scope:

Purpose. To reissue policy and procedures for a Credentials Review and Privileging Program for Department of the Navy (DON) fixed and nonfixed medical and dental treatment facilities (MTFs and DTFs), per references (a) through (c) and as part of the DON clinical quality management program. Adverse privileging actions, monitoring, and reporting of practitioner or clinical support staff misconduct and due process (fair hearings and appeals) are in reference (d). References (e) through (y) provide additional guidance. This is a complete revision and must be read in its entirety.

Applicability. This instruction applies to all military (active duty and Reserve) and civilian health care practitioners and clinical support staff (as defined in section 5), who are assigned to, employed by, contracted to, or under partnership agreement with DON activities or who are enrolled in a Navy-sponsored training program.