Credentialing and Reappointment Resources

Please view the HR Planning and Credentialing Guide for Clinical Departments for full process details relating to HR and Credentialing. Please familiarize yourself with processes documented within this guide, and should you have any questions, please contact @email

Resources below will assist the clinical department Chief office with departmental human resource planning, credentialing, and reappointment processes.

Application for New Privilege Requests

All new Professional Staff applicants must first be approved by the clinical department Chief. The office of the Chief will provide Medical Affairs with the applicant details, at which time Medical Affairs will provide the applicant with the required application forms and requirements. 

Credentialing Application details - Please do not send this link directly to the applicant. 

Appointment Categories for Professional Staff

Credentialed Professional Staff is the term used to define physicians, dentists and midwives. See the Credentialed Professional Staff appointment definitions. Credentialed Professional Staff members who require an appointment at both London Health Sciences Centre (LHSC) and St. Joseph's Health Care London (St. Joseph’s) are appointed to one of the following categories within each hospital.

The City-Wide Credentials Committee (CWCC) evaluates the "credentials" of an individual and ensures that all criteria for appointment to the credentialed Professional Staff are met as outlined in the Credentialed Professional Staff By-Laws.

Changes to Professional Staff Appointment

To request a change to an existing clinical appointment, the department must complete the “Chief Support form – Appointment Change” Form. Complete this form to document changes to privileges AND to report a leave of absence greater than 60 days.

This form will need to be signed by both the department Chief and the professional staff member.

Email completed form to @email

Consent for Release of Credentials

Professional Staff who wish to request a release of credentials from LHSC and St. Joseph's to another organization will be required to complete a Consent for Release of Credentials. 

The completed form will need to be emailed to @email

Delineation of Procedural Privileges

To view each clinical department Delineation of Procedural Privileges, click HERE.  

Each clinical department/division delineates procedural privileges outlining the scope of clinical practice granted to Professional Staff at London Health Sciences Centre (LHSC) and St. Joseph's Health Care London (St. Joseph's). 

Privilege categories are recommended by the Department Chief and are consistent with the Professional Staff's certification, education, and/or experience. 

Joint Professional Staff Human Resources Committee (JPSHRC)

The Human Resource Planning process is intended to provide departments with the opportunity to assess staffing needs related to the department's clinical and academic deliverables and to create departmental human resource (HR) plans. This is an ongoing process as each year the departments are asked to update their HR plans.

The Joint Professional Staff Human Resource Committee (JPSHRC) establishes criteria for HR plans and approves Credentialed Professional Staff positions.

The credentialed Professional Staff HR planning process is based on the following important principles that ensure there is a consistent and fair approach, city-wide, across all departments:

  • City-wide credentialed Professional Staff HR plans are based on clearly defined academic and clinical deliverables based on the vision, strategic direction and priorities of the London Hospitals and the Schulich School of Medicine & Dentistry;
  • The primary accountability for the completion of city-wide departmental credentialed Professional Staff HR plans rests with the department Chair/Chief; and
  • Credentialed Professional Staff HR planning is conducted in partnership with the appropriate university, hospital, research, administrative and clinical representatives.
Letters of Offer Templates
Joint Letter of Offer - Clinical Academic

The department Chair/Chief prepares the Joint Hospital and Schulich Compliment joint letter of offer. 

Clinical Academic Joint Letter of Offer TEMPLATE

The joint letter of offer should be as specific about the role as possible. In addition to documenting the mutual commitments and expectations of the recruit and the department, it serves a number of purposes after the recruit begins. For example, the joint letter of offer will be the basis for probationary reviews and the Career Development and Planning process.

There are a number of signatures required on the letter of offer:

  • The department Chair/Chief - If the department Chief role is split between two Chiefs, both individuals need to have a signature line. 
  • The Vice President of the clinical program -  Aligned to the hospital associated to the primary appointment (for Emergency Medicine - Chief of Medicine is included and VP for both LHSC and St. Joseph's. For Anesthesia & Perioperative Medicine, VP for both LHSC and St. Joseph's are included).
  • Integrated Vice President, Medical & Academic Affairs - For St. Joseph's primary appointed candidates only. 
  • Executive Lead, Finance - For LHSC primary appointed candidates only.​​ 

 

The following are steps to complete the letter of offer: 

  1. Chair/Chief writes the letter.
  2. Send the letter to Medical Affairs who will initiate the DRAFT letter of offer review with the following groups:
  • Medical Affairs - will review hospital related details and financial commitments aligned to Medical Affairs.
  • Schulich Human Resources - will review for Academic Role Category (ARC) and Western commitments (pension, benefits etc.)
  • AMOSO - will review for AFP related commitments

3. Once draft letter is reviewed and approved by Medical Affairs/Schulich/AMOSO, the department may proceed with preparing the final copy and obtains the required signatures from the various leaders.

