CREDENTIALING AND

PRIVILEGING
PROFESSIONAL STAFF APPOINTMENT

GAUDENCIO I. ABRATIQUE, MD
MARIA ISABELLE T. VIRATA, MD
ROBERT ANGELO T. MONTUYA
 GAUDENCIO I. ABRATIQUE, MD

MARIA ISABELLE T. VIRATA, MD

ROBERT ANGELO T. MONTUYA

 I. PURPOSE

• The purpose of the policy is to set out the standards

and processes for granting, continuing, and
discontinuing appointments to independent
medical practitioners.
 II. SCOPE

• This policy applies to all physicians, dentists, and

other professionals seeking independent practice at
the hospital.
• This policy covers all appointments, whether
permanent, fixed term contract, honorary, or
locum.
• This policy does not apply to medical/ dental
trainees, such as medical students, medical interns,
residents, fellows in training, observers
 III. POLICY STATEMENT

• The hospital develops and implements a

professional staff appointment process which
promotes fairness, merit, patient and staff safety
and the reputation of the hospital.
• All independent practitioners should be included in
the list of appointed staff in order to be granted
privileges to provide diagnostic, therapeutic,
interpretation or counseling services to hospital in-
and outpatients.
 III. POLICY STATEMENT

• All clinical positions should have an accurate up-to-

date position/role description that specifies
position/ title; duties, responsibilities and
accountabilities and/or delineation of clinical
privileges; qualifications, skills, licenses, education
and experience required; performance evaluation
criteria.
 IV. DEFINITIONS

• 1. Appointment – the process of including new

physicians in the hospital’s official roster of physicians
based on reviewing an initial applicant’s credentials and
on whether the hospital has patients, staff and
capabilities to support the particular physician’s
practice.
• 2. Credentials – documented evidence of an
applicant’s qualifications.
• 3. Clinical privileges – kind of work a physician/ dentist
is allowed to perform.
• 4. Competence – knowledge, skills, judgment, and
core practiced in decision making and performance
consistent with the individual’s practice role.
 IV. DEFINITIONS

• 5. Practitioner – physician or a dentist appointed

as professional staff by a hospital.

• 6. Role delineation – level of clinical services that

can be provided safely and is supported
appropriately by the hospital, as determined by the
availability of the necessary infrastructure, support
services, staff qualifications, minimum safety
standards, and other possible requirements
deemed appropriate by any regulating
organization.
 IV. DEFINITIONS

• 7. Performance review – process that determines

whether a practitioner continues to have the ability
to meet the terms and condition of their
appointment or employment contract.

• 8. Benchmark – standard or reference by which

others can be measured.
 IV. DEFINITIONS

• 9. Competencies – set of defined behavior and/or

qualifications that provide a structured guide,
enabling the identification, evaluation, and
development of the performance of individual
practitioners.
• a. Patient Care
• b. Medical/ clinical knowledge
• c. Practice- based learning and improvement
• d. Interpersonal and Communication Skills
• e. Professionalism
• f. System- based practice
• g. Stewardship practice
 IV. DEFINITIONS

• 10. Focused Professional Practice Evaluation (FPPE)

– a directed evaluation of practitioner competence
in the performance of specific clinical privilege(s).
• 11. Low/ No volume activity – volume of procedural
and/ or patient contact activity that is insufficient to
allow measurement of quality, proficiency, and
practice.
• 12. Strategic Improvement Plan – a facilitated
planning process that assists the professional in
analyzing their strengths, weaknesses, and
opportunities, in order to achieve acceptable
performance..
 IV. DEFINITIONS

• 13. Trigger – a significant variance that represents a

threat to patient or staff safety requiring an
immediate FPPE of the involved professional.
• 14. Medical Staff – physicians and other
professionals who are licensed to practice
independently (w/o supervision) who provides
preventive, curative, restorative, surgical,
rehabilitative, or other medical or dental services.
• 15. Active Staff – consist of physicians qualified for
staff membership who exercise clinical privileges
and also fulfilled the criteria of clinical activity.
 IV. DEFINITIONS

• 16. Visiting Staff – those who exercise clinical

privileges of active staff but have not fulfilled the
minimum criteria of clinical activity or have applied
as visiting staff only.
• 17. Inactive Staff – those who had zero hospital
activity for two (2) years or more.
• 18. Delisted – Physician who has no activity for three
(3) years will be removed to the roster.
 IV. DEFINITIONS

• 19. Credentials and Privileging Committee –

Committee responsible for reviewing department
recommendation for professional staff
appointments and delineation of clinical privileges
of individual practitioners.

• 20. Ongoing Professional Practice Evaluation (OPPE)

– summary on continuous data collected for the
purpose of assessing practitioner’s clinical
competence and professional behavior.
 IV. DEFINITIONS

• 19. Credentialing – the process of gathering,

verifying, and evaluating the credentials (license,
education, training, competence, and experience)
of those medical staff permitted to provide patient
care without supervision. The process of gathering
credentials prior to awarding new and/or renewing
existing privileges.
 IV. DEFINITIONS

