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 NPDB. 
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 
clinical privileges. 
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 
clinical privileges.
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 
receipt mail.

Approved By Governing Board    
Control #318.11