Medical Staff Medical Executive Committee (MEC)

Highland Hospital, John George Psychiatric Hospital, Fairmont Hospital, Ambulatory Wellness

Report to the Quality Professional Services Committee of the Board

October 28, 2018 A. Credentials and Privileges Detailed discussion of credentialing and privileging activity occurred in a Closed Session Meeting of the QPSC. The Medical Executive Committee (MEC) reviewed and recommended approval for Medical Staff membership and clinical privileges as follows:

• 10 Initial Appointments • 44 Temporary Privileges • 6 Reappointments • 1 Modification of Privilege • 12 Voluntary Resignations • 1 vRad Initial Appointment • 3 vRad Reappointments

Additional Credentialing Actions:

Medical Staff Provider Clinical Privileges (Exhibit 1) The following multi-facility forms were reviewed and approved.

• OB/GYN Multifacility • Psychiatry Multifacility

B. Professional Services/ Contracting The report continues to be presented.

C. Quality and Outcomes Improving Patient Throughput • Surge Red / Patient flow o Improving Patient Throughput to Mitigate Surge Process o Patient Flow and System Utilization Strategies

• AHS Core True North Metrics Dashboard FY201 o Dashboard was presented; reporting includes all 13 metrics

• SAPPHIRE Report- Electronic Health Record o Monthly updates for project and ongoing systemwide efforts for standardization and alignment

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Alameda Health System MEC Report to the Board of Trustees October 28, 2018

D. Other Issues • Alameda Health System, San Leandro Hospital, Alameda Hospital Medical Executive Committee Retreat, October 13, 2018 o Medical Staff Reporting Obligations, Strategies of Managing Disruptive Behavior, Care for the Caregiver, Wellness, Medical Staff Leadership

Retreat objectives: Apply knowledge of ethics and law to medical staff governance Recognize the fundamental of medical staff leadership Assess the legal and ethical dilemmas if actions that can lead to license suspension or revocation/restriction of privileges Identify strategies for managing disruptive behavior

• Orthopedic Department Annual Report What is quality in orthopedics? o Standard metrics are 30/90-day readmissions o Post op infections along with standard medical complications o Readmission rate 0.3%. Better than national average

Orthopedic surgeons see another category of quality o Functional outcomes o Return to work o 5/10/15 year revision rates o Narcotic use/abuse

• Wellness Program Individual-Free, Confidential, Flexible Schedule, In Person or Phone, Evenings

Initial data from 8/8/2018-10/5/2018 o Total scheduled visits 48

Medical Staff Medical Executive Committee (MEC)

Report to the Quality Professional Services Committee of the Board

October 19, 2018

A. Credentials and Privileges Detailed discussion of credentialing and privileging activity occurred in a Closed Session Meeting of the QPSC. The Medical Executive Committee (MEC) reviewed and recommended approval for Medical Staff membership and clinical privileges as follows:

• 5 Initial Appointments • 2 Proctoring Activity • 5 Resignations • 4 vRad Delegated Credentialing

Additional Credentialing Actions: Medical Staff Provider Clinical Privileges (Exhibit 1)

• Approval of Psychiatry Multifacility privileges

B. Professional Services/ Contracting The following items are notable with regards to Professional Services/Contracting: • A new community general surgeon did not receive a contract with AHS to provide ED call coverage. This will discourage community surgeon involvement with the hospital.

• Discussion was carried out with Dr. Jamaleddine and Dr. Yasumoto regarding the availability of certain radiologic procedures at San Leandro Hospital. The system is working towards a process for performance of those procedures.

C. Quality and Outcomes • The FY 2019 True North Metric Dashboard was reviewed. • San Leandro Hospital hosted an AHS Simulation Center open house this month and this was well received. • Random chart audit demonstrated > 90% compliance with the moderate sedation policy and procedures. • Medical Staff Office continues to gather flu vaccination documentation for all providers. • The OPPE corrective plan and other plans pertaining to the Joint Commission Survey were approved. • Total surgery volume remains steady when compared with prior years and our endoscopy volumes demonstrated an increase.

D. Other Issues • The rehab move to San Leandro Hospital and its implications was presented by Dr. Jamaleddine and was discussed at length. The Medical Staff urges the Board not to rush to a decision at the November meeting, and to allow more time to obtain input from the medical staff and to assess the potential ramifications.

