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Feature
Making Sure of the Doctor: Credentials and Privileges
Hospitals in India aiming for accreditation are increasingly
adopting credentialing and privileging to ensure that the physician or nurse
in charge of the patient's treatment has adequate education and training, as
Sonal Shukla discovers
 Credentialing
and privileging are seen as means that allow a hospital to optimise the utility
of its most crucial resources— the specialists— and provide efficient
and quality patient care. The concept, which is still in its infancy in India,
is slowly gaining momentum with the dawn of corporate healthcare and increasing
numbers of hospitals choosing different quality standards.
Bangalore's Columbia Asia Hospital, which achieved NABH accreditation recently,
has been using the dual credentialing and privileging procedure vigorously to
select its specialists. "The National Accreditation Board for Hospitals
and Healthcare Providers (NABH) and Joint Commission International (JCI), and
all other accrediting bodies have laid down standards and objective elements
on credentialing and privileging. The organisation is required to develop policies
to address this and put them in practice. The assessors verify this process
as a part of their assessment," explains Dr YP Bhatia, Chairman, Accreditation
Committee, NABH.
Credentialing is the process of obtaining, verifying and assessing the qualifications
of a healthcare practitioner who is supposed to provide patient care services
in a healthcare organisation. "Credentialing implies that an organisation
has specified the minimum requirements for entry in the medical or other professional
staff membership. Credentials are documented evidence of licensure, education,
training, experience, or other qualifications, and sometimes even the health
status," defines Dr Tilak Suvarna, Interventional Cardiologist, Asian Heart
Institute, Mumbai.
Privileging, on the other hand, accompanies credentialing and is a process by
which the healthcare organisation authorises a healthcare practitioner to perform
specific patient care services related to his or her speciality, based on the
evaluation of the individual's credentials. Says Dr Nandakumar Jairam, Chairman,
Columbia Asia, Bangalore, "Credentialing and privileging are ways of ensuring
medical quality. The skill ability and training adequacy of a clinician is assured
and thence the quality of care." Credentialing and privileging help in
assessing initial qualifications and evidence of continuing competence.
Determining Quality
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 "When
implemented, the processes will ensure that there is consistency in the
application of methods"
- Dr K Prabakar
Vice President, HR
Apollo Hospitals, Chennai
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 "All
accrediting bodies have laid down standards and objective elements on credentialing
and privileging"
- Dr YP Bhatia
Chairman, Accreditation Committee
NABH
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 "Credentialing
implies that an organisation has specified the minimum requirements for
entry in the medical or other professional staff membership"
- Dr Tilak Suvarna
Interventional Cardiologist
Asian Heart Institute, Mumbai
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While accreditation is a new phenomenon in the Indian healthcare
industry and has been taken up only recently, the importance of credentialing
has been highlighted and many hospitals now acknowledge it. "As an essential
requirement, the matter has become crucial for organisations trying for accreditation.
However, a few hospitals were quality conscious even before the accreditation
era and have been following it for many years," says Bhatia.
The credentialing and privileging process is vital to maintain
the standards of the medical staff. "Regular verification of the credentials
of healthcare practitioners and definition of their privileges are required
for ensuring patient safety, reduction of medical errors and the provision of
high quality healthcare services," says Dr Ramakanta Panda, Chief Cardiovascular
Surgeon and Vice-Chairman, Asian Heart Institute, Mumbai.
Hospitals are expected to provide competent and quality care with thorough assessment,
accurate diagnoses, and effective treatment of patients who come to avail of
their services. Medical practitioners as well as the paramedical personnel are
closely associated with this process and their level of competence determines
whether a patient receives appropriate care or not. "Competence assessment
of healthcare workers is very crucial to ensure that the practitioners providing
care are both qualified and competent to do so, especially in the litigious
modern society," opines Dr Akash Rajpal, Senior Manager, Medical Services,
Dr LH Hiranandani Hospital, Mumbai.
The credentialing policy also ensures that the hospitals
comply with applicable Indian laws, requirements of the JCI and other certifying
agencies and organisations that relate to the smooth operation of the hospital
with regard to the recruitment of its professional staff. "It helps to
prevent the appointment of a candidate with fraudulent degrees or training to
the medical staff. The process of grant of privileges ensures that professionals
are clearly identified to perform certain procedures or practices independently
or under supervision," says Dr Lloyd Nazareth, Chief Operating Officer,
Wockhardt Hospitals Group.
