HospitalInspections.org

Based on document review and staff interview it was determined that the facility failed to delineate the specific privileges of independent practitioners in three of three credential files reviewed.

Findings include:

1. On 2/23/16 Staff #5, #6, and #7's credential files were reviewed in the presence of Staff #1. The requested privileges form completed by each practitioner did not specify which, or all, privileges were granted by the credentialing committee, medical executive committee, and governing body.

a. The signature lines for the chairman and the governing body/CEO were blank.

2. Review of the meeting minutes for the credentialing committee, the medical executive committee, and the governing body each reflected discussion of and approval for Staff #5, #6, and #7 to join the medical staff.

a. Each credential file reviewed contained a 'Credential and Privilege Approval Process Candidate' form that had the approval signatures of the Department Chairman, Credentials Committee Chairman, Medical Executive Committee, CEO/Administrator, and Governing Body.

3. In interview, Staff #1 stated that since the 'Credential and Privilege Approval Process Candidate' form had all required signatures and that the candidates were reviewed at each of the above committees, it was presumed that the practitioners were granted all requested privileges. Staff #1 confirmed the above oversight, discussed with the Chairman of the Credentialing Committee, and agreed that the specific delineation of privileges was necessary.