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.
Due to the near-universal desire for safe and good quality healthcare, there is a growing interest in international healthcare accreditation. Providing healthcare, especially of an adequate standard, is a complex and challenging process. Healthcare is a vital and emotive issue—its importance pervades all aspects of societies, and it has medical, social,political, ethical, business, and financial ramifications.
Dissertation presentation: Study of the Process of Hospital Accreditation and Its Impact on Healthcare Facilities.
Presented By: Yasser Alsharif, Muwafag Kamash, Nasrat Esmat, Amer Tayeb
Supervised By: Dr. Mohammad Kamal Hussain
Hospital accreditation is a voluntary process that focuses on continuous quality improvement. It provides public commitment to patient safety and quality care. Accreditation standards aim to improve performance over minimum standards. In India, the National Accreditation Board for Hospitals and Healthcare Providers sets accreditation standards and has accredited several major hospitals. Accreditation benefits include improved public trust, safety culture, and systematic quality improvement processes.
The document discusses hospital accreditation in India. It defines hospital accreditation and outlines its key driving factors like consumer protection acts. The benefits of accreditation include ensuring quality care for patients, attracting foreign patients, and quality assurance. The major accrediting bodies in India are the National Accreditation Board for Hospitals (NABH) and the Quality Council of India (QCI). NABH has 10 chapters and 100 standards covering areas like patient care, medication management, and infection control. Benefits of NABH accreditation include improved patient outcomes and satisfaction. The document also summarizes two research studies on the impacts and effectiveness of healthcare accreditation standards.
Accreditation is a formal process where a recognized body assesses if a healthcare organization meets predetermined standards. The key purposes of accreditation are to improve healthcare quality and establish optimal standards. Health care accreditation bodies use various evaluation methods during on-site surveys, such as interviews, observations, and document reviews, to determine if organizations meet standards. Some of the main benefits of accreditation include stimulating quality improvement, enhancing healthcare organization image, and strengthening public confidence. In India, important accrediting bodies include the Quality Council of India, National Accreditation Board for Testing and Calibration Laboratories, and National Accreditation Board for Hospitals and Healthcare Providers.
The document provides biographies of several panelists moderating an event on medical records management. It lists their names, current positions, qualifications, areas of expertise, and experience in fields related to healthcare administration, quality, medical law, data analytics, and yoga & cancer research. Key details include years of experience ranging from 16 to 28 years across various leadership roles and institutions. Areas of focus mentioned include quality, compliance, medical administration, data sciences, and healthcare education.
The document discusses hospital accreditation and outlines the recommended processes for a hospital to undergo accreditation. It defines hospital accreditation as a voluntary process where a hospital applies for recognition or certification of compliance to certain standards set by a third party. The recommended steps include having top management decide to pursue accreditation to promote quality and viability. They should establish a steering committee representing key departments to oversee the project and formulate a master plan.
The document outlines the establishment of the Hospital Accreditation Commission (HAC) in the Philippines. It discusses the timeline of events leading to the creation of HAC through a DOH Administrative Order in 2013. The order established HAC as the national accrediting body for hospitals, using PhilHealth standards to improve quality. It describes HAC's activities in 2013 like orientations and its strategic planning workshop. Finally, it presents HAC's proposed calendar of activities for 2014, including advocacy campaigns, training surveyors, and piloting hospital surveys.
Due to the near-universal desire for safe and good quality healthcare, there is a growing interest in international healthcare accreditation. Providing healthcare, especially of an adequate standard, is a complex and challenging process. Healthcare is a vital and emotive issue—its importance pervades all aspects of societies, and it has medical, social,political, ethical, business, and financial ramifications.
Dissertation presentation: Study of the Process of Hospital Accreditation and Its Impact on Healthcare Facilities.
Presented By: Yasser Alsharif, Muwafag Kamash, Nasrat Esmat, Amer Tayeb
Supervised By: Dr. Mohammad Kamal Hussain
Hospital accreditation is a voluntary process that focuses on continuous quality improvement. It provides public commitment to patient safety and quality care. Accreditation standards aim to improve performance over minimum standards. In India, the National Accreditation Board for Hospitals and Healthcare Providers sets accreditation standards and has accredited several major hospitals. Accreditation benefits include improved public trust, safety culture, and systematic quality improvement processes.
The document discusses hospital accreditation in India. It defines hospital accreditation and outlines its key driving factors like consumer protection acts. The benefits of accreditation include ensuring quality care for patients, attracting foreign patients, and quality assurance. The major accrediting bodies in India are the National Accreditation Board for Hospitals (NABH) and the Quality Council of India (QCI). NABH has 10 chapters and 100 standards covering areas like patient care, medication management, and infection control. Benefits of NABH accreditation include improved patient outcomes and satisfaction. The document also summarizes two research studies on the impacts and effectiveness of healthcare accreditation standards.
Accreditation is a formal process where a recognized body assesses if a healthcare organization meets predetermined standards. The key purposes of accreditation are to improve healthcare quality and establish optimal standards. Health care accreditation bodies use various evaluation methods during on-site surveys, such as interviews, observations, and document reviews, to determine if organizations meet standards. Some of the main benefits of accreditation include stimulating quality improvement, enhancing healthcare organization image, and strengthening public confidence. In India, important accrediting bodies include the Quality Council of India, National Accreditation Board for Testing and Calibration Laboratories, and National Accreditation Board for Hospitals and Healthcare Providers.
The document provides biographies of several panelists moderating an event on medical records management. It lists their names, current positions, qualifications, areas of expertise, and experience in fields related to healthcare administration, quality, medical law, data analytics, and yoga & cancer research. Key details include years of experience ranging from 16 to 28 years across various leadership roles and institutions. Areas of focus mentioned include quality, compliance, medical administration, data sciences, and healthcare education.
