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Based on document review and interview, the provider's medical staff failed to periodically conduct appraisals of its members. Specifically, files for three of six physicians credentialed to administer moderate sedation reviewed during the morning of 3/5/14 did not contain supporting documentation of mandatory education evidencing compliance with privileging criteria for moderate sedation administration.

Findings:

Physician credential file #12 documented reappointment to the medical staff for the period 4/1/13- 3/31/15. The physician's privilege delineations included moderate sedation privileges. The file did not contain documentation of completion of mandatory education, "Practice Guidelines for Sedation & Analgesia by Non-Anesthesiologist."

Physician credential file # 11 documented reappointment to the medical staff for the period 4/1/13- 3/31/15. The physician's privilege delineations included moderate sedation privileges. The file did not contain documentation of completion of mandatory education, "Practice Guidelines for Sedation & Analgesia by Non-Anesthesiologist."

Physician credential file # 9 documented reappointment to the medical staff for the period 5/1/13- 6/30/15. The physician's privilege delineations included moderate sedation privileges. The file did not contain documentation of completion of mandatory education, "Practice Guidelines for Sedation & Analgesia by Non-Anesthesiologist."

Review of the form, "St. Peter's Hospital Credentialing Privileging Criteria for IV/ Moderate Sedation" notes the following "Reappointment Criteria: 2. Mandatory viewing of the on-line /DVD Practice Guidelines for Sedation & Analgesia by Non-Anesthesiologist. A successful passing grade of 80% on the written exam is required. Please print out the certificate as proof of successfully [sic] completion."

The Manager of Medical Staff Credentials was interviewed on 3/5/14 at 1:30 p.m. and confirmed the findings.