1. PERFORMANCE IMPROVEMENT3
Dr.Inas
Alassar

2. THE PRACTITIONER APPRAISAL
PROCESS
 CREDENTIALING OF LICENSED
INDEPENDENT PRACTITIONERS
Credentialing and privileging (in provider
organizations) are processes of confirming the
clinical competence and professional
performance of, at a minimum, all licensed
independent practitioners

3.  A licensed independent practitioner (LIP) is
any individual who is professionally licensed
by the state (U.S.) and permitted by the
organization to provide patient care services
without direction or supervision, within the
scope of that license

4. Core Criteria for credentialing /
privileging
Four core criteria that help validate the
practitioner's skills and physical and mental
ability to discharge patient care
responsibilities:
 1-Current licensure
 2-Relevant training and experience
(professional schools, residencies,
fellowships, postdoctoral programs, board
certifications, clinical certifications)

5.  3-Current competence (informed opinions
from authoritative sources concerning
current clinical judgment and technical
skills, peer recommendations);
 4-Ability to perform the privileges requested
or essential functions of the position

6. General Competencies for
Credentialing / Privileging
 Patient Care: "Provide patient care that is
appropriate, and effective for the promotion
of health, treatment of disease, and at the end
of life";
 Medical/Clinical Knowledge: "Demonstrate
know/edge of established and evolving
clinical, and social sciences and apply to
patient care and education of others";

7.  Practice-based Learning and Improvement: "Be
able to use scientific evidence and methods to
investigate, evaluate, and improve patient care
practices";
 Interpersonal and Communication Skills:
"Demonstrate interpersonal and communication
skills that enable them to establish and maintain
professional relationships with patients, families,
and other members of health care teams";

8.  Professionalism: "Demonstrate behaviours that
reflect a commitment to continuous professional
development, ethical practice, an understanding
and sensitivity to diversity and a responsible
attitude toward their patients, their profession
and society";
 Systems-based Practice: "Demonstrate both an
understanding of the contexts and systems in
which health care is provided, and the ability to
apply this knowledge to improve and optimize
health care. "

9. Credentialing/Re-credentialing Process
 Definition: The verification of the
practitioner's right and competency to provide
patient care in the appropriate setting.

10. Criteria of Credentialing / privileging
 Current, valid license to practice
 Current competence
 History of loss of license and, history of loss or
limitation of privileges or disciplinary actions .
 Evidence of physical ability to perform the requested
privilege (or) inability to perform essential functions
of the position

11. CLINICAL PRIVILEGING/REPRIVILEGING
PROCESS
 Clinical privileging and re-privileging
cannot be centralized. This process must
always be setting-specific, based on services
available, so it has to be accomplished at each
provider site

12.  Definition: "Privileging" means granting
permission to provide specific medical
or other patient care services in the organization,
within well-defined limits, based on the
individual's professional license and his or her
experience, competence, ability, and judgment
and on the organization's ability to provide and
support the service.

13.  Delineation of privileges: Clinical privileges are
granted individually, based on criteria established
by the organization, usually using privilege control
sheets that are specific to each department, section,
service, or specialty. The criteria determine the
level of competency appropriate for each privilege,
e.g., the number of procedures that
must be performed every two years for the
practitioner to be considered currently competent
and to retain the privilege

14. Privilege status
 Temporary: Temporary privileqe to practice until
credentialing and individual privilege delineation has been
processed and approved by the governing body.
 Approved: Delineated privileges approved for the time period
specified by the institution, but never longer than two years
 Emergency: Any practitioner is permitted to do everything
possible to save a life or protect a patient from further or
serious harm within the scope of his/her license, regardless of
membership status, credentialing status, or approval of
specific privileges.

15. Proctoring
 As part of the process of granting initial
privileges or a new privilege to a practitioner,
proctoring by peers (observation and/or a
review of cases) may occur within guidelines
established in the medical/professional staff
bylaws, rules and regulations, medical staff
department.