The document discusses hospital accreditation and outlines the recommended processes for a hospital to undergo accreditation. It defines hospital accreditation as a voluntary process where a hospital applies for recognition or certification of compliance to certain standards set by a third party. The recommended steps include having top management decide to pursue accreditation to promote quality and viability. They should establish a steering committee representing key departments to oversee the project and formulate a master plan.
The document outlines the establishment of the Hospital Accreditation Commission (HAC) in the Philippines. It discusses the timeline of events leading to the creation of HAC through a DOH Administrative Order in 2013. The order established HAC as the national accrediting body for hospitals, using PhilHealth standards to improve quality. It describes HAC's activities in 2013 like orientations and its strategic planning workshop. Finally, it presents HAC's proposed calendar of activities for 2014, including advocacy campaigns, training surveyors, and piloting hospital surveys.
Achieving Patient delight with Quality - Dr V.P Thomas at Knowledge Series Se...Hosmac India Pvt Ltd
This document discusses quality initiatives at Dr L H Hiranandani Hospital, an NABH accredited hospital in Mumbai. It provides an introduction to the hospital's history and mission of providing quality healthcare. It outlines how quality is emphasized at every level of care delivery, from interactions with security and cleanliness to nursing, doctors, and leadership. Charts show high patient satisfaction ratings. Best practices for maintaining quality include reviewing feedback, clear communication, identifying issues, and responding to complaints promptly. The hospital aims to be the preferred choice for healing through its commitment to continuous quality improvement.
The document discusses the implementation of Joint Commission International (JCI) standards at a tertiary care heart hospital in India, with a special focus on documentation. It provides background on JCI and outlines its standards and accreditation process. The document reports on a comparative study conducted between JCI and National Accreditation Board for Hospitals & Healthcare Providers (NABH) standards. The study found that some policies were not in place at the hospital and many needed improvement, particularly in areas like patient care, nursing care, hospital leadership procedures, and biomedical waste management. Remedial actions are required by hospital management to address key areas of weakness.
How to Improve Hospital Accreditation - Linta Meyla PutriLinta Meyla Putri
Hospital as a health care institution must provide quality services to the community. Quality of service is a standard that will be made to increase the hospital accreditation. In addition to the accredited national standards, some hospitals in Indonesia, especially government hospitals, will also be accredited to use international standards. Actually in Indonesia has a lot of hospitals which are internationally accredited, but most private hospitals. This condition is to give the impression that government hospitals are less credible and less able to provide the best service both communities. To achieve this, the government in collaboration with international accreditation agency that is Joint Commission International (JCI), USA.
Rodixon organiations study at polakkulathi narayanan renai medicityLibu Thomas
The document summarizes an organizational study conducted at Polakkulath Narayanan Renai Medicity hospital. The study aimed to understand the organization's different departments and their functions in a practical way beyond classroom knowledge. Key findings include that the hospital has experienced doctors and specialists across 36 departments but also faces tight competition. It was found that employees are mostly satisfied except regarding remuneration. The document also identifies strengths like modern facilities and opportunities in health tourism, as well as weaknesses like lack of employee input and threats from increasing competition in the growing healthcare industry.
W Pratiksha Hospital provides specialized healthcare through cutting-edge technology, experienced doctors, and compassionate care. It has 25 years of experience treating patients across India. The hospital aims to provide quality healthcare with transparency at an affordable cost. It offers over 30 specialties and 24/7 services like the laboratory, ambulance, emergency care, and pharmacy. The outpatient department is an important part of the hospital that provides diagnosis and care without requiring overnight stays. It is staffed by consultants and offers services like examinations, laboratory tests, radiology, and consultations. The goal of the OPD is to provide specialist care to the community and treat non-critical cases on an outpatient basis.
This document provides an overview of Aga Khan University Hospital (AKUH) in Karachi, Pakistan. It details AKUH's vision, mission, values and culture which emphasize quality, relevance, impact and access in healthcare. The document describes AKUH's facilities, purpose as a philanthropic teaching hospital, organizational structure, training programs, competitors, operating regions, finances, hierarchies, goals, challenges and strategic plan. It conducts a SWOT analysis and concludes with achievements and recommendations to further AKUH's mission.
The document discusses infection control in the ICU, including definitions, incidence of infection, and methods to limit infections in critical areas. It covers standard precautions like hand hygiene and personal protective equipment. It also discusses disinfection, sterilization, types of devices and appropriate decontamination methods. Specific bundles to prevent ventilator-associated pneumonia and central line-associated bloodstream infections are also outlined.
This case study describes the quality initiatives and milestones achieved by Ruby Hall Clinic, a 555-bed multi-specialty tertiary care hospital in Pune, India. Some key points:
- The clinic was established in 1959 and has expanded significantly over the years by introducing many medical "firsts" in Pune and Maharashtra.
- Its vision is to provide high-end technology, medical expertise, and compassionate personalized care.
- The clinic began its quality assurance journey in 2008 and achieved various accreditations like NABL, NABH for laboratory and hospital.
- It integrates quality into its operations through processes like credentialing clinicians, preventative maintenance, safety measures,
This manual provides guidance to certified investigators on conducting investigations of reportable incidents for the Pennsylvania Department of Human Services, Office of Developmental Programs. It outlines the types of incidents that require investigation, including abuse, neglect, rights violations, and deaths of individuals receiving services. The manual instructs investigators on identifying, collecting, and assessing evidence in a systematic manner to objectively describe what did or did not occur. It also defines key terms and concepts for classifying evidence, including distinguishing between relevant and irrelevant facts, as well as direct and circumstantial evidence.
The document discusses a study assessing patient satisfaction with outpatient services at a tertiary care teaching hospital in Lucknow, India. It outlines the study objectives to evaluate availability and utilization of services, information sources, waiting times, and reasons for (dis)satisfaction among internal and external patients. The methodology section describes a prospective descriptive study using interviews and record reviews involving 701 patients across departments from January to March 2013. Preliminary findings show most patients were female, from Uttar Pradesh, and utilization increasing over 2008-2012 for both internal and external patients.