The Ideal Approach
Experts believe that it helps if each hospital develops its own documents for
the process of credentialing and privileging as well as governance of medical
staff. "There are no standard norms and procedures, though there are books
and websites (eg Joint Commission Resources) which could serve as a guide. However,
organisations would do well to create processes which are tailored to the individual
facility's specific characteristics, such as mission, vision, resources and
patients served," suggests Dr Suvarna.
The only way to objectively determine the qualifications of physicians for patient
care and specialised services is to obtain information about their licensure,
education, and training and to judge their current competence by reviewing their
professional experience in detail. The methods available to hospitals to accomplish
this are complex and difficult to implement at first, but become routine as
the medical leadership and administrative staff become familiar with it. "When
implemented, the processes will ensure that there is consistency in the application
of methods, fairness in evaluating the suitability of applicant candidates,
and the continuing suitability of staff members to perform complex procedures,"
Dr K Prabakar, Vice President, HR, Apollo Hospitals, Chennai asserts.
Thus, the hospital may assure itself and the patients treated within its walls
that only qualified physicians and other professionals would perform patient
procedures. "About five years ago, we worked very closely with our associates
in Harvard Medical International who gave us a lot of inputs for designing our
medical staff governance process and for credentialing and privileging,"
Dr Nazareth reveals.
| Credentialing is a process by which the organisation
verifies the authenticity and appropriateness of the qualifications and
work experience of an individual. "First the need has to be ascertained.
This includes minimum number of years of experience, quantity and nature
of work done, preference to particular type of institute from where the
person has graduated," explains Dr Rajpal.
A core committee comprising CEO, medical director
and senior medical administrator interviews shortlisted candidates. If
possible, an external consultant of repute from the same field and seniority
should be invited to sit in on the credentialing process. Evidence of
licensure, registration, certification, and/or other relevant credentials,
for verification prior to appointment and throughout the employment process
should be checked. Experts stress on a reference check through a known
contact. The credentialing and privileging must be based on the availability
of the facility's resources for the said speciality and procedure. The
credentialing committee passes on its final recommendation/instructions
to the HR department for processing the appointment letter. The appointment
letter clearly states the privileges granted to the specialist, and must
be acknowledged by the specialist before coming on board.
Step by Step:
- The doctor who applies for association
to a hospital fills a credentialing form, giving details of his formal
training and work experience.
- The head of medical services and the department
head try to verify these details with the primary source or University.
- A formal reference check is done in communication
with a senior professional whom the candidate has trained with or worked
under.
- Assess the need for that particular skill
in the organisation.
- Meet the candidate.
- If found suitable, the candidate is recommended
for appointment to the medical staff by the credentialing and privileges
committee and the management of the organisation.
- There would also be a review of any medico-legal
cases in which the candidate is currently involved.
Privileging is a process by which after a person
joins the organisation, he would request to be granted privileges to perform
certain procedures. The head of the department or service would review
this request and if his training has been adequate, only then would he
be given privileges. "Privileges are always specific to the speciality
and are also limited by the organisation's resources. The law of the land
is always kept in mind with reference to the licence obtained by the specialist
from MCI," says Dr Rajpal.
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Benefits Galore
The process allows the hospital to optimise its use of resources and provide
most efficient and quality patient care. This includes deciding which specialist
can best perform which surgery or procedure. Each patient receives quality time
from the specialist. Each speciality has various specialised procedures, which
can be performed by the same surgeon. However, many organisations now like to
distribute sub-speciality procedures depending on the skills and training acquired
by the concerned surgeon in a particular procedure for optimal use of resources.
With increasing corporatisation of healthcare and wider patient choice, organisations
are striving to create centres of excellence in various specialities, especially
in certain procedures.
"One surgeon may be authorised to do only knee replacements, and the other
orthopaedic surgeon to do only arthroscopies given their skill sets and exposure.
This maximises use of the skills of both the doctors which results in better
patient confidence and higher patient turnout and better patient satisfaction,"
explains Dr Rajpal. The other objective is to create a face to reckon with for
that procedure, and thus garner better patient turnout for that particular centre
and the surgeon. "As the outcomes of treatment are definitely related to
the training, experience and skills of medical and paramedical staff, credentialing
has a great relevance to total patient experience and outcomes. It is known
that morbidity and mortality levels in organisations following a credentialing
system are much lower than in other organisations," states Dr Bhatia.
The paramedics and all support staff know better the protocols on the line of
care in relation to the concerned specialist and this results in a streamlined
approach to patient care.
According to experts, evaluating credentials and authorisation to perform clinical
procedures and services are important not only because they protect the patients
from unqualified practitioners, but also because they protect the hospital from
accusations of negligence. They also ensure the medical staff, employed or not,
that they are being treated fairly through a process that is equitable and transparent.
