(Today’s Northumberland file photo)
By Cecilia Nasmith/Today’s Northumberland
Credentialling for hospital staff – the why, what and how of it – was the subject of the educational session for the Northumberland Hills Hospital board of directors at their April meeting.
Chief of staff Dr. Mukesh Bhargava reviewed a list of the whys – patient safety, quality of care, regulatory compliance, upholding professional standards, liability protection, and collaboration and teamwork.
Dr. Bhargava reminded the board that they are the ones ultimately responsible for credentialling, but the process begins when someone applies. The first evaluation involves a simple 15-minute phone chat – “to figure out why they want to be here, do they have a license or do they have a pathway to licensing, what attracted them here, then share with them about the community and see if they would want to proceed,” he described.
Examination of the person’s licensing or pathway to licensing is verified first-hand, and the application forwarded to the appropriate department chief. This person contacts the applicant for a talk about what is expected of someone working at NHH. If it goes well, the department chief commends the applicant to a panel assembled of appropriate members of the hospital’s staff for a review of the applicant.
If the panel interview determines the applicant is a good fit (and all has gone well with primary source verification, references and background checks), he or she is offered an application, which Dr. Bhargava characterized as ”the start of the paperwork.”
The completed application goes to the credentialling committee, representing different departments and chaired by Dr. Kaes Al-Ali, to look for red and yellow flags.
Successful review at this level means the application goes to the Medical Advisory Committee for review by senior team members. If they approve, it goes to the board of directors – where approval means the applicant is appointed.
The board meets only five times a year, so temporary privileges pending board approval can be granted.
Privileges are granted to health-care professionals based on their credentials, experience and demonstrated competence. For example, one gynecologist may have privileges for laparoscopic surgery, while another may not.
Then there’s recredentialling, which is required of every staff member every year. The list of reasons Dr. Bhargava gave include ensuring continued competence, checking whether licensing and certification are still valid, performance evaluation, adapting to changing scope of practice, quality improvement and – most important – regulatory compliance.
There are four types of privileges. Active privileges permit managing patients in the hospital. Associate privileges are given as a one-year probation prior to active privileges. Courtesy privileges are temporary, granted as needed (for example, to a specialist who practices in Peterborough but runs periodic clinics at NHH). Then there are locum privileges, granted as needed when extra doctors are required.
The responsibility the board bears for this function is important, Dr. Bhargava said, expected of them by a long list of stake holders, from the Ministry of Health and Long-Term Care to the taxpayers and community members.
Similarly, when things are not satisfactory, it’s important to remember that physicians are independent contractors, as opposed to hospital employees, and can’t be terminated simply by being given notice or payment in lieu of notice. The MAC committee makes recommendations for dismissal, or suspension or restriction of privileges, to the board.
“We pick people with great care,” Dr. Bhargava stated.
“This mechanism needs to happen every time for every person.”