The document discusses quality and accreditation in Indian hospitals. It defines quality and outlines a quality improvement model involving plan-do-check-act cycles. It describes the roles of a quality steering committee and various quality indicators. NABH accreditation benefits all stakeholders by ensuring high quality care, patient safety, and continuous improvement. Accredited hospitals gain cost savings, consistent quality, and preferential treatment from customers and third parties.
This document provides an overview of the Medical Record Department at Paras Hospital in Gurgaon, India. It begins with an introduction to Paras Hospital and its establishment in 2006 with a mission of providing specialized healthcare. It then discusses the objectives of studying the Medical Record Department, which include understanding its roles and processes to identify areas for improvement. The document outlines the organizational structure of the Medical Record Department and provides flow charts of its processes. It also identifies the internal and external clients of different units within the department.
This internship report summarizes Abid Hussain's internship at the finance department of Aga Khan University Hospital in Karachi. The report provides an overview of AKUH, including its vision, mission and facilities. It then describes the various sections of the finance department and their functions, including bookkeeping, budgeting, billing and payroll. The report also summarizes Abid's learning experience, including understanding financial terminology and using the PeopleSoft software system. In conclusions, Abid states it was a valuable learning experience, and recommends improving training programs and customizing the PeopleSoft modules.
The National Accreditation Board for Hospitals & Healthcare Providers (NABH) was established to operate an accreditation program for healthcare organizations in India. NABH aims to accredit healthcare facilities, promote quality through various initiatives, provide education and training on quality and patient safety, and recognize quality healthcare courses. Accreditation benefits facilities by providing high quality care, patient safety, staff satisfaction, and an objective system for insurance empanelment. NABH standards are organized into 10 chapters covering patient-centric and organization-centric functions like access to care, infection control, management responsibilities, and human resource management. The human resource management standards address processes for staff planning, orientation, training, performance evaluation, credentialing
Intership Report; Shaukat Khanum Memorial Cancer Hospital & Research CentreWaseem Sajjad
The report provides an overview of SKMCH&RC, including its history and establishment by Imran Khan in 1994 to honor his mother and provide cancer treatment regardless of ability to pay. It describes the hospital's vision to "Bowl Out Cancer", mission, organizational structure, core values including patient focus and equality. The report also discusses the hospital's management practices including the dedicated human resources division and its hiring process of written tests and interviews.
The document discusses conducting a brand imagery study for Global Hospitals Group in Chennai. It outlines conducting qualitative depth interviews with medical professionals and past/potential patients to understand perceptions of Global Hospitals' brand. It also involves quantitative telephone surveys of 160 past patients of Global Hospitals and competitors to quantify brand imagery facets and generate a Brand Imagery Index. The study aims to identify strengths, weaknesses and opportunities to improve Global Hospitals' brand preference in its catchment area.
Nidhiya.s organiations study at puspagiri hospitalLibu Thomas
This organizational study examines Pushpagiri Medical College Hospital in Thiruvalla, Kerala. Some key points:
- It began in 1959 as a small clinic and has grown to a 1200-bed super specialty hospital with 210 doctors and over 1000 staff.
- Departments include HR, Marketing, Finance, and Systems. Each department has a clear structure and roles.
- Strengths include support from the local archdiocese, qualified doctors, and modern equipment. Weaknesses include lack of technology upgrades and employee retention issues.
- The hospital aims to provide affordable, high quality care through training programs and community outreach. Suggestions focus on reducing costs, improving training, and adopting new technologies.
Looking to enhance your healthcare provider credentialing process? Our team of experts can help you effectively manage licenses and certifications. Focus on delivering superior patient care while we handle the rest.
This article discusses the importance of credentialing and privileging in healthcare organizations and quality of care. It notes that credentialing includes gathering and verifying provider qualifications and experience. Failure to follow proper credentialing processes can result in legal action under the False Claims Act. The article recommends that compliance professionals engage with the credentialing process, ensure policies and procedures are documented and followed, and that two government databases are checked. Proper credentialing helps organizations meet standards for quality care and avoid penalties.
Achieving Patient delight with Quality - Dr V.P Thomas at Knowledge Series Se...Hosmac India Pvt Ltd
This document discusses quality initiatives at Dr L H Hiranandani Hospital, an NABH accredited hospital in Mumbai. It provides an introduction to the hospital's history and mission of providing quality healthcare. It outlines how quality is emphasized at every level of care delivery, from interactions with security and cleanliness to nursing, doctors, and leadership. Charts show high patient satisfaction ratings. Best practices for maintaining quality include reviewing feedback, clear communication, identifying issues, and responding to complaints promptly. The hospital aims to be the preferred choice for healing through its commitment to continuous quality improvement.
The document discusses the implementation of Joint Commission International (JCI) standards at a tertiary care heart hospital in India, with a special focus on documentation. It provides background on JCI and outlines its standards and accreditation process. The document reports on a comparative study conducted between JCI and National Accreditation Board for Hospitals & Healthcare Providers (NABH) standards. The study found that some policies were not in place at the hospital and many needed improvement, particularly in areas like patient care, nursing care, hospital leadership procedures, and biomedical waste management. Remedial actions are required by hospital management to address key areas of weakness.
How to Improve Hospital Accreditation - Linta Meyla PutriLinta Meyla Putri
Hospital as a health care institution must provide quality services to the community. Quality of service is a standard that will be made to increase the hospital accreditation. In addition to the accredited national standards, some hospitals in Indonesia, especially government hospitals, will also be accredited to use international standards. Actually in Indonesia has a lot of hospitals which are internationally accredited, but most private hospitals. This condition is to give the impression that government hospitals are less credible and less able to provide the best service both communities. To achieve this, the government in collaboration with international accreditation agency that is Joint Commission International (JCI), USA.
