Clinical Privileges

New Hanover Regional
Medical Center
POLICY ON APPOINTMENT, REAPPOINTMENT,

AND CLINICAL PRIVILEGES
Last Amended
Date Distributed
June 5, 2007
June 11, 2007
Policy on Appointment, Reappointment and Clinical Privileges
TABLE OF CONTENTS
PAGE
I.
DEFINITIONS
II.
APPOINTMENT TO THE MEDICAL STAFF

A.
B.
C.
D.
E.
F.
G.
H.
QUALIFICATIONS FOR APPOINTMENT

General
Specific Qualifications
No Entitlement to Appointment
Non-Discrimination Policy
3
3
4
4
CONDITIONS OF APPOINTMENT
Duties of Appointees
Professional Conduct
4
4
APPLICATION FOR INITIAL APPOINTMENT AND

CLINICAL PRIVILEGES
Information
Basic Responsibilities for Applicants and Appointees
Burden of Providing Information
Authorization to Obtain Information
4
7
9
9
PROCEDURE FOR INITIAL APPOINTMENT

Pre-Application Process
Submission of Application
Department Chair Procedure
Credentials Committee Procedure
Credentials Committee Recommendation
Unfavorable Credentials Committee Recommendation
11
11
12
12
13
14
PROVISIONAL STATUS
Duration of Initial Provisional Appointment
Duties of Provisional Appointees
14
14
CLINICAL PRIVILEGES
General
Clinical Privileges for Dentists
Clinical Privileges for Podiatrists
Residents
Clinical Privileges After Age 65
15
16
16
16
17
VOLUNTARY RELINQUISHMENT OF PRIVILEGES

Request to Relinquish Clinical Privileges
Procedure for Relinquishment of Clinical Privileges
17
17
PROCEDURE FOR TEMPORARY CLINICAL PRIVILGES

Temporary Privileges for Licensed Independent Practitioners
Temporary Privileges at Reappointment
18
19
Temporary Clinical Privileges in Emergency Situations

Special Requirements
Termination of Temporary Clinical Privileges
III.
19
20
20
ACTIONS AFFECTING MEDICAL STAFF APPOINTEES

A.
B.
C.
D.
PROCEDURE FOR REAPPOINTMENT

Application
Factors to be Considered
Department Chief Procedure
Credentials Committee Recommendation
Unfavorable Credentials Committee Recommendations
Meeting with Affected Individual
21
21
22
23
23
24
24
PROCEDURES FOR REQUESTING EXPANSION IN

CLINICAL PRIVILEGES
Application for Additional Clinical Privileges
Factors to be Considered
24
24
PROCEDURE FOR OTHER

MEDICAL STAFF APPOINTEES
Initial Procedure
Initiation of Investigation
Investigative Procedure
Suspension of Privileges
Procedure Thereafter
25
26
26
27
27
QUESTIONS
INVOLVING
SUMMARY SUSPENSION OF CLINICAL PRIVILEGES

Grounds for Summary Suspension
Care of Suspended Individuals Patients
28
28
28
OTHER ACTIONS
Failure to Complete Medical Records
Action by State Licensing Agency
Failure to be Adequately Insured
Failure to Satisfy Continuing Education Requirements
Failure to Provide Requested Information
Procedure for Leave of Absence
29
29
29
29
30
30
F.
INFORMAL PROCEEDINGS
31
G.
CONFIDENTIALITY AND REPORTING
31
H.
PEER REVIEW PROTECTION
31
E.
IV.
HEARING AND APPEAL PROCEDURES

A.
INITIATION OF HEARING
Grounds for Hearing
32
B.
THE HEARING
Notice of Recommendation
Request for Hearing
Notice of Hearing and Statement of Reasons
Witness List
Hearing Panel, Presiding Officer and Hearing Officer
32
33
33
33
34
HEARING PROCEDURE
Discovery
Pre-Hearing Conference
Failure to Appear
Record of Hearing
Rights of Both Sides
Admissibility of Evidence
Official Notice
Postponements and Extensions
35
36
36
36
37
37
37
37
HEARING CONCLUSION, DELIBERATIONS, AND

RECOMMENDATIONS
Order of Presentation
Basis of Decision
Adjournment and Conclusion
Deliberations and Recommendation of the Hearing Panel
Disposition of Hearing Panel Report
38
38
38
38
39
APPEAL PROCEDURE
Time for Appeal
Grounds for Appeal
Time, Place and Notice
Nature of Appellate Review
Final Decision of the Board
Further Review
Right to One Hearing and One Appeal Only
39
39
39
39
40
40
40
V.
AMENDMENTS
41
VI.
ADOPTION
41
C.
B.
E.
ARTICLE I.
DEFINITIONS
The following definitions shall apply to terms used in this policy:
1.
"Hospital" means the New Hanover Regional Medical Center, located at 2131 South 17th Street,
Wilmington, NC 28401 and the Cape Fear Campus located at 5301 Wrightsville Avenue,
Wilmington, NC 28403.
2.
"Board" means the Board of Trustees of New Hanover Regional Medical Center, who have the
overall responsibility for the conduct of the hospital;
3.
"Chief Executive Officer" means the President and Administrator of the hospital or that individual's
designee;
4.
"Executive Committee" means the Executive Committee of the Medical Staff unless specifically
written "Executive Committee of the Board";
5.
"Medical Staff" means all physicians, dentists and podiatrists who are given privileges to treat
patients at the hospital;
6.
"Physicians" shall be interpreted to include both doctors of medicine (MDs) and doctors of
osteopathy (D.O.s);
7.
"Dentist" shall be interpreted to include a doctor of dental surgery and doctor of dental medicine;
8.
"Podiatrist" shall be interpreted to mean a doctor of podiatric medicine;
9.
"Medical Director" means the physician appointed by the Board to act as the chief medical officer
of the hospital;
"President of the Medical Staff" means the Chief of Staff and Chairperson of the Executive
Committee;
10.
11.
"Unassigned patient" means any individual who comes to the hospital for care and treatment who
does not have an attending physician; or whose attending physician is unavailable and without a
physician substitute to attend the patient; or who does not want the attending physician to continue
to provide him or her care while a patient at the hospital;
12.
"Official notice" means an act by which a hearing body or individual may, on its own and without
the production of evidence, recognize the existence and truth of certain facts they already know or
which are universally regarded as accepted and/or established;
13.
"Professional review action" means an action or recommendation of a professional review body

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which is taken or made in the conduct of professional peer review activity, which is based on the
competence or professional conduct of a staff appointee, and which affects or may affect adversely
the clinical privileges or appointment of the individual;
14.
"Professional review body" means the governing Board of the hospital or any committee of the
same, which conducts professional peer review activity, and includes any committee of the medical
staff of the hospital when assisting the governing Board in a professional peer review activity;
15.
"Professional review activity" means a peer review activity of the hospital with respect to an
individual staff appointee (a) to determine whether the staff appointee may have clinical privileges
with respect to his or her appointment; (b) to determine the scope or conditions of those clinical
privileges and appointment; and (c) to change or modify such privileges and/or appointment;
16.
Words used in this policy shall be read as the masculine or feminine gender, and as the singular or
plural, as the content requires. The captions or headings are for convenience only and are not
intended to limit or define the scope or effect of any provision of this policy.
ARTICLE II.
APPOINTMENT TO THE MEDICAL STAFF
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Article II., Part A Qualifications for Appointment

Section 1. General
Appointment to the Medical Staff is a privilege which shall be extended only to professionally
competent individuals who continuously meet the qualifications, standards and requirements set
forth hereinafter and in such policies as are adopted from time to time by the Board. All individuals
practicing medicine, dentistry and podiatry in this hospital, unless excepted by specific provisions,
must first have been appointed to the Medical Staff.
Section 2. Specific Qualifications
Only physicians, dentists and podiatrists who satisfy the following conditions shall be qualified for
appointment to the Medical Staff:
a.
are currently licensed to practice in the State of North Carolina;
b.
in order to provide timely and continuous care for their patients at the hospital the physician, or
his covering physician must be within 30 minutes of the hospital, or in-house. Affiliate and
Visiting Staff are exempt from this requirement;
c.
possess current, valid professional liability insurance coverage from a company that is licensed
to do business in the state of North Carolina unless an exemption is granted by Medical
Executive Committee and the Board of Trustees, in such form and in amounts satisfactory to
the Board;
d.
have successfully completed an accredited American Council of Graduate Medical

Education/American Osteopathic Association residency training program appropriate to the
specialty in which the applicant seeks clinical privileges;
e.
are certified by the appropriate specialty board or admissible for examination for certification
by the American Board of Medical Specialties, in the area in which privileges are requested, or
by the American Board of Podiatric Surgery, or the American Board of Oral and Maxillofacial
Surgery, and thereafter certified within five (5) years of initial staff appointment, unless such
requirement is waived by the Board after considering the specific competence, training, and
experience of the individual in question, or waived by the Board for those applicants and
appointees who practice in medical subspecialties where there are specific practice
prerequisites for admissibility to board examination;
f.
1.
Dentist applicants requesting surgical privileges must be certified or admissible to

examination for certification by the American Board of Oral and Maxillofacial Surgery;
2.
Podiatrist applicants must be certified or admissible to examination for certification by

the American Board of Podiatric Surgery; and
can document their:

1.
background, experience, training and demonstrated competence,
2.
adherence to the ethics of their profession,

3
3.
good reputation and character, including the applicant's physical health and mental and
emotional stability, and
4.
ability to work harmoniously with others sufficiently to convince the hospital that all
patients treated by them at the hospital will receive quality care and that the hospital and
its Medical Staff will be able to operate in an orderly manner;
5.
In circumstances where the hospital has an exclusive contract, an application will not be
provided unless employment with the contracted entity is anticipated.
Section 3. No Entitlement to Appointment

No individual shall be entitled to appointment to the Medical Staff or to the exercise of particular
clinical privileges in the hospital merely by virtue of the fact that such individual:
a.
is licensed to practice a profession in this or any other state;
b.
is a member of any particular professional organization;
c.
has had in the past, or currently has, Medical Staff appointment or privileges at any hospital; or
d.
resides and practices within 30 minutes of the hospital.
Section 4. Non-Discrimination Policy

