PURPOSE: In order to develop and maintain a highly reliable and clinically excellent healthcare system, NAH requires the services of physicians to act as medical directors for various programs, departments, and service lines. The goal of medical direction is to utilize physician expertise in alignment with organizational goals to provide safe, highly reliable, evidenced-based care across the system. Medical direction may also be required to meet regulatory standards.

DUTIES AND RESPONSIBILITIES

1.1 The Medical Director of the Transfer Center (hereinafter "Transfer Center" Medical Director TCMD") shall be appointed to coordinate and oversee all patient transfer activities between outlying transferring facilities across Northern Arizona and the receiving physicians at NAH.

1.2 TCMD shall serve as the designated coordinator and primary point of contact for all matters pertaining to the establishment of policies, protocols, quality assurance programs, and communications related to the transfer center service line.

1.3 TCMD  shall perform all duties set forth herein in accordance with applicable federal, state, and local laws, regulations, and standards of medical practice, including but not limited to the Emergency Medical Treatment and Labor Act (EMTALA), 42 U.S.C. § 1395dd.

OPERATIONAL AND ADMINISTRATIVE DUTIES

2.1 TCMD shall work to ensure processes in place for the safest, highest quality, appropriate transfer of patient  and pertinent information for seamless care and ease of transfer to NAH from all referring facilities.

2.2 Protocol Development and Maintenance. The Medical Director shall continuously develop, review, and maintain acceptance protocols in cooperation with service line medical directors and staff physicians. Work to ensure protocols are followed appropriately. Such protocols shall be reviewed no less than annually and updated as clinically or operationally warranted.

2.3 Outpatient Collaboration. The Medical Director shall, where clinically appropriate, collaborate with outpatient care physicians and providers within the NAH system to ensure continuity of care for transferred patients.

2.4 Outreach Development. The Medical Director shall work in cooperation with NAH service line medical directors to develop and implement outreach programs serving the Northern Arizona region.

2.5 Help ensure expert, seamless communication and treatment for all patients amongst facilities. Regular review of transfer center cases, documentation, phone call recordings

COMMUNICATION AND LIAISON RESPONSIBILITIES

3.1 Liaison Function. The TCMD shall serve as the designated liaison between transfer center staff and the NAH medical staff, ensuring effective and timely communication regarding all transfer-related matters.

3.2 Specialty Department Participation. The TCMD shall attend specialty department meetings on an ongoing and regular basis to ensure that specialty-specific acceptance protocols are adequate, current, and aligned with the operational and clinical needs of each respective specialty.

3.3 EMTALA Education. In cooperation with the Facility's legal and risk management departments, the Medical Director shall provide and support ongoing education for NAH medical staff regarding obligations under EMTALA and applicable regulations governing accepting and referral center responsibilities.

3.4 Regional Communication Standards. The TCMD shall work to ensure expert and seamless communication and care coordination for all patients within the Northern Arizona service area, consistent with applicable standards of care and the Facility's policies and procedures.

QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT

4.1 General Quality Oversight. The Medical Director shall establish, maintain, and oversee a quality assurance and performance improvement program for the transfer center service line, including the identification, review, and resolution of quality-related issues.

4.2 Case Identification and Audit. The Medical Director shall identify, filter, and refer for review cases meeting criteria established under this Agreement, ensuring appropriate transition to the relevant service line, Morbidity and Mortality (M&M) conference, or department or other appropriate meeting, with documented loop closure and follow-up for both sending and receiving facilities.

4.3 Short Disposition Cases. The Medical Director shall review on a monthly basis:

• Mortality within Twenty-Four (24) Hours: Any patient death occurring within twenty-four (24) hours of transfer;
• Upgrade in Level of Care within Eight (8) Hours: Any patient requiring upgrade to a higher level of care within eight (8) hours of arrival;
• Early Discharge within Twelve (12) Hours: Any patient discharged from the Facility within twelve (12) hours of transfer; and
• Double Transfers: Any patient requiring a subsequent transfer from NAH to another facility within a clinically significant timeframe.

