The credentialing and privileging process shall be governed by the credentialing and

privileging committee with following mandate and functions.

 Review and evaluate the completed applications for privileging and supporting
documentation and reports of the Chairperson/ Head of the Department for all
applicants for medical staff appointment, re-appointment and/or clinical privileges
and make its recommendation concerning the same.
 Upon joining of a Medical Practitioner, he/she will serve a 180-day probationary
period in which provisional/temporary privileges shall be granted based on education,
current competence, ability to perform, training, experience, and documented
recommendations.
 The provisional review of privileging performed by the clinician, duly concurred by
the Chairperson/ Head of the Department, the Medical Director and C&P Committee
Members.
 Monitoring Probationary Period by the Chairman/Head of the Department will occur
by direct observation: -
o The new clinician will have chart audit/reviews performed on their patient
care documentation
o The new clinician will also be evaluated on behavior of patient care
encounters.
o Safe Medication and procedure practices.
o Upon Satisfactory Completion of the Probationary Period, the Chairperson/
Head of the Department with peer recommendations will assist with the
review of privileges and forward the application for initial privileges to the
Credentialing & Privileging Committee:
o The initial privileges will be valid for a period of 3 years.
o Upon satisfactory completion of the initial period, the Chairperson/Head of the
Department will recommend subsequent privileges and forward the
application to the Credentialing and Privileging Committee for delineation of
privileges: -
o In all cases of renewal or revalidating the privileges; performance appraisal
and ongoing professional practice evaluation will be conducted.
o The Performance Appraisal Form and the application for privilege will be
forwarded by the HR Department to the Chairperson of the C&P committee.
o In all cases the above forms will be forwarded at least two months prior to the
completion of the contract or expiry of the privileges whichever is earlier.
o Annual Clinical appraisal & re-appointment review system will include the
following,
 Professional performance, competence, judgment, skills, behavior, and
knowledge.
 Medical staff’s current licensure, physical and mental health.
 Meeting continuing education standards.
 Timely, completed, accurate clear medical entries in the medical files.
  Participation in Quality Improvement activities.
 Working relationship with colleagues.
 Attendance in the medical staff and committee meetings.
 Other Quality data such as patient complaints, Incident Report,
 Insurance and panel patient denials, etc.…
o When a member of the Credentialing and Privileging Committee is reviewed
for privileges, he /she will be excluded from that meeting.
o If a physician is involved in a clinical incident which results in untoward
effects on a patient, an immediate re-evaluation of his/her privileges will be
done by the Credentialing and Privileging Committee. This will be processed
further to involve the hospital management.
o Staff employed prior to implementation of accreditation requirements shall be
credentialed at the time of re-contracting.
 Credentialing Through Primary source verification
 Education
 Experience
 Training
 Licensure
 Approval of specific privileges
For detailed credentialing and privileges process (Refers to credentialing and privileging
policy)