No individual shall be denied appointment on the basis of sex, race, creed, religion, color or national
origin, or on the basis of any criteria unrelated to the delivery of quality patient care at the hospital,
to professional qualifications or to the hospital's purposes, needs and capabilities.
ARTICLE II., Part B. CONDITIONS OF APPOINTMENT
Section 1. Duties of Appointees
Appointment to the Medical Staff shall require that each appointee assume such reasonable duties
and responsibilities as the Medical Staff or the Board shall require.
Section 2. Professional Conduct
Individuals appointed to the Medical Staff shall be expected to relate in a positive and professional
manner to other health care professionals, and to cooperate and work collegially with the Medical
Staff leadership and hospital management and personnel.
ARTICLE II., Part C APPLICATION FOR INITIAL APPOINTMENT & CLINICAL
PRIVILEGES
Section 1. Information
a.
Applications for appointment to the Medical Staff shall be in writing, and shall be submitted on
forms approved by the Board upon recommendation of the Credentials Committee. These
forms shall be obtained from the office of the Director of the Medical Staff.
b.
The application shall contain a request for specific clinical privileges desired by the applicant
and shall require detailed information concerning the applicant's professional qualifications
including:
1.
the names and complete addresses of at least three (3) physicians, dentists, podiatrists or
other practitioners, as appropriate, who have had recent extensive experience in
observing and working with the applicant, and who can provide adequate information
pertaining to the applicant's present professional competence and character. These
references may not be from individuals associated or about to be associated with the
applicant in professional practice or personally related to the applicant. At least one
reference shall be from the same specialty area as the applicant;
2.
the names and complete addresses of the Department chairs of any and all institutional
affiliations which include hospitals, corporations, military assignment or government
agencies, at which the applicant has worked since completion of postgraduate
education;
3.
information as to whether the applicant's employment, medical staff appointment or

clinical privileges, status as a participating provider in a managed care organization,
professional society membership or academic appointment have ever been voluntarily
or involuntarily relinquished, withdrawn, denied, revoked, suspended, reduced,
investigated, challenged, subjected to probationary or other conditions, reduced or not
renewed at any other hospital or health care facility, or managed care organization;
4.
information as to whether the applicant has ever withdrawn his/her application for
appointment, reappointment and clinical privileges, or participating provider status in a
managed care organization, or resigned from a Medical Staff before final decision by a
hospital's or health care facility's governing board;
5.
information as to whether the applicant's license to practice any profession in any state,
or Drug Enforcement Administration registration is or has ever been voluntarily or
involuntarily relinquished, suspended, modified, terminated, restricted, limited, denied,
revoked, reprimanded or otherwise sanctioned by, or have any conditions been placed
on them, by any licensure agency. Also, whether any investigations or disciplinary
actions ever have been initiated by any state licensure agency, or if there are any
currently pending. (The submitted application shall include a list or copy of all the
applicant's current licenses to practice, as well as copies of Drug Enforcement
Administration registration, medical, dental or podiatric school diploma,certificates
from all post graduate training programs completed, ECFMG certificate, if applicable,
Board Certification certificates or letter or eligibility, current professional liability
insurance certificate, and current CV);
6.
information as to whether the applicant has currently in force professional liability

insurance coverage, including tail coverage, the name of the insurance company and the
amount and classification of such coverage, and whether said insurance covers the
clinical privileges the applicant or appointee seeks to exercise at the hospital. Also,
information regarding whether the applicants insurance coverage has ever been
terminated by action of the insurance company, or professional coverage has ever been
denied, or if specific procedures have ever been excluded from coverage, or a surcharge
imposed or additional premium added because of claims history;
7.
information concerning the applicant's professional liability litigation experience,

including professional liability suits which are currently pending, specifically
information concerning final judgments or settlements: (i) the substance of the
allegations, (ii) the findings, (iii) the ultimate disposition, and (iv) any additional
information concerning such proceedings or actions as the Credentials Committee may
deem appropriate;
8.
information as to proceedings or investigations presently taking place at any hospital,

health care facility, or managed care organization, or ever been the subject of any such
investigation, relating to clinical competence or professional conduct;
9.
information involving whether the applicant has been the subject of a focused individual
monitoring relating to clinical competence or professional conduct at any hospital,
health care facility, or managed care organization;
10.
a consent to the release of information from the applicant's present and past
professional liability insurance carriers;
11.
information concerning suspension, sanctioning, exclusion, or otherwise precluded from

participating in any private, federal, or state health insurance program, or if the
applicant has been the subject of an investigation by any private, federal, or state agency
concerning participation in any private, federal, or state health insurance program;
12.
current information regarding the applicant's physical, emotional, and mental health
status;
13.
information as to whether the applicant has ever been named as a defendant in a

criminal action and/or convicted of a crime, with details about any such instance;
14.
a complete chronological listing of the applicant's professional and educational

appointments, employment;
15.
information on the citizenship and/or visa status of the applicant;
16.
information as to whether the applicant has ever been convicted of any felony or any
misdemeanor relating to the practice of his/her profession, health care-related matters,
third-party reimbursement, violence, or controlled substances violations;
17.
information on military experience, including branch of service, type of discharge, dates

of service, and reserve status;
18.
information as to the ability to safely and competently exercise the clinical privileges
requested and perform the duties and responsibilities of appointment, including, but not
limited to, emergency service coverage and committee service;
19.
information relating to whether the applicant is presently, or has ever been, in treatment
for the abuse of controlled substances, habit-forming drugs, prescription medications, or
alcohol;
20.
information on board certification, if scheduled to take the certification exam, or the

date in which the applicant intends to apply, name of specialty board, date of initial
certification, and date of recertification. Also, information as to whether board
6
certification in any state has ever been relinquished, suspended, modified, restricted,
denied, challenged, surrendered, or terminated, whether voluntarily or involuntarily;
c.
21.
the applicant's signature; and
22.
such other information as the Board may require.
the history of malpractice verdicts and the settlement of malpractice claims, as well as pending
claims, will be evaluated as a criteria for appointment, reappointment, and the granting of
clinical privileges. However, the mere presence of verdicts, settlements or claims shall not, in
and of themselves, be sufficient to deny appointment or particular clinical privileges. The
evaluation shall consider the extent to which verdicts, settlements or claims evidence a pattern
of care that raises questions concerning the individual's clinical competence, or whether a
verdict, settlement or claim in and of itself, represents such deviation from standard medical
practice as to raise overall questions regarding the applicant's clinical competence, skill in the
particular clinical privilege, or general behavior.
Section 2. Basic Responsibilities for Applicants and Appointees

a.
The following basic responsibilities shall be applicable to every Medical Staff applicant and
appointee for staff appointment or reappointment as a condition of consideration of such
application and as a condition of continued Medical Staff appointment if granted:
1.
an obligation to provide timely and continuous care and supervision to all patients
within the hospital for whom the individual has responsibility;
2.
an agreement to abide by all bylaws and policies of the hospital, including all bylaws,
rules and regulations of the Medical Staff as shall be in force during the time the
individual is appointed to the Medical Staff;
3.
an agreement to accept committee assignments, emergency service call obligations, and

such other reasonable duties and responsibilities as shall be assigned;
4.
an agreement to keep this application current by informing the Hospital, through the
Chief Executive Officer, or his or her designee, of any changes in the information
provided, including, but not limited to, any investigations by a state licensure agency,
any change in my professional liability insurance coverage, any change in status at any
other hospital, any change in eligibility for participation in the Medicare or Medicaid
programs, and any change in the applicants ability to safely and competently exercise
clinical privileges because of health status issues, including impairment;
5.
a statement that the applicant has received and had an opportunity to read a copy of the
bylaws of the hospital, this policy, and the bylaws, rules and regulations of the Medical
Staff as are in force at the time of application, and that the applicant has agreed to be
bound by the terms thereof in all matters relating to consideration of the application
without regard to whether or not appointment to the Medical Staff and/or clinical
privileges are granted;
6.
a statement of the applicant's willingness to appear for personal interviews in regard to

the application;
b.
7.
a statement that any misrepresentation or misstatement in, or omission from, the

application whether intentional or not, shall constitute cause for automatic and
immediate rejection of the application resulting in denial of appointment and clinical
privileges. In the event that an appointment has been granted prior to the discovery of
such misrepresentation, misstatement or omission, such discovery may result in
summary dismissal from the Medical Staff;
8.
a statement that appointment to the medical staff and continued clinical privileges
remain contingent upon the applicants continued demonstration of professional
competence and cooperation, acceptable performance of all related responsibilities, as
well as the other factors deemed relevant by the Hospital;
9.
an agreement that the hearing and appeal procedures set forth in this policy shall be the
sole and exclusive remedy with respect to any professional review action taken at this
hospital;
10.
a statement of the applicants willingness to abide by HIPAA regulations and maintain

patient confidentiality;
11.
an agreement to adhere to the Corporate Compliance Policy of the Hospital and any
laws, regulations, and standards of conduct applicable to the applicants profession,
participation in any federal health program, or activities at the Hospital, and to report
any known or suspected violation of the same to the Chief Executive Officer or the
Compliance Officer; and
12.
a statement that it is the applicants responsibility to produce adequate information so

that the application can be properly evaluated. In addition to the information provided
in the application, the applicant agrees to provide the Hospital with any additional
information that the Hospital or one of its authorized representatives may request.
Failure to provide requested information will cause the application to be incomplete and
will prevent it from being processed.
The following requirements shall be applicable to every applicant and appointee for Medical
Staff appointment or reappointment as a condition of consideration of such application, and as
a condition of continued Medical Staff appointment, if granted:
1.
to refrain from illegal fee splitting or other illegal inducements relating to patient
referral;
2.
to refrain from delegating responsibility for diagnoses or care of hospitalized patients to

any individual who is not qualified to undertake this responsibility or who is not
adequately supervised;
3.
to refrain from deceiving patients as to the identity of an operating surgeon or any other
individual providing treatment or services;
4.
to seek consultation whenever necessary;
5.
to promptly notify the Chief Executive Officer, or a designee, and the Chairperson of
the Quality Management Committee of the Medical Staff of any change in eligibility for
payments by third-party payors or for participation in Medicare, including any sanctions
imposed or recommended by the federal Department of Health and Human Services
8
and/or the receipt of a PRO citation and/or quality denial letter concerning alleged
quality problems in patient care;
c.
6.
to abide by generally recognized ethical principles applicable to the applicant's or

appointee's profession;
7.
to provide continuous care for patients in the hospital;
8.
to participate in the monitoring and evaluation activities of clinical departments;
9.
to complete in a timely manner the medical and other required records for all patients as
required by the Medical Staff bylaws, rules and regulations, this policy and other
applicable policies of the hospital;
10.
to work cooperatively with Medical Staff appointees, Allied Health appointees, nurses
and other hospital personnel so as not to adversely affect patient care;
11.
to promptly pay any applicable Medical Staff assessments;
12.
to participate in continuing education programs for the benefit of the applicant or

appointee and for the benefit of other professionals and hospital personnel;
13.
to authorize the acquisition of information necessary for an evaluation of the

individual's qualifications for initial or continued appointment, reappointment, and/or
clinical privileges; and
14.
to extend absolute immunity to the hospital, its Medical Staff and all individuals acting
by or for the hospital and/or its Medical Staff for all matters relating to appointment and
clinical privileges or the individual's qualifications for the same.
Each applicant for Medical Staff appointment and reappointment shall specifically agree to
these responsibilities and requirements as part of appointment to the Medical Staff.
Section 3. Burden of Providing Information

a.
The applicant shall have the burden of producing information deemed adequate by the hospital
for a proper evaluation of competence, character, ethics and other qualifications, and of
resolving any doubts about such qualifications.
b.
The applicant shall have the burden of providing evidence that all the statements made and
information given on the application are true and correct.
c.
Until the applicant has provided all information requested by the hospital, the application for
appointment or reappointment will be deemed incomplete and will not be further processed.
Should information provided in the initial application for appointment change during the
course of an appointment year, the appointee has the burden to provide information about such
change to the Credentials Committee sufficient for the Committee's review and assessment.
Section 4. Authorization to Obtain Information

The following statements, which shall be included on the application form and which form a part of
9
this policy, are express conditions applicable to any Medical Staff applicant, any appointee to the
Medical Staff, and to all others having or seeking clinical privileges at the hospital. By applying for
appointment, reappointment or clinical privileges, the applicant expressly accepts these conditions
during the processing and consideration of the application, whether or not appointment or clinical
privileges are granted. This acceptance also applies during the time of any appointment or
reappointment.
a.
Immunity:
To the fullest extent permitted by law, the applicant or appointee extends absolute immunity to,
release from any and all liability, its medical staff, their authorized representatives and
appropriate third parties for any matter relating to appointment, reappointment, clinical
privileges, or the applicants qualifications for the same concerning the following: (This
includes any actions, recommendations, reports, statements, communications, or disclosures
which are made, taken, or received by the Hospital, the medical staff, their authorized
representatives, or appropriate third parties).
b.
1.
applications for appointment or clinical privileges, including temporary privileges;
2.
evaluations concerning reappointment or changes in clinical privileges;
3.
proceedings for suspension or reduction of clinical privileges or for revocation of

Medical Staff appointment, or any other disciplinary sanction;
4.
summary suspension;
5.
hearings and appellate reviews;
6.
medical care evaluations;
utilization reviews;
8.
other activities relating to the quality of patient care or professional conduct;
9.
matters or inquiries concerning the applicant's or appointee's professional qualifications,

credentials, clinical competence, character, mental or emotional stability, physical
condition, ethics or behavior; or
10.
any other matter that might directly or indirectly relate to the applicant's or appointee's
competence, to patient care, or to the orderly operation of this or any other hospital or
health care facility.
Authorization to Obtain Information

