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OPPE-FPPE
Physician Performance Toolkit

Contributed by

LifePoint Hospitals
Brentwood, 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 Joint
Commission can make no representations as to the results that any organization can expect from
their use 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 continuous


evaluation of a practitioners performance using an evidence-based approach
that 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 or
denial of privileges.

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

Focused Professional Practice Evaluations (Focused Review) -


A time-limited evaluation of practitioner competence in
performing a specific 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

Practitioner Individual 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 Evidence


Based Ongoing Professional Practice Evaluation

Step One
Complete a worksheet for each department and sometimes subspecialties
within the department based on what is already being measured. Compare the
list to the practitioners privilege list for specialties and subspecialties assigned
to that department. You must be collecting data that relates to what they are
privileged to perform.

Step Two
If the list is inadequate, meet with the Department Chair or other appropriate
medical staff member to add appropriate indicators. Develop a matrix of data
source. Again, using privilege list to make sure the data represents what the
members are privileged to do.

Step Three
Seek approval of the criteria by the appropriate medical staff leaders and/or
committees.

Step Four
Create the profiles from the indicator worksheet.

Step Five
Define 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 the
Quality Department or appropriate Quality group based on your structure.

Step Seven
Set up a process for the feed back to reach the database (file) of the
individuals being 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 Department Page 19

Anesthesia Department Page 26

Surgery Department Page 34

Radiology Department Page 42

Physician Assistant Surgery Department Page 50

Appendix
Examples of Evaluation Sheet for Surgical PA Page 58

Example Indicators Page 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 Evaluation


EXAMPLE POLICY
JC Standards: MS.4.40 and MS.4.45

Purpose
1. 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 Professional
Practice Evaluation, will be utilized as screening triggers for a possible Focused
Professional Practice Evaluation).
3. To ensure the information resulting from the ongoing professional practice
evaluation is used to determine whether to continue, limit or revoke any existing
privileges;
4. To define the process for collecting, investigating, and addressing clinical practice
concerns, including the process utilized to identify trends that impact Quality of care
and patient safety;
5. To ensure reported concerns regarding a privileged practitioner's professional
practice are uniformly investigated and addressed as defined by hospital
policy and applicable law;
6. To define those circumstances in which an external review or focused review
may be necessary; and
7. To define the medical staff's leadership role in the organization's performance
improvement activities related to practitioner performance and ensure that when
the findings are relevant to an individual's performance, the findings in the ongoing
evaluations of competence are in accordance with recognized standards.

Scope
This policy applies to all Medical Staff and Allied Health Professionals privileged through
medical staff mechanisms at the hospital.

Definitions
Focused Professional Practice Evaluations (Focused Review) - A
time- limited evaluation of practitioner competence in performing a
specific
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.

Ongoing Professional Practice Evaluation - A documented summary of


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

Practitioner - For purposes of this policy, practitioner is defined as


individuals with Medical Staff or Allied Health privileges.
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Policy
1. 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; and
d. 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
professional performance will be uniformly investigated and
addressed as defined by the organization and applicable law.
3. Relevant information from the practitioner performance review process
will be integrated into performance improvement initiatives and will be
utilized 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 bylaws
for further evaluation should be followed. It is not intended that this
policy supersede any provisions of the Medical Staff Bylaws. If the
performance of the practitioner is sufficiently egregious, the Chief of
Staff or CEO shall determine, within his/her sole discretion, whether
the provisions of this policy need not be followed, whereupon the
provisions of the Bylaws, and not this policy, shall govern.
5. The activities of the ongoing professional practice evaluation are
considered privileged and confidential.

Procedure

A. Screening

1. Quality Director, or designee will perform concurrent and retrospective chart


review 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 the
professional performance of a practitioner.
3. When appropriate, feedback sheets will be provided to key leaders in
the hospital.

B. Criteria/Indicators
1. 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; and
f. 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


the Medical Executive Committee, Department Chairperson, and/or
Department 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 in


conjunction with this policy.