Rodixon organiations study at polakkulathi narayanan renai medicityLibu Thomas
The document summarizes an organizational study conducted at Polakkulath Narayanan Renai Medicity hospital. The study aimed to understand the organization's different departments and their functions in a practical way beyond classroom knowledge. Key findings include that the hospital has experienced doctors and specialists across 36 departments but also faces tight competition. It was found that employees are mostly satisfied except regarding remuneration. The document also identifies strengths like modern facilities and opportunities in health tourism, as well as weaknesses like lack of employee input and threats from increasing competition in the growing healthcare industry.
W Pratiksha Hospital provides specialized healthcare through cutting-edge technology, experienced doctors, and compassionate care. It has 25 years of experience treating patients across India. The hospital aims to provide quality healthcare with transparency at an affordable cost. It offers over 30 specialties and 24/7 services like the laboratory, ambulance, emergency care, and pharmacy. The outpatient department is an important part of the hospital that provides diagnosis and care without requiring overnight stays. It is staffed by consultants and offers services like examinations, laboratory tests, radiology, and consultations. The goal of the OPD is to provide specialist care to the community and treat non-critical cases on an outpatient basis.
This document provides an overview of Aga Khan University Hospital (AKUH) in Karachi, Pakistan. It details AKUH's vision, mission, values and culture which emphasize quality, relevance, impact and access in healthcare. The document describes AKUH's facilities, purpose as a philanthropic teaching hospital, organizational structure, training programs, competitors, operating regions, finances, hierarchies, goals, challenges and strategic plan. It conducts a SWOT analysis and concludes with achievements and recommendations to further AKUH's mission.
The document discusses infection control in the ICU, including definitions, incidence of infection, and methods to limit infections in critical areas. It covers standard precautions like hand hygiene and personal protective equipment. It also discusses disinfection, sterilization, types of devices and appropriate decontamination methods. Specific bundles to prevent ventilator-associated pneumonia and central line-associated bloodstream infections are also outlined.
This case study describes the quality initiatives and milestones achieved by Ruby Hall Clinic, a 555-bed multi-specialty tertiary care hospital in Pune, India. Some key points:
- The clinic was established in 1959 and has expanded significantly over the years by introducing many medical "firsts" in Pune and Maharashtra.
- Its vision is to provide high-end technology, medical expertise, and compassionate personalized care.
- The clinic began its quality assurance journey in 2008 and achieved various accreditations like NABL, NABH for laboratory and hospital.
- It integrates quality into its operations through processes like credentialing clinicians, preventative maintenance, safety measures,
This manual provides guidance to certified investigators on conducting investigations of reportable incidents for the Pennsylvania Department of Human Services, Office of Developmental Programs. It outlines the types of incidents that require investigation, including abuse, neglect, rights violations, and deaths of individuals receiving services. The manual instructs investigators on identifying, collecting, and assessing evidence in a systematic manner to objectively describe what did or did not occur. It also defines key terms and concepts for classifying evidence, including distinguishing between relevant and irrelevant facts, as well as direct and circumstantial evidence.
The document discusses a study assessing patient satisfaction with outpatient services at a tertiary care teaching hospital in Lucknow, India. It outlines the study objectives to evaluate availability and utilization of services, information sources, waiting times, and reasons for (dis)satisfaction among internal and external patients. The methodology section describes a prospective descriptive study using interviews and record reviews involving 701 patients across departments from January to March 2013. Preliminary findings show most patients were female, from Uttar Pradesh, and utilization increasing over 2008-2012 for both internal and external patients.
The document discusses quality and accreditation in Indian hospitals. It defines quality and outlines a quality improvement model involving plan-do-check-act cycles. It describes the roles of a quality steering committee and various quality indicators. NABH accreditation benefits all stakeholders by ensuring high quality care, patient safety, and continuous improvement. Accredited hospitals gain cost savings, consistent quality, and preferential treatment from customers and third parties.
This document provides an overview of the Medical Record Department at Paras Hospital in Gurgaon, India. It begins with an introduction to Paras Hospital and its establishment in 2006 with a mission of providing specialized healthcare. It then discusses the objectives of studying the Medical Record Department, which include understanding its roles and processes to identify areas for improvement. The document outlines the organizational structure of the Medical Record Department and provides flow charts of its processes. It also identifies the internal and external clients of different units within the department.
This internship report summarizes Abid Hussain's internship at the finance department of Aga Khan University Hospital in Karachi. The report provides an overview of AKUH, including its vision, mission and facilities. It then describes the various sections of the finance department and their functions, including bookkeeping, budgeting, billing and payroll. The report also summarizes Abid's learning experience, including understanding financial terminology and using the PeopleSoft software system. In conclusions, Abid states it was a valuable learning experience, and recommends improving training programs and customizing the PeopleSoft modules.
The National Accreditation Board for Hospitals & Healthcare Providers (NABH) was established to operate an accreditation program for healthcare organizations in India. NABH aims to accredit healthcare facilities, promote quality through various initiatives, provide education and training on quality and patient safety, and recognize quality healthcare courses. Accreditation benefits facilities by providing high quality care, patient safety, staff satisfaction, and an objective system for insurance empanelment. NABH standards are organized into 10 chapters covering patient-centric and organization-centric functions like access to care, infection control, management responsibilities, and human resource management. The human resource management standards address processes for staff planning, orientation, training, performance evaluation, credentialing
Intership Report; Shaukat Khanum Memorial Cancer Hospital & Research CentreWaseem Sajjad
The report provides an overview of SKMCH&RC, including its history and establishment by Imran Khan in 1994 to honor his mother and provide cancer treatment regardless of ability to pay. It describes the hospital's vision to "Bowl Out Cancer", mission, organizational structure, core values including patient focus and equality. The report also discusses the hospital's management practices including the dedicated human resources division and its hiring process of written tests and interviews.