The applicant or appointee specifically authorizes the Hospital, its medical staff, and their
authorized representatives (i) to consult with any third party who may have information
bearing on the professional qualifications, credentials, clinical competence, character, ability to
perform safely and competently, ethics, behavior, or any other matter reasonably having a
bearing on the applicants qualifications for initial and continued appointment to the medical
staff, and (ii) to obtain any and all communications, reports, records, statements, documents,
recommendations or disclosures of said third parties that may be relevant to such questions. In
addition, the applicant specifically authorizes these third parties to release the information to
the Hospital, its medical staff, and their authorized representatives upon request.
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c.
Authorization to Release Information

The applicant or appointee authorizes the Hospital, its medical staff, and their authorized
representatives to release such information to other hospitals, health care facilities, managed
care entities, and their agents, who solicit such information for the purpose of evaluating the
applicant' qualifications pursuant to a request for appointment and clinical privileges,
participating provider status, or other credentialing matter.
ARTICLE II., Part D, PROCEDURE FOR INITIAL APPOINTMENT

Section 1. Pre-application Process
a.
An application form for appointment to the Medical Staff shall only be sent upon request to
those individuals who, according to the Medical Staff Bylaws and this policy, are eligible for
appointment; who meet the threshold criteria for appointment and clinical privileges
consideration; who desire to provide care and treatment to patients for conditions and diseases
for which the hospital has facilities and personnel; and who indicate an intention to utilize the
hospital as required by the staff category to which they desire appointment.
b.
An individual requesting an application form for appointment shall initially be sent a

questionnaire to be completed and returned to the Medical Staff Office to determine if the
applicant meets threshold criteria for appointment and clinical privileges consideration. The
questionnaire must be completed and signed by the applicant certifying that he/she meets
threshold criteria for appointment and clinical privileges before the applicant is sent an
application for initial appointment.
c.
Those individuals who meet the threshold criteria for consideration for appointment to the
Medical Staff and clinical privileges shall be given an application form. Individuals who fail to
meet the threshold criteria shall not be given an application form and shall be so notified.
Section 2. Submission of Application

a.
The application for Medical Staff appointment shall be submitted by the applicant to the
Director of the Medical Staff. It must be accompanied by payment of required processing
fees. After reviewing the application form to determine that all questions have been
answered, and after reviewing all references and other information or materials deemed
pertinent, and after verifying the information provided in the application form with the
primary sources, the Director of the Medical Staff shall transmit the complete application and
all supporting materials to the appropriate Department chair.
b.
An application shall be deemed to be complete when all questions on the application form
have been answered, all supporting documentation has been supplied and all information
verified. An application shall become incomplete if the need arises for new, additional or
clarifying information anytime during the evaluation. Any application that continues to be
incomplete ninety (90) days after the applicant has been notified of the additional information
required shall be deemed to be withdrawn. It is the responsibility of the applicant to provide a
complete application, including adequate responses from references. An incomplete
application will not be processed.
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c.
The Director of the Medical Staff shall post the name of the applicant so that each Medical
Staff appointee (member) may have an opportunity to submit to the Credentials Committee, in
writing, information bearing on the applicant's qualifications for staff appointment or clinical
privileges. In addition, any current Medical Staff appointee shall have the right to appear in
person before the Credentials Committee to discuss in private and in confidence any concerns
the appointee may have about the applicant.
Section 3. Department Chair Procedure

a.
The chairperson of each department in which the applicant seeks clinical privileges shall
provide the Credentials Committee with a written report concerning the applicant's
qualifications for requested clinical privileges. This report shall be appended to the Credentials
Committee's report. As part of the process of making this report, the Department chair has the
right to meet with the applicant to discuss any aspect of the application, qualifications and
requested clinical privileges.
b.
The Department chair, or the individual within the department to whom the chairperson has
assigned this responsibility, shall evaluate the applicant's education, training and experience
and make inquiries with respect to the same to the applicant's past or current department
chief(s), residency training director, and others who may have knowledge about the applicant's
education, training, experience, and ability to work with others.
c.
The Department chair shall be available to the Credentials Committee to answer any questions
that may be raised with respect to that chairperson's report and findings.
Section 4. Credentials Committee Procedure

a.
The Credentials Committee shall examine evidence of the applicant's character, professional
competence, qualifications, prior behavior, and ethical standing and shall determine, through
information contained in references given by the applicant and from other sources available to
the committee, including the report and findings from the chairperson of each clinical
department in which privileges are sought, whether the applicant has established and satisfied
all of the necessary qualifications for appointment and for the clinical privileges requested.
b.
As part of the process of making its recommendation, the Credentials Committee may require
for reasons as stated by the Credentials Committee, the applicant to undergo a physical and/or
mental examination by a physician or physicians satisfactory to the Credentials Committee.
The results of any such examination shall be made available to the committee for its
consideration. Failure of an applicant to undergo such an examination within a reasonable
time after being requested to do so in writing by the Credentials Committee shall constitute a
voluntary withdrawal of the application for appointment and clinical privileges, and all
processing of the application shall cease.
c.
The Credentials Committee shall have the right to require the applicant to meet with the
committee to discuss any aspect of the applicant's application, qualifications, or clinical
privileges requested.
d.
The Credentials Committee may use the expertise of the Department chair, or any member of
the department, or an outside consultant, if additional information is required regarding the
applicant's qualifications.
12
e.
If, after considering the report of the clinical Department chair concerned, the Credentials
Committee's recommendation for appointment is favorable, the Credentials Committee shall
recommend provisional assignment. All recommendations to appoint, including provisional
appointment, must specifically recommend the clinical privileges to be granted, which may be
qualified by any probationary or other conditions or restrictions.
f.
If the recommendation of the Credentials Committee is delayed longer than ninety (90) days,
the Chairperson of the Credentials Committee shall send a letter to the applicant, with a copy
to the Executive Committee and Chief Executive Officer, explaining the reasons for the delay.
Section 5. Credentials Committee Recommendation

a.
If the Credentials Committee's recommendation is to appoint the applicant and to grant the
requested clinical privileges, it shall send its recommendation and written findings in support
thereof to the Executive Committee.
b.
The Executive Committee shall make a recommendation to approve or to deny the requested
appointment and clinical privileges. The Executive Committee shall make any comment on
the recommendation it deems appropriate. If the Executive Committee disagrees with the
Credentials Committee recommendation, it shall specify the reasons for that disagreement and
refer the matter back to the Credentials Committee for additional research or information.
c.
Upon receipt of a favorable recommendation from the Executive Committee that the applicant
be granted appointment and the requested clinical privileges, the Board (or its designated
committee) may:
1.
appoint the applicant and grant clinical privileges as recommended; or
2.
refer the matter back to the Credentials Committee or to another source inside or
outside the hospital for additional research or information; or
3.
reject the recommendation. If the Board determines to reject the favorable

recommendation, it should first discuss the matter with the Chairperson of the
Credentials Committee. If the Board's determination remains unfavorable to the
applicant, that determination and the reasons in support thereof, shall be sent to the
Chief Executive Officer, who shall promptly notify the applicant in writing, certified
mail, return receipt requested. The Board shall make no final decision until the
applicant has exercised or waived the right to a hearing and appeal as outlined in this
policy.
Section 6. Unfavorable Credentials Committee Recommendation

If the Credentials Committee's recommendation is unfavorable and would entitle the applicant to
request a hearing pursuant to this policy, it shall be forwarded to the Executive Committee and to the
Chief Executive Officer. The Chief Executive Officer shall promptly notify the applicant in writing,
certified mail, return receipt requested. The application shall not be forwarded to the Board, nor
shall the Executive Committee submit its comments to the Board, until the applicant has exercised or
waived the right to a hearing as provided in this policy.
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ARTICLE II, Part E. PROVISIONAL STATUS

Section 1. Duration of Initial Provisional Appointment
a.
All initial appointments to the Medical Staff regardless of the category of the staff to which
the appointment is made, and all initial clinical privileges shall be provisional for a period of
at least twelve (12) months from the date of the appointment, or longer, if so recommended by
the Credentials Committee.
b.
During the term of this provisional appointment, the individual receiving the provisional
appointment shall be evaluated by the chairperson of the department or departments in which
the individual has clinical privileges, and by the relevant committees of the Medical Staff and
the hospital as to the individual's clinical competence and general behavior and conduct in the
hospital.
c.
Provisional clinical privileges shall be adjusted to reflect clinical competence at the end of the
provisional period, or sooner if warranted.
d.
Appointment after the provisional period shall be conditioned on an evaluation of the factors
to be considered for reappointment.
e.
Initial appointment after the provisional appointment, if granted by the Board, shall be for a
period of one (1) year.
Section 2. Duties of Provisional Appointees

a.
Appointment to the Medical Staff shall require that each appointee assume such reasonable
duties and responsibilities as the Board or the Medical Staff shall require.
b.
During the provisional period, an appointee must demonstrate all of the qualifications, may
exercise all of the prerogatives, and must fulfill all of the obligations attendant to his or her
staff category.
c.
Each provisional appointee shall regularly provide the Department chair with a list of patients
admitted, attended, or treated for required observation and assessment.
d.
During the provisional period, each appointee must fulfill all obligations required by the
department, Medical Staff, or Board, or otherwise become ineligible to apply for
reappointment, and all clinical privileges shall terminate at expiration of the provisional
appointment. This provision may be waived at the discretion of the Credentials Committee
and the Board.
ARTICLE II., Part F, CLINICAL PRIVILEGES
Section 1. General
a.
Medical Staff appointment or reappointment as such shall not confer any clinical privileges.
b.
Each individual who has been appointed to the Medical Staff shall be entitled to exercise only
those clinical privileges specifically granted by the Board.
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c.
The granting of clinical privileges shall carry with it acceptance of the obligations of such
privileges including emergency service and other rotational obligations established to fulfill
the hospital's responsibilities under the Emergency Medical Treatment and Active Labor Act
and/or other applicable requirements or standards.
d.
Clinical privileges shall be voluntarily relinquished only in the manner that provides for the
orderly transfer of such obligations.
e.
The clinical privileges recommended to the Board shall be based upon consideration of the
following:
1.
the applicant's education, training, experience, demonstrated current competence and

judgment, references, utilization patterns, and health status;
2.
the applicant's ability to meet all current criteria for the requested clinical privileges;
3.
availability of qualified physicians or other appropriate appointees to provide medical

coverage for the applicant in case of the applicant's illness or unavailability;
4.
adequate levels of professional liability insurance coverage with respect to the clinical
privileges requested;
5.
the hospital's available resources and personnel;
6.
any previously successful or currently pending challenges to any licensure or

registration, or the voluntary relinquishment of such licensure or registration;
7.
any information concerning professional review actions, voluntary or involuntary

termination of Medical Staff appointment or voluntary or involuntary limitation,
reduction, or loss of clinical privileges at another hospital; and
8.
other relevant information, including a written report and findings by the chairperson
of each of the clinical departments in which such privileges are sought.
f.
The applicant shall have the burden of establishing qualifications for and competence to
exercise the clinical privileges requested.
g.
The reports of the chairperson of the clinical department in which privileges are sought shall
be forwarded to the Credentials Committee and processed as a part of the initial application
for staff appointment.
Section 2. Clinical Privileges for Dentists

a.
The scope and extent of surgical procedures that a dentist may perform in the hospital shall be
delineated and recommended in the same manner as other clinical privileges.
b.
Surgical procedures performed by dentists shall be under the overall supervision of the
chairperson of the Department of Oral and Maxillofacial Surgery. A medical history and
physical examination of the patient shall be made and recorded by a physician who holds an
appointment to the Medical Staff before dental surgery shall be scheduled for performance,
and a designated physician shall be responsible for the medical care of the patient throughout
15
the period of hospitalization.

