Developing criteria-based privileging in British Columbia
Jon Slater, MD, and
Emma Bloch-Hansen, MBA
ARTICLE
Back to Index
Despite a foundation of engagement, transparency, and accountability, BC’s physician privileging project revealed some valuable lessons regarding communication, timing of implementation, and resistance to change. This four-and-a-half-year project provides an excellent case study in innovation and change management.
In 2010, the Interior Health Authority of British Columbia reviewed its privileging processes and considered the introduction of one based on criteria. In 2011, following concerns regarding diagnostic imaging, the province commissioned a report by Dr. Doug Cochrane,1 which recommended, among other things, the introduction of a single system of criteria-based privileging across the province. We were asked to lead this change process. In this article we review privileging systems, the system chosen, the process of engagement, and the lessons learned. Top
Privileging systems
Although many use the terms privileging and credentialing interchangeably, they are separate processes. Credentialing examines the past to inform the future. It’s a process that confirms an individual’s identity, training, licensure, experience, reputation, and skill. Although credentials are updated, the process generally occurs on initial application for membership to a medical staff.
Privileging is the process used to request, review, and grant a practitioner permission to undertake defined activities in a specific facility. The process is informed by the practitioner’s credentials, but also by the ability of the facility to support an activity. Top
In 2011, two systems of privileging were used in British Columbia. The most common was the permissive approach. Practitioners were granted privileges in their discipline and were expected to restrict their activities to the usual and customary activities of the discipline. This had the advantages of simplicity, flexibility, and ease of administration.
It also had disadvantages. What was considered usual and customary by some might be considered reckless by others. There was a tendency in some groups to grant privileges by clinical department. Members of the department of pathology for example, commonly had privileges in “pathology.” This ignored the reality that a pathology department might include as many as six unique disciplines, with no obvious overlap in activity. Although the vast majority of practitioners limited their activities to those in which they were skilled, the few that did not created doubts in the system, especially among boards of governance and the health authority’s insurer. Top
The second system involved checking off laundry lists of procedures. Although more precise than the permissive approach, it lacked guidance as to the appropriateness of applying for or granting a particular privilege. Some of these checklists comprised several pages and were overly detailed.
In contrast, criteria-based privileging sets criteria to be met before a practitioner can be considered for a privilege. The definitions in Table 1 may be helpful.
An effective privileging system ensures that patients are seen only by practitioners trained in the activities undertaken; reduces risk to the patient, the practitioner, and the organization; reduces unreasonable restrictions on a practitioner’s scope of practice; reduces unreasonable expectations of practitioners; and promotes mobility between sites. We believe that criteria-based privileging meets those objectives in a way that other systems do not. Top
Project framework and governance
The Provincial Privileging Project was part of a suite of projects2 intended to improve the quality of medical staff care across the province. The other projects included:
- Core Dataset Project, which established the information required for credentialing
- Physician Performance Enhancement Framework
- Legislative Review
- Radiology Quality Improvement System
- Physician Leadership Project
- Credentialing and Privileging Project (software solution)
These projects were overseen by the Physician Quality Assurance Steering Committee (PQASC) composed of representatives from the College of Physicians and Surgeons of British Columbia, the medical association, the Ministry of Health, and the health authorities. The project had its own steering committee drawn from the provincial college, the health authorities, and the medical association. A charter defined the goals and objectives as well as what was and was not within the scope of the project.
The project team consisted of a full-time project/change manager and a part-time (0.5 full-time equivalents) executive medical director as project lead. In addition, 12 senior medical leaders participated with the project/change manager to act as co-chairs at meetings with the various panels. No funding was available for administrative support. Funding for participation on panels was provided through the medical association for medical practitioners and the Ministry of Health for non-medical participants. Top
The project determined the approach, schedule, support materials, and routines that could be replicated for consistency, capitalizing on efficiency and effectiveness. Regular updates were provided to the PQASC.
