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Periodic / Probationary Review Process

Medical Staff bylaws require that all Practitioners be reviewed periodically.  Periodic reviews are required for the following categories:

  • Probationary  - initial review (at conclusion of their first year and then, if satisfactory, move to a review every three years)
  • Physicians 65 and older - annually
  • Active and Locum Tenens – every 3 years (or more frequently if specified in Letter of Offer) 

The Periodic Review is a process that falls under Section 5 of the AHS Medical Staff Bylaws (MSB) and Section 5 of the Covenant Health MSB. This is an AHS process, but to assist AHS with the process, Covenant Health Medical Affairs manages the distribution of the self assessment form to the physician being reviewed and the Periodic Review tool for the Medical Leader doing the review.

The list of actual physician names assigned  to have this review done in a given year is identified by the AHS  ZCD (Zone Clinical Department). This list is then provided to Covenant Health Medical Affairs who sends out the required forms. Covenant Health Medical Affairs collect them from the reviewers once the review has been conducted and forwards a copy  to AHS for them to be kept on file. 

Periodic Reviews (PR) are owned by AHS and the Zone Clinical Department. While Covenant Health houses electronic copies of all completed PRs, AHS Medical Affairs and the Zone Clinical Department Head also keep copies.  If any physician or Covenant Health Medical Leader requires a copy of a Periodic Review, they must contact their AHS Zone Clinical Department Head directly with their request.  Only the AHS Zone Clinical Department Head or AHS CMO can authorize / release copies of Periodic Reviews.

Covenant Health Bylaw User Guide Periodic Reviews

Forms Central Zone

Forms NORTH Zone

Edmonton Zone - Forms/Process

Instructions for the Reviewer:    

A.      In preparation for the review:

    • Contact the practitioner as soon as possible to book a meeting date/time on which to do his review; (for those UofA Faculty, there may be opportunity to align AHS review meeting with Faculty Evaluation (FEC) meeting, however please ensure AHS forms are completed as well)
    • Forward the practitioner a copy of the Practitioner’s Self-Assessment form (attached) and instruct him/her to complete it in advance of and bring to the review meeting;
    •  If helpful please contact physician colleagues or other health care professionals working in the Practitioner’s environment for additional feedback (form attached) (let them know that their comments are voluntary, the review is part of standard AHS bylaw requirements for medical staff appointments and that all of their comments will be anonymized)

B.      During the review:

    • Discuss the Self Assessment in a private place with no interruptions;
    • Provide specific, constructive feedback. This should include positive areas and those requiring improvements (if you know them). Outline specific actions the practitioner can take to improve any areas requiring improvement;
    • Assess and comment on the Self Assessment;
    • Provide any feedback obtained from other department members or health care team members;
    • Discuss what professional development the practitioner has done and is planning to do in the next 2 – 3 years;
    • Explore with the practitioner how he/she is doing this and if there are areas of improvement needed discuss with the practitioner how he/she may address these areas;
    • Ask what you can do to help and provide reasonable assistance if required;
    • Add you comments to the Reviewer’s report;
    • Obtain the Practitioner’s signature on the Reviewer’s Report and include your signature as well. 

C.      In follow-up to the review:

    • a copy of both the Practitioner’s Self Assessment as well as the Reviewer’s Report should be provided to the Practitioner;
    •  fax or scan and email a copy of ALL completed forms to your designate in Medical Affairs NO LATER THEN 2 weeks following the review meeting for tracking;   

Department of Family Medicine  Periodic Review Process - Instructions for the Reviewer: 

Identify those Physicians with privileges in acute care who admit less than 1 patient per month (< 12 pts per year) to acute care and admit outpatients

  • Forward these practitioner a copy of the Practitioner’s Self-Assessment form (attached) and instruct him/her to complete it and return the form to your office;
  • Reviewed the self-assessment form, if no significant issues or concerns are identified, no further action is required (no face-to-face meeting required);
  • Return a copy to Covenant Health Medical Affairs within two weeks of interview .  Copies will be filed in the Medical Staff Office and forwarded to the Zone Clinical Department Head.

Please fax, 780-735-9921, or scan and email a copy of both completed forms to Covenant Health Medical Affairs – following the review. 


Please email Maureen Korzan or call at 780.735.7185