Credentials Committee Orientation

Responsibilities of the Committee Review the credentials of all applicants to the Medical Staff and privileges requests 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 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 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

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) 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 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 Any other tasks as may be assigned by the MEC

Dates and Times of Meetings Committee meets monthly – first Tuesday Committee meets monthly – first Tuesday 7:30 a.m. – Physicians Conference Room 7:30 a.m. – Physicians Conference Room Last approx. 1.5 hrs. depending on number of applicants Last approx. 1.5 hrs. depending on number of applicants Mark on dates on office calendar, PDA, etc. 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

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

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 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. 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.

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

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

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