HR HealthCheck

Ontario Gives Hospitals More Flexibility in Respect of Credentialing Processes

HR HealthCheck

Ontario Gives Hospitals More Flexibility in Respect of Credentialing Processes

Date: May 6, 2020

On May 1, 2020, the Ontario government made a new temporary emergency order under the Emergency Management and Civil Protection Act which gives Hospitals more flexibility in respect of their credentialing processes. 

O. Reg. 193/20, Hospital Credentialing Processes (Order) gives Hospitals the authority and flexibility to quickly appoint, re-appoint and grant privileges to medical and other professional staff, in order to address potential surge volumes due to COVID-19.

The “credentialing process” refers to the activities, processes, procedures and proceedings for appointing or reappointing members of the medical, dental, midwifery or extended class nursing staff (i.e. registered nurses who hold an extended certificate of registration under the Nursing Act, 1991) (collectively, Professional Staff), and determining the nature and scope of privileges assigned to them.

Pursuant to the Order, a Hospital may take any reasonably necessary measure to respond to, prevent and alleviate the outbreak of COVID-19 with respect to any aspect of the Hospital’s credentialing process. In particular, Hospitals are authorized to:

  • appoint Professional Staff to any department of the Hospital and determine the nature and scope of privileges assigned to them
  • reappoint, continue or extend the appointment of, or extend the time for the application for reappointment of, any Professional Staff of the Hospital
  • determine the nature and scope of the privileges assigned to the Professional Staff at the Hospital
  • collect information from Professional Staff about their availability to provide services for the Hospital, and
  • collect information from Professional Staff about their likely or actual exposure to COVID-19, any positive results for the virus or about any other health conditions that may affect their ability to provide services.

This authority is granted to Hospitals, despite:

  • any other statute, regulation, order, policy, by-law
  • any provision of an arrangement or agreement
  • any provision of a by-law, rule, regulation, policy or procedure of a Hospital, and
  • terms of the appointment of Professional Staff or the nature or scope of the privileges assigned to Professional Staff.

The Order also allows the Board of a Hospital to prohibit, vary or rescind, by resolution, any measure that would otherwise be authorized under the Order by the Hospital’s authorized officers (i.e., the administrator, chair of the medical advisory committee, or the chief or president of the medical staff).

Nothing in this Order restricts the powers and duties of Hospitals under the emergency order (O. Reg. 74/20) that deals with the staffing of health service providers. See our FTR Now of March 22, 2020 COVID-19 and Staffing – Province Issues Emergency Order for Health Service Providers for more information on O. Reg. 74/20.

The Ontario government has stated that the rationale behind the Order is to help reduce administrative processes and better enable hospitals to focus operational resources on providing frontline services during the emergency.

For more information on this Order, please contact your regular Hicks Morley lawyer.


The article in this client update provides general information and should not be relied on as legal advice or opinion. This publication is copyrighted by Hicks Morley Hamilton Stewart Storie LLP and may not be photocopied or reproduced in any form, in whole or in part, without the express permission of Hicks Morley Hamilton Stewart Storie LLP. ©