Credentials Committee Orientation

1
Credentials Committee Orientation
2
Responsibilities of the Committee

• Review the credentials of all applicants to the
  Medical Staff and privileges requests
• Make recommendations to the Medical Executive
  Committee regarding appointment, reappointment,
  granting of privileges, and changes in staff
  status
• Make recommendations regarding the assignments of
  each Medical Staff applicant and Allied Health
  Professional to the various clinical Departments
  or sections of the Medical Staff

3
Responsibilities of the Committee, continued.

• Develop and recommend privileging criteria
  including any procedures that may be specific to
  more than one specialty (potential turf issues)
• To make recommendations regarding the conclusion
  and/or extension of focused and ongoing
  professional practice review
• Any other tasks as may be assigned by the MEC

4
Dates and Times of Meetings

• Committee meets monthly first Tuesday
• 730 a.m. Physicians Conference Room
• Last approx. 1.5 hrs. depending on number of
  applicants
• Mark on dates on office calendar, PDA, etc.

January 8 February 5 March4 April 8 May 6 June 3 July 1 August 5 September 2 October 7 November4 December 2
5
Agenda for Meeting

• Approval of minutes
• Review and discussion of credentials files for
  new applicants (approx. 10 minutes for review and
  discussion of each file)
• Interviews with new applicants (approx 5-10
  minutes for each interview)
• Reappointment applications (discuss only those
  with a concern or change in privileges)
• Other business (Review of policies, procedures,
  criteria, etc.

6
Review of Files/Documents

• Credentials files are available for review in
  advance of the meeting in the Medical Staff
  Office M-F between 8am-5pm
• Changes in policies, procedures, guidelines,
  etc., will be distributed in advance of the
  meeting. Those who cannot attend meeting will be
  asked to provide input in advance.

7
Credentials File Set Up

• Cover sheet with file summary
• Tab A Application
• Tab B Licensure copies and verification
• Tab C Primary Source Verification of
  Education/Training/Affiliations/Peer
  recommendations
• Tab D Professional Liability Insurance
  Information
• Tab E Continuing Education
• Tab F - Correspondence

8
Recommendation/Approval Process
Department Chair Recommendation
The Medical Staff RECOMMENDS The Governing Body
APPROVES or DOES NOT APPROVE The Governing Body
is the final authority
Credentials Committee Recommendation
Medical Executive Committee Recommendation
Governing Body Action (approve, not approve)
9
Contact Information

• Chairman name, contact info
• Credentials Committee members names, contact
  information
• Medical Staff office contact, contact info