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OPPE-FPPE

Physician Performance Toolkit

Contributed by

LifePoint HospitalsBrentwood, TN

Leading Practices Library

Organizations submit practices to The Joint Commission that they have found to be leading practices,with permission to share them with other organizations.

The Joint Commission makes these leading practices available to organizations that may wish to

examine their applicability to their particular circumstances. Please understand that The JointCommission can make no representations as to the results that any organization can expect from theiruse or adaptation of a leading practice to their particular circumstances.

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LifePoint Physician Performance Toolkit*

Introduction: Credentialing is now an ongoing process that involves continuousevaluation of a practitioners performance using an evidence-based approachthat is fairly and consistently applied using criteria appropriate to the specialty

area of practice and request privileges. Physician profile data should be robust,include comparisons, and lead to informed decision-making around granting ordenial of privileges.

Definitions: Ongoing Professional Practice Evaluation - A documented summary of

ongoing data collected for the purpose of assessing a practitioner'sclinical competence and professional behavior. The information gatheredduring this process factors into decisions to maintain, revise or revokeexisting privilege (s).

Focused Professional Practice Evaluations (Focused Review) -Atime-limited evaluation of practitioner competence in performing aspecific privilege. This process is implemented for: All newly requested privileges and Whenever a question arises regarding a practitioner's ability to provide

safe, high Quality patient care

PractitionerIndividual with Medical Staff or Allied Health privileges.

Core Competencies:

Patient Care Medical/Clinical Knowledge Practice-Based Learning and Improvement Interpersonal and communication skills Professionalism System-Based Practice

Steps for implementing OPPE: Identify all current criteria for each specialty/subspecialty Identify applicable core competencies (may meet more than one)

Identify the gaps Meet with key medical staff leaders to complete the criteria/indicators Complete a matrix for data sources to connect the data to Quality and

Medical Staff Office Define periodic timeframe for review Implement

* Toolkit adapted from McKenna & Associates Presentation and other resources

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Steps for Developing An EvidenceBased Ongoing Professional Practice Evaluation

Step OneComplete a worksheet for each department and sometimes subspecialties withinthe department based on what is already being measured. Compare the list tothe practitioners privilege list for specialties and subspecialties assigned to thatdepartment. You must be collecting data that relates to what they are privilegedto perform.

Step TwoIf the list is inadequate, meet with the Department Chair or other appropriatemedical staff member to add appropriate indicators. Develop a matrix of datasource. Again, using privilege list to make sure the data represents what themembers are privileged to do.

Step ThreeSeek approval of the criteria by the appropriate medical staff leaders and/orcommittees.

Step FourCreate the profiles from the indicator worksheet.

Step FiveDefine your periodic timeframe for reporting the profile i.e. 3 months or 6 months.

Step Six

Develop a standard report format to and from the Department Chair to theQuality Department or appropriate Quality group based on your structure.

Step SevenSet up a process for the feed back to reach the database (file) of the individualsbeing considered for reappointment.

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Toolkit Contents

Sample OPPE Policy Page 4

Sample FPPE Policy-- Page 13

Description of Forms -- Page 17

Toolkit Example Forms:

Emergency DepartmentPage 19

Anesthesia DepartmentPage 26

Surgery DepartmentPage 34

Radiology DepartmentPage 42

Physician AssistantSurgery DepartmentPage 50

Appendix

Examples of Evaluation Sheet for Surgical PAPage 58

Example IndicatorsPage 60

Sample Privilege Criteria-- Page 64

Sample Proctor Review FormPage 67

Medical Staff Case Review Tool---Page 68

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Ongoing Professional Practice EvaluationEXAMPLE POLICY

JC Standards: MS.4.40 and MS.4.45

Purpose1. To clearly define the process utilized for facilitating the continuous evaluation of each

practitioner's professional practice;2. To define the type of data (criteria/indicators) to be collected for the ongoing

professional practice evaluation. (Note: The criteria defined for Ongoing ProfessionalPractice Evaluation, will be utilized as screening triggers for a possible FocusedProfessional Practice Evaluation).

3. To ensure the information resulting from the ongoing professional practiceevaluation is used to determine whether to continue, limit or revoke any existingprivileges;

4. To define the process for collecting, investigating, and addressing clinical practiceconcerns, including the process utilized to identify trends that impact Quality of careand patient safety;

5. To ensure reported concerns regarding a privileged practitioner's professionalpractice are uniformly investigated and addressed as defined by hospitalpolicy and applicable law;

6. To define those circumstances in which an external review or focused reviewmay be necessary; and

7. To define the medical staff's leadership role in the organization's performanceimprovement activities related to practitioner performance and ensure that whenthe findings are relevant to an individual's performance, the findings in the ongoingevaluations of competence are in accordance with recognized standards.

ScopeThis policy applies to all Medical Staff and Allied Health Professionals privileged throughmedical staff mechanisms at the hospital.

Definitions Focused Professional Practice Evaluations (Focused Review) -A time-

limited evaluation of practitioner competence in performing a specificprivilege. This process is implemented for: All newly requested privileges and Whenever a question arises regarding a practitioner's ability to provide

safe, high quality patient care.

Ongoing Professional Practice Evaluation - A documented summary ofongoing data collected for the purpose of assessing a practitioner's clinicalcompetence and professional behavior. The information gathered during thisprocess factors into decisions to maintain, revise or revoke existing privilege(s).

Practitioner - For purposes of this policy, practitioner is defined as individualswith Medical Staff or Allied Health privileges.

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Policy1. The information used in the ongoing professional practice evaluation

may be acquired through the following:a. Periodic chart review;b. Direct observation;c. Monitoring of diagnostic and treatment techniques; andd. Feedback from other individuals involved in the care of the

patient, including consulting physicians, assistants at surgery,nursing and administrative personnel.

2. Reported concerns regarding privileged practitioner's professionalperformance will be uniformly investigated and addressed asdefined by the organization and applicable law.

3. Relevant information from the practitioner performance review processwill be integrated into performance improvement initiatives and will beutilized to determine whether to continue, limit or revoke existing

privileges.4. If there is uncertainty regarding the practitioner's professional

performance, the course of action defined in the medical staff bylawsfor further evaluation should be followed. It is not intended that thispolicy supersede any provisions of the Medical Staff Bylaws. If theperformance of the practitioner is sufficiently egregious, the Chief ofStaff or CEO shall determine, within his/her sole discretion, whetherthe provisions of this policy need not be followed, whereupon theprovisions of the Bylaws, and not this policy, shall govern.

5. The activities of the ongoing professional practice evaluation areconsidered privileged and confidential.

Procedure

A. Screening

1. Quality Director, or designee will perform concurrent and retrospective chartreview using medical staff approved screening criteria.

2. Any individual (including patient/family, medical staff, allied health

professional or hospital staff) may report any concerns regarding theprofessional performance of a practitioner.

3. When appropriate, feedback sheets will be provided to key leaders in thehospital.

B. Criteria/Indicators1. Criteria/indicators will include triggers and fall generally into the following

six areas of general competence:

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a. Patient care;b. Medical/clinical knowledge;c. Practice-based learning and improvement;d. Interpersonal and communication skills;e. Professionalism; andf. System-based practice.

2. Criteria/indicators for referral will include review of the following:a. Inpatient, outpatient, ED and ambulatory cases will be

screened for the presence of predefined criteria/indicators;b. Events associated with a practitioner exceeding his/her clinical

privileges.

3. Criteria/indicators may be added or deleted at the recommendation of theMedical Executive Committee, Department Chairperson, and/orDepartment Credentials Committee.

4. The applicable Medical Staff Department and the MEC will approve

indicator criteria and trigger (threshold) parameters.

5. The list of criteria/indicators will be reviewed on an ongoing basis and inconjunction with this policy.

III. Definitions and Responsibilities

1. Screenera. Definition - Quality Director, or designee

b. Responsibility - If a case meets the screening indicator criteria, thescreener will refer to a peer screener.