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Medical Staff Medical Executive Committee (MEC)

Report to the Quality Professional Services Committee of the Board

October 19, 2018

• 2 Initial Appointments • 8 Reappointments • 1 Proctoring Activity • 2 Resignations

• 1 vRad Telemedicine Initial Appointment • 3 vRad Telemedicine Reappointments

Additional Approved Credentialing Actions:

Medical Staff Provider Clinical Privileges (Exhibit 1)

• Provider Clinical Privileges o OB/GYN Multifacility o Psychiatry Multifacility

B. Professional Services/Contracting Non-physician contracts continue to be reported.

C. Quality and Outcomes Improving Patient Throughput • Patient Transfers o Recommendation to have multidisciplinary taskforce to develop and assess the current process key metrics/indicators for performance monitoring including the appropriateness / levels of care and availability of resources

Specialty Coverage • GI • Urology

D. Other Issues

Page 1 of 1 Obstetrics and Gynecology Delineation of Privileges

Applicant's Name:

Instructions:

1. Click the Request checkbox to request a group of privileges such as Core Privileges or a Special Privileges. 2. Uncheck any privileges you do not want to request in that group. 3. Check off any special privileges you want to request. 4. Sign form electronically and submit with any required documentation.

Required Qualifications Basic Education M.D. or D.O.

Education/Training Completion of an ACGME or AOA accredited Residency training program in Obstetrics and Gynecology.

Continuing Education Applicant must have [25] Category I CME credits per year (waived for applicants who have completed residency training during the previous 24 months). OR Applicant must be active in the MOC (maintenance of certification) program in obstetrics/gynecology.

Certification Current certification or active participation in the examination process leading to certification in Obstetrics and Gynecology by the American Board of Obstetrics and Gynecology or in Obstetrics and Gynecology by the American Osteopathic Board of Obstetrics & Gynecology.

Clinical Experience Recent clinical experience for initial appointment and reappointment is defined as having (Initial/Reappointment) performed at least 100 clinical services, procedures, or clinical consultations in a TJC-accredited hospital or hospital-based ambulatory setting in the last two years. The variety and type of clinical services must be sufficient to cover the scope of obstetrics/gynecology privileges requested.

Additional Qualifications 1) Provider must submit documentation of successful completion of an AWHONN or ACOG for Providers Requesting endorsed Fetal Heart Monitoring class that includes current NICHD nomenclature prior to, OR for Obstetric Privileges within 3 months of date of initial appointment and annually thereafter. All documentation will be reviewed by the Department Chair of Obstetrics and Gynecology. AND 2) Provider must submit documentation of successful completion of Baby Friendly training prior to, OR within 6 months of date of initial appointment. All documentation will be reviewed by the Department Chair of Obstetrics and Gynecology.

Published: 10/12/2018 Obstetrics and Gynecology Page 1 of 9 [applicant]

Core Privileges in Gynecology

Description: Evaluate, diagnose, provide consultation, treat and provide surgical and non-surgical management of reproductive health and pregnancy of female patients.

Request Request all privileges listed below. AHS Core AH Click shaded blue check box to Request all privileges. Uncheck any privileges you do not want to request.

- Currently granted privileges Admit to inpatient care or other level of care Perform history and physical examination Evaluate, diagnose, provide consultation and non-operative management of reproductive health and genitourinary system, including non-surgical treatment of injuries and disorders of the mammary glands. Moderate Conscious Sedation in Adults (current ACLS certification required) Procedures Minor GYN procedures including but not limited to: IUD insertion and removal, endometrial biopsy, Word catheter placement, and insertion and removal of contraceptive implants. Paracervical or pudendal block Marsupialization or excision of Bartholin's cyst or abscess Soft tissue biopsy of the genital-urinary tract or incidental biopsy of other lesions encountered in the course of a gynecologic procedure Simple vulvectomy Hymenotomy Dilation and curettage Dilation and evacuation (2nd trimester) Colpotomy, culdocentesis Colpocleisis Colposcopy Hysterectomy, abdominal, total or subtotal with or without BSO Hysterectomy, vaginal, with or without BSO Myomectomy via laparotomy Salpingectomy, salpingo-oophorectomy, salpingostomy, oophorectomy and/or resection of ovarian cyst Cold-knife conization of the cervix and or LEEP Amputation of cervix with colporrhaphy (Manchester Procedure) Colporrhaphy for urethrocele, cystocele, or rectocele Repair of enterocele Excision of vaginal/vulvar mass Vaginal myomectomy Cystoscopy as part of a gynecologic procedure Elective termination of pregnancy (1st trimester) Laparoscopy (diagnostic) Hysteroscopy (diagnostic)

