British Columbia Ministry of Health Provincial Review of Licensure, Credentialing, Privileging, Monitoring and Enhancement of Performance

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British Columbia

Ministry of Health –

Provincial Review of

Licensure,

Credentialing,

Privileging,

Monitoring and

Enhancement of

Performance

FINAL REPORT

October 2012

ADVISORY SERVICES
kpmg.ca

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Ministry of Health
Provincial Review of Physician Licensing, Credentialing, Privileging & Performance Management

© 2012 KPMG LLP, a Canadian limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative

Disclaimer

This document has been prepared for the British Columbia Ministry of Health’s Ministry Action Team and may not be edited, distributed, published, made
available or relied on by another person without KPMG LLP’s (KPMG) express written permission.

KPMG will not assume any responsibility or liability for damages or losses by anyone as a result of the circulation, publication, reproduction or use of this
document contrary to the provision of this disclaimer.

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Ministry of Health

Table of Contents

GLOSSARY

 

OF

 

ABBREVIATIONS

 

1

 

GLOSSARY

 

OF

 

KEY

 

TERMS

 

2

 

CHAPTER

 

1:

 

EXECUTIVE

 

SUMMARY

 

3

 

B

ACKGROUND

 

3

 

S

COPE

 

3

 

A

PPROACH

 

4

 

U

NDERSTANDING THIS REPORT

 

4

 

K

EY OBSERVATIONS

 

5

 

S

UGGESTIONS FOR 

I

MPROVEMENT

 

8

 

A

CCOUNTABILITY

 

8

 

R

OLE OF THE 

C

OLLEGE AND 

HA

S

 

10

 

C

LINICAL LEADERSHIP

 

12

 

F

UTURE 

S

TATE

 

13

 

A

CKNOWLEDGEMENT

 

13

 

CHAPTER

 

2:

 

REPORT

 

STRUCTURE

 

AND

 

BACKGROUND

 

14

 

U

NDERSTANDING THIS REPORT

 

14

 

R

EPORT STRUCTURE

 

15

 

B

ACKGROUND FOR THE REVIEW

 

16

 

T

ERMS OF OUR ENGAGEMENT

 

17

 

O

UR WORKPLAN FOR COMPLETING THIS REVIEW

 

18

 

 

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Ministry of Health

CHAPTER

 

3:

 

ROLES

 

OF

 

KEY

 

ORGANIZATIONS

 

IN

 

PHYSICIAN

 

LICENSING,

 

CREDENTIALING,

 

PRIVILEGING

 

AND

 

PERFORMANCE

 

MANAGEMENT

 

21

 

T

HE 

M

INISTRY OF 

H

EALTH

 

21

 

T

HE 

C

OLLEGE OF 

P

HYSICIANS AND 

S

URGEONS OF 

B

RITISH 

C

OLUMBIA

 

22

 

H

EALTH 

A

UTHORITIES AND 

D

ENOMINATIONAL 

F

ACILITIES

 

23

 

M

EDICAL EDUCATION BODIES

 

24

 

CHAPTER

 

4:

 

THE

 

MINISTRY’S

 

RESPONSE

 

TO

 

DR.

 

COCHRANE’S

 

REPORT

 

25

 

R

EVIEW OF THE PROVINCIAL SYSTEM

 

26

 

P

ROVINCIAL 

P

HYSICIAN 

R

EGISTRY

 

26

 

P

ROVINCIAL 

C

REDENTIALING 

&

 

P

RIVILEGING 

P

ROJECT

 

27

 

P

ROVINCIAL 

C

ORE 

D

ATA 

S

ET

 

27

 

P

ROVINCIAL 

P

ERFORMANCE 

A

SSESSMENT 

R

EVIEW

 

27

 

R

ADIOLOGY 

P

EER 

R

EVIEW

 

27

 

A

CCOUNTABILITY FOR 

DF

S

 

28

 

A

DVERSE 

E

VENT 

P

ROTOCOL

 

28

 

CHAPTER

 

5:

 

OUR

 

FINDINGS

 

 

LICENSING

 

29

 

K

EY OBSERVATIONS

 

29

 

R

OLE OF THE KEY ORGANIZATIONS

 

29

 

C

OMMUNICATION

 

29

 

G

OVERNANCE 

&

 

A

CCOUNTABILITY

 

30

 

P

ROCESS

 

30

 

T

ECHNOLOGY

 

31

 

L

EARNING FROM OTHER JURISDICTIONS

 

31

 

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Ministry of Health

CHAPTER

 

6:

 

OUR

 

FINDINGS

 

 

CREDENTIALING

 

&

 

PRIVILEGING

 

34

 

K

EY OBSERVATIONS

 

34

 

R

OLE OF ORGANIZATIONS

 

35

 

C

OMMUNICATION

 

35

 

G

OVERNANCE 

&

 

A

CCOUNTABILITY

 

36

 

P

ROCESS

 

38

 

T

ECHNOLOGY

 

39

 

L

EARNING FROM OTHER JURISDICTIONS

 

40

 

CHAPTER

 

7:

 

OUR

 

FINDINGS

 

 

PERFORMANCE

 

MANAGEMENT

 

42

 

K

EY OBSERVATIONS

 

42

 

R

OLE OF ORGANIZATIONS

 

43

 

C

OMMUNICATION

 

45

 

G

OVERNANCE 

&

 

A

CCOUNTABILITY

 

46

 

P

ROCESS

 

47

 

T

ECHNOLOGY

 

48

 

L

EARNING FROM OTHER JURISDICTIONS

 

48

 

CHAPTER

 

8:

 

