PAKISTAN KIDNEY & LIVER INSTITUTE AND RESEARCH

CENTER

Medical Staff Credentialing Policy

 PAKISTAN KIDNEY AND LIVER INSTITUTE AND
RESEARCH CENTER
Department Name: Medical Staff Affairs Document Number:
Title of the Policy & Procedure: Medical Staff Credentialing Version Number: 01
Policy
Effective Date:

ARTICLE 1
DEFINITIONS
1.1. BYLAWS DEFINITIONS
The definitions contained in the Bylaws apply to this Policy unless specifically stated otherwise.
1.2. DEFINITIONS SPECIFIC TO THIS CREDENTIALING POLICY
These definitions apply to terms in this Credentialing Policy:
1.2.1. ACGME: Accreditation Council for Graduate Medical Education.
1.2.2. AOA: American Osteopathic Association.
1.2.3. APA: American Psychological Association.
1.2.4. APMA: American Podiatric Medical Association.
1.2.5. Board Certification: The process that a Physician, Dentist, Podiatrist, or Clinical
Psychologist begins after the completion of residency, fellowship, and/or other training that
when completed will lead to the granting of initial certification by one (1) of the following
Specialty Boards:
1.2.5.1. A member board of the American Board of medical specialists, also known as
“ABMS Member Board”.
1.2.5.2. An American osteopathic association AOA specialty certifying board certified
by the AOA Bureau of Osteopathic Specialists.
1.2.5.3. The American Board of Oral and Maxillofacial surgery
1.2.5.4. A Specialty Board, such as the American Board of Podiatric Surgery,
recognized by the Council on Podiatric Medical Education
1.2.5.5. A Specialty Board affiliated with the American Board of Professional
Psychology.
1.2.5.6. If the initial certification is time‐limited, the Maintenance of Certification
(“MOC”) process described by the Specialty Boards is included in this meaning.

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Department Name: Medical Staff Affairs Document Number:
Title of the Policy & Procedure: Medical Staff Credentialing Version Number: 01
Policy
Effective Date:

1.2.6. Board Certified: means an Applicant or Member has successfully completed the Board
Certification process, has a current and valid certificate, and is deemed to be Board Certified
by their respective Specialty Board(s). For time‐limited certifications, the Applicant or
Member must keep the certification current and valid through the MOC process to remain
Board Certified.
1.2.7. Board Eligible: means an Applicant or Member meets the qualifications to enter the
Board Certification process of their Specialty Board(s) and is recognized by their Specialty
Board(s) as being in the Board Certification process but is not currently Board Certified.
1.2.8. Board Eligibility Period: means the time frame that begins at the completion of residency,
fellowship, or other training and ends after the period of time allotted by each Applicant’s or
Member’s Specialty Board for Board Eligible practitioners to complete the initial Board
Certification process. This is typically five (5) to seven (7) years. If a Specialty Board does
not specify a maximum time for completion of the Board Certification process, then the time
will be considered seven (7) years after the completion of residency or fellowship.
1.2.9. CPME: means the Council on Podiatric Medical Education.
1.2.10. Locum Tenens: means temporary medical service.
1.2.11. Maintenance of Certification or MOC: means the continuous education, evaluation, and
improvement activities sponsored or required by a Specialty Board described in this
Policy’s definition of “Board Certification” to maintain Board Certification after initial
Board Certification.

ARTICLE 2
2. QUALIFICATIONS FOR MEMBERSHIP AND CLINICAL PRIVILEGES

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Department Name: Medical Staff Affairs Document Number:
Title of the Policy & Procedure: Medical Staff Credentialing Version Number: 01
Policy
Effective Date:

2.1. GENERAL PRINCIPLES

2.1.1. Factors Considered by the Medical Staff and the Board. To be eligible to apply for initial
appointment or reappointment to the Medical Staff or for the granting of Clinical Privileges,
an Applicant or Member must demonstrate appropriate education, training and experience,
current clinical competence, professional conduct and judgment, the ability to provide
services for patients in a timely and appropriate manner, valid professional licensure, and
the ability to safely and competently perform the Clinical Privileges requested and provide
treatment and care for patients at the Hospital.
2.1.2. Authorization to Exercise Clinical Privileges in Life Threatening Situations. In the case of a
patient care emergency, any Member or individual who has been granted Clinical Privileges
may take any action permitted by the Member’s or individual’s license in order to save the
patient’s life or to save the patient from serious harm. Nothing in this section will obligate a
Member or other individual to take action outside of their Clinical Privileges.
2.2. ELIGIBILITY FOR MEMBERSHIP AND CLINICAL PRIVILEGES
2.2.1. Professional Licensure. Applicants and Members must be authorized to practice allopathic
medicine, osteopathic medicine, podiatric medicine, dentistry, or clinical psychology under
the prevailing laws of the State to be eligible for membership or to exercise Clinical
Privileges as a licensed independent practitioner.
2.2.2. Financial Responsibility. Applicants and Members must comply with the financial
responsibility law, in the form and the amount as determined by the Board, and must
provide proof of such compliance.
2.2.3. Residency Training: The following residency training requirements apply to Applicants and
Members:
2.2.3.1. Dentists. No formal postdoctoral training is required for Dentists who are only
seeking privileges for general dentistry.