Published: 10/12/2018 Obstetrics and Gynecology Page 2 of 9 [applicant]

Basic Operative Laparoscopy including treatment of endometriosis; assisted vaginal hysterectomy of uteri (anticipated to be less than 12 weeks gestational size); salpingectomy; salpingostomy; salpingo-oopherectomy; lysis of adhesions; myomectomy (pedunculated myoma); and ovarian cystectomy. Basic Operative Hysteroscopy including polypectomy; removal of IUD, incision of mild type 1 adhesions; resection of submucous myomas; resectoscopic endometrial ablation; global endometrial ablation; and hysteroscopic tubal sterilization. Incidental appendectomy Incidental bladder repair Incidental hernia repair (umbilical, incisional, ventral) Abdominal paracentesis Advanced Laparoscopy and Hysteroscopy Advanced Operative Laparoscopy including urethropexy (e.g. Burch); enterocele repair; vaginal vault suspension (sacrocolpopexy, utero-sacral ligament fixation); subtotal hysterectomy; assisted vaginal hysterectomy of uteri anticipated to be greater than 12 weeks gestational size; myomectomy (intramural, subserosal); presacral neurectomy; tubal reanastomosis; and total hysterectomy. Advanced Operative Hysteroscopy including the following procedures and other procedures that are extensions of the same techniques and skills: incision of uterine septum; incision of moderate to severe (type 2-3) intrauterine adhesions. Use of CO2 laser- requires successful completion of an approved residency in a specialty or subspecialty that included training in laser principles OR provide documentation appropriate to the specific laser to be utilized. Practitioner agrees to limit practice to only the specific laser types for which they have documentation of training and experience.

FPPE (Proctoring) Requirements AHS Core AH

Retrospective evaluation to include pre-operative work-up, surgical plan and post-operative course of events of 5 surgeries representative of the scope and complexity of privileges granted. Concurrent observation of 3 cases representative of the scope of privileges granted.

Special Privileges: Female Pelvic Medicine and Reconstructive Surgery (Urogynecology)

Description: Evaluation, treatment, consultation and care of women with complex pelvic floor conditions including urinary and fecal incontinence, pelvic organ prolapse, genitourinary fistulas, and congenital anomalies.

Qualifications Education/Training Completion of a Fellowship program in Female Pelvic Medicine and Reconstructive Surgery approved by the American Board of Obstetrics and Gynecology (ABOG)

Clinical Experience (Initial) Applicant must provide documentation of provision of clinical services (20 cases) representative of the scope and complexity of the privileges requested during the previous year (waived for applicants who completed fellowship training during the previous year).

Clinical Experience Applicant must provide documentation of provision of clinical services (20 cases) representative of (Reappointment) the scope and complexity of privileges requested during the past 24 months.

Additional Qualifications Applicant must be granted primary privileges in gynecology.

Published: 10/12/2018 Obstetrics and Gynecology Page 3 of 9 [applicant]

Request Request all privileges listed below. AHS Core AH Click shaded blue check box to Request all privileges. Uncheck any privileges you do not want to request.

- Currently granted privileges Procedures Mid-urethral sling Vaginal suspension of the vault (to include but not limited to paravaginal repair, sacrospinous, high utero-sacral, vaginal mesh kits) Abdominal suspension of the vaginal vault (to include but not limited to sacrocolpopexy and paravaginal repair) Anal Sphinchteroplasty Urodynamic testing Fascial grafts and biological grafts Repair of vesico-vaginal or rectovaginal fistulas Cystotomy Cystoscopy ureteral catheter/stent placement Cystoscopy including but not limited to hydrodistention, intradetrusor injection Cystourethroscopy Proctoscopy Sacral neuromodulation procedures Urethrolysis Vaginal reconstructive surgery Laparoscopic reconstructive surgery in an area where the applicant has concurrent privileges for open procedures Colpectomy, partial or complete Suprapubic catheter placement Abdominal retropubic urethropexy (Burch; Marshall-Marchetti-Krantz, etc.) Vaginal trachelectomy Vaginal mesh excision Revision or removal of mid-urethral sling Urethral bulking for incontinence

FPPE (Proctoring) Requirements AHS Core AH

Five retrospective case reviews chosen to represent a diversity of major surgical procedures and management challenges.

