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 
privileges requested.
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 
clinical privileges
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    
Control #353.0