All physicians and other licensed practitioners privileged through the medical staff process...

(1)

The organized medical staff prioritizes hospital-sponsored educational activities that relate, at least in part, to the type and nature of care, treatment, and services offered by the hospital.

(2)

Education is based on the findings of performance improvement activities.

(3)

Each individual’s participation in continuing education is documented.

(4)

Participation in continuing education is considered in decisions about reappointment to membership on the medical staff or renewal or revision of individual clinical privileges.