Medical Staff Bylaws - Arkansas Children's Hospital

ARTICLE 8: CLINICAL PRIVILEGES8.1 Clinical Privileges8.1.1 Every Practitioner practicing at this Hospital by virtue of Medical Staff membership orotherwise, will, in connection with such practice, be entitled to exercise only those clinical privilegesspecifically granted to him/her by the Board of Directors.8.1.2 The Hospital may grant privileges only for clinical care that is supported by Hospitaldepartments and services.8.2 Application for Privileges and Renewal of Clinical Privileges (Refer to Medical Staff PeerReview Program Policy)8.2.1 Applications for appointment and reappointment to the Active Medical Staff and ActiveAffiliated Staff must contain a request for the specific clinical privileges desired by the Applicant. TheApplicant has the burden of providing reasonable evidence to establish his/her qualifications andcompetency to perform the clinical privileges requested.8.2.2 The evaluation of the requests for privileges shall be based upon the Applicant'seducation, training, experience, demonstrated competence, peer recommendations, and other relevantinformation, including an appraisal by the service in which privileges are sought. Peer recommendationswill include written information regarding the Applicant’s medical/clinical knowledge, technical andclinical skills, clinical judgment, interpersonal skills, communication skills, and professionalism.8.2.3 A Focused Professional Practice Evaluation (FPPE) is required for all initially requestedprivileges.A. Criteria and methods for conducting this evaluation are established by the ServiceChief and approved by the Credentials Committee of the Medical Staff.B. Unless otherwise stated in the FPPE Plan, the duration of monitoring will be for adefined period of time, as described within the policy. Any modifications orextensions of the FPPE period will be reported by the Chief of Service (or SectionChief designee) to the Credentials Committee.8.2.4 Reassessment for clinical privileges requires demonstration of clinical competence asshown through Ongoing Professional Practice Evaluation (OPPE), monitoring and evaluation, peerrecommendations, and/or consideration of participation in continuing education activities that relate, inpart, to the privileges sought.A. If the Applicant has little or no activity at ACH identified in OPPE reports duringthe two (2) year appointment period, the Credentials Committee of the MedicalStaff will decide what, if any, evidence beyond peer recommendations is required.20