Credentialing and PrivilegingKrista Fairweather, BSc, RNQuality Improvement LeadMedical Director Education DayApril 4, 2019

College of Physicians and Surgeons of British Columbia 2

DisclosureI have nothing to disclose.

College of Physicians and Surgeons of British Columbia 3

Objectives• Outline governing structure for credentialing and privileging

• Understand definitions

• Review roles and responsibilities

• Examine tools for credentialing and privileging

• Review examples

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Why?• Credentialing and privileging processes ensure that patients receive care,

treatment and services from qualified and competent practitioners

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Expectations for Credentialing and Privileging Cochrane Report: • March 2011, Investigation into Medical Imaging Credentialing and Quality

Assurance

• Recommendation 24: Health care services are complex and require highly educated, skilled, and experienced practitioners. Health authorities create a single medical staff administration with information sharing agreements with the College so that results of licensing, credential review and privileging are available to all parties

Cochrane Review of NHMSFP:• January 2012, NHMSFP roles and responsibilities

• Recommendation: Participation with the health authorities in a unified provincial physician credentialing, privileging and performance assessment system as recommended in the diagnostic imaging review

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BC Medical Quality Initiative (BC MQI)• A governance structure which brings health-care partners together to

develop ways to improve the quality of medical care

• Supports medical practitioners to improve the services they individually and collectively provide

• Provides assurance to the public, boards, and Ministry of Health about the quality of medical care across the province

• Developed the Provincial Practitioner Credentialing and Privileging System i.e. CACTUS Software and the Provincial Privileging Dictionaries

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Roles and responsibilitiesCollegeregulates the practice of medicine under the authority of provincial law and is governed by the Health Professions Act and the Bylaws made under the Act.

Committeeestablishes accreditation and performance standards, procedures and guidelines for the NHMSFAP to ensure the delivery of high-quality and safe services in non-hospital facilities.

Medical Directors provide the leadership and are accountable for the quality and safety of the services delivered at non-hospital facilities.

NHMSFAPacts in the interest of the public to ensure the delivery of high-quality health services through accreditation.

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College BylawsSection 5-7 pertains to the medical director:(5) The medical director is responsible for

the selection, appointment and reappointment of all medical staff and must meet, at least annually, with each member of the medical staff and review the privileges granted to each member and document such review in a form approved by the registrar.

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College BylawsSection 5-11 pertains to medical staff application:(1) Only a registrant, dentist, oral maxillofacial surgeon, or podiatric surgeon in

good standing may be appointed to the medical staff of a facility.(2) A registrant, dentist, oral maxillofacial surgeon, or podiatric surgeon may apply

to the medical director for a medical staff appointment to a facility for a period of up to one year stating the procedures she or he wishes to perform and such applications are to be made annually and on a form approved by the registrar.

(3) The registrant, dentist, oral maxillofacial surgeon, or podiatric surgeon in their application to the medical director must include their qualifications and evidence of current experience in practice relevant to the procedure being requested.

(4) The committee may establish standards, rules, policies and guidelines respecting the skills and training necessary for the appointment of medical staff.

(5) Annual applications for reappointment must be made to the medical director, in a form approved by the registrar, and state any changes in the applicant’s hospital appointment or privileges and any material changes in clinical activities from the last application.

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Medical Director standard

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Policies

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DefinitionsCredentials – Professional education, clinical training, licensure, board and other certification, clinical experience, letters of reference, and other professional qualifications.

Credentialing – Reviewing, verifying and evaluating a practitioner’s application for privileges, credentials, letters of reference, CV, disciplinary actions, to establish the presence of the specialized professional background required for a position within a health-care organization.

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DefinitionsPrivileging – Determining a health-care professional’s current skill and competence to perform specific diagnostic or therapeutic procedures that the professional requests to perform and granting those procedures to be performed in a health-care facility.

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Current tools• Application forms

• Appropriate procedures list

• Hospital letter

• Certificate of professional conduct

• References

• BC MQI dictionaries

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Applications

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Appropriate procedures list

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Hospital letter• (Insert picture)

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Certificate of professional conduct

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References

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BC MQI dictionaries

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What’s new?• Checklist

• Guidelines

• New forms

• Certificate of professional conduct

• Reference forms

• BC MQI Cactus report

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Checklist

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Guidelines

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New forms

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Certificate of professional conduct

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Reference forms

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BC MQI CACTUS report

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Case study

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Ophthalmology

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Case study

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Urology

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Case study

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ENT

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Thank you• Questions?

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References• College website (all accessed March 12, 2019)

– https://www.cpsbc.ca/files/pdf/HPA-Bylaws.pdf– https://www.cpsbc.ca/programs/nhmsfap/policies– https://www.cpsbc.ca/files/pdf/NHMSFAP-G-Application-for-Appointment-to-

Facility.pdf– https://www.cpsbc.ca/files/pdf/NHMSFAP-Reference-for-Applicants-for-

Privileges.pdf• http://bcmqi.ca/credentialing-privileging/dictionaries/view-dictionaries• http://www.phsa.ca/medical-staff/appointments-

compensation/appointments/credentialing-privileging• Cochrane DD. Investigation into Medical Imaging, Credentialing and Quality

Assurance: Phase 2 report. British Columbia Patient Safety and Quality Council; 2011 Aug. Available from: www.health.gov.bc.ca/library/publications/year/2011/cochranephase2-report.pdf