c.
Oral surgeons who admit patients without medical problems may perform a complete medical
history and physical examination and assess the medical risks of the proposed procedure on
the patient if they are deemed qualified to do so by the Credentials Committee. "Oral
surgeons" shall be interpreted to refer to licensed dentists who have successfully completed a
postgraduate program in oral and maxillofacial surgery accredited by a nationally recognized
accrediting body approved by the United States Office of Education.
d.
The dentist shall be responsible for the dental care of the patient, including the dental history
and dental physical examination as well as all appropriate elements of the patient's record.
Dentists may write orders within the scope of their license and consistent with the Medical
Staff rules and regulations, and in compliance with the hospital and Medical Staff bylaws and
this policy.
Section 3. Clinical Privileges for Podiatrists

a.
The scope and extent of surgical procedures that a podiatrist may perform in the hospital shall
be delineated and recommended in accordance with the provisions of the policies governing
such practitioners as may be adopted by the Board from time to time.
b.
Surgical procedures performed by podiatrists shall be under the overall supervision of the
Chairperson of the Department of Orthopedic Surgery. A medical history and physical
examination of each patient shall have taken place and been recorded in the medical record by
a medical doctor who holds an appointment to the Medical Staff before podiatric surgery shall
be performed, and a designated medical doctor shall be responsible for the medical care of the
patient throughout the period of hospitalization.
c.
The podiatrist shall be responsible for the podiatric care of the patient, including the podiatric
history and the podiatric physical examination as well as all appropriate elements of the
patient's record. Podiatrists may write orders which are within the scope of their license,
consistent with the Medical Staff rules and regulations, and in compliance with the hospital
and Medical Staff bylaws and this policy.
Section 4. Residents
Residents in training at the hospital shall not hold appointments to the Medical Staff and shall not be
granted specific clinical privileges. Rather, they shall be permitted to exercise only those privileges
set out in training protocols developed by the respective training programs, and approved by the
Executive Committee and the Board.
Section 5. Clinical Privileges After Age 65
a.
The Credentials Committee shall specifically consider the mental and physical capabilities of
each appointee who has attained the age of 65 years and who has clinical privileges at the
hospital. Recommendations by the Credentials Committee for continued clinical privileges
for appointees between the ages 65 and 75 shall be based upon an evaluation of the
individual's current knowledge and skills.
b.
Upon attaining the age of 75, Medical Staff appointees shall automatically advance to the
"Honorary" Staff, unless exceptions are granted by the governing body, and no longer have
16
clinical privileges to admit or care for patients at the hospital. They shall be ineligible to vote,
hold office, or serve on committees. They shall pay no staff dues and shall assume full
Honorary Staff status with attendant prerogatives unless an exception continuing privileges is
recommended by the Credentials and the Executive committees, and approved by the Board.
ARTICLE II., Part G VOLUNTARY RELINQUISHMENT OF PRIVILEGES
Section 1. Request to Relinquish Clinical Privileges
a.
A Medical Staff appointee who desires to relinquish voluntarily any one (1) or more of the
clinical privileges granted at any time during the appointment period may submit a written
request to the Chairperson of the Credentials Committee specifying the clinical privilege(s) to
be relinquished. Said relinquishment of privileges shall not be effective until acknowledged
in writing by the Board.
b.
The procedure set forth in this Part shall not apply to situations where the appointee has been
deemed by the hospital to have voluntarily relinquished privileges pursuant to this policy, the
Medical Staff bylaws, rules and regulations or the hospital bylaws or policies.
c.
Likewise, voluntary relinquishment of clinical privileges while under an investigation or in

exchange for not conducting an investigation shall be considered a "surrender" of such
privileges, and shall be so reported when so required.
Section 2. Procedure for Relinquishment of Clinical Privileges

a.
Upon the receipt of a request to relinquish one or more clinical privileges, the Chairperson of
the Credentials Committee shall review the request and forward a recommendation to the
Board for final action with appropriate notification to the respective clinical department of the
physician. The Chairperson of the Credentials Committee may request a meeting with the
appointee involved if the decrease of the clinical privileges would create a deficiency in
available hospital services. A report of such meeting shall be submitted with the
recommendation of the Credentials Committee to the Board.
b.
The Board shall act on the request and its decision shall be reported in writing by the Chief
Executive Officer to the appointee, the Executive Committee, the Credentials Committee and
the chairperson of the applicable department. The decision of the Board shall specify a
specific date by which relinquishment of clinical privilege(s) shall become effective.
c.
Failure to relinquish any clinical privilege pursuant to Sections 1 and 2 of this Part or to
adhere to the effective date specified by the Board for the relinquishment of the clinical
privileges in question shall constitute grounds for professional review action pursuant to this
policy.
ARTICLE II., Part H, PROCEDURE FOR TEMPORARY CLINICAL PRIVILEGES

Section 1. Temporary Privileges for Licensed Independent Practitioners
a.
The Joint Commission has determined two circumstances for which the granting of temporary
privileges would be acceptable:
17
1.
To fulfill an important patient care need.
Under this provision, temporary privileges can be granted on a case-by-case basis when there
is an important patient care need that requires an immediate authorization to practice for a
period not to exceed 120 days, while the full credentials information is verified and approved.
Examples of situations where temporary privileges could be granted under the exception
would include, but would not be limited to, the following:
2.
An important patient care need is a situation where a physician becomes ill or takes
a leave of absence and an LIP would need to cover his/her practice until he/she
returns.
A specific LIP has the necessary skills to provide care to a patient that an LIP
currently privileged does not possess (i.e. outside physician with expertise to
participate in new technology procedures). Once expertise for a procedure is
available in the community, temporary privileges will not be granted to an outside
LIP to either perform or assist in the procedure. In these circumstances, temporary
privileges may be granted on a case by case basis provided there is verification of:
- current competence
- current North Carolina license
- current professional liability coverage from a company that is licensed to do
business in the state of North Carolina unless an exemption is granted by
Medical Executive Committee and the Board of Trustees.
When an initial applicant has a complete, clean application and is awaiting review and
approval of the Medical Executive Committee and the Governing Body.
In this circumstance temporary privileges may be granted when the initial applicant for
medical staff membership or privileges is waiting for a review and there may be some undue
delay (i.e. hurricane or other extraordinary events) before the application can be reviewed and
approved by the Medical Executive Committee and the Governing Body.
Temporary
privileges may be granted for a limited period of time, not to exceed 90 days, by the Chief
Executive Officer, or his designee, upon recommendation of the applicable Department
Chairman, and the Credentials Committee Chairman, or the President of the Medical Staff
provided:
There is verification of
- current licensure
- relevant training or experience
- current competence
- ability to perform the privileges requested
- other criteria required by Medical Staff Bylaws
The results of the National Practitioner Data Bank query have been obtained and
evaluated
The applicant has
- a complete application
- no current or previously successful challenge to licensure or
registration
- not been subject to involuntary termination of medical staff
membership at another organization
- not been subject to involuntary limitation, reduction, denial, or loss of
clinical privileges
18
Section 2. Temporary privileges at reappointment

Temporary privileges are not to be routinely used for other administrative purposes such as the
following situations:
a.
the Licensed Independent Practitioner fails to provide all information necessary to the
processing of his/her reappointment in a timely manner.
b.
failure of the staff to verify performance data and information in a timely manner.
In the above situations, the LIP would be required to cease providing care in the facility until the
reappointment process is completed.
Section 3, Temporary Clinical Privileges in Emergency Situations
a.
Emergency Privileges in the Event Of Disaster

Practitioners who are not members of the medical staff at the Hospital and who do not possess
medical staff privileges may practice at the facility during an emergency (defined as any
officially declared emergency, whether it is local, state, or national) Any practitioner
providing patient care must be granted emergency privileges prior to providing patient care in
a disaster situation. Emergency privileges would be granted by the Chief Executive Officer,
or Medical Staff President, or their designee(s). The decision to grant emergency privileges to
any individual is made on a case-by-case basis at the discretion of those authorized to grant
emergency privileges. Emergency privileges may be granted upon presentation of any of the
following.
a current picture hospital ID card

a current license to practice and a valid picture ID issued by a state, federal, or
regulatory agency
identification indicating that the individual is a member of a federal or state disaster
medical assistance team
identification indicating that the individual has been granted authority to render
inpatient care, treatment, and services in disaster circumstances (such authority having
been granted by a federal, state, or municipal entity)
presentation by current hospital or medical staff members(s) with personal knowledge
regarding practitioners identity
An individual granted emergency privileges will display identification as listed above. When the
privileges are granted based upon a current hospital or medical staff members personal knowledge
regarding the practitioners identity, a name badge will be displayed including the individuals name
and signature of the hospital or medical staff member who presented the individual for privileges as
described above.
Supervision of individuals with disaster privileges will be the responsibility of the appropriate
department chairman or his designee. A high priority will be placed on having the individuals partner
with a member of the medical staff or a clinical hospital employee to facilitate the most efficient care
and the adherence to hospital policy.
The verification process of the credentials and privileges of individuals who receive emergency
19
privileges will begin as soon as the immediate situation is under control and the medical staff will
follow the process as established in this policy for granting temporary privileges to meet an important
patient care need.
When the emergency no longer exists, the emergency privileges will be deemed to be automatically
relinquished.
b.
In case of an emergency, any medical staff member who has clinical privileges is permitted to
provide any type of patient care necessary as a life-saving measure, or to prevent serious harm
regardless of his or her medical staff status or clinical privileges, provided that the care
provided is within the scope of the individuals license.
Section 4. Special Requirements

a.
No applicant has a right to be granted temporary privileges. Temporary privileges granted

under this section are granted as a courtesy only. The failure to grant temporary privileges
requested under this section, or the termination of temporary privileges granted under this
section shall not constitute grounds for, or entitle the applicant to request a hearing under the
provisions of the Hospitals Policy on Appointment, Reappointment and Clinical Privileges.
b.
Temporary privileges are granted by the Chief Executive Officer, or his designee, upon
recommendation of the applicable Department Chairman, and the Chairman of the Credentials
Committee or the President of the Medical Staff provided that the President of the Hospital
first obtain such individuals signed acknowledgement to be bound by the Hospital Bylaws
and the Medical Staff Bylaws, then in force in all matters relating to temporary clinical
privileges.
c.
The granting of temporary privileges under this section shall be subject to any conditions,
limitations and restrictions deemed necessary or appropriate by the Chief Executive Officer,
or his designee, the appropriate Department Chairman and the Chairman of the Credentials
Committee or President of the Medical Staff.
d.
Any applicant who is granted temporary privileges shall be assigned to an appropriate clinical
department pending final action on the application.
e.
The Chief Executive Officer, or his designee, upon recommendation of the applicable
Department Chairman and the Chairman of the Credentials Committee, or the President of the
Medical Staff, may terminate an applicants temporary privileges granted under this section if
the applicant fails to comply with any of the conditions, restrictions or limitations imposed on
the granting of temporary privileges, or if the applicant violates any rule, regulation, or policy
of the Medical Staff or of the Hospital.
f.
Special requirements of supervision and reporting may be imposed by the department

chairperson concerned on any individual granted temporary clinical privileges. Temporary
privileges shall be immediately terminated by the Chief Executive Officer, or a designee,
upon notice of any failure by the individual to comply with such special requirements.
Section 5. Termination of Temporary Admitting and Clinical Privileges

a.
The Chief Executive Officer, or his designee, may at any time after consulting with the
Chairman of the Department responsible for the individuals supervision, and the Chairman of
Credentials Committee or the President of the Medical Staff, terminate temporary admitting
20
privileges. Clinical privileges shall then be terminated when the individuals inpatients are
discharged from the Hospital or transferred to care of another attending physician. However,
where it is determined that the care or safety of such patients would be endangered by
continued treatment by the individual granted temporary privileges, a termination of
temporary clinical privileges may be imposed by the Chief Executive Officer, or his designee,
the applicable Department Chairman and the Chairman of the Credentials Committee, or the
President of the Medical Staff and such termination shall be immediately effective.
b.
The appropriate Department Chairman or the President of the Medical Staff shall assign to the
Medical Staff appointee responsibility for the care of such terminated individuals patients
until they are discharged from the Hospital, giving consideration wherever possible to the
wishes of the patient in the selection of the substitute.
c.
The granting of any temporary admitting and clinical privileges is a courtesy on the part of the
Hospital and any or all may be terminated if a clinical performance question, or question
about demeanor has been raised. Neither the granting, denial or termination of such privileges
shall entitle the individual concerned to any of the procedural rights provided in this policy.
ARTICLE III.
ACTIONS AFFECTING MEDICAL STAFF APPOINTEES
ARTICLE III., Part A, PROCEDURE FOR REAPPOINTMENT
All terms, conditions and procedures relating to initial appointment shall apply to continued appointment
and clinical privileges and to reappointment.
Section 1. Application
a.
Each current appointee who is eligible to be reappointed to the Medical Staff shall be
responsible for completing the reappointment application form upon request.
The
reappointment application form shall be forwarded by the Director of the Medical Staff at
least four (4) months prior to the expiration of the appointee's current appointment period.
Failure to return an application by forty-five (45) days prior to the expiration of the current
term will result in automatic expiration of the appointee's appointment and clinical privileges
at the end of the current appointment period.
b.
Reappointment, if granted by the Board, shall be for a period of not more than two (2) years.
Section 2. Factors To Be Considered

a.
Each recommendation concerning reappointment of an individual currently appointed to the