2. Quality Director/Designeea. Definition - Individual responsible for coordinating and facilitating

review activitiesb. Responsibility -

i. Identifies appropriate peer screeners utilizing the rosterprovided by Medical Staff Office and collaborates with theDepartment Chairperson to determine appropriate peer screener

if necessary;

ii. Provides medical record to be reviewed to the peer screener;

iii. Trends data related to individual practitioner performance forcases scored 0,1 or 2 by the peer screener;

iv. Forwards to the designated Department Chairperson or Peer

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Review Panel, as appropriate, all cases scored a 3,4 or 5 by thepeer screener;

v. Provides periodic summary reports (Ongoing ProfessionalPractice Feedback Reports) on an ongoing basis to individualpractitioners, Department Chairpersons. Summary Reports willbe shared with Department Credentials Committee and MECand patterns/trends identified. The summary reports for reviewby Department chairs will include the documentation of thepeer reviewers. The Department chair is looking for trendsbased on the review by peers. Utilization review data, asappropriate, will also be provided.

3. Peer Screenera. Definition - Practitioner from the same discipline and with essentially

equal qualifications as the individual under review (for example,physician and physician, dentist and dentist, etc).

b. Responsibility-i. Reviews the medical record for the case and assigns a score of

0-5 on the Professional Practice Review Form and returns thecompleted form to the Quality Director; and

ii. Documents on the form pertinent findings to support theassigned review score, and identifies opportunities forimprovement and recommends any need for furtheraction/intervention.

4. Department Chairpersona. Definition - Defined in Medical Staff Bylaws/Rules/Regs.

b. Responsibility

i. Retains final responsibility for practitioner performance withinthe Department;

ii. Assigns Peer Review Panels, as appropriate;iii. Provides summary reports to the MEC, on practitioner

performance activities;iv. May send any questionable determinations for further review

or mayv. request an external review;vi. Facilitates and provided oversight of any recommended

actions/interventions; andvii. Presents cases findings as appropriate at medical staff

committee meetings as part of the performance improvementprocess.

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viii. Reviews the Ongoing Professional Practice Feedback Reportsand meets with individual practitioners when trends orsuboptimal performance is identified.

ix. Implements a Focused Professional Practice Evaluation whenindicated.

5. Peer Review Panel

a. Definition - The Peer Review Panel consists of practitioners assignedby the Department Chairperson, and may include others asdesignated the MEC.

b. Responsibility -i. Reviews cases (scored a category 3, 4 or 5) or when threshold

parameters are exceeded;ii. Documents a final score on reviewed cases (unless case

forwarded for external review); andiii. The Peer Review Panel minutes will reflect findings,

conclusions, recommendations, and actions taken. Minutes will

also reflect if any additional action is indicated.iv. Recommends a Focused Professional Practice Evaluationwhen indicated.

6. Department Credentials Committeea. Definition - Defined in Medical Staff Bylaws

b. Responsibility -

i. Considers all documented cases which have been reviewedand trigger (thresholds) parameters at the time of renewing,

revising, limiting, or revoking existing privileges.ii. Recommends a Focused Professional Practice Evaluation when

indicated

7. Medical Executive Committeea. Definition- Defined in Medical Staff Bylaws

b. Responsibility -i. Serves as oversight committee for medical staff performance

improvement activities;ii. Reviews findings of ongoing practice review, specifically as itpertains to cases scored a 4 or 5 and takes actions asappropriate;

iii. Considers all documented cases, which meet the criteria forreview, at the time of renewing, revising, limiting or revokingexisting privileges.

iv. Recommends a Focused Professional Practice Evaluationwhen indicated.

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v. Reports and recommends to the Board of Directors regardingOngoing Professional Practice Review and FocusedProfessional Practice Evaluation activities, as appropriate.

8. Individual Under Reviewa. Definition - The individual whose performance is being reviewed.

b. Responsibilityi. Provides a response to all cases scored 3, 4 or 5, or for any

case requested.ii. Reviews Ongoing Professional Practice Feedback Reports

when received.iii. Participates in Focused Professional Practice Evaluation

process when indicated.

IV. Method for Selecting Reviewer Panels, Including SpecificCircumstances

1. Assignmentsa. The Quality Director will identify a peer screener utilizing the roster

provided by the Medical Staff Office and in collaboration with theDepartment Chairperson.

b. If the Department Chairperson is the individual being reviewed, theChief of Staff will determine the peer screener and may recommend

an alternative peer review panel.

2. Conflict of Interest -Within the context of the review process, a conflict ofinterest will preclude an individual from making a performance reviewdetermination in the evaluation of the performance of another practitioner. Aconflict of interest may exist if the reviewer has significant financial interest inthe hospital or direct professional or personal involvement in the case underevaluation. In those cases the Department Chairperson or Chief of Staff willassign an alternate peer screener. If necessary, hospital legal counsel maybe contacted to assist in identifying a review process that will minimizeconflict of interest.

3. Special Peer Review Panels - If requested by the Chief of Staff, MEC orDepartment Chairperson, a special panel of peers may be assigned to reviewthe case.

a. External Review - External performance review is required under thefollowing circumstances:a. Conflict of Interest - The review may not be conducted by any peer on

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staff due to a potential conflict of interest that cannot be appropriatelyresolved by the MEC or Board of Directors.

b. Lack of Internal Expertise - There is no peer on staff with similar or likeprivileges in the specialty under review.

c. Ambiguity - There is confusion when internal reviews reach conflictingor vague conclusions.

d. Litigation - When the hospital faces a potential medical malpracticesuit, corporate legal counsel or risk management may recommendexternal review.

e. New Technology/Technique There is a new technology/techniqueinvolved that the hospital does not have the expertise to assesswhether the practitioner possesses the required skills associated withthe new technology/technique.

f. Miscellaneous - The Department Chairperson, Medical ExecutiveCommittee or Board of Directors recommends an external review (Withthe exception of the Board of Directors, the MEC has final decision if anexternal review is required);

V. Notification Review Determinations

1. The individual under review will receive written notification on casesscored a 3, 4 or 5 or when trends exceed threshold parameters onestablished indicator criteria. The trend reports will be provided on theOngoing Professional Practice Feedback reports.

2. All action/follow-up/requests for interventions will be in a writtenresponse or meeting with the involved practitioner.

3. All correspondence will be confidential.

4. Copies of letters and notifications will be kept on file.

VI. InterventionsDepending upon the findings of the ongoing professional practice review,

interventions may be implemented. The criteria utilized to determine the type ofintervention includes severity, frequency of occurrence and trigger (thresholds)level exceeded. Interventions include, but may not be limited to, proctoring,focused review and corrective action.

VII. Effectiveness of Review Process1. Consistency - Cases meeting the criteria for reviewable circumstances will

undergo review, conducted according to this defined procedure.

2. Timelinessa. Routine Performance Review - Time review initiated to time case

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closed should closely adhere to a 60-day timeframe. However, theremay be circumstances when this timeline is exceeded due to externalreview process. The time frame should be adhered to as reasonable.

b. Fast Track Review - Circumstances may arise in which the reviewprocess must be expedited. This includes cases meeting theorganization's sentinel event definition. In other cases, thedetermination for fast-tracking may be left to the discretion of the Chiefof Staff, Department Chairperson or Medical Executive Committeeand corporate Quality Director. The timeframe for a Fast Track Reviewshould not exceed 45 days from the time the event is determined to bea sentinel event. This time frame should be adhered to as reasonable.

3. Defensible - The conclusions reached during the review process are to besupported by rationale that specifically address the issues for which thereview was conducted, including, as appropriate, reference to theliterature and relevant clinical practice guidelines.

4. Balanced - Minority opinions and views of the individual under review are

to be considered and recorded.

5. Useful - The results of review activities are to become part of thepractitioner's Quality profile and to be used for credentialing andprivileging decisions and, as appropriate, in performance improvementactivities.

