OO - Organizational Overview

OO18: A description of the process by which CNO or his/her designee participates in credentialing, privileging, and evaluating advanced-practice nurses. Include the frequency of re-privileging.

Advanced Practice Nurses are credentialed by the Medical-Dental staff in the same manner that physicians are credentialed. The completed application is delivered to the Medical-Dental staff office and reviewed by the Chairperson of the division and the Chief Nursing Officer. The Department Chair and the CNO conduct a personal interview with the applicant. The Department Chairperson submits the completed application to the Credentials Committee and his/her recommendations as to staff appointment and as to staff category, department, division and/or section affiliation, clinical privileges to be granted and any limitations or considerations. The Credentials Committee than verifies the data as far as credentials, licensure and references. The Credentials Committee forwards the approved application to the Liberty Board for final approval of the candidate.

Credentialing Process

The Credentials Committee reviews the completed application, the supporting documentation and the Reports and recommendations from the Department Chair(s) in which the applicant seeks privileges. See Reference OO18-A for further information on credentialing process). The Credentials Committee may:

  • Defer the application and require additional information
  • Provide a favorable recommendation
  • Provide an adverse recommendation

The Credentials Committee forwards the information to the Medical Executive Committee (MEC) in the form of a written report as to the recommendations for appointment. If an appointment is favorable, recommendations are made as to staff category, department category, department affiliation, clinical privileges to be granted, and any special conditions to be attached to the appointment. The recommendation is supported by reference to the completed application and all other documentation considered by the Credentials Committee.

The Credentials Committee forwards its determination to the Chief Executive Officer as to recommendations for approval or rejection of appointment. If an appointment is favorable, recommendations are passed on to the Board of Trustees for a final decision. The Board may accept, reject or refer the recommendations back to the Credentials Committee for further review and/or consideration. The final recommendation pertaining to Nurse Practitioners is approved and signed by the Chairperson of the specific department and the Chief Nursing Officer. The recommendation for appointment form is attached to the delineation of privileges form. (See completed form in Reference OO18-B).

Determination of Clinical Privileges

Any member of the medical staff providing direct clinical services are entitled to exercise only those clinical privileges or specified services specifically authorized by the Board of Trustees. These privileges must be within the realm of the license, certificate or other legal credential authorizing the Practitioner to practice in the state. Requests are evaluated on the basis of the Practitioners education, training, experience and demonstrated ability and judgment. Recommendations from the applicant’s professional peers are reviewed and taken into consideration. The specific department for which the applicant seeks privileges is delegated the authority to develop rules and regulations governing the exercise of privileges granted. Requests for clinical privileges are processed by the procedures which are outlined in the previous paragraphs.

Allied Health Professionals (AHP) are subject to any licensure requirements or other legal limitations, may exercise independent judgment within the areas of their competence, and participate in the medical management of patients under the supervision of a physician who has been accorded privileges to provide such care and who has the ultimate responsibility for the patient. Prerogatives of the AHP are to: Write orders to the extent established by the Executive Committee, provide specified patient care functions under the supervision or direction of a physician member of the Medical Staff, serve on staff, department and hospital committees, and attend meetings of the Staff and Department to which that Practitioner is assigned and hospital education programs.


The evaluations of the Advanced Practice Nurses are either performed by the Clinical Director or the Chief Nursing Officer. The evaluation incorporates issues such as: the ability to assess, plan and implement and evaluate continuum of care, general medical knowledge, interpersonal and communication skills, professionalism and system-based practice. Verification of licensure, DEA/CDS license, malpractice insurance and continuing education credits, completion of delineation of privileges form and overall professional performance including judgment and technical skills and quality issues also takes place during evaluation process. Meeting attendance and participation in departmental audits and activities are also evaluated. The Department Chair approves the evaluation/reappointment as well as the supervising physician, Director of Nursing and CNO. The process of evaluation and re-privileging occurs every two years.