Mercy Hospital Medical Staff Credentialing Manual - Mercy Health

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CREDENTIALING MANUAL REVISED AND APPROVED BY THE BOARD OF DIRECTORS JANUARY 24, 20083.1.5 Include mechanisms for ensuring that those who hold Clinical Privilegesremain within their respective delineations;3.1.6 Employ appropriate means of surveillance, including the results of<strong>Hospital</strong> quality monitoring, to assess the exercise of delineated Privileges;3.1.7 Where new Privileges are sought, privilege criteria are developed by theDepartment, reviewed by the Credentials Committee and the MEC andapproved by the Board before Privileges are granted to particularPractitioners.3.2 Processing Temporary Privileges3.2.1 Temporary privilege requests will be processed as promptly as possible ina manner consistent with the Bylaws.3.2.2 Initial Applicants Awaiting Credentials Committee, MEC or Board Action3.2.2.1 An applicant is considered for temporary privileges when allprimary source verifications have been completed, including, butnot limited to,• A complete application• Current licensure;• Relevant training and experience;• Current competence and ability to perform the privilegesrequested;• Results of the National Practitioner Data Bank query have beenobtained and evaluated;• The applicant has in force professional liability insurance asspecified by the Board, covering the exercise of the privilegesrequested;• No current or previously successful challenge to licensure orregistration• No voluntary or involuntary limitation, reduction, loss orsuspension of membership or clinical privileges at anotherorganization.3.2.2.2 Once the preceding requirements are met, temporary privilegesmay be granted for a limited period of time, not to exceed 120days, by the Chief Executive Officer (or designee) uponrecommendation of either the applicable clinical department18
CREDENTIALING MANUAL REVISED AND APPROVED BY THE BOARD OF DIRECTORS JANUARY 24, 2008chairperson or the chief of the medical staff (or their respectivedesignees) when the applicant’s file is awaiting review andapproval of the Credentials Committee, <strong>Medical</strong> ExecutiveCommittee or the Board of Directors.3.2.3 Temporary Privileges to Fulfill an Important Patient Care Need3.3 Locum Tenens3.2.3.1 Temporary privileges may be granted on a case-by-case basis whenthere is an important patient care need.3.2.3.2 Under these circumstances, the Chief Executive Officer (ordesignee) applicable clinical department chairperson or the chiefof the medical staff (or their respective designees) provided there isverification of current licensure and current competence. Inaddition, a query to the National Practitioner Data Bank isrequired. A documented Internet or telephone verification oflicensure is sufficient. A documented telephone call to a Physicianwith firsthand knowledge of the applicant’s current competencesuffices for verification of competence. Verification ofprofessional liability insurance must occur as soon as possible, andnot later than the next business day.Applications for Locum Tenens practitioners are processed in the same manneras an initial applicant.3.4 Procedural Sedation3.4.1 For the following specialties procedural sedation is included in the coreprivileging for those invasive procedures that normally utilize suchsedation: Anesthesiology, Cardiology, Emergency Medicine, ENT,Gastroenterology, General Surgery, Oral Surgery, Orthopedics, PlasticSurgery, Pulmonary Medicine, Radiology, Thoracic Surgery and VascularSurgeryIn order to perform procedural sedation, physicians must:Complete the MHP Procedural Sedation Competency Test and supplyrequired documentation to support the request.Monitoring for continued competency is performed at the individual sites,with outcomes provided for review at the time of request for privileges.4.0 LOW VOLUME/NO VOLUME PRACTITIONER POLICY FORREAPPOINTMENT APPLICANTS:LOW VOLUME PRACTITIONERS - The Practitioner that treats a majority or all ofhis or her patients at another facility.19
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Mercy Hospital Medical Staff Credentialing Manual - Mercy Health

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