III. Definitions and Responsibilities

1. Screener
a. Definition - Quality Director, or designee

b. Responsibility - If a case meets the screening indicator criteria, the


screener will refer to a peer screener.

2. Quality Director/Designee
a. Definition - Individual responsible for coordinating and facilitating
review activities
b. Responsibility -
i. Identifies appropriate peer screeners utilizing the roster
provided by Medical Staff Office and collaborates with the
Department 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 for


cases 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 the


peer screener;

v. Provides periodic summary reports (Ongoing Professional


Practice Feedback Reports) on an ongoing basis to individual
practitioners, Department Chairpersons. Summary Reports will
be shared with Department Credentials Committee and MEC
and patterns/trends identified. The summary reports for review
by Department chairs will include the documentation of the
peer reviewers. The Department chair is looking for trends
based on the review by peers. Utilization review data, as
appropriate, will also be provided.

3. Peer Screener
a. 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 the
completed form to the Quality Director; and

ii. Documents on the form pertinent findings to support the


assigned review score, and identifies opportunities for
improvement and recommends any need for further
action/intervention.

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

b. Responsibility
i. Retains final responsibility for practitioner performance within
the 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 may
v. request an external review;
vi. Facilitates and provided oversight of any recommended
actions/interventions; and
vii. Presents cases findings as appropriate at medical staff
committee meetings as part of the performance improvement
process.

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viii. Reviews the Ongoing Professional Practice Feedback Reports


and meets with individual practitioners when trends or
suboptimal performance is identified.
ix. Implements a Focused Professional Practice Evaluation when
indicated.
5. Peer Review Panel
a. Definition - The Peer Review Panel consists of practitioners assigned
by the Department Chairperson, and may include others as
designated 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); and
iii. 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 Evaluation
when indicated.

6. Department Credentials Committee


a. Definition - Defined in Medical Staff Bylaws
b. Responsibility -
i. Considers all documented cases which have been reviewed
and 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 Committee


a. 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 it
pertains to cases scored a 4 or 5 and takes actions as
appropriate;
iii. Considers all documented cases, which meet the criteria for
review, at the time of renewing, revising, limiting or revoking
existing privileges.
iv. Recommends a Focused Professional Practice Evaluation
when indicated.

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v. Reports and recommends to the Board of Directors regarding


Ongoing Professional Practice Review and Focused
Professional Practice Evaluation activities, as appropriate.

8. Individual Under Review


a. Definition - The individual whose performance is being reviewed.

b. Responsibility
i. 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 Specific


Circumstances

1. Assignments
a. The Quality Director will identify a peer screener utilizing the roster
provided by the Medical Staff Office and in collaboration with the
Department Chairperson.

b. If the Department Chairperson is the individual being reviewed, the


Chief 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 of


interest will preclude an individual from making a performance review
determination in the evaluation of the performance of another practitioner. A
conflict of interest may exist if the reviewer has significant financial interest in
the hospital or direct professional or personal involvement in the case under
evaluation. In those cases the Department Chairperson or Chief of Staff will
assign an alternate peer screener. If necessary, hospital legal counsel may
be contacted to assist in identifying a review process that will minimize
conflict of interest.

3. Special Peer Review Panels - If requested by the Chief of Staff, MEC or


Department Chairperson, a special panel of peers may be assigned to
review the case.

a. External Review - External performance review is required under


the following 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


appropriately resolved by the MEC or Board of Directors.
b. Lack of Internal Expertise - There is no peer on staff with similar or like
privileges in the specialty under review.
c. Ambiguity - There is confusion when internal reviews reach conflicting
or vague conclusions.
d. Litigation - When the hospital faces a potential medical malpractice
suit, corporate legal counsel or risk management may recommend
external review.
e. New Technology/Technique There is a new technology/technique
involved that the hospital does not have the expertise to assess
whether the practitioner possesses the required skills associated with
the new technology/technique.
f. Miscellaneous - The Department Chairperson, Medical Executive
Committee or Board of Directors recommends an external review
(With the exception of the Board of Directors, the MEC has final
decision if an external review is required);

V. Notification Review Determinations

1. The individual under review will receive written notification on cases


scored a 3, 4 or 5 or when trends exceed threshold parameters on
established indicator criteria. The trend reports will be provided on
the Ongoing Professional Practice Feedback reports.

