Performance

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
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