Medical Staff shall be based upon such appointee's:
1.
patient contacts at the hospital during the previous appointment term;
2.
ethical behavior, clinical competence and clinical judgment in the treatment of

patients;
3.
participation in staff duties;

21
4.
compliance with the bylaws, policies and rules and regulations of the Medical Staff
and the hospital;
5.
behavior at the hospital, including cooperation with Medical Staff and hospital
personnel as it relates to patient care, the orderly operation of the hospital, and general
attitude toward patients, the hospital and its personnel;
6.
use of the hospital's facilities for patients, taking into consideration the individual's
comparative utilization patterns;
7.
current physical, mental and emotional health status;
8.
capacity to satisfactorily treat patients as indicated by the results of the quality

assessment activities or other reasonable indicators of continuing qualifications;
9.
satisfactory completion of such continuing education requirements as may be imposed

by law, this hospital or applicable accreditation agencies;
current professional liability insurance status as required by the governing body and
pending malpractice challenges, including claims, lawsuits, judgments and settlements;
10.
11.
current licensures, including currently pending challenges to any license or

registration;
12.
voluntary or involuntary termination of Medical Staff appointment or voluntary or

involuntary limitation, reduction, or loss of clinical privileges at another hospital;
13.
relevant findings from the quality assessment activities; and
14.
other reasonable indicators of continuing qualifications.
Section 3. Department Chief Procedure

a.
Prior to the end of the current appointment period, the Director of the Medical Staff shall send
to the chairperson of each department a current list of all applicants for reappointment who
have clinical privileges in that department, together with a description of the clinical
privileges each holds, accompanied by copies of their applications.
b.
After receipt of the applications, the Department chair shall provide the Credentials
Committee with a written report concerning each individual seeking reappointment. The
chairperson shall include in each written report, the reasons for any changes recommended in
staff category, in clinical privileges, or for non-reappointment. The chairperson of the
department concerned shall be available to the Credentials Committee to answer any questions
that may be raised with respect to any such report.

a.
The Credentials Committee, after receiving the reports from each Department chair, shall
review all pertinent information, including all information provided from other committees of
the Medical Staff and from hospital management, for the purpose of determining its
recommendations for staff reappointment, for change in staff category, and for the granting of
22
clinical privileges for the ensuing appointment period.

b.
c.
As part of the process of making its recommendation, the Credentials Committee may require
that an individual currently seeking reappointment undergo a physical and/or mental
examination by a physician or physicians satisfactory to the Credentials Committee either as
part of the reapplication process or at any time during the appointment period to aid it in
determining whether clinical privileges should be granted or continued. The reason for this
request shall be stated to the appointee/reappointee. The results of such examination shall be
available for the Credentials Committee's consideration and shall be made known to the
physician in question. Failure of an individual seeking reappointment to undergo such an
examination within a reasonable time after being requested to do so in writing by the
Credentials Committee shall constitute a voluntary relinquishment of all clinical privileges
until such time as the Credentials Committee has received the examination results and has had
a reasonable opportunity to evaluate them and make a recommendation thereon. At the point
of voluntary relinquishment on the part of the physician in question, the Department chair of
the physician shall secure alternative coverage for any inpatients who are under the care of the
physician.
The Credentials Committee shall have the right to require the appointee to meet with the
committee to discuss any aspect of the individual's reappointment application, qualifications,
or clinical privileges requested.
d.
The Credentials Committee may use the expertise of the Department chair, or any member of
the department, or an outside consultant(s) if additional information is required regarding the
appointee's qualifications for reappointment.
e.
If, after considering the report of the clinical Department chair concerned, the Credentials
Committee's recommendation is favorable, it shall recommend reappointment and the specific
clinical privileges to be granted, which may be qualified in writing by any probationary or
other conditions or restrictions, as appropriate.
Section 5. Credentials Committee Recommendation

a.
If the Credentials Committee's recommendation is to reappoint the individual and to grant the
requested clinical privileges, it shall send its recommendation and written findings in support
thereof to the Executive Committee, and to the Board, through the Chief Executive Officer.
All recommendations to reappoint shall also specifically recommend the clinical privileges to
be granted, which may be qualified by any probationary or other conditions or restrictions
relating to such clinical privileges.
b.
The Executive Committee shall make any comment on the recommendation it deems
appropriate. If the Executive Committee disagrees with the Credentials Committee
recommendation, it shall specify the reasons for that disagreement and refer the matter back to
the Credentials Committee for additional research or information.
c.
Upon receipt of a favorable recommendation from the Credentials Committee that the
individual be granted reappointment and the requested clinical privileges, the Board (or its
designated committee) may:
1.
reappoint the individual and grant clinical privileges as recommended; or
2.
refer the matter back to the Credentials Committee or to another source inside or
outside the hospital for additional research or information; or reject the
23
recommendation. If the Board determines to reject the favorable recommendation of

the Credentials Committee, it should first discuss the matter with the Chairperson of
the Credentials Committee. If the Board's determination remains unfavorable to the
applicant, that determination and the reasons in support thereof, shall be sent by the
Chief Executive Officer, who shall promptly notify the applicant in writing, certified
mail, return receipt requested. The Board shall make no final decision until the
applicant has exercised or waived the right to a hearing and appeal as outlined in this
policy.
Section 6. Unfavorable Credentials Committee Recommendation
If the Credentials Committee's recommendation is unfavorable and would entitle the applicant to
request a hearing pursuant to this policy, it shall be forwarded to the Executive Committee and to the
Chief Executive Officer who shall promptly notify the applicant in writing, certified mail, return
receipt requested. The application shall not be forwarded to the Board, nor shall the Executive
Committee submit its comments to the Board until the applicant has exercised or waived the right to
a hearing as provided in this policy.
Section 7. Meeting with Affected Individual
If, during the processing of an individual's reappointment, it becomes apparent to the Credentials
Committee or its Chairperson that the committee is considering a recommendation that would deny
reappointment, deny a requested change in staff category or clinical privileges, or reduce clinical
privileges, the Chairperson of the Credentials Committee may notify the individual of the general
tenor of the possible recommendation and ask if the individual desires to meet with the committee
prior to any final recommendation by the committee. At such meeting, the affected individual shall
be informed of the general nature of the evidence supporting the action contemplated, and shall be
invited to discuss, explain or refute it. This interview shall not constitute a hearing and none of the
procedural rules provided in this policy with respect to hearings shall apply. Minutes of the
discussion in the meeting shall not be kept. However, the committee shall indicate as part of its
report to the Executive Committee and the Board whether such a meeting occurred, and shall include
a summary of the meeting.
ARTICLE III., Part B PROCEDURES FOR REQUESTING EXPANSION IN CLINICAL
PRIVILEGES
Section 1. Application for Additional Clinical Privileges
Whenever, during the term of appointment, additional clinical privileges are desired, the appointee
requesting increased privileges shall apply in writing to the Director of the Medical Staff on a form
approved by the Board. The application shall state in detail the specific additional clinical privileges
desired and the appointee's relevant recent training and experience which justify the additional
privileges. This application shall be transmitted by the Director of the Medical Staff to the
appropriate Department chair. Thereafter, it shall be processed in the same manner as any
application for initial clinical privileges.
Section 2. Factors To Be Considered
a.
Recommendations for additional clinical privileges shall be based upon:
24
1.
relevant recent training;
2.
applicant's ability to meet the qualifications and criteria for the clinical privileges
requested; and
3.
results of quality assessment activities of the appointment.
b.
The recommendation for such increased privileges may carry with it such requirements for
supervision or consultation or other conditions, for such periods of time as are thought
necessary.
c.
Whenever the criteria for the expansion of privileges requires the applicant to perform
procedures under the supervision of a proctor, or to observe a proctor performing certain
procedures, the expert proctor must not be subject to any rule or order of a hospital or its
medical staff that adversely affects the clinical privileges of the proctor. A physician will be
disqualified from serving as a proctor if the physician has at any time been the subject of
disciplinary action imposed by any federal agency that adversely impacted the physicians
right to participate in any federally funded program, or by the North Carolina Medical Board
(or the comparable board of any other state) that adversely impacted the physician's license to
practice medicine in the State of North Carolina or in any other state.
ARTICLE III., Part C, PROCEDURE FOR OTHER QUESTIONS INVOLVING MEDICAL

STAFF APPOINTEES
Section 1. Initial Procedure
a.
Whenever a concern or question has been raised regarding:

1.
the clinical competence or clinical practice of any Medical Staff appointee;
2.
the care or treatment of a patient or patients or management of a case by any Medical

Staff appointee;
3.
the known or suspected violation by any Medical Staff appointee of applicable ethical
standards or the bylaws, policies, rules or regulations of the hospital or the Medical
Staff, including, but not limited to the hospital's quality assessment, risk management,
and utilization review programs; and/or
4.
behavior or conduct on the part of any Medical Staff appointee that is considered lower
than the standards of the hospital or disruptive to the orderly operation of the hospital
or its Medical Staff, including the inability of the appointee to work harmoniously with
others; the President of the Medical Staff, Department chair, Chairperson of the
Credentials Committee or Chief Executive Officer shall make sufficient inquiry to
satisfy themselves that the concern or question raised is credible, after which it shall be
submitted in writing to the Credentials Committee. If any of the inquiring individuals
set forth in this provision believe it to be in the best interest of the hospital and the
appointee concerned, they may, but are not required to, discuss the matter with the
affected appointee.
Section 2. Initiation of Investigation

25
a.
When a concern or question involving clinical competence or behavior/conduct has been

referred to the Credentials Committee, that committee shall determine either to discuss the
matter with the physician concerned, or to begin an investigation. An investigation shall
begin only after a formal resolution of the Credentials Committee to that effect. The
Credentials Committee may also, by formal resolution, initiate an investigation on its own
motion. If the Board wishes to begin such an investigation, it shall also formally resolve to do
so, but may delegate the actual investigation.
b.
The Chairperson of the Credentials Committee shall promptly notify the Executive Committee
in writing of all such requests and investigations, and shall keep the Chief Executive Officer
and Executive Committee fully informed of all action taken in connection therewith.
Section 3. Investigative Procedure

Upon resolving to initiate an investigation, the Credentials Committee shall meet as soon as
possible:
a.
If the concern contains sufficient information to warrant a recommendation, the Credentials

