PCCC Renewal or Initial Application Forms

The following steps outline the application process to renew your status or initially apply as a Pediatric Critical Care Center (PCCC) with an Emergency Department Approved for Pediatrics (EDAP). Please note that completion of this application and the Pediatric Plan should be developed through interaction and collaboration with all appropriate disciplines within your facility.

1. Review your original Pediatric Critical Care Center (PCCC) and Emergency Department Approved for Pediatrics (EDAP) Pediatric Plan
2. Using the Pediatric Critical Care Center Plan and the Emergency Department Approved for Pediatrics Renewal checklists, complete an update of your PCCC and EDAP Pediatric Plan. Refer to the EDAP Requirements and PCCC Requirements. Include all appropriate supporting documentation (schedules, policies, procedures, protocols, guidelines, plans, etc.).
   
3. The Pediatric Plan should follow the checklist format and include all supporting documentation, including but not limited to scope of services/care, policies (both administrative and department specific), procedures, protocols, guidelines, flow charts, rosters, calendars, schedules, etc.
   
4. Complete and obtain appropriate signatures on the Request for Re-Recognition of Pediatric Critical Care Center and Emergency Department Approved for Pediatrics Status Application Form
   
5. Complete and obtain signatures on the following credentialing forms:
   
   • Emergency Department Physician Credentialing Form
   • Fast Track/Urgent Care Physician Credentialing Form
     
   • Emergency Department Nurse Practitioner/Clinical Nurse Specialist/Physician Assistant Credentialing Form
     
   • Emergency Department Nursing Staff Credentialing Form
     
   • PICU Physician Credentialing Form
     
   • PICU Nurse Practitioner/Clinical Nurse Specialist/Physician Assistant Credentialing Form
     
   • PICU Nursing Staff Credentialing Form
   • Pediatric Unit Hospitalists Credentialing Form
   • Pediatric Unit Nursing Staff Credentialing Form
     
6. Complete the Hospital Pediatric Preparedness Checklist
   
7. Complete the Emergency Department Equipment Checklist and PICU and Pediatric Unit Equipment Checklist
   
8. The Pediatric Plan should be submitted electronically as outlined by the EMSC Program.
9. Submit one paper copy of your Pediatric Plan (with an original signed Application Form). Use one set of tabs provided by EMSC for the original signed copy. Submit single-sided and unstapled. Do not place pages in individual plastic sleeves. Each application must contain the following:
   
   • Signed Request for Re-Recognition of Pediatric Critical Care Center and Emergency Department Approved for Pediatrics Status Application Form
   • Completed Pediatric Critical Care Center Plan Checklist and EDAP Plan Checklist
   • Completed PCCC Plan and EDAP Plan (including supporting documentation)
   • Completed Physician, Nurse Practitioner/Clinical Nurse Specialist/Physician Assistant and Nursing credentialing forms for the Emergency Department, PICU and Pediatric Inpatient Unit
   • Completed Hospital Pediatric Preparedness Checklist
   • Completed EDAP, PICU, and Pediatric Inpatient Unit Equipment Checklists
10. Maintain a copy for your files (using one set of tabs provided by EMSC).
11. Submit these documents (including all supporting documentation) by the designated due date in the order listed to:
    EMSC Coordinator
    Division of EMS & Highway Safety
    Illinois Department of Public Health
    422 S. 5^th St., 3^rd Floor
    Springfield, IL 62701
    
12. Please note that any submitted requests to waiver any of the EDAP or PCCC requirements must include the criteria by which compliance is considered to be a hardship, and demonstrate how there will be no reduction in the provision of medical care
    
13. For questions regarding the application process, please contact the EMSC Program at (217)785-2080 or DPH.EMSCProgram@illinois.gov.

1. Within 6-8 weeks following receipt of your Pediatric Plan and supporting documents, the hospital will be informed as to the status of the application. If all documentation is in order, a site visit will be scheduled.
2. In preparation for the site visit, hospital personnel will prepare evidence to verify adherence to the facility recognition requirements.
   
3. The site visit will include a survey of the Emergency Department, Pediatric Intensive Care Unit, the Pediatric units and a meeting with the following individuals:
   
   • The Hospital’s Chief Administrative/Executive Officer or designee
   • The Chief of Pediatrics
     
   • The Medical Director of the Pediatric Intensive Care Services
     
   • The Medical Director(s) of the Pediatric Units
     
   • The Medical Director of Pediatric Ambulatory Care
     
   • The Nursing Director or Nurse Manager of the Pediatric Intensive Care Services
     
   • The Nursing Director or Nurse Manager of the Pediatric Units
     
   • The Administrator of Pediatric Services
     
   • The Administrator of Emergency Services
     
   • Pediatric Physician Champion
     
   • The Pediatric Quality Coordinator
     
   • The Hospital Quality Improvement Department Director or designee
     
   • The Emergency Department Medical Director and/or the Pediatric Emergency Department Medical Director
     
   • The Emergency Department Nurse Manager and/or the Pediatric Emergency Department Nurse Manager
     
   • The Hospital Emergency/Disaster Preparedness Coordinator
     
   • The Transport Team Medical Director
     
   • The Transport Team Nurse Coordinator
     
   • Nurse Practitioner/Clinical Nurse Specialist and/or Physician Assistant for those facilities that utilize these clinicians in their emergency department and/or on their pediatric units
     
   • For EMS Resource or Associate Hospitals: The EMS Medical Director and EMS Coordinator

The EMSC program within the Division of EMS & Highway Safety will appoint the site survey team. Site survey teams will be composed of a physician/nurse team along with a representative from the Illinois Department of Public Health (IDPH). All team members will attend formal training in the site survey responsibilities, expectations and process.

1. Within four to six (4-6) weeks following the site visit, the hospital shall receive the results of the survey from IDPH. Those facilities meeting all requirements will receive a formal recognition of their Pediatric Critical Care capabilities.
2. Hospitals that do not meet the requirements will receive a letter from the Illinois Department of Public Health outlining the areas of non-compliance. IDPH can deny a request for recognition if findings show failure to substantially comply with the EDAP and/or PCCC requirements. Hospitals may appeal the results of the survey by submitting a written request to the Illinois Department of Public Health, Division of EMS & Highway Safety.
3. Re-recognition shall occur every four years, with site visits scheduled as necessary.

• PCCC Application Packet
• PCCC and EDAP Pediatric Plan Checklist
• Request for Re-recognition of PCCC and EDAP Status
• Emergency Department Physician Credentialing Form
• Fast Track/Urgent Care Physician Credentialing Form
• Emergency Department Nurse Practitioner/Clinical Nurse Specialist/Physician Assistant Credentialing Form
• Emergency Department Nursing Staff Credentialing Form
• PICU Physician Credentialing Form
• PICU Nurse Practitioner/Clinical Nurse Specialist/Physician Assistant Credentialing Form
• PICU Nursing Staff Credentialing Form
• Pediatric Unit Hospitalists Credentialing Form
• Pediatric Unit Nursing Staff Credentialing Form
• Hospital Pediatric Preparedness Checklist
• Emergency Department Equipment Checklist
• PICU and Pediatric Unit Equipment Checklist