SUGGESTIONS

 

FOR

 

IMPROVEMENT

 

AND

 

SUGGESTED

 

FUTURE

 

STATE

 

51

 

S

UGGESTIONS FOR 

I

MPROVEMENT

 

51

 

A

CCOUNTABILITY

 

51

 

R

OLE OF THE 

C

OLLEGE AND 

HA

S

 

57

 

C

LINICAL LEADERSHIP

 

61

 

F

UTURE 

S

TATE

 

62

 

 

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Ministry of Health

APPENDIX

 

A:

 

OVERVIEW

 

OF

 

LICENSING,

 

CREDENTIALING,

 

PRIVILEGING

 

AND

 

PERFORMANCE

 

MANAGEMENT

 

PROCESSES

 

64

 

L

ICENSING

 

64

 

C

REDENTIALING AND PRIVILEGING

 

67

 

P

ERFORMANCE MANAGEMENT

 

76

 

APPENDIX

 

B:

 

PROCESS

 

MAPS

 

FOR

 

INITIAL

 

PRIVILEGING

 

APPOINTMENTS

 

79

 

APPENDIX

 

C:

 

PROCESS

 

MAPS

 

FOR

 

PRIVILEGING

 

RE

APPOINTMENTS

 

86

 

APPENDIX

 

D:

 

CREDENTIALING

 

STANDARDS

 

93

 

APPENDIX

 

E:

 

US

 

DATA

 

BANK

 

DETAILS

 

95

 

APPENDIX

 

F:

 

BOARD

 

DIRECTIVES

 

ON

 

PEER

 

REVIEW

 

97

 

APPENDIX

 

G:

 

REVIEW

 

ASSESSMENT

 

FRAMEWORK

 

99

 

APPENDIX

 

H:

 

HOSPITAL

 

ONLINE

 

SURVEY

 

&

 

SUMMARY

 

OF

 

RESULTS

 

106

 

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Ministry of Health 1

Glossary of Abbreviations

Abbreviation Full Name Abbreviation Full Name

ABMS American Board of Medical Specialties NHA Northern Health Authority

AHS Alberta Health Services NHMSF Non-Hospital Medical Surgical Facility

AIT Agreement on Internal Trade NPDB National Practitioner Databank (U.S.)

BC/the Province The Province of British Columbia NQSIP National Surgical Quality Improvement Program

BCLP British Columbia Locum Program PAR Physician Achievement Review

BCMA British Columbia Medical Association PHSA Provincial Health Services Authority

CFPC College of Family Physicians of Canada Providence Providence Health Care (BC)

CEO Chief Executive Officer PSSAC Physician Services Strategic Advisory Committee

CME Continuing Medical Education QA Quality Assurance

CMO Chief Medical Officer RAF Review Assessment Framework

CMPA Canadian Medical Protective Association Royal College Royal College of Physicians and Surgeons of Canada

CPC Certificate of Professional Conduct UBC University of British Columbia

College College of Physicians and Surgeons of British Columbia VCHA Vancouver Coastal Health Authority

DAP Diagnostic Accreditation Program VIHA Vancouver Island Health Authority

DF Denominational Facility VP Med Vice President Medicine

FHA Fraser Health Authority

GMC General Medical Council (UK)

GP General Practitioner

HA Health Authority

HACC Health Authority Credentials Committee

HAMAC Health Authority Medical Advisory Committee

HIPDB Healthcare Integrity and Protection Databank

HPA Health Professions Act

HR Human Resources

IHA Interior Health Authority

IMG International Medical Graduate

JCAHO Joint Commission on Accreditation of Healthcare
Organizations (US)

MAC Medical Advisory Committee

MAO Medical Affairs Office

MCC Medical Council of Canada

Minister The Minister of Health (BC)

Ministry Ministry of Health (BC)

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Ministry of Health 2

Glossary of Key Terms

To provide a greater understanding of the meaning of the key terms used for this engagement, the following definitions were generated and approved by the
Ministry:

Licensing: The process whereby an authorized regulatory body issues a permit to practice medicine.

Credentialing: An approach to obtaining, verifying and assessing against consistent criteria the qualifications of a physician for the purposes of licensing
and/or privileging.

Privileging: The process whereby an authorized body permits a specific scope and content of patient care services to a health care practitioner based
upon:

A standardized evaluation, typically beyond that required for licensure purposes, of a practitioner’s training, experience and competence related to
the delivery of specific services; and

A defined practice setting with its associated service needs, support infrastructure, patient mix, etc.

Performance management: An ongoing evaluation, including formative and summative assessments, of a physician’s quality of care, conduct, clinical
competencies, compliance with regulations, by-laws, rules and standards, and individual practice performance improvement.

Stewardship: The role of government in formulating strategic policy directions, generating intelligence, exerting influence through regulation and
ensuring accountability1.

1 Travis, P., D. Egger, P. Davies and A. Mechbal. 2003. “Towards Better Stewardship: Concepts and Critical Issues.” In C.J.L. Murray and D.B. Evans, eds., Health Systems

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Ministry of Health 3

Chapter 1: Executive Summary

Background

In late 2010 and early 2011, problems were identified with the quality of radiology image interpretations within three Health Authorities (HAs) in British Columbia
(BC/the Province). Dr. Doug Cochrane, Provincial Patient Safety and Quality Officer and Chair of the BC Patient Safety & Quality Council, conducted a review of
these incidents and reported a number of issues and gaps in oversight and performance management of radiologists. As part of its response to Dr. Cochrane’s
report, the Ministry of Health (the Ministry) engaged KPMG LLP (KPMG) to conduct a review of systems and processes for the licensing, credentialing, privileging
and performance management of all physicians across the Province.

