Resident and Fellow Policy Manual

Appendix 1 - Policy on Credentialing for All Clinical Activities:

The following policy on resident/fellow credentialing has been developed to conform to the New York State Health Code and Section MS.6.9/MS.6.9.1 of the Standards of the Joint Commission on Accreditation of Healthcare Organizations.

Credentialing

Each Program Director will delineate those activities that a resident in the program will be able to perform under general supervision.  General supervision means that a supervising physician/dentist does not need to be physically present while the resident performs the clinical activity/procedure, provided the resident: (1) has permission from the physician/dentist to perform the clinical activity/procedure, and (2) has documented adequate training (i.e., has been credentialed) to perform the clinical activity/procedure.  Each program will have a process in place to verify trainee competence prior to allowing him/her to perform activities under general supervision.

When a trainee has completed the credentialing process, the program director/coordinator will have a method to record a trainee's completing the credentialing process under general and direct supervision.  This will be kept at the program level and transferred at intervals to the Medical Staff Office via an updated Delineation of Competencies form by individual.

Advanced Level Credentialing

Residents entering our programs at advanced levels who have been credentialed for clinical activities/procedures at another institution may be credentialed by the Program Director after reviewing the credentialing documents from the other institution if those materials are adequate.  If the advanced resident has not been credentialed by another institution, the Program Director has the right to modify that resident/fellow's clinical activity and procedure credentialing process after reviewing the nature of that resident’s prior training and clinical experience.  Though the manner in which the advanced resident is credentialed may be different than a resident entering at the first year level, it will still be necessary for the Program Director to maintain on file any internal or external documentation of the credentialing process for that resident, and to provide an updated Delineation of Competencies to the Medical Staff Office.

Updated by GMEC 2/12/01, 4/21/03