Item Description:
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Delegate authority to the HHS Finance and Operations Committee to approve initial and reappointment applications for appointment to the HHS Medical Staff, review provider requests for clinical privilege modifications, and review requests for clinical privilege form modifications
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Resolution:
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BE IT RESOLVED, that the Hennepin Healthcare Systems, Inc. (HHS) Governing Board delegates authority to the HHS Finance and Operations Committee to approve initial appointment and reappointment applications for medical staff clinical privileges, requests for clinical privilege modifications, and requests for clinical privilege form modifications contained in the monthly credentialing reports, and further directs that the HHS Finance and Operations Committee shall receive, for information, completed Focused Professional Practice Evaluation (FPPE) plans and medical staff resignations included in those reports; and
BE IT FURTHER RESOLVED, that the Finance and Operations Committee shall serve as the primary approval body for these credentialing actions; however, the Governing Body expressly retains the right, at its discretion, to exercise this approval authority directly through the full HHS Governing Board, or the Hennepin County Board of Commissioners, and
BE IT FURTHER RESOLVED, that a full report of credentialing actions be provided to the Board of Hennepin County Commissioners-HHS Governing Body on an annual basis.
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Background:
The HHS Medical Staff operates in accordance with its Bylaws of the Medical Staff which were last approved February 24, 2024. Those bylaws provide the formal organizational structure through which membership on the Medical Staff may be obtained or renewed.
The medical staff credentialing process begins when a current or prospective medical staff member submits an application. A credentialing specialist then reviews and verifies the information, flagging any notable items for additional evaluation. The file is subsequently reviewed by the Department Chair and the Medical Staff Credentials Committee. For new applicants, two committee members, both HHS medical staff, conduct an in-depth review; for reappointments, one committee member performs the detailed review.
The clinical privileges modification process follows a similar structure. A current medical staff member or HHS employee submits an application, which is reviewed and verified by a credentialing specialist, with any concerns identified. The file then proceeds to the Department Chair and the Medical Staff Credentials Committee for review and recommendation.
Committee reviewers present their findings to the full Credentials Committee, which includes the President of the Medical Staff and an Assistant Hennepin County Attorney specializing in malpractice litigation. The committee determines whether to recommend the applicant or practitioner to the Medical Executive Committee (MEC) and ultimately the HHS Board for approval. The Credentials Committee’s report confirms that the standard medical staff credentialing process for Hennepin Healthcare System has been followed and that the file has been thoroughly vetted prior to MEC consideration.
Current Request: This request seeks delegation of authority to the HHS Finance and Operations committee to grant medical staff privileges to medical providers who have successfully completed the HHS application process for inclusion to the HHS medical staff; authorization to grant current medical staff additional privileges, where expertise has been demonstrated and is necessary to provide expanded patient care, and approve modifications to clinical privilege forms. The action also requires annual reporting of credentialing activities to the HHS Governing Board.
recommendation
Recommendation from County Administrator: Recommend Approval