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Health Care Facilities Credentialling Committee

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For the last year (2005), the process of reviewing physicians' training and experience prior to granting privileges has been undertaken by the RHAs. The College has continued to offer advice as to what privileges would be appropriate to grant physicians upon request from the RHAs. This advice has been restricted to Level 2 and 3 privileges only, and has been on a cost recovery basis.

BYLAW 18(7) HEALTH CARE FACILITIES CREDENTIALLING COMMITTEE

  1. Composition

    The Chair and members of the Committee shall be appointed annually by the Council.

    The membership shall consist of:

    1. a Specialist from each of the following disciplines: General Surgery; Obstetrics & Gynaecology; Internal Medicine and Anaesthesia;

    2. three General Practitioners;

    3. one Chief Executive Officer of a Health District; and

    4. additional members as required.

  2. Objectives

    1. For the purpose of making recommendations to the District Board, the Committee may assess the qualifications, training and experience of:

      1. new registrants of the College of Physicians and Surgeons of Saskatchewan applying for privileges in Health Care Facilities of 100-beds, or less;

      2. registered practitioners moving from one location to another and applying for privileges in a Health Care Facility;

      3. members of the Medical Staff of a Health Care Facility as part of a Health Care Facility Assessment;

      4. members of the Medical Staff of any Health Care Facility, upon request by the District Board.

      5. any physicians requesting this service for self-assessment or reassessment.

    2. Carry out Health Care Facility Assessments upon receipt of a request from a District Board.

  3. Method

    1. Physicians' Privileges

      The Committee in making recommendations shall take the following factors into consideration:

      1. the qualifications, training and medical experience of the physicians;

      2. the physical facilities available;

      3. the backup personnel available, i.e. physicians, nurses, laboratory and x-ray technicians, physiotherapists, and others;

      4. location of the Health Care Facility; and,

      5. transport facilities available.

      The Committee makes recommendations for privileges as they apply to elective procedures only. The applicants and District Boards are advised physicians must be given every opportunity to deal with an emergency to the best of his/her knowledge, training and ability.

      Applicant-physicians are required to complete the prescribed application in a form approved by the Committee and present it to the Committee or its designate. A provisional list of recommended privileges (to Level 1 only) is forwarded to the District Board and physician based on the documented postgraduate training and experience presented by the applicant. When applicants request privileges beyond Level 1, and appropriate documentation of formal training and experience is available, provisional privileges up to Level II, may be recommended by the Committee or its designate.

      Applicants applying for privileges beyond the Level II category, or privileges that are not consistent with the guidelines, may be required to meet with the Committee, to review their requests for privileges.

      The provisional lists of recommendations are presented to the next regular meeting of the Committee for review, modification, and/or ratification. The final recommendation of the Committee shall be communicated to the District Boards and the physicians involved.

    2. Health Care Facility Assessments

      Health Care Facility Assessments are carried out by a subcommittee of the Committee. The Health Care Facility Assessment Team may include members who are not members of the Committee.

      Health Care Facility Assessments may be carried out at the request of a District Board.

      District Boards requesting assessments will be required to complete documentation relating to facilities, personnel, and any other relevant matter.

      The Assessment Team appointed to carry out the assessment may make recommendations with respect to:

      1. privileges of individual physicians;

      2. medical staff changes;

      3. facility improvements;

      4. ancillary staff;

      5. equipment, etc.;

      6. any other relevant matter.

      The Assessment Team reports to the Committee and subsequently to the Registrar. The final written assessment report is communicated to the District Board after approval by the Registrar.

  4. Reporting

    1. The Chair reports to the Registrar.

    2. The Committee will provide minutes to the Registrar who may distribute these minutes to the Council for information.

  5. Meetings

    The Committee will meet at the call of the Chair.