The document discusses conducting a brand imagery study for Global Hospitals Group in Chennai. It outlines conducting qualitative depth interviews with medical professionals and past/potential patients to understand perceptions of Global Hospitals' brand. It also involves quantitative telephone surveys of 160 past patients of Global Hospitals and competitors to quantify brand imagery facets and generate a Brand Imagery Index. The study aims to identify strengths, weaknesses and opportunities to improve Global Hospitals' brand preference in its catchment area.
Nidhiya.s organiations study at puspagiri hospitalLibu Thomas
This organizational study examines Pushpagiri Medical College Hospital in Thiruvalla, Kerala. Some key points:
- It began in 1959 as a small clinic and has grown to a 1200-bed super specialty hospital with 210 doctors and over 1000 staff.
- Departments include HR, Marketing, Finance, and Systems. Each department has a clear structure and roles.
- Strengths include support from the local archdiocese, qualified doctors, and modern equipment. Weaknesses include lack of technology upgrades and employee retention issues.
- The hospital aims to provide affordable, high quality care through training programs and community outreach. Suggestions focus on reducing costs, improving training, and adopting new technologies.
Looking to enhance your healthcare provider credentialing process? Our team of experts can help you effectively manage licenses and certifications. Focus on delivering superior patient care while we handle the rest.
This article discusses the importance of credentialing and privileging in healthcare organizations and quality of care. It notes that credentialing includes gathering and verifying provider qualifications and experience. Failure to follow proper credentialing processes can result in legal action under the False Claims Act. The article recommends that compliance professionals engage with the credentialing process, ensure policies and procedures are documented and followed, and that two government databases are checked. Proper credentialing helps organizations meet standards for quality care and avoid penalties.
Healthcare facility Quality and Operational proposal by Mahboob ali khan MHA,...Healthcare consultant
1) Mahboob Ali Khan proposes establishing a quality management system and pursuing accreditation for a client hospital from JCI, NABH, and CBAHI.
2) The scope of consultancy services includes gap assessments, developing documentation, training programs, and providing support through the accreditation process over 12 months.
3) The client hospital is expected to commit resources including a dedicated quality team and provide access to records to support the accreditation work.
Therapy Practice Services (TPS) is a nationwide provider of credentialing, start-up consulting and contract negotiation services. Since 2008, we have had the privilege of helping over 5000 providers across the country and start 25-30 new practices each month.
Credentialing ,licensure and nursing syndicateMahmoud Shaqria
This document defines key terms related to credentialing, licensure, and nursing syndicates. It defines credentialing as documents that communicate one's competence in a field. Licensure provides legal permission to practice and is usually regulated by the government. A syndicate is a temporary group authorized to perform specific duties. The document outlines the purpose of credentialing in healthcare, the accreditation process, and the history and importance of nursing licensure. It also discusses the establishment of nursing syndicates and their objectives to support and regulate the nursing profession.
Read and discuss the following three articles 1. ACAs Perform.pdfSALES97
Read and discuss the following three articles:
1. ACAs Performance Based Healthcare
Standards ACAsPerformanceBasedHealthCareStandards.pdf
2. Road to Accreditation RoadToAccreditation.pdf
3. JCAHO Accreditation and Quality of Care for Acute Myocardial Infarction JCAHO
accreditation and quality of care for acute myocardial infarction.pdf
Have an open discussion about these articles. Share your thoughts
For example, here are some questions to answer and discuss:
Does accreditation impact quality? Are there less errors in hospitals that are accredited? What is
the value of accreditation? Do quality concerns initiate changes in staff behavior? Should
accreditation be based on results?
Read and discuss the following three articles:
1. ACAs Performance Based Healthcare
Standards ACAsPerformanceBasedHealthCareStandards.pdf
2. Road to Accreditation RoadToAccreditation.pdf
3. JCAHO Accreditation and Quality of Care for Acute Myocardial Infarction JCAHO
accreditation and quality of care for acute myocardial infarction.pdf
Have an open discussion about these articles. Share your thoughts
For example, here are some questions to answer and discuss:
Does accreditation impact quality? Are there less errors in hospitals that are accredited? What is
the value of accreditation? Do quality concerns initiate changes in staff behavior? Should
accreditation be based on results?
Solution
ACAs Performance Based Healthcare Standards-
This booklet is intended to assist anyone dealing with or affected by Health and Employment
issues. It is one of a series of booklets and handbooks designed to give impartial advice on
employment matters to employers, employees and their representatives. Legal information is
provided for guidance only and should not be regarded as an authoritative statement of the law,
which can only be made by reference to the particular circumstances which apply. It may,
therefore, be wise to seek legal advice.
Acas is committed to building better relationships in the workplace and offers training to suit
you. From a two-hour session on the key points of new legislation or employing people to
courses specially designed for people in your organisation. Click here to find out about training
sessions in your area. We also offer hands-on practical help and support to tackleissues in your
business with you. This might be through one of our wellknown problem-solving services or a
programme we have worked out together to put your business firmly on track for effective
employment
relations.
road to accrediation -
Accreditation is usually a voluntary program, sponsored by a non-governmental organization
(NGO), in which trained external peer reviewers evaluate a healthcare organization\'s
compliance and compare it with pre-established performance standard
Accreditation is a quality assurance process designed to ensure an educational program meets a
national standard. It serves to support and encourage program responsiveness to the ra pidly
changing environmental .
Medical credentialing services are important in the healthcare business because they assist both healthcare practitioners and patients. By ensuring the competence and credibility of practitioners, medical credentialing contributes to patient safety and quality care. Additionally, it streamlines healthcare processes, opens up career opportunities for medical professionals, and facilitates insurance provider enrollment. With its far-reaching impact, medical credentialing is undoubtedly a vital and indispensable aspect of the healthcare ecosystem.
The document discusses vendor credentialing in healthcare from multiple perspectives. It explores the two main schools of thought around credentialing - controlling access to hospitals for pricing negotiations versus ensuring safety and security. Experts from hospitals, suppliers, and credentialing companies provide opinions on which school is more prevalent and important. They also discuss efforts over the past year to develop universal standards and best practices for credentialing, but note more work still needs to be done. Opinions are given on how an ideal credentialing system could work to satisfy both providers and suppliers.