2. All action/follow-up/requests for interventions will be in a written


response or meeting with the involved practitioner.

3. All correspondence will be confidential.

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

VI. Interventions
Depending upon the findings of the ongoing professional practice
review, interventions may be implemented. The criteria utilized to determine the
type of intervention 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 Process


1. Consistency - Cases meeting the criteria for reviewable circumstances will
undergo review, conducted according to this defined procedure.

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

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closed should closely adhere to a 60-day timeframe. However, there


may be circumstances when this timeline is exceeded due to external
review process. The time frame should be adhered to as reasonable.
b. Fast Track Review - Circumstances may arise in which the review
process must be expedited. This includes cases meeting the
organization's sentinel event definition. In other cases, the
determination for fast-tracking may be left to the discretion of the
Chief of Staff, Department Chairperson or Medical Executive
Committee
and corporate Quality Director. The timeframe for a Fast Track Review
should not exceed 45 days from the time the event is determined to
be a sentinel event. This time frame should be adhered to as
reasonable.

3. Defensible - The conclusions reached during the review process are to be


supported by rationale that specifically address the issues for which the
review was conducted, including, as appropriate, reference to the
literature 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 the


practitioner's Quality profile and to be used for credentialing and
privileging decisions and, as appropriate, in performance improvement
activities.

6. Ongoing - The review conclusions are tracked over time, and actions
based on review conclusions are monitored for effectiveness by the
Medical Executive Committee.

Scoring

SCORE DEFINITION

0 No problem with process*/documentation/acts of omission or commission** or


Quality of care, treatment or services provided

1 Minor problem with process*/documentation/acts of omission or commission** or


Quality of care, treatment or services provided (patient outcome not affected)

2 Problem with process*/documentation/acts of omission or commission** or Quality


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

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

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5 Death attributable to acts of omission or commission** or Quality of care, treatment


or services provided

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 to


measure, assess, and improve performance on an
organization wide basis, including the ongoing professional
practice review process defined herein.

2. The review process involves monitoring, analyzing, and


understanding those special circumstances of practitioner
performance, which require further evaluation.

3. When findings of this process are relevant to an individual's


performance, the medical staff is responsible for determining their
use in ongoing evaluation of a practitioner's competence, in
accordance with the JC standards on renewing or revising clinical
privileges.

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

References
JC CAMH - MS.4.40 and MS.4.45

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FOCUSED PROFESSIONAL PRACTICE EVALUATION POLICY

Purpose
To establish a systematic process to evaluate and confirm the current
competency of practitioners performance of privileges at
hospital. This process is known as focused professional practice
evaluation (FPPE or focused evaluation).

Definition of FPPE
Focused professional practice evaluation is defined as a time-limited period
during which the organization evaluates and determines a practitioners
professional performance of privileges. FPPE will occur in all requests for new
privileges and when there are concerns regarding the provision of safe, high
quality care by a current medical staff member, as recognized through the peer
review process.

This process includes an assessment for proficiency in the following six areas
of general competencies:
1. Patient care.
2. Medical and clinical knowledge
3. Practice-based learning and improvement
4. Interpersonal and communication skills
5. Professionalism
6. 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 review
3. Monitoring clinical practice patterns
4. Proctoring
5. Simulation
6. External peer review

Responsibilities
The department chair (or division chief) shall be responsible for overseeing
the evaluation process for all applicants or staff members assigned to their
department or division.

The credentials committee is charged with the responsibility of monitoring


compliance with this policy. It accomplishes this by receiving regular status
reports on the progress of all practitioners undergoing focused evaluation as
well as any issues or problems involving the implementation of this policy.