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Department Name: Medical Staff Affairs Document Number:
Title of the Policy & Procedure: Medical Staff Credentialing Version Number: 01
Policy
Effective Date:

2.2.3.2. Oral and Maxillofacial Surgeons. Oral and Maxillofacial surgeons must have
completed a dental surgery training program accredited by the Commission on
Dental Accreditation of the American Dental Association.
2.2.3.3. Physicians (MD or DO). Physicians must have successfully completed a
residency accredited by the ACGME or the AOA in the specialty in which they are
seeking Clinical Privileges.
2.2.3.4. Podiatrists. Podiatrists must have successfully completed a two (2) year
surgical residency program accredited by the CPME.
2.2.3.5. Psychologists. Psychologists must have successfully completed an APA
approved doctoral degree program in psychology with at least three (3) years of post‐
doctoral experience in the practice of clinical psychology, or a two (2) year post‐
doctoral residency in Clinical Neuropsychology conforming to the Houston
Conference Guidelines for Advanced Training in Clinical Neuropsychology, or be
accredited by the American Psychological Association, or otherwise be qualified by
training and/or experience. Applicants must have a minimum of one (1) year
experience in an acute hospital setting, community mental health setting, and/or an
emergency room setting involving assessment for safety, especially suicidality and
homocidality.
2.2.3.6. Exemption from Residency Training Requirement for Legacy Members.
Medical Staff Members who have continuously held Clinical Privileges at this
Hospital without residency training certification since August 22, 2001, are
exempted from the residency‐training qualification for their area of practice.
2.2.3.7. Waiver of residency training qualification for Board‐certified individuals.
Applicants and Members who have obtained initial Board certification or who are
Board Eligible and within the Board Eligibility Period may apply for a waiver of the

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Department Name: Medical Staff Affairs Document Number:
Title of the Policy & Procedure: Medical Staff Credentialing Version Number: 01
Policy
Effective Date:

residency training qualification in the clinical area represented by their

Specialty Board.
2.2.4. Board Certification.
2.2.4.1. Applicants must be Board Certified or Board Eligible and still within the
Board Eligibility Period in the specialty in which Clinical Privileges are
requested to be eligible to join the Medical Staff.
2.2.4.1.1. An Applicant or Member who is Board Eligible may be granted
Conditional Appointment and Conditional Privileges during their Board
Eligibility Period.
2.2.4.1.2. If initial Board Certification is not achieved within the Board
Eligibility Period, the Member’s Conditional Appointment and Conditional
Privileges will be Automatically Relinquished unless a waiver to the
initial Board Certification requirement has been granted by the Board as
outlined in this Policy.
2.2.4.1.3. An Applicant or Member who is Board Certified by a Subspecialty Board
of a primary Specialty Board (e.g., Subspecialty Board, Pulmonary
Medicine, of primary Specialty Board, Internal Medicine) and whose
Clinical Privileges will be exercised in the area of the Subspecialty Board
will not be required to be Board Certified by the primary Specialty Board if
the Subspecialty Board does not require Board Certification by the primary
Board to hold Subspecialty Board Certification.
2.2.4.1.4. Applicants who achieved initial Board Certification but are not currently
Board Certified may be considered for membership to the Affiliate
category only. Affiliate Members of the Medical Staff who wish to apply
for a change of membership to the Active or Courtesy staff must meet the
Board Certification requirements for Applicants described in this section.

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Department Name: Medical Staff Affairs Document Number:
Title of the Policy & Procedure: Medical Staff Credentialing Version Number: 01
Policy
Effective Date:

2.2.4.1.5. Applicants and Members of the Department of Oral and Maxillofacial

Surgery that will be practicing solely non‐ surgical dentistry are exempt
from the Board Certification requirements
2.2.4.1.6. Members: Medical Staff Members who have achieved initial Board
Certification and whose Board Certification is time‐ limited are strongly
encouraged, but not required, to maintain ongoing, active Board
Certification in the area in which Clinical Privileges are held.
2.2.4.2. Continuing Medical Education (“CME”) Requirements for Members not Board
Certified. Members who were initially Board Certified but have allowed their Board
Certification to lapse and Legacy Members described above will complete the
following requirements:
2.2.4.2.1. Members will complete at least fifty percent (50%) of the CME hours
required by their applicable licensure board within the specialty area in
which Clinical Privileges are held. For example, a licensed Member
would be required to submit at least thirty (30) CME hours within their
specialty at each reappointment.
2.2.4.2.2. Members will submit to the Medical Staff Office copies of certificates,
letters, or other evidence of CME completion at each reappointment.
2.2.4.2.3. The Clinical Department chairperson will review the submitted
evidence to validate completion of the required CME hours. The
chairperson may ask the Member to provide further evidence from a
particular course (i.e., course outline, course syllabus) to support its
inclusion in the required CME hours.
2.2.4.2.4. Members who do not meet this requirement during the reappointment
process will be given a Conditional Appointment not to exceed twelve (12)
months. During this time, the required CME hours for the previous

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Department Name: Medical Staff Affairs Document Number:
Title of the Policy & Procedure: Medical Staff Credentialing Version Number: 01
Policy
Effective Date:

appointment period will be completed, and evidence of completion

submitted to the Medical Staff Office. After review by the Clinical
Department chairperson and the Credentials Committee, a recommendation
for removing the condition on the appointment may be forwarded to the
MEC and the Board. If the CME hours are not completed in the time
period allowed, the Member’s Conditional Appointment and Conditional
Privileges will be Automatically Relinquished.
2.2.4.2.5. Members who are Board‐Eligible and within their Board Eligibility Period
or who are Board Certified are exempt from the CME reporting
requirement described in this section.
2.2.4.3. Waiver of Initial Board Certification Requirement. The Credentials Committee
may consider a request for a waiver of the initial Board Certification requirement
from a Member granted a Conditional Appointment and Conditional Privileges.
The Credentials Committee and the MEC will make a recommendation to the Board
regarding each request for a waiver. The Board will make the final determination
regarding each request.
2.2.4.3.1. The Member must provide the Credentials Committee a detailed
written explanation of the circumstances surrounding the failure to achieve
Board Certification and provide documentation from his Specialty Board
that the Member is taking the necessary steps to complete Board
Certification.
2.2.4.3.2. The Member may be asked to attend a Credentials Committee
meeting to discuss the circumstances of the Member’s Board Certification
status. The request to attend the meeting will be considered a Mandatory
Meeting as outlined in the Bylaws.