6. Ongoing - The review conclusions are tracked over time, and actionsbased on review conclusions are monitored for effectiveness by theMedical Executive Committee.

Scoring

SCORE DEFINITION

0 No problem with process*/documentation/acts of omission or commission** orQuality of care, treatment or services provided

1 Minor problem with process*/documentation/acts of omission or commission** orQuality of care, treatment or services provided (patient outcome not affected)

2 Problem with process*/documentation/acts of omission or commission** or Qualityof care, treatment or services provided (potential for adverse consequence)

3Problem with process*/documentation/acts of omission or commission**, or Qualityof care; treatment or services provided (disease, or symptoms caused,exacerbated or allowed to progress)

4Problem with process*/documentation/acts of omission or commission**, or Qualityof care, treatment or services provided(longevity, and/or functional Quality of life shortened or adversely affected bymedical action or inaction)

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Includes, but is not limited to delays in care, treatment and services provided

** Includes, but is not limited to disruptive behavior

IX. Performance Improvement

1. Members of the medical staff are involved in activities tomeasure, assess, and improve performance on anorganization wide basis, including the ongoing professionalpractice review process defined herein.

2. The review process involves monitoring, analyzing, andunderstanding those special circumstances of practitionerperformance, which require further evaluation.

3. When findings of this process are relevant to an individual'sperformance, the medical staff is responsible for determining theiruse in ongoing evaluation of a practitioner's competence, inaccordance with the JC standards on renewing or revising clinicalprivileges.

Supporting Policies/Procedures Disruptive Behavior Policy Patient Complaint/Grievance Policy Impaired Practitioner Policy Focused Professional Practice Evaluation Policy Medical Staff Bylaws Fair Hearing Plan Allied Health Grievance Policy

ReferencesJC CAMH - MS.4.40 and MS.4.45

5 Death attributable to acts of omission or commission** or Quality of care, treatmentor services provided

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FOCUSED PROFESSIONAL PRACTICE EVALUATION POLICY

PurposeTo establish a systematic process to evaluate and confirm the currentcompetency of practitioners performance of privileges at______________hospital. This process is known as focused professional practice evaluation(FPPE or focused evaluation).

Definition of FPPEFocused professional practice evaluation is defined as a time-limited periodduring which the organization evaluates and determines a practitionersprofessional performance of privileges. FPPE will occur in all requests for newprivileges and when there are concerns regarding the provision of safe, highquality care by a current medical staff member, as recognized through the peerreview process.

This process includes an assessment for proficiency in the following six areas ofgeneral competencies:1. Patient care.2. Medical and clinical knowledge3. Practice-based learning and improvement4. Interpersonal and communication skills5. Professionalism6. Systems-based practice

Information for this evaluation may be derived from the following:1. Discussion with other individuals involved in the care of each patient (e.g.consulting physician, assistants in surgery, nursing, or administrative personnel)2. Chart review3. Monitoring clinical practice patterns4. Proctoring5. Simulation6. External peer review

ResponsibilitiesThe department chair (or division chief) shall be responsible for overseeing theevaluation process for all applicants or staff members assigned to their

department or division.

The credentials committee is charged with the responsibility of monitoringcompliance with this policy. It accomplishes this by receiving regular statusreports on the progress of all practitioners undergoing focused evaluation as wellas any issues or problems involving the implementation of this policy.

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Performance of FPPEThe type of focused professional performance evaluation to be used will bedetermined by the department chair based on the individual practitionerscircumstance using the following guidelines:

1. New applicant.a. Peer recommendations from previous institutions will be confirmed by thedepartment chair.

b. Performance indicators, or aggregate data, within the department will bemonitored.

c. FPPE peer evaluations by the department chair and one other active staffmember will be completed within 3 months of initiation of clinical activity. Thedepartment chair should seek input from colleagues, consultants, nursing

personnel, and administration.

d. Procedure and clinical activity logs will be reviewed from either previousinstitutions or training programs.

If current competency from previous institution is well-documentedthrough case logs of activity within recent year, then no additionalmonitoring is required.

If current competency and adequate clinical activity is not well-documented from previous institution, then a higher level of focusedevaluation will be necessary for this type of applicant. Specifically,concurrent chart review, proctoring, or simulation should occur to fullyevaluate the ability to perform requested privileges. The focusedevaluation plan will be determined by the department chair withapproval of the credentials committee.

2. New privilege for existing staff member.If a new requested privilege is significantly different from ones current practice,then training in the new privilege or proctoring of cases should be arranged,documented, and confirmed. This process and the number of cases necessaryshould be determined by the department chair and the credentials committee. Ifnew technology is involved, then the CSC committee recommendations should

be considered.

3. FPPE required as a result of peer review.The department chairman will establish a plan on an individual basis to beapproved by the medical executive committee when focused evaluation has beenrecommended by the department peer review committee.

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The proctor or any practitioner, however, should nonetheless render emergencymedical care to the patient for medical complications arising from the careprovided by the proctored practitioner. The hospital will defend and indemnify anypractitioner who is subjected to a claim or suit arising from his or her acts oromissions in the role of proctor.

ReferencesJC CAMH - MS.4.30

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Description of Forms in the Toolkit

Form 1000 Indicator/Criteria List and Data Source MatrixEach department and/or specialty needs indicators appropriate to the area ofpractice. The indicator/criteria for each department or division should beapproved through the Medical Staff approval process. It will be important to

identify the group accountable for providing the data so the data can be broughtforward to the practitioner driven profile. Many of the indicator/ criteria will beconsistent across the organization with the same data source. The ones that areapproved for patient care are the ones that will change the most frequently fromone department to another.

Form 2000 Ongoing Professional Practice Evidence Based DataThis form reflects the indicators/criteria presented for individual practitioners fromthe Departments/Divisions. The trigger level should be established by themedical staff.

Form 3000 Periodic Report to the Department/Division Chair from theQuality DepartmentThis form provides an example of communication from the Quality Department orMedical Staff Office to the Department Chair/Division Chair outlining practitionersin their department or division that were at trigger levels. It will be important toyour success that appropriate communication links are established and there isan appropriate action taken based on the trigger.

Form 4000 Department/Division Responses Back to the QualityDepartment or Medical Staff OfficeThis form provides an example of how the Department/Division chair starts todocument the appropriate action taken based on the periodic review.

Important Notes

1. The example forms do not include utilization or resource data (LOS, AvgCharge, variance days, SIMS, etc), but this type of information should beincluded on the profiles.

2. The data/numbers in these examples are just thatexamples. Your facilitywill need to develop your own comparisons and targets.3. Sample documents should be used as a guideline for developing your ownunique documents that fit your healthcare organization. Make certain that youuse criteria that your hospital has adopted and you follow all of your state andlocal laws.

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Form 1000

Indicator/Criteria List and Data Source MatrixEmergency Department

Indicator/Criteria CaseMgt.Review

HIM MSO QualityDept.

MRRGroup

CMEComm.

EducationDept.

UR PT.Rep

IC Pract. Pharm Adm/Dept

Patient Care

Acute MI Mgt ASA Usage X

FibrinolyticTherapy

X

Pneumonia

Blood Cultures X X

Antibiotic with 4hours X

Moderation Sedation

Reversal Rates X

Medical/ClinicalKnowledge

Hospital BasedCMEs

X

New Training orExperience

X

Board Cert-Initialor Renewal X

Interpersonal andCommunicationSkills

Pt/Family/StaffWritten PositiveFeedback

X

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Form 1000




MRRGroup

CMEComm.

EducationDept.

UR PT.Rep


Complaints from

Patients/Family X X

Practice BasedLearningImprovements

Illegible Orderssent for Review

X

Adherence toNPSG:

Abbreviations

X

UniversalProtocol X

Emergent ElderCare Protocols

System BasedPractice

Medical RecordDelinquencywarnings

X

Number ofSuspensions forDelinquency

X

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Form 1000




MRRGroup

CMEComm.

EducationDept.