• 20. Reappointment – the process of reviewing a

current medical staff member’s life to verify
continued licensure, credentials for new or
expanded privileges and to ascertain that the
medical staff member is not compromised by
disciplinary actions of licensing and certification
agencies and is physically and mentally able to
provide patient care and treatment without
supervision.
 V. GENERAL POLICIES AND
PROCEDURES (OVERVIEW)
• 5.1 Application for Appointment
• 5.2 Minimum Mandatory required credentials
• 5.3 Other Requirements
• 5.4 Application fees
• 5.5 Forwarding of application packets
• 5.6 The application review process
• 5.7 The applicant interview process
• 5.8 Evaluation of applicants
• 5.9 Determining clinical privileges
• 5.10 The Process of delineating clinical privileges
• 5.11 Categories of Clinical Privileges
• 5.12 Responding to applications
• 5.13 Outcomes of the Application
• 5.14 Appointment Decision
• 5.15 Re-appointment
• 5.16 Classification of the Professional Staff
• 5.17 Dissemination of information on professional staff appointment
 5.1 APPLICATION FOR
APPOINTMENT
V. GENERAL POLICIES AND PROCEDURES
5.1 APPLICATION FOR APPOINTMENT

• Medical and dental practitioners may apply during

1st 6 weeks of any quarter. The application periods
are therefore from January 1 to February 15, from
April 1 through May 15, from July 1 through August
15 and from October 1 through November 15.

• All applicants to the hospital professional staff must

completely accomplish the Professional Staff
Application Packet and submit it with all original
supporting documents to the Chief Medical Officer.
Only complete application packets shall be
accepted for processing. Application packets with
incomplete entries and/or supporting documents
shall be returned to the applicant.
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5.2 MINIMUM MANDATORY
REQUIRED CREDENTIALS
V. GENERAL POLICIES AND PROCEDURES
 5.2 MINIMUM MANDATORY REQUIRED
CREDENTIALS

• 1. Medical/ dental school diploma

• 2. Professional Regulation Commission (PRC) ID
card.
• 3. Specialty Board Certification or training
certification, if there is no Board certification
program covering the specialty.
• 4. Sub-specialty Board Certification or training
certification.
 5.2 MINIMUM MANDATORY REQUIRED
CREDENTIALS

• 5. Valid Cardiopulmonary resuscitation Certificate if

applicable, Advance Life Support (ALS), Pediatric
Advance Life Support (PALS) (All must be at least 6
months from expiry).
• 6. TIN card.
• 7. Philhealth Accreditation ID Card
• 8. Other credentials supporting clinical practice
 5.3 OTHER REQUIREMENTS

• 6. Health and medicolegal declarations

• 7. Signed Contract for contracted physicians
• 8. A current PRC license or a “provisional license
number” if not registered in the Philippines
• 9. Two referees who can comment fairly and
objectively on an applicant’s clinical skills and
experience.
5.3 OTHER REQUIREMENTS
V. GENERAL POLICIES AND PROCEDURES
 5.3 OTHER REQUIREMENTS

• 1. Signed criminal record check consent form

• 2. Signed health declaration form
• 3. Signed standard consent for employment related
checks
• 4. Overseas criminal record checks for overseas
applicants
• 5. A declaration of all current appointments and
the clinical privileges held at any other health
provider facility and a declaration of the clinical
privileges being applied for by the applicant.
 5.4 APPLICATION FEES
V. GENERAL POLICIES AND PROCEDURES
 5.4 APPLICATION FEES

• All applicants are required to pay all requisite fees

• Additional fees may be required for extraordinary

activities related to the applicant process, such as
internal source verification.
 5.5 FORWARDING OF
APPLICATION PACKETS
V. GENERAL POLICIES AND PROCEDURES
 5.5 FORWARDING OF APPLICATION
PACKETS
• Copies of the completed application packets shall
be forwarded to the relevant clinical department
chair and the respective committee for review.

• Once the review of the applicant’s application

packet has been completed, the relevant clinical
department chair will make a recommendation for
interview or for discontinuation of the application
process, based on the factors listed under the 5.8
Evaluation of Applicants.
5.6 THE APPLICATION REVIEW
PROCESS
V. GENERAL POLICIES AND PROCEDURES
5.6 THE APPLICATION REVIEW PROCESS

• All application documents will be reviewed by the

assigned interview panel before the applicant
interview.
• The minimum mandatory documents will be verified
from primary source.
• Statements from the applicant’s referees will be
verified as needed
• Other information about the applicant that the
professional staff may have first hand knowledge of.
5.7 THE APPLICANT INTERVIEW
PROCESS
V. GENERAL POLICIES AND PROCEDURES
5.7 THE APPLICANT INTERVIEW PROCESS

• All applicants for appointment must be interviewed

by (1) a member of the Credentials and Privileging
Committee, (2) the chair or representative of the
involved department and (3) a physician member
of MANCOM sitting en banc.

• The interview must be conducted within the quarter

in w/c the application was made. For this purpose,
interviews will be made in March, June, September,
and December.
5.7 THE APPLICANT INTERVIEW PROCESS

• Interview questions should be related to the

selection criteria, job description/ delineation of
clinical privileges. A common set of initial questions
should be asked of all applicants.

• The objective of the selection/ interview panel is to

develop the appropriate application outcome
based on the totality of available material available
to the Credentials and Privileging Committee.
5.7 THE APPLICANT INTERVIEW PROCESS

• During the interview, applicants must be informed

of:

1. The need to comply with the goals and

programs of the hospital, and work in a
cooperative and collegiate fashion as a member
of a team in achieving those objectives.

2. The requirement to participate in the annual

performance review process (OPPE policy).
5.7 THE APPLICANT INTERVIEW PROCESS

• During the interview, applicants must be informed

of:

3. Any mandatory physical, psychological or

sensory requirements necessary to perform inherent
requirements of the job.