Looking for reliable medical billing and insurance credentialing services? Look no further! Our team of experts specializes in providing excellent and efficient services to healthcare providers. Trust us with your credentialing needs and focus on what you do best - providing excellent healthcare,..
The document discusses the credentialing and privileging process for APRNs. Credentialing involves verifying qualifications like education, licensure and certifications. Privileging authorizes providers to perform specific services. Both aim to ensure practitioners are qualified while protecting facilities and patients. The document also outlines national certification requirements, various regulatory bodies at the state and federal level that oversee nursing practice, and recommendations from organizations to reform regulation.
Recruitment refers to the process of identifying, attracting, interviewing, selecting, hiring and onboarding employees. Its. only for study purposes. Kindly share to others.
Credentialing refers to the process of collection and verification of the evidences of credentials of a doctor who is to be given the responsibility of
treating patients in the hospital. The process
ensures the authenticity of the details provided
by the healthcare practitioner or doctor.
By choosing Instapay Healthcare Services, healthcare providers can save time, reduce administrative burdens, and ensure ongoing compliance with changing regulations.
Quality assurance in nursing originated with Florence Nightingale and involves establishing standards of care and measuring patient care against those standards to evaluate and promote excellence. A quality assurance program is a systematic, ongoing process that sets standards, measures patient care, gathers data, and makes recommendations for improvement. The goal is to ensure efficient, effective, and economical care. Approaches include credentialing like licensure and certification, peer review, auditing care standards and documentation, and identifying areas for improvement. Quality assurance helps improve patient care standards and professional development.
What is Credentialing in Healthcare_ A Comprehensive Guide to Understanding I...Cosentus
Credentialing is not merely a bureaucratic formality; it is the foundation upon which patient trust is built, healthcare revenue cycle management quality is assured, and regulatory compliance is maintained. Now you know all about the multifaceted components of credentialing, from verifying qualifications to assessing ethical conduct, showcasing how it serves as the guardian of patient well-being.
Florence Nightingale introduced the concept of quality nursing care in 1855. Quality assurance aims to provide care efficiently, effectively and economically through cost analysis and quality control programs. It involves setting standards, measuring care against standards, collecting data, and making recommendations. Quality assurance originated in manufacturing to ensure customer satisfaction and is now a process through which nurses are accountable for the quality of care provided.
The document summarizes a seminar presentation on quality assurance in nursing. It discusses key topics like the meaning of quality, quality assurance, and approaches to quality assurance programs. It describes credentialing methods like licensure, accreditation, and certification. Specific quality assurance approaches covered include peer review, nursing audits, utilization review, and evaluation studies. Models of quality assurance and the roles and responsibilities of nurses in ensuring quality are also summarized.
The document summarizes a seminar presentation on quality assurance in nursing. It discusses key topics like the meaning of quality, quality assurance, and approaches to quality assurance programs. It describes credentialing methods like licensure, accreditation, and certification. Specific quality assurance approaches covered include peer review, nursing audits, utilization review, and evaluation studies. Models of quality assurance and the roles and responsibilities of nurses in ensuring quality are also summarized.
This document discusses issues related to nursing licensure and credentials. It explains that licensure is required by law to practice nursing and protects public safety. Requirements for licensure include graduating from an approved nursing program and passing the NCLEX exam. Maintaining licensure involves continuing education requirements. Alternative credentials include certification in specialty areas, which demonstrates expertise beyond basic licensure. Advanced practice roles like Nurse Practitioners and Certified Nurse Midwives have additional education and scope of practice compared to registered nurses.
This document discusses regulatory and professional oversight of medical laboratories in Ethiopia. It covers workplace legal issues, licensure and inspection of laboratories, codes of professional ethics, and accreditation programs. Specifically, it notes that while legal cases between health providers and patients are not common currently in Ethiopia, standards are moving towards those of developed countries. Laboratory managers must be aware of legal issues and ensure proper documentation, training, and insurance to protect against liability. Government regulation and licensure aim to ensure quality services and standards of care.
Similar to Doctor worst fear:Credentials and Privileges by Dr.Mahboob ali khan Phd (20)
In India, Young Graduates Struggle by Dr. Mahboob Khan to Get Jobs.pdfHealthcare consultant
In the world’s most populous country, tens of thousands of graduates and postgraduates, many with professional degrees, such as engineering, spend years studying at the tutoring centers that have mushroomed in Indian cities, hoping to qualify for a highly sought-after government job. The chances are slim. Less than one-half of 1% of the more than 1 million who take the exam each year pass.
The middle class in India is growing unexpectedly, however they're still dealing with demanding situations in accessing excellent and low-priced healthcare. This is because of a number of of factors, such as inefficient healthcare gadget, high price of healthcare, and lack of know-how.
Chat GPT for Doctors -Revolutionizing Healthcare Communication by Dr.Mahboob.pdfHealthcare consultant
Learn how Chat GPT for doctors can revolutionize healthcare communication by improving efficiency and accuracy of patient-provider interaction.
In recent years, there has been a growing interest in the potential of artificial intelligence (AI) to transform healthcare. One area that has received particular attention is communication between patients and healthcare providers. The emergence of chatbots powered by AI has provided a new tool for improving the efficiency and effectiveness of healthcare communication. One of the most promising applications of AI-powered chatbots is Chat GPT for doctors.
As an expert in hospital management and administration i have written this book -Hospital Management is a new theory in management faculty. Earlier a senior doctor used to perform the role of a hospital manager. However, nowadays everything demands a specialist. Almost all the things related to hospital have changed. Many categories concerning medical sciences and hospital have altered totally. There are various types of hospitals today, including ordinary hospitals, specialty hospitals and super specialty hospitals. The categories are regarding to the types of facilities they offer to the people.
