Credentials Policy

CREDENTIALS POLICY Deer Valley Medical Center John C. Lincoln Medical Center Scottsdale Osborn Medical Center Scottsdale Shea Medical Center Scottsdale Thompson Peak Medical Center Proposed April 11, 2018 Horty, Springer & Mattern, P.C. 259050.19 CREDENTIALS POLICY TABLE OF CONTENTS PAGE 1. GENERAL ..........................................................................................................................1 1.A. TIME LIMITS .........................................................................................................1 1.B. DELEGATION OF FUNCTIONS ..........................................................................1 1.C. CONFIDENTIALITY AND PEER REVIEW PROTECTION ...............................1 1.C.1. Confidentiality .............................................................................................1 1.C.2. Peer Review Protection ................................................................................2 1.D. INDEMNIFICATION..............................................................................................2 1.E. DEFINITIONS .........................................................................................................2 2. QUALIFICATIONS, CONDITIONS, AND RESPONSIBILITIES .............................7 2.A. QUALIFICATIONS ................................................................................................7 2.A.1. Threshold Eligibility Criteria .......................................................................7 2.A.2. Extension of Time Frame to Satisfy Board Certification Criterion .............9 2.A.3. Waiver of Threshold Eligibility Criteria ....................................................10 2.A.4. Factors for Evaluation ................................................................................11 2.A.5. No Entitlement to Appointment .................................................................11 2.A.6. Nondiscrimination......................................................................................12 2.B. GENERAL CONDITIONS OF APPOINTMENT, REAPPOINTMENT, AND CLINICAL PRIVILEGES ........................................12 2.B.1. Basic Responsibilities and Requirements ..................................................12 2.B.2. Burden of Providing Information...............................................................13 2.C. APPLICATION .....................................................................................................15 2.C.1. Information ................................................................................................15 2.C.2. Misstatements and Omissions ....................................................................15 2.C.3. Grant of Immunity and Authorization to Obtain/Release Information .......................................................................15 a 259050.19 PAGE 3. PROCEDURE FOR INITIAL APPOINTMENT AND PRIVILEGES ......................19 3.A. PROCEDURE FOR INITIAL APPOINTMENT AND PRIVILEGES.................19 3.A.1. Application .................................................................................................19 3.A.2. Initial Review of Application .....................................................................19 3.A.3. Department Chair and Chief Nursing Officer Procedure ..........................20 3.A.4. Credentials Committee Procedure .............................................................20 3.A.5. Division Executive Committee Recommendation .....................................21 3.A.6. Network Executive Committee Recommendation .....................................21 3.A.7. Board Action ..............................................................................................21 3.A.8. Time Periods for Processing ......................................................................22 4. CLINICAL PRIVILEGES ..............................................................................................23 4.A. CLINICAL PRIVILEGES .....................................................................................23 4.A.1. General ....................................................................................................23 4.A.2. Requests for Limited Privileges Within a Core or Specialty ..................24 4.A.3. Resignation of Limited Clinical Privileges .............................................25 4.A.4. Resignation of Appointment and Clinical Privileges ..............................25 4.A.5. Clinical Privileges for New Procedures ..................................................25 4.A.6. Clinical Privileges That Cross Specialty Lines .......................................27 4.A.7. Clinical Privileges for Dentists and Oral Surgeons ................................28 4.A.8. Clinical Privileges for Podiatrists ...........................................................29 4.A.9. Physicians and Other Practitioners in Training ......................................29 4.A.10. Telemedicine Privileges ..........................................................................29 4.A.11. Initial Focused Professional Practice Evaluation ....................................30 4.B. TEMPORARY CLINICAL PRIVILEGES ...........................................................30 4.C. EMERGENCY SITUATIONS ..............................................................................32 4.D. DISASTER PRIVILEGES.....................................................................................32 5. PROCEDURE FOR REAPPOINTMENT ....................................................................34 5.A. PROCEDURE FOR REAPPOINTMENT .............................................................34 b 259050.19 PAGE 5.B. REAPPOINTMENT CRITERIA ...........................................................................34 5.B.1. Eligibility for Reappointment ....................................................................34 5.B.2. Factors for Evaluation ................................................................................34 5.C. REAPPOINTMENT PROCESS ............................................................................35 5.C.1. Reappointment Application Form..............................................................35 5.C.2. Conditional Reappointments ......................................................................35 5.C.3. Potential Adverse Recommendation ..........................................................36 6. QUESTIONS INVOLVING MEDICAL STAFF OR ALLIED HEALTH STAFF MEMBERS ................................................................37 6.A. OVERVIEW AND GENERAL PRINCIPLES .....................................................37 6.A.1. Options Available to Medical Staff Leaders and Hospital Administration ......................................................................37 6.A.2. Documentation ...........................................................................................38 6.A.3. No Recordings of Meetings .......................................................................38 6.A.4. No Right to Counsel...................................................................................38 6.A.5. No Right to the Presence of Others ............................................................38 6.A.6. Involvement of Supervising Physician in Matters Pertaining to Allied Health Staff Members .................................................................39 6.B. COLLEGIAL INTERVENTION AND PROGRESSIVE STEPS ........................39 6.C. ONGOING AND FOCUSED PROFESSIONAL PRACTICE EVALUATION .................................................................................39 6.D. MANDATORY MEETING...................................................................................40 6.E. FITNESS FOR PRACTICE EVALUATION ........................................................40 6.F. COMPETENCY ASSESSMENT ..........................................................................41 6.G. AUTOMATIC RELINQUISHMENT ...................................................................41 6.G.1. Failure to Complete Medical Records .......................................................42 6.G.2. Failure to Satisfy Threshold Eligibility Criteria ........................................42 6.G.3. Criminal Activity .......................................................................................42 6.G.4. Failure to Provide Information ...................................................................42 6.G.5. Failure to Attend a Mandatory Meeting .....................................................42 c 259050.19 PAGE 6.G.6. Failure to Complete or Comply with Training or Educational Requirements .....................................................................43 6.G.7. Failure to Comply with Request for Fitness for Practice Evaluation ...............................................................................43 6.G.8. Failure to Comply with Request for Competency Assessment .................43 6.G.9. Reinstatement from Automatic Relinquishment and Automatic Resignation ........................................................................43 6.H. LEAVES OF ABSENCE .......................................................................................44 6.H.1. Initiation .....................................................................................................44 6.H.2. Duties of Member on Leave ......................................................................45 6.H.3. Reinstatement .............................................................................................45 6.I.

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