Chief Medical Officer. If the item is deemed to be egregious, the item will be forwarded immediately to the Chair of the Credentialing and Privileging Committee to initiate possible action. If not deemed egregious or serious, the item will be forwarded along with all other potential findings on the Sanctions Monitoring Log to the Credentialing and Privileging Committee for review at their next meeting.
a. The above-mentioned sources are checked on a monthly basis and reviewed for possible actions. When a report is updated quarterly it is still reviewed monthly as part of this process for consistency. From time to time, credentialing software may be used to facilitate a more efficient review of data as long as the software pulls its information directly from the primary source.
b. The Medical Staff Office will also seek out from its various health plan partners, where feasible, a list of patient complaints regarding members of the Medical Staff. These will be included on the Sanctions Log and reviewed on a monthly basis for further action as warranted.
c. If any adverse events from within Renown are identified involving a Medical Staff member, these will either be identified on the Sanctions log or routed through the Peer Review process so that they may be handled accordingly as well.
7. A. 9. Reinstatement from Automatic Relinquishment and Resignation:
( a) If an individual believes that the matter leading to the automatic relinquishment of appointment and privileges has been resolved within sixty( 60) days of the relinquishment, the individual may request to be reinstated.
( b) A request for reinstatement from an automatic relinquishment following completion of all delinquent records will be processed in accordance with applicable policies and rules and regulations. Failure to complete the medical records that caused relinquishment within the time required will result in automatic resignation from the Medical Staff or the Advanced Practice Provider Staff.
( c) Requests for reinstatement from an automatic relinquishment following the expiration or lapse of a license, controlled substance authorization, or insurance coverage will be processed by the Medical Staff Office. If any questions or concerns are noted, the Medical Staff Office will refer the matter for further review in accordance with( d) below.
( d) All other requests for reinstatement from an automatic relinquishment will be reviewed by the relevant department chair, Credentials Committee Chair, Chief of Staff, and CMO / VPMA. If these individuals make a favorable recommendation on reinstatement, the individual may immediately resume clinical practice at the Hospital. This determination will then be forwarded to the Credentials Committee, MEC, and Board for ratification. If, however, any of the individuals reviewing the request have any questions or concerns, those questions will be noted and the
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