British Columbia Ministry of Health Provincial Review of Licensure, Credentialing, Privileging, Monitoring and Enhancement of Performance

delivery and rollout of the revalidation program.
19 Future State Centralization and standardization of structure We were asked to consider whether a single, centralized process for licensing, credentialing, privileging and managing performance of physicians would be beneficial and have concluded that the case for having a central organization manage the process has not been made, although our suggestions for improvement identify where activities can be better aligned. Continuum of future system improvement Based on our analysis of the current system, our suggestions for improvement, learning from other jurisdictions and input from stakeholders throughout this process, we have suggested a future-state view of how the system could be designed. This future state will be characterized by: The Ministry performing a stronger stewardship role, with HA Boards and Executive Teams having greater accountability for physician performance management and links made between physician payment and outcomes; A stronger and more integrated role for the College, taking an enhanced leadership role in setting minimum standards for all physicians in BC and realigning certain identified other responsibilities with HAs; and Improved clinical leadership with clinical leaders being better supported in order to fulfill their role in managing the day-to-day activities of physicians. We appreciate that reaching this end state vision will take time and will be informed by the work already underway through the eight projects being undertaken by the Ministry Action Team, the suggestions for improvement in this report and the Osborne Margo review. Acknowledgement KPMG has appreciated: The opportunity to serve the Ministry; The excellent level of cooperation from the Ministry, the College and other stakeholders for pulling together background materials and their participation in our interview and survey process; and The frank and open input received from interviewees. Ministry of Health 13

activities can be better aligned.
20 Chapter 2: Report structure and background Understanding this report The purpose of this report is to outline certain matters that came to our attention during our work and to offer our comments and suggestions for improvement for the Ministry s consideration. These comments, by their nature, are critical, as they relate solely to opportunities for enhancement and do not address the many positive features of the Ministry s current activities and undertakings. Our procedures consisted of inquiry, surveying, and analysis of information provided by the Ministry, the College and HAs. The Ministry approved the interview list and the extent of the other materials provided by project participants. Such work does not constitute an audit. Accordingly, we express no opinion on processes, other information or internal controls. The evidence that supports our suggestions for improvement has been gathered through completed questionnaires, interview feedback and other comments, explanations and information received during our work. We are not responsible for this evidence; the sole responsibility lying with those who provided us with information and those we interviewed or otherwise interacted with during this review. Our findings arise from our enquiries, although we can provide no assurance as to the day-to-day operation of either those procedures reviewed or issues relating to physician licensing, credentialing, privileging and performance management in general. KPMG assumes no responsibility for our findings and we have not attempted to establish whether the issues raised in the report are pervasive, commonplace or rare; the issues raised are merely those that occurred during the course of our interviews and other work. All procedures covered in this report are dependent for their effectiveness on the diligence and propriety of those responsible for operating them and are capable of being overridden by persons holding positions of authority and trust. We have not graded our suggestions for improvement and have not sought to emphasize their importance in any way. Our report has been factually checked by the Ministry and senior clinicians, as well as all members of the Ministry Action Team and VP Medicines (VP Meds), or equivalent, at all HAs. The Ministry is responsible for the decisions to implement any recommendations and for considering their impact. Implementation of these opportunities will require the Ministry to plan and test any changes to ensure that the Ministry will realize satisfactory results. Ministry of Health 14

These comments, by their nature, are critical, as they relate solely to opportunities for enhancement and do not address the many positive features of the Ministry s current activities and
21 Report structure This Chapter provides context for the reader on the background of this review, our mandate and approach to completing the work. Chapter 3 provides the reader with an understanding of the roles and responsibilities of all organizations which informs our analysis in subsequent Chapters. It also includes an analysis of progress on the eight initiatives put in place to address the Ministry s response to Dr Cochrane s report. Chapter 4 details the Ministry s response to Dr. Cochrane s report and sets out commentary on the eight initiatives being managed by the Ministry Action Team as part of that response. Chapters 5, 6 and 7 outline our findings related to physician licensing, credentialing and privileging and performance management respectively, under seven headings: Key observations Role of organizations; Communication; Governance and accountability; Process; Technology; and Learning from other jurisdictions; Chapter 8 details our suggestions for improvement and sets out a suggested future state for managing licensing, credentialing and privileging and performance management in BC. Appendix A is an overview of current licensing, credentialing, privileging and performance management processes, including process maps that illustrate the processes and systems in place by the College, the HAs and healthcare providers. Appendix A is informed by Appendices B and C that set out process maps in more detail for initial privileging and ongoing privileging re-appointments. Appendix D details credentialing standards used at all HAs that informs our analysis of credentialing in Chapter 6. Appendix E sets out an overview of the US Data Bank and Appendix F sets out different Board directives for peer review, both informing our analysis of performance management in Chapter 7. Finally, Appendices G to I detail the Review Assessment Framework discussed further in this Chapter. Ministry of Health 15

