evaluation processes. These processes include, but are not limited to, the review and assessment of an individual’ s clinical performance, professionalism, and ability to exercise clinical privileges safely and competently.
( 6)“ PROFESSIONAL REVIEW ACTION” and“ PROFESSIONAL REVIEW ACTIVITY” have the meanings defined in the Health Care Quality Improvement Act of 1986(“ HCQIA”).
( 7)“ RESTRICTION” means a professional review action based on clinical competence or professional conduct which results in the inability of an individual to exercise their own independent judgment for a period longer than fourteen( 14) days( for example, a mandatory concurring consultation, where the consultant must approve the proposed procedure or treatment before privileges may be exercised, or other requirement that another physician must agree before privileges can be exercised). Conditions built into a performance improvement plan are not considered a restriction.
1. B. TIME LIMITS
Time limits referred to in this Manual and related bylaws, policies and manuals are advisory only and are not mandatory, unless it is expressly stated.
1. C. DELEGATION OF FUNCTIONS
( 1) When a function is to be carried out by a Medical Staff Leader, a Medical Staff committee, or a member of Administration, the individual, or the committee through its chair, may delegate performance of the function to one or more designees. Any such designee must treat and maintain all credentialing, privileging, and peer review information in a strictly confidential manner and is bound by all other terms, conditions, and requirements of the Medical Staff Bylaws and related policies.
( 2) When a member of the Medical Staff is unavailable or unable to perform an assigned function, one or more of the Medical Staff Leaders may perform the function personally or delegate it to another appropriate individual.
1. D. CONFIDENTIALITY AND PEER REVIEW PROTECTION 1. D. 1. Confidentiality:
Actions taken and recommendations made pursuant to this Manual will be strictly confidential. There should be no disclosure of any of this information( discussions or documentation) outside of committee meetings, except:
( a) to another authorized individual or body and for the purpose of conducting professional review activity;
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