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Performance of FPPE
The type of focused professional performance evaluation to be used will
be determined by the department chair based on the individual
practitioners circumstance using the following guidelines:

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

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


monitored.

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

d. Procedure and clinical activity logs will be reviewed from either


previous institutions or training programs.
If current competency from previous institution is well-documented
through case logs of activity within recent year, then no additional
monitoring is required.
If current competency and adequate clinical activity is not well-
documented from previous institution, then a higher level of
focused evaluation will be necessary for this type of applicant.
Specifically,
concurrent chart review, proctoring, or simulation should occur to fully
evaluate the ability to perform requested privileges. The focused
evaluation plan will be determined by the department chair with
approval 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 necessary
should be determined by the department chair and the credentials committee.
If new 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 be
approved by the medical executive committee when focused evaluation has
been recommended by the department peer review committee.

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4. When a privilege is used infrequently.


The department should determine a minimum number of cases to be performed
to maintain proficiency. This should be denoted in the delineation of privileges
plan. If the minimum amount is not being met, then the department chairman
will establish a plan for focused evaluation.

Duration of FPPE
FPPE shall begin with the applicants first admission or performance of the newly
requested privilege. Each department/division will determine the number of
cases or charts to be reviewed. FPPE for new applicants should be completed by
3 months. This will allow for further evaluation, if indicated, prior to the end of the
initial appointment cycle. All proctoring activity, summaries, and reports need to
be completed prior to the end of the 12 month initial appointment cycle. If the
FPPE has not been completed, then unrestricted privileges will not be granted.

Supervision of FPPE
Assignment of focused professional practice evaluations will be the
responsibility of the department chair or division chief. The chair/chief may
appoint active staff members to complete the appropriate tasks. Division
consultants and medical directors should be utilized. It is recommended that
each department establish a panel of proctors.

Proctor Qualifications
If proctoring is required, the following guidelines should be used:
1. Proctors must be in good standing of the active medical staff of MHMH.
2. The proctor must have unrestricted privileges to perform any procedure to
be concurrently observed.
3. Proctors will be mutually agreed upon between the department chair and
the physician being proctored.
4. The proctor may be a member of the same practice group as the
physician being proctored.

Responsibilities of Proctors
1. Proctor shall directly observe the procedure being performed, concurrently
observe medical management or retrospectively review the completed
medical record following discharge and will complete appropriate forms.
2. Ensure confidentiality of proctor results and forms. Submit completed forms
to the medical staff office.
3. Submit a summary report at conclusion of proctoring period.
4. If at any time during the proctoring period the proctor has concerns about the
practitioners competency to perform specific clinical privileges or care related
to a specific patient, the proctor shall promptly notify the department chair.

Medical Staffs Ethical Position on Proctoring


Concurrent proctoring is one method of evaluation for competency for
procedures that may be used. The proctor is not a mentor or a consultant.
The proctor is an agent of the hospital. The proctor shall receive no
compensation from any patient for this service.

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The proctor or any practitioner, however, should nonetheless render emergency


medical care to the patient for medical complications arising from the care
provided by the proctored practitioner. The hospital will defend and indemnify
any practitioner who is subjected to a claim or suit arising from his or her acts or
omissions in the role of proctor.

References
JC CAMH - MS.4.30

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Description of Forms in the Toolkit

Form 1000 Indicator/Criteria List and Data Source Matrix


Each department and/or specialty needs indicators appropriate to the area of
practice. The indicator/criteria for each department or division should be
approved through the Medical Staff approval process. It will be important to
identify the group accountable for providing the data so the data can be brought
forward to the practitioner driven profile. Many of the indicator/ criteria will be
consistent across the organization with the same data source. The ones that
are approved for patient care are the ones that will change the most frequently
from one department to another.

Form 2000 Ongoing Professional Practice Evidence Based Data


This form reflects the indicators/criteria presented for individual practitioners
from the Departments/Divisions. The trigger level should be established
by the
medical staff.

