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Tip of the week: Use a policy to establish your credentials committee

Credentialing Resource Center Connection, April 26, 2007

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The credentials committee is responsible for reviewing each complete application and making recommendations to the medical executive committee (MEC) regarding staff appointment, reappointment, and clinical privileges.

But who should serve in this capacity at your facility? While the composition of each organization's MEC will differ, it is good practice to develop a policy that clearly delineates which individuals will serve and in what capacity.

A credentials committee might include, for example:

• The immediate past president of the medical staff, serving as chair (voting member)
• At least five members of the active medical staff appointed to represent the major clinical specialties, the majority of whom shall have been on the active staff for five years or more (voting members)
• Two members who are former department chiefs (voting members)
• Medical staff president/chief of staff (non-voting member)
• Medical director/vice president of medical affairs (non-voting member)
• Medical staff office representative (non-voting member)

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