16. PRACTITIONER PROFILING
 Represent a performance monitoring and
analysis, helping to effectively communicate
appropriate findings to those leaders who
need to know.
 Profiles are practitioner-specific data and
information summaries used in the reappraisal
process, usually in conjunction with re-
credentialing and re-privileging activities.

17.  Ideally profiling should be as concurrent as
possible, with review, analysis, and
reporting at least quarterly, to identify better
practices, as well as permit appropriate
intervention in quality of care and patient
safety issues.

18. Profiling in Hospital process
 All independent practitioners with delineated clinical
privileges, whether or not they are medical staff
members, are profiled, based on an ongoing
measurement process. Department chairs, section
chairs, medical/clinical directors, or chief medical
officers, depending on the setting and structure, must
review the profile data for both positive findings and
any areas of concern.

19. Practitioner profiles
Used in :
 1-Monitoring of clinical processes, e.g., mortality review
findings; peer-reviewed events with rating below standard of
care; performance on core measures.
 2--Use of operative and other procedures placing patients at
risk, e.g., unplanned return to operating room;
 --Use of medications, e.g., use of preoperative antibiotics; use
of beta blockers post CABG
 --Use of blood and blood products, e.g., usage not meeting
criteria after peer review (inpatient and outpatient )

20.  3-Significant infection surveillance
findings,
 4--Utilization management findings, e.g.,
readmissions related to previous
hospitalization w/in 31 days; total
inpatient stays and average length of stay ,
total inpatient and outpatient procedures;
 5--Pharmacy and therapeutics function

21.  6-Patient safety findings, including adverse
events, root cause analyses;
 --Risk management findings;
 7---Medical record review.
 8--Pertinent findings/successes resulting
from QI Team activities;

22.  9-Pertinent findings from external review,
including the Quality Improvement
Organization (QIO), State Department of
Health, private review and case
management companies.
 10-Information concerning patient care
activity in the organization, e.g., numbers
of patients admitted or treated, numbers
and types of procedures performed;

23.  11-Outpatient activity, e.g., unscheduled
inpatient admissions due to adverse
outcome from outpatient procedure;
 12--Information concerning fulfillment of
administrative responsibilities, e.g.,
meeting attendance, committee
membership, QI team participation,
productivity, etc.;

24.  Practitioner profiles must:
-Be maintained in a strictly confidential
environment, As part of a credentials file
or In a separate locked file, stamped as
"Confidential-Part of Credentials File.
-Be released only in accordance with bylaws, rules
and regulations, and/or policy, to authorized
individuals or committees, within the limits of
the law; Except for activity data, be comprised
only of peer-reviewed findings; raw data is
unacceptable, as it has not been validated

25.  Be reviewed and signed off by:
--Medical directors and/or peer review
committee
--Department chairs, at the time of reappraisal
for reappointment to the medical staff and
re-privileging in hospitals; or

26. APPOINTMENT/REAPPOINTMENT
(Medical/Professional Staff Membership
 • Eligibilitv: The medical/professional staff
includes fully licensed physicians and may
include other licensed individuals permitted
by law and the organization to provide
independent patient care services (e.g.,
psychologists, podiatrists, dentists).

27. Initial appointment is provisional
 Initial appointment is provisional, with a time period
consistent for all applicants, generally 6 months to 1
year, as determined by the medical staff bylaws.
 The full appointment period is also determined by
the bylaws, but cannot exceed two years, as The
Joint Commission accreditation standards require
renewal of privileges at least every two years.

