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Changes proposed in Credentials Procedure Manual and bylaws

17 Feb 2019

Review proposed changes and respond with feedback

By: Kelly Aebi, Medical Staff Office manager

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Proposed changes in medical staff bylaws and the credentials procedure manual regarding clinical advisors went to the Jan. 17 Board Governance Committee for approval. Now it’s time for medical staff to vote on the changes — so watch for a Survey Monkey email.

Historically, when physicians from outside the medical staff served as monitors for new procedures they received temporary privileges. During the review of our TAVR program, we learned this process may not adequately meet the need of vendor requirements for minimum cases to be monitored by a clinical expert outside of our Focused Professional Practice Evaluation Policy. 

A team reviewed our process and proposed a staff category for clinical advisors.  According to the Oregon Medical Board, a physician does not need to hold an Oregon license if they are not treating patients. Other hospitals use different pathways outside of temporary privileges to meet this growing need.

Medical staff bylaws
Credentials Procedure Manual

Email me at if you have questions or concerns. After the medical staff vote on the revisions (via Survey Monkey), they’ll go to the Medical Executive Committee and Board of Trustees for final approval.  Revisions to the Credentials Procedure Manual will be posted for 14 days prior to going to the Medical Executive Committee and Board of Trustees for final approval.