Scope

We agreed the following scope of the review:

1. The systems and processes of the College of Physicians and Surgeons of British Columbia (the College) in licensing physicians to practice medicine in
British Columbia, including procedures and policies for special categories of licensure;

2. The systems and processes of the HAs in credentialing, privileging and monitoring the performance of physicians. This included a review of HA bylaws,
rules and policies as well as a review of processes and procedures in a sample of facilities from across the Province in metro, urban and rural settings;
3. The regulatory framework for ensuring the quality and competence of physicians including, but not limited to, a review of the Health Professionals Act;

and

4. The effectiveness of BC’s approach to licensing, credentialing, privileging, monitoring and enhancing performance for physicians compared to other
Canadian jurisdictions and against evidence-based best practices.

KPMG sub-contracted with the law firm Osborne Margo to complete the legal and regulatory review in conjunction with our work. That report summarizes the
legal framework for physician regulation in BC and identifies key issues regarding BC’s current regulatory framework. The report also includes a summary of the
physician regulatory frameworks in Alberta, Saskatchewan and Ontario. While we quote the Osborne Margo report in the context of our findings, their report has
been submitted as a stand-alone document.

As an extension to the original scope, the Ministry requested that KPMG provide commentary on all the initiatives underway and link progress with our
suggestions for improvement.

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Ministry of Health 4

Approach

We agreed the following key deliverables in our approach with the Ministry to frame the work we would undertake to review existing processes for licensing,
credentialing, privileging, physician performance monitoring and peer review in BC at the College, the Ministry, HAs and hospitals:

Development of a project charter and work plan;

Development of a Review Assessment Framework (RAF);

Final report with summary of findings and advice; and

Final report presentation to the Ministry Action Team.

Given the time and resources available for this review, we agreed with the Ministry that we would focus our attention on the acute care sector and, in a more
limited way, private Non-Hospital Medical Surgical Facilities (NHMSFs) in the Province. Specifically we agreed that we would not examine practices within other
areas of the health care system such as community provision, mental health services or long-term care.

Understanding this report

The purpose of this report is to outline certain matters that came to our attention during our work and to offer our comments and suggestions for improvement
for the Ministry’s consideration. These comments, by their nature, are critical, as they relate solely to opportunities for enhancement and do not address the
many positive features of the Ministry’s current activities and undertakings.

Our procedures consisted of inquiry, surveying, and analysis of information provided by the Ministry, the College and HAs. The Ministry approved the interview
list and the extent of the other materials provided by project participants. Such work does not constitute an audit. Accordingly, we express no opinion on
processes, other information or internal controls.

The evidence that supports our suggestions for improvement has been gathered through completed questionnaires, interview feedback and other comments,
explanations and information received during our work. We are not responsible for this evidence; the sole responsibility lying with those who provided us with
information and those we interviewed or otherwise interacted with during this review.

Our findings arise from our enquiries, although we can provide no assurance as to the day-to-day operation of either those procedures reviewed or issues relating
to physician licensing, credentialing, privileging and performance management in general. KPMG assumes no responsibility for our findings and we have not
attempted to establish whether the issues raised in the report are pervasive, commonplace or rare; the issues raised are merely those that occurred during the
course of our interviews and other work. All procedures covered in this report are dependent for their effectiveness on the diligence and propriety of those
responsible for operating them and are capable of being overridden by persons holding positions of authority and trust.

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Ministry of Health 5
We have not graded our suggestions for improvement and have not sought to emphasize their importance in any way. Our report has been factually checked by
the Ministry and senior clinicians, as well as all members of the Ministry Action Team and VP Medicines, or equivalent, at all HAs.

The Ministry is responsible for the decisions to implement any recommendations and for considering their impact. Implementation of these opportunities will
require the Ministry to plan and test any changes to ensure that the Ministry will realize satisfactory results.

Key observations

Licensing

The Provincial Physician Registry project being undertaken by the Ministry Action Team will assist in helping structure information on licensing and will make it
easier for information on restrictions on physician licenses to be made more readily available across the healthcare system.

We make the following key observations in respect of licensing:

The College has a robust and sound system for processing applications to be licensed in BC;

The Federation of State Medical Boards in the US has a universal database that contains information on any disciplinary procedure across the US since
the 1960s. BC would benefit from a similar system across Canada that incorporates standardization of aspects of the Agreement on Internal Trade; and

The UK system of revalidation requires all doctors to demonstrate their licenses are up to date and their ongoing fitness to practice through five years of

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Ministry of Health 6

Credentialing and Privileging

The replacement of the current paper-based system for reappointment of privileges through the Provincial Physician Registry system will address many of the
identified issues and gaps identified. It will also assist in better structuring information on privileging, along with the Provincial Core Data Set project. The
Provincial Credentialing and Privileging project will be key to advancing the debate on the establishment of Province-wide standards and the creation of definitions
for use in privileging across the Province.

We make the following key observations in respect of credentialing and privileging:

The current BC Locum Program registry has potential to be used inappropriately as some physicians could view it as a license to practice without
formally obtaining privileges

The College currently plays a statutory role in reviewing credentials for physicians seeking privileges for restricted activities. Most stakeholders agreed
this was not an appropriate role for the College given the amount of due diligence already conducted by the HAs, although it will require a change in
statute to correct;

There is no common definition for ‘credentialing’ and ‘privileging’ within the system and they are used interchangeably, creating confusion;

There are no independent checks that privileging processes are being followed in HAs;

Few HAs have Board approved minimum standards that contain definitions for expectations of the minimum number of years experience/number of
procedures regularly performed and any standards that are defined are not standardized across the Province;

Duties need to be better segregated, especially within smaller facilities;

The structure for regular physician reviews is inconsistent across and within HAs;

The time taken to formally approve privileges is sometimes too long and results in significant use of the granting of temporary privileges; and

Local processes could be streamlined to reduce the number of steps in the credentialing and privileging process.