UR PT.Rep


*Utilization DataReport (eg TATs,proper admissionstatus)

X

*Provided as an attachment with the Ongoing Professional Practice Evaluation

ProfessionalismMeetingsAttended

X

Complaintsrelated toProfessionalismfrom Staff

X

CasePresentation

X

Teaching anEducationalProgram

X

HIMHealth Information Management IC PractInfection Control PractitionerMSOMedical Staff Office AdmAdministration/DepartmentMRRMedical Record Review GroupUR- Utilization ReviewPT Rep = Patient Representative

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Form 2000

Ongoing Professional Practice Evaluation - Evidence Based DataDepartment of Emergency Medicine.Subspecialty if applicable N/A .Practitioner ID # 0876 Last Appointment Date July 07 .Status Active Reporting Period: 4

thQarter 2008

Indicator/Criteria Trigger Q 42008

Q 32008

Q 22008

Q 12008

Q 42007

Q 32007

Q 22007

Ytd DeptData

Ytd NatlData

Patient CareAcute MI Management

Percent receiving ASAupon arrival (except foracceptablecontraindications)

Below95%

96% 97% 100% 97% 98% 99% 95% 92% 93%

Fibrinolytic Therapywithin 30 minutes ordocumentedcontraindications

Below95%

96% 97% 96% 96% 95% 97% 95% 94% 93%

Pneumonia

Blood Cultures

Below95%

99% 96% 96% 99% 97% 95% 96% 95% 97%

Antibiotic within 4 hours Below95%

90% 96% 97% 95% 96% 97% 95% 97% 94%

Moderation SedationReversal Rates

Greaterthan 5% 3% 3% 4% 3% 5% 4% 4% 2% Not Available

Medical/ClinicalKnowledge Hospital CME Hours * 5 0 0 10 0 5 10 New Training or

Experience * Board Certification

Renewal/Initial Yes 100%

Interpersonal andCommunication Skills

Patient Family/Staff *

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Form 2000


thQarter 2008


Q 32008

Q 22008

Q 12008

Q 42007

Q 32007

Q 22007

Ytd DeptData

Ytd NatlData

Written positivefeedback

Yes Yes Yes

Complaints fromPatients/Families

3 or More1 0 1 0 1 1 1

Practice BasedLearning Improvements

Illegible Orders sent forReview

5 or More 3 2 0 0 2 2 0 4 Not Available

Adherence to NationalPatient Safety Goals:

Abbreviations 3 or More 0 2 3 2 3 4 5 3 Not Available

Universal Protocol, asapplicable

Less than90%

N/A 100% N/A N/A 90% 100% N/A 90% Not Available

Emergent Elder CareProtocols (% patients

inappropriatelydischarged)

Less than5% 2% 3% 5% 5% 9% 10% 10% 6% Not Available

System BasedPractice Medical Record

Delinquency


Number of Suspensionsfor DelinquencyWarnings


* Utilization Data Report X

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Form 2000


thQarter 2008


Q 32008

Q 22008

Q 12008

Q 42007

Q 32007

Q 22007

Ytd DeptData

Ytd NatlData

*Provided as an attachment with the Ongoing Professional Practice Evaluation.

Professionalism Meetings Attended * 2 0 1 0 3 0 1

Complaints related toProfessionalism fromStaff

1 or More 0 0 0 0 0 0 0 4

Case Presentation * 0 0 1 0 0 0 1

Teaching an EducationProgram

* 1 0 0 1 0 0 1

Reviewed and approved by Dept. of Emergency Medicine 1/15/07Reviewed and approved by Medical Executive Committee 2/11/07

Information only

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Form 3000Periodic Report

Ongoing Professional Practice EvaluationDepartment of Emergency Medicine

Reporting Period October, November, December 2008

Number of Members 52

Members Listed Below Exceeded the Trigger for Evaluation# 0876 .# _______________# _______________

The profile for each member exceeding the Trigger for Evaluation is attached foryour review. Also, attached are any additional documents that relate to thespecific findings. Please review the findings and indicate the action taken on theattached form for inclusion in the practitioners Ongoing Professional PracticeEvaluation File kept in the Quality Department.

Thank you for your help with this important Medical Staff Process.

Sue SmithDirector of Medial Staff Affairs

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Form 4000DEPARTMENT DIRECTOR RESPONSE

DEPARTMENT OF EMERGENCY MEDICINE

Reporting Period: October, November, December 2007Date: Mar 1, 2008

Physician Number : 0876 .

As the Department Chair for Emergency Medicine, I have reviewed the results ofthe Ongoing Professional Practice Evaluation for the above named physician. Ihave taken the following action:

I reviewed the findings and no further action is needed at this time.

I reviewed the findings and discussed them with the Practitioner. Thepractitioner has been informed that if the threshold is exceeded for two Quartersor more during this reappointment cycle, a focus review will be initiated based onthe Peer Review Policy.

I reviewed the findings and discussed them with the practitioner. As a result, Iam recommending a focus professional practice review by the Peer ReviewCommittee for April, May, and June 2007. The results should be forwarded to me

as a part of the practitioners Quarterly review.

Comments:The physician was receptive to our discussion

________________________________________________________________.

Dr. Thomas Quick

Department ChairDepartment of Emergency Medicine

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Form 1000

Indicator/Criteria List and Data Source MatrixAnesthesia Department

Indicator/Criteria CaseMgt.

Review


MRRGroup

CMEComm.

Education

Dept.

UR PT.Rep

ICPract.

Pharm Adm/Dept

Patient Care

Re-intubation inOR or PACU

X

Anesthesiaincidents (brokenteeth)

X

MI within 48hours postanesthesia

X

Pneumothoraxfrom Cen-lineinsertion

X


Hospital BasedCMEs

X X


X

Board Cert-Initialor Renewal

X


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Form 1000




MRRGroup

CMEComm.

EducationDept.

UR PT.Rep

ICPract.

Pharm Adm/Dept


X

Complaints fromPatients/Family

X X



X

Adherence toNPSG: labeledmeds

Abbreviations X

UniversalProtocol

X

System BasedPractice

Med RecordDelinquencyWarnings

X

Number ofSuspensions forDelinquency

X

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Form 1000




MRRGroup

CMEComm.

EducationDept.

UR PT.Rep

ICPract.

Pharm Adm/Dept

*Utilization dataReport

X


Professionalism

MeetingsAttended

X


X

CasePresentation

X


X

HIMHealth Information Management IC PractInfection Control Practitioner

MSOMedical Staff Office Adm - AdministrationMRRMedical Record Review GroupUR- Utilization ReviewPT Rep = Patient Representative

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Form 2000

Ongoing Professional Practice Evaluation - Evidence Based Data Department of Anesthesia.Subspecialty if applicable N/A .Practitioner ID # 9288 Last Appointment Date July 07 .Status Active Reporting Period: 4

thQarter 2008

Indicator Trigger Q 4

2008

Q 3

2008

Q 2

2008

Q 1

2008

Q 4

2007

Q 3

2007

Q 2

2007

Ytd

DeptData

Ytd Natl

Data

Re-intubation in OR orPACU


Anesthesia Incidents(Broken Teeth)


