GHS Medical Staff Appointments and Reappointments Process Overview May 2017

Credentialing and Privileging Assure competency of practitioners to provide high quality, safe patient care Implement process to support objective, evidence-based decisions about medical staff appointments and recommendations to grant or deny privileges Organized Medical Staff Develop approved procedure list Implement a process to evaluate applicants Licensure Education Training Current competence Physical ability to care for patients Submit applicants to the governing body for approval Notify the applicant and other required entities about privileging decisions Monitor use of privileges and quality of care Governing Body Quality and Regulatory Committee GMH Board of Directors Approve appointments and reappointments Approve criteria for expedited process Applicants not eligible for expedited process MEC recommendation is adverse or has limitations Challenges to licensure Involuntary termination at another hospital Involuntary limitation, reduction, denial or loss of clinical privileges Unusual pattern of or excessive professional liability actions with judgments against the applicant The Joint Commission MS.06.01.01

Credentialing and Privileging 2009 Added Concepts Six general competencies inform the credentialing and privileging process Medical knowledge Patient care Interpersonal and communication skills Professionalism Systems-based practice Practice-based learning and improvement Focused Professional Practice Evaluation Ongoing Professional Practice Evaluation

Credentialing and Privileging Grady Memorial Hospital New Appointments Application Review and Assessment Approval Peer references Primary source verification Current licensure Relevant training Evidence of physical ability to preform privileges Performance at other hospital Credentials Committee reviews and recommends approval to MEC Application Request Associate Dean verifies request MEC reviews and recommends approval to Quality and Regulatory Committee App Central used to complete application Grady Service Chief Reviews Approves requested privileges Recommends approval to Credentials Committee Quality and Regulatory committee recommends approval by GMHC Board

Credentialing and Privileging Grady Memorial Hospital Reappointments Application and Review Approval Reappointment application to practitioner 6 months in advance Credentials Committee reviews and recommends approval to MEC Reappointment terminated 30 days allowed to complete and return application MEC reviews and recommends approval to Quality and Regulatory Committee NO Complete at 45 days Application complete Reminder sent Quality and Regulatory committee recommends approval by GMHC Board Use Crimson to determine volume and to assess quality indicators (OPPE) GMHC Board approves Service Chief Reviews Approves privileges Recommends to Credentials Committee

Credentialing and Privileging Focus Professional Practice Evaluation What is Focused Professional Practice Evaluation (FPPE)? Systematic, time-limited process to evaluate privilege-specific competency Used when a question arises about the ability to provide safe, high quality patient care. FPPE at Grady Memorial Hospital Chief of Service reviews three medical records for each practitioner during the initial 6 month period Planned Improvements Expand evaluation methods to include direct observations – specifically for operative and other procedures -- Link FPPE plan to initial medical staff privileging documents Build consistent evaluation criteria Standardize tools used to communicate FPPE outcomes

Credentialing and Privileging Ongoing Professional Practice Evaluation What is Ongoing Professional Practice Evaluation? Systematic process to collect, review and use information about professional practice for all members of the medical staff to identify trends that impact quality of care and patient safety Each services approves the type of data collected Data collection includes hospital-wide and specialty specific measures OPPE information is integrated into performance improvement activities and reappoint decisions OPPE at Grady Memorial Hospital Use practitioner performance profiles from the Crimson Technology Suite Chief of Service reviews Crimson performance profiles every six months and includes the outcome of profile reviews in reappointment and privileging recommendations Planned Improvements Review and update OPPE data collection and review plan Standardize criteria used to trigger focused assessment or FPPE