Privileging, Proctoring, and Status Information
Below is general information regarding privileging, proctoring and the various medical staff status options. Please contact the Medical Staff Services Office at (626)574-3795 for specific specialty requirements.
Each application for appointment and reappointment to the Medical must contain a request for the specific clinical privileges desired. Privileging requests are evaluated for eligibility. Following this review a recommendation is made based of the applicant’s; education, training, experience, demonstrated competence & judgment, clinical performance and the documented results of patient care and other quality review and monitoring activities. Certain privileges may have specific credentialing criteria to be eligible. Please contact the Medical Staff Office (626)574-3795 for this information.
IMPORTANT NOTE: Please make sure to include supportive documentation of your education, training and experience for privileging requests
All initial members of the Medical Staff shall be given the designation of Provisional status and shall be subject to a period of comprehensive proctoring and monitoring to evaluate the practitioner’s proficiency in exercising of clinical privileges granted and overall eligibility for Medical Staff membership. The monitoring shall follow whatever frequency or format the Department to which the practitioner has been assigned deems appropriate; including but not limited to, concurrent and retrospective chart review, mandatory consultation and/or direct observation.
PROCTORING FORMS: Proctoring forms must be completed by the Proctor/Observer and are available in the Medical Staff Office as well as the Cath Lab, GI Lab as well as the Surgical Services Department. Completed forms must be submitted to the Medical Staff Services Office to obtain credit for cases proctored. Physicians are encouraged to work closely with the Medical Staff Office personnel to ensure this process is completed properly and efficiently. Thank you.
IMPORTANT NOTE: Refer to Department Rules and Regulations for specific Proctoring/Observation Requirements. Also, please contact the Medical Staff Office (626) 574-3795 for assistance and additional information regarding proctoring matters.
MEDICAL STAFF STATUS:
Each member of the medical staff is assigned a “status” according to their eligibility. Reference the criteria and routes for advancement listed below.
PROVISIONAL STATUS (All physicians are initially appointed to this status) : Criteria: Must meet general qualifications for membership set forth in Section 2.2 and in the General Rules and Regulations. Term: Period of not less than six (6) months and not more than two (2) years. Advancement: May request advancement after six (6) months as long as there is sufficient patient activity to evaluate competency. If there is not sufficient patient activity to evaluate competency after two (2) year provisional term physician may not be eligible for reappointment.
COURTESY STATUS: Criteria: Must meet qualifications set forth in Section 3.2-1 (a-b). Satisfactorily completed terms of provisional period. Term: Unlimited, as long as physician continues to satisfy eligibility requirements for Courtesy status. Advancement: May request advancement to Active status after serving a minimum of 12 months on Courtesy and satisfying meeting attendance (3 per year) requirements.
ACTIVE STATUS: Criteria: Must meet the general qualifications for membership set forth in Section 2.2 and in the General Rules and Regulations. Have sufficient patient care activity and satisfy meeting attendance requirements. Term: Unlimited, as long as physician continues to satisfy eligibility requirements for Active status. Advancement: No further advancement options.
Note: Refer to Bylaws regarding the following status’: Consulting, Affiliate, Honorary, and Leave of Absence
Please contact the appropriate staff personnel for questions related to specific privileging, proctoring and status requirements:
Janeen Brayton, Credentials Specialists
Emergency Medicine Department, Ob/Gyn/Peds Department, and Surgery Department Members
Claudia Eredia, Med. Staff Specialist
Medicine Department Members
Jill Parker, CPMSM, Coordinator