Physician Approvals

Accredited facility approvals/privileging

Updated process for privileging in accredited facilities: step 1 now in effect

CPSA continuously reviews our processes to ensure they align with our mandate under the Health Professions Act and support and guide regulated members to proudly provide safe, high-quality care. After careful review, the process for privileging and modality approvals of regulated members to work in accredited medical facilities has been updated. Effective Nov. 7, 2022, medical directors are now responsible for decisions on credentialing and privileging of regulated members within their CPSA-accredited medical facilities.

To support this change, we have outlined a 2-step process.

Step 1: interim privileging process (in effect from Nov. 7, 2022 – June 30, 2023)

During Step 1, CPSA will continue to review the credentials of regulated members and, if requested by a facility medical director, we will offer recommendations on privileging.

Forms to be completed during Step 1
To be completed by the CPSA regulated member:

• CPSA regulated members applying for privileging within an accredited facility must complete a Privilege Credentialing Form and submit it to the facility. This form is for the medical director’s review.
  Important: this form is for new privileging only—regulated members who are already privileged to provide specific clinical services within your facility do not need to complete this form.
• CPSA regulated members seeking non-hospital surgical facility (NHSF) privileges must also complete the NHSF Procedures by Scope Form and submit it to the facility along with their Privilege Credentialing Form.

To be completed by the medical director:

Facility medical directors will complete the Privilege/Approval Record Form and submit it to CPSA for each regulated member applying for privileging within their facility.

If the medical director chooses to grant privileges within their facility to the regulated member, the Privilege/Approval Record Form is all we need.

If the medical director would like CPSA to provide a recommendation on privileging for a specific regulated member, please include their completed Privilege Credentialing Form and NHSF Procedures by Scope Form (if applicable) when you send us the Privilege/Approval Record Form.

Step 2: final process (effective July 1, 2023)

Step two—the final process—begins July 1, 2023. At this point, CPSA will no longer require medical directors to submit the Practitioner Privileging Information Form as a regular practice. Medical directors will now be fully responsible for reviewing credentials and making decisions on privileging. This will include adhering to any expected accreditation policies, procedures and standards.

Non-accredited services

CPSA is undertaking a review of the legislative authority by which we provide approvals for non-accredited services. In the interim, no applications for these approvals are being entertained.