28. Initial Appointment
 Once the provisional time period has elapsed
and required proctoring is completed, the
practitioner is advanced to an active staff
(depending on the categories available and the
bylaws provisions)

29. Reappointment
 Reappointment includes reappraisal of:
-Re-credentialing: Updated information concerning
current activity, licensure and certifications/
registrations, liabilities/claims leading to judgments
against the practitioner, and malpractice insurance
coverage;
-Current competency review (profile information):
Quality management activities; peer review activities

30. Reappointment
 -Review of other reasonable indicators of continuing
qualifications, sometimes including attendance at
medical/ professional staff, department, and assigned
committee and team meetings;
 -Peer and departmental recommendations;
 -Review and renewal of specific clinical privileges

31. Reappointment
 Compliance with continuing medical
education requirements.
 Reappointment is granted for the time period
specified in the bylaws or policies/procedures,
but never for longer than two years, again
based on Joint Commission accreditation
standards requirement regarding renewal of
privileges.

32. PATIENT/MEMBER ADVOCACY AND
FEEDBACK PROCESSES
One of the most exciting results of the emphasis on
continuous quality improvement concepts is the
renewed interest in the patient/member as:
 Integrally involved in, and controlling, his or her
care;
 A "customer", with specific needs and expectations;
 A "processor" and "supplier" in the process of
patient care;
 Having very specific rights, as well as
responsibilities, within the process of care.

33. The Organization's Responsibilities to the
Patient/Member Include:
Respect for:
 -The patient/member as an individual with unique
healthcare needs, including consideration of
psychosocial, spiritual, and cultural variables
influencing the perception of illness and
accommodation of right to religious/spiritual
services;
 -Personal dignity and the right to considerate and
respectful care.

34.  Reasonable responses to requests and needs for
treatment or service (access), including pain
management
 Information concerning the patient's/member's
right, in collaboration with his or her physician
and to the extent permitted by law, to make
decisions regarding his or her care, treatment, and
services, including providing informed consent
and making the decision to refuse treatment.

35.  Development of policies regarding provision or
withholding of resuscitation, life sustaining
treatment, and decisions concerning end of life
care and treatment;
 Policies and procedures to both protect and
permit the exercise of patient/member rights,
including mechanisms for the communication of
needs, and resolution of patient/member
complaints or grievances

36.  Protection, within the limits of the law, of
personal privacy, security, and
confidentiality of information; appropriate
consents obtained, including recording or
filming for purposes other than
identification, diagnosis, or treatment;
 Freedom from mental, physical, sexual,
verbal abuse, neglect

37.  Communication of information related to
ethical issues or human experimentation
or other research projects affecting his or
her care or treatment;
 Protection as research subjects and
respect of rights during research,
investigation, and clinical trials;

38. Patient / Member Responsibilities to the
Provider of Care
 Provide, to the extent possible, information
that providers need to care for them
 Follow plans and instructions for care they
have agreed on with their practitioners and
 Participate in understanding their health
problems and developing mutually agreed
upon treatment goals

39. Complaints , Grievances, and Appeals
 Complaint: An oral or written expression of
dissatisfaction. A person "registers" a
complaint, generally about the processes of
care.

40.  Grievance: A formal expression of
dissatisfaction, usually written but may be
oral. A person "files" a grievance,
generally about quality of care or financial
issues.
 Appeal: A request to change a previous
decision made by the organization

41. PATIENT/MEMBER FEEDBACK
PROCESSES
 Healthcare Quality and Customer Satisfaction
-Consumers will evaluate quality based on such criteria
as:
 Access to practitioners
 Geographical access
 Service
 Relationship/connectedness/affinity
 Cost

42. Collection of Patient/Member Feedback
 Feedback is based on perceptive quality and
may take the form of complaints, positive or
negative perceptions of care, or even
innovative ideas for improvement

43. Patient/member satisfaction and risk
management
 Patient satisfaction is one of the key factors
in quality management and performance
improvement that provides perceptive
quality information and helps measure
outcomes of care and service.
 Patient dissatisfaction is one of the key
factors in risk management that prompts
patient/family action to file a claim.

