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New quality framework for medical profession

Media Release Thursday 15 March 2001

Health Ministry introducing new quality framework for medical profession

A new quality framework for clinical practice is being introduced for public hospitals by the Ministry of Health.

The Health Ministry expects its new national framework for credentialling senior medical officers will improve the quality and safety of medical and surgical services on offer in New Zealand's hospitals.

The new framework, "Toward Clinical Exellence: A Framework for the Credentialling of Senior Medical Officers in New Zealand" was released today as part of the Health Ministry's ongoing quality improvement programme.

Director-General of Health, Dr Karen Poutasi, says credentialling applies to all health professionals, and that it will support and protect them as well as patients. The first stage has been to work with clinical leaders to develop a common approach to credentialling senior medical officers.

There are about 4000 senior medical officers, including physicans and surgeons, who belong to about 95 specialist professional colleges. They work as hospital specialists and consultants for District Health Boards.

"Credentialling will be used by hospitals within District Health Boards and focus on the clinical competence of their doctors and surgeons within a specific hospital environment. The DHBs have been asked to make implementing credentialling a priority. Some District Health Boards have already seen the importance of this framework and are well down the track introducing it. Each of the DHBs will develop their own credentialling system based on the national framework.

"DHBs as employers are responsible for ensuring that their people are competent to do the job they are required to do. Everyone expects a safe service from medical professionals. Credentialling means that patients can be more certain surgeons and physicians have the appropriate training, qualifications, and experience. For example, someone who does knee replacements might not have the credentials to do spinal surgery, or a doctor who is credentialled within a big city hospital may not be credentialled for the environment of a small rural hospital.

"The credentialling framework will build on existing requirements. It will involve peer review, clinical audits, and enhance the clinical quality improvement activities which are already part of our systems.

"The framework is the result of comprehensive consultation with medical and nursing colleges professional groups especially nurses, hospital chief executives, consumer groups and other stakeholders and has been well supported by them. This model has international significance. I expect that the credentialling model we have developed may be used overseas as well.

"Credentialling will not eliminate human error. It will identify and monitor clinical competence within a given scope of practice. It protects both practitioners and patients. It has been well supported by all the professional clinical organisations."

Copies of the document are available on the Ministry of Health website:

For more information contact: Christine Field, Communications, Ministry of Health, ph 04 496 2115 Dr Robert Logan, Chair, Medical Advisors Group, ph 04 566 6999 Dr Peter Leslie, Council of Medical Colleges of New Zealand, ph 04 460 8124 Susan Pattullo, Communications, Medical Council of New Zealand ph 04 381 6782 John Harvey, Press Secretary, Minister of Health ph 04 471 9305

Backgrounder follows


Toward Clinical Excellence: A Framework for the Credentialling of Senior Medical Officers in New Zealand. 14 March 2001

Toward Clinical Excellence: A Framework for the Credentialling of Senior Medical Officers in New Zealand completes the work commenced by the Health Funding Authority in response to a recommendation by the Health and Disability Commissioner in the report on Canterbury Health. A credentialling system for senior medical officers in public hospitals consistent with the framework described in the document will be a requirement for publicly funded service provision by June 2002.

1. Credentialling is a relatively new concept to the New Zealand health sector and its development to date has focused on senior medical officers in public hospitals. The purpose of credentialling is to protect patients by carefully defining the clinical responsibilities of practitioners. In so doing it also protects District Health Boards (DHBs) which are requred to ensure that appropriate systems are in place to manage service quality.

2. 'Credentialling' in the New Zealand context is defined as: a process used to assign specific clinical responsibilities (scope of practice) to health professionals on the basis of their training, qualifications, experience and current practice, within an organisational context. This context includes the facilities and support services available and the service the organisation is funded to provide. Credentialling is part of a wider organisational quality and risk management system designed primarily to protect the patient.

3. Credentialling is an employer responsibility with a professional focus that commences on appointment and continues throughout the period of employment. Credentialling protects patients by carefully defining the scope of practice for senior medical officers within the organisation

4. The central purpose of any quality initiative in health care must be to improve health outcomes for patients. Credentialling does this by clearly defining and monitoring practitioner competence within a given scope of practice. In so doing it also protects the practitioner and the employer. The organisation demonstrates a proactive approach towards their responsibility to be accountable for the actions of practitioners they employ. In turn practitioners are supported to work within and develop their level of competence in a particular setting or service environment.

5. Credentialling of health professionals is just one of the tools an organisation can use to improve the quality of patient care and needs to be viewed within this context. As such, it supports the 'clinical governance' approach promoted by the British National Health Service (NHS) and which is increasingly being discussed in New Zealand where:

Organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which clinical excellence will flourish (NHS 1999/065:6)

6. The Medical Credentialling Project commenced in 1999 with a Health Funding Authority (HFA) study to describe the development of the credentialling process in Hospital and Health Services (HFA 1999). At that time only three of the 22 Hospital and Health Services had a process in place. In response to the recommendations made in that report, the Medical Credentialling Working Party was established, jointly sponsored by the HFA and the Ministry of Health. The Working Party's task was to assist clinical leaders to develop a common approach to the credentialling of senior medical officers, focusing on framework development and implementation issues, and collecting the available 'best practice' information.

7. One of the notable features of this project has been the readiness with which organisations and individual practitioners in the sector have engaged in the debate about credentialling. The task is complex and there are no models available internationally that can be readily applied to New Zealand. In addition, the timeframe from planning through to implementing the process is lengthy ? somewhere around two to three years. The support of organisations that had commenced a credentialling process prior to the development of the credentialling framework has been particularly helpful. Not only have they shared their experience and expertise, but they have also been prepared to address the issues raised by the Working Party in their own process development.

