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

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3. Department Chairman Procedure : The chairman of each department in which the applicant seeks membership and clinical privileges, if any, shall provide the Credentials Committee with specific written recommendations for approving or disapproving the application and for delineating the applicant's clinical privileges. These recommendations shall be made a part of the Credentials Committee's report. (01/09) As part of the process of making his or her recommendation, the department chairman may meet with the applicant to discuss any aspect of the applicant's application, qualifications and clinical privileges. 4. Credentials Committee Procedure: (a) (b) (c) The Credentials Committee shall examine the evidence of the character, professional competence, qualifications and ethical standing of the applicant and shall determine, through information contained in references given by the applicant and from other sources available to the committee, including an appraisal from the chairman of the clinical department in which privileges are sought, whether the applicant has established and meets all of the necessary qualifications for the category of staff membership and clinical privileges requested. After considering the recommendations of the clinical departments concerned the Credentials Committee shall recommend department assignments and clinical privileges, if any, for all medical staff applicants and for all other approved individuals with clinical privileges. (01/09) As part of the process of making its recommendation, the Credentials Committee may meet with the applicant to discuss any aspect of the applicant's application, qualifications and clinical privileges. 5. Credentials Committee Report: (a) Not later than ninety (90) days from its receipt of the completed application and all supporting material, the Credentials Committee shall make a written report and recommendations on the applicant to the Medical Executive Committee. (b) If the recommendation of the Credentials Committee is delayed longer than ninety (90) days, the Chairman of the Credentials Committee shall send a letter of explanation to the applicant, with a copy to the Medical Executive Committee. (c) The Credentials Committee shall transmit to the Medical Executive Committee the complete application and all supporting materials and its recommendation that the applicant be appointed to the medical staff, that the application be deferred for further consideration, or that the applicant be rejected for medical staff membership. The chairman of the Credentials Committee or the Chairman's designee shall be available to the Medical Executive Committee to answer any questions that may be raised with respect to the recommendation. 6. Subsequent Action on the Application: (a) At the next regular meeting after receipt of the Credentials Committee report, the Medical Executive Committee shall consider the report and such other relevant information as is available, and shall forward to the Board a written report and recommendations on the prescribed form as to staff appointment. The Committee may also defer action on the application. January 2010 Credentialing Policy & Procedures 6
(b) (c) (d) (e) When the recommendation of the Medical Executive Committee is favorable to the applicant, the application shall be promptly forwarded, together with all supporting documentation, to the Board. All recommendations to appoint must also specifically recommend the clinical privileges to be granted, which may be qualified by any probationary conditions relating to such clinical privileges. When the recommendation of the Medical Executive Committee is to defer the application for further consideration, it must be followed within ninety (90) days with a subsequent recommendation to the Board for appointment to staff membership with specified clinical privileges, or for rejection of the application for staff membership. When the recommendation of the Medical Executive Committee is adverse to the applicant with respect to either appointment or clinical privileges, the applicant shall be promptly notified by certified mail, return receipt requested. The application shall then be held until after the applicant has exercised or has been deemed to have waived the right to a hearing as provided in the Fair Hearings and Appeals Policy and Procedure. At the time the applicant has been deemed to have waived the right to a hearing, the recommendation of the Medical Executive Committee, together with all supporting documentation, shall be forwarded to the Board. If the applicant requests a hearing, the initial report of the Medical Executive Committee, the recommendation and hearing record of the Hearing Panel, together with all supporting documentation, shall be promptly forwarded to the Board. II. TEMPORARY CLINICAL PRIVILEGES A. Temporary Clinical Privileges for Applicants: Upon receipt of an application for medical staff membership and clinical privileges from an appropriately licensed applicant, the Chief of Staff may, upon the basis of information then available which may reasonably be relied upon as to the current competence, character and ethical standing of the applicant, and with the written concurrence of the department chairman concerned, grant temporary clinical privileges to the applicant. The granting of such clinical privileges shall specify a termination date, which shall be no more than 120 days from the date granted. In exercising such clinical privileges, the applicant shall act under the supervision of the chairman or the chairman’s designee of the department in which the applicant has requested primary clinical privileges. (01/09) B. Temporary Clinical Privileges for Non-Applicants: 1. Temporary Clinical Privileges for Care of Specific Patient: Temporary clinical privileges for care of a specific patient or patients may be granted by the Chief of Staff with the concurrence of the chairman of the department concerned, to a physician, dentist, and podiatrist who is not an applicant for membership in the same manner and upon the same conditions as set forth in Section II.A. above, provided that the Chief of Staff shall first obtain such individual's signed acknowledgment that he or she agrees to be bound by the hospital bylaws and medical staff bylaws, rules and regulations, and policies and procedures which are then in force in all matters relating to his or her temporary clinical privileges. Such clinical privileges shall be restricted to the specific patients for which they are granted. The physician, dentist, or podiatrist shall present proof of current licensure, and supply any additional information and documentation requested. (01/09) January 2010 Credentialing Policy & Procedures 7
Page 1 and 2: ORLANDO HEALTH MEDICAL STAFF POLICI
Page 3 and 4: ORLANDO HEALTH MEDICAL STAFF POLICI
Page 5 and 6: (4) Proceedings for disciplinary or
Page 7: the Fair Hearings and Appeals Polic
Page 11 and 12: F. Emergency Action In an emergency
Page 13 and 14: 2. The Credentials Committee shall
Page 15 and 16: (2) The request for investigation d
Page 17 and 18: Such an investigation may be reques
Page 19 and 20: 1. The Chief of Staff, the Chairman
Page 21: C. Failure to Request Reinstatement

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