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

B. Factors to be Considered:
Increase of clinical privileges shall be based upon compliance with the requirements for such clinical
privileges as set forth in the applicable clinical privilege description, as well as relevant recent training, the
direct observation of patient care provided, review of the appropriate records of patients treated in this or,
where available, other hospitals, and review of all other appropriate records and information from applicable
departments of the medical staff which evaluate the member's participation in the delivery of medical care that
justify increased privileges. The granting of such increased privileges may carry with it such supervision or
consultation for such period of time as thought necessary.
C. Request for Clinical Privileges by an Active Affiliate Staff Member: (01/09)
Active Affiliate staff members have no clinical privileges. An Active Affiliate staff member who wishes to
apply for clinical privileges must also apply for a change in staff category. The application will be processed
in the same manner as an application for initial clinical privileges.
V. CORRECTIVE ACTION
A. PROCEDURE FOR ACTIONS INVOLVING CLINICAL COMPETENCE, PATIENT CARE OR
TREATMENT
1. Grounds for Action:
Whenever, on the basis of information and belief, the Chief of Staff, the chairman of a clinical
department, the chairman of any Medical Staff committee or a majority of any Medical Staff
committee, the Chairman of the Board, or the President has cause to question: (01/09)
(a)
(b)
(c)
The clinical competence of a staff member; or,
The care or treatment of a patient accorded by a staff member; or,
A known or suspected violation of the bylaws, policies and directives of the hospital, or the
bylaws, rules or regulations or policies and procedures of the medical staff relating to his or
her patient care or professional activity by a staff member, (01/09)
a written request for an investigation shall be addressed to the Medical Executive Committee making
specific reference to the activity or conduct which gave rise to the request. (01/09)
2. Investigation Procedure: (01/09)
(a)
The request shall be considered by the Medical Executive Committee at its next meeting
and if, in the opinion of that Committee:
(1) The request for investigation contains information sufficient to warrant a
recommendation, the Medical Executive Committee shall make one. If the
Medical Executive Committee is considering a recommendation that would entitle
the staff member to fair hearing and appeal rights, the Chief of Staff shall notify
the medical staff member of the general tenor of the possible recommendation and
ask the staff member if he or she desires to meet with the committee prior to any
final recommendation by the committee. At such meeting, the affected staff
member shall be informed of the general nature of the evidence supporting the
action contemplated and shall be invited to discuss, explain, or refute it. This
interview shall not constitute a hearing, shall be preliminary in nature, and none of
the policies and procedures with respect to hearings shall apply. Or, (01/09)
January 2010 Credentialing Policy & Procedures
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