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