Our work also identified the following leading practices in credentialing and privileging in BC:

Independent Director participation in the Credentials Committee and Health Authority Medical Advisory Committee (HAMAC) at Vancouver island health
Authority (VIHA);

Department Heads meet with all physicians at Vancouver Coastal Health Authority (VCHA) and Provincial Health Services Authority (PHSA) during the
re-appointment process; and

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Ministry of Health 7

Performance Management

The Provincial Performance Assessment Review project due to be undertaken by the Ministry will provide the opportunity for the system to address the issues
raised in our report and will provide the platform for feedback and wider rollout of the Radiology Peer Review and Support project and the Accountability for
Denominational Facilities (DFs) project.

We make the following key observations in respect of performance management:

Stakeholders interviewed stated they would like the Ministry to prioritize performance metrics and provide standardized performance measurement
tools;

Our review identified a consistent theme that the College is perceived to have an advocacy role for physicians although our investigations showed this
not to be the case. Any perception was refuted by College Board members;

Our review found that clinical leadership needs to be addressed across the system, especially the role and function of the Chief of Staff;

Communication gaps exist across the system, resulting in inconsistent or poor information flows;

Stakeholders across the Province acknowledged that the collaborative approach demonstrated by the Registrar and her colleagues over the last year
have improved their impressions of the College as a partner in strengthening the system;

The value and importance of good performance management was a common theme in our interviews and stakeholders stated that the focus of
performance and peer reviews needs to be aligned to improvement agenda and not viewed as confrontational;

The College and HAs could share more performance information and participate in a more structured system-wide discussion of performance issues;
and

The Physician Achievement Review in Alberta and the Revalidation process in the UK allow for regular (typically 5 year) reviews of all physicians and 360
degree surveys that assist in the monitoring and focus of physician performance have been adopted in the US.

Our work also identified the following leading practices in performance management of physicians in BC:

PHSA has adopted a pilot program to assist in training and supporting Department Heads; and

Staff at PHSA have a mandatory 360 degree review every three years.

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Ministry of Health 8

Suggestions for Improvement

Our findings indicate that there are a number of areas that need to be improved. When considering our suggestions for improvement we found that a number
were relevant to more than one of the three key areas of licensing, credentialing and privileging and performance management. Accordingly we have grouped our
suggestions for improvement under three headings:

Accountability;

Role of the College and HAs; and

Clinical leadership.

Our suggestions for improvement need to be put in context of the current workload of the Ministry and its perception of both the need and the extent for change.

Accountability

Aligning performance to contracts

The system of contracting with physicians within BC should be compared to other jurisdictions so that the pros and cons of changing the system could
be assessed within the context of making physicians more accountable for their performance and encouraging greater levels of self- and
peer-assessment. Any changes should be addressed through medical by-laws or other mechanisms as appropriate. Options could include:

Mandate that annual appraisals form an integral part of the Medical Services Plan (MSP) process, potentially with physicians asking to self-certify
and the Ministry then performing central checks to ensure compliance, installing powers to suspend registration if physicians do not comply;

Introducing an element of performance-related bonus to award good quality, and alternatively a withdrawal of an element of pay for poor
performance;

Consider mandating HAs to hold MSP contracts for all procedures performed in their HA, thereby providing the opportunity for local input and
performance management into those areas that HAs consider most productive and effective; and

Mandate physicians move to central contracts with HAs and put in place appropriate support and Human Resources (HR) processes similar to other
professional staff groups.

Stewardship and management of HA Boards

The Ministry should review its wider role and define the extent to which it provides effective stewardship to the system by studying models from other
jurisdictions. Depending on the outcome of that review, the Ministry should assess the short-term and longer-term changes required so that a
framework for holding HA and DF Boards accountable for the implementation of policy directives and for physician governance and management in
particular can be developed, along with the associated reporting mechanisms.

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Ministry of Health 9

Executive accountability on HA Boards

The Ministry should review governance models in other jurisdictions to establish whether a case could or should be made for a different model of
governance within healthcare to reflect commercial leading practice and allow greater levels of direct accountability for Executive management. This may
be necessary especially if contractual accountability changes;

All HAs should establish an audit process through internal audit or another independent body to regularly review appointment and re-appointment
processes and compliance (we consider that clinical audit is not capable of performing such a review as they are not necessarily experts in process). The
Ministry should mandate HAs to perform this function and self-certify that they have complied with that mandate; and

Where HA Boards have identified clinical challenge as a weakness, they should be encouraged to consider how to augment their ability to challenge
clinically, potentially seeking to appoint an independent Medical Adviser mandated to specifically assist them gain comfort on the adoption of processes
and the performance management of physicians generally.