Special Privileges: Gynecologic Oncology

Description: Evaluation, treatment, consultation and care of women with gynecologic cancer, including those diagnostic and therapeutic procedures necessary for the total care of the woman with gynecologic cancer or complications resulting from them. Published: 10/12/2018 Obstetrics and Gynecology Page 4 of 9 [applicant]

Qualifications Education/Training Completion of a Fellowship program in Gynecologic Oncology approved by the American Board of Obstetrics and Gynecology (ABOG) or by the AOA

Certification Board eligibility or current certification in Gynecologic Oncology by the American Board of Obstetrics and Gynecology or in Gynecologic Oncology by the American Osteopathic Board of Obstetrics & Gynecology.

Clinical Experience (Initial) Applicant must provide documentation of provision of clinical services (10 cases) representative of the scope and complexity of the privileges requested during the previous year (waived for applicants who completed fellowship training during the previous year).

Clinical Experience Applicant must provide documentation of provision of clinical services (10 cases) representative of (Reappointment) the scope and complexity of privileges requested during the past 24 months.

Additional Qualifications Applicant must be granted primary privileges in gynecology .

Request Request all privileges listed below. AHS Core AH Click shaded blue check box to Request all privileges. Uncheck any privileges you do not want to request.

- Currently granted privileges Procedures Vascular access including placement of central venous lines and arterial lines Placement of intraperitoneal access catheters Placement of thoracostomy tube and thoracentesis Select, initiate and administer chemotherapeutic agents for the treatment of cancer via all therapeutic routes Radical hysterectomy with/without lymph node dissection including laparoscopic assist Lymphadenectomy of the inguinal, femoral, pelvic and para-aortic areas Inguinal-femoral lymph-node dissection Incision and drainage of abdominal or perineal abscess Intercavitary brachytherapy insertion Use of a laparoscope in a procedure where the applicant is a concurrent privilege holder Pelvic exenteration (anterior, posterior or total) Ureteral anastomosis Ureteral resection and reconstruction Ureterolysis Urinary diversion, including pouch Ileal conduit or continent urinary diversion Large or small bowel resection Colostomy, cecostomy, gastrostomy Ileostomy Vaginectomy or vulvectomy - simple and radical Neo-vaginoplasty and vulvar reconstruction Interstitial perineal template Presacral neurectomy

Published: 10/12/2018 Obstetrics and Gynecology Page 5 of 9 [applicant]

Gastroenterostomy Resection of upper abdomen tumor metastases involving omentum, diaphragm, spleen or liver Resection of metastatic tumors involving the abdominal wall or skin Abdominal sacrocolpopexy Endoscopic exam of the rectum and colon with or without biopsy Local tissue rearrangement flaps for closure of perineal defects Laser ablation of vulvar, vaginal and perineal lesions OR assist only for gynecologic surgery

FPPE (Proctoring) Requirements AHS Core AH

Five retrospective case reviews chosen to represent a diversity of major surgical procedures and management challenges.

Core Privileges in Obstetrics

Description: Evaluate, diagnose, provide consultation, treat and provide surgical and non-surgical management of reproductive health and pregnancy of female patients. To be granted OB privileges, applicant needs to show a minimum of 6 shifts per year or 12 shifts in two years.

Request Request all privileges listed below. AHS Core AH Click shaded blue check box to Request all privileges. Uncheck any privileges you do not want to request.

- Currently granted privileges Admit to inpatient care or other level of care Perform history and physical examination Evaluate, diagnose, treat and medically manage reproductive health, pregnancy, and medical diseases or problems that are complicating factors in pregnancy. Procedures 3rd trimester amniocentesis OB Ultrasound Normal labor and delivery with/without episiotomy Local anesthesia, pudendal and paracervical blocks Induction and augmentation of labor Operative delivery including the use of forceps and vacuum External cephalic version Repair of vaginal, cervical and perineal lacerations including 3rd and 4th degree lacerations Post vaginal delivery tubal sterilization Cesarean section including hysterectomy and tubal sterilization Cervical cerclage

Published: 10/12/2018 Obstetrics and Gynecology Page 6 of 9 [applicant]

Management and delivery of multiple pregnancy Specialized Obstetrical Procedures Vaginal delivery only Cesarean section assist only

FPPE (Proctoring) Requirements AHS Core AH

Concurrent observation of 3 cesarean deliveries Retrospective review of 5 vaginal deliveries Review of data collected for OPPE for physicians in this specialty

Special Privileges: Maternal-Fetal Medicine

Description: Evaluation, treatment, consultation and care of women with complicated pregnancies. This cluster includes privileges specific to Maternal-Fetal Medicine that were not previously referenced in the cluster for Primary privileges in Obstetrics.

