Performance

Health Authorities and Denominational Facilities
HAs have primary responsibility for the quality of care and services within their respective regions. Part of this role includes owning and managing publicly owned
hospitals and facilities within their territory as well as contracting with and performance managing other health care providers. Five of the six HAs in BC have
regional mandates (FHA, Interior Health Authority (IHA), Northern Health Authority (NHA), VCHA and VIHA) with one, PHSA, having a Province-wide mandate for
selected services. Through the Hospitals Act, the Boards of the HAs are responsible for granting physician privileges. Within their mandate of providing quality of
care and services, HAs have a role in monitoring physician performance.
Each HA has a Board of Directors, accountable to the Minister of Health. Within the HA structure, there are a number of committees and individuals 14 involved in
physician credentialing, privileging and performance management:
HAMAC: An advisory committee to the Board and the CEO, the Committee makes recommendations to the Board on physician privileges as well as
have some oversight responsibility for performance management.
Chief Executive Officer: Along with regular management duties, the CEO has the authority to grant temporary privileges subject to Board approval.
Vice President, Medicine: Also referred to as the Chief Medical Officer (CMO), they act as a key resource and point of contact for the Board and Senior
Medical Directors. They also play a role at a Provincial level in coordinating initiatives related to physician credentialing, privileging and performance
management. In some HAs, the CEO has delegated the authority to grant temporary privileges to the VP Med.
Regional Medical Advisory Committee (MAC): Some Authorities have Regional MACs which review applications for privileges after they have been
reviewed by the Credentials Committee but before going to HAMAC.
HA Credentials Committee (HACC): This body reviews applications for privileges before they are sent to HAMAC.
Senior Medical Directors: Some HAs have adopted a regional approach to managing physician privileges and performance. The Senior Medical Director
has a role in oversight and ensuring compliance of procedures at a local level. This person is often involved in reviewing applications and managing
performance issues before they reach the VP Med/CEO and/or Credentials Committee levels.
Local Credentials Committees and Medical Advisory Committees: These Committees (if they exist) function at an individual hospital or facility and
review applications for privileges before they are sent through the approval process.
Department/Division Heads and Chiefs of Staff: At the hospital-level, these individuals have a role in physician recruitment, reviewing and
recommending applications for privileges as well as fulfilling performance management duties in their area.
Medical Affairs Office: Administrative staff within the HA as well as each hospital who manage administrative functions. This includes reviewing
applications to confirm that they are complete, flagging any concerns for further review, and coordinating the distribution of documents through the
process.
14 Committee and position titles vary from HA to HA. This list is intended to provide an overall representation of the roles and responsibilities.
Ministry of Health 23
Provincial Review of Physician Licensing, Credentialing, Privileging & Performance Management
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