( 2) the clinical indications for when the procedure or service is appropriate;
( 3) the extent( time frame and mechanism) of focused monitoring and supervision that should occur if the privileges are granted; and
( 4) the manner in which the procedure would be reviewed as part of the Hospital’ s ongoing and focused professional practice evaluation activities.
( e) The Credentials Committee will forward its recommendations to the MEC, which will review the matter and forward its recommendations to the Board for final action.
( f) If the Board determines to offer the new procedure, it will adopt threshold qualifications that an individual must demonstrate to be eligible to request the clinical privileges in question.
( g) If the Board determines not to offer the new procedure, it will state the reasons why for the provider and provide feedback indicating what the prepared report would need to contain in the future for the request to be granted. This determination not to offer the new procedure will not constitute any Fair Hearing rights.
( h) Once the above steps have been completed, specific requests from eligible individuals may be processed. The newly granted procedure will then be added to the department delineation of privileges form as appropriate.
4. A. 6. Clinical Privileges That Cross Specialty Lines:
( a) Requests for clinical privileges that previously, at the Hospital, have been exercised only by members in another specialty will not be processed until the steps outlined in this Section have been completed and a determination has been made regarding the member’ s eligibility to request the clinical privilege( s) in question.
( b) As an initial step in the process, the individual seeking the privilege will submit a report to the Credentials Committee, via the Medical Staff Office, that specifies the qualifications needed to perform the procedure safely and competently, whether the individual’ s specialty is performing the clinical privilege at other similar hospitals, and the experiences of those other hospitals in terms of patient care outcomes and quality of care.
( c) The Credentials Committee may conduct additional research and consult with experts, as necessary, including individuals on the Medical Staff( e. g., department chairs, individuals on the Medical Staff with special interest and / or expertise) and individuals outside the Hospital( e. g., other hospitals, residency training programs, specialty societies).
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