This is the pertinent language from Spectrum Health Hospitals requiring new grads (older physicians are grandfathered in – does MOC not matter for everyone?) to participate in MOC lest they lose their privileges in the hospital (pertinent sections from Article II).
ARTICLE 2 – MEDICAL STAFF MEMBERSHIP AND PRIVILEGES
2.1 Nature of Membership
2.1.1 Medical Staff membership is a privilege granted by the Board and shall be extended only to Practitioners who continuously meet the qualifications, standards, and requirements set forth in these Bylaws, Medical Staff Rules and Regulations, Medical Staff policies and procedures and Hospital policy. Appointment to the Medical Staff shall confer only such privileges and prerogatives as have been recommended by the Medical Staff and granted by the Board in accordance with these Bylaws. 8
2.1.2 Membership or clinical privileges shall not be granted or denied on the basis of race, religion, color, age, sex, national origin, ancestry, economic status, marital status, disability, or sexual orientation, or licensure as a doctor of medicine, dentistry or podiatry, provided the individual is competent to render care of the generally-recognized professional level of quality established by the MEC and the Board.
2.1.3 No individual shall be automatically entitled to Medical Staff membership or to exercise any particular clinical privilege merely because he/she holds a certain degree; is licensed to practice in Michigan or any other state; is a member of any professional organization; is certified by any clinical board; previously had membership or privileges at the Hospital or any other facility owned or operated by Spectrum Health System; or had, or presently has, membership or privileges at another facility.
2.1.4 No individual shall admit, diagnose, or treat patients at the Hospital unless he or she is a member of the Medical Staff (as applicable for the requested privileges) and possesses the necessary privileges in accordance with these Bylaws.
2.2 Criteria for Membership and Privileges
Each individual who seeks or is granted Medical Staff membership and privileges must present evidence of, and continuously demonstrate to the satisfaction of the Medical Staff and the Board, compliance with all the requirements set forth in this Section 2.2.
2.2.1 Basic Qualifications
- License Possess a current unrestricted license issued by the State of Michigan (unless specifically exempted by Michigan law and approved by the President of SHH and the President of the Medical Staff)
Education and Training
- Practitioners must graduate from a school of Medicine, Osteopathy, Dentistry or Podiatry, approved by the Liaison Committee on Medical Education (LCME), the American Osteopathic Association, the American Dental Association, or the American Podiatric Medical Association, respectively.
- In the case of foreign medical graduates, fulfillment of the graduate and post-graduate requirements prescribed by the applicable licensing board or as otherwise approved by the MEC.
- Additional qualifications may be required for education and training by the specific departments and/or divisions to which the individual is assigned, subject to approval by the MEC.
- Practitioners seeking initial appointment to the Medical Staff and clinical privileges whose applications are submitted after January 1, 2011, must meet the following requirements, as applicable:
- Physician applicants shall possess current board certification the American Board of Medical Specialties (ABMS), the American Osteopathic Association (AOA), or the Royal College of Physicians and Surgeons of Canada (RCPSC), 9
and possess the necessary Certificate of Added Qualification (CAQ) in the specialty the applicant will practice (if applicable to the privileges requested). Applicants with a time-limited board certification or CAQ are required to maintain current board certification, if available, and/or CAQ within the specialty for which they primarily practice. In fields such as Medicine and Pediatrics, in which there is general training followed by subspecialty training, individuals may retain basic privileges in their general field if they maintain active board certification in their subspecialty.
- An applicant for podiatric appointment and privileges shall be certified by the American Podiatric Medical Specialties Board or the American Board of Podiatric Surgery.
- A dentist applicant shall be certified by a board recognized by the American Dental Association.
- Applicants who are not board certified at the time of application, must be qualified to sit for the certifying examination administered by the applicable board within two years of initial application to the Medical Staff, and must be board certified within six (6) years following completion of his/her residency or fellowship.
- For physicians trained outside of the U.S. and Canada, the requirements as described in 2.2.1.C.1.a, shall apply. The MEC may grant rare exceptions if the candidate can prove equivalency of training and board certification in the country of their post-graduate training. The documentation proving equivalency must be verifiable and specific. Evaluation of equivalency of training and board certification shall be reviewed and determined by the department chair or division chief and presented in writing to the Credentials Committee, subject to approval by the MEC.
- For members with clinical privileges whose initial applications were submitted before January 1, 2011, board certification is encouraged, but not required. This does not prevent the departments or divisions from adopting board certification requirements, subject to approval by the MEC.
- Departments and divisions may adopt additional requirements for board certification, subject to approval by the MEC.
- The MEC may waive the requirement for board certification for those who possess medical education and training, extraordinary experience and reputation, and any additional evidence of current competency acceptable to the applicable department or division and the MEC, with input from the Credentials Committee.
Current Competence Providers must present documentation of current clinical activity and quality data demonstrating competency and ability to provide quality patient services, to perform the core clinical privileges and any special clinical privileges requested and to demonstrate overall qualifications for appointment to the Medical Staff and/or clinical privileges. Such documentation includes, but is not limited to, quality data from another hospital, information from the individual’s office practice, information from managed care organizations in which the individual participates, and/or receipt of confidential evaluation forms completed by referring physicians or physicians to which the individual refers. 10
Ability to Perform the Privileges Requested Providers must continuously demonstrate their ability and judgment to provide quality patient services and to perform the applicable core privileges and any additional clinical privileges requested.
Department/Division Requirements Providers must meet the qualifications and requirements established by the department(s)/division(s) to which they are appointed, subject to MEC approval.
Health Providers must be free from any physical, psychological or behavioral impairment or condition that cannot be reasonably accommodated without imposing an undue hardship on the Hospital or that interferes with, or presents a reasonable probability of interfering with, the ability to safely and competently exercise clinical privileges. Providers must not be under the influence of or abuse any type of substance or chemical that affects cognitive, motor, or communication abilities and that interferes with, or presents a reasonable likelihood of interfering with, the ability to safely and competently exercise clinical privileges. All Providers are subject to a medical, cognitive, psychiatric, or psychological examination if requested by the MEC. Examining practitioners must be approved by a member of Medical Staff Leadership and any examination shall be performed at the applicant’s expense.
Professional Ethics and Conduct Possess high moral character and adherence to generally recognized standards of medical and professional ethics, honesty and integrity and shall provide care and treatment without regard to a patient’s age, gender, race, religion, disability, national origin, sexual orientation, and/or disease status.
Verbal and Written Communication Skills Possess sufficient written and oral communication skills and be able to communicate effectively in writing and verbally and prepare medical record entries and other required documentation in a legible manner.
Insurance Unless specifically excused by the Board, Providers shall continuously maintain and provide written evidence to the Medical Staff Office of professional liability insurance with limits defined in Medical Staff policy, as approved by the MEC.
Program Participation Providers must not be excluded from participation in Federal and State health insurance programs, including, but not limited to, Medicare and Medicaid.
2.2.2 No Right to Hearing Providers who are denied membership for failure to meet the requirements for licensure, education and training, board certification, specific requirements applicable to the department and division to which they seek appointment, or professional liability insurance requirements, shall not be entitled to a hearing under Article 7.