Accreditation and Credentialling A presentation to the National Medical Boards Conference Brisbane,

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Accreditation and Credentialling A presentation
to the National Medical Boards Conference
Brisbane, 30 July 2008 Chris Baggoley

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ACSQHC

• Health Ministers Established ACSQHC to
• Lead and coordinate safety and quality in health
  care
• Advocate for safety and quality and report
  publicly
• Recommend national data sets
• Provide strategic advice to Health Ministers
• Recommend nationally agreed standards

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ACSQHC

• Our Priority Programs
• 1. Australian Charter of Healthcare Rights
• 2. Open Disclosure
• 3. Basic Care Issues
• Healthcare Associated Infection
• Patient Identification
• Medication Safety
• Clinical Handover
• Patient at risk
• Falls Guidelines
• 4. Tools
• Accreditation and credentialling
• Information Strategy
• Harnessing IT Communication

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Alternative Model for Safety and Quality
Accreditation

• Task set by Health Ministers
• Endorsed in principle by AHMC on 18 April 2008
• Commission to develop phase one of implementation

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Alternative Model for Safety and Quality
Accreditation

• Australian Health Standards
• Quality Improvement Framework
• Expanded scope for accreditation
• National data collection and reporting
• Mutual recognition of accreditation processes and
  outcomes
• National coordination
• Formal obligations to comply and consequences for
  non-compliance

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Alternative Model for Safety and Quality
Accreditation

• Phase one of implementation
• Development of preliminary set of Australian
  Health Standards (AHS)
• Determination of processes, costs and funding
  options of implementation
• Review and analysis of Sate and Territory private
  health facility licensing
• Review of overlaps and potential linkages between
  accreditation and contractual obligation between
  private hospitals, jurisdictional health services
  and health insurance funds

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Alternative Model for Safety and Quality
Accreditation

• Pilot projects
• Review of surveyor participation
• Pilot of short notice surveys
• Pilot of patient journey methodologies

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Alternative Model for Safety and Quality
Accreditation

• Development of preliminary set of AHS Key
  Principles
• AHS facilitate delivery of healthcare that
  minimises risks and supports optimal health
  outcomes
• AHS formulated via consultatory approach
• AHS evidence based, focussed on measurable
  clinical outcomes and achievable
• Adoption of AHS should support innovation and
  focus on continuity of care for consumers

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Alternative Model for Safety and Quality
Accreditation

• Preliminary set of AHS
• Patient identification
• Healthcare associated infection
• Clinical handover
• Open disclosure
• Medication safety

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Alternative Model for Safety and Quality
Accreditation

• Example Patient identification

DRAFT
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Alternative Model for Safety and Quality
Accreditation

• Example Patient Identification
• Reporting may include
• Quantitative report on number of incidents by
  category
• Qualitative report on action taken for serious
  incidents
• Assessment by surveyors may include
• Auditing of application of wrist band guidelines
  in institutions
• Observation of an admission process

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Credentialling

• Commission tasked by Health Ministers to
  implement the Council's
• Standard for Credentialling and Defining the
  Scope of Clinical Practice A National Standard
  for credentialling and defining the scope of
  clinical practice of medical practitioners, for
  use in public and private hospitals

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Credentialling
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Credentialling

• Steps
• Verification of professional credentials (initial
  credentialling)
• Defining the scope of practice or delineation of
  clinical privileges
• Re-credentialling, including formal review of
  credentials and scope of practice
• Periodic performance review and appraisal

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Credentialling

• Seven implementation principles for
  credentialling and defining the scope of clinical
  practice laid out by the Council
• Organisational governance responsibilities
• Complemented by medical practitioner registration
  and individual professional responsibilities
• Effective processes benefit patients,
  communities, healthcare organisations and medical
  practitioners
• They are essential components of a broader system
  of organisational management of relationships
  with medical practitioners

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Credentialling

• Seven implementation principles for
  credentialling and defining the scope of clinical
  practice laid out by the Council
• Reviewing the scope of clinical practice should
  be a non-punitive process
• Effective processes depend on strong partnerships
  between healthcare organisations and professional
  colleges, associations and societies
• Processes must be fair, transparent and legally
  robust

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Credentialling

• Issues
• Jurisdictions
• Seek national evaluation of compliance
• Slow rate of implementation
• Colleges
• Not well engaged
• Responsibilities not discussed
• Accountabilities not discussed
• Non-hospital sites
• Many where credentialling does not exist
• Inefficient, ineffective to establish in same way
  as hospitals

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Credentialling

• Issues
• Registration system
• Has potential to support credentialling
• Requires access to comprehensive and timely data
• Peer review
• Effectiveness critical
• Additional supports needed

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Credentialling

• Interface between registration function and
  credentialling
• Registration status
• Healthcare facilities ability to check
  registration status
• Specialist recognition publicly available
• Consideration of publicly available information
  in international jurisdictions
• Opportunities for revalidation from annual
  renewal process

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Credentialling

• Priority options for national support for
  implementation
• Engage with medical colleges regarding national
  outlines for scope of practice
• Engage with national registration body to
  maximise the potential for this process to
  support credentialling
• Develop national peer review standard

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Effecting Change
Prime Minister COAG National Health and
Hospitals Reform Commission
External Influences
AHMC
AHMAC
Jurisdictional Safety and Quality organisations
IJC
CHF Consumer engagement Community
Commission
Private Hospital Sector Committee
Information Strategy Committee
Primary Care
Committee

Staff
Clinical Quality Registries Committee
Advisory Committees Working Parties
AIHW TGA CPMC NHMRC NICS
NeHTA ACHSE Nursing Orgs Health
Care Complaints Commissioners Private
Hospital Organisations AHIA
Allied Health Orgs
University Sector
Research Sector