Qualifications Education/Training Completion of a Fellowship program in Maternal-Fetal Medicine approved by the American Board of Obstetrics and Gynecology (ABOG) or by the AOA

Certification Board eligibility or current certification in Maternal and Fetal Medicine by the American Board of Obstetrics and Gynecology or in Maternal and Fetal Medicine by the American Osteopathic Board of Obstetrics & Gynecology.

Clinical Experience Applicant must provide documentation of provision of clinical services (20 cases) representative of (Reappointment) the 20scope and complexity of privileges requested during the past 24 months.

Request Request all privileges listed below. AHS Core AH Click shaded blue check box to Request all privileges. Uncheck any privileges you do not want to request.

- Currently granted privileges Outpatient diagnosis and management of management of obstetric patients Inpatient consultation and management of obstetric patients Evaluate, diagnose, treat and provide consultation regarding genetic, or possibly genetically linked diseases or disorders or birth defects Provide genetic counseling for commonly recognized disorders

Published: 10/12/2018 Obstetrics and Gynecology Page 7 of 9 [applicant]

Procedures Amniocentesis, genetic Ultrasound examination, all types and at all stages of pregnancy Chorionic villus sampling Intrauterine transfusion Intrauterine fetal therapy (fetal thoracentesis, paracentesis and administration of fetal medications, intrauterine umbilical vessel aspiration or injection)

FPPE (Proctoring) Requirements AHS Core AH

Five retrospective case reviews chosen to represent a diversity of procedures and management challenges.

Acknowledgment of Applicant

I have requested only those privileges for which by education, training, current experience, and demonstrated competency I believe that I am competent to perform and that I wish to exercise at Alameda Health System hospital(s) and I understand that:

A. In exercising any clinical privileges granted, I am constrained by applicable Hospital and Medical Staff policies and rules applicable generally and any applicable to the particular situation.

B. Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such situation my actions are governed by the applicable section of the Medical Staff Bylaws or related documents.

Practitioner's Signature Date

Department/Service Chair Recommendation - Privileges

I have reviewed the requested clinical privileges and supporting documentation and make the following recommendation(s):

Privilege Condition/Modification/Deletion/Explanation

Published: 10/12/2018 Obstetrics and Gynecology Page 8 of 9 [applicant]

Department/Service Chair Recommendation - FPPE Requirements

Signature of Department/Service Chair or Designee Date

Published: 10/12/2018 Obstetrics and Gynecology Page 9 of 9 Psychiatry Multi-facility Privileges Form Delineation of Privileges

Applicant's Name:

Instructions:

Required Qualifications Membership Meet all requirements for medical staff membership.

Education/Training Completion of an ACGME or AOA accredited Residency training program in Psychiatry. OR Completion of at least 2 years of training in an ACGME or AOA approved psychiatry residency training program and active participation as a resident or fellow in an ACGME or AOA approved training program.

Continuing Education Applicant must have [50] Category I CME credits every two years (waived for applicants who are currently in a residency or fellowship training program or have completed training during the previous 24 months). OR Applicant must be active in the MOC (maintenance of certification) program in psychiatry.

Certification For all new applicants who will be appointed on/after January 1, 2017, current certification in Psychiatry by the American Board of Psychiatry and Neurology or in Psychiatry by the American Osteopathic Board of Neurology & Psychiatry or its equivalent. OR Active participation in the examination process leading to certification (application must be within six months of initial appointment) in Psychiatry by the American Board of Psychiatry and Neurology, or in Psychiatry by the American Osteopathic Board of Neurology and Psychiatry. Board certification must be achieved within the timeframe established by the applicable board. OR Enrollment in an ACGME or AOA approved residency or fellowship training program in psychiatry or a psychiatric sub-specialty.

Clinical Experience (Initial) Applicant must provide documentation of provision of psychiatry services (3 cases) representative of the scope and complexity of the privileges requested during the previous year.

Clinical Experience Applicant must provide documentation of provision of clinical services (6 cases) representative of (Reappointment) the scope and complexity of the privileges requested during the past 24 months.

