WILLIAM DONALD SCHAEFER, Governor Ch. 671

Section 19-319(e)
Annotated Code of Maryland
(1990 Replacement Volume)

BY repealing and reenacting, with amendments,
Article - Health Occupations
Section 14-601(b)
Annotated Code of Maryland
(1986 Replacement Volume and 1989 Supplement)

SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF
MARYLAND, That the Laws of Maryland read as follows:

Article - Health - General

19-319.

(e) (1) As a condition of licensure, each hospital shall establish a
credentialling process for the physicians who are employed by or who have staff
privileges at the hospital.

(2) The Secretary shall, by regulation and in consultation with hospitals,
physicians, interested community and advocacy groups, and representatives of the
Maryland Defense Bar and Plaintiffs' Bar, establish minimum standards for a
credentialling process which shall include:

(i) A formal written appointment process documenting the
physician's education, clinical expertise, licensure history, insurance history, medical
history, claims history, and professional experience.

(ii) A requirement that an initial appointment to staff not be
complete until the physician has successfully completed a probationary period.

(iii) A formal, written reappointment process to be conducted at least
every 2 years. The reappointment process shall document the physician's pattern of
performance by analyzing claims filed against the physician, data dealing with
utilization, quality, and risk, a review of clinical skills, adherence to hospital bylaws,
policies and procedures, compliance with continuing education requirements, and
mental and physical status.

(3) If requested by the Department, a hospital shall provide
documentation that, prior to employing or granting privileges to a physician, the
hospital has complied with the requirements of this subsection and that, prior to
renewing employment or privileges, the hospital has complied with the requirements of
this subsection.

(4) If a hospital fails to establish or maintain a credentialling process
required under this subsection, the Secretary may impose the following penalties:

(i) Delicensure of the hospital; or
- 2845 -