Form 3000 Periodic Report to the Department/Division Chair from the


Quality Department
This form provides an example of communication from the Quality Department or
Medical Staff Office to the Department Chair/Division Chair outlining practitioners
in their department or division that were at trigger levels. It will be important to
your success that appropriate communication links are established and there is
an appropriate action taken based on the trigger.

Form 4000 Department/Division Responses Back to the Quality


Department or Medical Staff Office
This form provides an example of how the Department/Division chair starts to
document the appropriate action taken based on the periodic review.

Important Notes
1. The example forms do not include utilization or resource data (LOS,
Avg Charge, variance days, SIMS, etc), but this type of information should
be included on the profiles.
2. The data/numbers in these examples are just thatexamples. Your facility
will need to develop your own comparisons and targets.
3. Sample documents should be used as a guideline for developing your
own unique documents that fit your healthcare organization. Make certain that
you use criteria that your hospital has adopted and you follow all of your state
and local laws.

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Form 1000
Indicator/Criteria List and Data Source Matrix
Emergency Department
Indicator/Criteria Case HIM M SO Quality MRR CM E Education UR PT. IC Pract. Pharm Adm/
Mgt. Dept. Group Comm. Dept. Rep Dept
Review
Patient Care
Acute MI Mgt
ASA Usage X
Fibrinolytic X
Therapy
Pneumonia
Blood Cultures X X
Antibiotic with 4
hours X
Moderation Sedation
Reversal Rates X
Medical/Clinical
Knowledge
Hospital Based X
CMEs
New Training or X
Experience
Board Cert-Initial
or Renewal X
Interpersonal and
Communication
Skills
Pt/Family/Staff
Written Positive X
Feedback

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Form 1000
Indicator/Criteria List and Data Source Matrix
Emergency Department
Indicator/Criteria Case HIM M SO Quality MRR CM E Education UR PT. IC Pract. Pharm Adm/
Mgt. Dept. Group Comm. Dept. Rep Dept
Review
Complaints from
Patients/Family X X

Practice Based
Learning
Improvements
Illegible Orders X
sent for Review
Adherence to X
NPSG:
Abbreviations
Universal
Protocol X
Emergent Elder
Care Protocols

System Based
Practice

Medical Record
Delinquency X
warnings
Number of
Suspensions for X
Delinquency

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Form 1000
Indicator/Criteria List and Data Source Matrix
Emergency Department
Indicator/Criteria Case HIM M SO Quality MRR CM E Education UR PT. IC Pract. Pharm Adm/
Mgt. Dept. Group Comm. Dept. Rep Dept
Review

*Utilization Data
Report (eg TATs,
proper admission
X
status)

*Provided as an attachment with the Ongoing Professional Practice Evaluation

Professionalism
Meetings
Attended
X
Complaints
related to X
Professionalism
from Staff
Case X
Presentation
Teaching an
Educational X
Program
HIM Health Information Management IC Pract Infection Control Practitioner
MSO Medical Staff Office Adm Administration/Department
MRR Medical Record Review Group
UR- Utilization Review
PT Rep = Patient Representative

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Form 2000
Ongoing Professional Practice Evaluation - Evidence Based Data
Department of Emergency Medicine.
Subspecialty if applicable N/A .
Practitioner ID # 0876 Last Appointment Date July 07 .
th
Status Active Reporting Period: 4 Qarter 2008
Indicator/Criteria Trigger Q4 Q3 Q2 Q1 Q4 Q3 Q2 Ytd Dept Yt d Nat l
2008 2008 2008 2008 2007 2007 2007 Data Data
Patient Care
Acute MI Management
Percent receiving ASA
upon arrival (except for Below 96% 97% 100% 97% 98% 99% 95% 92% 93%
acceptable 95%
contraindications)
Fibrinolytic Therapy Below 96% 97% 96% 96% 95% 97% 95% 94% 93%
within 30 minutes or 95%
documented
contraindications
Pneumonia Below 99% 96% 96% 99% 97% 95% 96% 95% 97%
Blood Cultures 95%
Antibiotic within 4 hours Below 90% 96% 97% 95% 96% 97% 95% 97% 94%
95%
Moderation Sedation Greater
Reversal Rates than 5% 3% 3% 4% 3% 5% 4% 4% 2% Not Available
Medical/Clinical
Knowledge
Hospital CME Hours * 5 0 0 10 0 5 10
New Training or
Experience *
Board Certification
Renewal/Initial Yes 100%
Interpersonal and
Communication Skills
Patient Family/Staff *