Process
The project was based on three foundations for success: engagement, transparency, and accountability. We employed change management methods to encourage active and visible executive sponsorship, develop and deploy communications and training, engage in coaching conversations, and address and manage resistance to the change. Top
Initially, we consulted with the chair of Interior Health’s board, senior administrative and medical leaders, and chiefs of staff. As the project expanded to become provincial in scope, consultation included the College of Physicians and Surgeons of British Columbia, the medical association, the Ministry of Health, and the medical leadership of the other five health authorities, each of which had consulted with its stakeholders.
Early feedback revealed discomfort among chiefs of staff with a permissive privileging system that gave no guidance around how they should recommend certain privileges. There was also unease among operational administrators and directors of the board about the quality of the recommendations received. Top
The project defined a recruitment process for panel members and key information and expectations to share with the selected representatives. We contacted the leaders of each medical staff discipline, usually through the provincial medical association, but in the cases of dentists, midwives, and nurse practitioners through their regulatory colleges and professional associations. We briefed the board of the medical association and its two component societies representing family physicians and specialists.
Reaction to the project was positive among the non-medical disciplines and mixed among the medical ones. Those disciplines that had previously been under public scrutiny, notably diagnostic imaging and hematopathology, were more enthusiastic than others. Trust between practitioners and regulatory bodies influenced reaction to change and, in some cases, was a barrier that needed to be addressed. Working through the marinade of emotions and perspectives required patience, curiosity, and energy to allow us to maintain a conversation with all groups. Key to our strategy was the inclusion of medical staff advocates, such as the societies representing each discipline, and the medical association. Top
3BC Medical Journal4
Following the process defined by the project, we asked each discipline’s society to nominate an expert panel with members from each subspecialty and each health authority. The health authorities also had input into the panels. Typically, panels met for 4 hours face-to-face on three occasions. Meetings were scheduled to allow panel members to obtain feedback between meetings. The “dictionary” defining a discipline’s scope of practice was finalized in a 2-hour teleconference. Top
The first meeting was devoted to orienting panel members to the reasons for change and the terminology involved, defining in broad terms the scope of practice for the discipline, and addressing questions and reactions to the work. The panel was introduced to the HCPro5 dictionary template and asked to establish credentialing criteria for members seeking privileges in the discipline.
During the second meeting, panels reviewed feedback from colleagues, addressed additional questions and concerns, defined activities core to the discipline, and started to consider non-core activities. Usually, in this meeting, the recommended current experience for core privileges was established. Top
At the third meeting, panels also reviewed feedback and revised the core and non-core activities accordingly through additional thoughtful debate. By the end of the third meeting, the dictionary was usually complete. It was then distributed through the Ministry of Health to the health authorities for discussion with staff.
At the final meeting, a teleconference, panels approved final changes before the dictionary was submitted for entry into electronic privileging software.
For the most part, members of the various panels worked well together, had thoughtful and respectful debates, and felt a sense of accomplishment in completing the development of their dictionary. As one panel member said, “Now I can tell my mum what it is I actually do!” Top
Panel members had variable success in sharing the work with colleagues. Organization structure, supports (visible and active executive sponsorship, established communication channels, time), along with a sense of accountability and comfort/confidence in discussing the work with colleagues outside the panel, all affected the level of success in sharing the work and its intention with the broader community.
This process evolved during a pilot project with diagnostic imaging. The project plan scheduled writing of the remaining dictionaries for December 2012 through to December 2014. The credentialing and privileging project, which depended on our output, drove this aggressive schedule. Top
Change and resistance management
It is difficult to create enthusiasm among medical staff for any change initiative, and cultural change is particularly challenging. It’s not just that medical staff organizations are conservative; most members don’t have the time to consider anything not immediately affecting their practice. The privileging project extended over four and a half years; it was easy to ignore until just before implementation.
Resistance management demanded fast, personalized responses to contain damage in an environment where trust is fragile. Our difficulties in getting the message out to the medical staff allowed rumours to flourish. The ones we heard were dire and difficult to manage despite attempts at communicating facts. Top
The most prevalent rumour was that current experience would be used as a surrogate for competency and that physicians whose experience fell below the recommended level would be disqualified. This was not the intent of the project or of senior medical administrators, but the rumour persisted. For one panel in particular, this resulted in the need to double the number of scheduled meetings.