22 Background for the review In late 2010 and early 2011, problems were identified with the quality of radiology image interpretations within Fraser Health Authority (FHA), VCHA and VIHA. Upon investigation, the HAs found that there were deficiencies in the experience and performance of the identified radiologists. Third party reviews were commissioned to assess the situation and determine whether patient care was adversely affected. In all cases, the privileges of these radiologists were suspended 3. As the deficiencies did not involve a single isolated event, rather were driven by identified, systemic concerns in a number of different parts of the Province, the Honourable Colin Hansen, then Minister of Health Services, commissioned an independent review by Dr. Doug Cochrane, Provincial Patient Safety and Quality Officer and Chair of the BC Patient Safety & Quality Council. Dr. Cochrane s review was split into two phases. Phase 1 reviewed the credentials of all radiologists in the Province to determine if all were qualified to review radiology images. The report concluded that as of February 2011 there were 287 practitioners licensed (at the time) to provide diagnostic imaging services. He concluded that all met the criteria required by the College for licensure and that all were providing services within the scope defined by their license 4. Phase 2 provided a description of the [four] incidents, an analysis of causes, the response by the HA to the event and the role of the College. 5 The report, along with the Ministry s response, was released on September 27, 2011 when the new Minister of Health, the Honourable Mike de Jong, confirmed that the Ministry had accepted Dr. Cochrane s 35 recommendations and had created an action plan to implement his advice. 6 Given that Dr. Cochrane s review focused on radiology, and to a certain extent focused on the three HAs involved in the initial incidents, the Ministry commissioned this review for the whole Province in November Cochrane, D., Investigation into Medical Imaging, Credentialing and Quality Assurance, Phase 2 Report. Available at: Page Cochrane, D., Investigation into Medical Imaging, Credentialing and Quality Assurance, Phase 1 Report. Available at: Page 3. 5 Cochrane, D., Investigation into Medical Imaging, Credentialing and Quality Assurance, Phase 2 Report. Available at: Page Ministry of Health, Action plan to protect patient safety unveiled. Press Release, September 27, Available at: Ministry of Health 16

23 Terms of our engagement KPMG was contracted to conduct a review of the existing College, Ministry, HA and hospital processes/systems for: licensure, credentialing, privileging, physician performance monitoring and peer review in BC, and relevant legislation pertaining to the previously mentioned items. This included the identification of suggestions for improvement and a suggested quality improvement strategy. Key deliverables included: Development of a project charter and work plan; Development of an assessment framework; Final report with summary of findings and advice; and Final report presentation to the Ministry Action Team. As an extension to the original scope, the Ministry requested that KPMG provide commentary on all the initiatives underway and link progress with our suggestions for improvement. Out of scope Given the time and resources available for this review, we agreed with the Ministry that we would focus our attention on the acute care sector and, in a more limited way, private Non-Hospital Medical Surgical Facilities in the Province 7. This review did not examine practices within other areas of the health care system such as community provision, mental health services or long-term care. KPMG sub-contracted with the law firm Osborne Margo to complete the legal and regulatory review. While we quote their report in our findings, their report has been submitted as a stand-alone document. 7 These private facilities were involved in an online survey and covered through our interviews with leaders from the College, however, we did not conduct on-site visits or follow up with telephone interviews. Ministry of Health 17

24 Our workplan for completing this review Our approach to completing this review, including the key activities, is illustrated below (Figure 2-1). Figure 1-1. Our Approach Project initiation The project began with a working session with the Action Team 8 during the first week of January and the Project Charter was approved by the Project Sponsor on January 10, The key elements of the Project Charter included: Project objectives; Key messages to be used with stakeholders; An evaluation framework which outlined how the success of this engagement would be measured; Project management methods including roles and responsibilities, weekly status reports and the approach to raising and addressing issues and challenges; Project risks and mitigation strategies; and Detailed workplan on each project activity. 8 This group is mandated with overseeing the implementation of the Physician Quality Assurance Portfolio which was created based on the recommendations in the review completed by Dr. Cochrane. Membership includes representatives from the Ministry, College and HAs, as well as other consultants who act as advisers to the group. Ministry of Health 18