MI within 48 hours postanesthesia


Pneumothorax fromCDIRECTOR LineInsertion


Medical/ClinicalKnowledge Hospital CME Hours * 0 2 3 0 0 5 5

New Training or

Experience

*

Board CertificationRenewal/Initial

Yes


Patient/Family/StaffWritten positivefeedback

* Yes Yes N/A Not Available


3 or more 0 0 0 1 0 0 0 2 Not Available

ACCEPTED


31/70

April 2008 30

Form 2000


thQarter 2008


Q 32008

Q 22008

Q 12008

Q 42007

Q 32007

Q 22007

YtdDept

Data

Ytd NatlData

Practice BasedLearning Improvements Illegible Orders sent for

Review


Adherence to NationalPatient Safety LabeledMedication


Abbreviations 3 or more 3 0 2 0 2 0 4 3 Not Available


Less than90%

100% 100% 100% 95% 95% 85% 90% 92% Not Available

System Based Practice

Documentation ofappropriate pre-andpost anesthesia

assessments

Below90%

95% 90% 100% 100% 95% 90% 100% 92% Not Available

Medical RecordDelinquency


Number of Suspensionsfor Delinquency


*Utilization Data Report X


Professionalism

Meetings Attended * 1 2 1 3 1 5 2 Not Available

ACCEPTED


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April 2008 31

Form 2000


thQarter 2008


Q 32008

Q 22008

Q 12008

Q 42007

Q 32007

Q 22007

YtdDept

Data

Ytd NatlData



Case Presentation * 0 0 1 0 0 0 0


* 0 1 1 0 0 0 0

Reviewed and approved by Dept. of Anesthesia 1/15/07Reviewed and approved by Medical Executive Committee 2/11/07

* information only

ACCEPTED


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April 2008 32


Ongoing Professional Practice EvaluationDepartment of Surgery / Anesthesia







ACCEPTED


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April 2008 33


DEPARTMENT OF SURGERY/ANESTHESIA

Reporting Period: October, November, December 2008 Date:June 1, 2007


As the Department Chair for Surgery and Chair of Anesthesia, we have reviewedthe results of the Ongoing Professional Practice Evaluation for the above named

physician. I have taken the following action:



I reviewed the findings and discussed them with the practitioner. As a result, Iam recommending a focus professional practice review by the Peer Review

Committee for March, April, and May 2007. The results should be forwarded tome as a part of the practitioners Quarterly review.

Comments:The Physician was receptive to our discussion. We also noted the willingness toparticipate in the education of the staff and to participate in case presentationand extended our thanks .

Dr. Ima Cutter

Department Chair SurgeryDr. Sam SleepChair of Anesthesia

ACCEPTED


35/70

April 2008 34

Form 1000

Indicator/Criteria List and Data Source MatrixSurgery Department

Indicator/Criteria CaseMgt.

Review


MRRGroup

CMEComm.

EducationDept.

UR PT.Rep

ICPract.

Pharm Adm/Dept

Patient Care

Organ Injury X

Prophyladicantibiotic with onehour to incision

X X

Prophyladicantibioticdiscontinued within24 hrs

Compliance withDVT prevention

Postwoundinfection

X X

Post- op ventilator

associatedpneumonia

X X

Medical/ClinicalKnowledge Hospital Based

CMEs

X X


X

Board Cert-Initial orRenewal

X

ACCEPTED


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April 2008 35

Form 1000




MRRGroup

CMEComm.

EducationDept.

UR PT.Rep

ICPract.

Pharm Adm/Dept



X


X X



Adherence toNPSG:

X

Abbreviations X

Universal Protocol X

System BasedPractice History & Physical

Current/updated

X X

Informed ConsentSurgery

X

Submits SSI report

ACCEPTED


37/70

April 2008 36

Form 1000




MRRGroup

CMEComm.

EducationDept.

UR PT.Rep

ICPract.

Pharm Adm/Dept

to ICP monthly *Utilization Data

Report

X

*Provided as an attachment with the Ongoing Professional Practice Evaluation,

Professionalism

Meetings attended X

Complaints relatedto Professionalismfrom Staff

X

Case Presentation X


X

HIMHealth Information Management IC PractInfection Control PractitionerMSOMedical Staff Office Adm - AdministrationMRRMedical Record Review GroupUR- Utilization Review

PT Rep = Patient Representative

ACCEPTED


38/70

April 2008 37

Form 2000

Ongoing Professional Practice Evaluation - Evidence Based DataDepartment of Surgery .Subspecialty if applicable N/A .Practitioner ID # 2207 Last Appointment Date July 07 .Status Active Reporting Period: 4

thQarter 2008


2008

Q 3

2008

Q 2

2008

Q 1

2008

Q 4

2007

Q 3

2007

Q 2

2007

Ytd

DeptData

Ytd Natl

Data

Patient Care

Organ Injury 1 or More 0 0 0 1 0 0 0 2 Not Available

Prophyladic antibioticwithin 1hr prior tosurgical incision

Less than95%

95% 97% 100% 98% 96% 95% 98% 97% 98%

Prophyladic antibioticdiscontinued within 24hrs

Less than95%

95% 94% 90% 80% 85% 78% 75% 90%

Compliance with DVTprevention

Less than90%

93% 99% 84% 82% 88% 43% 22% 88%

Post-op wound Infection Less than2% of totalcases

.5% 0 1% 1% 0 0 0 1.0% 1.0%

Post-op ventilatorassociated pneumonia



Hospital CME Hours * 0 4 5 0 0 3 4


*

Board CertificationRenewal/Initial due 8/07

Yes 100%


Patient Family/Staff * Yes Yes

ACCEPTED


39/70

April 2008 38

Form 2000


thQarter 2008


Q 32008

Q 22008

Q 12008

Q 42007

Q 32007

Q 22007

YtdDept

Data

Ytd NatlData

Written positivefeedback


3 or more 0 0 2 0 0 0 1 4

Practice BasedLearning Improvements Illegible Orders sent for

Review



Abbreviations 3 or more 0 0 2 3 4 4 6 3 Not Available


Less than90%

100% 100% 100% 98% 100% 96% 95% 96% Not Available

System Based Practice

History & PhysicalCurrent

Less than100%

100% 100% 95% 100% 100% 100% 100% 98% Not Available

Informed Consent Less than100%

100% 100% 100% 98% 100% 100% 100% 95% Not Available

Submits SSI report toICP monthly

< 3 3 3 3 3 3 3 2 2.4 Not Available


*provided as an attachment with the Ongoing Professional Practice Evaluation.

Professionalism

ACCEPTED


40/70

April 2008 39

Form 2000


thQarter 2008


Q 32008

Q 22008

Q 12008

Q 42007

Q 32007

Q 22007

YtdDept

Data

Ytd NatlData

Meeting Attended * 3 3 2 3 1 3 3


1 or more 0 0 0 0 0 0 0 4

Case Presentation * 1 1 1


*

Reviewed and approved by Dept. of Surgery 1/15/07Reviewed and approved by Medical Executive Committee 2/11/07

ACCEPTED


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April 2008 40


Ongoing Professional Practice EvaluationDepartment of Surgery







ACCEPTED


42/70

April 2008 41


DEPARTMENT OF SURGERY

Reporting Period: October, November, December 2008Date: June 1, 2007


As the Department Chair for Surgery, I have reviewed the results of the OngoingProfessional Practice Evaluation for the above named physician. I have taken thefollowing action:



I reviewed the findings and discussed them with the practitioner. As a result, Iam recommending a focus professional practice review by the Peer ReviewCommittee for March, April, and May 2007. The results should be forwarded to

me as a part of the practitioners Quarterly review.

Comments :We reviewed the current ventilator management pathway and discussed areasfor improvement .

________________________________________________________________________________.

Dr. Ima CutterDepartment Chair for Surgery

ACCEPTED


43/70

April 2008 42

Form 1000

Indicator/Criteria List and Data Source MatrixRadiology Department

ndicator/Criteria CaseMgt.

Review


MRRGroup

CMEComm.

EducationDept.

UR PT.Rep

ICPract.

Pharm Adm/Dept

Patient Care

Percent ofAgreement forover-reads

X

ProceduralComplications

X

ModerateSedation-reversal rates

X


Hospital BasedCMEs

X X


X

Board Cert-Initialor Renewal

X

nterpersonal andCommunicationSkills


X

ACCEPTED


44/70

April 2008 43

Form 1000


ndicator/Criteria CaseMgt.Review


MRRGroup

CMEComm.

EducationDept.

UR PT.Rep

ICPract.