4. That a verification of all credentials will be

undertaken on all applicants.
 Sample name
Ongoing Professional Practice Evaluation for General Surgery
Reporting Period: July 2016 - June 2017
Physician Number: 0
Department: Surgery Surgery
Specialty: General Surgery General Surgery
Sub-Specialty: General Surgery
Status/Classification: Active
Benchmark/
Indicator/Criteria 2017
Trigger
BEHAVIOR
Participation in hospital wide activities on patient safety and quality improvement 20% 0%
Report on disruptive behavior /patient safety issue 1 0
PROFESSIONAL GROWTH
Patient Care
Total number of patient encounters(Admissions & Procedures) 12 24
Medical/Clinical Knowledge
Total number of CME/CPD points 20 0/0
Practice-Based Learning and Improvements
Attendance to hospital clinical conferences/meetings 50% 0%
Attendance in department/ section meetings 50% 100%
Interpersonal and Communication Skills
Favorable patient/family satisfaction survey comments 1 0
Written complaints from peers and associates 1 0
Professionalism
Non-response to consultation/referral within 24 hours 1 0
Delays in OR start time due to surgeon tardiness 1 0

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System-Based Practices
Percent of patient charts with illegal abbrevations <10% 0%
Percent of patient charts with complete medical records >90% 100%
Stewardship of Resources
-
CLINICAL RESULTS
Hospital Wide Data Sources
Number of sentinel events / adverse events / Medical error 1 0
Surgical Site Infection Rate 4% 0%
Unplanned transfer to ICU 1 0
Department Specific Data Sources
Unintended return to OR within 7days 1 0
Wrong site Surgery 1 0
Morbidity rate 0.43% 0%
Mortality rate 0.23% 0%
Conclusions:
Acceptable performance
Performance falls below acceptable limits
Insufficient data
Additional comments/recommendations:

Noted by:
____________________________________ _____________________________________________
Signature over printed name/Date and time Evaluation Results and RecommendationsConcurred by:
Section Head/Department Head Chief Medical Officer

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 5.8 EVALUATION OF
APPLICANTS
V. GENERAL POLICIES AND PROCEDURES
 5.8 EVALUATION OF APPLICANTS

• Applicant should be considered in light of:

1. Their ability to meet privileging and selection

criteria and against requested clinical privileges.

2. Qualifications and experience

3. Their current and past performance

 5.8 EVALUATION OF APPLICANTS

• Applicant should be considered in light of:

4. The institutional needs of the hospital

5. The capacity of the applicants to work

effectively as a member of a team to achieve the
hospital’s goal.
 5.8 EVALUATION OF APPLICANTS

• When the assessment process has been completed,

the credentialing and privileging committee must
analyze all information and identify suitable
applicants.
 5.8 EVALUATION OF APPLICANTS

• Applicants should also be considered against

• Source Value – qualification credentials and
experience enable the practitioners to provide
clinical source needed by the department.
• Leadership Value – applicant can lead/manage
a hospital’s program.
• Research and Innovation Value – applicant can
lead research and innovation projects and
programs.
• Training and Staff Development Value – applicant
is able to teach mentor other physician,
especially in the residency/ fellowship training
programs.
5.9 DETERMINING CLINICAL
PRIVILEGES
V. GENERAL POLICIES AND PROCEDURES
5.9 DETERMINING CLINICAL PRIVILEGES

• The granting of requested clinical privileges is

associated with the practitioner’s appointment to
the professional staff and shall be in concordance
with the policy for the Delineation of Clinical
Privileges for the Professional Staff.

• The determination of clinical privileges assesses a

practitioner’s defined clinical service and matches
that with the services provided by the hospital.
5.9 DETERMINING CLINICAL PRIVILEGES

• Privileges for independent practice may be

granted only upon completion of primary source
verification; otherwise, only privileges for practice in
consultation with independent practitioners will be
granted.
5.9 DETERMINING CLINICAL PRIVILEGES

• One time clinical privilege for independent practice

may be granted for a limited duration no
exceeding one month if
• The hospital does not have a practitioner who
can provide a specific service
• patient or family requests for a practitioner who
does not have a hospital appointment
• There are other justifiable clinical or psychosocial
concerns as determined.
5.10 THE PROCESS OF DELINEATING
CLINICAL PRIVILEGES
V. GENERAL POLICIES AND PROCEDURES
 5.10 THE PROCESS OF DELINEATING
CLINICAL PRIVILEGES
• The process of delineation of clinical privileges has 2
steps:
• A. Credentialing, the process of renewing a practitioners
licenses, education, training, skills, experience, and
competencies.
• B. Role delineation, to determine the clinical privileges to be
allowed within and supported by the facility.
 5.10 THE PROCESS OF DELINEATING
CLINICAL PRIVILEGES
• The purpose of the clinical privileges delineation
process is to assess a practitioner’s ability to provide
defined clinical services and to match that with the
capability of being properly supported by the
infrastructure of the hospital. This process must take
place as a part of appoint process and be
undertaken on a routine basis as part of a
performance review.
 5.10 THE PROCESS OF DELINEATING
CLINICAL PRIVILEGES
• Applicants should be given the opportunity to
respond to criticism and/or negative outcomes
before the committee finalizes its decision.

