Best Practices: Applications for Hospital Privileges

September 29, 2011 | Joshua Liswood

Pursuant to the Ontario Corporations Act and Public Hospitals Act, the Board of Directors of a public hospital is responsible for the governance and management of the hospital.  This includes responsibility for the appointment of physicians to the medical staff of the Hospital and conferring privileges upon such appointed physicians. 

The Public Hospitals Act mandates at section 36 that the Board appoint physicians and determine the hospital privileges to be attached to the appointment.  Section 35 requires that the Medical Advisory Committee (“MAC”) consider and make recommendations to the Board with regards to such appointments.  The MAC has sixty days from the date of receipt of a completed application to consider the application and make its recommendation.  

To help ensure that this obligation can be met, we recommend that the application form contain an acknowledgement by the applicant that: (a) an application will not be considered complete for the purposes of consideration by the MAC until all required documents have been received and (b) that after sixty days a submitted but incomplete application will be considered withdrawn.  Such an acknowledgement puts the onus on the applicant to ensure the completion of their application and can help minimize allegations of breach of process.

In addition, in order to ensure that only complete applications are put before the MAC, we recommend that hospitals review their current application forms for clarity and consistency with the requirements for applications set out in the by-laws and associated credentialing policies.  Among other things, an application for privileges form should contain all of the representations and warranties required of applicants under the hospital’s by-laws, for example, a statement that the applicant has read and agrees to abide by applicable legislation and specified hospital documents.  A complete list of application requirements should be included in the applicant’s statement along with an affirmative statement that all required documents (i.e. a certificate of Professional Conduct, up to date curriculum vitae, etc.) have been completed and attached to the application.  Finally, the application form should contain a statement from the applicant authorizing the hospital to make such inquiries as it considers necessary in connection with the application.

Such minor amendments to the application form can help avoid unnecessary delays in the application process and ensure that due process obligations are met. 

Miller Thomson’s Health Industry Group has significant experience in developing and advising on credentialing policies and procedures.  We would be pleased to assist you in reviewing your current application form, or to answer any questions you may have about the credentialing process.


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