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GENERAL ONGOING PROFESSIONAL PRACTICE EVALUATION

Name: ____________________________________

1

Indicator

Data source(s)(in addition to credentialing file review)

   A  c  c  e  p   t  a   b   l  e

   N  e  e   d  s

   I  m  p  r  o  v  e  m  e  n   t

   U  n  a  c  c  e  p   t  a   b   l  e

   N  o   t   O   b  s  e  r  v  e   d   /

   N  o   t   A  p  p   l   i  c  a   b   l  e

   T   R   E   N   D 

PATIENT CARE: 1. Clinical Assessment of Patients

2. Quality of Patient Management Plans

3. Clinical Competence and Judgement

4. Appropriate and Timely Use of

Consultants

5. Responds to Pages and Concerns;

Availability

6. Patient/Family Education Including

Discharge Instructions

7. Medication Management

8. Supports National Patient Safety GoalsInitiatives

9. Admissions and Assigned Level of CareAppropriate

10. Follows Accepted ManagementGuidelines/Standards of Care

Comments:

Recommendations:

MEDICAL KNOWLEDGE

1. Basic Medical Knowledge

2. Medical Knowledge – Specialty-Specific

3. CME Requirements Satisfied

4. Participates Willingly and Effectively in

the Education of Medical Students and

Residents

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GENERAL ONGOING PROFESSIONAL PRACTICE EVALUATION

Name: ____________________________________

2

   A  c  c  e  p   t  a   b   l  e

   N  e  e   d  s

   I  m  p  r  o  v  e  m  e  n   t

   U  n  a  c  c  e  p   t  a   b   l  e

   N  o   t   O   b  s  e  r  v  e   d   /

   N  o   t   A  p  p   l   i  c  a   b   l  e

   T   R   E   N   D 

5. Appropriate use of Laboratory and

Imaging Services

Comments: 

Recommendations: 

INTERPERSONAL AND

COMMUNICATION SKILLS: 1. Relationship with Medical Staff and

Hospital Staff

2. Clarity of Records

3. Histories and Physical ExamDocumentation Complete and Timely

4. Progress Notes Documentation Completeand Timely

5. Collaborates with SBAR Method

6. Uses Approved Standardized Orders(When Appropriate)

7. Signs Orders in a Timely Fashion

Comments: 

Recommendations: 

PROFESSIONALISM: 1. Respectful of Others

2. Collegial, Courteous, Pleasant, Positivewith all Staff, Patients, and Families

3. Compassionate

4. Accountable for Personal Behavior andActions

5. Maintains Patient Confidentiality

6. Maintains Confidentiality in all Peer

Review Processes

7. Follows Ethical Principles at all Times

8. Adheres to the Medical Staff By-Laws,

Rules and Regulations, and Policies.

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GENERAL ONGOING PROFESSIONAL PRACTICE EVALUATION

Name: ____________________________________

3

   A

  c  c  e  p   t  a   b   l  e

   N

  e  e   d  s

   I  m

  p  r  o  v  e  m  e  n   t

   U

  n  a  c  c  e  p   t  a   b   l  e

   N

  o   t   O   b  s  e  r  v  e   d   /

   N

  o   t   A  p  p   l   i  c  a   b   l  e

   T   R   E   N   D 

9. Quarterly Medical Staff, Committee,

Department Meeting Participation and

Attendance

10. Participates Cooperatively and

Constructively in Peer Review Activities,Case Reviews, RCA’s

11. Press Ganey Patient Satisfaction Scores

12. Follows Admission Processes and Policies

Comments: 

Recommendations:

UTILIZATION MANAGEMENT/QUALITY

OF CARE: 1. Adjusted LOS

2. Maintains Legible Records

3. Blood Usage

4. Discharge Summaries Complete and

Timely5. Re-Admission Rate

6. Cooperates with Discharge Planning

Process; Discharge to Appropriate Level of

Care

7. Ancillary Utilization (appropriate Social

Service, Respiratory Therapy, PhysicalTherapy)

8. Appropriate and Timely Attention to

Lifesaving Orders/Advance Directives

9. Appropriately Completes Imaging and

Laboratory Requests/Pre-Authorization10. Appropriate Documentation

11. Cooperates With CDI; Query System

Comments:

Recommendations:

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GENERAL ONGOING PROFESSIONAL PRACTICE EVALUATION

Name: ____________________________________

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PHYSICIAN SIGNATURE: ______________________________________________________

CONDUCT

1. Incident Reports

2. Unusual Occurrence Reports

3. Staff/Patient/Family Complaints

Comments:

Recommendations:

MORBIDITY & MORTALITY

Including:

“Never Events” as defined by CMS, BCBSM

“Sentinel Events” as defined by TJC

Medication Errors

□ None r equiring review Mortalities reviewed: ______________

Resuscitations reviewed: _________ Targeted reviews: ________

 ______________________________________________________

□ No adverse outcomes □ Medical management appropriate. No

quality issues

 ______________________________________________________

Minor adverse outcomes: ___ Major adverse outcomes: ___

Care appropriate: ___ Care appropriate: ___

 ______________________________________________________

Medical management controversial: ___

Medical management inappropriate: ___

Comments:

Recommendations:

FOCUSED REVIEW/ACTION

Including:

FPPE

PEER ReviewsSuspension/Privilege Restrict

 ______________________________________________________

 ______________________________________________________

Comments:

Recommendations:

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GENERAL ONGOING PROFESSIONAL PRACTICE EVALUATION

Name: ____________________________________

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EVALUATION COMPLETED BY: ______________________________________________________

Chief Medical Officer

______________________________________________________Date

EVALUATION REVIEWED BY: _____________________________________________________

Department Chair

Department of ________________________________________

_____________________________________________________

Date

EVALUATION APPROVED BY: ______________________________________________________

Chief of Staff

______________________________________________________

Date

EVALUATION REVIEWED WITH: ____________________________________________________

Practitioner

_____________________________________________________

Date