The decision to grant or deny a privilege(s) and/or to renew an existing privilege(s) is an o...

(1)

The hospital, based on recommendations by the organized medical staff and approval by the governing body, develops and implements criteria that determine if a physician or other licensed practitioner is allowed to provide patient care, treatment, and services within the scope of the privilege(s) requested. Evaluation of all of the following are included in the criteria: - Current licensure and/or certification, as appropriate, verified with the primary source - Specific relevant training, verified with the primary source - Evidence of physical ability to perform the requested privilege - Data from professional practice review by an organization(s) that currently privileges the applicant (if available) - Peer and/or faculty recommendation - When renewing privileges, review of the physician's or other licensed practitioner’s performance within the hospital

(2)

The hospital has a clearly defined procedure approved by the organized medical staff for processing applications for the granting, renewal, or revision of clinical privileges.

(3)

An applicant submits a statement that no health problems exist that could affect their ability to perform the privileges requested.

(4)

The hospital queries the National Practitioner Data Bank in accordance with applicable law and regulation.

(5)

Completed applications for privileges are acted on within the time period specified in the medical staff bylaws, rules, and regulations, or in policies and procedures.

(6)

The hospital designates the practitioners who are allowed to perform surgery, in accordance with appropriate policies and procedures and with scope of practice laws and regulations. Surgery is performed only by the following: - A doctor of medicine or osteopathy, including an osteopathic practitioner recognized under section 1101(a)(7) of the Social Security Act - A doctor of dental surgery or dental medicine - A doctor of podiatric medicine

(7)

The surgical service maintains a current roster listing each practitioner’s surgical privileges. Note: The roster may be in paper or electronic format.

(9)

All physicians and other licensed practitioners who provide care, treatment, and services possess a current license, certification, or registration, as required by law and regulation.

(10)

If obstetrical services are provided, obstetrical privileges are delineated for all practitioners providing obstetrical care in accordance with the competencies of each practitioner. Note: For hospitals that use Joint Commission accreditation for deemed status purposes: Obstetrical privileges are delineated in accordance with 42 CFR 482.22(c). For 482.22(c), refer tohttps://www.ecfr.gov/current/title-42/part- 482/subpart-C#p-482.22(c).