4. Once signed by the required leaders, the Chair/Chief's office is to send the signed letter to the candidate for signature along with other department documentation.

5. Once all signatures have been obtained, the Chair/Chief's office is to send a copy of the final signed letter to Medical Affairs. 

Joint Letter of Offer - Non-Clinical Academic (Hospitalists)

The department Chair/Chief prepares the joint letter of offer for non-Clinical Academic appointments (ie. Hospitalist appointments). 

Non-Clinical Academic Joint Letter of Offer TEMPLATE

The letter of offer should be as specific about the role as possible. In addition to documenting the mutual commitments and expectations of the recruit and the department, it serves a number of purposes after the recruit begins.

There are a number of signatures required on the letter of offer: 

  • The department Chair/Chief - If the department Chief role is split between two Chiefs, both individuals need to have a signature line. 
  • The Vice President of the clinical program -  Aligned to the hospital associated to the primary appointment (for Emergency Medicine - Chief of Medicine is included and VP for both LHSC and St. Joseph's. For Anesthesia & Perioperative Medicine, VP for both LHSC and St. Joseph's are included).
  • Integrated Vice President, Medical & Academic Affairs - For St. Joseph's primary appointed candidates only. 
  • Executive Lead, Finance - For LHSC primary appointed candidates only.​​ 

 

The following are steps to complete the letter of offer:

  1. Chair/Chief writes the letter.
  2. Send the letter to Medical Affairs who will initiate the DRAFT letter of offer review with the following groups:
  • Medical Affairs - will review hospital related details and financial commitments aligned to Medical Affairs.

3. Once draft letter is reviewed and approved by Medical Affairs/Schulich/AMOSO, the department may proceed with preparing the final copy and obtains the required signatures from the various leaders.

4. Once signed by the required leaders, the Chair/Chief's office is to send the signed letter to the candidate for signature along with other department documentation.

5. Once all signatures have been obtained, the Chair/Chief's office is to send a copy of the final signed letter to Medical Affairs. 

Hospital Only Letter of Offer - Reduced Workload (0.5 FTE - 0.9 FTE)

The below process is required to complete a REDUCED WORKLOAD (.FTE-.9 FTE) compliment letter of offer for any NEW Clinical Academic appointment. 

Hospital Only Letter of Offer TEMPLATE

There are a number of signatures required on the letter of offer: 

  • The department Chair/Chief - If the department Chief role is split between two Chiefs, both individuals need to have a signature line. 
  • The Vice President of the clinical program -  Aligned to the hospital associated to the primary appointment (for Emergency Medicine - Chief of Medicine is included and VP for both LHSC and St. Joseph's. For Anesthesia & Perioperative Medicine, VP for both LHSC and St. Joseph's are included).
  • Integrated Vice President, Medical & Academic Affairs - For St. Joseph's primary appointed candidates only. 
  • Executive Lead, Finance - For LHSC primary appointed candidates only.​​ 

 

The following are steps to complete the letter of offer:

  1. Chair/Chief writes the letter.
  2. Send the letter to Medical Affairs who will initiate the DRAFT letter of offer review with the following groups:
  3. Medical Affairs - will review hospital related details and financial commitments aligned to Medical Affairs.
  4. Schulich Human Resources - will review for Academic Role Category (ARC) and Western commitments (pension, benefits etc.)
  5. AMOSO - will review for AFP related commitments
  6. 3. Once draft letter is reviewed and approved by Medical Affairs/Schulich/AMOSO, the department may proceed with preparing the final copy and obtains the required signatures from the various leaders.

    4. Once signed by the required leaders, the Chair/Chief's office is to send the signed letter to the candidate for signature along with other department documentation.

    5. Once all signatures have been obtained, the Chair/Chief's office is to send a copy of the final signed letter to Medical Affairs. 

Joint Letter of Understanding - Internal Change Process

The department Chair/Chief prepares the letter of offer for any Clinical Academic physician to confirm a change in hospital privileges or Academic Role Category.

Internal Change Process Letter of Understanding TEMPLATE

There are a number of signatures required on the letter of offer: 

  • The department Chair/Chief - If the department Chief role is split between two Chiefs, both individuals need to have a signature line. 
  • The Vice President of the clinical program -  Aligned to the hospital associated to the primary appointment (for Emergency Medicine - Chief of Medicine is included and VP for both LHSC and St. Joseph's. For Anesthesia & Perioperative Medicine, VP for both LHSC and St. Joseph's are included).
  • Integrated Vice President, Medical & Academic Affairs - For St. Joseph's primary appointed candidates only. 
  • Executive Lead, Finance - For LHSC primary appointed candidates only.​​ 

 

The following are steps to complete the letter of understanding: 

1. Send the letter to Medical Affairs for review.

2. Once draft letter is reviewed and approved by Medical Affairs, the department may proceed with preparing the final copy and obtains the required signatures from the various leaders.

