Clinical Staff Office
 

Credentials Committee

Contacts

Administration: Stephanie Allen, Clinical Staff Office
Chair: Scott Syverud, M.D.

Charge

The Credentials Committee shall review and evaluate the qualifications of each Applicant for initial appointment, reappointment or modification of appointment to the Clinical Staff in accordance with the procedures outlined in the Credentials Manual and the Clinical Staff Bylaws.  The Credentials Committee shall recommend to the Clinical Staff Executive Committee and the MCOB appointment or denial of all Applicants to the Clinical Staff and the granting of Clinical Privileges.  When appropriate, the Credentials Committee shall interview a Member or Applicant and/or the Chair of the involved Department in order to resolve questions about appointment, reappointment, or change in privileges.  The Credentials Committee shall review and make recommendations for revisions to the Credentials Manual from time to time; provided however the Chair of the Credentials Committee, in consultation with the Clinical Staff President and the Chief Executive Officer, shall have authority to amend the Credentials Manual. The Credentials Committee shall also monitor initial Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) processes for members of the Clinical Staff to ensure compliance with the Joint Commission.  The Credentials Committee shall also serve as the investigatory body for all matters set forth in Article VIII of the Clinical Staff Bylaws. The Credentials Committee shall also independently assess the departmental Peer Review process for Members of the Clinical Staff and for Allied Health Professionals in order to ensure that data related to qualifications and performance of individual Practitioners is collected, regularly assessed, compared to Peers, and acted upon by the Department in a timely manner.   When appropriate, the Credentials Committee shall also refer Practitioners to the Physician Wellness Program or Employee Assistance Program, and shall work with these programs to determine appropriate privileges for each Practitioner’s individual circumstances.

Membership: The Vice President of the Clinical Staff shall serve as chair of the Credentials Committee.  Only Members of the Clinical Staff serving on the Credentials Committee shall be eligible to vote on Credentials Committee matters.

Staff support is provided by the Clinical Staff Office.

Meetings: The Credentials Committee shall meet monthly or as otherwise deemed necessary by the Chair.

Duties and Responsibilities:

  • Oversees credentialing and privileging for Members of the Clinical Staff and for Allied Health Professionals to ensure that data related to qualifications and performance is collected and regularly assessed
  • Ensures that information from Departmental peer review processes and performance improvement data collection is assessed and considered for each applicant who will be Members of the Clinical Staff or Allied Health Professionals
  • Refers Members of the Clinical Staff to the Physician Wellness Program and works cooperatively with the program in determining appropriate privileges for certain practitioners
  • Refers Allied Health Professionals to the Employee Assistance Program and works cooperatively with the program in determining appropriate privileges for certain practitioners
  • Recommends Applicants for appointment to the Clinical Staff
  • Participates in investigation of and fair hearing process for Members of the Clinical Staff under Articles VII and VIII of the Clinical Staff Bylaws
  • Conducts an annual review of credentialing/re-credentialing policies and procedures to comply with JCAHO/NCQA standards and other regulatory requirements
Members Specialty
Scott Syverud, M.D., Chair Emergency Medicine
Reid Adams, M.D. Surgery
Stephanie Allen Clinical Staff Office
Christian Chisholm, M.D. Obstetrics & Gynecology
Gary Cuccia, CRNA OR
Sharon Esau, M.D. Pulmonary, Critical Care
Jen Slaughter, Esq UPG General Counsel
Lynne Fleming, Esq General Counsel
Robert Gibson, M.D. President, Clinical Staff
Susan Kirk, M.D. Internal Medicine, Assoc. Dean of GME
Fred Jung, RN, PhD
Administrator, Quality & Performance Improvement
Eugene McGaren, M.D. Pediatrics
Stanton Nolan, M.D. Professor Emeritus
Michael Ragosta, M.D. Interventional Cardiology
Mitchell Rosner, M.D. Nephrology
Vanessa Shami, M.D. Gastroenterology
Worthington Schenk, M.D. Surgery
Jason Sheehan, M.D. Neurosurgery
Ashley Shilling, M.D. Anesthesiology
Jeff Young, M.D. Chief Patient Safety Officer