( b ) As an initial step in the process , the individual seeking to perform the new procedure will prepare and submit a report to the CMO / VPMA addressing the following :
( 1 ) appropriate education , training , and experience necessary to perform the new procedure safely and competently ;
( 2 ) clinical indications for when the new procedure is appropriate ;
( 3 ) whether there is empirical evidence of improved patient outcomes with the new procedure or other clinical benefits to patients ;
( 4 ) whether proficiency for the new procedure is volume-sensitive and if the requisite volume would be available ;
( 5 ) whether the new procedure is being performed at other similar hospitals and the experiences of those institutions ; and
( 6 ) whether the Hospital currently has the resources , including space , equipment , personnel , and other support services , to safely and effectively perform the new procedure .
( c ) The CMO / VPMA will review this report and consult with Administration , department chair / section chief , and Credentials Committee ( any of which may conduct additional research as may be necessary ) and will make a preliminary recommendation as to whether the new procedure should be offered at the Hospital .
( d ) If the preliminary recommendation is favorable , the Credentials Committee will consider whether the request constitutes a “ new procedure ” or if it is an extension of an existing privilege . If it is a “ new procedure ,” the Credentials Committee will then develop threshold criteria . In developing the criteria , the Credentials Committee may conduct additional research and consult with experts , as necessary , and develop recommendations regarding :
( 1 ) the appropriate education , training , and experience necessary to perform the procedure or service ;
( 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 .
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