Credentialing and privileging

All medical staff in accredited private medical/surgical facilities in British Columbia must undergo an appointment process. Privilege requests are made through the medical director of the facility. 

What is the role of the Non-Hospital Medical and Surgical Facilities Accreditation Program?

The Non-Hospital Medical and Surgical Facilities Accreditation Program (NHMSFAP) reviews and verifies the privileges granted by the facility medical director.

The NHMSFAP Committee has adopted the BCMQI dictionaries as objective criteria within each specialty. This includes the following requirements:

  • privileges that are core and non-core for each specialty
  • training and current experience requirements


Steps in the process
  1. The physician submits the application and supporting documentation to the medical director of the facility.
  2. The medical director meets with the applicant to review the application, procedures requested and current experience.
  3. The facility medical director submits the completed application and supporting documentation to the NHMSFAP.
  4. The NHMSFAP sends written verification to the medical director and applicant after reviewing the application. Medical staff may not perform procedures at the facility until verification is received.

Checklist for appointment to a medical/surgical facility

Responsibilities of the medical director

The medical director must do the following:

  • confirm the applicant’s current experience
  • confirm the procedures selected are appropriate for the facility
  • follow the BC MQI privileging dictionaries to ensure physician procedure requests meet specialty privileging and current experience requirements
After an application is submitted

Within 60 days of receiving a completed application, the NHMSFAP is required to forward to the applicant

All medical staff must be reappointed on a yearly basis. The facility must keep the reapplication form on file. The facility must submit a copy to the NHMSFAP if requested or outlined in the form.