Credentialing and privileging
Appointment process for medical staff
What is an appointment process?
An appointment process is the formal procedure medical directors use to:
- review a medical professional's credentials, qualifications, and experience
- determine if they meet the requirements to work at that facility
- grant them permission (privileges) to perform specific medical procedures or services
Who completes the appointment process?
Medical staff looking to perform specific medical procedures or services must apply and request privileges through the facility's medical director.
Depending on the type of facility or service, the facility's medical director or health authority is responsible for reviewing the medical staff's credentials and privileges.
The medical director is also responsible for submitting a notification of new/updated medical staff appointment form and a copy of the staff’s appropriate procedures list to the accreditation programs (NHMSFAP or DAP).
NHMSFAP guide on credentialing and privileging for medical directors
DAP guide on credentialing and privileging for medical directors
BC Medical Quality Initiative (BCMQI)
Credentialing standards
The DAP Committee and NHMSFAP Committee use the BCMQI provincial privileging dictionaries as objective criteria for core, non-core, training, and experience requirements within each specialty.
The dictionaries outline the following requirements:
- privileges that are core and non-core for each specialty
- training and current experience requirements
- performing diagnostic services
- interpreting diagnostic services
- identifying diagnostic services that are considered core or non-core privileges
Role of the accreditation programs
The accreditation programs, DAP and NHMSFAP:
- maintain records of current medical staff in facilities
- provides educational support to the medical director in the process of medical staff appointment and reappointment
- ensures that the privileges granted are appropriate procedures for the facility
- performs medical staff appointment audits to ensure that the facility meets the accreditation standards for the medical director
Credentialing and privileging is required for all non-hospital facility staff
Medical staff must complete an appointment application and request privileges through the facility's medical director.
Credentialing and privileging for diagnostic services and procedures
For independent diagnostic facilities
Medical staff must complete an appointment application and request privileges through the facility's medical director.
If the health authority privileges of the medical staff reflect the privileges they are applying for in the independent facility, the medical director is not required to complete a full review of the physician’s credentials and currency.
The medical director is required to review the medical staff’s appropriate supporting documentation and complete and submit the Notification of Medical staff Appointment Form to the program.
The DAP developed policies to clarify the qualifications and training for physicians in community facilities.
For health authority facilities
The health authority's medical affairs office completes the credentialing and privileging functions.
Medical directors can refer to the BCMQI dictionaries to determine the requirements for the medical staff’s credentials, qualifications, and experience.
For community-based practices
Many medical offices are owner-operated solo practices. In these instances, the physician may not hold privileges with a health authority. They also may not have gone through a credentialing process for restricted services with the health authority.
Physician's responsibility: As the medical director of the practice, they must attest and provide evidence of their scope of practice to the DAP upon notification of appointing themselves as the medical director.
In community-based multi-practitioner facilities, the medical director and ownership are responsible for ensuring the physicians practising in their facility are appropriately credentialed and privileged, either through the health authority or through DAP processes.
Medical directors and owners: Verify the medical staff credentials through:
- health authority credentialing
- DAP appointment process