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Department Name: Medical Staff Affairs Document Number:
Title of the Policy & Procedure: Medical Staff Credentialing Version Number: 01
Policy
Effective Date:

2.2.4.3.3. The time period allowed for the waiver will be determined on a case‐by‐
case basis. The maximum time allowed will not exceed twenty‐four (24)
months.
2.2.4.3.4. If Board Certification is not achieved within the time period allotted,
the Member’s Conditional Appointment and Conditional Privileges will
be Automatically Relinquished unless the Member requests and is granted
a leave of absence (“LOA) for the purpose of attaining Board Certification.
The maximum time period allowed for LOA to achieve Board Certification
will not exceed a total of twelve (12) months.
2.2.4.3.5. The granting of a waiver or a LOA in one case does not set a precedent for
any other case and is not intended to serve as a general exception to the
initial Board Certification requirement.
2.2.5. Geographical Location of Home and Practice. Each Applicant and Member requesting
Clinical Privileges will have his primary home and practice office close enough to the
Hospital Campus(es) at which they practice to meet their obligations for patient care and for
practitioner response and availability as detailed in the Rules and Regulations. The primary
home and practice office must be within a twenty‐five (25) mile radius of one of the
Campuses, unless an exception or waiver applies.
2.2.5.1. Exceptions to Geographical Location Requirements. The Geographical
Location Requirements do not apply to Honorary or Affiliate Members.
2.2.5.2. Waiver of Geographical Location Requirements. Members or Applicants
whose practice will not involve patient care obligations, who provides a unique or
important needed service on the Medical Staff, who only requests telemedicine
privileges, or who only exercises these patient care obligations when physically
present within the Hospital may petition for a waiver from the geographical
requirements.

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Department Name: Medical Staff Affairs Document Number:
Title of the Policy & Procedure: Medical Staff Credentialing Version Number: 01
Policy
Effective Date:

2.2.6. Cross‐Coverage for Illness and Unavailability. Each Member must at all times have
another qualified Member who is readily available and who has the necessary Clinical
Privileges to fulfill the duties and responsibilities of the Member as outlined in the
Bylaws, Medical Staff policies, and Rules and Regulations in the event of the individual's
illness or unavailability. Honorary and Affiliate Members are exempt from this cross‐
coverage requirement.
2.2.6.1. Subspecialists. In situations where a Member holds Clinical Privileges in a
Subspecialty in which only a limited number of practitioners in the community are
qualified for Clinical Privileges at the Hospital, but the Member’s Subspecialty
provides a unique or important needed service on the Medical Staff, the Board upon
recommendation of the Credentials Committee and MEC may approve a waiver of
the cross coverage requirement from the same Subspecialty if the intent of the
cross‐coverage requirement is satisfied from practitioners in similar specialties.
2.2.6.2. Failure to Provide Cross‐Coverage. Failure of a Member to arrange
cross‐coverage may result in the Automatic Relinquishment of the Member’s
appointment and Clinical Privileges.
2.2.7. Exclusion from Federally‐Funded Programs. Individuals excluded from federally‐funded
health care programs or included on the List of Excluded Individuals and Entities (LEIE) are
not eligible for appointment, reappointment, or Clinical Privileges.
2.2.8. Disclosure of Health Information. Each Applicant and Member seeking Clinical
Privileges must disclose health issues or conditions that could affect the individual’s ability
to exercise Clinical Privileges.
2.3. NO ENTITLEMENT TO APPOINTMENT
2.3.1. No individual will be entitled to appointment to the Medical Staff or to exercise particular
Clinical Privileges in the Hospital merely because he is licensed to practice a profession in
this or any other state; is a member of any particular professional organization; has had in

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Policy
Effective Date:

the past or currently has Medical Staff appointment or Privileges at any hospital or other
health care facility; resides in the geographic service area of the Hospital; is affiliated with,
or under contract to, any managed care plan, insurance plan, HMO, PPO, or other entity; or
applies for any waiver to the qualifications for appointment or reappointment to the Medical
Staff.
2.4. NON‐DISCRIMINATION
2.4.1. No individual will be denied appointment, reappointment, or Clinical Privileges on the
basis of sex, race, creed, religion, color, national origin, sexual orientation, or on the basis of
any criteria unrelated to the delivery of quality patient care at the Hospital, professional
qualifications, or the Hospital’s purposes, needs and capabilities.
ARTICLE 3
3. CREDENTIALING PROCESS
3.1. APPLICATIONS: The MEC will recommend application forms to the Board for
approval. Currently, the Board has approved applications for:
3.1.1. Appointment
3.1.2. Reappointment
3.1.3. Reinstatement
3.1.4. Change of Medical Staff category
3.1.5. Grant of specific Clinical Privileges
3.1.6. leave of absence and reinstatement from a leave of absence
3.1.7. temporary privileges
3.1.8. disaster privileges
3.1.9. establishment of new categories of Clinical Privileges
The Credentials Committee has the authority to adopt corrections and clarifications to the
above Board‐approved forms that are, in the Committee’s judgment, technical
modifications, reorganization or renumbering, clarifications of previously approved
language, or corrections of punctuation, spelling, or other errors of grammar or expression.
Notice of such adopted corrections and clarifications must be given to the MEC and the
Board

