The Credentials Committee Manual

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The Credentials Committee Manual

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The Credentials Committee Manual

Mark A. Smith, MD, MBA, FACS

Get the tools and forms you need to operate an effective credentials committee

In The Credentials Committee Manual, former credentials committee member/chair Mark A. Smith, MD, MBA, FACS, provides practical advice on committee structure and duties (both current and future, including data analysis and legal considerations), tables and forms for managing meetings, as well as tools MSPs can use for effective committee operations. All forms are downloadable and customizable.

This book provides readers with:

  • What CMS’ guidance for unified, integrated medical staff might mean for credentials committees
  • What new and prospective committee members (including APPs) need to know
  • Information on technology’s role in streamlining meetings
  • Ways to address the challenges of credentialing telemedicine providers
  • Simulation training techniques
  • Ways to avoid potential legal issues (including negligent credentialing)
  • New credentials committee structures


Readers will also learn best practices for compiling and using data in reappointment decisions, navigating credentialing considerations for nonphysician practitioners, and preventing turf battles.

Table of Contents

  1. Introduction/the credentials committee’s place in the organization
  2. New members, new roles and responsibilities (including MSPs’ roles)
  3. How an effective credentials committee functions
  4. Stipends/compensation
  5. Credentials committee–specific meeting management
  6. Privacy and information security
  7. Technology for new procedures, telemedicine, and simulation training
  8. Virtual meetings/paperless techniques/automation
  9. Legal considerations (case studies)
  10. New challenges, including consolidation of credentials committees and credentialing telemedicine/telepsychology practitioners 
  11. Sample bylaws language
  12. Tools and forms/additional resources


About the Author

Mark A. Smith, MD, MBA, FACS, is a senior consultant with HG Healthcare Consultants, a healthcare consulting firm. He also works as chief medical consultant with Morrisey Associates, Inc. He brings 25 years of clinical practice and hospital administration experience to his work with physicians and hospitals across the United States, where he provides expertise in system quality and performance improvement, peer review, ongoing and focused professional practice evaluation, management of deficient practitioner performance, criteria-based privileging, low-volume practitioners, ED call, and external focused review. Dr. Smith is a board-certified surgeon who practices part time as a clinical assistant professor of surgery in the Vascular and Endovascular Surgery section at the University of California, Irvine Medical Center. Dr. Smith previously practiced general and vascular surgery in a private practice setting.


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Published May 2016