Pharm Adm/Dept


X

Practice BasedLearningmprovements

Critical ValuesTimeliness

X

Abbreviations X

UniversalProtocol

X

System BasedPractice History &

Physical forappropriateprocedures

X

Documentationof appropriateanesthesiaassessment formoderatesedation

X

*Utilization DataReport

X

ACCEPTED


45/70

April 2008 44

Form 1000




MRRGroup

CMEComm.

EducationDept.

UR PT.Rep

ICPract.

Pharm Adm/Dept

*Provided as an attachment with the Ongoing Professional Practice EvaluationProfessionalism

Meetings Attended X


X

CasePresentation

X


X

HIMHealth Information Management IC PractInfection Control PractitionerMSOMedical Staff Office Adm - AdministrationMRRMedical Record Review GroupUR- Utilization ReviewPT Rep = Patient Representative

ACCEPTED


46/70

April 2008 45

Form 2000

Ongoing Professional Practice Evaluation - Evidence Based DataDepartment of Radiology .Subspecialty if applicable N/A .Practitioner ID # 2244 Last Appointment Date July 07 .Status Active Reporting Period: 4

thQarter 2008


Q 32008

Q 22008

Q 12008

Q 42007

Q 32007

Q 22007

YtdDept

Data

Ytd NatlData

Patient Care

Percent of Agreementfor Over-reads

95% orless

98% 99% 100% 100% 98% 100% 100% 97%

ProceduralComplications

2 or more 0 0 0 1 0 0 0 1

Moderate Sedation

Reversal Rate

Greaterthan 5%

2% 0% 0% 1% 1% 0% 0% 2.5%

Medical/ClinicalKnowledge Hospital CME Hours * 4 2 2 0 0 3 3


*

Board CertificationRenewal/Initial due

8/2007

Yes 100%


Patient Family/StaffWritten positivefeedback

* Yes Yes Yes


3 or more 0 0 0 1 0 0 0 2

Practice BasedLearning Improvements

ACCEPTED


47/70

April 2008 46

Form 2000


thQarter 2008


Q 32008

Q 22008

Q 12008

Q 42007

Q 32007

Q 22007

YtdDept

Data

Ytd NatlData

Critical ValueTimeliness

1 or moreexceeding

2 0 0 1 0 0 0 5


Abbreviations 3 or more 0 0 0 0 2 2 1 2


Less than90%

100% 100% 96% 95% 92% 90% 90% 95%

System Based Practice History & Physical for

appropriate procedures

Less than100%

100% 100% 95% 100% 100% 100% 100% 100%

Documentation ofappropriate anesthesia

assessment formoderate sedation

Less than100%

95% 100% 96% 100% 100% 90% 85% 95%



Professionalism

Meetings attended * 2 2 2 2 0 1 2


1 or more 0 0 0 0 0 0 0 2

Case Presentation * 1

ACCEPTED


48/70

April 2008 47

Form 2000


thQarter 2008


Q 32008

Q 22008

Q 12008

Q 42007

Q 32007

Q 22007

YtdDept

Data

Ytd NatlData


* 1

Reviewed and approved by Dept. of Radiology 1/15/07Reviewed and approved by Medical Executive Committee 2/11/07

* information only

ACCEPTED


49/70

April 2008 48


Ongoing Professional Practice EvaluationDepartment of Radiology







ACCEPTED


50/70

April 2008 49


DEPARTMENT OF RADIOLOGY

Reporting Period: October, November, December 2008Date: June 1, 2007


As the Department Chair for Radiology, I have reviewed the results of theOngoing Professional Practice Evaluation for the above named physician. I have

taken the following action:



I reviewed the findings and discussed them with the practitioner. As a result, Iam recommending a focus professional practice review by the Peer Review

Committee for March, April, and May 2007. The results should be forwarded tome as a part of the practitioners Quarterly review.

Comments:

________________________________________________________________

Dr. Patty Picture

Department ChairDepartment of Radiology

ACCEPTED


51/70

April 2008 50

Form 1000

Indicator/Criteria List and Data Source MatrixAllied HealthPA

ndicator/Criteria CaseMgt.

Review


MRRGroup

CMEComm.

EducationDept.

UR PT.Rep

ICPract.

Pharm Adm/Dept

Corrections toH&P X

Feedback onaseptictechnique

X X

Feedback onsurgical skills

X X


CE Hours X X


X

nterpersonal andCommunicationSkills

Feedbackrelated tocommunicationskills

X

ACCEPTED


52/70

April 2008 51

Form 1000




MRRGroup

CMEComm.

EducationDept.

UR PT.Rep

ICPract.

Pharm Adm/Dept

Complaints fromPatients/Family X

Practice BasedLearningmprovements


X

Adherence toNPSG:

Abbreviations X

UniversalProtocol

X X X

System BasedPractice Timeliness of

H&Ps

X

Dating andTiming of entries

X

*Utilization DataReport

X

Professionalism

ACCEPTED


53/70

April 2008 52

Form 1000




MRRGroup

CMEComm.

EducationDept.

UR PT.Rep

ICPract.

Pharm Adm/Dept

Feedbackrelated toProfessionalismfrom Staff

X X


HIMHealth Information Management IC PractInfection Control PractitionerMSOMedical Staff Office AdmAdministration/DepartmentMRRMedical Record Review GroupUR- Utilization ReviewPT Rep = Patient Representative

ACCEPTED


54/70

April 2008 53

Form 2000

Ongoing Professional Practice Evaluation - Evidence Based DataDepartment of Surgery .Subspecialty if applicable Allied Health/PA.Practitioner ID # 2143 Last Appointment Date .Status Active Reporting Period: 4

thQarter 2008


2008

Q 3

2008

Q 2

2008

Q 1

2008

Q 4

2007

Q 3

2007

Q 2

2007

Ytd

DeptData

Ytd Natl

Data

Patient Care

Corrections to H&P 2 or moreH&Ps withcorrections

0 0 0 3 1 0 0 1.2 Not Available

Feedback on aseptictechnique

1 or morebreaks

0 0 1 0 0 0 0

Feedback on surgicalskills

Below 4rating onfeedback

4 4 4 4 4 4 3 3.5 Not Available

Medical/ClinicalKnowledge CE Hours * 10 4 6 0 8 16 0


* Yes newortho

systemInterpersonal andCommunication Skills

Feedback related tocommunication skills

Score of 2 orless

3 3 3 3 3 3 3 3 Not Available



Practice BasedLearning Improvements Illegible Orders sent for 2 or more 0 0 0 0 0 0 0 2 Not Available

ACCEPTED


55/70

April 2008 54

Form 2000

Ongoing Professional Practice Evaluation - Evidence Based DataDepartment of Surgery .Subspecialty if applicable Allied Health/PA.Practitioner ID # 2143 Last Appointment Date .Status Active Reporting Period: 4

thQarter 2008


Q 32008

Q 22008

Q 12008

Q 42007

Q 32007

Q 22007

YtdDept

Data

Ytd NatlData

Review


Abbreviations


Universal Protocol,as applicable

Less than90%

100% 100% 100% 100% 95% 90% 95% 95% Not Available

System Based Practice Timeliness of H&P 2 or more 0 1 1 0 2 0 1 4 Not Available

Dating and timing ofentries

Less than90%

90% 90% 90% 85% 80% 80% 75% 80% Not Available


Professionalism Meeting Attended * 0 3 2 0 2 2 2 Not Available

Feedbacks related to

Professionalism fromStaff

Score of 2 or

less

3 3 3 3 3 3 3 3 Not Available


* Information onlyReviewed and approved by Dept. of Surgery 1/15/07Reviewed and approved by Medical Executive Committee 2/11/07

ACCEPTED


56/70

April 2008 55


Ongoing Professional Practice EvaluationDepartment of SurgerySubspecialty PA







ACCEPTED


57/70

April 2008 56


DEPARTMENT OF SURGERY

Reporting Period: October, November, December 2008 Date:June 1, 2007

Practitioner Number : 2143 (PA) .