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Department Name: Medical Staff Affairs Document Number:
Title of the Policy & Procedure: Medical Staff Credentialing Version Number: 01
Policy
Effective Date:

3.2. COMPLETING THE APPLICATION

3.2.1. General. The Applicant or Member is responsible for accurately completing the application.
3.2.2. Electronic Submission. Applications must be submitted electronically, where applicable,
using the Hospital’s Medical Staff credentialing database.
3.2.3. Completed Applications. An application will be complete when all questions on the
application form have been answered, all supporting documentation has been supplied, all
primary source information (including licensure, relevant training, and current competence)
has been verified by the Medical Staff Office or by a Credentials Verification Organization
utilized by the Medical Staff, and all dues, fees, and fines are paid in full.
3.2.4. Incomplete Applications. Any application that remains incomplete sixty (60) Business Days
after notification of acceptance will be deemed to be withdrawn without a refund of the
application fee, unless the Credentials Committee grants an extension of time. If additional
information is requested by a Clinical Department chairperson or the Credentials Committee
less than twenty (20) Business Days before the completion deadline the deadline will be
advanced to twenty (20) Business Days after the date of the notification of the request for
additional information.
3.2.5. Material Misrepresentations, Misstatements, and Omissions.
3.2.5.1. Any misrepresentations, misstatements, or omissions of a material fact in
an application, regardless of intent, will result in no further processing of the
application.
3.2.5.2. There is no entitlement to hearing or appeal of the decision of the Credentials
Committee not to further process any application under this section.
3.2.5.3. The Applicant or Member will not be entitled to make a new application for a
period of three (3) years, unless the Credentials Committee determines that the fact
was not material or that the failure to provide correct information was inadvertent, in
which case the Credentials Committee may allow the Applicant to amend the

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Department Name: Medical Staff Affairs Document Number:
Title of the Policy & Procedure: Medical Staff Credentialing Version Number: 01
Policy
Effective Date:

application and proceed to consider the Applicant. The Credentials Committee may
also recommend that a fine be levied for the violation of the Policy and as a
condition of granting Medical Staff membership.
3.3. DOCUMENTATION FOR APPLICATIONS: The following information, if applicable to
the particular application, will be required:
3.3.1. Authorizations. Any necessary electronic or written authorizations to allow third‐parties to
release any confidential information relevant to the request for membership or Clinical
Privileges.
3.3.2. Immunity and Release Forms. Agreements to extend immunity from liability and suit to the
fullest extent permitted by law to anyone who participates in the credentialing process,
including the Hospital, the Hospital’s employees, the Medical Staff and all other individuals
gathering information, providing information, or considering information.
3.3.3. References. Names and addresses of two (2) references as defined in the relevant
application. Additional references may be requested.
3.3.4. Medical Staff Appointments. List of previous Medical Staff appointments and a signed
release to allow other hospitals to disclose information about the Applicant’s or Member’s
current and previous Medical Staff appointment(s) or Clinical Privileges.
3.3.5. Ongoing/Additional Information. The following information must be provided as
part of an initial or reappointment application. Members and Applicants must notify the
Medical Staff Office within f iv e ( 5 ) B u s in es s D ay s if there are changes in this
information during the term of any appointment.
3.3.5.1. any administrative complaint issued by a professional licensing board or
governmental agency
3.3.5.2. any action by a professional licensing board or governmental agency that
resulted in the payment of any fine, formal discipline, educational requirements,

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Title of the Policy & Procedure: Medical Staff Credentialing Version Number: 01
Policy
Effective Date:

conditions, reprimands, limitations or restrictions on an Applicant’s or Member’s

license to practice a health care profession, including settlements
3.3.5.3. any administrative complaint issued by the DRAP r eg ar d ing an A p p li c
a n t ’s or M e m b e r ’s r e g i s tr a tio n
3.3.5.4. any action by the DRAP regarding registration or regarding any controlled
substance certificate that has ever been voluntarily or involuntarily relinquished,
suspended, modified, terminated, restricted or is currently being challenged even if
the Applicant or Member does not currently prescribe medications.
3.3.5.5. all financial responsibility forms filed with any licensing Boards, or other
documentation demonstrating compliance with the applicable law or the
requirements of the Board
3.3.5.6. professional liability claims and litigation, including new and pending
claims, final judgments, or settlements
3.3.5.7. any health information about the Applicant’s or Member’s physical and mental
health if the condition would affect the ability to exercise Clinical Privileges, work
cooperatively with other health care providers, or protect the safety of patient
3.3.5.8. documentation of compliance with medical records requirements, education
requirements, workplace safety requirements, and any requirements regarding the
reduction or control of infectious diseases as specified by the MEC (except for
Honorary and Affiliate Applicants and Members who are exempt from this
requirement)
3.3.5.9. past or pending suspension or termination for any period of time in Medicare,
Medicaid, or any other government sponsored program
3.3.5.10. identification information to allow the Hospital to conduct a criminal
background check
3.3.5.11. any criminal case in which the Applicant or Member was a defendant

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Policy
Effective Date:

3.3.6. Designation of Primary Campus. Applicants and Members will designate one Campus as
their Primary Campus. If requested by the President, the Credentials Committee
chairperson, a Clinical Department chairperson, or a Campus Chief of Staff, the Medical
Staff Office will provide a report of the Campus distribution of Member’s Patient Contacts.
Upon request by a Medical Staff Leader designated in this section, the Member’s Primary
Campus may be reassigned upon approval of the Credentials Committee and the MEC.
3.4. MEMBERSHIP PROCESS FOR APPLICATIONS FOR APPOINTMENT,
REAPPOINTMENT, REINSTATEMENT, CHANGE OF MEDICAL STAFF CATEGORY,
GRANTING SPECIFIC CLINICAL PRIVILEGES, OR FOR LEAVE OF ABSENCE
3.4.1. Initial Review. The Medical Staff Office will verify that the application is complete.
3.4.2. Report by Clinical Department Chairperson. Complete applications are transmitted to the
applicable Clinical Department chairperson for review. The Clinical Department chairperson
may request a personal interview with the Applicant or Member. The Clinical Department
chairperson will prepare a recommendation for action to be taken by the Credentials
Committee. The Clinical Department chairperson may designate the Clinical Department
vice chairperson, a Clinical Subspecialty chairperson, or a Campus Clinical Section
chairperson to assist with the Clinical Department level review.
3.4.3. Expedited Process for Conditional Membership and Conditional Privileges (Fast‐Track
Process).
3.4.3.1. After completion of the application and verification of the required elements by
the Medical Staff Office, an Applicant or Member may be granted Conditional
Appointment and Conditional Privileges prior to the meeting of the Credentials
Committee when the application documents the following:
3.4.3.1.1. consistent and successful residency training program record
3.4.3.1.2. no record of any disciplinary action or conditions during residency
training

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Policy
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3.4.3.1.3. unrestricted and unconditional license to practice

3.4.3.1.4. all references received about the Applicant contain a recommendation
without reservations for appointment and for the Clinical Privileges
requested
3.4.3.1.5. no prior, current, or pending investigations or challenges to professional
licensure or DRAP registration
3.4.3.1.6. no unusual patterns of, or an excessive number of, professional
liability actions resulting in a final judgment or settlement
3.4.3.1.7. no pending or past investigations or reports of disciplinary action taken at
any hospital, academic medical institution, or other health care facility
including involuntary limitation, reduction, denial or loss of Clinical
Privileges
3.4.3.1.8. no Member of the Medical Staff has raised a question or concern about the
Applicant’s qualifications for appointment or Clinical Privileges
3.4.3.1.9. no questions or concerns have been raised about the Applicant by the
Clinical Department chairperson(s) responsible for making a report on the
Applicant.
3.4.3.2. Review. The application and supporting documentation will be reviewed by
the following individuals, who will verify that the information is complete and that
the criteria for granting Conditional Appointment and Conditional Privileges has
been met:
3.4.3.2.1. Clinical Department chairperson(s) or designee(s) in which the Clinical
Privileges are sought
3.4.3.2.2. Credentials chairperson or designee
3.4.3.2.3. Approval of Conditional Appointment and Conditional Privileges.

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Policy
Effective Date:

3.4.3.2.4. Once the above individuals have reviewed the application and have
approved the request for expedited Conditional Appointment and
Conditional Privileges, the Chief Medical Officer, the CEO, or their
designees will have the final authority to grant Conditional Appointment
and Conditional Privileges prior to a meeting of the Credentials
Committee, based on the application and submissions.
3.4.4. Consideration by the Credentials Committee. The Credentials Committee, or a
subcommittee formed for this purpose, will review the initial report of the Clinical
Department chairperson or designee, the completed application, and all supporting
materials, and then make a recommendation to the MEC. The Credentials Committee may
request a personal interview, and/or may refer an application to external reviewers or other
experts for additional recommendations. The Credentials Committee may modify
existing Conditional Privileges or may approve new Conditional Privileges pending
consideration by the MEC. If the recommendation of the Credentials Committee is delayed
longer than sixty (60) Business Days from the initial presentation of the application to the
Credentials Committee, then the Credentials Committee chairperson will give Notice to the
Candidate or Member explaining the reasons for the delay.
3.4.5. Actions and Recommendations by the MEC. The MEC will review the report and
recommendations of the Credentials Committee and may accept the recommendation, refer
the application back to the Credentials Committee for further review, or modify or reject the
recommendation and state specific reasons for disagreement with the recommendation of the
Credentials Committee.
3.4.5.1. If the recommendation is favorable, the Applicant may be awarded Conditional
Appointment and Conditional Privileges, if not yet granted, and the
recommendation will be forwarded to the Professional Affairs Committee for review.

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Department Name: Medical Staff Affairs Document Number:
Title of the Policy & Procedure: Medical Staff Credentialing Version Number: 01
Policy
Effective Date:

3.4.5.2. If the recommendation is unfavorable, the Applicant or Member is notified of

the MEC’s action and, if a right to a hearing exists under the Bylaws, the Applicant
or Member is notified by the CEO of the right to request a hearing. Any
Conditional Appointment and Conditional Privileges expire unless specifically
renewed by the MEC.
3.4.6. Actions and Recommendations of the Professional Affairs Committee. The Professional
Affairs Committee will review the recommendations of the MEC and may accept the
recommendation, refer the application back to the MEC for further review, or modify or
reject the recommendation and state specific reasons for disagreement with the
recommendation of the MEC.
3.4.6.1. If the Professional Affairs Committee’s recommendation agrees with the
MEC’s recommendation, the application will be forwarded to the Board for final
action.
3.4.6.2. If the Professional Affairs Committee’s recommendation modifies or rejects
the MEC’s recommendation, the Professional Affairs Committee will discuss the
matter with the President. If the Professional Affairs Committee’s determination
after discussion with the President remains unfavorable, the Applicant or Member is
notified. Any Conditional Appointment and Conditional Privileges expire upon
notification unless specifically renewed by the Professional Affairs Committee
3.4.7. Final Decision by the Board. The Board will review the Professional Affairs Committee’s
recommendations and will have the final decision on all credentialing matters. If the final
Board decision entitles the Applicant or Member to a hearing, the CEO will notify the
Applicant or Member of the right to request a hearing.
3.4.8. Term of Initial Appointment. Initial appointments to the Medical Staff will be granted for a
period of time to coincide with the current reappointment period of the new Member’s