• There may be particular circumstances where

clinical privileges may be granted subject to the
applicant practitioner undertaking a period of
supervised practice or training to address identified
deficiencies.
5.11 CATEGORIES OF CLINICAL
PRIVILEGES
V. GENERAL POLICIES AND PROCEDURES
 5.11 CATEGORIES OF CLINICAL
PRIVILEGES
• Each practitioner may be granted clinical privileges
in 3 categories:

• Core 1 (Broad)
• Procedures or treatment areas in keeping with
the practitioners qualifications and training.
 5.11 CATEGORIES OF CLINICAL
PRIVILEGES
• Each practitioner may be granted clinical privileges
in 3 categories:

• Core 1 (Broad)
• The Credentials and Privileging committee
should not assume that because a specialty
group generally undertakes a specific
procedure, that privileges would automatically
be granted to all specialist practitioners in the
group.
 5.11 CATEGORIES OF CLINICAL
PRIVILEGES
• Each practitioner may be granted clinical privileges
in 3 categories:

• Core 2 (Specific)
• Procedures/treatment areas that are a part of a
practitioner’s training but may be performed
regularly.
 5.11 CATEGORIES OF CLINICAL
PRIVILEGES
• Each practitioner may be granted clinical privileges
in 3 categories:

• Core 2 (Specific)
• These may be procedures/ treatments in
subspecialties or areas where additional training
has been undertaken.
• Each specialty group/clinical department should
define the special treatment areas where specific
privileges need to be granted.
 5.11 CATEGORIES OF CLINICAL
PRIVILEGES
• Each practitioner may be granted clinical privileges
in 3 categories:

• Core 3 (Non- routine)

• Procedures or treatment areas not routinely
associated with the practitioner’s professional
group (i. e. family medicine providing obstetric
services)
DEPARTMENT OF SURGERY
DIVISION OF GENERAL SURGERY
Delineation of Clinical Privileges 1 of 6

Applicant’s Name: __________________________________________ Date:_______________

(Applicant completes left column) (Dept Chair/designee initials right column)

PRIVILEGES REQUESTED RECOMMEND GRANTING

The exercise of all privileges may occur only in context of hospital by-laws, rules and regulations and
hospital policies.

CLASS I
( ) Closure of Simple Lacerations ______________________
( ) Excision and/or Biopsy of Skin Tumors ______________________
(Include Small Basal Cell Carcinomas)
( ) Circumcision – Meatotomy ______________________
( ) Treatment of Burns (Less than 100%) ______________________
( ) Thoracentesis ______________________
( ) Removal of Superficial Foreign Bodies ______________________
( ) Evacuation of Thrombosed Hemorrhoid ______________________
( ) Bone Marrow Aspirations ______________________
( ) Proctoscopy and Sigmoidoscopy ______________________
( ) Incision and Drainage of Abscess ______________________
(Include Bartholin and Pilonidal)
( ) Cut down: Tap ______________________
( ) Single Undisplaced Fractures ______________________
( ) Excision of Ingrown Toenails ______________________
 2 of 6

CLASS II
( ) Tenorrhaphy (Extensor only) ______________________
( ) Elective Tracheostomy ______________________
( ) Anoplasty (Martin) ______________________
( ) Pilonidal Cystectomy ______________________
( ) Varicose Veins Procedure ______________________
( ) Paracentesis ______________________
( ) Minor Split Thickness Skin Crafts ______________________
( ) Hemorrhoidectomy ______________________
( ) Anal Fissurectomy and Sphincterotomy ______________________
( ) Tyroglossal Duct, Congenital Clefts and Sinuses ______________________
( ) Cervical Esophageal Diverticulectomy ______________________
( ) Treatment of Major Hand Infections ______________________
( ) Repair of Recto-Vaginal Fistula ______________________
( ) Inguinal Herniorrhaphy-All Types ______________________
(Including incarcerated)/Mesh

(Applicant completes left column) (Dept Chair/designee initials right column)

PRIVILEGES REQUESTED RECOMMEND GRANTING
 ( ) Umbilical Herniorrhaphy ______________________
(Including incarcerated)/Mesh
( ) Gastric Resection ______________________
( ) Vagotomy-Abdominal or Thoracic Approach ______________________ 3 of 6
( ) Biliary Tract Surgery ______________________
( ) Splenectomy ______________________
( ) Retro Peritoneal Node Dissection ______________________
( ) Breast Surgery/Mastectomy/Breast ______________________
Conservation Surgery (BCS) or equivalent
Procedure/Mammotome procedure
( ) Neurorrhaphy (Exclude Transplants) ______________________
( ) Limb Amputation- Elective and Traumatic ______________________
( ) Excision Sub Maxillary Gland ______________________
( ) Major Split Thickness Skin Grafts ______________________
( ) Pedicle Grafts ______________________
( ) Radical Groin Dissection ______________________
( ) Radical Axillary Dissection ______________________
( ) Major Colo-Rectal Surgery ______________________
( ) Care of Major Burns ______________________
( ) Small Intestinal Procedures ______________________
( ) Orchiopexy ______________________
( ) Spermatocele ______________________
( ) Breast Surgery Sub-Q Mastectomy ______________________
MRM/BCS