Province-wide reporting protocol

The College, HAs and DFs should share information to establish agreed definitions for the sort of issues or problems that indicate where physicians may
present a risk. Once defined, the size of the population of those physicians should be determined and used to establish the urgency of the timetable for
establishing a Province-wide performance management framework;

The Ministry should oversee the establishment of a Province-wide reporting protocol which should be agreed by the College, each HA and all DFs. The
protocol should outline what information related to performance should be provided, how it is to be provided, and when it should be provided. Moreover,
each layer of the system (Ministry, HAs, DFs, College) should define what data it requires and why, to establish robust information and systems required
for managing physician performance. Datasets from these deliberations can then be used to inform the development of the provincial information
system. This reporting protocol should also be incorporated into the model staff by-laws which are currently being developed;

The Ministry should consider whether the by-laws of the College need to be amended to reflect the need for certain performance information to be
shared with HAs to mirror the by-laws of Saskatchewan. This is critical to enable the system to respond to potential areas of public concern, especially
regarding the safety of patients;

The Ministry’s Legislation and Professional Regulation Branch should review the legislative amendments being proposed in Ontario to establish whether
the recommendations made by the College could be applicable in addressing the gaps identified in BC; and

The College should review the Pulse Program in more depth to ascertain how the processes contained within it could be brought into assisting with the
monitoring and processing of performance management concerns and the College’s own processes within BC.

Medical school participation in any new performance management framework

The Terms of Reference for each Joint Advisory Committee between the HAs and the University of British Columbia (UBC) should be amended to
include issues of performance management and remediation, including:

Discussing performance issues of residents in the HA; and

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Ministry of Health 10

HA systems for granting privileges

While a number of the initiatives launched by the Ministry in response to Dr. Cochrane’s report address some of the inefficiencies identified above, the
Ministry should mandate that HAs implement and effectively use the new systems being developed to minimize the risk of different levels of uptake in
different HAs;

Some of the recommendations may be processed by updating the medical staff by-laws within HAs. Any changes to the by-laws should be reviewed by
the Ministry’s Legislation and Professional Regulation Branch prior to HAs seeking to obtain Physician Services Strategic Advisory Committee (PSSAC) or
other approval so that the Ministry has the opportunity to consider the recommendations and has made decisions on the broader systemic issues;

The Ministry should provide structure to confirm that the new Physician Registry and Peer Review software systems are set up correctly from the

beginning, establishing:

The datasets required by all parties;

The right levels of functionality and reporting for all parties;

The ownership of the system and maintenance arrangements, with suitable methods of cross-charging for cost established; and

Governance arrangements, especially in relation to privacy of information, etc; and

The Physician Registry should have the datasets available to all stakeholders so that compliance with privileging and performance management
processes can be audited and levers so that the Ministry retains the right to withhold or suspend MSP status until and unless issues can be satisfactorily
resolved.

Systems for Provisional Registrants

The College and the Ministry should work together to review whether the system for continual review of Provisional Registrants should be adopted for
performance managing physicians identified as posing a risk.

BC Locum Program

The Physician Registry currently being developed should have the capability of identifying and tracking locums, and the Ministry’s registry through the
BC Locum Program should be discontinued once the new system is in place and working correctly.

Role of the College and HAs

Stronger role for the College

The Ministry should work with the College to agree the financial and organizational impact of any realignment of role. While some of that impact may be
derived from contributions to the College, other aspects may need to be agreed centrally.

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Ministry of Health 11

Enhancing the role of the College (1) – Provincial Performance Management Framework

The College should be an integral part of the new performance management framework. As this involves all organizations across the system and the
Ministry, we have included recommendations in the Accountability section above.

Enhancing the role of the College (2) – New technology and procedures

The College should be accountable for publishing, on a timely (perhaps annual) basis, a list of new technology and procedures with guidance on training,
standards and testing to inform the privileging process for those new developments. This work should be done in collaboration with the HAs and aligned
with the mandate and activities of the new Health Technology Assessment Committee being set up by the Ministry; and

The Tariff Committee rules should be amended to align with the process established by the College such that no fee, whether temporary, permanent or
otherwise, is granted until the appropriate supporting resources (i.e.: space, nursing staff, etc.) as well as minimum competency standards are
established.

Enhancing the role of the College (3) – Providing Minimum Standards for Credentialing

The College should be mandated to manage the current procurement for a Provincial Credentialing & Privileging technology solution and should take
responsibility for expediting the project completion timeline. A revised structure and timeline should be agreed with the Ministry and robustly
performance managed;

On an ongoing basis, the College (as the body that is consistent and is the most established and credible in terms of peer review and assessment) in
collaboration with the VP Meds of the HAs, should be mandated to be responsible for establishing and agreeing minimum credentialing standards for all
disciplines and report back progress to the Ministry and HA Boards as appropriate;

The College should report to the Ministry on how to best to engage the debate on standardizing credentialing and privileging definitions across Canada. It
is important that an action plan for that debate is constructed, including stakeholder maps and an analysis of the timeline (with associated local
performance management goals). Once systems are in place in BC, the College (with support from the Ministry) should seek to establish minimum
standards with other Colleges across Canada so that the system can have confidence in the work performed in other jurisdictions for doctors moving to
BC; and

The Ministry should consider engaging the public in a structured debate on standards across the Province to assess what services are acceptable to the
public and where the boundaries of the postal code medicine2 debate should be drawn. Before the question can be answered, the Ministry could assess
firstly whether the public should or could be consulted on acceptability of service, either in market research groups or more widely, and then work to
define acceptability to inform definitions of minimum standards (potentially by geography).

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Ministry of Health 12

Enhancing the role of the College (4) – Revalidation

The College should expedite its efforts in implementing a process for physician revalidation. The Ministry should consider timelines for the introduction
of revalidation, how to effectively performance manage the College if this task is mandated and establish an accountability framework for delivery and
rollout of the revalidation program.

Redefining the College’s stewardship of quality

The College needs to consider how it can engage with the system, especially the HAs, consulting with stakeholders and seeking to consolidate its
mandate and build greater awareness of the function of the College, its commitment to quality and to build the relationships and understanding that will
underpin the development of a performance management framework.