44. Patient feedback systems in loss prevention
and reduction
 To establish effective outcome databases;
 use of patient feedback in outcomes management
 There must be a system of distribution of aggregated
patient feedback information to all who need to
know in order for appropriate response to take place:

45. Patient / Member Feedback Processes
 -Surveys/questionnaires (written and Internet)
--Patient perception of care/satisfaction --Health
status
 -Telephone and face-to-face interviews
 -Focus group
 Internet e-mail communications (questions,
comments, etc.)
 -Complaint and grievance processes

46. PATIENT AND FAMILY EDUCATION
PROCESS
 The educational assessment should:
 -Address the relevant healthcare needs,
abilities, and readiness to learn;
 -Include cultural and religious beliefs,
emotional barriers, desire and motivation,
physical and / or cognitive limitations, and
language barriers

47. The education should:
 -Be understandable;
 -Include instruction necessary to meet ongoing healthcare
needs, including, if relevant:
--Plan for care, treatment, and services
--Basic safety health practices
--Safe and effective use of medication
--Safe and effective use of medical equipment and supplies
--Education about pain management, including risk, assessment,
and methods
-for management --Potential drug-food interactions --Counseling
on nutrition and modified diets

48. REPORTING MECHANISMS
information for hospital governing body review may include :
 -Activity: Admissions, patient days, encounters, etc., as
applicable
 -Unplanned admissions / readmissions as defined by the
organization or the appropriate reference database;
 -Discharges against medical advice
 -Summaries of media stories;
 -Satisfaction survey trends: patient, staff (professional and
organization);

49. REPRTING MECHANISM
 Complaints: patient, professional staff,
organization staff;
 -Pattern analyses of --Occurrences --Claims
--Mortalities
 Summary utilization data: --Average length of
stay --Cost per case --Cost avoidance

50. REPORTING MECHANISM
 Rates: --C-sections --Mortalities, e.g.,
neonatal/maternal
 --Medication errors
 --Healthcare-associated infections, e.g., surgical site,
outbreaks
 A balanced scorecard/dashboard is a good way to
organize the data, with key performance measures
supported by other department/service measures as
relevant

51. EVALUTAION OF QM / PI FUNCTION
 Evaluation of QM/PI activities is critical to
determine whether processes in the
organization have really improved and
whether strategic and operational goals and
objectives have been met.

52. COMPONENTS OF EXCELLENCE
 Valid, reliable data and information about
important functions and associated processes
of care and service and patient safety;
 Collaboration for continuous improvement in
organizational performance by all appropriate
leaders, medical staff, departments/services,
cross-functional teams, and committees;

53.  Timely assessment of data to identify significant
variations in processes and outcomes, both
undesirable and best practices;
 Identification and prioritization of quality activities ,
performance measures, variances, and other
opportunities to improve care and. services;
 Validated effectiveness of actions/strategies
implemented to improve care processes;

54.  Communication of clear information across
and within all appropriate
departments/services, organizations, etc.;
 Complete documentation and follow-up;
 Evidence of supportive QM structure and
systems, including information
management

55.  Evidence of support and involvement of all
key leaders;
 Integration with all other pertinent activities,
including utilization management, risk
management, and safety;
 Ongoing quality education efforts
organization wide.

56.  Any of these components can be prioritized
as annual objectives for organization wide
quality strategy improvement or as a
checklist for annual evaluation of
effectiveness of the function.

57. EVALUATION OF PI PROCESSES AND
OUTCOMES
 Evaluation of quality
management/performance improvement
activities must address their relevance to the
organization's mission, vision, and strategic
plan

58. Process effectiveness:
 Viability of the Plan, given current resources,
including the practicality of OM/PI activities;
 -Ability to measure patient outcomes and
improvement in the quality of patient care
(utilizing as many outcome parameters as
possible);
 -Accurate communication of information to
the appropriate persons, teams, committees,
board, or other groups;

59.  Documentation to support compliance with The
Joint Commission, NCOA, and other standards
and state and federal regulations, as applicable;
 -Cost-effectiveness and efficiency benefits of the
activities;
 Patient and staff safety benefits of the activities;
 -Ability of all QM/PI activities to assess customer
needs and expectations and to meet or surpass
those needs.