Committee, at its discretion, may make such a recommendation, with or without a personal
interview with the individual being investigated.
b.
If the concern does not contain sufficient information to warrant a recommendation, the
Credentials Committee shall immediately investigate the matter, or appoint an ad hoc
investigating committee consisting of up to three (3) persons, who may or may not hold
appointments to the Medical Staff. This ad hoc investigating committee shall not include
partners, associates or relatives of the individual being investigated.
c.
The Credentials Committee, its subcommittee or the ad hoc investigating committee, shall
have available to it full resources of the Medical Staff and the hospital, as well as the authority
to use outside consultants, if needed. The committee may also require a physical and mental
examination (reasons for which shall be made known to the physician in question) of the
individual being investigated by a physician or physicians satisfactory to the committee, and
shall require that the results of such examination be made available for the committee's
consideration and to the physician in question.
d.
The individual being investigated shall have an opportunity to meet with the investigating
committee before it makes its report. At this meeting (but not, as a matter of right, in advance
of it) the individual shall be informed of the general nature of the evidence supporting the
question being investigated and shall be invited to discuss, explain or refute it. This interview
shall not constitute a hearing, and none of the procedural rules provided in this policy with
respect to hearings shall apply. A summary of such interview shall be made by the
investigating committee and included with its report to the Credentials Committee.
e.
If a subcommittee or ad hoc investigating committee is used, the Credentials Committee may

accept, modify or reject the recommendation it receives from that committee.
Section 4. Suspension of Privileges

a.
At any time during the investigation, the Credentials Committee, with the approval of the
Chief Executive Officer, may suspend all or any part of the clinical privileges of the
individual being investigated. This suspension shall be deemed to be administrative in nature,
26
for the protection of the patients. The suspension shall remain in effect, without hearing or
appeal, during the investigation only, shall not indicate the validity of the charges, and shall
remain in force, without appeal, during the course of the investigation. If such a suspension is
placed into effect, the investigation shall be completed within fourteen (14) days of the
suspension or reasons for the delay shall be transmitted to the Board so that it may consider
whether the suspension should be lifted.
b.
In the event of suspension of privileges, the appropriate Department chair, or if unavailable,

the President of the Medical Staff, shall immediately assign to another staff appointee with
appropriate clinical privileges responsibility for the care of the patients of the suspended
appointee until the suspension has been lifted or such patients are discharged or are transferred
from the hospital. Wherever possible, the wishes of the patient in the selection of the assigned
appointee shall be given consideration.
Section 5. Procedure Thereafter

a.
In acting after the investigation, the Credentials Committee may:

1.
determine that no action is justified;
2.
issue a written warning;
3.
issue a letter of reprimand;
4.
impose terms of probation;
5.
impose a requirement for consultation;
6.
recommend reduction of clinical privileges;
7.
recommend suspension of clinical privileges for a term;
8.
recommend revocation of staff appointment; or
9.
make such other recommendations as it deems necessary or appropriate.
b.
Any recommendation by the Credentials Committee that would entitle the individual being
investigated to the procedural rights provided in this policy shall be forwarded to the Chief
Executive Officer, who shall promptly notify the affected individual by certified mail, return
receipt requested. The Chief Executive Officer shall then hold the recommendation until after
the individual has exercised or has waived the right to a hearing.
c.
The Credentials Committee shall forward its recommendation to the Board, and the
Chairperson of the Credentials Committee shall be available to the Board to answer any
questions that may be raised with respect to the recommendation.
d.
If the action of the Credentials Committee does not entitle the individual to a hearing, the
action shall take effect immediately without action of the Board and without the right of
appeal to the Board. A report of the action taken and reasons therefore shall be made to the
Executive Committee and to the Board through the Chief Executive Officer, and the action
shall stand unless modified by the Board.
27
e.
In the event the Board determines to consider modification of the action of the Credentials
Committee and such modification would entitle the individual to a hearing in accordance with
this policy, it shall so notify the affected individual, through the Chief Executive Officer, and
shall take no final action thereon until the individual has had an opportunity to exercise the
right to a hearing and appeal as provided in this policy.
ARTICLE III., Part D, SUMMARY SUSPENSION OF CLINICAL PRIVILEGES

Section 1. Grounds for Summary Suspension
a.
The President of the Medical Staff, the chairperson of a clinical department, the Chief
Executive Officer, or the Chairperson of the Board or their appropriate designees shall each
have the authority to summarily suspend all or any portion of the clinical privileges of a
Medical Staff appointee or other licensed individual whenever failure to take such action may
result in an imminent danger to the health and/or safety of any individual or to the orderly
operations of the hospital. Such suspension shall not imply any final finding of responsibility
for the situation that caused the suspension.
b.
Such summary suspension shall become effective immediately upon imposition, shall
immediately be reported in writing to the Chief Executive Officer, the President of the
Medical Staff, the Chairperson of the Credentials Committee, and chairperson of the
respective clinical department, and shall remain in effect unless or until modified by the Chief
Executive Officer or the Board. Notification to the physician involved shall be by certified
mail, return receipt requested.

a.
Any individual who exercises authority under Section I of this Part to summarily suspend
clinical privileges shall immediately report this action to the Chairperson of the Credentials
Committee to take further action in the matter.
b.
A review of the matter resulting in summary suspension shall be completed within fourteen
(14) days of the suspension or reasons for the delay shall be transmitted to the Board so that
the Board may consider whether the suspension should be lifted. In the event the suspension
is lifted, the Credentials Committee shall take such further action as is required in the manner
specified under Part C of this Article.
Section 3. Care of Suspended Individual's Patients

a.
Immediately upon the imposition of a summary suspension, the appropriate Department chair
or, if unavailable, the President of the Medical Staff, shall assign to another individual with
appropriate clinical privileges responsibility for care of the suspended individual's patients
still in the hospital. The assignment shall be effective until such time as the patients are
discharged or transferred to another facility. The wishes of the patient shall be considered in
the selection of the assigned appointee.
b.
It shall be the duty of all Medical Staff appointees to cooperate with the President of the
Medical Staff, the Department chair concerned, the Credentials Committee and the Chief
Executive Officer in enforcing all suspensions.
28
ARTICLE III., Part E, OTHER ACTIONS

Section 1. Failure to Complete Medical Records
The elective and emergency admitting clinical privileges of any individual shall be deemed to be
voluntarily relinquished for failure to complete medical records in accordance with applicable
regulations governing the same, after notification by the Medical Records Department of such
delinquency. Such relinquishment shall continue until all the records of the individual's patients are
no longer delinquent. Failure to complete the medical records that caused relinquishment of clinical
privileges for a period of more than sixty (60) days from the relinquishment of such privileges shall
constitute a voluntary relinquishment of all clinical privileges and resignation from the Medical
Staff.
Section 2. Action by State Licensing Agency
Action by the appropriate State licensing board or agency revoking or suspending an individual's
professional license, or loss or lapse of State license to practice for any reason, shall result in
voluntary relinquishment of all hospital clinical privileges as of that date, until the matter is
resolved, and an application for reinstatement of privileges has been approved by the Credentials
Committee and the Board. In the event the individual's license is only partially restricted, the
clinical privileges that would be affected by the license restriction shall be similarly restricted.
Section 3. Failure to be Adequately Insured
If, at any time, an appointee's professional liability insurance coverage lapses, falls below the
required minimum as required by the governing body, is terminated or otherwise ceases to be in
effect (in whole or in part), the appointee's clinical privileges that would be affected shall be
voluntarily relinquished as applicable as of that date, until the matter is resolved and necessary
professional liability insurance coverage is restored.
Section 4. Failure to Satisfy Continuing Education Requirements
a.
Failure to complete mandated continuing education requirements shall constitute a voluntary

relinquishment of Medical Staff appointment and shall be sufficient grounds for refusing to
consider the individual for reappointment. Such failures shall be documented and specifically
considered by the Credentials Committee when making recommendations for reappointment
and by the Board when making its final decisions.
b.
Any appointee who is ineligible for reappointment for failure to satisfy continuing education
requirements shall be entitled to meet with a committee to be designated by the Board before
final action is taken. This meeting with the Board committee shall not be conducted under the
procedural rules provided in this policy.
c.
If reappointment is refused by the Board, the individual shall be eligible to reapply for staff
appointment, and the application shall be processed in the same manner as if it were an initial
application.
Section 5. Failure to Provide Requested Information

If, at any time, an appointee fails to provide required information pursuant to a formal request by the
Credentials Committee or the Chief Executive Officer, the appointee's clinical privileges shall be
29
deemed to be voluntarily relinquished until the required information is provided to the satisfaction of
the requesting party. For purposes of this section "required information" shall refer to (1) physical
or mental examinations as specified elsewhere in this policy, or (2) information necessary to explain
an investigation, professional review action, or resignation from another facility or agency, (3) any
change in eligibility for participation in Medicare or Medicaid programs, or (4) any change in ability
to safely and competently exercise clinical privileges because of health status issues including
impairment.
Section 6. Procedure for Leave of Absence
a.
Individuals appointed to the Medical Staff may, for good cause, be granted leaves of absence
by the Board for a definitely stated period of time not to exceed one (1) year. Absence for
longer than one (1) year shall be considered by the Board on a case by case basis.
b.
Requests for leaves of absence shall be made to the appropriate Department Chair with a copy
to the Chief Executive Officer, and shall state the beginning and ending dates of the requested
leave. The Department chair shall transmit the request together with a recommendation to the
Chair of the Credentials committee. The Credentials Committee shall forward its
recommendation regarding the request to the Medical Executive Committee, and the
recommendation of the Medical Executive Committee shall be forwarded to the Quality
Review Committee of the Board, and ultimately to the Board for final action.
c.
A leave of absence shall be effective as of the date requested by the individual, unless a
different effective date is assigned by the Chair of the Department. As of the effective date of
a leave of absence, the individual shall not exercise the individuals clinical privileges in the
hospital until such time as the individuals request for reinstatement is approved by the Board.
d.
At the conclusion of a leave of absence, the individual may request to be reinstated. The
individual shall file a written statement with the Chair of the Credentials Committee
summarizing the professional activities completed during the leave of absence, and any other
information requested by the Chair of the Credentials Committee. If the leave of absence was
for medical reasons, the individual must submit a report from the individuals attending
physician indicating that the individual is physically and/or mentally capable of resuming a
hospital practice and exercising the clinical privileges requested. The appointee shall also
provide such other information as may be requested by the Credentials Committee at that
time. After considering all relevant information, the Credentials Committee shall then make a
recommendation to the Medical Executive Committee which shall, in turn, forward its
recommendation to the Quality Review Committee of the Board and to the Board for final
action.
e.
In acting upon the request for reinstatement, the Board may approve reinstatement either to
the same or a different staff category, and may limit or modify the clinical privileges to be
extended to the individual upon reinstatement, consistent with the recommendations of the
Credentials Committee.
ARTICLE III., Part F, INFORMAL PROCEEDINGS

Nothing in this policy or the Medical Staff Bylaws shall preclude collegial or informal efforts to address
questions or concerns relating to an individual's practice and conduct at the hospital, and this policy
specifically encourages voluntary structuring of clinical privileges to achieve a clinical practice mutually
acceptable to the individual, the Credentials Committee, the Executive Committee, and the Board.
30
ARTICLE III., Part G, CONFIDENTIALITY AND REPORTING

a.
Actions taken and recommendations made pursuant to this policy shall be treated as
confidential in accordance with applicable legal requirements and such policies regarding
confidentiality as may be adopted by the Board. In addition, reports of actions taken pursuant
to this policy shall be made by the Chief Executive Officer to such governmental agencies as
may be required by law.
b.
All records and other information generated in connection with and/or as a result of
professional review activities shall be confidential, and each individual or committee member
participating in such review activities shall agree to make no disclosures of any such
information except as authorized, in writing, by the Chief Executive Officer or by legal
counsel to the hospital. Any breach of confidentiality by an individual or committee member
may result in a professional review action, and/or may result in appropriate legal action to
ensure that confidentiality is preserved, including application to a court of law for injunctive
or other relief.
ARTICLE III., Part H, PEER REVIEW PROTECTION

