Members of the medical staff are reviewed periodically (usually every two or three years) to ensure that they are providing good medical care to their patients. Their privileges may be adjusted for changes in medical practice. If serious problems are found, then corrective action needs to be made.


Adequacy of Information


Is there sufficient activity at the hospital to evaluate clinical practice?

(1) If not, letters of recommendation from the staff member's primary hospital are solicited.


Interval Change Since Last Review


Change in medical practice

(1) Any additions or deletions to privileges requested?

(2) Any significant change in clinical activity?

(3) Any change in medical staff membership status?


Evidence of ongoing competence

(1) Is there adequate documentation of continuing education?

(2) Has the staff member performed an adequate number of procedures to maintain skills?


Any change in home or office location that might interfere with the ability to provide essential coverage within an acceptable period of time?




Quality Review:

(1) Any difficulties with required documentation such as completion of medical records in a timely manner or signing of orders?

(2) Has the physician been practicing within the scope of the privileges granted?

(3) Any minor problems in care provided?

(4) Any intermediate problems in care provided?

(5) Any serious problems found in the medical care provided due to poor judgment, negligence, or other cause?



(1) Any professional liability cases indicating medical negligence or problems in providing medical care?

(2) Any physical or mental health problems, including substance abuse, that might interfere with the practice of medicine?

(3) Any action (suspension, revocation, limitation, nonrenewal, relinquishment, sanctions) affecting privileges taken by a hospital, health care facility or professional organization?

(4) Any investigation into quality care issues currently in progress?

(5) Any conviction for felony, fraud or other criminal activity?

(6) Any problems with interaction with patients, facility staff or other medical staff members?


Review Process


Sequence in the review process:

(1) completion of a recredentialing request by the medical staff member

(2) initial review by a Credentialing Committee with recommendation for action

(3) review by the Executive Committee for the Medical Staff

(4) final action taken by the Board of Trustees


Recommendation options for the Credentialing Committee:

(1) approve of request without reservation

(2) approval contingent upon completion of assigned task

(3) refer for further discussion

(4) recommend review by an Ad Hoc Committee for corrective action


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