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Collect external information to ensure physician reappointment

Ambulatory Safety Monitor, May 18, 2006

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Gather information from outside sources regarding a practitioner's practice during his or her last term of appointment by sending questionnaires to all other hospitals and healthcare organizations in which the practitioner holds privileges.

If representatives from such organizations don't return the questionnaires promptly, the executive director or appropriate person at your center should request the practitioner's assistance and indicate a date by which the center must receive all information.

Such information includes

• patterns of care, as demonstrated in findings of quality/utilization monitoring activities
• medical records/organization reports
• continuing education activities (if any)
• attendance during required medical staff meetings (if any)
• service on medical staff committees
• timely and accurate completion of medical records
• compliance with the medical staff bylaws and all applicable policies, rules, regulations, and procedures
• a current National Practitioner Data Bank report
• information from the Office of Inspector General's List of Excluded Individuals and Entities (Medicare and Medicaid), if applicable

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