CLASS III
( ) Inguinal Herniorrhaphy ______________________
( ) Umbilical Herniorrhaphy ______________________
( ) Biopsy of Superficial Lymph Node ______________________
( ) Tube Thoracosctomy ______________________
( ) Appendectomy ______________________
( ) Hydrocelectomy ______________________
( ) Ganglionectomy ______________________
( ) Orchiectomy ______________________
 4 of 6
CLASS IV
( ) Repair of Dehiscence ______________________
( ) Repair of Incisional Hernia ______________________
( ) Exploratory Laparotomy (including ______________________
Closure of Perforated Viscus)
( ) Diaphragmatic Herniorrhaphy ______________________
( ) Abdominal or Thoracic Approach ______________________
( ) Pancreatic Surgery ______________________
( ) Major Colo-rectal Surgery (Exclude Congenital) ______________________
( ) Breast Surgery (Must include ALL procedures ______________________
except Cosmetic)
( ) Tenorrhaphy (Exclude Transplants) ______________________
( ) Digital Amputation-Elective and Traumatic ______________________
( ) Thyroid Surgery ______________________
( ) Incidental Surgery of G.U. or Gyne Organs ______________________
( ) Parotid Gland Surgery ______________________
( ) Radical Neck Dissection ______________________

(Applicant completes left column) (Dept Chair/designee initials right column)

PRIVILEGES REQUESTED RECOMMEND GRANTING
( ) Excision of Malignant Skin Tumors ______________________
(Must include ability to Skin Graft and
Rotate Flaps( Exclude Small Basal Cell 5 of 6
Carcinoma)
( ) Pyloromyotomy ______________________
( ) Hyperalimentation Catheter ______________________
( ) C.V.P. Insertion ______________________
( ) Umbrella Procedures ______________________
( ) Incidental Surgery of G.U. or Gyne Organs ______________________

ADDITIONAL PROCEDURES (not listed):

( ) _____________________________________ ______________________
( ) _____________________________________ ______________________
( ) _____________________________________ ______________________

I request privilege as indicated above and shall restrict my clinical activities to same. I am mentally and
physically able to perform clinical privileges as indicated above.

____________________________
Signature of Applicant / Date
 6 of 6
Recommended by:

________________________________________
ROUEL MATEO M. AZORES, MD., FPCS, FPALES
Division Head, General Surgery

Approved by:

_____________________________________
MIGUEL C. MENDOZA, MD. FPCS, FPALES
Chairman, Department of Surgery

Credential Committee meeting of ____/_____/___

Medical Executive Committee meeting of _____/_____/_____
Board of Directors meeting of _____/_____/_____
DEPARTMENT OF MEDICINE
Delineation of Clinical Privileges 1 of 14

Applicant Name: __________________________________________ Date:________________

(APPLICANT COMPLETES LEFT COLUMN) (Dept Chair/designee initials right column)

PRIVILEGES REQUESTED RECOMMEND GRANTING

(The exercise of all clinical privileges may occur only in context of professional staff bylaws, rules and
regulations, and hospital policies)

[] General _______
[] Hospital Admission _______
[] Patient Care Orders _______
[] In hospital consultation _______
[] Emergency Room Consultation _______

In the case of an emergency, any individual who is a member of the professional staff or who has been
granted clinical privileges is permitted to do everything possible within the scope of his/her license, to
save a patient’s life or to save a patient from serious harm, regardless of staff status or privileges granted.

Consultations are expected to be obtained when the diagnosis or management is in doubt for an unduly
long period of time, when complications arise or when specialized treatments or procedures are
contemplated that are different from privileges granted.
[ ] CATEGORY I Diagnosis and therapy of general medical illnesses, injuries or 2 of 14
conditions, or performance of procedures, within minimal threat of
life. Procedures generally acquired during residency training
include but are not limited to Bone marrow aspiration,
thoracentesis, pericardiocentesis, paracentesis, Renal biopsy, joint
aspiration, Fine needle aspiration biopsy, etc
[ ] CATEGORY IA Care Station Privileges:
[ ] CATEGORY II Major Diagnosis and therapy of general medical illnesses,
injuries, or conditions, or the performance of procedures, with
possible serious threat to life.

Criteria for above: Approved internal medicine residency; board

qualification/certification
[ ] CATEGORY III Unusually complex or critical diagnosis and therapy of illnesses,
injuries, or conditions, or the performance of the procedures, with
possible threat to life, within area of sub-specialization.

Criteria: Category III - Approved fellowship program; board

certified an internal medicine if required; subspecialty board
qualification/certification within two cycles of completion of
fellowship of applicant’s particular board.
Exception: AHMC physicians granted privileges prior to ____ the
applicant’s particular board
 3 of 14
GENERAL INTERNAL MEDICINE CLINICAL PRIVILEGES
[] ALLERGY and IMMUNOLOGY
Asthma with Desensitization
Differential Diagnosis
Hay Fever
Serum Sickness
Urticaria
Others: ________________________________

[] CARDIOLOGY
Hypertension
Hypertension with Cardiac Insufficiency
Hypertension with Renal Insufficiency
Essential Hypertension, Unresponsive
Malignant Hypertension
Acute Coronary Syndromes
Myocardial Infarction
Myocarditis
Pericardial Disease
Rheumatic Fever
Shock, Cardiogenic
Others: ________________________________