As the Department Chair for Surgery, and the Director of the PhysiciansAssistants we have reviewed the results of the Ongoing Professional PracticeEvaluation for the above named allied health member. We have taken thefollowing action:



I reviewed the findings and discussed them with the practitioner. As a result, Iam recommending a focus professional practice review by the Peer ReviewCommittee for March, April, and May 2007. The results should be forwarded to

me as a part of the practitioners Quarterly review.

Comments:

________________________________________________________________.

Dr. Ima Cutter

Dept Chair SurgeryHope Floats, PADirector of Physicians Assistant

ACCEPTED


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April 2008 57

APPENDIX

ACCEPTED


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April 2008 58

EXAMPLEEvaluation of Surgical PA4thQarter 2008

Please rate the following individual________________________________________ in the areas listed below:

1). Communication with staff/patients

1 2 3 4 5Poor Fair Average Good Excellent

For a score of 2 or below, please provide examples:

2). Professionalism

1 2 3 4 5Poor Fair Average Good Excellent

For a score of 2 or below, please provide examples:

3). Aseptic Technique

Has the individual had any reported breaks in sterile technique for thisreporting period? If so, please provide details and any actions taken.

ACCEPTED


60/70

April 2008 59

EXAMPLEPA COMPETENCY EVALUATION

Operative Performance Rating Form

PA_______________________________________________

Please circle the number corresponding to the residents performance in each area,irrespective of training level.

Knowledge of Operative Steps

1 2 3 4 5Unfamiliar with the steps of the operation;Unable to recall or describe many operative steps

Instrument Handling

1 2 3 4 5Makes tentative or awkward moves byinappropriate used of instruments

Knowledge of Instruments

1 2 3 4 5FreQently asks for wrong instruments orused inappropriate instruments

Flow of the Operation

1 2 3 4 5FreQently stopped operating andseemed unsure of next move

Respect For Tissue

1 2 3 4 5FreQently used unnecessary force on tissue or

caused damage by inappropriate use of instruments

Physician Signature: ____________________ Date: ______________________

ACCEPTED


61/70

April 2008 60

Examples of Medical Staff Indicators

TIPS:1. Whenever possible, use data that is already collected and/or is easily

obtained

2. Select measures that relate to problems for your facility3. Assure that measures are pertinent to the specialty of the physician and

his/her requested privileges (some physicians may need a combinationform from 2 or more specialties)

4. Clearly define/specify all indicators so that everyone understands what isbeing measured and how it is to be measured

5. Dont select too many measures, but assure that you have enough to trulyevaluate the physicians performance

General

Core Measure compliance (as pertinent to practice) Readmissions within 31 days for related condition

Unscheduled return to ED within 48 hours

Discharge summary

Unexpected transfer or return to ICU

Pharmacy interventions and reasons (i.e. duplicative therapy, incomplete orunclear orders, dosing errors, ordering medications to which a patient has aknown allergy, etc.)

ALOS (overall and/or by pertinent targeted DRGs)

Average charge or cost per pertinent targeted DRG

Variance days

Assignment of patients to correct status (IP vs Observation vs OP) Resource overutilization (lab, imaging, etc)

Antibiotic usage

Blood usage (CT ratio, inappropriate units, etc)

Non-compliance with hospital protocols and care paths (eg DVT prevention)

Patient Complaints

Incident reports

Disruptive behavior

Responsiveness to ER call

Delays in responding to calls from nursing regarding critical values and/or a

change in the patients condition Mortality rates

Meeting attendance

CMEs as required

H&P in 24 hours and updated preop

Documentation issues (eg MS-DRGs)

ACCEPTED


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April 2008 61

Timeliness of consultation requests

Use of Do not use abbreviations

Legibility

Delinquent medical records

Signing/timing/authenticating medical record entries per CMS guidelines

Compliance with hand hygiene

Surgical

Volume of procedures by type of procedure

Post-operative mortality

Complications

Organ injury

Excessive bleeding/hemorrhage

Retained foreign body

Readmissions within 30 days Returns to OR

Infections

Admission from Ambulatory Surgery

Discrepancies (tissue: non-tissue)

Normal tissue/organ removed

Submits monthly SSI log to ICP

Documentation of timely post-op note

Compliance with Universal Protocol

Delays in OR start times due to physician being late

Anesthesia (& Related Moderate Sedation Practitioners)

Deaths

Respiratory arrests

MI or CVA within 48 hours postop

Injury to peripheral nerves

Anesthesia incidents (injury secondary to intubation, broken teeth, etc.)

Use of reversal agents

Documentation of pre/post anesthesia notes

Labeling medications Medication security breaches

Participation during final time-out

ACCEPTED


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April 2008 62

OB

C-Section Rates (Primary, repeat, total)

VBACs

Induction rates

% of inductions meeting critieria Rates of operative Vaginal Deliveries (forceps or vacuum)

Shoulder Dystocia rates/outcomes

Neonatal Birth Injuries

Rates of 3rd & 4th degree laceration

Cases of severe Neonatal Depression: Apgar < 3@ 5 minutes or ongoingresuscitation @ 5 minutes

Neonatal Transfers to higher level of care

Deliveries at less than 36 weeks gestation

Intrapartum Fetal Death 24 weeks

Readmissions related to an obstetric complication

PP infection Maternal hemorrhage

ER

Wait times (to see ER Physician)

Door to door time (overall)

Complaints

AMAs & LWOTs

Returns within 72 hours

Medical Record completion

Complications

EEC initiative (patients not discharged when adm/obs criteria met)

Compliance with AMP protocols

Misinterpretation of diagnostic test (imaging, EKG)

Imaging Related Procedures

Volumes data by invasive procedures

CT-guided or US-guided BX complications Imaging interpretation discrepancies (may wish to focus on certain studies

such as mammography or head CT)

Delays in reporting a critical finding to ordering/attending physician

ACCEPTED


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April 2008 63

Pediatrics

Volume of invasive procedures (lumbar puncture, umbilical artery catheter,etc)

Medication safety issues (dosing errors, etc)

Outcomes for certain diagnosis (examples: asthma, pneumonia, RSV)

GI

Perforations

Reversal agents

ENT

Post-op Bleeding (T&A)

Path

Discrepancy between Frozen section and final report

Reversed Cytology

Reversed Bone Marrow

ACCEPTED


65/70

April 2008 64

SAMPLE PRIVILEGE ELIGIBILITY CRITERIA

General Medical Staff Procedural Sedation Overview. Procedural sedation isa drug-induced depression of consciousness during which patients respondpurposefully to verbal commands, either alone or accompanied by light tactile

stimulation. Procedural sedation is a credentialed privilege of the Medical Staff.Ordering, administering and monitoring of IV Procedural Sedation for all patientsin all areas of the Hospital shall be guided by Administrative Policy: IV Sedation.IV procedural sedation may be administered by an RN as ordered by a medicalstaff appointee who is physically present. This policy does not apply to PCApumps, pain medication unrelated to IV procedural sedation, deep sedation orany privilege credentialed to the medical staff.

General Medical Staff Procedural Sedation - AdultEducation: MD, DO, DDS, DMD or DPM. Minimum formal training:Completion of an ACGME/AOA/ADA-accredited advanced/ABPM residency

program, and /or approved fellowship that included the use of proceduralsedation in their practice. Required previous experience: The applicant must beable to demonstrate that he or she has provided procedural sedation for at least12 patients in the past 24 months. ReappointmentApplicants must be able todemonstrate that they have maintained competence by showing evidence thathe/she has administered procedural sedation for at least 5 patients in the past 24months. If the physician has not performed 5 procedures in the past 24 monthsthe physician is to be concurrently observed for the first 2 procedures.

(or)Education: MD, DO, DDS, DMD or DPM. Minimum formal training: ACLSCertification. The applicant must be concurrently observed for the first 3 cases.Reappointment: Current ACLS Certification. The applicant must be able todemonstrate he/she has maintained competency by showing evidence thathe/she has administered procedural sedation for at least 5 patients in thepast 24 months. If the physician has not performed 5 procedures the physicianmust be concurrently observed for the first 2 procedures.