4.4 Lost Case Review. The TCMD shall review all instances in which patients were not accepted or retained at NAH (hereinafter "Lost Cases") and shall conduct ongoing analysis of the contributing factors associated with each such occurrence. Lost Cases subject to review shall include, but are not limited to, cases lost due to the following circumstances:

• Capacity Limitations: Instances in which the Facility was unable to accept a patient due to insufficient bed availability or facility capacity;
• Staffing Limitations: Instances in which the Facility was unable to accept a patient due to inadequate staffing resources at the time of the transfer request;
• Service Unavailability:Instances in which a required clinical service was not available at the Facility at the time of the transfer request;
• Delay in Securing a Physician:Instances in which an undue delay in identifying or engaging an accepting physician resulted in the patient being directed to another facility;
• Delay in Securing a Bed:Instances in which an undue delay in bed assignment or placement resulted in the patient being directed to another facility;
• Recommendation for Higher Level of Care:Instances in which the patient was directed to another facility based on a determination that a higher level of care than available at NAH was required;
• Continuity of Care:Instances in which the patient was directed to another facility for reasons related to established or ongoing care relationships at that facility;
• Physician Refusal:Instances in which an on-call or accepting physician declined to accept the patient without documented clinical justification; and
• High Call Volume:Instances in which excessive call volume within the transfer center contributed to delays or failures in patient acceptance.

Based on such review, the Medical Director shall:

• Provide structured feedback and recommendations to hospital administration and service line leaders regarding methods to reduce the incidence of Lost Cases; and
• Provide appropriate feedback to the relevant accepting service line when warranted by the findings of such review.

4.5 Requested Case Review. The TCMD shall conduct or facilitate a review of any transfer center case upon request by an involved physician or provider, whether from the sending or accepting facility. The results of any such review shall be communicated to all involved parties, relevant staff, safety committees, and any other appropriate stakeholders, and shall include specific recommendations for improvement in the delivery of transfer patient care.

4.6 Collaboration with Transfer Center Staff. The Medical Director shall collaborate with transfer center staff in the implementation, ongoing management, and periodic revision of all policies, protocols, and quality assurance activities set forth herein.

COMPLIANCE

5.1 The Medical Director shall perform all services described herein in compliance with all applicable federal, state, and local laws and regulations, including but not limited to EMTALA, applicable state medical practice acts, and all accreditation standards applicable to NAH.

5.2 The Medical Director shall promptly notify the Facility of any actual or potential compliance concerns arising in connection with the transfer center service line.

5.3 Nothing in this Agreement shall be construed to limit the Facility's authority to establish, modify, or enforce policies and procedures applicable to transfer center operations.

PERFORMANCE STANDARDS AND EVALUATION

7.1 TCMD must be an active member of the NAH medical staff in good standing.

7.1 Annual Goal Setting. On an annual basis, the Medical Director, in collaboration with the Medical Director's designated administrative dyad partner, shall establish no fewer than three (3) and no more than five (5) professional performance goals for the forthcoming calendar year (hereinafter "Annual Goals"). Such Annual Goals shall be submitted for review and shall require the written approval of the Chief Medical Officer and the Chief Operating Officer of NAH prior to taking effect.

7.2 Annual Performance Review. At the conclusion of each calendar year, the Medical Director's progress toward and achievement of the approved Annual Goals shall be formally reviewed by the Chief Medical Officer and the Chief Operating Officer, or their respective designees. Such review shall be conducted in a manner consistent with the Facility's standard performance evaluation policies and procedures.

7.3 Use of Annual Goals in Evaluation. The Annual Goals established pursuant to Section 7.1 shall serve as one factor, among others, in the assessment of the Medical Director's overall effectiveness in fulfilling the duties and responsibilities of the Medical Director role. The parties expressly acknowledge that progress toward or achievement of the Annual Goals shall not serve as the sole determinant of the Medical Director's effectiveness or success in the role.