8. Credentialling is an employer responsibility with a professional focus, which commences on appointment and continues throughout the period of employment. This professional focus transcends purely organisational boundaries, making the contribution of medical colleges, specialist societies and the Medical Council an integral part of the process. Credentialling complements the Health Professionals Competency Assurance Bill, which focuses on the scope of practice defined by the professional body responsible for the registration and licensing of senior medical officers, the Medical Council of New Zealand.

10. The implementation of credentialling for senior medical officers within publicly funded provider organisations has been identified as a priority to improve patient safety and public confidence in the health system. The December 2000 Planning Signal sent to Hospital and Health Services by the Ministry of Health through the HHS National Service Framework Project requires District Health Boards to have a credentialling process in place for public hospitals by June 2002.

11. Credentialling implementation will be by 'evolution' not 'revolution'. Putting in place a credentialling process will not eliminate the occasional medical error. It will help to manage this risk by identifying both systems errors and individual practitioners who are developing a pattern of poor performance. Similarly, credentialling will not eliminate those very few practitioners who deliberately attempt to defraud the system. The credentialling process relies largely on the ability of practitioners to engage actively in self and peer assessment. It takes a quality improvement rather than disciplinary approach, where practitioners actively participate in the process as part of professional accountability.

12. The main aim of credentialling is to improve outcomes for patients. However, practitioners are sometimes uncertain about the purpose of involving patients or members of the public in clinical quality improvement activities. Public confidence in the health and disability system has been undermined by cases such as the recent Ministerial Inquiry into the Under-Reporting of Cervical Smear Abnormalities in Gisborne. Internationally, the same concerns are evident, with a recent British Medical Journal (BMJ 18 March 2000) dedicating an entire issue to reducing error and improving safety in medicine. The ease with which public input is incorporated into the credentialling process will depend on a number of factors, some related to practitioner acceptance and some outside the control of the practitioners who manage the process. However, it is imperative that New Zealand has systems in place to reassure consumers about the quality of health care they can expect from the public health system.

13. Credentialling has relevance for all health professionals and the principles are generic, although the process may differ between professions. Currently the Nursing Council of New Zealand is developing a competency assurance framework that includes credentialing. Other professional groups are expected to develop models over time.

14. Quality Health New Zealand, which provides health service accreditation, requires organisations to have a credentialling process in place. Other quality certification programmes do not have specific requirements for credentialling. A national standard for credentialling of senior medical officers is yet to be developed and no decision has been made as to which agency should audit this standard. The priority now is to assist hospitals that are in the process of implementing a credentialling system.

15. Credentialling has relevance to all professional groups in health care, but it is not the purpose of the document to describe a generic system. The focus of the Working Party and this document is the medical profession; specifically, senior medical officers in public hospitals. For most groups outside the medical profession the more immediate concern is for development in two areas: the ability to require evidence of practitioner competence as a prerequisite for the issue of practicing certificates and the development and formalisation of professional sub-specialisation. Some aspects of these developments will require empowerment through the Health Practitioners Competency Assurance Bill.

16. There are three practical reasons why a shared approach to the credentialling of senior medical officers in public hospitals is advantageous: a) It will assist in the development of a national approach to clinical quality improvement for practitioners. b) There may be some ability to transport information about credentialled status from one organisation to another, thereby simplifying initial credentialling of practitioners on subsequent appointment. c) It will assist in developing a process that can be audited nationally - an expectation of Health and Disability Sector Standard implementation.

17. Credentialling is more specific than vocational registration; both in terms of the skills and scope of practice that is organisation specific, and in relation to a particular timeframe (the period between reviews). While information about the credentialled status of a practitioner in one organisation could be made available to another as part of an appointment process, it is an organisation specific finding. Each organisation must make its own decision about the credentialled status of practitioners they employ.

18. The New Zealand Health Strategy directs public health care providers to focus on improving the quality of health care and health outcomes for patients. It also outlines what the public can expect from the health system in terms of consultation and assurance of the quality of services provided. Credentialling will assist in achieving these objectives.

19. The development of a national framework for credentialling senior medical officers in New Zealand is an initiative that was requested by Hospitals and Health Services in the 1999 HFA credentialling study. This request has been supported and co-ordinated by the central agencies, initially by the HFA and now by the Ministry of Health.

20. Each public hospital is required to develop and progressively implement a system to credential senior medical officers consistent with this framework, and to develop documented policies and procedures to be implemented by June 2002. While some resources will be made available to assist in this process, the responsibility lies with the DHBs. The credentialling framework provides a structure that allows for adaptation to meet local requirements. This ability to develop local policy was requested by practitioners and managers and supported by the working party. However, policy development can be time- and resource-intensive, often requiring broader debate on organisational philosophy in such areas as the relationship between practitioners and managers, the role of the public and the place of quality improvement in service provision. These issues are much broader than credentialling.

21. A credentialling system for senior medical officers in public hospitals consistent with the framework described in this document will be a requirement for publicly funded service provision by June 2002. It is expected that organisations will actively engage in developing a local credentialling process within the framework described in this document.

22. The framework for the credentialling of senior medical officers in public hospitals provides a template for credentialling. DHBs will use this framework to develop local policy. A key message to all DHBs is that for credentialling to succeed practitioners must accept and become actively involved in this process. This requires a partnership between practitioners and managers. It also requires organisational prioritisation of clinical quality improvement activities, of which credentialling is a part.

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