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