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Learning from other jurisdictions Other Canadian Provinces Based on the interviews with the Colleges in Alberta, Saskatchewan and Ontario we found that there were only a few ‘operational’ leading practices in other Provinces. This view is supported by a literature review conducted by a member of the Ministry Action Team which states that “the literature review found virtually nothing addressing leading practice per se although there is a substantial body of American literature focusing on credentialing and related processes as impacted by Joint Commission on Accreditation of Healthcare Organizations standards.” 32 The review concluded that “In summary, no perfect process in terms of form and content emerges from the literature, from standards or from the experience of organizations outside BC. Processes remain subject to design failure (i.e., applicant selected referees) and execution failure (i.e., references not checked) although, theoretically, these should be easily avoided or remedied.” 33 AHS is the sole HA in the Province and has responsibility for the provision of publicly-funded health care services, including hospitals. As a result, the Board of AHS is ultimately responsible for granting and revoking privileges. The AHS by-laws provide an overview of the process for granting privileges in Alberta, a process which is similar to the one conducted in BC 34 . In summary, the steps include: The physician completes the AHS application form and provides all necessary documentation. Once completed, the application goes to the AHS Medical Affairs Office (MAO); The MAO confirms that the application is complete and sends it to the Primary Zone 35 Clinical Department Head for approval. If a physician applies for privileges in multiple zones, other Zone Clinical Department Heads must also give their approval. Once approved, the application is returned to the MAO; The MAO sends the application to the Zone Application Review Committee for approval; If approved, the application is sent to the CMO for their approval; If the CMO approves the application, a letter is sent to the physician with the terms of their appointment; and The list is sent to the Board for ratification. As noted earlier, our review did not involve discussions with hospitals or AHS and hence we cannot verify whether and to what extent this process is followed. 32 Murtagh, J., 2011. Physician Credentialing & Privileging, Literature Review & Environmental Scan. December 2011. [Received electronically from Ministry of Health] Page 3. 33 Murtagh, J., 2011. Physician Credentialing & Privileging, Literature Review & Environmental Scan. December 2011. [Received electronically from Ministry of Health] Page 17. 34 This review did not include discussions with the AHS, nor were their by-laws reviewed by Osborne Margo as part of the legal review. Hence, our referencing the by-laws is for the purposes of delineating the process as described. We have not verified whether this process is in practice. 35 Alberta Health Services is split into five administrative zones Ministry of Health 40 Provincial Review of Physician Licensing, Credentialing, Privileging & <strong>Performance</strong> 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.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in the United States The JCAHO is a US based not-for-profit organization which accredits over 19,000 healthcare organizations and programs in the US. JCAHO standards are seen, by many, to be the benchmark for credentialing and related processes 36 . The JCAHO publishes detailed standards regarding credentialing. These act as a guide for hospitals and organizations when they review credentials for the purposes of granting privileges. 36 Murtagh, J., 2011. Physician Credentialing & Privileging, Literature Review & Environmental Scan. December 2011. [Received electronically from Ministry of Health] Page 3. Ministry of Health 41 Provincial Review of Physician Licensing, Credentialing, Privileging & <strong>Performance</strong> 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.
Page 1 and 2: ADVISORY SERVICES British Columbia
Page 3 and 4: Table of Contents GLOSSARY OF ABBRE
Page 5 and 6: CHAPTER 6: OUR FINDINGS - CREDENTIA
Page 7 and 8: Glossary of Abbreviations Abbreviat
Page 9 and 10: Chapter 1: Executive Summary Backgr
Page 11 and 12: We have not graded our suggestions
Page 13 and 14: Performance Management The Provinci
Page 15 and 16: Executive accountability on HA Boar
Page 17 and 18: Enhancing the role of the College (
Page 19 and 20: Future State Centralization and sta
Page 21 and 22: Report structure This Chapter provi
Page 23 and 24: Terms of our engagement KPMG was co
Page 25 and 26: Development of the Review Assessmen
Page 27 and 28: Chapter 3: Roles of Key Organizatio
Page 29 and 30: Health Authorities and Denomination
Page 31 and 32: Chapter 4: The Ministry’s respons
Page 33 and 34: Provincial Credentialing & Privileg
Page 35 and 36: Chapter 5: Our Findings - Licensing
Page 37 and 38: Technology The College’s annual l
Page 39 and 40: Other Canadian Provinces The AIT wa
Page 41 and 42: Role of organizations It is widely
Page 43 and 44: Appendix D provides the responses p
Page 45: Those interviewed felt that it is i
Page 49 and 50: Role of organizations Ministry of H
Page 51 and 52: Communication Issues around communi
Page 53 and 54: Process In discussing performance m
Page 55 and 56: Legislative changes to enhance comm
Page 57 and 58: Suggestions for Improvement Chapter
Page 59 and 60: Executive accountability on HA Boar
Page 61 and 62: Medical school participation in any
Page 63 and 64: Role of the College and HAs Stronge
Page 65 and 66: Suggestion for Improvement #22: On
Page 67 and 68: Clinical leadership Clinical leader
Page 69 and 70: This future state will be character
Page 71 and 72: Step 2 - Receipt of the application
Page 73 and 74: Credentialing and privileging The r
Page 75 and 76: Process for restricted activities i
Page 77 and 78: Figure 3-3. Application Process at
Page 79 and 80: We noted that the privileges being
Page 81 and 82: The process involves the following
Page 83 and 84: QA Committee: This Committee focuse
Page 85 and 86: Appendix B: Process Maps for Initia
Page 87 and 88: Ministry of Health 81 Provincial Re
Page 97 and 98:
Ministry of Health 91 Provincial Re
Page 99 and 100:
Appendix D: Credentialing Standards
Page 101 and 102:
Appendix E: US Data Bank details Th
Page 103 and 104:
Appendix F: Board Directives on Pee
Page 105 and 106:
Appendix G: Review Assessment Frame
Page 107 and 108:
Additional Areas of Inquiry for mee
Page 109 and 110:
HA Meeting Participants: Vice Presi
Page 111 and 112:
Hospitals Meeting Participants: Hos
Page 113 and 114:
In another response, it was indicat
Page 115 and 116:
Performance Management 1. Do you ha
Page 117 and 118:
11. Are there any instances where i
Page 119 and 120:
Many facilities report this informa
Page 121 and 122:
7. Do you have any special performa
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