Writing 62 dictionaries over two years led to challenges. One unfortunate misstep was the circulation of a draft dictionary as a final document. This damaged trust between the panel and the project team and between the members of the panel and their professional colleagues; this damage had to be repaired. Top
The other major difficulty was the presence of gaps in planning between development and implementation, as these were separate projects. These gaps included the need for a consistent approach to reappointment, a process for issues management, a process for renewal of dictionaries, and a process to catalogue requests for a privilege not in the dictionary.
Lessons learned
As we approach the end of the project, it’s time to reflect on lessons learned. We intended to develop dictionaries for each discipline represented on the medical staffs and we succeeded. We appreciated the fact that the dictionaries are a first effort and will require an iterative improvement process, but we could not let perfect be the enemy of good. We also intended to do this in a manner acceptable to the major stakeholders. Results can be described as mixed. Bujak6 argues that the only power the medical staff has is in saying no. That’s rather extreme, but physician autonomy and conservative attitudes make change a difficult process. Top
The first lesson we would like to emphasise is the importance of active and visible executive leadership and the need for ongoing communication. Setting and communicating clear expectations and supporting staffs through the transition are key. Engaging in two-way communication, explaining the whys and emphasizing benefits, and inviting and encouraging tough questions and comments make a significant difference. There is a difference between having change done to you and feeling part of it.
Lesson two: there is no such thing as too much communication. Our communication plan relied heavily on panel members doing much of the one-on-one messaging, but this idea was crippled by the lack of appropriate communication channels and funding for that function. We know that face-to-face communication is most effective and email is least effective and most problematic. We learned that email, even from representatives elected by the medical staff, is rarely read. Top
The third lesson is that no project should be undertaken without considering implementation. Plans are underway to deal with the gaps we identified, but at the cost of considerable anxiety among the medical staff.
Fourth, fear is a powerful emotion to contend with when introducing change. Thoughtful and timely responses are required. Naysayers need to be confronted by appropriate stakeholders, and resistance needs to be dissected, accountabilities defined, and resolutions implemented. Transition can be a relatively easy response or a challenging reaction. Many factors and influential individuals can shape the path individuals will take. Top
Finally, savings in administrative support are illusory. The physician lead and project manager found themselves doing administrative work at a higher cost and with less effectiveness than would have been the case with appropriate administrative assistants. Focusing on administrative tasks also took away from higher-value work and additional efforts that could have been directed toward tackling identified gaps or opportunities.
Summary
The entire privileging project was planned and executed over four and a half years. It achieved its assigned goal of developing privileging dictionaries for each discipline of medical staff. The proof of the value of criteria-based privileging will be the degree to which the medical staff accept the dictionaries and the degree to which they support the other initiatives of the PQASC.Top
References
1.Cochrane DD. Investigation into medical imaging, credentialing and quality assurance: phase 2 report. Victoria: Ministry of Health; 2011. Available: www.health.gov.bc.ca/library/publications/year/2011/cochrane-phase2-report.pdf (accessed 12 Nov. 2012)
2.Strengthening BC’s quality framework. Physician Quality Assurance Steering Committee website; 2013. Available http://qaframework.ca (accessed 20 Feb. 2015).
3.Slater J. Introducing the Privileging Project. Privileging Project website; 2012. Available http://privileging.typepad.com (accessed 20 Feb. 2015).
4.Slater J, Bloch-Hansen E. Changes to medical staff privileging in British Columbia. BC Med J 2014;56(1):23-7.
5.Crimp W, Pelletier SJ, Searcy VL, Smith M. Core privileges for physicians: a practical approach to developing and implementing criteria-based privileges (4th ed). Marblehead: HCPro; 2007.
6.Bujak JS. How to improve hospital-physician relationships. Front Health Serv Manage 2003;20(2):3-21.
Jon Slater, MD, MBA, CCPE, is executive medical director, special projects for the Interior Health Authority, Kelowna, BC.
Emma Bloch-Hansen, MBA, CPC, is a project/change manager with Western Management Consultants’ Vancouver office.
Correspondence to: