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Appendix I: Private Facility Online Survey & Summary of Results Physician Privileging 1. When was the last time that you conducted a facility-wide review of physician privileges? Note: If a facility-wide review is not completed, please indicate when each Department/Area conducted a review. The majority of respondents indicated that a facility-wide review is conducted annually, usually in the winter months. The remaining respondents do not conduct a facility-wide review since there may be only one doctor working at the facility. 2. How do you manage the files and administrative work around physician privileging (i.e.: software, excel spreadsheet, database, paper files)? 36/53 respondents stated that paper files are used. The second most common response was using a software such as an excel spreadsheet to manage the files. 3. Are there any instances where information related to physician privileging would be reported to BCs Ministry of Health? If yes, please describe them. 46/48 respondents stated there are no instances where this information would be reported to the Ministry. If there were any instances to be reported, ex. misconduct, they would be reported to the College. 4. Are there any instances where information related to physician privileging would be reported to the BC College of Physician and Surgeons? If yes, please describe them. Yes. The majority of respondents indicated there are instances where this information would be reported to the College. They include: Altered scope of practice; Any activity deemed a criminal offence or malpractice; Complaint or concern; If any changes to applicants surgical privileges or practice by a hospital or medical surgical facility; Any disciplinary action; Has any blood borne communicable disease; Any factors that may limit suitability to work at facility; and, Relinquished hosp/anaesth privileges. Ministry of Health 112 Provincial Review of Physician Licensing, Credentialing, Privileging & Performance Management © 2012 KPMG LLP, a Canadian limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
Many facilities report this information to the College as part of an annual application for renewing privileges. 5. Are there any instances where information related to physician privileging would be reported to other private facilities? If yes, please describe them. Almost all respondents stated they would not report this information to other facilities. The response was that the College should be involved in this process, not the individual private facility. The response from the CPSBC states they would report this information. They provided an example: “If a physician's privileges have been suspended at a hospital and the circumstances were relevant to the NH setting and in light of patient safety the College would as appropriate suspend privileges at any nonhospital where the physician worked.” Performance Management 1. Do you have a process within your facility for physician performance management? 35/55 respondents stated “yes”. 2. Who is responsible for performance management in your facility? If this is completed by each Department, please also identify who within the facility is accountable for all performance management activities. The Medical Director is responsible for performance management in almost all facilities. This aligns with the response from the College. In a few cases the Director of Anesthesiology, Nursing Manager, or Surgical Director are responsible for performance management in their respective departments. 3. Is your performance management process guided by an evidence-based model such as a Balanced Score card? If so, please provide a brief description of the model. Almost all facilities indicated “no”. However, some facilities indicated that they use: Reviewing outcomes – these include pregnancy rates related to treatments, treatment and outcome complications, and incidents. We also survey patients for feedback on their experience at the facility. Outcome Analysis. At one clinic, a proprietary Outcome Analysis software is used where every patient's pre-operative data, surgical refractive treatment and post-operative outcome are analyzed per software. Any unexpected outcomes are then automatically flagged and brought to the Medical Director's attention and dealt with. Ministry of Health 113 Provincial Review of Physician Licensing, Credentialing, Privileging & Performance Management © 2012 KPMG LLP, a Canadian limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
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ADVISORY SERVICES British Columbia
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Table of Contents GLOSSARY OF ABBRE
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CHAPTER 6: OUR FINDINGS - CREDENTIA
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Glossary of Abbreviations Abbreviat
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Chapter 1: Executive Summary Backgr
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We have not graded our suggestions
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Performance Management The Provinci
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Executive accountability on HA Boar
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Enhancing the role of the College (
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Future State Centralization and sta
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Report structure This Chapter provi
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Terms of our engagement KPMG was co
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Development of the Review Assessmen
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Chapter 3: Roles of Key Organizatio
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Health Authorities and Denomination
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Chapter 4: The Ministry’s respons
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Provincial Credentialing & Privileg
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Chapter 5: Our Findings - Licensing
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Technology The College’s annual l
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Other Canadian Provinces The AIT wa
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Role of organizations It is widely
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Appendix D provides the responses p
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Those interviewed felt that it is i
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Joint Commission on Accreditation o
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Role of organizations Ministry of H
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Communication Issues around communi
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Process In discussing performance m
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Legislative changes to enhance comm
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Suggestions for Improvement Chapter
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Executive accountability on HA Boar
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Medical school participation in any
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Role of the College and HAs Stronge
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Suggestion for Improvement #22: On
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