Organizations offering the services of licensed independent
practitioners (LIP) through a telemedical link for either
direct care or interpretive services must meet the following
The individual must be credentialed and privileged as
described in the credentialing and privileging process of
this organization Volume 4 GE.17 which describes primary and
secondary source credentialing as well as the use of the
National Practitioner Data Bank, please see the afore
mentioned policy for a complete description of the
credentialing and privileging process.
The credentialing process includes a mechanism to ensure that
the individual requesting approval is the same individual
identified in the credentialing documents.
An applicant submits a statement that no health problems
exist that could affect his or her ability to perform the
The medical director participates in the evaluation of
practitioners practicing within the organization.
Information regarding each practitioner's scope of privileges
is updated as changes in clinical privileges for each
practitioner are made.
Before granting privileges, designated clinical leaders1
evaluate the following:
Challenges to any licensure or registration
Voluntary and involuntary relinquishment of any license or
Voluntary and involuntary termination of medical staff
Voluntary and involuntary limitation, reduction, or loss of
Any evidence of an unusual pattern or an excessive number of
professional liability actions resulting in a final judgment
against the applicant
A query and evaluation of the NPDB information
Documentation as to the applicant's health status
Performance Measurement Data including morbidity and
mortality data, when available
Peer recommendations are obtained from a practitioner in the
same professional discipline as the applicant with personal
knowledge of the applicant's ability to practice.
Each reappraisal includes information concerning professional
performance, including clinical and technical skills and
information from organization performance improvement
activities, when such data are available.
Recommendations from peers in the same professional
discipline as the applicant are used as part of the basis for
the initial granting of privileges. Peer review is conducted
periodically and recommendations are used to recommend
individuals for the renewal of clinical privileges when
insufficient practitioner-specific data are available.
Approved By Governing Board