60. Outcome effectiveness:
 -Degree to which Strategic Ouality Initiatives
were met;
 -Degree to which outcome objectives for
quality initiatives were met;
 -Comparison of current performance
measures (indicators) with previous ratings

61.  -Comparison of the current findings from patient
and staff surveys/questionnaires with previous
measures;
 -Evidence of improved clinical performance;
 Amount of new information available to leaders
for the next planning period: --Strategic and
quality goals; --Organizational objectives;
--Strategic Ouality Initiatives.

62. Evaluate QM activities
-Are strategic goals and objectives being met?
-Are program strengths being maintained?
-Are weaknesses being corrected?
-Are quality objectives and activities meeting current
standards, regulations, and other review
requirements?
-AreQM/PI activities comprehensive, including all
relevant disciplines, teams and committee -Is OM/PI
activity coordination efficient and effective?

63.  Are QM/PI activities supported by the governing
body, administration, and physicians/LIPs?
 Does each understand their role and
responsibilities?
 -Are important and meaningful problems and
issues identified, analyzed, and resolved?
 -Are all appropriate and available data sources
being utilized to support teams and to measure
and assess performance?
 -Are predetermined, valid performance measures
used when appropriate?

64.  Are data aggregated, displayed, analyzed,
trended, and reported?
 -Are improvements recommended?
 Are they implemented?
 Are they evaluated for effectiveness?
 -Are all OM activities adequately and accurately
documented?
 -Are reporting mechanisms adequate (frequent
enough; to all appropriate persons, departments,
teams, committees, settings; clear communication
tools)?

65. • Methods of evaluation
 Review of patient processes and outcomes
(data summaries, activity reports, critical
events, claims information);
 -Review of perceptions and attitudes
(observation, interview, questionnaires,
complaints);
 Review of services (availability, timeliness,
and quality based on critical events, adverse
outcomes, patient satisfaction).

66. Infection Prevention and Control
 Infection: "The transmission of a pathogenic
microorganism to a host, with subsequent
invasion and multiplication, with or without
resulting symptoms of disease." [The Joint
Commission]

67.  Healthcare-associated (nosocomial): Infections
that patients acquire during the course of
receiving treatment for other conditions or that
healthcare workers acquire while performing
their duties within a healthcare setting. [CDC]
 Iatrogenic: An infection or other complication of
treatment induced in a patient by a physician's or
other licensed independent practitioner's activity,
manner, or therapy

68.  Epidemic infection: .~ higher than expected level of
infection by a common agent in a defined population during a
defined period.“
 individuals with a healthcare-associated infection
The ratio describing the number of individuals with a healthcare-
associated infection [numerator] divided by the number of
individuals at risk of developing healthcare-associated
infections [denominator], for a specified group, e.g., surgical
site infections, probably stratified by type of procedure,
condition, location (geographic or body part), etc., based on
the organization's population and experience

69. Goal and scope
 Goal: "...reduce the risk of acquisition and
transmission of health care-associated
infections
 Evidence of goal achievement: Reduced
healthcare-associated infection rates.

70. Scope of the function:
 Coordination of all activities related to the
surveillance, prevention, and control of
healthcare associated infections;
 - Linkages with support systems to reduce the
risks of infection from the environment,
including food and water sources.

71. Responsibilities of the QC ,team or
committee
 Approval of the type and scope of surveillance
activities, including data collection and analysis
methodologies;
 -Approval of actions taken to prevent or control
infections
 Documentation in minutes of conclusions,
recommendations, actions, and person(s) responsible
for implementation of action;

72. Responsibilities of the QC or Committee
 Communications to the medical executive
committee, if applicable, CEO, nurse
executive, persons responsible for
organization wide quality management
activities, and governing body;
 --Review and approval of all infection control
policies and procedures;

73. Responsibilities of the infection control
professional
-Development and management of
policies/procedures/processes; -Participation
in strategic and other organizational planning;
-Participation in organization wide PI
activities/strategic initiatives;
-Quality control/monitoring/review of equipment
and/or processes