Published: 10/19/2018 Psychiatry Multi-facility Privileges Form Page 1 of 5 [applicant]

Core Privileges for General Psychiatry

Description: Diagnosis, treatment and prevention of the following types of disorders: mental, emotional, psychotic, mood, anxiety, developmental disabilities, behavioral, sexual and gender identity, and adjustment. Biologic, psychological, and social components of illnesses are explored and understood in treatment of the whole person.

Request Request all privileges listed below. AHS Core AH SLH Click shaded blue check box to Request all privileges. Uncheck any privileges you do not want to request.

- Currently granted privileges Admit to inpatient or appropriate level of care Perform history and physical examination, including mental status and neurological examination Evaluate, diagnose, provide care and consultation to adolescent and adult patients with mental, emotional and behavioral disorders including pharmacotherapy, psychotherapy, behavior modification and biofeedback therapy. Management of detoxification and problems associated with substance withdrawal Psychotherapies: adult Psychotherapies: adolescent Psychopharmacotherapy Evaluation and treatment of patients with substance-related and addictive disorders Management of uncomplicated general medical conditions

FPPE Requirements AHS Core AH SLH

Two (2) psychiatric admissions/consultations and three (3) follow ups for general psychiatry privileges

Privilege Cluster:Inpatient

Request Request all privileges listed below. AHS Core AH SLH Click shaded blue check box to Request all privileges. Uncheck any privileges you do not want to request.

- Currently granted privileges Admitting, attending in psychiatric conditions: adult Admitting, attending in psychiatric conditions: adolescent age greater than 13

Published: 10/19/2018 Psychiatry Multi-facility Privileges Form Page 2 of 5 [applicant]

FPPE Requirements AHS Core AH SLH

Two (2) psychiatric admissions and three (3) follow ups for inpatient privileges

Privilege Cluster: Outpatient

Request Request all privileges listed below. AHS Core AH SLH Click shaded blue check box to Request all privileges. Uncheck any privileges you do not want to request.

- Currently granted privileges Outpatient diagnosis and treatment: Partial Hospitalization and Intensive Outpatient Program Outpatient diagnosis and treatment: adult Outpatient diagnosis and treatment: adolescent age greater than 13 Outpatient consultation only

FPPE Requirements AHS Core AH SLH

Two(2) psychiatric initial evaluations and three (3) follow ups for outpatient visits

Privilege Cluster: Psychiatric Emergency Services

Request Request all privileges listed below. AHS Core AH SLH Click shaded blue check box to Request all privileges. Uncheck any privileges you do not want to request.

- Currently granted privileges Diagnosis and treatment of patients in psychiatric emergency settings: adult Diagnosis and treatment of patients in psychiatric emergency settings: adolescent

Published: 10/19/2018 Psychiatry Multi-facility Privileges Form Page 3 of 5 [applicant]

FPPE Requirements AHS Core AH SLH

Five (5) emergency department visits for psychiatric emergency services (PES) privileges

Privilege Cluster: Consultation Liaison Psychiatry

Request Request all privileges listed below. AHS Core AH SLH Click shaded blue check box to Request all privileges. Uncheck any privileges you do not want to request.

- Currently granted privileges Psychiatric consultation for patients in Emergency Settings: Adults Psychiatric consultation for patients on medical, surgical, and OB/GYN services Psychiatric consultation for patients on medical, surgical, and OB/GYN services: adolescents Psychiatric consultation for patients in Emergency settings: adolescents

FPPE Requirements AHS Core AH SLH

Two (2) psychiatric initial evaluations and three (3) follow ups for consultation liaison psychiatry

Acknowledgment of Applicant

A. In exercising any clinical privileges granted, I am constrained by applicable Hospital and Medical Staff policies and rules applicable generally and any applicable to the particular situation.

Published: 10/19/2018 Psychiatry Multi-facility Privileges Form Page 4 of 5 [applicant]

Practitioner's Signature Date

Department/Svc Chair Recommendation - Privileges

I have reviewed the requested clinical privileges and supporting documentation and make the following recommendation(s):

Privilege Condition/Modification/Deletion/Explanation

Department/Svc Chair Recommendation - FPPE Requirements

Signature of Department or Service Chair/Designee Date

Published: 10/19/2018 Psychiatry Multi-facility Privileges Form Page 5 of 5