Inappropriate Credentialing, Reappointment, and Performance Management

The discourse around credentialing has increased in recent years, partly due to increased litigation resulting from lapses in the credentialing process. As evidenced by HIROC claims and related Canadian inquests, credentialing, privileging, and performance management processes are closely linked to the provision of safe and high-quality patient care. The credentialing process should be recognized as more than a mere administrative duty of healthcare organizations. Decisions made should be based on standardized criteria and processes that are transparent, freely accessible, fair, non-discriminatory, balanced, and equally applied to all. Inconsistent and questionable credentialing and privileging practices may directly impact patient safety, the culture of an organization, and jeopardize its reputation. In circumstances where credentialing functions are outsourced, the healthcare organization remains accountable to its patients for the quality of its professional staff selection process.

Expected Outcomes

Adopt evidence-based, fair, and inclusive appointment, reappointment, and privileging processes.

Implement ongoing and targeted education to medical / clinical leaders and teams administering the organization’s recruitment, appointment, reappointment, and privileges processes.

Adopt standardized quality indicators to monitor and measure compliance with the organization’s appointment, privileging, reappointment, and professional practice evaluation processes. 

Definitions and Acronyms

  • Class action – a lawsuit that groups people with a common claim together against the same defendant
  • DEIB – diversity, equity, inclusion, and belonging
  • Healthcare organizations – organizations engaged in providing, financing, improving, supervising, evaluating, or other activity related to health care
  • MAC – medical advisory committee

Common Claims Themes and Contributing Factors

Claims by Patients and Families
  • Perceived and actual ‘rubber stamping’ of recommendations for appointment and reappointment by healthcare organizations.
  • Perceived and actual overreliance on insufficient information from provincial / territorial professional regulatory authorities to inform appointment and privilege decisions.
  • Failure to identify and / or evaluate multi-patient harm incidents involving the same practitioner, including some resulting in class actions.
  • Lack of evidence (documentation) to support:
    • The initial appointment (e.g., insufficient or no documentation despite the fact the practitioner had been appointed and undergone multiple reappointment cycles);
    • That quality and utilization data and performance reviews were considered during the reappointment process.
  • Lack of performance evaluation processes for credentialed members of staff and leadership / chiefs / heads.
  • Failure to have a robust process that requires the applicant to appointment or reappointment to disclose all pertinent malpractice claim settlements where the settlement includes a financial contribution on behalf of the staff person (versus those with a legal judgment) and complaints resulting in a regulatory body hearing (versus those with negative finding / undertaking).
  • Perceived and actual lack of independent verification of information provided by applicants.
Claims by Credentialed Members of Staff 
  • Outdated professional staff by-laws.
  • Appointment, reappointment, privileging, and disciplinary decisions as well as decisions related to educational, advancement, and leadership opportunities that were unreasonable, not equitable, discriminatory, arbitrary, and / or made in bad faith.
  • Perceived lack of independent verification of information provided by applicants.
  • Breakdown in the process for restricting, suspending, or revoking privileges: 
    • Not well defined clinical or behavioural conduct criteria and / or not related to quality of care issues (e.g., to resolve interdisciplinary / conflicts among practitioners);
    • Without following due process (e.g., progressive disciplinary and natural justice).
  • Perceived and actual systemic tolerance of unprofessional, disruptive, and / or discriminatory behaviours by credentialed members of staff and leadership.
  • Lack of documentation of:
    • Discussions with credentialed staff regarding their unprofessional, disruptive, or discriminatory behaviour resulting in ongoing conflicts and denial of the conversations and the behaviour;
    • The rationale to support appointment, reappointment, privileging, and disciplinary decisions.

Mitigation Strategies

Diversity, Equity, Inclusion, Belonging, and Anti-Racism

  • Implement strategies to ensure all professional staff policies and practices (recruitment, reference checks, parental leaves, retention, performance management, advancement, etc.) and by-laws:
    • Are evidence-informed, fair, equitable, and inclusive from a DEIB and anti-discriminatory perspective;
    • Embed explicit language (including but not limited to professional staff by-laws) that the organization prohibits discrimination in granting or denying professional staff membership, clinical privileges, educational, or career advancement opportunities (Government of Canada, 2021).

