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What do hospital boards need to know about Professional Staff credentialing?

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As you may know, the Auditor General released a report criticizing the Public Hospitals Act Professional Staff appointment appeals process for being time-consuming and costly.

Here is an excerpt from that report. Auditor General Report 2016 Excerpt

Your hospital board may be interested to hear what it’s all about and their 18 responsibilities and the 9 tools they can use to discharge those duties.

Have you delivered board credentialing training lately?

You will want to make sure your hospital board members understand their 18 responsibilities (reference to “PHA” means a requirement of the Public Hospitals Act and/or its Hospital Management Regulation 965):

  1. Annually appoint and re-appoint a Professional Staff and revoke, suspend or restrict privileges if required (PHA requires for physicians and PHA Regulation + by-laws for others)
  2. Determine scope of privileges (PHA)
  3. Review temporary appointments made by CEO (PHA)
  4. Hold hearings on privileges issues (PHA for Medical Staff + By-laws for other Professional Staff)
  5. Comply with the rules for privileges hearings (PHA)
  6. Represent hospital at appeals to Health Professions Appeal and Review Board (PHA Reg)
  7. Approve Rules and Regulations for the Professional Staff
  8. Approve policies and procedures applicable to Professional Staff
  9. Making decisions about granting leave of absence where there will be a suspension or restriction of privileges (or approve a policy to be administered by Chief of Staff)
  10. .Monitor activities in the hospital and take measures to ensure compliance with PHA, regulations and by-laws (PHA)
  11. Pass by-laws to set standards for appointing and re-appointing Professional Staff (PHA)
  12. Appoint Chief of Staff to chair MAC (PHA)
  13. Establish the MAC to assess credentials, health records, patient care, infection control, utilization and treatment (PHA)
  14. Determine whether MAC will include non-Medical Staff members
  15. Establish sub-committees of MAC and appoint non-Medical Staff members as appropriate (PHA)
  16. Receive reports from the MAC through its Chair about the work of the MAC
  17. Determine departmental and divisional structures if any (PHA)
  18. Appoint Chiefs of Department if any (PHA)

(Source: Ontario Hospital Association, Professional Staff Credentialing Toolkit, I was the primary author)

There are 9 tools a hospital board uses to ensure it meets its duties:

  1. Professional Staff by-laws
  2. Application forms for Professional Staff
  3. Rules and Regulations and Policies
  4. Certificate of Integrity of the Credentialing Process
  5. Questions for the Chief of Staff/Chair of MAC
  6. Reflection exercise
  7. Audit
  8. Training
  9. Board hearings

Board Credentialing Training

This is a great time of year when your Board is getting ready for its AGM and for the process of approving the annual appointments and reappointments of the Professional Staff to do credentialing training. Let me know if you are interested in some help to make that training relevant, memorable and fun!


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