Steve Jobs logged off too soon. He was a serial innovator whose illness cost the world a bright talent who was also a great company leader. I hope that the music from the hymns of praise sung to him in his waning days is playing on his iPod as he ascends into the firmament of the greatest American business leaders. If there were a Nobel prize for business, surely he would have won it. He did what he set out to do and more. He saw the potential for computing power for the masses, useful and accessible to everyone. In a phrase that drove the early Apple, he created bicycles for the mind.
The document discusses psychopathic traits in corporate CEOs. It notes that around 4-12% of CEOs exhibit psychopathic personality traits, much higher than the general population. Psychopaths can often disguise their lack of empathy and manipulate others with charm. They seek power and dominance. Stories from CFOs describe their experiences with CEOs exhibiting psychopathic behaviors like intimidation, lack of empathy, narcissism, and manipulation. While their behavior may not meet the clinical definition, it can still be damaging. There is no consensus on how to deal with psychopathic CEOs, but carefully documenting concerning behavior is advised.
Some of the lower vibrations, as you can see on the chart are anger, grief, shame, fear. Some of the higher vibrations are love, joy, appreciation and excitement.
Going to higher vibrations means more energy ,lower vibration is easily achieved and is default in everyone of us and is easily aggravated by gravity.
thats why anger, grief,shame and fear are more common than love ,joy appreciation and excitement.
Hospitals profitability can be increased by boosting patient satisfaction, reducing readmissions and understanding revenue cycle performance.
In this period of healthcare reform, numerous organizations continue to change their business practices so they can obtain more hospital profitability while also delivering quality care. Healthcare expenditures are expected to reach $4.4 trillion by 2022, and this high level of spending activity has hospitals currently under a lot of pressure to reduce costs.
Development of the digital economy started way before COVID-19. The exact date of the beginning may be defined in different ways, depending on different definitions of “digital economy.” The popularly understood “digital economy” phenomenon began when T-Mall was set up in 2003 and when Alipay came online in 2004. While the digital technology brings about the fourth industrial revolution, just like the steam engine, electrical machines, and computers, respectively.
Strategy is not complex. But it is hard. It’s hard because it forces people and organizations to make
specific choices about their future—something that doesn’t happen in most companies. Dr .Mahboob
Khan
Couch potatoes as they are called are the ones who stick on to their sofas just watching the idiot box that has caused many such unwarranted developments in health.
Probably a long vacation could be a precipitating factor for inactivity while the unexpected strife in the country’s developments has brought with it some unexpected holidays. This is the time when children tend to relax but when they cross the line the human body becomes mentally and physically inactive.
While Metaverse is evolving, it holds new potential in healthcare that combines the technologies like Artificial Intelligence, Virtual Reality, Augmented Reality, Internet of Medical Devices, Web 3.0, intelligent cloud, edge and quantum computing along with robotics to provide new directions to healthcare.
Robotic Process Automation in Healthcare-An Urgency! By.Dr.Mahboob KhanHealthcare consultant
Robotic process automation (RPA) can help the healthcare industry address current challenges by automating repetitive manual tasks. This allows staff to focus on higher value work while improving efficiency. RPA has the potential to save $350-410 billion annually in the healthcare sector by 2025 by streamlining processes like patient scheduling, claims management, and treatment workflows. As healthcare workers are overburdened during the pandemic, RPA can reduce their workload and risk of exposure by handling administrative tasks digitally. Widespread adoption of RPA in the Indian healthcare system is urgently needed to address staffing shortages and enhance response efforts amid the ongoing crisis.
Apply This to Your Life
We know this is boring, but you know you need to do it!
Clear an hour in your schedule somewhere in the next week, and set your filing system up!
Many inventions originated in wealthy countries and these were responsible to produce global public goods and medical goods.In which everyone got benefitted even developing and poor countries too.This transfer of knowledge is now compromised by the extension of intellectual property rights and held by high-income countries.
New standards of care have emerged in response to the COVID-19 pandemic. Healthcare facilities and professionals have had to rapidly adopt new protocols for treating COVID patients, including guidelines for management, vaccines, telemedicine, and increased use of personal protective equipment. Some key new standards include wearing face masks, social distancing, treatment guidelines, mobile health apps, limiting gatherings and travel, and increasing sanitization and hygiene practices. As the pandemic evolves, precision medicine approaches may drive new standards, with a focus on using the right tests and treatments tailored for individual patients.
Ways That Quantum Technology Could transform Health Care. By.Dr.Mahboob KhanHealthcare consultant
You probably don’t grasp the finer points of how quantum mechanics works, but scientists are using its tricky rules to make medicine faster, less painful, and more personalized.
How is COVID-19 Reshaping the role of Institutional strategy? By.Dr.Mahboob KhanHealthcare consultant
While workers around the globe are keeping essential services running, it is imperative for business leaders, particularly senior strategy executives, to reflect on the lasting implications of COVID-19 and what they can do to best position their people, their businesses, and society to recover and thrive in the long term. Five key shifts can help chief strategy officers (CSOs) successfully guide their organizations through the pandemic.
Retaining Healthcare Quality During COVID-19 and Future of Care Delivery. By....Healthcare consultant
With the onset of COVID-19, healthcare delivery organizations around the world were collectively faced with one primary challenge: How to effectively deliver quality healthcare to all patients, regardless of the entry point into the system, while protecting the well-being of non-COVID-19 patients and the healthcare workforce.
Under Pressure : Kenneth Kruk's StrategyKenneth Kruk
Kenneth Kruk's story of transforming challenges into opportunities by leading successful medical record transitions and bridging scientific knowledge gaps during COVID-19.