Appointment and Reappointment Practices

  • Ensure the written applications for appointment and reappointment require applicants to agree to disclose whether the applicant:
    • Is involved in business or research relationships for personal profit or gain (or related financial activities) based upon their appointment or reappointment;
    • Is named (or has been since last appointment), as a defendant in any civil legal action arising from their professional conduct, competence, or capacity, including whether the claim is resolved or a judgment rendered;
    • Is currently or has ever been involved in any professional regulatory body investigation resulting in a referral to a disciplinary or fitness to practice committee, and / or a decision of a regulatory body affecting the applicant’s licensure or registration;
    • Has ever been (or has been since last appointment), found liable for a breach of the standard of care in any Canadian or international court of competent jurisdiction;
    • Has ever been (or has been since last appointment), charged or convicted with a criminal offence in Canada or internationally, including the nature of offence charged;
    • Has voluntarily or involuntarily relinquished any professional license or registration, terminated medical, midwifery, dental, or nurse practitioner professional staff membership, or had their clinical privileges restricted, reduced, or removed (Clarke, 2014) (Ontario Hospital Association, 2021b).
  • Adopt a standardized evidence-based / best practice process for applicant background checks that includes (but is not limited to):
    • A release form to enable any third party to release relevant information related to the applicant;
    • Standardized criteria for references to evaluate the applicant;
    • Ensuring all references are personally contacted for a verbal discussion if possible, or a focused written response to a request for recommendation prior to the granting of privileges;
    • Criminal record background report.
  • Ensure the written application for reappointment requires the applicant to disclose continuing education courses, training, and retraining.

Privileging Processes

  • Implement formal strategies to validate the applicant’s clinical competency, judgment, and skills (e.g., direct observation by discipline lead, department chief clinical evaluation) prior to offering or renewing privileges to practitioners:
    • In higher risk areas or specialty roles;
    • With low or minimal patient volumes (Department of Health, Province of New Brunswick, 2008) (Sinclair, n.d.).
  • Adopt a standardized process for establishing new categories of privileges whenever new technology or clinical advances justify their consideration and potential introduction (e.g., virtual care, medical assistance in dying) (Ontario Hospital Association, 2021a).
  • Maintain an up to date list of privileges in each credentialed staff member’s file; provide a copy of the registry of privileges granted to each applicant to each appropriate department, service, program, or clinic.
  • Adopt a standardized policy for credentialed staff regarding maternity or parental and other leaves of absence including, the obligation on the staff member to ensure proper coverage within the department in the case of non-protected, discretionary leaves, permitted time away from the role, and the process for returning to active duties following a leave (Ontario Hospital Association, 2022). 
  • Ensure appropriate legal advice is sought before:
    • Refusing or limiting an application or re-application for privileges;
    • Restricting, suspending, or terminating privileges (Ontario Hospital Association, 2021a).

Performance Management 

  • Adopt a fair, effective, and timely complaint management process for credentialed staff, including tracking and reviewing complaints to identify trends and themes.
  • Ensure policies, by-laws, and processes for the immediate and non-immediate suspension, restriction, or revocation of privileges clearly define:
    • The roles of the board, chief executive officer, chief of staff, department chief, and professional or MAC;
    • Confirmation that provincial or territorial regulatory colleges will be notified in specified circumstances;
    • Procedural rights of the professional whose privileges are at risk of suspension, restriction, or revocation;
    • Process for and need for procedural fairness when investigating quality of care or behavioural issues and for bringing issues of concern to the attention of the chief of staff who can then assess next steps, which may include (but not limited to) obtaining legal advice, graduated discipline, formal investigation, external review, engaging corporate leadership for medical service, MAC and board of directors. 
  • Ensure a performance management and / or professional practice evaluation is conducted (and documented) prior to the annual application for reappointment or other appointment renewal processes.
  • Implement a formal evidence-based and principle-based protocol and strategies to minimize and manage unprofessional, disruptive, and / or discriminatory behaviour by credentialed members of staff and leadership (Canadian Medical Protective Association, 2022) (College of Physicians and Surgeons of Ontario, 2016) (College of Physicians and Surgeons of Nova Scotia, 2018) (Health Quality Council of Alberta, 2013) (College of Physicians and Surgeons of Ontario & Ontario Hospital Association, 2008).

