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Check-ins: The Importance of Performance Reviews to the Hospital Credentialing Process

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Physicians (as well as dentists, midwives and some NPs) working at hospitals in Ontario must undergo an annual credentialing process to receive privileges.  The initial application process to consider a new physician brings with it the highest levels of scrutiny. Subsequent renewals of physician privileges are perceived as more of a formality and sometimes even a nuisance.

Hospitals beware! The passive annual renew of privileges without any scrutiny of a physician’s performance can pose problems.  If a physician presents problems, there is often a lack of foundation upon which to justify the denial of the privileges renewal application. If years have gone by without documenting and addressing low level (or worse) behavioural, competence, or resource utilization problems – trying to take action can lead to privileging disputes and even litigation.

We recommend that hospital Chiefs conduct annual performance reviews for all professional staff in their department or division.

An application for reappointment that goes to the Medical Advisory Committee and hospital Board for consideration should contain feedback from the Chief. That feedback should be thoughtful and deliberate, as it is afforded significant weight.

Performance reviews can take many forms:

  • Ideally, there is a discussion at least once per year between the Chief and each professional staff member. Also ideally, there is an opportunity for the professional staff to share their successes and respond to any concerns.
  • Otherwise, a performance review could be a written review of the member’s credentialing file or the Chief’s notes to file to review compliments, concerns or complaints about the member that have arisen in the year.
  • The review could include conversations with other departmental or divisional leaders including identifying professional staff who are succeeding and the ones who are struggling (if any).

Note, if there have been concerns with a physician, those concerns should be addressed as they arise during the year. Problems should not wait until performance review time. At the time of re-appointment, the Chief must reassess those concerns and decide whether there is anything giving rise to the need to reconsider the member’s duties, privileges and relationship with the hospital. Chiefs must get advice before taking any action to restrict a member’s activities within the hospital.

Acknowledging that some hospitals have hundreds of physicians, performance review time can be daunting.  To combat overload, some hospitals institute “major” and “minor” reappointment processes.

  • If there are no major successes or problems identified, professional staff go through a “minor” reappointment process that is expedited. So long as the individual continues to meet the criteria for reappointment, the individual’s application is supported.
  • But every few years, on a rotating basis to reduce the numbers, every member of the professional staff undergoes a “major” review which includes a more formal performance review and higher level of attention and scrutiny to the member’s successes and challenges. This ensures that a hospital takes the opportunity to connect with each member of the professional staff and hear from them directly. That contact creates opportunities for the hospital to learn about its staff and to protect against low level problems that overtime undermine patient safety, collegiality and efficiency.

Not sure what Chiefs should be thinking about during performance reviews? Here are our suggestions:

  • Have there been any compliments or complaints regarding the staff member’s bedside manner, competence, use of hospital resources or collegiality?
  • Have there been any accomplishments of note? Should these be brought to the attention of the Credentials Committee or Medical Advisory Committee?
  • Have there been any concerns relating to the staff member’s occupational health and safety practices, competence, capacity or conduct?
  • Have there been any academic accolades or problems?
  • Have there been any research achievements or concerns?
  • Have there been any regulatory college reports about the professional staff member?
  • Has the staff member demonstrated an ability to:
  1. provide patient care at an appropriate level of quality and efficiency;
  2. work and communicate with, and relate to, others in a cooperative, collegial and professional manner;
  3. communicate with, and relate appropriately to, patients and patients’ relatives and/or substitute decision makers;
  4. participate in the discharge of staff, committee and, if applicable, teaching responsibilities, and other duties appropriate to staff category;
  5. communicate satisfactorily in English both orally and in writing;
  6. meet an appropriate standard of ethical conduct and behaviour;
  7. govern themselves in accordance with the requirements set out in the hospital’s Bylaws, mission, vision and values, Rules and Regulations and Policies?

Interested in more privileging content? The Ontario Hospital Association’s 2021 Professional Staff Credentialing Toolkit is chock full of amazing content. And it is FREE!


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