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Credentials Credentials Committee Committee OrientationOrientation
Responsibilities of the Responsibilities of the CommitteeCommittee
Review the credentials of all applicants to Review the credentials of all applicants to the Medical Staff and privileges requeststhe Medical Staff and privileges requests
Make recommendations to the Medical Make recommendations to the Medical Executive Committee regarding Executive Committee regarding appointment, reappointment, granting of appointment, reappointment, granting of privileges, and changes in staff statusprivileges, and changes in staff status
Make recommendations regarding the Make recommendations regarding the assignments of each Medical Staff assignments of each Medical Staff applicant and Allied Health Professional to applicant and Allied Health Professional to the various clinical Departments or the various clinical Departments or sections of the Medical Staffsections of the Medical Staff
Responsibilities of the Responsibilities of the Committee, continued.Committee, continued.
Develop and recommend privileging Develop and recommend privileging criteria including any procedures that may criteria including any procedures that may be specific to more than one specialty be specific to more than one specialty (potential “turf” issues)(potential “turf” issues)
To make recommendations regarding the To make recommendations regarding the conclusion and/or extension of focused conclusion and/or extension of focused and ongoing professional practice reviewand ongoing professional practice review
Any other tasks as may be assigned by the Any other tasks as may be assigned by the MECMEC
Dates and Times of Dates and Times of MeetingsMeetings
Committee meets Committee meets monthly – first Tuesdaymonthly – first Tuesday
7:30 a.m. – Physicians 7:30 a.m. – Physicians Conference RoomConference Room
Last approx. 1.5 hrs. Last approx. 1.5 hrs. depending on number depending on number of applicantsof applicants
Mark on dates on office Mark on dates on office calendar, PDA, etc.calendar, PDA, etc.
January 8January 8
February 5February 5
March4March4
April 8April 8
May 6May 6
June 3June 3
July 1July 1
August 5August 5
September September 22
October 7October 7
November4November4
December December 22
Agenda for MeetingAgenda for Meeting
Approval of minutesApproval of minutes Review and discussion of credentials files Review and discussion of credentials files
for new applicants (approx. 10 minutes for for new applicants (approx. 10 minutes for review and discussion of each file)review and discussion of each file)
Interviews with new applicants (approx 5-Interviews with new applicants (approx 5-10 minutes for each interview)10 minutes for each interview)
Reappointment applications (discuss only Reappointment applications (discuss only those with a concern or change in those with a concern or change in privileges)privileges)
Other business (Review of policies, Other business (Review of policies, procedures, criteria, etc.procedures, criteria, etc.
Review of Files/DocumentsReview of Files/Documents
Credentials files are available for review Credentials files are available for review in advance of the meeting in the in advance of the meeting in the Medical Staff Office M-F between 8am-Medical Staff Office M-F between 8am-5pm5pm
Changes in policies, procedures, Changes in policies, procedures, guidelines, etc., will be distributed in guidelines, etc., will be distributed in advance of the meeting. Those who advance of the meeting. Those who cannot attend meeting will be asked to cannot attend meeting will be asked to provide input in advance.provide input in advance.
Credentials File Set UpCredentials File Set Up
Cover sheet with file summary Cover sheet with file summary Tab A – ApplicationTab A – Application Tab B – Licensure copies and verificationTab B – Licensure copies and verification Tab C – Primary Source Verification of Tab C – Primary Source Verification of
Education/Training/Affiliations/Peer Education/Training/Affiliations/Peer recommendationsrecommendations
Tab D – Professional Liability Insurance Tab D – Professional Liability Insurance InformationInformation
Tab E – Continuing EducationTab E – Continuing Education Tab F - CorrespondenceTab F - Correspondence
Recommendation/Approval Recommendation/Approval ProcessProcess
Department ChairRecommendation
Credentials CommitteeRecommendation
Medical Executive CommitteeRecommendation
Governing BodyAction
(approve, not approve)
The Medical Staff RECOMMENDS
The Governing Body APPROVES or DOES NOT APPROVE
The Governing Body is the final authority
Contact InformationContact Information
Chairman name, contact infoChairman name, contact info Credentials Committee members Credentials Committee members
names, contact informationnames, contact information Medical Staff office contact, contact Medical Staff office contact, contact
infoinfo