3. Chair/Chief's office sends the signed letter to the candidate for signature along with other department documentation.

4. Chair/Chief's office sends a copy of the final signed letter to Medical Affairs along with the Appointment Change Chief Support form.

Office Space Set-up

If applicable, office space must be identified with the initial position request that is submitted to Medical Affairs. As part of the position approval process, Facilities Management will review the office space location that is being submitted with a position request and will review for appropriateness and confirm approval.

Once a candidate has been identified, a Candidate Review Impact Summary form is submitted to Medical Affairs. Office space location will be documented on this form and Facilities Management will provide a second review for approval. Should the office space location change after the Candidate Review process, the department will need to inform Medical Affairs who will consult with Facilities Management to ensure approval of the revised office location. 

Prior to the candidate start date, the department Manager of Administration and Finance will be required to submit a Space Request form via the Archibus system. Additional information can be obtained from the Facilities Management website. 

How to Submit a Project Request 
Project requests for new recruits are initiated by the hiring department. Click on the links below and follow the steps outlined on the Facilities Management website.

  • LHSC Project Request - Part A of the process is to create a Project Request which is forwarded to Facilities to assign a project number. Part B is to complete the Project Approval form, which is forwarded to Medical Affairs for approval. You will receive a confirmation email with a project number.
  • St. Joseph's Project Request - Click on the "Space/Project Request Form (leaders only) link using the login and password provided to you by Facilities Management. Part A of the process is to complete a Project Request which is forwarded to Facilities to assign a project number. Part B is to complete the Project Approval form, which is forwarded to Medical Affairs for approval. You will receive a confirmation email with a project number.
Probationary Evaluation Process

Under the current London Health Sciences Centre (LHSC) and St. Joseph's Health Care London (St. Joseph's) and credentialed Professional Staff By-Laws, all new Active Staff appointees are required to fulfill a 12-month probationary period and during this period, the appointment category is referred to as Associate. Once a successful final evaluation is submitted, the category will change from Associate to Active for the duration of the credentialed Professional Staff's appointment.

The probationary period is intended to assess, among other areas, an appointee's clinical competency (impact on patient safety) and collegiality.

There are currently two evaluations that occur throughout the probationary period:

  1. Preliminary Evaluation - occurs at approximately the 4-month service date
  2. Final Evaluation - occurs at the 10-month service date

The appointee’s direct supervisor generally performs the evaluations, although the appointee and the Chief are required to co-sign the document and are encouraged to actively participate in the process. Upon receipt of a satisfactory final evaluation, Medical Affairs will review and recommend progression to an Active appointment to the City-Wide Credentials Committee (CWCC) who will then recommend to the Joint Medical Advisory Committee (MAC) and then subsequently recommend to the LHSC and St. Joseph's Boards of Directors.

This process will be completed by the 12-month end date of the appointees’ privilege line and shall not exceed the privilege end date. If by the end of the 12-month period, the probationary supervisor does not feel that the probationary credentialed Professional Staff member should not yet be granted full Active Staff privileges, they can extend the probationary period to 24-months, or suggest complete denial of hospital privileges. The extended probationary evaluation will need to be completed should this occur.

Recruitment

To request a new position or if you have identified a potential candidate for an existing approved position, complete the Position Request/Candidate Review Impact Summary Form and submit to Medical Affairs.

  • PART A - complete when submitting for a NEW position request.
  • PART B - complete when a candidate has been identified. 

Medical Affairs will review the form and if necessary, distribute to the stakeholder group for review/approval. Subsequently, the Joint Professional Staff Human Resource Committee (JPSHRC) will review and provide final approval for all position requests. Approval must be obtained by the JPSHRC and approval confirmed by Medical Affairs before recruitment may begin.

Once a candidate has been identified, the department is required to submit the following documents to Medical Affairs: 

For ease of process, we encourage departments to submit the above forms all at once. This allows Medical Affairs to initiate the following steps:

1. Email the application package to the candidate to initiate the credentialing process.

2. Complete the Candidate Review process which informs the necessary stakeholders and JPSHRC that a candidate has been identified. 

3. Complete the letter of offer review process which allows for the department to send the candidate the approved letter of offer. 

Determining a Candidate Start Date 
All Professional Staff application requests are reviewed and approved through the following groups: 

  • City-wide Credentials Committee (CWCC)
  • Medical Advisory Committee (MAC)
  • LHSC and St. Joseph's Boards of Directors

To ensure full review and approval, the credentialing process can take up to 6 weeks to process and approve. Review the application submission schedule to determine an appropriate start date. Refer to "Hospital Appointment Approval Process" section. 