Realignment of the role of the College – Credentialing and privileging

Responsibility for credentialing for diagnostic imaging and non-hospital surgical medical facilities should be transferred to another organization. For this to
occur:

The Ministry needs to confirm that the entity that undertakes this responsibility are also signatories to the performance management framework
(see below) so that they have the ability to communicate and share concerns for NHMSFs across the system; and

All MSP-related activity for restricted activities should be performed through existing mechanisms;

The Ministry and College should work together to review whether the amendments being proposed in the Out-of-Hospital Premises Inspection Program
in Ontario could be applicable in addressing the gaps in NHMSFs in BC; and

The Ministry should consider the support the College requires to enable all of the above changes to take place. This would include providing independent
support to the Board as required and in establishing a plan for managing change.

Clinical leadership

The role of clinical leaders and their recruitment needs to be reviewed so that their role can be defined and standardized across the Province. The review
needs to consider how to make these roles attractive to the right leaders through a combination of various levers including remuneration, the bestowing
of real authority and the ability to contribute to the wider change agenda.

The Ministry should work with all HAs to agree clinical leadership models that can be installed across the Province, with physicians taking far greater
responsibility for the management of services and the modernization agenda generally. These models should then be linked to broader accountability
frameworks so that real local accountability and performance management structures can be agreed across the system, with escalation policies in place
that inform Boards and provide impetus to the service improvement agenda of all HAs.

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Ministry of Health 13

Future State

Centralization and standardization of structure

We were asked to consider whether a single, centralized process for licensing, credentialing, privileging and managing performance of physicians would be
beneficial and have concluded that the case for having a central organization manage the process has not been made, although our suggestions for improvement
identify where activities can be better aligned.

Continuum of future system improvement

Based on our analysis of the current system, our suggestions for improvement, learning from other jurisdictions and input from stakeholders throughout this
process, we have suggested a future-state view of how the system could be designed. This future state will be characterized by:

The Ministry performing a stronger stewardship role, with HA Boards and Executive Teams having greater accountability for physician performance
management and links made between physician payment and outcomes;

A stronger and more integrated role for the College, taking an enhanced leadership role in setting minimum standards for all physicians in BC and
realigning certain identified other responsibilities with HAs; and

Improved clinical leadership with clinical leaders being better supported in order to fulfill their role in managing the day-to-day activities of physicians.
We appreciate that reaching this end state vision will take time and will be informed by the work already underway through the eight projects being undertaken
by the Ministry Action Team, the suggestions for improvement in this report and the Osborne Margo review.

Acknowledgement

KPMG has appreciated:

The opportunity to serve the Ministry;

The excellent level of cooperation from the Ministry, the College and other stakeholders for pulling together background materials and their participation
in our interview and survey process; and

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Ministry of Health 14

Chapter 2: Report structure and background

Understanding this report

The purpose of this report is to outline certain matters that came to our attention during our work and to offer our comments and suggestions for improvement
for the Ministry’s consideration. These comments, by their nature, are critical, as they relate solely to opportunities for enhancement and do not address the
many positive features of the Ministry’s current activities and undertakings.

Our procedures consisted of inquiry, surveying, and analysis of information provided by the Ministry, the College and HAs. The Ministry approved the interview
list and the extent of the other materials provided by project participants. Such work does not constitute an audit. Accordingly, we express no opinion on
processes, other information or internal controls.

The evidence that supports our suggestions for improvement has been gathered through completed questionnaires, interview feedback and other comments,
explanations and information received during our work. We are not responsible for this evidence; the sole responsibility lying with those who provided us with
information and those we interviewed or otherwise interacted with during this review.

Our findings arise from our enquiries, although we can provide no assurance as to the day-to-day operation of either those procedures reviewed or issues relating
to physician licensing, credentialing, privileging and performance management in general. KPMG assumes no responsibility for our findings and we have not
attempted to establish whether the issues raised in the report are pervasive, commonplace or rare; the issues raised are merely those that occurred during the
course of our interviews and other work. All procedures covered in this report are dependent for their effectiveness on the diligence and propriety of those
responsible for operating them and are capable of being overridden by persons holding positions of authority and trust.

We have not graded our suggestions for improvement and have not sought to emphasize their importance in any way. Our report has been factually checked by
the Ministry and senior clinicians, as well as all members of the Ministry Action Team and VP Medicines (VP Meds), or equivalent, at all HAs.

The Ministry is responsible for the decisions to implement any recommendations and for considering their impact. Implementation of these opportunities will
require the Ministry to plan and test any changes to ensure that the Ministry will realize satisfactory results.

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Ministry of Health 15

Report structure

This Chapter provides context for the reader on the background of this review, our mandate and approach to completing the work.

Chapter 3 provides the reader with an understanding of the roles and responsibilities of all organizations which informs our analysis in subsequent Chapters. It
also includes an analysis of progress on the eight initiatives put in place to address the Ministry’s response to Dr Cochrane’s report.

Chapter 4 details the Ministry’s response to Dr. Cochrane’s report and sets out commentary on the eight initiatives being managed by the Ministry Action Team
as part of that response.

Chapters 5, 6 and 7 outline our findings related to physician licensing, credentialing and privileging and performance management respectively, under seven
headings:

Key observations

Role of organizations;

Communication;

Governance and accountability;

Process;

Technology; and

Learning from other jurisdictions;

Chapter 8 details our suggestions for improvement and sets out a suggested future state for managing licensing, credentialing and privileging and performance
management in BC.

