Credentialling Criteria

 

 

DRAFT Framework for Credentialling.


 

CONTENTS

1.0 BACKGROUND                                                                 

2.0 VOCATIONAL REGISTRATION (VR)                                 

3.0 CREDENTIALLING FRAMEWORK                                  

            3.1 The Credentialling Framework                                

            3.2 Credentialling Committee                                        

            3.3 Entry Criteria                                                          

            3.4 Annual Review                                                        

            3.5 Triennial Review and Certification                          

4.0 APPEALS PROCESS                                                          

           

1.0 BACKGROUND

Procedural Phlebology (PP) in New Zealand (NZ) is the non-surgical treatment of lower limb venous disease. PP is practiced by a variety of different medical practitioners, in different vocational scopes, including but not limited to surgeons, general practitioners (GP’s), dermatologists and radiologists. There has never been a consistent method of accrediting medical practitioners to perform these procedures. However “the NZ public needs to be assured that health professionals are competent to undertake specific clinical responsibilities in particular practice settings. Credentialling is currently the only organisational process in the health system addressing competence in a specific practice situation.” “The professional focus of credentialling means that professional colleges or specialist societies have a large part to play in the process. Such organisations may specify the standards required for membership, or define levels of competence required for clinical practice.” (Credentialling Framework for New Zealand Health Professionals, New Zealand Ministry of Health [MoH] 2010.) Therefore the New Zealand Society of Procedural Phlebology (NZSPP) has created this credentialling framework to certify competence in phlebology procedures for medical practitioners in NZ.

2.0 VOCATIONAL REGISTRATION (VR)

The NZSPP believes that to ensure the highest clinical standards across all vocational scopes that medical practitioners practicing independently in NZ should have VR.  The Medical Council of New Zealand (MCNZ) stipulates: “Vocational registration is a form of permanent, specialist registration which allows you to work independently in New Zealand.’ (https://www.mcnz.org.nz/get-registered/scopes-of-practice/vocational-registration/) There are several areas of medicine, or vocational scopes, which are recognised by MCNZ. These are areas of specialised medical practice, each defined by an accredited postgraduate training programme and qualification. Neither Phlebology nor PP is recognised by MCNZ as a vocational scope and thus PP is practiced as a sub-specialty of many different vocational scopes. There has been no specific procedural training or accreditation for PP and thus this credentialling framework addresses the issue of accreditation for all vocational scopes beginning with VR as a prerequisite.

3.0 CREDENTIALLING FRAMEWORK

3.1 The Credentialing Framework has 3 phases, overseen by the credentialing committee and being:

a) Entry

b) Annual Review

c) Triennial Certification

3.2 Credentialling Committee

The credentialling committee will be appointed by the NZSPP committee on an annual basis. It will consist of 3 full members and include at least one member of the NZSPP committee who will chair the credentialing committee. The chair will report credentialing activities to the NZSPP committee. The NZSPP committee may appoint non-voting lay people to advise the credentialing committee and provide community/consumer representation at their sole discretion. All credentialing committee decisions should be unanimous and where there is uncertainty further information should be sought from the requesting physician until a unanimous decision can be reached. If there is uncertainty regarding the information supplied then further investigation, with physician consent, is warranted. If the credentialing committee is still unable to reach a unanimous then a majority decision is accepted as final. The physician will have the right of appeal to the NZSPP committee.

3.3 Entry Criteria

3.31 Vocational Registration with the Medical Council of New Zealand

a)      Evidence of VR with a copy of the medical practitioner’s annual practicing certificate.

b)      Evidence of participation in a suitable vocational recertification programme. (e.g. Royal New Zealand College of General Practitioners [RNZCGP] Maintenance of Professional Standards [MOPS] or Royal Australia and New Zealand College of Radiology [RANZCR] Continuing Professional Development [CPD].) Participation in a recertification programme infers the medical practitioner is participating in appropriate professional development activities such as audit, peer review, self-directed learning and cultural competence.

3.32 Curriculum Vitae (CV) to include:

a)      training and experience in PP detailing a minimum of 3 years involvement in PP,

b)      any teaching or research in PP,

c)      2 Referees who can confirm validity of CV.

3.33 Certificates of Training / Preceptorships in PP (N.B. both general Phlebology  training and training specific to procedures for which applying for credentialling.)

3.34 Evidence of Professional Indemnity Insurance, including cover for PP.

3.35 Standardised NZSPP Log Books for each separate procedure requiring credentialling, documenting at least 50 such procedures and signed by a peer or member of staff. Procedures include but are not limited to:

a)      Duplex Ultrasound, Lower Limb, Mapping Scan.

b)      Ultrasound Guided Sclerotherapy (with either sclerosant liquid or foam.)

c)      Endovenous Laser Ablation (e.g. EVLT ®.)

d)      Endovenous Radiofrequency Ablation (e.g. VNUS Closure®.)

e)      Endovenous Mechano-chemical Ablation (e.g. Clarivein®.)

f)       Endovenous Adhesive Ablation (e.g. Venaseal®.)

g)      Other or New Procedures with prior approval from NZSPP.

3.36 Written declaration of any:

a)      Criminal investigations or convictions,

b)      Denial, suspension or termination to practice by any organization,

c)      Physical or mental condition, including substance abuse, which would affect ability to practice safely.

3.37 Consent for NZSPP to verify all claims and documents provided.

3.38 N.B. All certificates should be “certified copies” signed by a NZ Justice of the Peace.

3.4 Annual Review

The annual review requires reporting on a standardized NZSPP form of:

3.41 current clinical position and responsibilities

3.42 logbooks of credentialled  phlebology procedures, to include a minimum of 20 of each procedure, including audit and any complications encountered annually

3.43 any training or extra experience gained since last review including one major phlebology conference / meeting each triennium

3.44 peer review report with a minimum of 5 hours of peer review annually

3.45 professional development plan (PDP) for coming year including planned PP education, audit and peer review activities.

3.5 Triennial Review and Certification

The triennial review and certification includes:

3.51 successful completion of 3 years annual reviews

3.52 successful “Regular Peer Review” (RPR) visit each triennium including :

a)      discussion of current clinical position, responsibilities, support network and clinical environment (including resuscitation facilities and drug audit)

b)      observation of at least one of each clinical procedure credentialed by NZSPP (e.g. duplex mapping scan, ultrasound guided sclerotherapy, endovenous thermal ablation, endovenous adhesive ablation and/or endovenous mechano-chemical ablation)

c)      discussion of any procedural complications or patient complaints

d)      discussion of cultural competence issues

e)      discussion of any criminal investigations, convictions, disciplinary action, physical or mental conditions (including substance abuse) that may relate to ability to practice safely

3.53 triennial certificate of ACLS level 5 from the Resuscitation Council of New Zealand.

4.0 APPEALS PROCESS

A written letter of appeal with supporting written evidence may be submitted to the NZSPP committee within 30 days of an official decision from the credentialing committee by the requesting physician. The committee may investigate the appeal by any appropriate means that may include but are not limited to interviewing the physician, requesting further particulars, checking the validity of information supplied. Written Physician consent is given at the entry to credentialing. A majority decision of the committee is final and should be sent to the physician within 90 days of receiving the letter of application.