work with the MEC to assure that all supervising physicians possess clinical privileges commensurate with their supervising activities.
( b) A physician in training at the fellowship level may request clinical privileges in an area for which they have already completed residency training if they can demonstrate that all necessary eligibility criteria as set forth in this Manual have been met. Requests for such clinical privileges will be reviewed in accordance with the initial credentialing process outlined in this Manual.
( c) Physicians who are in a residency training program and who wish to moonlight( outside of the training program) will be granted specific privileges as set forth in this Manual. A resident who is moonlighting must comply with the institutional and program training requirements. Failure to comply with these requirements or termination from the residency program will result in the automatic relinquishment of clinical privileges, without a right to the hearing and appeal procedures.
4. A. 8. Focused Professional Practice Evaluation for Initial Privileges:
All initial grants of clinical privileges, whether at the time of appointment, reappointment, or during the term of an appointment, will be subject to focused professional practice evaluation by the department chair / section chief or by a physician( s) designated by the Credentials Committee.
4. B. TEMPORARY CLINICAL PRIVILEGES 4. B. 1. Temporary Clinical Privileges for Initial Applicants:
( a) Temporary privileges to an applicant for initial appointment may be granted by the CEO or CMO / VPMA( or designee, in absentia), upon recommendation of the Chief of Staff, when review by the MEC and Board is pending and when the following conditions are met:
( 1) the credentialing file is complete and raises no concerns;
( 2) information required of the initial applicant has been received and verified including the following:( i) current licensure;( ii) relevant training and experience;( iii) current competence;( iv) current professional liability coverage acceptable to the Hospital;( v) an ability to perform the clinical privileges requested;( vi) the result from a query to the National Practitioner Data Bank; and( vii) the result from a query to the Office of Inspector General’ s List of Excluded Individuals / Entities;
( 3) the applicant demonstrates there have been:( i) no current or previously successful challenges to licensure or registration; and( ii) no involuntary limitation, restriction, reduction, denial, loss or termination of appointment or clinical privileges at another health care facility; and
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