Appendix A is an overview of current licensing, credentialing, privileging and performance management processes, including process maps that illustrate the
processes and systems in place by the College, the HAs and healthcare providers. Appendix A is informed by Appendices B and C that set out process maps in
more detail for initial privileging and ongoing privileging re-appointments.

Appendix D details credentialing standards used at all HAs that informs our analysis of credentialing in Chapter 6.

Appendix E sets out an overview of the US Data Bank and Appendix F sets out different Board directives for peer review, both informing our analysis of
performance management in Chapter 7.

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Ministry of Health 16

Background for the review

In late 2010 and early 2011, problems were identified with the quality of radiology image interpretations within Fraser Health Authority (FHA), VCHA and VIHA.
Upon investigation, the HAs found that there were deficiencies in the experience and performance of the identified radiologists. Third party reviews were
commissioned to assess the situation and determine whether patient care was adversely affected. In all cases, the privileges of these radiologists were
suspended3.

As the deficiencies did not involve a single isolated event, rather were driven by identified, systemic concerns in a number of different parts of the Province, the
Honourable Colin Hansen, then Minister of Health Services, commissioned an independent review by Dr. Doug Cochrane, Provincial Patient Safety and Quality
Officer and Chair of the BC Patient Safety & Quality Council.

Dr. Cochrane’s review was split into two phases. Phase 1 reviewed the credentials of all radiologists in the Province to determine if all were qualified to review
radiology images. The report concluded that as of February 2011 there were 287 practitioners licensed (at the time) to provide diagnostic imaging services. He
concluded that all met the criteria required by the College for licensure and that all were providing services within the scope defined by their license4.

Phase 2 provided “a description of the [four] incidents, an analysis of causes, the response by the HA to the event and the role of the College.”5 The report, along
with the Ministry’s response, was released on September 27, 2011 when the new Minister of Health, the Honourable Mike de Jong, confirmed that the Ministry
had accepted Dr. Cochrane’s 35 recommendations and had created an action plan to implement his advice.6

Given that Dr. Cochrane’s review focused on radiology, and to a certain extent focused on the three HAs involved in the initial incidents, the Ministry
commissioned this review for the whole Province in November 2011.

3 Cochrane, D., 2011. Investigation into Medical Imaging, Credentialing and Quality Assurance, Phase 2 Report. Available at:

www.health.gov.bc.ca/library/publications/year/2011/cochrane-phase2-report.pdf. Page 13.

4 Cochrane, D., 2011. Investigation into Medical Imaging, Credentialing and Quality Assurance, Phase 1 Report. Available at:

www.health.gov.bc.ca/library/publications/year/2011/cochrane-phase1-report.pdf. Page 3.

5 Cochrane, D., 2011. Investigation into Medical Imaging, Credentialing and Quality Assurance, Phase 2 Report. Available at:

www.health.gov.bc.ca/library/publications/year/2011/cochrane-phase2-report.pdf. Page 13.

6 Ministry of Health, 2011. Action plan to protect patient safety unveiled. Press Release, September 27, 2011. Available at:

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Ministry of Health 17

Terms of our engagement

KPMG was contracted to conduct a review of the existing College, Ministry, HA and hospital processes/systems for: licensure, credentialing, privileging, physician
performance monitoring and peer review in BC, and relevant legislation pertaining to the previously mentioned items. This included the identification of
suggestions for improvement and a suggested quality improvement strategy. Key deliverables included:

Development of a project charter and work plan;

Development of an assessment framework;

Final report with summary of findings and advice; and

Final report presentation to the Ministry Action Team.

As an extension to the original scope, the Ministry requested that KPMG provide commentary on all the initiatives underway and link progress with our
suggestions for improvement.

Out of scope

Given the time and resources available for this review, we agreed with the Ministry that we would focus our attention on the acute care sector and, in a more
limited way, private Non-Hospital Medical Surgical Facilities in the Province7. This review did not examine practices within other areas of the health care system
such as community provision, mental health services or long-term care.

KPMG sub-contracted with the law firm Osborne Margo to complete the legal and regulatory review. While we quote their report in our findings, their report has
been submitted as a stand-alone document.

7 These private facilities were involved in an online survey and covered through our interviews with leaders from the College, however, we did not conduct on-site visits or follow up

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Ministry of Health 18

Our workplan for completing this review

Our approach to completing this review, including the key activities, is illustrated below (Figure 2-1).
Figure 1-1. Our Approach

Project initiation

The project began with a working session with the Action Team8 during the first week of January and the Project Charter was approved by the Project Sponsor on
January 10, 2012. The key elements of the Project Charter included:

Project objectives;

Key messages to be used with stakeholders;

An evaluation framework which outlined how the success of this engagement would be measured;

Project management methods including roles and responsibilities, weekly status reports and the approach to raising and addressing issues and
challenges;

Project risks and mitigation strategies; and

Detailed workplan on each project activity.

8 This group is mandated with overseeing the implementation of the Physician Quality Assurance Portfolio which was created based on the recommendations in the review

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Ministry of Health 19

Development of the Review Assessment Framework

Upon confirming our mandate, we developed the RAF which outlined the data we would require and areas of inquiry we would pursue with every entity being
reviewed. The RAF was approved by the Action Team on January 31, 2012 and is attached at Appendix G.

To inform the development of this framework, we completed the following activities:

Stakeholder meetings with officials from the Ministry, the College and the UBC Faculty of Medicine. We also met with Dr. Doug Cochrane;

Meetings with the Royal College of Physicians and Surgeons of Canada (Royal College), the College of Family Physicians of Canada (CFPC), the Medical
Council of Canada (MCC) and senior leaders within the Colleges of Physicians and Surgeons in Ontario, Saskatchewan and Alberta;

An online survey of all acute care hospitals in BC (attached at Appendix H); and

An online survey of selected, agreed private NHMSFs (attached at Appendix I).

