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.