The NABH Standards on credentialing and privileging
are:
- HRM 10: There is a process for collecting, verifying and evaluating
the credentials (education, registration, training and experience) of
medical professionals permitted to provide patient care without supervision.
- HRM 11: There is a process for authorising all medical professionals
to admit and treat patients and provide other clinical services commensurate
with their qualifications
- HRM 12: There is a pro#DEEFEFcess for collecting, verifying
and evaluating the credentials (education, registration, training and
experience) of nursing staff
- HRM 13: There is a process to identify job responsibilities
and make clinical work assignments to all nursing staff members commensurate
with their qualifications and any other regulatory requirements.
In Comparison
Effective from January 2008, JCI standards are covered under the
chapter Staff Qualifications and Education (SQE). SQE 9, 10 and 11 deal
with credentialing of medical staff, SQE 12, 13 and 14 with Nursing staff,
while SQE 15, 16 and 17 deal with other healthcare professionals. JCI
standards are much more elaborate in their needs.
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Issues to Tackle
Nonetheless, hospitals contemplating or already practising
credentialing and privileging must also be ready to face some issues. "These
are issues of writing the rules, ensuring a unbiased process and ensuring that
it is medically and legally sound," enumerates Dr Jairam. During the verification
process with a primary source, the hospital often does not get an appropriate
or immediate response from the registration body or University concerned. This
causes delay in offering privileges.
"We should get support from the University / registration councils for
feedback upon solicitation. Some directions from the health ministry at the
national / state level to the University / registration councils to support
this process will help," Dr Prabakar offers a solution.
The other significant barrier faced would be the challenge of developing and
then implementing a thorough credentialing and privileging process. This being
a novel concept to many practitioners, one would expect initial resistance from
them, especially if the hospital attempts uniform application of credentialing
criteria. "But that is how it should be. The process should be based on
solid criteria, which should be fair and consistent and not appear discriminatory,"
cautions Dr Suvarna.
It would be a challenge for some organisations to rigidly withhold an appointment
until the completion of the verification process. Unavoidable delays in paperwork
could annoy some consultants, but it is imperative that the process of verification
is completed. Experts say, proper counselling and explanation of the importance
of the credentialing process will go a long way in making the entire process
smooth both for the healthcare practitioner as well as the hospital. For some
speciality procedures, volume building may take time to develop. This may lead
to insecurity in the mind of the concerned consultant. Patience is the key.
"The consultant may feel that his other surgical skills are not being utilised.
Detailed interaction and counselling is necessary before the person is taken
on board or before the decision of privileging is taken," opines Dr Rajpal.
There can also be resistance from senior medical professionals to go through
this process or resentment when a consultant does not like his privileges being
curtailed for certain procedures. "Some medical professionals believe that
if the patient is their patient they should not be restricted by privileges.
Sometimes, therefore, a hospital could face some loss of business if a consultant
takes his case to another centre because he does not have privileges in the
first hospital," says Dr Nazareth.
One solution could be to disperse clear instructions to all stakeholders and
strictly follow the protocols. Documenting and appending the protocols for ready
reference by the credentialing committee is also recommended. The privileges
should be stated in black and white in the appointment letter. Effective implementation
also requires dissociating with the specialist if he/she does not adhere to
the norms prescribed by the organisation. "A strong in-house training department,
which can identify training needs for effective credentialing and continually
and continuously enable skill upgrading, would create the most effective credentialing
system in an organisation," opines Dr Bhatia.
Future Prospects
As healthcare gets more organised and quality conscious, experts believe that
it is likely that more hospitals will start implementing the process of credentialing
and privileging. The Indian healthcare industry is rapidly growing with good
clinical practice systems with the emerging new standards like ISO 9001 for
healthcare organisations, National Accreditation Board for Laboratories (NABL),
NABH and JCI for healthcare organisations.
Many hospitals in India are moving towards such accreditation programmes to
strengthen their patient care process and to deliver quality and safe healthcare.
"With the emerging insurance systems in India, this may also become a probable
expectation for including a hospital in a panel. Therefore, it is expected that
this concept will become a key requirement for establishing hospitals in India,"
predicts Dr Prabakar.
"In the same way that increasing focus on patient safety, medical tourism,
competition and insurance companies are pushing hospitals to go in for accreditation,
it won't be long before market forces and ground realities prod hospitals to
adopt a well-documented and efficient credentialing and privileging system.
In fact, hospitals will increasingly use credentialing and privileging as a
risk management tool," Dr Suvarna believes.
sonal.shukla@expressindia.com
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