HARRY HUGHES, Governor                                      2373

(2) Does not represent as true any matter that the
person does not reasonably believe to be true.

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 AND PHYSICIANS PHYSICIANS,
INTERESTED COMMUNITY AND ADVOCACY GROUPS, AND REPRESENTITIVES 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
CREDENTIALING PROCESS REQUIRED UNDER THIS SUBSECTION, THE
SECRETARY MAY IMPOSE THE FOLLOWING PENALTIES:

(I) DELICENSURE OF THE HOSPITAL; OR

(II) $500 PER DAY FOR EACH DAY THE VIOLATION
CONTINUES.

(F) (1) AS A CONDITION OF LICENSURE, EACH HOSPITAL SHALL
ESTABLISH A RISK MANAGEMENT PROGRAM.