1. Credentialing and Scope of Practice Dr Chris Beck Medical Administration Registrar Queen Elizabeth II Hospital Brisbane

2. Overview What is it?? What is it?? Why do it?? Why do it?? How do you do it?? How do you do it?? What do you need to do it?? What do you need to do it?? Challenges Challenges

3. Credentialing?? What’s that? refers to the formal process used to verify the qualifications, experience, professional standing and other relevant professional attributes of medical practitioners for the purpose of forming a view about their competence, performance and professional suitability to provide safe, high quality health care services within specific organisational environments Standard for Credentialing and Defining the Scope of Clinical Practice, July 2004. Australian Council for Safety and Quality in Health Care

4. Scope of Practice?? What’s that? an individual medical practitioner’s clinical practice within a particular organisation based on the individual’s credentials, competence, performance and professional suitability, and the needs and the capability of the organisation to support the medical practitioner’s scope of clinical practice. Standard for Credentialing and Defining the Scope of Clinical Practice, July 2004. Australian Council for Safety and Quality in Health Care

5. Why do we do it?? Because it is the one thing that keeps the Minister and the Director General awake at night!!!

6. Why do we do it?? Patient safety Patient safety Risk management Risk management Quality improvement Quality improvement Public assurance Public assurance It is good clinical governance – it makes sense! And we have to!!

7. Why do we have to?? HQCC standard: All medical practitioners in hospitals: Are credentialed (and re-credentialed) in accordance with the Australian Council for Safety and Quality in Health Care’s Standard for Credentialing and Defining the Scope of Clinical Practice (2004); and Provide medical interventions: within their defined scope of clinical practice, and within the service capability of the health care facility.

8. How do you do it?? Principles Safety and quality focus Safety and quality focus Protect the community Protect the community Effective processes Effective processes Management of relationships Management of relationships Non-punitive Non-punitive Strong partnerships Strong partnerships Fair Fair

9. How do you do it? Qld Health Policy (2002 – currently being rewritten…) HQCC Standard requires implementation of the National Standard So National Standard = Statutory requirement

10. What do you need?? Credentialing and Clinical Scope of Practice Committee Terms of Reference Terms of Reference Documented processes Documented processes Application form templates Application form templates Minimum “threshold” credentialing criteria Minimum “threshold” credentialing criteria Administrative support Administrative support IT resources IT resources

11. Committee Composition (current QH Policy) Core membership EDMS as chair EDMS as chair At least 2 other medical practitioners At least 2 other medical practitioners Variable Membership College and/or University representative College and/or University representative Relevant clinical department representative Relevant clinical department representative

12. Committee Role Review applications from: New employees New employees New employees with Scope of Practice granted on temporary basis New employees with Scope of Practice granted on temporary basis Existing employees at least every 3 years (or sooner at own request or by appropriate officer) Existing employees at least every 3 years (or sooner at own request or by appropriate officer)

13. Review of Applications Minimum credentialing criteria Minimum credentialing criteria Developed for each position within the facility Developed for each position within the facility Evidenced based, relevant to competence and performance Evidenced based, relevant to competence and performance College/Association/Society input (eg FRACP, FRACS, Conjoint Committee for the Recognition of Training in Gastrointestinal Endoscopy) College/Association/Society input (eg FRACP, FRACS, Conjoint Committee for the Recognition of Training in Gastrointestinal Endoscopy) Medical degree, Medical Board Registration, CME, MoPS, quality /audit activities Medical degree, Medical Board Registration, CME, MoPS, quality /audit activities

14. Categories of Scope of Practice 1. New applications 2. Temporary 3. Renewal applications 4. Emergency applications

15. Review of Applications Initial Applications need: Registration history (including current status) Registration history (including current status) Education and training history Education and training history Affiliations and accreditations Affiliations and accreditations Employment history Employment history Summary of recent clinical activity Summary of recent clinical activity Requested scope of clinical practice Requested scope of clinical practice Level of indemnity cover Level of indemnity cover Declarations Declarations Consent for verification Consent for verification Referee reports Referee reports

16. Review of Applications Renewal applications need to detail changes since last review: Any changes to registration or conditions, as well as current status Any changes to registration or conditions, as well as current status Subsequent education/training history Subsequent education/training history New affiliations and accreditations New affiliations and accreditations New employment arrangements New employment arrangements Summary of recent clinical activity Summary of recent clinical activity Requested scope of clinical practice Requested scope of clinical practice Current indemnity cover Current indemnity cover Changes/additions to previous declarations Changes/additions to previous declarations Consent for verification Consent for verification Referee reports Referee reports

17. Recommendations Committee can make recommendations on SoP when satisfied that: 1. Medical practitioner is competent 2. There is an acceptable record of performance 3. The scope of practice is compatible with the organisations need and capability

18. Recommendations If not satisfied, options include: Evaluation by peer, followed by review Evaluation by peer, followed by review Limited duration of scope of practice followed by review Limited duration of scope of practice followed by review Limit scope of practice Limit scope of practice Grant scope of practice with a period of supervision Grant scope of practice with a period of supervision If doesn’t meet threshold criteria, refuse SoP and document reasons

19. Recommendations In Qld Health, recommendations regarding the granting of scope of practice are made to the District Manager, or Clinical CEO In Qld Health, recommendations regarding the granting of scope of practice are made to the District Manager, or Clinical CEO The DM/CEO then grants SoP to Clinician The DM/CEO then grants SoP to Clinician

20. Documentation Increasing demand for good documentation District Clinical Governance self-assessment tool District Clinical Governance self-assessment tool Credentialing and Scope of Practice Audits Credentialing and Scope of Practice Audits Admin staff move around Admin staff move around Everyone wants to know that this is being done well and want to see documentation that will let them sleep at night

21. Credentialing Databases Quick ring around in 2006 Most used Excel spreadsheets Most used Excel spreadsheets Some used an Access database Some used an Access database One used slips of paper (yikes!) One used slips of paper (yikes!) Centralised Rural Credentialing database (yucky!) Centralised Rural Credentialing database (yucky!) Pathology system Pathology system

22. Suspension of Right to Practice High potential for severe detriment to future career – professional, personal, financial High potential for severe detriment to future career – professional, personal, financial Only in exceptional circumstances Only in exceptional circumstances Summon committee together URGENTLY! Summon committee together URGENTLY!Eg blameworthy acts, serious criminal convictions/charges blameworthy acts, serious criminal convictions/charges Facility can no longer safely offer service and agreement to change SoP can’t be reached Facility can no longer safely offer service and agreement to change SoP can’t be reached Doctor not registered for any reason! Doctor not registered for any reason! Serious concerns re competence/current fitness to practice Serious concerns re competence/current fitness to practice

23. Challenges Accurate medical staff lists Accurate medical staff lists Conflicts of interest Conflicts of interest Retention of corporate memory Retention of corporate memory Cooperation with process Cooperation with process Rural credentialing Rural credentialing Super-specialty units Super-specialty units The impaired practitioner The impaired practitioner Getting three busy clinicians + Med Super together! Getting three busy clinicians + Med Super together!

24. Good – now we can get back to sleep