There are a number of tools available for departments to use in their recruitment efforts:

Reappointment Process for Annual Renewal of Hospital Privileges 

All Credentialed Professional Staff appointments are for the period July 1 to June 30th. In February of each year, Medical Affairs sends an e-mail to all credentialed Professional Staff members to provide information and a link to access an online reappointment website.

Medical Affairs manages the process to validate each appointment, obtains support from the department Chief, obtains approvals from the City-wide Credentials Committee (CWCC), the Medical Advisory Committee (MAC) and the Boards of Directors for LHSC and St. Joseph's. If any changes are required, credentialed Professional Staff will be notified in advance.

Credentialed Professional Staff are notified by email by Medical Affairs after the Boards approve annual reappointments at their June meeting.

Resignation and Retirement Planning Process
Resignation Process

The Hospitals’ By-Laws state within section 4.2(d)(xix)(E): 

“the applicant will use best efforts to provide the Hospital with three (3) months’ prior written notice of the applicant’s intention to resign or otherwise limit their exercise of privileges and that a failure to provide the required notice will result in the Chief of Department notifying the College that the applicant has failed to comply with the Hospital’s By-Laws and a notation of the breach of the By-Laws in the applicant’s file.  The applicant may be exempted from the notice requirements if the Chief of Department believes, after considering the Credentialed Professional Staff Human Resources Plan, that the notice is not required or if the Chief of Department believes that there are reasonable or compassionate grounds to grant the exemption”. 

Resignations notices must be forwarded to Medical Affairs in advance of the resignation date.  If the resignation is from a Clinical Academic professional staff, the position that they hold will be added back onto the department clinical HR plan for recruitment to begin.

Failure to communicate privilege end dates, or changes to an end date will affect systems access which could pose a security risk to the hospital, or delay patient care.

Notice to secretaries requires minimum 4-5 months pre-resignation/pre-retirement, depending on whether the secretary is a hospital non-union employee, a hospital union employee, or an independently hired employee. 

Retirement Planning Process

In accordance with the hospitals’ Retirement Planning Policy, all Credentialed Professional Staff members must complete a Notification of Intent to Retire Planning Form at least 12 months prior to the date at which they intend to retire unless there are extraordinary circumstances, such as illness or disability.

Retirement dates should be determined as far in advance as possible, but no later than 12 months in advance of the appointee giving up their Active or Modified-Active status in order to help with succession planning.

Following the submission of the Notification of Intent to Retire Planning form, retirement plans should be reviewed every two years thereafter. 

FULL Retirement: 
Once a full retirement date has been announced:

  1. Professional Staff member to provide a signed letter of retirement to the department Chief. 
  2. Department to email retirement letter to Medical Affairs at @email
  3. Form Clinical Academic Professional Staff, Medical Affairs will add the position back onto the clinical department HR plan to enable future recruitment into the position. 

Note: Notice to secretaries requires minimum 4-5 months pre-resignation/pre-retirement, depending on whether the secretary is a hospital non-union employee, a hospital union employee, or an independently hired employee. 

PARTIAL Retirement: 
Professional Staff who are reducing their scope of practice, but will continue to work clinically may have their Professional Staff category changed to MODIFIED ACTIVE. 

  • Department Chief to submit to @email the Modified Active Staff Planning form.
  • When submitting the Modified Active Staff Planning form to Medical Affairs, it is important that the following is identified to Medical Affairs:
    • Identify if the Professional Staff will work within a partial Clinical Academic capacity, meaning that they will continue to utilize hospital resources and/or AMOSO funding. 
    • Identify if the position should be added back onto the clinical department HR plan for partial or full recruitment. If the Professional Staff that is reducing their scope of practice will continue to work within a partial Clinical Academic capacity, resources for the position will be shared. 
    • Reduced workload is a clinical academic appointment .5FTE - .9FTE. The full process and required document templates for reduced workload for clinical academic professional staff are outlined here.

View the Retirement Planning Resource Guide for Credentialed Professional Staff for additional information. 

Upon reaching a retirement date a Credentialed Professional Staff member may:

  • Retire;
  • Apply for appointment to the Honorary or Supportive staff.
Systems Access - Corporate ID, Outlook, and Cerner

The Manager of Administration and Finance (Manager) or delegate will request the corporate ID, hospital email, and Cerner access for incoming professional staff using the Systems Access Request form. The request will be routed to Medical Affairs for review and approval.

Once the access has been set up by the IT department, the login details will be sent to the Manager or delegate. The Manager/delegate will complete the following:

  1. Verify that the physician has completed the Privacy eLearning and agreement via the Professional Staff and Trainee Directory.
  2. Once Privacy has been complete, the Manager/delegate will send the physician their login details by entering the login details into the standard template to ensure professional staff receive the full details related to the corporate ID, email, remote access, and ME (MyEducation), etc.

    NOTE: Login details must be emailed to the applicant's personal email address using the hospital's File Safe system.