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

Appeal Policy and Procedure with respect to hearings shall apply. A record of such
interview shall be made by the Investigation Committee and included with its report to the
Medical Executive Committee. (01/09)
(f)
(g)
The investigation shall be completed and the report and recommendation submitted to the
Medical Executive Committee within a reasonable time. If an investigation cannot be
completed within 180 days, the Medical Executive Committee shall be advised of the
delay and the reasons therefor.
At any time during the investigation, the persons authorized pursuant to Section VI may
summarily suspend all or any part of the clinical privileges of the member of the medical
staff being investigated, whenever such action must be taken immediately in the best
interest of patient care or safety in the hospital, or for the continued effective operation of
the hospital, in accordance with the procedures in Section VI for precautionary summary
suspension. (01/09)
3. Procedure Thereafter:
(a)
(b)
At its next meeting following receipt of the Investigation Committee report and
recommendation, the Medical Executive Committee shall make its recommendation to the
Board if it has sufficient information to do so. If the Medical Executive Committee needs
additional information, it may refer the matter back to the Investigation Committee for such
additional information. The Medical Executive Committee may recommend continuing
medical education or other instructional, non-disciplinary requirements including
educational consultation; a written warning; a letter of reprimand; terms of probation;
requirement for consultation; reduction of clinical privileges; suspension of clinical
privileges for a term; revocation of staff membership and/or clinical privileges or such other
action or combination of actions as it deems appropriate. The Medical Executive
Committee may accept, modify or reject the recommendation it receives from the
Investigation Committee. (01/09)
Any recommendation by the Medical Executive Committee to impose a requirement for
mandatory concurring consultation for reduction of clinical privileges, for revocation of
clinical privileges, for suspension of clinical privileges (other than a precautionary summary
suspension), or for revocation of staff membership shall entitle the affected staff member to
the procedural rights provided in the Fair Hearing and Appeal Policy and Procedure. Such
a recommendation shall be forwarded to the President who shall promptly notify the
affected member by certified mail. The President shall then hold the recommendation until
after the member has exercised or has been deemed to have waived the right to a hearing as
provided in the Fair Hearing and Appeal Policy and Procedure. At the time the member has
been deemed to have waived the right to a hearing, the President shall forward the
recommendation of the Medical Executive Committee, together with all supporting
documentation, to the Board. The Chairman of the Medical Executive Committee or the
chairman's designee shall be available to the Board or its appropriate committee to answer
any questions that may be raised with respect to the recommendation. (01/09)
The Chairman of the Medical Executive Committee shall keep the President fully informed
of all requests for investigation and all action taken in connection therewith. (01/09)
VI.
PRECAUTIONARY SUMMARY SUSPENSION OF MEMBERSHIP AND/OR CLINICAL
PRIVILEGES
A. Grounds for Precautionary Summary Suspension:
January 2010 Credentialing Policy & Procedures
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