A Self-Assessment Guide for Health Care Organizations - IFC

Clinical Privileging Committee
The Committee is charged with advising on credentialing and
defining the Clinical Privileges of Medical Practitioners and Allied
Health Professionals by:
1. Providing advice, guidance and/or endorsement to other
clinical and advisory committees with regard to policies and
procedures, clinical reviews, and safety, quality, audit and
education processes.
2. Advising the Director of Medical Services on the range of
clinical services, procedures and other interventions that can be
provided safely in the Relevant Hospital setting.
3. Advising the Director of Medical Services on the minimum
credentials necessary for a Medical Practitioner or Allied Health
Professional to fulfill competently the duties of a specific
position or Clinical Privileges, within the Relevant Hospital.
4. Advising the Hospital Director on the information that should
be requested and provided by applicants for appointment to
specific Medical Practitioner and Allied Health Professional
positions or for specific clinical privileges.
5. Accepting requests to undertake the processes of credentialing
and defining the clinical privileges in line with the range of
clinical services, procedures and other interventions:
a) relevant to all Medical Practitioners applying for initial
appointment,
b) from an Authorized Person, in respect of a review of the
Medical Practitioner or Allied Health Professional and/or
their clinical Privileges, and
c) from any Medical Practitioner or Allied Health Professional
who requests a review of their clinical privileges.
6. Ensuring the credentials of each Medical Practitioner or Allied
Health Professional are reviewed and verified in accordance
with the organization’s by-laws and policies.
7. Advising the Hospital Director of the committee’s
recommendations in relation to the clinical privileges of each
Medical Practitioner and Allied Health Professional.
IFC Self-Assessment Guide for Health Care Organizations 93