credentialing table of contents i. appointment to the ... - Orlando Health

(b)
(b)
(c)
No member of the Senior Staff shall be appointed or reappointed to that category unless
the member has a minimum of four (4) patient contacts per year at OH during the two (2)
year period preceding the application for reappointment. Exception for good cause (as in
the event the medical staff member was absent from practice) to this requirement may
be recommended by the Credentials Committee. (01/09)
A member of the Active Associate Staff who has twelve (12) or more patient contacts
within a one-year period will be reappointed to the Active Staff instead of the Active
Associate Staff. (01/07)
“Patient contacts” shall include inpatient and outpatient admissions and consultations.
“Patient contacts” shall not include referrals for diagnostic testing to be done by other
practitioners or hospital personnel. (01/09)
6. All staff members shall be evaluated for reappointment on an individual basis after appropriate
quality review.
7. No staff member shall be reappointed unless the staff member is a provider in good standing who
has not been excluded from federal or state healthcare programs and has not been convicted of a
healthcare related crime.
C. Burden of Providing Information:
The medical staff member who is applying for reappointment shall have the burden of providing adequate
information for a proper evaluation of his or her current clinical competence, clinical judgment, professional
ethics, ability to perform the clinical privileges requested, and other qualifications, and of resolving any
doubts about such qualifications. The member shall have the burden of providing evidence that all the
statements made and information given on the application for reappointment and in support of the application
are factual and true. (01/09)
D. Department Procedure:
1. The chairman of each department shall be provided with the reappointment applications of all
members of that department applying for reappointment, together with the clinical privileges each
then holds, if any, continuing medical education information, and a completed reappointment
summary. (01/09)
2. The chairman of the department shall transmit his/her recommendations to the Credentials
Committee. In addition, the chairman shall submit individual recommendations and the reasons
therefor, for any changes recommended in staff category, in clinical privileges, or for nonreappointment.
(01/09)
3. Recommendations for membership and clinical privileges, if any, by the department chairman shall
be based upon relevant recent training, the observation of patient care provided, review of the
appropriate records of patients treated in this or other hospitals, and review of all other appropriate
records of the medical staff which evaluate the member's participation in the delivery of medical
care. (01/09)
E. Credentials Committee Procedure:
1. The Credentials Committee, after receiving recommendations from the chairman of each
department, shall review all pertinent information available including all information provided from
other committees of the medical staff and from hospital management for the purpose of determining
its recommendations for staff reappointment, for change in staff category, and for the granting of
clinical privileges for the ensuing reappointment period.
January 2010 Credentialing Policy & Procedures
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