25 Development of the Review Assessment Framework Upon confirming our mandate, we developed the RAF which outlined the data we would require and areas of inquiry we would pursue with every entity being reviewed. The RAF was approved by the Action Team on January 31, 2012 and is attached at Appendix G. To inform the development of this framework, we completed the following activities: Stakeholder meetings with officials from the Ministry, the College and the UBC Faculty of Medicine. We also met with Dr. Doug Cochrane; Meetings with the Royal College of Physicians and Surgeons of Canada (Royal College), the College of Family Physicians of Canada (CFPC), the Medical Council of Canada (MCC) and senior leaders within the Colleges of Physicians and Surgeons in Ontario, Saskatchewan and Alberta; An online survey of all acute care hospitals in BC (attached at Appendix H); and An online survey of selected, agreed private NHMSFs (attached at Appendix I). Legal & Regulatory Review A legal and regulatory review was completed by the law firm Osborne Margo. That report summarizes the legal framework for physician regulation in BC and identifies key issues regarding BC s current regulatory framework. The report also includes a summary of the physician regulatory frameworks in Alberta, Saskatchewan and Ontario. The Osborne Margo report should be read in conjunction with this report. Ministry of Health 19

26 Review Using the agreed RAF we held a series of meetings and interviews with leaders within four groups of organizations: The Ministry; including fifteen staff from the HAs and Medical Services Divisions; The College; including two half-day sessions, one with the Registrar and Deputy Registrar (Registration) and another with the Senior Deputy Registrar. We also interviewed six members of the College Board; Every HA; three separate interviews were held at each of the six HAs: one with the VP Med and staff responsible for credentialing (which in some cases also included the Chair of the Credentials Committee), one with the VP Med and Chief executive Officer (CEO), and one with either the Board s Quality Committee and/or Board Chair. In the case of the PHSA, an interview was held with the VP of Physician Compensation, and A sample of hospitals in BC; eight facilities with interviews involving the Chief of Staff or Chair of the local Credentials Committee and staff from the Medical Affairs Office (MAO), as agreed with the Ministry, who also approved the following list of hospitals reviewed: BC Children s Hospital; Cowichan District Hospital; Peace Arch General Hospital; South Okanagan General Hospital; Squamish General Hospital; St. John Hospital (Vanderhoof); St. Joseph s General Hospital (Comox); and University Hospital of Northern British Columbia. Reporting The key themes and data emerging from the review are analyzed and presented in this report. Project management A number of project management methods were used throughout the engagement to assist in meeting project milestones. Specific activities included: Developing a detailed project charter which outlined key activities and milestones; Providing weekly status reports, including highlighting of weekly activities as well as risks and challenges; and Participating in briefings and seeking approval of key activities and deliverables with the Ministry and key stakeholders. Ministry of Health 20

27 Chapter 3: Roles of Key Organizations in Physician Licensing, Credentialing, Privileging and Performance Management This Chapter introduces the key organizations involved in physician licensing, credentialing, privileging and performance management within BC and the current role that they serve, dealing in turn with the Ministry, the College, HAs and DFs and medical education bodies. The Ministry of Health The Ministry has a narrow, but important, role in relation to the practice of physicians in BC. The Minister of Health (Minister) has overarching responsibility for public safety and health service quality and as such has specific and final authority for regulation under the Health Authorities Act, Hospital Act, and Health Professions Act (HPA). The Minister can appoint a person to inquire into aspects of the operation of the College or the state of practice of the profession. They also approve College and HA by-laws which include physician privileging and performance management governance. The Minister enters into accountability and performance agreements (called Government Letters of Expectation) with HAs on an annual basis that define the expectations and performance obligations of each HA. The role that the Ministry undertakes in regulating the system is set out in more detail in the legal and regulatory review completed by Osborne Margo. Through our review meetings with the Ministry, we identified several functions and initiatives which relate to physician management: Assistance with work permits: Providing Confirmation Letters of Need to support an application for a work permit in Canada. Funding post-graduate placements: Setting out the number of placements that will be funded for post-graduate residents. BC Locum 9 Program: Refers to a registry of physicians who are available to provide locum services. Locum positions can be posted through this registry, yet the physician will apply directly to the facility and/or HA to provide the service. Model medical staff by-laws: Work has been initiated to look at model medical staff by-laws. Over time, it is anticipated that each HA and DF would amend their by-laws to conform with a Provincial standard. 9 A locum is a physician who temporarily fulfills the role and responsibilities of another physician. Ministry of Health 21

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