( a) Requests for clinical privileges to perform either a procedure not currently being performed at the Hospital or a new technique to perform an existing procedure(“ new procedure”) will not be processed until a determination has been made that the procedure will be offered by the Hospital and criteria for the clinical privilege( s) have been adopted.
( b) As an initial step in the process, the individual seeking to perform the new procedure will prepare and submit a report, not a vendor brochure, addressing all of the following items, which must be included to be considered for review to the CMO / VPMA:
( 1) appropriate education, training, and experience necessary to perform the new procedure safely and competently;
( 2) clinical indications for when the new procedure is appropriate;
( 3) whether there is empirical evidence of improved patient outcomes with the new procedure or other clinical benefits to patients;
( 4) whether proficiency for the new procedure is volume-sensitive and if the requisite volume would be available;
( 5) whether the new procedure is being performed at other similar hospitals and the experiences of those institutions; and
( 6) whether the Hospital currently has the resources, including space, equipment, personnel, and other support services, to safely and effectively perform the new procedure.
( c) The Medical Staff Office and the CMO / VPMA will review this report and consult with Administration, department chair / section chief, and Credentials Committee( any of which may conduct additional research as may be necessary) and will make a preliminary recommendation as to whether the new procedure should be offered at the Hospital.
( d) If the preliminary recommendation is favorable, the Credentials Committee will consider whether the request constitutes a“ new procedure” or if it is an extension of an existing privilege. If it is a“ new procedure,” the Credentials Committee will then develop threshold criteria. In developing the criteria, the Credentials Committee may conduct additional research and consult with experts, as necessary, and develop recommendations regarding:
( 1) the appropriate education, training, and experience necessary to perform the procedure or service;
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