Accreditations
Accreditations
Clinical Privileging
Dr. Rajini Ashok Director Quality, Zulekha Group
Zulekha Healthcare Group
Hospital in Dubai
Hospital in
Sharjah
Diagnostic Centers
Pharmacies
Medical Centers
Alexis Hospital,
Nagpur, India
Diagnostic
Centres Pharmacies
Belief
“We look for Medicine to be
an orderly field of knowledge
and Procedure”
Facts • It is an imperfect science
• An enterprise of constantly changing
knowledge
• Uncertain information
• Fallible individuals and
• Patient centered practice
• At the same time lives on the line
• Patients’ Right - Receive care from competent practitioners
• Organizations’ Responsibility – A system to ensure patients
receive quality care, treatment and service
• One such critical process in healthcare industry:
Clinical Privileging
Definitions • Licensure – The granting of
permission by a competent authority
(usually a government agency) to an
organization or individual to engage in
a practice or activity that would
otherwise be illegal
• Credentialing – Process of obtaining,
verifying & assessing the qualifications
of a healthcare practitioner to provide
patient care services
Definition
Clinical Privileging: Is a process
wherein a collective body in the
organization decides
“What clinical services a doctor can
provide and what clinical services a
doctor cannot provide”
Our Mission
To provide easy accessibility to
high quality healthcare
Our Vision
To be the most efficient, competent and
courteous providers of comprehensive
healthcare in the world
Appropriately developed sustainable
process of clinical privileging
Our Strategy
Inputs
Clinical
Privileging
Credentialing
&
Privileging
Committee
(CPC)
HR and Mktg
teams
Coordination
Practitioner
Orientation
Data and
Peer review
HR- Human Resources; Mktg - Marketing
Leadership
Support
Accreditation
Standards
& Regulatory
Requirements
*HOD: Head of Dept. DOJ: Date of Joining
Process
New Licensed Practitioner joins HR orients doctor
Clinical privileging form filled - DOJ
Practitioner specific
Temporary privileges assigned &
Forwarded to areas of scope of work
HR coordinates the meeting of HOD,
medical director and doctor. Provides
all the required documents
Doctor starts clinical practice
Licensed status
Experience
Training
Reference letters
Temporary Privileges Confirmed/Denied -
Credentialing and Privileging Committee (after 3
months of clinical practice) & Forwarded to areas
of scope of work
Outcome Informed to the
practitioner
Annual Performance evaluation & review of
privileges every 3 yrs or as needed (Medical Staff
Bylaws) & forwarded to areas of scope of work
Data - Focused Professional Practice
Evaluation (FPPE) and peer review
Continues to practice as per confirmed privileges
Data - Ongoing Professional
Practice Evaluation (OPPE) and
Peer review
Additional privileges
by practicing doctors
Right to Appeal
(Medical Staff Bylaws)
At any stage CPC can revoke privileges if there is an unsafe practice
Professional Practice
Evaluation
• Valuable tool in clinical privileging
• Objectivity in performance
monitoring
• Addresses critical elements
• Peer review
Critical Elements QUALITY OF CARE • Clinical outcomes
• Evidence based practice
• Key Performance Indicators
( Medication Errors, Morbidity & Mortality)
• Compliance to Hospital Policies and procedures
• Complaints from local authorities
UTILIZATION OF SERVICES
• OPD care
• Inpatient admissions
• Use of diagnostic services
COMMUNICATION &
INTERACTION
• With peers
• Patient and family
• Other staff
OTHERS
• Continuous Medical
Education
• Punctuality
• Flexibility
Data source: Medical records, KPIs, Audits, Tracers and Peer review
Practitioner Performance Dashboard Doctor’s
Name
Quality of
Patient Care
Utilization of
Services
Communication
and Interaction Others
Total
Average
Doctor 1
Doctor 2
Doctor 3
Doctor 4
Doctor 5
Doctor 6
Average
Excellent - 5
Exceeds
Expectation - 4
Satisfactory
– 3
Needs
Improvement - 2
Unsatisfactory
1
Average Score < 3 – Training, Counseling, and Supervision
Average Score > 4 – Expansion of responsibilities
Benefits
•Care from the most
competent
practitioner
•Patient Satisfaction
•Expertise to optimal
level
•Team Work
•Safeguards from
litigation due to medical
negligence
•Safeguards from litigation
•Resource Utilization
•Financial benefits
•Culture of Safe practice
•Brand Image
Practitioner
Organization
Clinical privileging is a key to
safe clinical practice.
Objective - Clinical privileging
before the practitioner starts
providing clinical care
Our Journey
Birth of the concept - JCI
Drafting of Policies
Orientation of staff and Implementation
Leadership Support
Introduced a process and
privileged staff as per JCI initial survey requirements
Done by Medical Director & Director Quality
Formation of Credentialing & Privileging Committee (CPC)
Completed the privileges of all practicing doctors
& some community doctors
2006
2007
2008
Our Journey
Ongoing Performance Evaluation
Review of Privileges
Medical Staff Bylaws
2010
Performance evaluation of Practitioners
(Uniform format - Data & Peer Review)
2009
Terms of reference & objectives of CPC reviewed
Process restructured to ensure clinical
privileging before joining
Extension of process to include community
doctors
HR and Marketing role redefined
2011
Compliance to regulatory standards
Compliance to accreditation requirements
2012
Our Journey
Challenges
Challenges Approach
Practitioner
Acceptance of decision
Leadership Support
Practitioner involvement in review process
Staff orientation and training
Acquiring new skills and
changing license status
Addressed as additional privileges
Peer review reliability Objective data from KPI
Lack of Benchmarking Identify benchmark from Practitioner
performance dashboard
Introduction of new
specialty
Inputs from near specialties, relevant websites
& societies
Challenges Approach
Extension to Community &
Visiting doctors
Involvement of Mktg and HR dept
Transparency in Communication & Leadership
support
Process
Clinical privileging before joining
•Coordination and team work
(HR, Medical Director and Marketing)
•Document availability
Sustainability •Professional Practice Evaluation
•Review of clinical privileges
Awareness in areas of work HR team forwards updated privileges to areas of
scope of work
Prevent clinical service in life
saving situations
Staff orientation of Medical staff Bylaws –
“Clinical privileges overridden of in case of life
saving emergency”
Sustainability • Deploying effective strategies
• Staff involvement Policy preparation and
implementation
• Staff orientation
• Team work & coordination
• Peer Review
• Strong performance monitoring tool (PPE)
• Periodic review( medical staff bylaws)
Results
215 doctors (In house, Visiting and Community doctors)
15
100
15
89
100
85
0
10
20
30
40
50
60
70
80
90
100
2010 2011 2012 till date
Pe
rce
nta
ge
ZHS
ZHD
Target
Clinical Privileging Before Start of Practice
(Percentage Compliance)
657071
75
8885
0
10
20
30
40
50
60
70
80
90
100
2010 2011 2012 till date
Perc
en
tag
e
ZHS
ZHD
Target
Patient Satisfaction on Doctors
Participation in Care Results
Quality & Safety
EVERY SYSTEM IS PERFECTLY DESIGNED
TO GET THE RESULTS IT GETS
Quality
has to be
caused, not
controlled
Safety does
not happen
by accident
Thank You