The Credentialing Committee reviewed Dr. Jones application for recredentialing. They noted that Dr. Jones had a high incidence of nosocomial infections after hip replacement surgery. In addition, his compliance to appropriate indications for the performance of hip replacement surgery was only 40%. While Dr. Jones' general medical staff appointment was renewed, the Committee recommended that his privileges for hip replacement surgery be denied. They recommended that Dr. Jones complete an AMA approved course on infection control, observe the Chief of Orthopaedic Surgery conduct a minimum of three hip replacement evaluations, and reapply for hip replacement credentials in six months. The Credentialing committee discovered the problems by
O reviewing Dr. Jones' quality profile
O inquiring of The National Physician's Data Bank
O talking with the Chief of Surgery
O sampling and reviewing Dr. Jones' patient records