CARDIOLOGY Category III Procedures not included in core cardiology

privileges
 CARDIOLOGY Category III Procedures not included in core cardiology
privileges 4 of 14
[] Cardiac Catheterization (Right and Left)
[] Coronary angiography
[] Myocardial biopsy
[] Angioplasty
[] Valvulopasty
[] Pacemaker Implantation
[] Carotid Interventional procedures
[] Electrophysiology and Ablation
[] Electrocardiogram
[] Holter Monitor
[] Treadmill Exercise Test
[] 2-D Echocardiogram (TTE) and Doppler
[] Treadmill Stress Echocardiogram
[] Dobutamine Stress Echocardiogram
[] Dipyridamole Stress Echocardiogram
[] Transesophageal Echocardiogram (TEE)
[] Intraoperative TEE
[] Contrast Study (for TTE and TEE)
[] Ambulatory BP Monitoring
[] Carotid Ultrasound Duplex Scan
[] Venous Ultrasound Duplex Scan
[] Peripheral/Arterial Ultrasound Duplex Scan
[] Renal artery/graft Ultrasound Duplex Scan
[] Cardiac Rehabilitation
Intraoperative Cardiac Monitoring
Others: ________________________________
[] GASTROENTEROLOGY 5 of 14
Diseases of oral cavity and salivary glands
Diseases of esophagus, stomach and duodenum
Diseases of appendix
Hernia
Noninfective enteritis and colitis
Other diseases of intestines
Diseases of peritoneum and retroperitoneum
Diseases of liver
Disorders of gallbladder, biliary tract and pancreas
Cholecystitis
Intestinal Obstruction
Malabsorption
Pancreatitis
Peptic Ulcer
Regional Ileitis
Ulcerative Colitis
Cirrhosis
Cirrhosis, with Bleeding Varices
Cirrhosis, with Coma
Cirrhosis, Decompensated
Hepatitis
Jaundice
Others: ________________________________
 GASTROENTEROLOGY Category III Procedures not included in core
Gastroenterology privileges
[] Colonoscopy: Gastroenterology fellowship; demonstrate performance of 6 of 14
100 colonoscopies during past 20 months with 20 snare polypectomy
[] Flexible Sigmoidoscopy: Confirmation of 5 supervised cases from program
director; 5 supervised procedures by a AHMC gastroenterologist with
current flex sig privileges
[] Flex Sigmoidoscopy w/ hemorrhoid banding
[] Laser: Subspecialty training; if directly out of training: documentation from
Program director. Or 16 hour Laser surgery course at least 8hrs with
animals, or, comparable privileges at an accredited hospital with
documentation of previous 3 years’ case list with letter from
Dept. Chair verifying case load and quality. If GI fellowship, 4 hrs of
practical can be obtained by performing 8 cases under supervision of
AHMC with Laser privileges.
[] ERCP: Diagnostic: 75 cases; Therapeutic: incl. Sphinterotomy, stone
Extraction and/or stent placement : 20 sphinterotomies & 5 stent
placement as a primary endoscopist.
[] [ ] Upper Endoscopy: 100 cases of diagnostic as primary endoscopist
[] [ ] Active Endoscopic Therapy for Variceal Hemostasis: 5 active bleeders,
20 as primary endoscopist
[] [ ] Liver biopsy with/without fluoroscopy : 20 cases

[] HEMATOLOGY
Nutritional anemias
Hemolytic anemias
Aplastic and other anemias and other bone marrow failure syndromes
Coagulation defects, purpura and other hemorrhagic conditions
Other disorders of blood and blood-forming organs
 Intraoperative and postprocedural complications of spleen 7 of 14
Certain disorders involving the immune mechanism
Others: ________________________________

[] INFECTIOUS DISEASE
Sepsis, with or without Shock
Intestinal infectious diseases
Tuberculosis
Bacterial infections, both local and systemic
Viral infections, both local and systemic
Spirochete
Rickettsioses
Other diseases caused by chlamydiae
Arthropod-borne viral fevers and viral hemorrhagic fevers
Human immunodeficiency virus [HIV] disease
Mycoses
Protozoal diseases
Helminthiases
Pediculosis, acariasis and other infestations
Others: ________________________________
[] METABOLIC and ENDOCRINOLOGY
Diabetes mellitus
8 of 14
Other disorders of glucose regulation and pancreatic internal secretion
Disorders of other endocrine glands
Intraoperative complications of endocrine system
Malnutrition
Other nutritional deficiencies
Overweight, obesity and other hyperalimentation
Metabolic disorders
Postprocedural endocrine and metabolic complications and disorders, not
elsewhere classified
Addison’s Disease
Aldosteronism
Cushing’s Syndrome
Diabetes Mellitus
Diabetes Mellitus with Acidosis
Diabetes Mellitus with Coma
Differential Diagnosis
Parathyroid Conditions
Pheochromocytoma
Pituitary Conditions
Sex Hormone Abnormalities
Thyroid Conditions
Thyroid Conditions with Coma
Thyroid Conditions with Thyrotoxic Crisis
Others: ________________________________
 9 of 14