All minutes, reports, recommendations, communications, and actions made or taken pursuant to this
policy are deemed to be covered by the provisions of N.C. Gen. Stat. Section 131E-95 (1973, amended
1987), or the corresponding provisions of any subsequent Federal or State statute providing protection to
peer review or related activities. Furthermore, the committees and/or panels charged with making
reports, findings, recommendations or investigations pursuant to this policy shall be considered to be
acting on behalf of the Hospital and its Board when engaged in such professional review activities and
thus shall be deemed to be "professional review bodies" as that term is defined in the Health Care Quality
Improvement Act of 1986 and Article I of this policy.
31
ARTICLE IV.
HEARING AND APPEAL PROCEDURES
ARTICLE IV., Part A, INITIATION OF HEARING

Section 1. Grounds for Hearing
a.
An applicant or an individual holding a Medical Staff appointment shall be entitled to request

a hearing whenever an unfavorable recommendation has been made by the Credentials
Committee or the Professional Affairs Committee of the Board regarding the following:
1.
denial of initial Medical Staff appointment;
2.
denial of Medical Staff reappointment;
3.
revocation of Medical Staff appointment;
4.
denial of requested initial clinical privileges;
5.
denial of requested additional clinical privileges;
6.
decrease of clinical privileges;
7.
suspension of clinical privileges (other than summary suspension or suspension while

under an investigation); or
8.
imposition of mandatory concurring consultation requirement.
b.
No other recommendations except those enumerated in (a) of this section shall entitle the
individual to request a hearing.
c.
The affected individual shall also be entitled to request a hearing before the Board enters a
final decision, in the event the Board should determine, without a similar recommendation
from the Credentials Committee, to take any action set forth above.
d.
The hearing shall be conducted in as informal a manner as possible, subject to the rules and
procedures set forth in this policy.
e.
Neither voluntary relinquishment of clinical privileges, as provided in this policy, nor the
imposition of any general consultation requirement, nor the imposition of a requirement for
retraining, additional training or continuing education, shall constitute grounds for a hearing,
but shall take effect without hearing or appeal.
ARTICLE IV., Part B, THE HEARING

Section 1. Notice of Recommendation
When a recommendation is made which, according to this policy, entitles an individual to a hearing
prior to a final decision of the Board, the affected individual shall promptly be given notice by the
32
Chief Executive Officer, in writing, certified mail, return receipt requested.

contain:
a.
a statement of the recommendation made and the general reasons for it;
This notice shall
b.
notice that the individual has the right to request a hearing on the recommendation within
thirty (30) days of receipt of this notice; and
c.
a copy of this Article outlining the rights in the hearing as provided for in this policy.
Section 2. Request for Hearing

An individual shall have thirty (30) days following the date of the receipt of such notice within
which to request the hearing. The request shall be in writing to the Chief Executive Officer. In the
event the individual does not request a hearing within the time and in the manner required by this
policy, the individual shall be deemed to have waived the right to the hearing and to have accepted
the action involved. That action shall become effective immediately upon final Board action.
Section 3. Notice of Hearing and Statement of Reasons
a.
b.
The Chief Executive Officer shall schedule the hearing and shall give written notice, certified
mail, return receipt requested, to the person who requested the hearing. The notice shall
include:
1.
the time, place and date of the hearing;
2.
a proposed list of witnesses, as known at that time, but which may be modified, who
will give testimony or present evidence at the hearing in support of the Credentials
Committee or the Board;
3.
the names of the Hearing Panel members and Presiding Officer (Hearing Officer), if
known;
4.
a statement of the specific reasons for the recommendation as well as the list of patient
records and information supporting the recommendation. This statement, and the list
of supporting patient record numbers and other supporting information, may be revised
or amended at any time, even during the hearing, so long as the additional material is
relevant to the continued appointment or clinical privileges of the individual requesting
the hearing. The individual and counsel shall have sufficient time, up to thirty (30)
days, to study this additional information and rebut it.
The hearing shall begin as soon as practicable, but no sooner than thirty (30) days after the
notice of the hearing unless an earlier hearing date has been specifically agreed to in writing
by the parties.
Section 4. Witness List

a.
The individual requesting the hearing shall provide a written list of the names and addresses
of the individuals expected to offer testimony or evidence on the affected individual's behalf
within ten (10) days after receiving notice of the hearing.
b.
The witness list of the hospital in support of the recommendation of the Credentials
33
Committee (or the Board), shall include a brief summary of the nature of the anticipated
testimony. The witness list of either party may, in the discretion of the Presiding Officer or
Hearing Panel Chairperson, be supplemented or amended at any time during the course of the
hearing, provided that notice of the change is given to the other party. The Presiding Officer
shall have the authority to limit the number of witnesses, especially character witnesses or
witnesses whose testimony is merely cumulative, as set forth in Section 5 of this Part.
Section 5. Hearing Panel, Presiding Officer and Hearing Officer
a.
b.
Hearing Panel
1.
When a hearing is requested, the Chief Executive Officer, acting for the Board and
after considering the recommendations of the President of the Medical Staff (and that
of the Chairperson of the Board, if the hearing is occasioned by a Board determination)
shall appoint a Hearing Panel which shall be composed of not less than three (3)
members. The Hearing Panel shall be composed of Medical Staff appointees who shall
not have actively participated in the consideration of the matter involved at any
previous level or of physicians or laypersons not connected with the hospital or any
combination of such persons.
2.
The Hearing Panel shall not include any individual who is in direct economic
competition with the affected person or any such individual who is professionally
associated with or related to the affected individual. Such appointment shall include
designation of the Chairperson or the Presiding Officer. Knowledge of the matter
involved shall not preclude any individual from serving as a member of the Hearing
Panel.
Presiding Officer
1.
In lieu of a Hearing Panel Chairperson, the Chief Executive Officer may appoint an
attorney at law as Presiding Officer. Such Presiding Officer must not act as a
prosecuting officer, or as an advocate for either side at the hearing. The Presiding
Officer may participate in the private deliberations of the Hearing Panel and be a legal
advisor to it, but shall not be entitled to vote on its recommendations.
2.
If no Presiding Officer has been appointed, a Chairperson of the Hearing Panel shall be
appointed by the Chief Executive Officer, shall serve as the Presiding Officer, and
shall be entitled to one (1) vote.
3.
The Presiding Officer (or Hearing Panel Chairperson) shall:

i.
act to insure that all participants in the hearing have a reasonable opportunity to
be heard and to present oral and documentary evidence subject to reasonable
limits on the number of witnesses and duration of direct and cross examination,
applicable to both sides, as may be necessary to avoid cumulative or irrelevant
testimony or to prevent abuse of the hearing process;
ii.
prohibit conduct or presentation of evidence that is cumulative, excessive,

irrelevant, abusive or that causes undue delay;
maintain decorum throughout the hearing;
iii.
34
4.
c.
iv.
determine the order of procedure throughout the hearing;
v.
have the authority and discretion, in accordance with this policy, to make rulings
on all questions which pertain to matters of procedure and to the admissibility of
evidence;
vi.
act in such a way that all information relevant to the continued appointment or
clinical privileges of the individual requesting the hearing is considered by the
Hearing Panel in formulating its recommendations; and
vii.
conduct argument by counsel on procedural points outside the presence of the

Hearing Panel unless the panel wishes to be present.
The Presiding Officer may be advised by legal counsel to the hospital.
Hearing Officer
1.
As an alternative to the Hearing Panel described in paragraph (a) of this Section, the
Chief Executive Officer, after consulting with the President of the Medical Staff (and
Chairperson of the Board if the hearing was occasioned by a Board determination) may
instead appoint a Hearing Officer to perform the functions that would otherwise be
carried out by the Hearing Panel. The Hearing Officer shall preferably be an attorney
at law.
2.
The Hearing Officer may not be in direct economic competition with the individual
requesting the hearing, and shall not act as a prosecuting officer or as an advocate to
either side at the hearing. In the event a Hearing Officer is appointed instead of a
Hearing Panel, all references in this Article to the "Hearing Panel" or "Presiding
Officer" shall be deemed to refer instead to the Hearing Officer, unless the context
would clearly otherwise require.
ARTICLE IV., Part C, HEARING PROCEDURE

Section 1. Discovery
a.
b.
There is no right to discovery in connection with the hearing. However, the individual
requesting the hearing shall be entitled, upon specific request, to the following, subject to a
stipulation signed by both parties that such documents shall be maintained as confidential and
shall not be disclosed or used for any purpose outside the hearing:
1.
copies of, or reasonable access to, all patient medical records referred to in the
Statement of Reasons, at the individual's expense;
2.
reports of experts relied upon by the Credentials Committee or the Board;
3.
redacted copies of relevant committee or department minutes (such provision does not
constitute a waiver of the state peer review protection statute); and
4.
copies of any other documents relied upon by the Credentials Committee or the Board.
Prior to the hearing, on dates set by the Presiding Officer or agreed upon by counsel for both
35
sides, each party shall provide the other party with a list of proposed exhibits. All objections
to documents or witnesses to the extent then reasonably known, shall be submitted in writing
in advance of the hearing. The Presiding Officer shall not entertain subsequent objections
unless the party offering the objection demonstrates good cause.
c.
Neither the affected individual, nor his or her attorney, nor any other person on behalf of the
affected individual, shall contact hospital employees appearing on the hospital's witness list
concerning the subject matter of the hearing, unless specifically agreed upon by counsel.
Section 2. Pre-Hearing Conference

The Presiding Officer may require counsel for the individual and for the hospital's Credentials
Committee (or the Board) to participate in a pre-hearing conference for purposes of resolving all
procedural questions in advance of the hearing. The Presiding Officer may specifically require that:
1.
all documentary evidence to be submitted by the parties be presented at this conference; any
objections to the documents shall be made at that time and the Presiding Officer shall resolve
such objections;
2.
evidence unrelated to the reasons for the unfavorable recommendation or unrelated to the
individual's qualifications for appointment or the relevant clinical privileges be excluded;
3.
the names of all witnesses and a brief statement of their anticipated testimony be submitted;
4.
the time granted to each witness' testimony and cross-examination be agreed upon, or
determined by the Presiding Officer, in advance; and
5.
witnesses and documentation not provided and agreed upon in advance of the hearing may be
excluded from the hearing.
Section 3. Failure to Appear

Failure, without good cause, of the individual requesting the hearing to appear and proceed at such a
hearing shall be deemed to constitute voluntary acceptance of the pending recommendations or
actions pending, which shall then be forwarded to the Board for final action.
Section 4. Record of Hearing
The Hearing Panel shall maintain a record of the hearing by a stenographic reporter present to make
a record of the hearing or a recording of the proceedings. The cost of such reporter shall be borne by
the hospital, but copies of the transcript shall be provided to the individual requesting the hearing at
that individual's expense. Oral evidence shall be taken only on oath or affirmation administered by
any person designated by such body and entitled to notarize documents in the State of North
Carolina.
Section 5. Rights of Both Sides

a.
At a hearing both sides shall have the following rights, subject to reasonable limits determined
by the Presiding Officer or Hearing Panel Chairperson:
36
b.
1.
to call and examine witnesses to the extent available;
2.
to introduce exhibits;
3.
to cross-examine any witness on any matter relevant to the issues and to rebut any
evidence;
4.
representation by counsel who may call, examine, and cross-examine witnesses and
present the case. Both sides shall notify the other of the name of that counsel at least
ten (10) days prior to the date of the hearing; and
5.
to submit a written statement at the close of the hearing.
Any individual requesting a hearing who does not testify in his or her own behalf may be
called and examined as if under cross-examination.
Section 6. Admissibility of Evidence