(or)Education: MD, DO, DDS, DMD or DPM. Minimum formal training: Successfulcompletion of XYZ Hospital MEC approved Procedural Sedation Self-TeachingModule. The applicant must be concurrently observed for the first 3 cases.Reappointment: Successful completion of XYZ Hospital MEC approvedProcedural Sedation Self-Teaching Module. The applicant must be able todemonstrate he/she has maintained competency by showing evidence thathe/she has administered procedural sedation for at least 5 patients in the past 24months. If the physician has not performed 5 procedures the physician must beconcurrently observed for the first 2 procedures.

General Medical Staff Procedural Sedation -Pediatric

ACCEPTED


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April 2008 65

Education: MD, DO, DDS, DMD or DPM. Minimum formal training: Completionof an ACGME/AOA/ADA-accredited advanced/ABPM residency program, and/orapproved fellowship that included the use of procedural sedation for pediatricpatients in their practice.Required previous experience: The applicant must be able to demonstrate that

he or she has provided procedural sedation for at least 12 pediatric patients inthe past 24 months.ReappointmentApplicants must be able to demonstrate that they havemaintained competence by showing evidence that he/she has administeredprocedural sedation for at least 5 pediatric patients in the past 24 months. If thephysician has not performed 5 pediatric procedures in the past 24 months

DEPARTMENT PRIVILEGE ELIGIBILITY CRITERIA: Ventilator ManagementIncluded in basic privileges for Anesthesiology, Thoracic Surgery, EmergencyMedicine and Pulmonary Disease. Privileges in Cardiovascular Disease, Family

Practice, Internal Medicine, Neurosurgery, Pediatrics, General Surgery, VascularSurgery require documentation of management of 20 patients on ventilatorsduring an accredited residency or under the supervision of a physician skilled inventilator management. Required previous experience (also required forreappointment): Satisfactorily managed four (4) patients on ventilator in past 24months.

Department of Family Practice Privileges & Clinical ObservationQualifications:

A. Privileges will be considered for physicians who have completed a FamilyPractice residency program and are board certified or actively pursuing boardcertification by a board approved by the ACGME or the AOA.B. Hospital Experience: Applicants must demonstrate, to the satisfaction of theDepartment of Family Practice, current clinical competence in an acute caresetting (within the past two years) for all privileges requested.C. Physicians who qualify for medical staff appointment but cannot documentrequired current competency and/or recent hospital experience may apply forReferring category status. Referring Category physicians may not admit patients,treat, or write orders for patient care but are the physician is to be concurrentlyobserved for the first 2 pediatric procedures.

(or)Education: MD, DO, DDS, DMD or DPM. Minimum formal training: PALSCertification. The applicant must be concurrently observed for the first 3 cases.Reappointment: Current PALS Certification. The applicant must be able todemonstrate he/she has maintained competency by showing evidence thathe/she has administered procedural sedation for at least 5 pediatricpatients in the past 24 months. If the physician has not performed 5 pediatricprocedures the physician must be concurrently observed for the first 2 pediatricprocedures.

ACCEPTED


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April 2008 66

(or)Education: MD, DO, DDS, DMD or DPM. Minimum formal training: Successfulcompletion of XYZ Hospital MEC approved Procedural Sedation Self-TeachingModule. The applicant must be concurrently observed for the first 3 pediatriccases. Reappointment: Successful completion of XYZ Hospital MEC approved

Procedural Sedation Self-Teaching Module. The applicant must be able todemonstrate he/she has maintained competency by showing evidence thathe/she has administered procedural sedation for at least 5 pediatric patients inthe past 24 months. If the physician has not performed 5 pediatric procedures thephysician must beconcurrently observed for the first 2 pediatric procedures.

FAMILY PRACTICE DEPARTMENT ELIGIBILITY CRITERIAA. ICU Admissions require a Family Practice physician to have the first 3admissions retrospectively reviewed by a Family Practice physician with the

privilege.B. OB deliveries require a Family Practice physician to have the first 3 deliveriesretrospectively reviewed by a Family Practice or OB-GYN physician with theprivilege.

Department of Family Practice Cesarean Section ParticipationPhysician is required to obtain co-management by an NRP certified Pediatrician,Neonatologist, or Neonatologist supervised NNP for a Family Practice physicianto participate/attend a cesarean section.

Department of Family Practice Level II Pediatric High Risk PrivilegesPhysician is required to obtain consultation and/or co-management by an NRPcertified Pediatrician, Neonatologist, or Neonatologist supervised NNP toparticipate in the care of Level II newborns.Observation The Family Practice may impose observation if it is determined tobe appropriate.

ACCEPTED


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April 2008 67

CONFIDENTIAL

Surgical Care Proctoring Evaluation Form

Procedure_________________________________ Procedure Date____________

Procedure was carried out without an unusual occurrence/outcome

There was an unusual occurrence/outcome (describe in comment section below)

There were no technical issues during the procedure

There were technical issues during the procedure (describe in comment sectionbelow)

Preoperative and postoperative documentation was appropriate and thorough

There were issues with preoperative and/or postoperative documentation (describe

in comment section below)

COMMENTS (explain observations and/or issuesmay continue on reverse side orattach additional sheets if additional space is needed)

Signature of observing physician

PLEASE RETURN COMPLETED FORM TO ______________________________

Patient Name________________________________

MR #______________________

ACCEPTED


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April 2008 68

Medical Staff Case Review Tool

Meeting Date: _____________________

Hosp/ MR #Event

Date(s)Indicator and Description

Source of Referral

_ __ Quality Indicator __ _ Nursing/other clinical staff concern____Pattern of clinical or behavioral issues __ _ Other Medical Staff Member____Patient/Family complaint ____QCC/Incident Report____Potential litigation (attorney requests record) ____Formal notice of litigation

Evaluation of Case

1) Does the case represent a deviation from the standard of care for this patient population? No Yes*2) Were the H&P, OP notes, and Progress notes adequate and timely? No* Yes3) Were there any identifiable breakdowns in communication? No Yes*4) Was judgment/decision making sound in this case? No* Yes5) Were there any clinical process problems that contributed to the patient outcome? No Yes*6) Could this incident have been readily prevented? No Yes*7) Is there an educational opportunity? No Yes*8) Was the management/documentation of the case a problem after the complication occurred? No Yes*9) Is there a strong probability that this case will lead to litigation? No Yes*

*Explanation of any above noted deviations:_______________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Reviewing physician signature and date:

ACCEPTED


70/70

Severity (Patient Outcome)0 No problem or complication unrelated to quality/safety issue1 Minor problem or complication2 Problem with significant but temporary adverse affect on patient (example- extended LOS, extra

surgery, etc)3 Problem with significant adverse affect on patient that is likely to be longer-term (ie pain, mobility,

dietary restrictions, other problems)4 Problem as #3 but with permanent disability/significant injury5 Death possibly related to quality/safety issue6 Death likely related to quality/safety issue7 Unknown outcome

Action by Committee1 No action other than documentation in minutes and record for profile2 Trend3 Telephone or verbal discussion4 Letter to practitioner with no request for response5 Letter to practitioner with request for response6 Counseling conversation between Chair & practitioner

7 Request practitioner to attend MSPR meeting to discuss case8 Intensive review of _____ additional cases9 Referred for review by outside reviewer10 Referred for Root Cause Analysis11 Classified as a Sentinel Event12 Refer to Medical Staff Executive Committeeto assess potential disciplinary action13 Refer to Hospital Patient Safety Team or IQC for concerns about hospital processes14 Consider medical staff education session on topic:

_________________________________________

Additional ActionsA Mandatory consultation for specific type of cases as noted______________B Suspension of privileges-type/timeframe specified_____________________

C Report to Data Bank ____________________________________________D Other:___________________________________________________________

ACCEPTED

OPPE Dokter Di RS_english

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