[] NEUROLOGICAL DISEASES
Convulsive States
Dementia
Differential Diagnosis
Meningitis-Encephalitis
Multiple Sclerosis
Parkinsonism
NEUROLOGICAL DISEASES (Cont.)
Stroke
Others: ________________________________
[] ONCOLOGY 10 of 14
Malignant neoplasms, stated or presumed to be primary (of specified sites),
and certain specified histologies, except neuroendocrine, and of lymphoid,
hematopoietic and related tissue
Malignant neoplasms of lip, oral cavity and pharynx
Malignant neoplasms of digestive organs
Malignant neoplasms of respiratory and intrathoracic organs
Malignant neoplasms of bone and articular cartilage
Malignant neoplasms of skin
Malignant neoplasms of mesothelial and soft tissue
Malignant neoplasms of breast
Malignant neoplasms of female genital organs
Malignant neoplasms of male genital organs
Malignant neoplasms of urinary tract
Malignant neoplasms of eye, brain and other parts of central nervous
system
Malignant neoplasms of thyroid and other endocrine glands
Malignant neuroendocrine tumors
Secondary neuroendocrine tumors
Malignant neoplasms of ill-defined, other secondary and unspecified sites
Malignant neoplasms of lymphoid, hematopoietic and related tissue
In situ neoplasms
Benign neoplasms, except benign neuroendocrine tumors
Benign neuroendocrine tumors
Neoplasms of uncertain behavior, polycythemia vera and myelodysplastic
syndromes
Neoplasms of unspecified behavior
Malignant neoplasms of skin
Others: ________________________________
[] PULMONOLOGY 11 of 14
Influenza and pneumonia
Other acute lower respiratory infections
Other diseases of upper respiratory tract
Chronic lower respiratory diseases
Lung diseases due to external agents
Other respiratory diseases principally affecting the interstitium
Suppurative and necrotic conditions of the lower respiratory tract
Other diseases of the pleura
Intraoperative and postprocedural complications and disorders of
respiratory system, not elsewhere classified
Chronic Obstructive Pulmonary Disease
Pulmonary Embolism/Infarction
Pneumonia, Complicated
Pneumonia, Uncomplicated
Pneumothorax, Spontaneous
Others: ________________________________
 PULMONOLOGY Category III Procedures not included in core
Pulmonology privileges 12 of 14
[] Bronchoscopy (minimum 50 procedures)
[] Closed Pleural biopsy (minimum 10 supervised procedures)
[] Percutaneous Needle biopsy (minimum 8 supervised procedures)
Criteria for above: Board certification and/or qualification in Pulmonary
Medicine and minimum required procedures noted.
Applicant is responsible for submitting documentation attesting to
competency in above procedures. Applicants currently practicing
pulmonary medicine are responsible submitting documentation attesting
to their competency in performing above procedures since completion of
subspecialty training.

[] RENAL DISEASES
Acute Insufficiency
Acute Insufficiency, Conservative
Acute Insufficiency, Dialysis
Nephritis
Nephrosis
Pyelonephritis
Glomerular diseases
Renal tubulo interstitial diseases
Acute kidney failure and chronic kidney disease
Urolithiasis
Other disorders of kidney and ureter
Other diseases of the urinary system
[] RHEUMATOLOGY
Gouty Arthritis
Juvenile Rheumatoid Arthritis 13 of 14
Osteoarthritis
Polymyalgia Rheumatica and Temporal Arthritis
Rheumatoid Conditions
Ankylosing Spondylitis
Dermatomyositis/Polymyositis
Lupus Erythematosus
Necrotizing Granulomatosis
Osteoporosis
Polyarteritis Nodosa
Scleroderma
Sympathetically Mediated Pain Disorders (reflex sympathetic disorders)
Vasculitis
Inflammatory polyarthropathies
Osteoarthritis
Other joint disorders
Dentofacial anomalies [including malocclusion] and other disorders of jaw
Systemic connective tissue disorders
Deforming dorsopathies
Spondylopathies
Other dorsopathies
Disorders of muscles
Disorders of synovium and tendon
Other soft tissue disorders
Disorders of bone density and structure
Other osteopathies
Chondropathies
Other disorders of the musculoskeletal system and connective tissue
Intraoperative and postprocedural complications and disorders of
musculoskeletal system, not elsewhere classified
Biomechanical lesions, not elsewhere classified
Others: ________________________________
[] MISCELLANEOUS
Acute Peripheral Embolism
Central Nervous System Infections
Fever of Undetermined Origin 14 of 14
Thrombophlebitis
Uncomplicated Infections

Note: The above is a representative, but of necessity not exhaustive list of conditions, problems, and
procedures in Internal Medicine. It is not intended to be construed as limiting the physician’s ability to
provide care, and it is presumed that other procedures, techniques, and problems of similar complexity
will fall within the granted privliges.

I request privileges as indicated above and shall restrict my clinical activities to same. I am mentally and
physically able to perform clinical privileges as indicated above.

_______________________________
Signature over Printed Name / Date

Recommended by:

JOHN ANONUEVO, M.D.

Chairman, Department of Medicine

Credential Committee meeting of ____/_____/___

Medical Executive Committee meeting of _____/_____/_____
Board of Directors meeting of _____/_____/_____
 5.12 RESPONDING TO
APPLICATIONS
V. GENERAL POLICIES AND PROCEDURES
5.12 RESPONDING TO APPLICATIONS

• All applicants to the Professional Staff must:

1. Have their application dated on the application

fee receipt.

2. Receive an acknowledgement of receipt of their

application.
5.12 RESPONDING TO APPLICATIONS

• All applicants to the Professional Staff must:

3. Be informed of the outcome of the application

within the quarter in which the application was
made.

