Section 10 . Overview of Basic Steps and Procedures for Appointment , Clinical Privileges , Collegial Intervention , and Hearings
The details associated with the following Basic Steps and Procedures are contained in the Credentialing & Privileging Manual in a more expansive form .
10.1 Qualifications for appointment , reappointment , and clinical privileges
To be eligible to apply for initial appointment or reappointment to the Medical Staff , or for the granting of clinical privileges , an applicant must demonstrate appropriate education , training , experience , current clinical competence , professional conduct , licensure , and ability to safely and competently perform the clinical privileges requested as set forth in detail in the Credentialing & Privileging Manual .
10.2 Process for credentialing and privileging
10.2.1 The Medical Staff Office will notify the Department Chair of the department in which the applicant seeks clinical privileges when the application and supporting materials are available for review . The Department Chair will review the applicant ’ s education , training , and experience and prepare a written report stating whether the applicant meets all qualifications .
10.2.2 The Credentials Committee will review the report from the Department Chair , the application , and supporting materials and will make a recommendation . The recommendation of the Credentials Committee will be forwarded to the MEC for review and recommendation .
10.2.3 The MEC may adopt the report and recommendation of the Credentials Committee as its own , refer the application back to the Credentials Committee for further consideration , or state its reasons for disagreement with the report and recommendation of the Credentials Committee . If the recommendation of the MEC is to grant appointment or reappointment , and clinical privileges , it will be forwarded to the Board for final action . If the recommendation of the MEC would entitle the applicant to request a hearing , the CEO will send special notice to the applicant .
10.2.4 Temporary privileges may be granted by the CEO , when there is a favorable review by the Department Chair , the Credentials Committee , or its chair , and Chief of Staff , to applicants for initial appointment and to non-applicants , when there is an important patient care , treatment , or service need . The grant of temporary clinical privileges will not exceed 120 days .
10.3 Indications and process for automatic relinquishment of appointment and clinical privileges
10.3.1 Appointment and clinical privileges may be automatically relinquished if an individual : 10.3.1.1 fails to do any of the following :
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