The objective of this policy is to promote optimal patient care by promoting a safe, cooperative, and professional healthcare environment by preventing or eliminating, to the extent possible, behavior that disrupts the efficient and effective operation of the hospital.

A practitioner practicing outside the scope of privileges indicates an immediate threat to patient health and safety as determined by the Centers for Medicare & Medicaid Services (CMS) and other organizations. Therefore, it is important for everyone in your organization to know who has what...

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