4. Be informed if the application processing has

been delayed or discontinued.
5.13 OUTCOMES OF THE
APPLICATION
V. GENERAL POLICIES AND PROCEDURES
5.13 OUTCOMES OF THE APPLICATION

• The outcomes of the application are

• Appointed with clinical privileges
• Appointed without clinical privileges (for those
seeking honorary membership to the professional
staff)
• Not appointed
5.13 OUTCOMES OF THE APPLICATION

• Successful applicants shall be advised and shall be

invited to attend a mandatory Hospital Orientation.
• Applicant should be advised that any engagement
is conditional on their agreement in writing to abide
by the hospital’s rules and regulations, code of
conduct/ code of ethics and maintenance of other
professional licenses and requirements.
5.13 OUTCOMES OF THE APPLICATION

• Unsuccessful applicants must be advised, with

contact details provided for use if they wish to seek
a face to face feedback from the clinical
department chair on why their application was
unsuccessful.
5.14 APPOINTMENT DECISION
V. GENERAL POLICIES AND PROCEDURES
 5.14 APPOINTMENT DECISION

• The CMO, upon the recommendation of the

Credentials and Privileging Committee, endorses all
appointed practitioners to the CEO.
• The CEO, acting in behalf of the Board, approves
the appointments.
• The CMO provides a quarterly report of
appointments to the Board.
• All appointments expire after three years.
5.15 RE-APPOINTMENT
V. GENERAL POLICIES AND PROCEDURES
 5.15 RE-APPOINTMENT

• Reappointment is the process of reviewing every

three years, the professional staff member’s file to
verify:
1. Continued licensure;

2. that the professional staff member is not

compromised by disciplinary actions of licensing
and certification agencies or by any court
conviction;
 5.15 RE-APPOINTMENT

• Reappointment is the process of reviewing every

three years, the professional staff member’s file to
verify:

3. that the file contains sufficient documentation for

seeking new or expanded privileges or duties in the
hospital; and

4. that the professional staff member is physically

and mentally able to provide patient care and
treatment without supervision.
 5.15 RE-APPOINTMENT

• Any one of the conditions will justify non

reappointment of a professional staff.

• In addition, failure to apply for renewal of

appointment at least three to six months before the
expiration date of the appointment will constitute
sufficient grounds for non- reappointment. There is
no automatic reappointment process.
5.16 CLASSIFICATION OF THE
PROFESSIONAL STAFF
V. GENERAL POLICIES AND PROCEDURES
 5.16 CLASSIFICATION OF THE
PROFESSIONAL STAFF
• Active Staff
• The active staff shall consist of credentialed
Medical Doctors and Doctors Dentistry, who fulfill
the ff:
1. Meets the basic qualifications of staff
membership and have demonstrated a willingness
to work for the best interest of the Hospital, its
patients, and the professional staff.
 5.16 CLASSIFICATION OF THE
PROFESSIONAL STAFF
2. The minimum criteria of clinical activity including:
a. Minimum clinic hours of 6 hrs/week or 3
days per week, or its equivalent in clinical time for
institutional staff members and;
b. Minimum of 12 Hospital Encounters, which
may include inpatient admission, operative and/or
other procedures in a 12 month period, and/or
other criteria that the Department/Section may set
forth, and;
c. Minimum of 50% attendance to the
Department and Sectional Staff meetings.
 5.16 CLASSIFICATION OF THE
PROFESSIONAL STAFF
• Visiting Staff
• The visiting staff shall consist of physicians qualified
for staff membership who exercise clinical privileges
granted in the same manner as an active staff
member, but who have not fulfilled the minimum
criteria of clinical activity or have specifically
applied as visiting staff only.
 5.16 CLASSIFICATION OF THE
PROFESSIONAL STAFF
• Delisted
• The Physician who has no activity for 1-2 years is
considered as visiting consultant. In the 3rd year,
he/she will be delisted/removed from the roster.

• Inactive Staff
• A professional staff who has had zero hospital
activity for 2 or more years.
5.17 DISSEMINATION OF INFORMATION ON
PROFESSIONAL STAFF APPOINTMENT
V. GENERAL POLICIES AND PROCEDURES
5.16 DISSEMINATION OF INFORMATION
ON PROFESSIONAL STAFF APPOINTMENT
• Each hospital staff member is responsible for
ensuring that only appointed professional staff
members are allowed to provide therapeutic,
diagnostic or interpretation services to in- and
outpatients.
5.16 DISSEMINATION OF INFORMATION
ON PROFESSIONAL STAFF APPOINTMENT
• For this purpose, hospital staff members must check
the roster of appointed professional staff and the
corresponding clinical privileges BEFORE admitting,
scheduling, or conducting procedures on patients.
5.16 DISSEMINATION OF INFORMATION
ON PROFESSIONAL STAFF APPOINTMENT
and finally …

• An updated list of appointed physicians and their

clinical privileges will be made available to all
hospital staff members who assign patients to
specific physicians or schedule patients for
procedures under a specific physician.
 V. GENERAL POLICIES AND
PROCEDURES (OVERVIEW)
• 5.1 Application for Appointment
• 5.2 Minimum Mandatory required credentials
• 5.3 Other Requirements
• 5.4 Application fees
• 5.5 Forwarding of application packets
• 5.6 The application review process
• 5.7 The applicant interview process
• 5.8 Evaluation of applicants
• 5.9 Determining clinical privileges
• 5.10 The Process of delineating clinical privileges
• 5.11 Categories of Clinical Privileges
• 5.12 Responding to applications
• 5.13 Outcomes of the Application
• 5.14 Appointment Decision
• 5.15 Re-appointment
• 5.16 Classification of the Professional Staff
• 5.17 Dissemination of information on professional staff appointment
"No eye has seen, no ear has heard, and no mind has
imagined what God has prepared for those who love
him.“
1 Corinthians 2:9
Thank you!