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Policy
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primary Clinical Department. The initial appointment period will not exceed thirty‐six (36)
months.
3.4.9. Leave of Absence. Members may be granted a Leave of Absence (“LOA”) according to the
following process:
3.4.9.1. A Member will request either a medical LOA (for example, physical illness or
condition, cognitive issue, mental disorder, alcohol and substance abuse disorder,
etc.) or a non‐medical LOA (for example, family obligation, pursuit of additional
education or training, preparation for board certification, military service, legal issue,
etc.). The application for LOA will state the reason(s) for the leave and will include
the beginning and ending dates of the requested leave.
3.4.9.2. The request for a LOA will be processed and reviewed in the same manner as
other applications for Members.
3.4.9.2.1. In addition to any other recommendations, the Clinical Department
chairperson or a designee will provide information to the Credentials
Committee on whether the Clinical Department chairperson believes that
granting the LOA will adversely affect the ability to provide emergency
call coverage.
3.4.9.2.2. The LOA may be denied, delayed, or modified to ensure that emergency
call coverage is not adversely affected.
3.4.9.2.3. For all applications for medical LOA, the Credentials Committee will
determine whether the Member will be referred for monitoring in
accordance with the Organizational Policy and, if applicable, the Impaired
Practitioner Policy.
3.4.9.3. A LOA will not exceed twelve (12) months. Absence by a Member for a
period of time in excess of the granted LOA will constitute voluntary resignation of
Medical Staff appointment and Clinical Privileges. An additional LOA may be

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requested but must be reviewed and approved according to the process outlined
herein and the total of all LOAs may not exceed twenty‐four (24) consecutive
months.
3.4.9.4. Reinstatement. A Member must request reinstatement of Clinical Privileges
by submission of the request to the Medical Staff Office within thirty 30) Business
Days from the expiration date of the LOA.
3.4.9.4.1. If the leave was a medical LOA and was referred to the PHAC for
monitoring, then the PHAC will provide a recommendation regarding
reinstatement to the Credentials Committee. If applicable, all conditions
for reinstatement imposed, including any conditions in the Impaired
Practitioner Policy, must be satisfied prior to consideration of the
reinstatement.
3.4.9.4.2. Change of Medical Staff Category. Members may request a change in their
Medical Staff category at any point during an appointment period. Any
emergency call assigned at the point the application is submitted to the
Medical Staff Office must be covered by the Member. The change in
category will not be in effect until processed and reviewed in the same
manner as outlined in this section.
3.5. DELINEATION OF CLINICAL PRIVILEGES
The Board will determine which categories and specific Clinical Privileges will be available for
application at the Hospital after considering the recommendations of the Medical Staff.
3.5.1. Process for Recommending Delineation of Clinical Privileges.
3.5.1.1. Clinical Department chairpersons and Clinical Subspecialty chairpersons will
propose the qualifications and the specific categories and descriptions of
Clinical Privileges for their respective Members. These recommendations will be
forwarded to the Credentials Committee and the MEC for consideration.

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Policy
Effective Date:

3.5.1.2. When the delineation of Cross‐Specialty Privileges is required, the Credentials

Committee chairperson may request information, input, and collaboration from each
specialty’s chairperson in this process.
3.5.1.3. The Credentials Committee, or a subcommittee, will review all requests
for Clinical Privilege delineation, the qualifications required and the specific
Members permitted to exercise those privileges and will make recommendations to
the MEC.
3.5.1.4. The MEC will make recommendations to the Board on the
delineation of and qualifications for specific Clinical Privileges.
3.5.1.5. In the case where recommendations for the delineation of a new Clinical
Privilege are presented at the same time that Applicants or Members are applying to
exercise the new Clinical Privilege, the Committees and Board will first determine
whether the Hospital will offer the new Clinical Privilege and then whether the
Applicant or Member meets the adopted criteria for the new Clinical Privilege.
3.5.2. Advice from Outside the Medical Staff. The Hospital and Medical Staff may also retain
external reviewers, experts, and consultants from multiple specialties to advise on the
delineation of Clinical Privileges.
3.6. TELEMEDICINE PRIVILEGES
3.6.1. Practitioners who diagnose or treat patients via telemedicine link will be subject to the
same credentialing and privileging process as outlined in this policy.
3.6.2. The Credentials Committee will conduct research and consult with the appropriate Clinical
Department or Clinical Subspecialty chairpersons or individuals on the Medical Staff with
respect to the clinical services to be provided by telemedicine; and develop
recommendations regarding any specific education, training, or experience necessary to
perform the Clinical Privileges via telemedicine. The Credentials Committee will then

