While there is a broad exclusion for credentialing records, the medical staff office still needs to be part of the FIPPA implementation process. Even if large portions of the records maintained by medical staff offices are excluded, they need to understand the legislation, review the records that they maintain, and determine what is or is not covered by the exclusion.

The following records are excluded from FIPPA pursuant to an amendment specific to hospitals – records collected, prepared, maintained or used by hospitals in relation to “meetings, consultations, discussions or communications about applications for hospital appointments, the appointments or privileges of persons who have hospital privileges, and anything that forms part of the personnel file of those persons” – section 65(6)(5).

This is a very broad exclusion for a wide range of records relating to the Public Hospitals Act appointment process and physician relationship. “Meetings, consultations, discussions or communications” will cover both formal meetings (eg. MAC and Board) as well as other records from all stages of the credentialing process. “Personnel file” is not a defined term but would cover the types of records that would typically be found in an employee file in the human resources department. Overall, the legislative intention would appear to have been to exclude the same types of records for physicians as are excluded for employees under existing exclusions for labour relations and employment records.

The medical staff office needs to determine what is the “personnel file” of the physician within their hospital. This file probably has a different name, such as credentials or medical staff file, as hospitals have not traditionally thought of physician records as personnel files. There may also be multiple files, dealing with different aspects of the physician relationship, including service or other agreements, performance evaluations, complaints, etc. Finally, there may be separate files kept by others in the hospital, such as chiefs of department and program directors or vice-presidents. These could all be part of the personnel file where they deal with different aspects of the physician’s relationship with the hospital.

As part of getting ready for FIPPA, the medical staff office needs to review how physician records are kept within the hospital and determine what is part of the personnel file. It is recommended that hospitals define the personnel file and use it as the place where all records relating to physician relationships are kept.

The medical staff office also needs to review the other types of records that relate to functions of the medical staff leadership, that are not directly related to physician credentialing or personnel matters, and how FIPPA will apply to these records – for example, the medical leadership is involved in many administrative matters and policy development, the records for which would not be covered by the exclusion. Therefore, the medical staff office needs to be prepared to respond to FIPPA requests that relate to these records.

Others involved in the credentialing process will also have to review their record keeping practices. Everyone involved in the physician appointment or privileges process needs to understand the scope of the exclusion and, to the extent that they are engaged in related “meetings, consultations, discussions or communications”, appropriately identify their records so that the exclusion can be properly applied.


  • The medical (professional) staff office needs to create a “personnel file” for each member of the medical/professional staff within its hospital, and decide what is to be included in such personnel files. Records that are part of the personnel function should be organized and maintained within the personnel file, as this will assist in responding to FIPPA requests. In the interest of clarity, the fact that the file is called the personnel file does not mean it needs to be transferred to or administered by the HR department, and it can still be maintained in the medical (professional) staff office.
  • This is also a good time to review record retention policies and practices within the medical staff office, to ensure that hospital policy in this regard is appropriately established and followed