ACFAS Position Statement

Guidelines for Institutional Credentialing and Due Process Rights

Approved by ACFAS Board of Directors, February 2020

Healthcare institutional bylaws are written documents that govern each individual hospital, ambulatory surgical center, etc. These bylaws state policies and governance procedures, identify staff levels of appointment, describe the credentialing and privileging process and provide the rules and regulations for the institution. Bylaws can vary significantly from one institution to another and must be evaluated closely prior to applying for privileges.

Institutions are governed by state law that specifically identify who is eligible to hold medical staff positions within that institution. In many cases, the statute grants to the individual institution the right to determine the types of providers who may obtain privileges. For foot and ankle surgeons interested in pursuing privileges, local state podiatric associations, ACFAS Divisions, hospital committees or legal counsel can be helpful in finding and reviewing relevant statutory law.

Guidelines for Foot and Ankle Surgeons to use in obtaining related information:
  1. Obtain a copy of the institutional bylaws and thoroughly analyze key areas:
    • Definitions
    •  staff appointments by categories
    • credentialing and privileging process
    • bylaws amendment process
    • fair hearing and/or appeal process, if you are denied or have been revoked of privileges.
  2. Become familiar with the state laws for podiatric surgical scope of practice.
  3. Become knowledgeable of the institution’s section or department policies and rules.
  4. Become familiar with The Joint Commission’s (TJC) medical staff standards or the applicable standards of your institution’s accrediting organization.
  5. Become knowledgeable about specific regulations or rules relative to extension of additional privileges.
  6. Become familiar with the organizational hierarchy and activity level of pertinent staff members.
  7. Keep track of surgical delivery and patient quality of care issues.
  8. Develop a working relationship with the professional medical staff, medical executive committee members (MEC), section department chairmen and relevant colleagues.
  9. Know the exact make-up of the relevant committees such as surgery,
    credentials, executive, hospital administration, etc. Foot and ankle surgeons should have input into the names, specialty, and training of each member on these committees. Open discussions with these individuals to lay the groundwork collegial relationships that will assist in obtaining privileges.
  10. Attend medical staff committee meetings and other events, along with your institution’s board of directors meetings.
  11. Learn how other medical staff members obtain additional privileges.
  12. Bylaws may contain provisions which prohibit or restrict foot and ankle surgeon’s privileges. Learn what procedures are able to be amended in the existing institutional bylaws. List any provisions which require amending and propose changes to the appropriate bodies of the administration.
  13. Determine who will review request for clinical privileges and what the procedures are for a fair hearing if current privileges are not aligned with the state’s scope of practice laws.

If the bylaws are found to be ambiguous, it is up to the foot and ankle surgeon to resolve any issues of privileging at their local institutions. ACFAS members should demonstrate and portray themselves as a medical and surgical specialist.

(Note: This document is solely to be used as a guideline. ACFAS does not provide legal advice. Members with legal issues are encouraged to seek legal consultation from an attorney licensed to practice in the state of issue.)