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Policy
Effective Date:

forward these recommendations to the MEC, which will review the matter and forward
its recommendations to the Board for final action.
3.7. PROCESSES FOR GRANTING CLINICAL PRIVILEGES WITHOUT
MEMBERSHIP
3.7.1. Disaster Privileges (Emergency Clinical Privileges Under Disaster Conditions). Disaster
privileges may be granted to a health care professional when the emergency management
plan has been activated and the organization is unable to handle the immediate patient
needs. The emergency management plan will outline the requirements for such temporary
privileges. The CEO/Hospital Administrator/Incident Commander, with the concurrence of
the President or a designee and the appropriate Clinical Department chairperson or Disaster
Medical Director, will grant the emergency Clinical Privileges necessary, provided the
individual’s documentation is adequate and acceptable, and his identity confirmed.
3.7.2. Temporary and locum Tenens privileges. Applications may request temporary or locum
tenens. Clinical privileges without medical staff membership or more than 4 times per year.
3.7.2.1. Purpose of Granting. Temporary and locum tenens privileges are available.
Privileges may be granted for following reasons:
3.7.2.1.1. Proctors for Medical Staff Members. To provide observation to verify
competency in a procedure or technique that the Member was previously
trained to perform.
3.7.2.1.2. Preceptors for Medical Staff Members. To provide supervision and training
for a Member to learn a new procedure or technique.
3.7.2.1.3. Team Physicians. To provide medical services to athletes on sports teams
competing within the service area of the Hospital if the need arises for care
or treatment at the Hospital.
3.7.2.1.4. Important patient treatment Needs. To provide important patient care or
patient needs.

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Policy
Effective Date:

3.7.2.2. Application Process. Each Applicant for temporary or locum tenens Clinical
Privileges without Medical Staff membership will complete the applicable
application form. The application and supporting documentation will be reviewed
by the following individuals who will verify that the information is complete and that
the criteria for granting temporary or locum tenens Clinical Privileges has been met:
3.7.2.2.1. Medical Staff Office
3.7.2.2.2. Department chairperson(s) or designee(s) in which the Clinical Privileges
are sought
3.7.2.2.3. Credentials chairperson or designee
3.7.2.2.4. President or designee
3.7.2.2.5. Chief Medical Officer or CEO, or designees
3.7.2.3. Approval of temporary clinical privileges. The chief medical officer, the CEO,
or designees will have the final authority to grant temporary or locum tenens clinical
privileges based on the application and submission.
3.7.2.4. Expiration of Temporary Privileges. The temporary Clinical Privileges
granted under this section will expire no later than eighty (80) Business Days one
hundred and twenty (120) days after being granted. Shorter expiration periods may
be used,
3.7.2.5. Expiration of locum tenens privileges. Locum tenens privileges granted under
this section will expire no later than 180 days after being granted. Shorter expiration
periods may be used, including but not limited to where the expiration date falls on a
non-business day.
3.7.2.6. Termination or temporary and Locum Tenens privileges. The president, chief
Medical officer, or CEO, or designees, will have the right to terminate temporary or
locum tenens clinical privileges at any time.

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Policy
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3.7.2.7. No procedural rights. There is no right to a hearing or appeal for denial,

expiration, or termination of any temporary or locum tenens clinical privileges.

4. ARTICLE

INQUIRIES, INVESTIGATIONS, ANDRECOMMENDATIONS FOR CORRECTIVE ACTI

4.1. INFORMAL INQUIRY

Any question concerning a Member’s professional demeanor, conduct, competence, or
qualifications may be referred to the President, Campus Chief of Staff, Clinical Department
chairperson, Credentials Committee chairperson, Chief Medical Officer, or CEO.
4.1.1. Initiation. Any of the individuals named above may verify facts that resolve or clarify
the concern raised.
4.1.2. Collegial resolution. The Member who is the subject of the concern may be consulted
for information or to resolve the concern. There is no requirement that the Member who
is the subject of the concern be contacted during an informal inquiry.
4.1.3. Referral to Committees. The individual making the inquiry may refer the concern to
any appropriate Medical Staff committee or officer for immediate action or further
review or Investigation.
4.1.4. Inquiry is not an Investigation. An informal inquiry is not a disciplinary proceeding or
an Investigation and will remain PSWP of the Hospital.
4.2. PRECAUTIONARY SUSPENSION
Any officer authorized under the Bylaws to do so may take immediate action to suspend all or a
portion of a Member’s Clinical Privileges as set forth in the Bylaws.
4.3. VOLUNTARY COOPERATION IN LIEU OF A PRECAUTIONARY
SUSPENSION

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Policy
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Members may be given the opportunity to voluntarily refrain from exercising Clinical Privileges
or taking other actions in cases where a precautionary suspension might be considered.
4.3.1. Documentation. The decision to voluntarily refrain from exercising Clinical Privileges or
from any other action must be documented by the Medical Staff Office and signed by the
Member. Voluntarily refraining from exercising Clinical Privileges will not be deemed to
be a surrender of Clinical Privileges nor a suspension of Clinical Privileges nor a waiver of
any rights to a hearing or appeal under the Bylaws.
4.3.2. Cooperation Does Not Preclude Immediate Action Under the Bylaws. The decision to
voluntarily refrain from exercising Clinical Privileges does not prevent any immediate
action from being taken, up to and including precautionary suspension.
4.3.3. Extends to Investigation. The Member may continue to voluntarily refrain from
exercising Clinical Privileges during any subsequent Investigation.
4.3.4. Duty to Notify the End of Cooperation. Members who voluntarily refrain from
exercising Clinical Privileges must notify the Medical Staff Office at least three (3)
Business Days before electing to resume the exercise of Clinical Privileges.
4.4. PROCEDURES FOR INVESTIGATIONS
4.4.1. Initiation. Both the MEC and the Board may initiate an Investigation of a Member.
The Administrative Subcommittee of the MEC may also initiate an Investigation between
meetings of the MEC.
4.4.2. Responsibility for Investigation. Once the determination has been made to begin an
Investigation, the MEC is responsible for investigating the concern and for making a
recommendation to the Board.
4.4.2.1. If the Board initiates the Investigation but the MEC fails to take any further
action to investigate or to make a recommendation back to the Board, then the Board
may appoint its own Investigative Committee to make a recommendation.

