a. Medical Staff Officers shall have access to all Medical Staff records. b.
Medical Staff Department and Section Chiefs shall have access to all Medical Staff records pertaining to the activities of their respective sections.
c. Consultants( who may or may not be Members of the Medical Staff) reviewing a practitioner’ s performance at the request of a Medical Staff committee or section shall have access to the credentials and peer review files of the practitioner being reviewed and any other pertinent Medical Staff committee records. d.
The CEO, the CMO / VPMA, and the Chief of Staff shall have access to all Medical Staff records.
2. General Access by Practitioners to Medical Staff Records. a.
b.
Credentialing and Peer Review Files. A practitioner shall have the right to copies of any document in his or her own credentialing and peer review files that he / she submitted or filled out on behalf of Renown,( i. e., his or her application, reapplication, privileges list, or correspondence from him or her) or that were addressed directly to the practitioner. A practitioner shall not be allowed access to any further information in his or her credentialing and quality file without a subpoena or on advice of Renown legal counsel.
Medical Staff Committee Files. A practitioner shall be allowed access to Medical Staff committee files( to include committee minutes) only if, they are a member of the committee or were at the time of the minutes or following a written request by the practitioner that is approved by the MEC and the Board of Governors, for good cause or as directed by Renown legal counsel.
3. Access by Outside Persons or Organizations. a. Credentialing Or Peer Review At Other Hospitals.
( 1) Routine Requests for Information. If a practitioner has not encountered disciplinary or peer review problems or been denied privileges at the Hospital, the CEO, the CMO / VPMA, or Chief of Staff may release information contained in the practitioner’ s credentials and peer review file in response to a request from another Hospital or its medical staff. Such requests must include notification that the practitioner is a member of that Hospital’ s medical staff,
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