Medical Staff Appointment, Credentialing and Re-appointment

The medical executive committee recommends approval of appointment privileges to the governing body of the surgery center in which then the governing body grants and approves the initial appointment, reappointment, assignment or curtailment of clinical privileges based on professional peer review evaluation and verification.  If you are a smaller facility you may not have a need for a medical executive committee.  Most of the time the medical executive committee and the governing body are one in the same.

Each physician, practitioner or allied healthcare has to submit an application for appointment.  Along with the application you must include certain documents so the surgery center’s committee can perform peer reference check and primary source verification on the information submitted with your application for privileges.

On an application for initial privileges, the applicant is required to provide sufficient evidence of training, experience, and current competence in performance of the procedures for which privileges are requested.  The information will include items such as education and training, current state license, DEA, and liability insurance to name few.  When a request to submit an application is made, the surgery center must provide with the application a list of required documents and licenses needed to include during this process as well as a delineation of privileges list.  The delineation of privileges list is a simply just a list denoting the types of procedures the surgeon is competent to perform at the facility.

Don’t forget to perform primary source verification.  This process is mandatory in which provide the facility with information on the practitioner regarding professional liability claims history, information regarding licensure revocations, suspensions, or probationary status, and complaints or adverse actions.  Resources for primary source verification include American Medical Association and National Practitioners Data Bank.  You will find yourself performing second source verification for allied health practitioners and podiatrist.  Second source verification is a reference check of training and education.

Once credentials are verified the governing body will grant privileges based on the number of years pertaining to your appointment policy.  This can be up to 3 years, depending on what is stated in your policy.  The governing body can also grant temporary privileges right away just remember to do so according to your policy.

The re-appointment process is based on continuous peer review, conduct and competency based on an on-going monitoring of the practitioners performance. The application for reappointment, the applicant will provide evidence of present compliance with the requirements listed above.

Credentialing files are maintained for each member of the facility, including the initial application, reapplication, verifications, privileges granted, and other pertinent information.  Keep in mind to keep all credentialing files in a locked secure area within the facility.

For more information I am available for consultation and for service if you need assistance on the surgery center re-accreditation/certification process.  You can reach me at ABA headquarters.  Contact information can be found in the “about me” tab or email me at

Here’s to your success



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