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4.4.3. Selection of the Investigative Committee Members. If an Investigative Committee is

formed, the MEC or the Administrative Subcommittee of the MEC may select the members
of the Investigative Committee or delegate that task to the President or his designee. The
MEC may act as a committee‐of‐ the‐whole and serve as its own Investigative Committee
with all the same powers as set forth in this Policy.
4.4.3.1. The Investigative Committee should include a minimum of three (3)
persons of which at least one (1) must be a Member of the Medical Staff.
4.4.3.2. The Investigative Committee should include at least one (1) individual
who practices the same specialty as the individual being investigated, whenever the
questions raised concern the clinical competence of the individual under review.
For example, an Investigation involving the clinical competence of a clinical
psychologist would include a licensed clinical psychologist on the Investigative
Committee.
4.4.4. Scope of the Investigation. Any committee conducting an Investigation under this policy
will respond to the specific concerns referred to it by the MEC or the Board and will have
the power to consult with expert reviewers, call witnesses, gather statements, and review
Hospital records, medical records, office charts, medical literature and any other documents
or evidence deemed necessary to make a recommendation.
4.4.5. Investigative Committee Process.
4.4.5.1. Committee Chair. The President or designee will select the
chairperson of the Investigative Committee to conduct the meetings and assist with
scheduling and administrative issues.
4.4.5.2. Meetings. The Investigative Committee will meet as often as necessary to
complete the Investigation and will set its own schedule

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4.4.5.3. External Reviewers. The Investigative Committee may request that the
Hospital retain an external reviewer to obtain testimony, written reports, or other
information from the reviewer pertinent to the issues being investigated.
4.4.5.4. Member’s Opportunity to Respond. Before the conclusion of the
Investigation, the Investigative Committee will give the Member an opportunity to
address the concern being investigated and offer information for the consideration
of the Investigation.
4.4.5.4.1. The opportunity to respond is not a hearing or appeal. There is no right to
have legal counsel or other personal representatives present during the
meeting.
4.4.5.4.2. The Member may be compelled to provide office medical records and
other information relevant to the case or cases under review and/or to
attend the Investigative Committee meeting if the Investigative
Committee requests the Members’ attendance.
4.4.5.5. Transcripts and Records. The Investigative Committee may keep transcripts of
witness statements and other records of the committee’s proceedings that it deems
necessary to document its report.
4.4.5.6. Attendance. The Investigative Committee may choose to meet even though not
all committee members can be present provided that the absent committee member
can review the transcripts and records of the meeting(s) at which he or she was not
present. All members must participate in the final deliberations of the Committee
that develops the recommendation to the MEC.
4.4.5.7. Investigative Committees will strive to complete their Investigation in a timely
manner.
4.4.5.8. If the Investigation continues for more than twenty (20) Business Days, the
Investigative Committee will make an interim report to the President prior to each

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MEC meeting. The interim report to the President will include any items needed by
the Investigative Committee.
4.4.5.9. At the conclusion of the Investigation, the Investigative Committee will report
to the MEC regarding the outcome of the Investigation, pertinent facts, and
recommendations including but not limited to the following:
4.4.5.9.1. no action
4.4.5.9.2. a letter of counsel or reprimand
4.4.5.9.3. imposition of a fine
4.4.5.9.4. additional education or training,
4.4.5.9.5. reduction or suspension of Clinical Privileges
4.4.5.9.6. imposition of conditions for continued appointment including but not
limited to monitoring or mandatory consultation
4.4.5.9.7. revocation of Medical Staff appointment and Clinical Privileges
4.4.5.10. The MEC will consider the information and the report and make its own
recommendation regarding the Member’s Clinical Privileges and membership to the
Board.
4.4.5.11. If the recommendation of the MEC is an adverse recommendation that
would entitle the Member to a hearing under the Bylaws, the Bylaws procedure for a
hearing and any subsequent proceedings will apply.

5. ARTICLE

NOTICE AND TELEPHONE NOTIFICATION OF PROCEDURES

5.1. FORM OF NOTICE

5.1.1. Applicants and Members have no entitlement to any particular form of Notice.

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Policy
Effective Date:

5.1.2. This article does not alter any requirement under the Bylaws to give Notice of an
adverse recommendation that would entitle the Applicant or Member to a hearing.
5.2. TIMING OF NOTICES
5.2.1. Granting of Conditional Privileges Pending Board Approval. Applicants and Members
will be given Notice within two (2) Business Days if they are approved for Conditional
Privileges.
5.2.2. Other Notices from the Medical Staff to Members and Applicants. Other Notices of
credentialing requests or actions may be given as soon as practical.
5.3. CONTENT OF NOTICES
Notices will include the name of the individual or Committee taking the action, the action taken
or recommendation made, and, in the case of Privileges, a delineation of the Clinical Privileges
that will be affected. If Information is requested, a list of the information requested will be kept
in electronic or written form in the Applicant’s or Member’s credentialing file.
5.4. EFFECT OF FAILURE TO FOLLOW NOTICE PROVISIONS
5.4.1. The failure to provide Notice in the format or within the time frames set forth in this
Policy will not be the basis to invalidate any action taken by the Hospital, its employees,
or its Medical Staff.

APPROVALS:

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Department Name: Medical Staff Affairs Document Number:
Title of the Policy & Procedure: Medical Staff Credentialing Version Number: 01
Policy
Effective Date:

     
Prepared by:
Signature &
Employee ID
Name Title Date

Reviewed by:
Signature &
Employee ID
Name Title Date

Authorized by:
Signature &
Employee ID
Name Title Date

Date Reviewed: ___________________ Next Review Date: ________________

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