1. GHS Medical Staff Appointments and Reappointments
Process Overview
May 2017

2. Credentialing and Privileging
Assure competency of practitioners to provide high quality, safe patient care
Implement process to support objective, evidence-based decisions about medical staff appointments and recommendations to grant or deny privileges
Organized Medical Staff
Develop approved procedure list
Implement a process to evaluate applicants
Licensure
Education
Training
Current competence
Physical ability to care for patients
Submit applicants to the governing body for approval
Notify the applicant and other required entities about privileging decisions
Monitor use of privileges and quality of care
Governing Body
Quality and Regulatory Committee
GMH Board of Directors
Approve appointments and reappointments
Approve criteria for expedited process
Applicants not eligible for expedited process
MEC recommendation is adverse or has limitations
Challenges to licensure
Involuntary termination at another hospital
Involuntary limitation, reduction, denial or loss of clinical privileges
Unusual pattern of or excessive professional liability actions with judgments against the applicant
The Joint Commission MS

3. Credentialing and Privileging 2009 Added Concepts
Six general competencies inform the credentialing and privileging process
Medical knowledge
Patient care
Interpersonal and communication skills
Professionalism
Systems-based practice
Practice-based learning and improvement
Focused Professional Practice Evaluation
Ongoing Professional Practice Evaluation

4. Credentialing and Privileging Grady Memorial Hospital New Appointments
Application
Review and Assessment
Approval
Peer references
Primary source verification
Current licensure
Relevant training
Evidence of physical ability to preform privileges
Performance at other hospital
Credentials Committee reviews and recommends approval to MEC
Application Request
Associate Dean verifies request
MEC reviews and recommends approval to Quality and Regulatory Committee
App Central used to complete application
Grady Service Chief
Reviews
Approves requested privileges
Recommends approval to Credentials Committee
Quality and Regulatory committee recommends approval by GMHC Board

5. Credentialing and Privileging Grady Memorial Hospital Reappointments
Application and Review
Approval
Reappointment application to practitioner 6 months in advance
Credentials Committee reviews and recommends approval to MEC
Reappointment terminated
30 days allowed to complete and return application
MEC reviews and recommends approval to Quality and Regulatory Committee NO
Complete at 45 days
Application complete
Reminder sent
Quality and Regulatory committee recommends approval by GMHC Board
Use Crimson to determine volume and to assess quality indicators (OPPE)
GMHC Board approves
Service Chief
Reviews
Approves privileges
Recommends to Credentials Committee

6. Credentialing and Privileging Focus Professional Practice Evaluation
What is Focused Professional Practice Evaluation (FPPE)?
Systematic, time-limited process to evaluate privilege-specific competency
Used when a question arises about the ability to provide safe, high quality patient care.
FPPE at Grady Memorial Hospital
Chief of Service reviews three medical records for each practitioner during the initial 6 month period
Planned Improvements
Expand evaluation methods to include direct observations – specifically for operative and other procedures --
Link FPPE plan to initial medical staff privileging documents
Build consistent evaluation criteria
Standardize tools used to communicate FPPE outcomes

7. Credentialing and Privileging Ongoing Professional Practice Evaluation
What is Ongoing Professional Practice Evaluation?
Systematic process to collect, review and use information about professional practice for all members of the medical staff to identify trends that impact quality of care and patient safety
Each services approves the type of data collected
Data collection includes hospital-wide and specialty specific measures
OPPE information is integrated into performance improvement activities and reappoint decisions
OPPE at Grady Memorial Hospital
Use practitioner performance profiles from the Crimson Technology Suite
Chief of Service reviews Crimson performance profiles every six months and includes the outcome of profile reviews in reappointment and privileging recommendations
Planned Improvements
Review and update OPPE data collection and review plan
Standardize criteria used to trigger focused assessment or FPPE