Provisional Status Policy
Provisional period
All initial appointments and clinical privileges, as well as any new clinical privileges granted to an existing medical staff appointee, are provisional for a period of six to 12 months, during which time all individuals with provisional privileges may be subject to review of their clinical performance by the chair(s). Department chairs will conduct their reviews in accordance with the proctoring and provisional procedures adopted by the department, credentials committee, and medical executive committee (MEC).
Successful conclusion
Sixty days before the end of a provisional period, the hospital president will notify the practitioner by written notice of the date his or her provisional period may end. This notice will state that to document the successful conclusion of the provisional period, the practitioner must submit to the credentials committee 30 days before the end of his or her provisional
period the following statements from
• the chair of the department in which his or her appointment was made, attesting that by observed performance, the practitioner has demonstrated his or her qualifications for staff appointment and for his or her staff category, stating that he or she has not abused his or her prerogatives and that he or she has discharged his or her appointment obligations and understood.
• the chair of each department in which he or she was granted initial or increased privileges, stating that he or she has satisfactorily demonstrated his or her ability to exercise these privileges
Action required
The credentials committee considers the requests and statement(s) furnished to it and defers action for not more that 30 days or prepares a written report with recommendations and supporting documentation for transmittal to the MEC. Final processing follows the procedures set forth in the Initial Appointment Policy.
Automatic extension
If an initial appointee or a practitioner is unable to obtain the statements required of him or her with respect to a particular clinical privilege because his or her caseload at the hospital was inadequate to demonstrate an ability to exercise that privilege, and if he or she submits to the credentials committee a statement to this effect describing his or her caseload and signed by the chair of the applicable department, the practitioner’s provisional period will automatically be extended for an additional one-year period by approval of the credentials committee. Only one automatic extension is permissible.
Termination by practitioner
If the practitioner no longer wishes the privilege or privileges at issue, then his or her request for their removal or his or her lack of timely response to the letter of notification will initiate the removal of these privileges without creating an adverse action that triggers the fair hearing procedures.
Shortened provisional period
If a practitioner wishes to end his or her provisional period in less than 12 months, he or she may do so by submitting the required documentation to the credentials committee. No provisional period will be for a period shorter than three months except as explicitly stated in these procedures or the medical staff bylaws.
Adverse conclusions—procedural rights
Whenever a provisional period (including any period of extension) expires with an adverse recommendation for the practitioner based on professional conduct or quality of care, or whenever an extension is denied, the hospital president will provide the practitioner with special notice of the adverse result and of his or her entitlement to procedural rights provided in the medical staff bylaws.
Note: For the purposes of this provision, an adverse recommendation from the credentials committee or MEC, or an adverse action by the governing board—as referred to in the appointment process—means a recommendation or action to change, deny, or restrict requested clinical privileges without the staff appointee’s consent.