The Purpose of Credentialing and defining

The Scope of Clinical Practice

• Maintain and improve safety and quality of care
that patient receive from health professional
• Sustain the confidence of both trhe public and
the profession through demonstrable impartiality
• Support and embed good practice, the majority
of doctors are excellent doctor who strive to be
better
• Integration into organizational clinical governance
process
 CLINICAL PRIVILAGE
• Clinical privileges result from a process in which the Governing Body or its
delegate grants a health care professional the authority to provide health
care services within defined limits in a health care facility.

• They represent the range and scope of clinical responsibility that a

professional may exercise in the facility.

• Clinical privileges are specific to the individual, usually in a single health

care facility (or group of facilities such as a rural District/Region or a Multi-
Purpose Service) and relate to the resources, equipment and staff
available.

• Recommendations are made to the Governing Body following the

determination of what a health care professional can or cannot do in a
facility.
 APPOINTMENT
• Appointment is the formal process of selecting a preferred
candidate from among competing applicants and setting the
terms and conditions of appointment, consistent with relevant
industrial awards or other determinants.

• Consideration should be given at the time of appointment to the

assessment of credentials and delineation of clinical privileges for
the successful applicant in line with needs and resources of the
facility as determined by the levels of service provided by the
facility. The process is required to comply with guidelines
designed to ensure fairness and equity.
 COMPETENCE
• Competence is the application of knowledge and skills in
interpersonal relations, decision making and performance consistent
with the professional’s practice role.

• Credentials represent the formal qualifications, training, experience

and clinical competence of the health care professional. They are
evidenced by documentation such as university degrees,
fellowships/memberships of professional colleges or associations,
registration by professional bodies, certificates of service, certificates
of completion of specific courses, periods of verifiable formal
instruction or supervised training, validated competence, information
contained in confidential professional referee reports and
professional indemnity history and status.
 CREDENTIALLING
Credentialling is the formal process of
assessing a professional health care
professional’s credentials in relation to
that professional role within a specific
facility.
 GOVERNING BODY
• Governing Body refers to the body or its delegate who has ultimate
responsibility for the health care facility.

• Health Care Professional is a health care worker eligible for

registration with a State or Territory professional body or complies
with the requirements of a professional body where registration is
not a requirement to practise. All health care professionals working
in a facility should hold current registration or its equivalent.

• Performance describes how the output of a process conforms to

requirements and expectations and suggests how well an
individual, process or team is operating.
 Mekanisme Credensialing
1. Dokter mengajukan permohonan untuk
mendapat kewenangan klinis dengan metode
self assessment
2. Mitra Bestari (Peer Group) mengkaji dan
memberikan rekomendasi tindakan medis
yang dilakukan pemohon
3. Kepala RS menerbitkan surat penugasan
(clinical appointment) berdasar rekomendasi
mitra bestari yg berlaku periode tertentu
 1. Dokter Pemohon
Mengisi beberapa formulir:
• Daftar tindakan medik yang ingin dilakukan
sesuai bidangnya dg mencontreng daftar
tersebut
• Menyerahkan semua kopi dokumen yang
disyaratkan meliputi kesehatan fisik, mental
untuk melakukan tindakan medis tertentu
 2. Kajian Mitra Bestari (Peer Group)
• Komite medik  subkomite kredensial sub komite kredensial
menyiapkan mitra bestari
• Mitra bestari (4-5 org) sesuai bidang keahlian pemohon (tidak
harus angg sub komite kredensial, bisa dari luar RS, bisa bbrp
bidang spes), misal tiroidektomi  SpB, SpB Onk, Sp THTKL
• Mitra bestari mengkaji secara objektif didasari white paper (berisi
syarat 2 kapan seorang dokter dianggap kompeten untuk
melakukan tindakan medis ttt ), misal tiroidektomi diperlukan
pendidikan bedah dasar, pelatihan tertentu , telah menangani
jumlah kasus tertentu dalam kurun waktu tertentu
• Mitra Bestari menilai kemampuan berdasar kesehatan fisik dan
mental
• Mitra bestari buat rekomendasi kelompok tindakan medis tertentu
yg boleh dilakukan pemohon
 3. Penerbitan Surat Penugasan
• Kepala RS menerbitkan SP (surat penugasan/clinical
appointment) berdasarkan rekomendasi tsb
• SP memuat daftar sejumlah kewenangan klinis yg boleh
dilakukan pemohon di RS tsb
• Tindakan medis ttt di RS hanya boleh dilakukan oleh dr
yang memiliki kewenangan klinis berdasarkan SP
• Daftar Kewenangan klinis dapat dimodifikasi ditambah
atau dikurangi, setelah recredensialing
• Setiap saat seorang dr dapat mengajukan penambahan
kewenangan klinis sesuai dengan peraturan yang berlaku