The Credentials Committee shall review and evaluate the qualifications of each Applicant for initial appointment, reappointment or modification of appointment to the Clinical Staff in accordance with the procedures outlined in the Credentials Manual and the Clinical Staff Bylaws. The Credentials Committee shall recommend to the Clinical Staff Executive Committee and the HSB appointment or denial of all Applicants to the Clinical Staff and the granting of Clinical Privileges. When appropriate, the Credentials Committee shall interview a Member or Applicant and/or the Chair of the involved Department in order to resolve questions about appointment, reappointment, or change in privileges. The Credentials Committee shall review and make recommendations for revisions to the Credentials Manual from time to time; provided however the Chair of the Credentials Committee, in consultation with the Clinical Staff President and the Chief Executive Officer, shall have authority to amend the Credentials Manual. The Credentials Committee shall also monitor initial Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) processes for members of the Clinical Staff to ensure compliance with the Joint Commission. The Credentials Committee shall also serve as the investigatory body for all matters set forth in Article VIII of the Clinical Staff Bylaws. The Credentials Committee shall also independently assess the departmental Peer Review process for Members of the Clinical Staff and for Allied Health Professionals in order to ensure that data related to qualifications and performance of individual Practitioners is collected, regularly assessed, compared to Peers, and acted upon by the Department in a timely manner. When appropriate, the Credentials Committee shall also refer Practitioners to the Clinician Wellness Program or the Employee Assistance Program, and shall work with these programs to determine appropriate privileges for each Practitioner’s individual circumstances.

Current Members



Margaret Tracci, MD, JD, Chair


Christian A. Chisholm, MD


Gary Cuccia, CRNA


Klaus Hagspiel, MD


Bradley W. Kesser, MD


Susan E. Kirk, MD


Carol A. Manning, PhD


Eugene D McGahren, MD


Diane Pappas, MD, JD


Michael Ragosta, MD


Vanessa Shami, MD


Worthington G. Schenk, MD


Jason Sheehan, MD, PhD

Ashley Shilling, MD Anesthesiology
Stephanie Allen Director, Clinical Staff Office
Sally Miller, DNP, CNM APP Representitive
Jennifer Slaughter, JD Legal Counsel
Mary Frances Southerland, JD Legal Counsel