A Working Model for the Extraordinary Review of Clinical Privileges for Doctors and Dentists in the Australian Capital Territory
Jakobs, Olivia M., O'Leary, Elizabeth M., Cormack, Mark F., Chong, Guan C., Australian Health Review
The strategic context
Data exist to demonstrate that hospital admissions may be associated with adverse outcomes, including permanent disabling injury and death. 1^4 Although the incidence of adverse events reported varies between 2.9-10.6%, the actual number is clearly less important than doing something to prevent them. '6 On the premise that human errors are inevitable,7 iatrogenic injury to hospitalised patients is not surprising. That said, there are opportunities to reduce this type of injury since at least half of the adverse outcomes reported in the literature are deemed highly preventable.'4 The primary goal in the administration of health care should be to put in place strategies to minimise, and where ever possible prevent, the occurrence of avoidable human error. Still today, however, efforts to identify and understand vulnerabilities in the health care system that cause iatrogenic injury continue to challenge policy makers and legislators.
As data on the risks associated with being a patient in the health care system accumulate, consumers are becoming increasingly aware of, and knowledgeable about, what is an 'appropriate' standard of care across the different health professions. In the Australian Capital Territory (ACT), as in other Australian jurisdictions, there is a community expectation that health care facilities will engage competent clinicians, sufficiently capable of, and properly qualified to perform, work activities at a level acceptable to peers. This requires a system for the evaluation of clinical competence in the context of organisational need and capability. From an organisational perspective, it seems to make sense, at least in the first instance, to focus on the provision of care by doctors and dentists. This is not only because of the significant contribution these professionals make to the health care system, but also because of the already established processes within these professions for the credentialing and re-credentialing of clinical privileges to delineate the extent of a doctor's or dentist's clinical practice within a health facility based on the individual's credentials, competence, performance and professional suitability, and the needs and the capability of the health facility to support the doctor's or dentist's scope of clinical practice.8
A systems approach to error in health care
As with other hazardous industries, such as aviation, a systems approach to safety improvement is generally recognised as the best means of dealing with many of the problems that occur in health care.9-12 The Swiss cheese model of system accidents shows how breaches of layers of defences, barriers and safeguards can be penetrated by an accident trajectory so that seemingly minor errors in one area of a health care organisation combine with errors in other areas to result in an adverse event.13 Of course, a focus on the design of systems to minimise human error redefines, but in no way lessens, personal accountability; whilst health care organisations are responsible for designing safe systems, individual practitioners maintain responsibility for delivering safe, quality care within those systems. I0_l2 In this way, the clinical competence of individual practitioners is relevant where ever a systems approach to error in health care is taken.
The routine and extraordinary review of clinical privileges
In Australia, there is a national standard for credentialing and defining the scope of clinical practice for doctors working in hospital settings/ Developed in 2004, the standard is aimed at improving administrative processes for the routine review of clinical privileges, for credentialing and re-credentialing purposes and, since it is based on common principles, could apply equally to dentists (and nurses and allied health professionals) in a broad range of clinical settings.
In terms of safeguarding patients, the routine review of clinical privileges can identify issues around suboptimal perfonnance. …