Can coffee help me lose weight? Yes, 25,422 users in the USA use it for that ...nirahealhty
The South Beach Coffee Java Diet is a variation of the popular South Beach Diet, which was developed by cardiologist Dr. Arthur Agatston. The original South Beach Diet focuses on consuming lean proteins, healthy fats, and low-glycemic index carbohydrates. The South Beach Coffee Java Diet adds the element of coffee, specifically caffeine, to enhance weight loss and improve energy levels.
Rate Controlled Drug Delivery Systems, Activation Modulated Drug Delivery Systems, Mechanically activated, pH activated, Enzyme activated, Osmotic activated Drug Delivery Systems, Feedback regulated Drug Delivery Systems systems are discussed here.
Chandrima Spa Ajman is one of the leading Massage Center in Ajman, which is open 24 hours exclusively for men. Being one of the most affordable Spa in Ajman, we offer Body to Body massage, Kerala Massage, Malayali Massage, Indian Massage, Pakistani Massage Russian massage, Thai massage, Swedish massage, Hot Stone Massage, Deep Tissue Massage, and many more. Indulge in the ultimate massage experience and book your appointment today. We are confident that you will leave our Massage spa feeling refreshed, rejuvenated, and ready to take on the world.
Visit : https://massagespaajman.com/
Call : 052 987 1315
Michigan HealthTech Market Map 2024. Includes 7 categories: Policy Makers, Academic Innovation Centers, Digital Health Providers, Healthcare Providers, Payers / Insurance, Device Companies, Life Science Companies, Innovation Accelerators. Developed by the Michigan-Israel Business Accelerator
KEY Points of Leicester travel clinic In London doc.docxNX Healthcare
In order to protect visitors' safety and wellbeing, Travel Clinic Leicester offers a wide range of travel-related health treatments, including individualized counseling and vaccines. Our team of medical experts specializes in getting people ready for international travel, with a particular emphasis on vaccines and health consultations to prevent travel-related illnesses. We provide a range of travel-related services, such as health concerns unique to a trip, prevention of malaria, and travel-related medical supplies. Our clinic is dedicated to providing top-notch care, keeping abreast of the most recent recommendations for vaccinations and travel health precautions. The goal of Travel Clinic Leicester is to keep you safe and well-rested no matter what kind of travel you choose—business, pleasure, or adventure.
TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardso...rightmanforbloodline
TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardson, Verified Chapters 1 - 18, Complete Newest Version
TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardson, Verified Chapters 1 - 18, Complete Newest Version
TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardson, Verified Chapters 1 - 18, Complete Newest Version
Healthy Eating Habits:
Understanding Nutrition Labels: Teaches how to read and interpret food labels, focusing on serving sizes, calorie intake, and nutrients to limit or include.
Tips for Healthy Eating: Offers practical advice such as incorporating a variety of foods, practicing moderation, staying hydrated, and eating mindfully.
Benefits of Regular Exercise:
Physical Benefits: Discusses how exercise aids in weight management, muscle and bone health, cardiovascular health, and flexibility.
Mental Benefits: Explains the psychological advantages, including stress reduction, improved mood, and better sleep.
Tips for Staying Active:
Encourages consistency, variety in exercises, setting realistic goals, and finding enjoyable activities to maintain motivation.
Maintaining a Balanced Lifestyle:
Integrating Nutrition and Exercise: Suggests meal planning and incorporating physical activity into daily routines.
Monitoring Progress: Recommends tracking food intake and exercise, regular health check-ups, and provides tips for achieving balance, such as getting sufficient sleep, managing stress, and staying socially active.
We are one of the top Massage Spa Ajman Our highly skilled, experienced, and certified massage therapists from different corners of the world are committed to serving you with a soothing and relaxing experience. Luxuriate yourself at our spas in Sharjah and Ajman, which are indeed enriched with an ambiance of relaxation and tranquility. We could confidently claim that we are one of the most affordable Spa Ajman and Sharjah as well, where you can book the massage session of your choice for just 99 AED at any time as we are open 24 hours a day, 7 days a week.
Visit : https://massagespaajman.com/
Call : 052 987 1315
At Apollo Hospital, Lucknow, U.P., we provide specialized care for children experiencing dehydration and other symptoms. We also offer NICU & PICU Ambulance Facility Services. Consult our expert today for the best pediatric emergency care.
For More Details:
Map: https://cutt.ly/BwCeflYo
Name: Apollo Hospital
Address: Singar Nagar, LDA Colony, Lucknow, Uttar Pradesh 226012
Phone: 08429021957
Opening Hours: 24X7
About this webinar: This talk will introduce what cancer rehabilitation is, where it fits into the cancer trajectory, and who can benefit from it. In addition, the current landscape of cancer rehabilitation in Canada will be discussed and the need for advocacy to increase access to this essential component of cancer care.
Can Allopathy and Homeopathy Be Used Together in India.pdfDharma Homoeopathy
This article explores the potential for combining allopathy and homeopathy in India, examining the benefits, challenges, and the emerging field of integrative medicine.
Can Allopathy and Homeopathy Be Used Together in India.pdf
Doctor worst fear:Credentials and Privileges by Dr.Mahboob ali khan Phd
1. 1
Doctor worst fear: Credentials and Privileges
By Dr.Mahboob ali khan Phd
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.
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," I reiterate.
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,"I define.
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. I say "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.
2. 2
Determining Quality "When implemented, the processes will ensure that there
is consistency in the application of methods"
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," I strongly says.
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," I suggests.
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," I reiterate.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," I strongly suggests.
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," I suggests.
The only way to objectively determine the qualifications of physicians for
patient care and specialised services is to obtain information about their
3. 3
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," I 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," I have seen.
The Process
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," I say.
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
4. 4
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," I suggests.
5. 5
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," I
think.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," I think.
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.
6. 6
All for Quality
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.
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," I enumarites.During the verification process with a primary
source, the hospital often does not get an appropriate or immediate response
7. 7
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,"
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," I
reiterate.
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," I opines.
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,"
I reiterates.
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,"I opines.
8. 8
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," I predicts.
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," I strongly reiterate.