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Form 2000
Ongoing Professional Practice Evaluation - Evidence Based Data
Department of Emergency Medicine.
Subspecialty if applicable N/A .
Practitioner ID # 0876 Last Appointment Date July 07 .
th
Status Active Reporting Period: 4 Qarter 2008
Indicator/Criteria Trigger Q4 Q3 Q2 Q1 Q4 Q3 Q2 Ytd Dept Yt d Nat l
2008 2008 2008 2008 2007 2007 2007 Data Data
Written positive Yes Yes Yes
feedback
Complaints from 3 or More
Patients/Families 1 0 1 0 1 1 1
Practice Based
Learning Improvements
Illegible Orders sent for 5 or More 3 2 0 0 2 2 0 4 Not Available
Review

Adherence to National
Patient Safety Goals:
Abbreviations 3 or More 0 2 3 2 3 4 5 3 Not Available
Universal Protocol, as Less than N/A 100% N/A N/A 90% 100% N/A 90% Not Available
applicable 90%
Emergent Elder Care Less than
Protocols (% patients 5% 2% 3% 5% 5% 9% 10% 10% 6% Not Available
inappropriately
discharged)
System Based
Practice
Medical Record 3 or More 0 2 0 0 1 0 0 5 Not Available
Delinquency
Number of Suspensions 1 or More 0 0 0 0 0 0 0 0 Not Available
for Delinquency
Warnings
* Utilization Data Report X

April 2008 22
ACCEPTED

Form 2000
Ongoing Professional Practice Evaluation - Evidence Based Data
Department of Emergency Medicine.
Subspecialty if applicable N/A .
Practitioner ID # 0876 Last Appointment Date July 07 .
th
Status Active Reporting Period: 4 Qarter 2008
Indicator/Criteria Trigger Q4 Q3 Q2 Q1 Q4 Q3 Q2 Ytd Dept Yt d Nat l
2008 2008 2008 2008 2007 2007 2007 Data Data

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

Professionalism
Meetings Attended * 2 0 1 0 3 0 1

Complaints related to 1 or More 0 0 0 0 0 0 0 4


Professionalism from
Staff
Case Presentation * 0 0 1 0 0 0 1
Teaching an Education * 1 0 0 1 0 0 1
Program

Reviewed and approved by Dept. of Emergency Medicine 1/15/ 07


Reviewed and approved by Medical Executive Committee 2/11/07

Information only

April 2008 23
ACCEPTED

Form 3000
Periodic Report
Ongoing Professional Practice Evaluation
Department of Emergency Medicine
Reporting Period October, November, December 2008

Number of Members 52

Members Listed Below Exceeded the Trigger for Evaluation


# 0 876 .
#
#

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

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

Sue Smith
Director of Medial Staff Affairs

April 2008 24
Form 4000
DEPARTMENT DIRECTOR RESPONSE
DEPARTMENT OF EMERGENCY MEDICINE

Reporting Period: October, November, December 2007


Date: Mar 1, 2008

Physician Number : 0876 .

As the Department Chair for Emergency Medicine, I have reviewed the results
of the Ongoing Professional Practice Evaluation for the above named physician.
I have 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. The
practitioner has been informed that if the threshold is exceeded for two Quarters
or more during this reappointment cycle, a focus review will be initiated based
on the Peer Review Policy.

