Credentialing and Privileging
Credentialing: This organization utilizes the American
Medical Association for primary source credentialing on the
following individuals: MD.
Additionally the National Practitioner Data Bank is also
queried for the MD, DO, Podiatrist,DDS and CRNAs. AAAHC
organizations will also report practitioners as necessary to
The organization will contact all schools of the following
individuals, Professional Nurses, and ancillary medical staff
such as Estheticians, Audiologists, Acupuncturists, Massage
Therapists, Ultra sound Technologists, Radiological
Technologists, Certified Operating Room Technicians,
Certified Medical Assistants, Laser Technicians, etc in this
In addition, the State License Department is contacted for
verification of information on anyone in the organization
that carries or claims a state license. If an individual
holds a certificate versus a license, this will also be
verified, either through the on line program or via the
institution that issued that certificate.
This organization is committed to assuring that its entire
professional staff has the appropriate qualifications to
provide gastroenterology services and anesthesia services
through review of a credentialing process and documentation.
The Credentialing Committee consists of the medical director
and the safety officer. This committee meets on an ad hoc
basis to review the credentials of any new professional staff
and annually during the first quarter of each year.
Appointment time for staff that is credentialed and
privileged is 2 years.
Before granting, renewing, or revising privileges, the
clinical leadership evaluates the following:
Challenges to any licensure or registration
Voluntary and involuntary relinquishment of any license or
Voluntary and involuntary termination of medical staff
membership at another
Voluntary and involuntary limitation, reduction, or loss of
Any evidence of an unusual pattern or an excessive number of
professional liability actions resulting in a final judgment
against the applicant; this organization queries the
National Practitioner Data Bank (NPDB) at the time of initial
granting of privileges, as well as at least every two years
thereafter for information on physicians and dentists granted
Documentation as to the applicant's health status.
Privileging in this organization is not only based on
credentials. (See Appointment/Reappointment, By-Laws)
Privileges are also based on clinical skills, interpersonal
skills, and appropriateness of the physician with the patient
If the physician requesting privileges received additional
training outside the scope of his/her residency, he/she must
show proof of this additional training via a certificate.
This organization verifies in writing training related to the
privileges requested from the primary source at the time of
initial granting and renewal and revision of clinical
This organization also verifies in writing current competence
from the primary source, i.e. hospitals other office based
facilities, training programs, etc at time of initial
granting of clinical privileges and evidence of the ability
to perform the requested privilege.
At any time including an adverse outcome, should the medical
director have question with the ability of any licensed
independent practitioner (LIP) with regard to clinical
skills, interpersonal skills, or appropriateness with the
patient population, a meeting will be arranged with the LIP.
All areas of concern will be addressed as well as actions to
be taken, plans to implement, etc. This will be documented in
the form of minutes and kept in the individual's file.
Should the action taken be corrective or performance
improvement in nature, the committee shall meet again in 1
month to evaluate improvement and make further
The Medical Director can curtail privileges.
Should individual privileges be curtailed, the following can
Said individual may request a meeting with the credentialing
and privileging committee to consist of the Medical Director,
to present their cause.
After reviewing all details the committee will make
recommendation to the Medical Director regarding Curtailing
of Privileges, Re-instating privileges with restrictions, or
Re-instating of privileges, unrestricted.
Inactive Licensed Independent Practitioners:
The Medical Director can curtail privileges, after 3 months
of inactivity, by the LIP within the facility.
Results of all actions will be documented in the
Credentialing Committee minutes. All individuals that are
affected by any decision made will be notified by return
Approved By Governing Board