Additional Considerations

Examples of elements to consider within protocols to minimize and manage unprofessional, disruptive, and / or discriminatory behaviour:
  • Definitions for unprofessional, disruptive, and / or discriminatory behaviour; 
  • The reporting procedure (fair and transparent);
  • Procedures for those receiving the complaints;
  • Description of the review process, informal resolution process (mediation), the investigation process, and appear process;
  • Protection of persons against retaliation for making complaints about unprofessional, disruptive, and / or discriminatory behaviour; 
  • Thresholds for taking disciplinary-related action based on type of infraction and frequency of the behaviour (e.g., just culture and progressive approaches to interventions and consequences).
  • Ensure complete and timely documentation of all attempts to address the credentialed staff’s or leader’s:
    • Unprofessional, distributive, or discriminatory behaviour (including confirming the expectations of the disruptive practitioner in writing);
    • Clinical skills and competency issues.

Team Training and Education

  • Implement formal strategies to the facilitate the onboarding / orientation and ongoing education to the board, chief executive officer, chief of staff, medical / clinician leaders, and MAC regarding their respective roles and responsibilities related to the immediate and non-immediate suspension, restriction, or revocation of privileges, including (but not limited to):
    • Notification of applicable provincial or territorial regulatory colleges where indicated / required;
    • Rights of the professional whose privileges are at risk of suspension, restriction, or revocation;
    • Investigating quality of care issues and for bringing issues of concern to the appropriate internal attention (Sonnenberg, 2018).
  • Implement formal strategies to facilitate the provision of onboarding / orientation and ongoing education to professional staff, administration, and leaders, including (but not limited to) the following areas:
    • Professional staff by-laws and rules;
    • Conducting performance management and peer reviews including (but not limited to) performance reviews to move practitioners from probationary staff to active staff;
    • Conflict prevention and management;
    • Leading teams of professionals;
    • Cultural competency;
    • Patient safety and quality improvement.

Retention of Records

  • Adopt best practices for the retention, storage, and destruction of applications for appointment, reappointment, and professional practice reviews (Ontario Hospital Association, 2022).

Monitoring and Measurement

  • Implement formal strategies to monitor compliance with the facility’s credentialing, privileging, reappointment, and professional practice evaluation processes.
  • Prior to obtaining an external input with respect to a credentialed staff’s practices or records (e.g., which may be required due to lack of internal expertise, new technology or conflict of interest), consider whether the investigation should be carried out through a quality assurance or legally protected forum; obtain risk management and legal advice where indicated.

  • Canadian Medical Protective Association. (2022). Addressing disruptive behaviour from other physicians. Retrieved from
  • Clarke, C. (2014). Best practices in physician annual reappointment, performance management, and disruptive behavior [PowerPoint]. 2014 Annual HIROC Risk Management Conference. HIROC.
  • College of Physicians and Surgeons of Nova Scotia. (2018). Disruptive behaviour by physicians. Retrieved from
  • College of Physicians and Surgeons of Ontario & Ontario Hospital Association. (2008). Guidebook for managing disruptive physician behaviour. 
  • College of Physicians and Surgeons of Ontario. (2016). Physician behaviour in the professional environment. Retrieved from,the%20provision%20of%20health%20care.
  • Department of Health, Province of New Brunswick. (2008). Commissioner’s Report, Vol. 1: Commission of Inquiry into Pathology Services at the Miramichi Regional Health Authority. 
  • Government of Canada. (2021). Canadian Human Rights Act (R.S.C., 1985, c. H-6). Retrieved from Justice Laws Website:
  • Health Quality Council of Alberta. (2013). Managing disruptive behaviour in the healthcare workplace. Calgary, AB.
  • Ontario Hospital Association. (2021a). Professional Staff Credentialing Toolkit. Second Edition. 
  • Ontario Hospital Association. (2021b). Hospital prototype board – Appointed professional staff by-law. 
  • Ontario Hospital Association. (2022). Records retention toolkit: A guide to the maintenance and disposal of hospital records. 
  • Sinclair, M. (n.d.). The report of the manitoba pediatric cardiac surgery inquest: An inquiry into twelve deaths at the Winnipeg Health Sciences Centre in 1994. Provincial Court of Manitoba.
  • Sonnenberg, M. (2018). Changing roles and skill sets for chief medical officers. Retrieved from American Association for Physician Leadership: