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Revised credentials manual released for your review

07 May 2021

FAQ answers most questions about changes

By: Kelly Aebi, medical staff services director

The Bylaws Committee, Credentials Committee and Medical Executive Committee have thoroughly reviewed the Credentials Procedure Manual, which is a sub-document of the Medical Staff Bylaws. 

As part of the approval process, the document with “red line” changes noted will be posted below for 14 days for medical staff input. Please send Kelly Aebi, Director of Medical Staff Services your questions, concerns and feedback to:, by May 23, 2021. All feedback from the Medical Staff will be reviewed at a Medical Executive Committee meeting to determine if further revisions need to be made or if the proposal can move forward to the full Board of Trustees for final approval and implementation.

Most of the changes are administrative to align with practices executed by the Medical Staff Office and the credentialing team.  There are changes to board certification requirements that may raise questions so below is an FAQ to help identify how this may impact you as a member of the Medical Staff, a credentialed provider or one of your future recruits. 

I am a member of the medical staff and I am not currently board certified as I have five years from my appointment date to obtain board certification.  Will I need to become board certified within 5 years of my program completion under these revisions?

No, you follow requirements based on whatever board certification rules were in place when you were appointed.  You have 5 years from your appointment date to obtain board certification.  Please contact Kelly Aebi if you would like your specific due date.   See section 2.3.1 for further details. 

I am a current member of the medical staff, do I have to maintain my board certification with the proposed changes? 

No, as long as you have been board-certified at least once since your appointment to the medical staff then you do not have to maintain your board certification unless there are additional requirements outlined in your specialty’s privilege form.  If you are contemplating whether you should renew your board certification, we encourage you to confirm with the Medical Staff Office, your employer and health care plans whether it is required elsewhere before you choose to not renew your certification.  See section 2.3.1 for further details.

I am a credentialed provider through the Medical Staff Office (NP, PA, etc.) and not a member of the medical staff.  Am I required to be board-certified and maintain my certification?

You are required to follow the board requirements outlined in your privilege forms and with your licensing board. Please contact Kelly Aebi if you have questions regarding your privilege requirements.

If our practice recruits a physician who completed Residency and/or Fellowship over 5 years ago and s/he is no longer board-certified, will s/he qualify for membership and privileges?

No, the physician would not qualify under the proposed changes. The physician would need to be board- certified since s/he completed the applicable Residency and/or Fellowship over 5 years ago.