74. Responsibilities of the infection control
professional
 Budgeting/management reporting (Infection
control needs, occurrences, etc.);
 -Participation in safety inspections,
emergency/disaster preparedness, drills;
 -Participation in space, resource, and service
allocation;
 -Staff performance evaluation/competency
review

75. Responsibility as a patient safety activity
 Preventive activities :
Policies and procedures, education, and infection
control measures
 Surveillance :
case finding, investigation of significant infections,
data analysis, and reporting
-All of these processes and steps have as their goal a
safe experience for the patient and should be
integrated with the patient safety program

76.  The Joint Commission states that a
healthcare-associated infection involving a
death or permanent disability should be
considered a sentinel event, requiring
intensive analysis and root cause analysis
 The key element is collaboration among
infection control professionals, physicians,
other clinical staff, administrative directors,
and others as identified.

77. A typical hospital policy statement
 It might read: "Healthcare-associated
infections are defined as those infections not
present or incubating at the time of
admission.

78.  As a rule, an infection will be considered
healthcare-associated if there is documentation of
infection occurring 48 hours after the admission
date, or if the physician indicates a diagnosis of
healthcare-associated infection.
 Specific criteria will be used for identifying
healthcare-associated infections by site, based on
the guidelines established by the Centers for
Disease Control and Prevention.
 These guidelines shall be approved by the
[Infection Control] Committee and the [Medical
Executive] Committee [or Quality Council]. "

79. Disease surveillance
 It is an epidemiological practice by which the spread
of disease is monitored in order to establish patterns
of progression. The main role of disease surveillance
is to predict, observe, and minimize the harm caused
by outbreak, epidemic, and pandemic situations, as
well as increase our knowledge as to what factors
might contribute to such circumstances. A key part
of modern disease surveillance is the practice of
disease case reporting.

80. The Surveillance/Control Cycle in infection
control

81. Minimal Requirements for Surveillance
 Monitor infection patterns (sites, pathogens, risk
factors, location within the facility)
 Detect changes in the patterns that may indicate an
infection problem
 Direct the rapid implementation of control measures
 Monitor antibiotic use and resistance
 Provide the staff with exactly the information they
need in order to improve infection prevention
practices.

82. Types of surveillance approaches include:
 100% surveillance
--Detection and recording of all healthcare-associated
infections occurring on every service in every area at
every setting;
--Calculation of infection rates to identify potential
infection problems in specific areas;
--Appropriate analyses include collection of
denominators;
--Continuous conduction (e.g., lab report screening) or
periodically (e.g., 100% every 3 months for 1
month).

83. Types of surveillance approaches include
 Priority-directed, targeted surveillance
--Specific services, e.g.:
-All patients in surgical settings;
-All patients in special care areas in hospitals

84. Priority-directed, targeted surveillance
 Targeted patient populations (disease-specific
or based on adverse occurrence), e.g.:
---All patients with Class I surgical wounds who
develop infections;
---All patients on ventilators who acquire
pneumonia;
---Patients developing infection from certain
antibiotic-resistant bacteria.

85. Priority-directed, targeted surveillance
 Procedures, e.g.:
--All ambulatory cardiac and orthopedic surgical
procedures;
---All Swan-Ganz catheter insertions in
hospitals.

86. Types of surveillance approaches
C-Problem-oriented or outbreak response
surveillance
 --Conducted to measure the occurrence of specific
infection problems;
 --Further evaluation as necessary, collecting
comparable data from control groups to identify risk
factors and appropriate control measures;
 --Continued surveillance to determine effectiveness
of control measures

87.  Standards for infection control
• CDC guidelines as infection control standards
The CDC has specific guidelines for prevention
of healthcare-associated infections, e.g.,
pneumonia, surgical site, intravascular device,
catheter associated urinary tract, isolation,
environmental, hand hygiene, personnel
safety, home care, long term care.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr521