Credentialing and Privileging Guidelines

Medical Staff Rules and Bylaws

All medical staff are required to sign in agreement to the Medical Staff Rules and the Medical Staff Bylaws before working with Island Health.

Medical Staff Rules

Island Health’s Medical Staff Rules outline the details of the organization of the medical staff and the day-to-day processes by which the medical staff provide patient care.

Medical Staff Rules are established by the Board of Directors upon the recommendation of the Health Authority Medical Advisory Committee (HAMAC) and the Medical staff.

Medical Staff Bylaws

Island Health’s Medical Staff Bylaws set out the conditions under which members of the medical staff serve the facilities and programs operated by Island Health, provide patient care, and offer medical advice to the Board of Directors.

Medical Staff Bylaws are established when adopted by the Board of Directors and approved by the Minister of Health of British Columbia.

Other Relevant Legislation

• Hospital Act 
• Hospital Regulations

Tools, Forms and Application Documents

Tools and Forms

• Provider Address Form
• Categor​ies of Privileges Quick Reference Guide
• ​Department Recommendation Form

Application Documents

• Authorization For Release of Information
• Appendix A
• Consent for Certificate of Professional Conduct
• Institutional Request for Certificate of Professional Conduct
• The Practitioner Performance Appraisal (for Provision to Active; to be completed by Department Head or delegate)
• Team Member Feedback form (for Provisional to Active)
• Practitioner Self-Assessment form (for Provisional to Active)

Guidelines

The following guidelines have been approved by HAMAC and are maintained by the Medical Planning and Credentials Committee (MPCC).

• Application Review
• Categories of Privileges Quick Reference 
• MAiD Privileging Guideline​ 
• Non-Routine Applicati​on Management​ 
• Provisional to Active Review Process Guideline​ 
• ​Surgical Assist Privileging Guideline 
• Surgical Centre Privileging Guideline 
• Temporary Privileging Guideline
• Filling a Vacancy in Medical Leadership

Questions?

If you have additional questions, the Credentialing & Privileging team is available to help. Please contact Credentialing_Office@islandhealth.ca.