialing Process.

Begin Credentialing Process—Credentialing Specialist contacts selected applicant and starts them on the onlineapplication process with Medversant CVO. Once application is completed and submitted, the CVO will verify the following:

Education, training and experience:Relevant education and training are verified, the applicant’s experience is reviewed for continuity, relevance and documentation of any interruptions in that experience.

Three (3) Peer References:Current competence is verified and documented.

Board Certification, if applicable.

Current hospital affiliation, if applicable.

Employment history.

State license(s): The primary and California state licenses held during the past five (5) years shall be verified and documented at the time of credentialing including current, unrestricted California license

Drug Enforcement Administration (DEA) registration, if applicable, for location address.

Proof of current medical liability coverage meeting Governing Body requirements, if any.

Information obtained from the National Practitioner Data Bank (NPDB).

Information obtained from the Office of Inspector General (OIG).

Once verified profile is completed and returned by the CVO— Credentialing Specialist reviews, audits and analyzes all pertinent reports. If adverse actions or incomplete information is received, the Credentialing Specialist will consult with the Credentialing Committee/Governing Board prior to convening them for approval.Once the file is in order and all information has been satisfactorily verified, the Credentialing Specialist will convene the Credentialing Committee/Governing Board.The Credentialing Specialist will then present the applicant’s file for review, discussion and approval/denial.The Credentialing Committee/Governing Body may at their discretion provisionally approve the applicant pending specific follow up as will be documented in the file.In this event, the Credentialing Specialist will track follow up requirements and reconvene the Credentialing Committee/Governing Body when they have been completed.

 

Credential Specialist notifies Health Center HR staff member and hiring supervisor that applicant has been approved and the final steps can be taken to move forward to Staff HR for the formal job offer.

SHR On-boarding—after formal offer is accepted, SHR sets up the datefor Campus SHROn-boarding.

SHS Orientation—New hire comes to SHC for Orientation to include: Confidentiality, HIPAA, I2P2and other relevant topics. Staff must provide copy of CPR card, Immunization records and other credentials as required. Physicians will sign the Statement of Approval for theSHC Standardized Procedures and Protocols for Midlevel Providers.

      New hire will complete the request for specific privileges at this time.  The Credentialing Specialist will convene the Credentialing Committee/Governing Body to meet, discuss and approve/deny the request for specific privileges.  A copy of the privilege form will be given to the provider for reference. New privileges may be granted by the Credentialing Committee/Governing Body upon written request documenting satisfactory training and experience. The copy of the updated privilege form will be given to provider for their records.

For physicians, initial review of clinical work is done on a minimum of 30 cases within the first 30 days of the initial assumption of duties.  Additional chart review may be deemed appropriate at the discretion of the Medical or Psychiatry Director.  The Medical or Psychiatry Director or designees will use the standard peer review format in reviewing cases.  Results of this initial review are evaluated by the Medical or Psychiatry Director, who will hold a conference with the staff member regarding the results.

Documentation pertaining to the LIP credentialing is maintained in confidential files in the Credentialing Specialist office.It is the responsibility of the LIP staff to notify the Credentialing Specialist of any changes or updates in credentials or licensure.

Appointment and privileges for LIP staff are granted for a maximum of 3 years.

 

Procedure for Re-Credentialing

All state issued licenses/certifications are monitored monthly by the CVO for expiration dates and any adverse actions. The Credentialing Specialist uses this report in conjunction with other reports to track license, certifications, CPR and other trainings for expiration.

It is each staff member’s responsibility to renew their license/certifications/CPR in a timely manner and give a copy to the Credentialing Specialist prior to the expiration of the old one.No staff member may work with an expired license/certification.Current California license in good standing is required as a special condition of employment for all LIP staff.

Every 3 years, the LIP staff members will go through re-credentialing which consists of updating their online application through the CVO (verifying demographics, expiration dates, hospital affiliation if applicable, liability coverage, disclosure questions and attesting and signing) and completing a new privilege form.

Once the credential profile is completed and returned from the CVO— the Credentialing Specialist reviews and audits all pertinent paperwork. The file is presented along with updated privilege form to the Medical Director , Psychiatry Director or CAPS Director, as applicable, to review prior to committee.

The Medical Director, Psychiatry Director and CAPS Director will evaluate their LIP staff’s professional performance, judgment, patterns of patient/client care, and when appropriate, technical skill (through direct observation or consultation with other UCSC Student Health Center practitioners  who have observed the candidate). The evaluation shall also include the practitioner’s practitioner specific performance improvement and patient/client safety data (peer review). They will sign a form recommending or not-recommending the staff member for reappointment.

Credential Committee/Governing Body convenes to review re-credential packet (credential file, updated privilege form and recommendation from Medical, Psychaitry or CAPS Director) and discuss any relevant issues as applicable. After any discussions, the Credentialing Committee/Governing Bodythen approves the file, or if applicable defer or place conditionspending further information before final approval. The Credentialing Committee/Governing Body signs off and approves re-appointment for 3 more years.

Credential Specialist sends letter to staff members with copy of updated Privilege form and notice of re-appointment.

 

 

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