The hearing shall not be conducted according to rules of evidence. Hearsay evidence shall not be
excluded merely because it constitutes hearsay. Any relevant evidence shall be admitted if it is the
sort of evidence on which responsible persons are accustomed to rely in the conduct of serious
affairs, regardless of the admissibility of such evidence in a court of law. Each party shall have the
right to submit a memorandum of points and authorities, and the Hearing Panel may request such a
memorandum to be filed, following the close of the hearing. The Hearing Panel may interrogate the
witnesses, call additional witnesses or request documentary evidence.
Section 7. Official Notice
The Presiding Officer shall have the discretion to take official notice of any matters, either technical
or scientific, relating to the issues under consideration that could have been judicially noticed by the
courts of the State of North Carolina. Participants in the hearing shall be informed of the matters to
be officially noticed and such matters shall be noted in the record of the hearing. Either party shall
have the opportunity to request that a matter be officially noticed or to refute the noticed matter by
evidence or by written or oral presentation of authority. Reasonable additional time shall be granted,
if requested, to present written rebuttal of any evidence admitted on official notice.
Section 8. Postponements and Extensions
Postponements and extensions of time beyond any time limit set forth in this policy may be
requested by anyone but shall be permitted only by the Presiding Officer or the Chief Executive
Officer on a showing of good cause.
ARTICLE IV., Part D, HEARING CONCLUSION, DELIBERATIONS &

RECOMMENDATIONS
Section 1. Order of Presentation
37
The Credentials Committee or the Board, depending on whose recommendation prompted the
hearing initially, shall first present evidence in support of its recommendation. Thereafter, the
burden shall shift to the individual who requested the hearing to present evidence.
Section 2. Basis of Decision
a.
The Hearing Panel shall recommend in favor of the Credentials Committee or the Board
unless it finds that the individual who requested the hearing has proved that the
recommendation that prompted the hearing was arbitrary, capricious, or not supported by
substantial evidence.
b.
The decision of the Hearing Panel shall be based on the evidence produced at the hearing.
This evidence may consist of the following:
1.
oral testimony of witnesses;
2.
memorandum of points and authorities presented in connection with the hearing;
3.
any information regarding the individual who requested the hearing so long as that
information has been admitted into evidence at the hearing and the person who
requested the hearing had the opportunity to comment on and, by other evidence,
refute it;
4.
any and all applications, references, and accompanying documents;
5.
other documented evidence, including medical records; and
6.
any other evidence that has been admitted.
Section 3. Adjournment and Conclusion

The Presiding Officer may, without special notice, adjourn the hearing and reconvene the same at
the convenience and with the agreement of the participants. Upon conclusion of the presentation of
evidence by the parties and/or questions by the Hearing Panel, the hearing shall be closed.
Section 4. Deliberations and Recommendation of the Hearing Panel
Within twenty (20) days after final adjournment of the hearing, the Hearing Panel shall conduct its
deliberations outside the presence of any other person except the Presiding Officer, and shall render
a recommendation, accompanied by a report, which shall contain a concise statement of the reasons
for the recommendation.
Section 5. Disposition of Hearing Panel Report

The Hearing Panel shall deliver its report and recommendation to the Chief Executive Officer who
shall forward it, along with all supporting documentation, to the Board for further action. The Chief
Executive Officer shall also send a copy of the report and recommendation, certified mail, return
receipt requested, to the individual who requested the hearing, and to the Credentials Committee for
information and comment.
38
ARTICLE IV., Part E, APPEAL PROCEDURE

Section 1. Time for Appeal
Within ten (10) days after notice of the Hearing Panel's recommendation, either party may request an
appellate review. The request shall be in writing, and shall be delivered to the Chief Executive
Officer either in person or by certified mail, return receipt requested, and shall include a statement of
the reasons for appeal and the specific facts or circumstances which justify further review. If such
appellate review is not requested within ten (10) days as provided herein, both parties shall be
deemed to have waived appellate review, and the Hearing Panel's report shall be forwarded to the
Board for final action.
Section 2. Grounds for Appeal
The grounds for appeal shall be that:
a.
there was substantial failure to comply with this policy and/or the hospital or Medical Staff
bylaws prior to the hearing so as to deny due process or a fair hearing; or
b.
the recommendations of the Hearing Panel were made arbitrarily, capriciously or with
prejudice;
c.
the recommendations of the Hearing Panel were not supported by substantial evidence; or
d.
there exists new substantive evidence.
Section 3. Time, Place and Notice

Whenever an appeal is requested as set forth in the preceding sections, the Chairperson of the Board
shall, within ten (10) days after receipt of such request, schedule and arrange for an appellate review.
The affected individual shall be given notice of the time, place and date of the appellate review. The
date of appellate review shall be not less than ten (10) days, nor more than thirty (30) days from the
date of receipt of the request for appellate review; provided, however, that when a request for
appellate review is from an appointee who is under a suspension then in effect, the appellate review
shall be held as soon as the arrangements may reasonably be made and not more than fourteen (14)
days from the date of receipt of the request for appellate review. The time for appellate review may
be extended by the Chairperson of the Board for good cause.
Section 4. Nature of Appellate Review
a.
The Chairperson of the Board shall appoint a Review Panel composed of not less than three
(3) persons, either members of the Board or others, including but not limited to reputable
persons outside the hospital, to consider the record upon which the recommendation before it
was made, or the Board may hear the appeal as a whole body.
b.
The Review Panel or the Board as a whole may accept additional oral or written evidence
subject to the same rights of cross-examination or confrontation provided at the Hearing Panel
proceedings. Such additional evidence shall be accepted only if the party seeking to admit it
at the hearing was denied, and then only at the discretion of the Review Panel or the Board as
a whole. The Review Panel or the Board as a whole may accept additional oral or written
39
evidence subject to the same rights of cross-examination or confrontation provided at the

hearing proceedings.
c.
Each party shall have the right to present a written statement in support of its position on
appeal. In its sole discretion, the Review Panel may allow each party or its representative to
appear personally and make oral argument. The Review Panel shall recommend final action
to the Board.
d.
The Board may affirm, modify or reverse the recommendation of the Review Panel or, in its
discretion, refer the matter for further review and recommendation, or make its own decision
based upon the Board's ultimate legal responsibility to grant appointment and clinical
privileges. In the event the Board determines to modify or reverse the recommendation of the
Review Panel and such action would entitle the affected individual to a hearing in accordance
with this policy, it shall so notify the affected individual through the Chief Executive Officer,
and shall take no final action thereon until the individual has exercised or has waived the
procedural rights in this policy.
Section 5. Final Decision of the Board

Within thirty (30) days after the Board hears the appeal, or within thirty (30) days after receipt of the
Review Panel's recommendation, the Board shall render a final decision in writing, including
specific reasons, and shall deliver copies thereof to the affected individual and to the Chairpersons of
the Credentials and the Executive Committees, in person or by certified mail, return receipt
requested.
Section 6. Further Review
Except where the matter is referred for further action and recommendation in accordance with
Section 4 of this Part, the final decision of the Board following the appeal shall be effective
immediately and shall not be subject to further review. If the matter is referred pursuant to Section 4
of this Part for further action and recommendation, such recommendation shall be promptly made to
the Board in accordance with the instructions given by the Board. This further review process and
the report back to the Board shall in no event exceed thirty (30) days, except as the parties may
otherwise stipulate.
Section 7. Right to One Hearing and One Appeal Only
No applicant or Medical Staff appointee shall be entitled to more than one (1) hearing and one (1)
appellate review on any matter which may be the subject of an appeal. If the Board determines to
deny initial Medical Staff appointment or reappointment to an applicant, or to revoke or terminate
the Medical Staff appointment and/or clinical privileges of a current appointee, that individual may
not apply for staff appointment or for those clinical privileges at this hospital for a period of five (5)
years unless the Board provides otherwise.
-
ARTICLE V.
AMENDMENTS
This policy may be amended by a majority vote of the Credentials Committee, with approval of the
40
Medical Executive Committee and the Board of Trustees.

This policy may also be amended by the Board on its own motion provided that any such amendment is
first submitted to the Credentials and the Executive Committees for review and comment at least thirty
(30) days prior to any final action by the Board on such amendment. Instances where such action by the
Board is warranted shall include:
a.
action to comply with changes in federal and state laws that affect this hospital and the
hospital corporation, including any of its entities; and/or
b.
requirements imposed by the hospital's general and professional liability or Director's and
Officer's insurance carrier; and/or
c.
action to comply with state licensure requirements, JCAHO Accreditation Standards, and
Medicare/Medicaid Conditions of Participation for Hospitals.
ARTICLE VI.
ADOPTION
This policy is adopted and made effective upon approval of the Board, superseding and replacing any and
all other Medical Staff bylaws, rules and regulations or hospital policies pertaining to the subject matter
thereof.
END
41

Clinical Privileges

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Clinical Privileges

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New Hanover Regional

POLICY ON APPOINTMENT, REAPPOINTMENT,

Policy on Appointment, Reappointment and Clinical Privileges

APPOINTMENT TO THE MEDICAL STAFF

QUALIFICATIONS FOR APPOINTMENT

APPLICATION FOR INITIAL APPOINTMENT AND

PROCEDURE FOR INITIAL APPOINTMENT

VOLUNTARY RELINQUISHMENT OF PRIVILEGES

PROCEDURE FOR TEMPORARY CLINICAL PRIVILGES

Policy on Appointment, Reappointment and Clinical Privileges

Temporary Clinical Privileges in Emergency Situations

ACTIONS AFFECTING MEDICAL STAFF APPOINTEES

PROCEDURE FOR REAPPOINTMENT

PROCEDURES FOR REQUESTING EXPANSION IN

PROCEDURE FOR OTHER

SUMMARY SUSPENSION OF CLINICAL PRIVILEGES

CONFIDENTIALITY AND REPORTING

PEER REVIEW PROTECTION

HEARING AND APPEAL PROCEDURES

Policy on Appointment, Reappointment and Clinical Privileges

HEARING CONCLUSION, DELIBERATIONS, AND

Policy on Appointment, Reappointment and Clinical Privileges

"Podiatrist" shall be interpreted to mean a doctor of podiatric medicine;

"Professional review action" means an action or recommendation of a professional review body

Policy on Appointment, Reappointment and Clinical Privileges

Policy on Appointment, Reappointment and Clinical Privileges

Article II., Part A Qualifications for Appointment

are currently licensed to practice in the State of North Carolina;

have successfully completed an accredited American Council of Graduate Medical

Dentist applicants requesting surgical privileges must be certified or admissible to

Podiatrist applicants must be certified or admissible to examination for certification by

can document their:

background, experience, training and demonstrated competence,

adherence to the ethics of their profession,

Policy on Appointment, Reappointment and Clinical Privileges

Section 3. No Entitlement to Appointment

is licensed to practice a profession in this or any other state;

is a member of any particular professional organization;

resides and practices within 30 minutes of the hospital.

Section 4. Non-Discrimination Policy

Policy on Appointment, Reappointment and Clinical Privileges

information as to whether the applicant's employment, medical staff appointment or

information as to whether the applicant has currently in force professional liability

Policy on Appointment, Reappointment and Clinical Privileges

information concerning the applicant's professional liability litigation experience,

information as to proceedings or investigations presently taking place at any hospital,

information concerning suspension, sanctioning, exclusion, or otherwise precluded from

information as to whether the applicant has ever been named as a defendant in a

a complete chronological listing of the applicant's professional and educational

information on the citizenship and/or visa status of the applicant;

information on military experience, including branch of service, type of discharge, dates

information on board certification, if scheduled to take the certification exam, or the

Policy on Appointment, Reappointment and Clinical Privileges

the applicant's signature; and

such other information as the Board may require.

Section 2. Basic Responsibilities for Applicants and Appointees

an agreement to accept committee assignments, emergency service call obligations, and

a statement of the applicant's willingness to appear for personal interviews in regard to

Policy on Appointment, Reappointment and Clinical Privileges

a statement that any misrepresentation or misstatement in, or omission from, the

a statement of the applicants willingness to abide by HIPAA regulations and maintain

a statement that it is the applicants responsibility to produce adequate information so

to refrain from delegating responsibility for diagnoses or care of hospitalized patients to

to seek consultation whenever necessary;