Legal & Regulatory Review

A legal and regulatory review was completed by the law firm Osborne Margo. That report summarizes the legal framework for physician regulation in BC and
identifies key issues regarding BC’s current regulatory framework. The report also includes a summary of the physician regulatory frameworks in Alberta,
Saskatchewan and Ontario. The Osborne Margo report should be read in conjunction with this report.

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Ministry of Health 20

Review

Using the agreed RAF we held a series of meetings and interviews with leaders within four groups of organizations:

The Ministry; including fifteen staff from the HAs and Medical Services Divisions;

The College; including two half-day sessions, one with the Registrar and Deputy Registrar (Registration) and another with the Senior Deputy Registrar.
We also interviewed six members of the College Board;

Every HA; three separate interviews were held at each of the six HAs: one with the VP Med and staff responsible for credentialing (which in some cases
also included the Chair of the Credentials Committee), one with the VP Med and Chief executive Officer (CEO), and one with either the Board’s Quality
Committee and/or Board Chair. In the case of the PHSA, an interview was held with the VP of Physician Compensation, and

A sample of hospitals in BC; eight facilities with interviews involving the Chief of Staff or Chair of the local Credentials Committee and staff from the
Medical Affairs Office (MAO), as agreed with the Ministry, who also approved the following list of hospitals reviewed:

BC Children’s Hospital;

Cowichan District Hospital;

Peace Arch General Hospital;

South Okanagan General Hospital;

Squamish General Hospital;

St. John Hospital (Vanderhoof);

St. Joseph’s General Hospital (Comox); and

University Hospital of Northern British Columbia.

Reporting

The key themes and data emerging from the review are analyzed and presented in this report.

Project management

A number of project management methods were used throughout the engagement to assist in meeting project milestones. Specific activities included:

Developing a detailed project charter which outlined key activities and milestones;

Providing weekly status reports, including highlighting of weekly activities as well as risks and challenges; and

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Ministry of Health 21

Chapter 3: Roles of Key Organizations in

Physician Licensing, Credentialing, Privileging

and Performance Management

This Chapter introduces the key organizations involved in physician licensing, credentialing, privileging and performance management within BC and the current
role that they serve, dealing in turn with the Ministry, the College, HAs and DFs and medical education bodies.

The Ministry of Health

The Ministry has a narrow, but important, role in relation to the practice of physicians in BC. The Minister of Health (Minister) has overarching responsibility for
public safety and health service quality and as such has specific and final authority for regulation under the Health Authorities Act, Hospital Act, and Health
Professions Act (HPA). The Minister can appoint a person to inquire into aspects of the operation of the College or the state of practice of the profession. They
also approve College and HA by-laws which include physician privileging and performance management governance.

The Minister enters into accountability and performance agreements (called Government Letters of Expectation) with HAs on an annual basis that define the
expectations and performance obligations of each HA. The role that the Ministry undertakes in regulating the system is set out in more detail in the legal and
regulatory review completed by Osborne Margo.

Through our review meetings with the Ministry, we identified several functions and initiatives which relate to physician management:

Assistance with work permits: Providing ‘Confirmation Letters of Need’ to support an application for a work permit in Canada.

Funding post-graduate placements: Setting out the number of placements that will be funded for post-graduate residents.

BC Locum9 Program: Refers to a registry of physicians who are available to provide locum services. Locum positions can be posted through this
registry, yet the physician will apply directly to the facility and/or HA to provide the service.

Model medical staff by-laws: Work has been initiated to look at model medical staff by-laws. Over time, it is anticipated that each HA and DF would
amend their by-laws to conform with a Provincial standard.

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Ministry of Health 22

The College of Physicians and Surgeons of British Columbia

The College is the licensing and regulatory body governing physicians in British Columbia. It is responsible for physician registration and licensure, complaints,
investigations and discipline, as well as a variety of quality assurance (QA) programs and related matters. The College website states that “The College’s
overriding interest is the protection and safety of patients, and the quality of care they receive from licensed physicians in BC.”11

The role of the College includes12:

“Establishing standards that must be met by physicians in order to get a license to practice medicine in BC;

Ensuring physicians meet high standards of practice and conduct;

Addressing and dealing with complaints about physicians; and where necessary, disciplining physicians;

Ensuring that medical facilities such as private surgical clinics, labs and diagnostic imaging centres meet established standards through a formal
accreditation process; and

Working collaboratively with government, universities, hospitals and other organizations to address issues such as improving access to health care
services and improving the quality of care patients receive.”

Through this mandate, the College has taken responsibility for two statutory accreditation programs:

The Diagnostic Accreditation Program (DAP); and

The Non-Hospital Medical Surgical Facility Program.

The College is governed by a 15-person Board of Directors which includes ten physicians elected by College registrants, and five public members who are
appointed by the Provincial government.13

11 College of Physicians and Surgeons of British Columbia, 2012. About the College. [online] Available at: https://www.cpsbc.ca/about-the-college. [Accessed on March 30, 2012].
12 College of Physicians and Surgeons of British Columbia, 2012. Mandate and Role. [online] Available at: https://www.cpsbc.ca/node/48. [Accessed on March 2, 2012].

13 College of Physicians and Surgeons of British Columbia, 2012. Role of the Board. [online] Available at: https://www.cpsbc.ca/ board-and-committees/role-board. [Accessed on

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