Bedside Procedure Credentialing Policy

As required by the New York State Department of Health and The Joint Commission, the University at Buffalo Office of Graduate Medical Education (GME) is responsible for providing a process for system-wide access to procedure privileging reports for all residents and fellows.

Requirements and Regulations

Privileges are granted to individual residents/fellows by program directors or their designee(s) after documentation of a previously specified number of successfully performed, supervised procedures. Each residency and fellowship program is responsible for maintaining the appropriate list of resident credentialing/privileges in MedHub, the web-based residency management system. Through MedHub, details of a procedure are entered by a resident/fellow, forwarded for approval to the supervisor indicated, and then certified by the program administrator/faculty mentor/program director. Once privileges have been certified, a privilege report can be generated in MedHub. Instructions are available on the MedHub home screen for program administrators and directors.

While GME provides oversight of the process of granting trainee privileges in MedHub, faculty who verify bedside procedures are responsible for ensuring that data entered are valid and programs are responsible for ensuring that privilege reports are populated correctly in MedHub. Granting of privileges based upon prior training is at the discretion of the program director. Non-credentialed residents must be directly supervised by a faculty member or a credentialed resident who is either in their final year of postgraduate training or has completed at least 3 years of postgraduate training (i.e. PGY-4 or higher).  Residents who perform procedures independently who are not authorized to do so face disciplinary action in accordance with the UB Misconduct Policy.

Established: 1996
GMEC Approved Date:  September 18, 2018