I reviewed the findings and discussed them with the practitioner. As a result,
I am recommending a focus professional practice review by the Peer
Review Committee 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 Chair
Department of Emergency Medicine
ACCEPTED

Form 1000
Indicator/Criteria List and Data Source Matrix
Anesthesia Department

Indicator/Criteria Case HIM MS O Quality MRR CME Educatio UR PT. IC Pharm Adm/
Mgt. Dept. Group Comm. n Rep Pract. Dept
Review Dept.
Patient Care
Re-intubation in X
OR or PACU
Anesthesia X
incidents (broken
teeth)
MI within 48 X
hours post
anesthesia
Pneumothorax X
from Cen-line
insertion
Medical/Clinical
Knowledge
Hospital Based X X
CMEs
New Training or X
Experience
Board Cert-Initial X
or Renewal
Interpersonal and
Communication
Skills

April 2008 26
ACCEPTED

Form 1000
Indicator/Criteria List and Data Source Matrix
Anesthesia Department

Indicator/Criteria Case HIM MS O Quality MRR CME Educatio UR PT. IC Pharm Adm/
Mgt. Dept. Group Comm. n Rep Pract. Dept
Review Dept.
Pt/Family/Staff X
Written Positive
Feedback
Complaints from X X
Patients/Family

Practice Based
Learning
Improvements
Illegible Orders X
sent for Review
Adherence to
NPSG: labeled
meds
Abbreviations X
Universal X
Protocol
System Based
Practice
Med Record X
Delinquency
Warnings
Number of X
Suspensions for
Delinquency

April 2008 27
ACCEPTED

Form 1000
Indicator/Criteria List and Data Source Matrix
Anesthesia Department

Indicator/Criteria Case HIM MS O Quality MRR CME Educatio UR PT. IC Pharm Adm/
Mgt. Dept. Group Comm. n Rep Pract. Dept
Review Dept.
*Utilization data X
Report
*Provided as an attachment with the Ongoing Professional Practice Evaluation.
Professionalism
Meetings
X
Attended
Complaints X
related to
Professionalism
from Staff
Case X
Presentation
Teaching an
Educational X
Program
HIM Health Information Management IC Pract Infection Control Practitioner
MSO Medical Staff Office Adm - Administration
MRR Medical Record Review Group
UR- Utilization Review
PT Rep = Patient Representative

April 2008 28
ACCEPTED

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 .
th
Status Active Reporting Period: 4 Qarter 2008
Indicator Trigger Q4 Q3 Q2 Q1 Q4 Q3 Q2 Ytd Ytd Na tl
2008 2008 2008 2008 2007 2007 2007 Dept Data
Data
Re-intubation in OR or 1 or More 0 0 0 1 0 0 0 2 Not Available
PACU

Anesthesia Incidents 1 or More 0 0 0 0 1 0 0 2 Not Available


(Broken Teeth)
MI within 48 hours post 1 or More 0 0 0 0 0 0 0 0 Not Available
anesthesia
Pneumothorax from 1 or More 0 0 0 0 0 0 0 0 Not Available
CDIRECTOR Line
Insertion
Medical/Clinical
Knowledge
Hospital CME Hours * 0 2 3 0 0 5 5
New Training or *
Experience
Board Certification Yes
Renewal/Initial
Interpersonal and
Communication Skills
Patient/Family/Staff * Yes Yes N/A Not Available
Written positive
feedback
Complaints from 3 or more 0 0 0 1 0 0 0 2 Not Available
Patients/Families

April 2008 29
ACCEPTED

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 .
th
Status Active Reporting Period: 4 Qarter 2008
Indicator Trigger Q4 Q3 Q2 Q1 Q4 Q3 Q2 Ytd Ytd Na tl
2008 2008 2008 2008 2007 2007 2007 Dept Data
Data
Practice Based
Learning Improvements
Illegible Orders sent for 5 or more 0 0 2 3 3 5 5 3 Not Available
Review
Adherence to National
Patient Safety Labeled 3 or more 3 4 9 10 8 9 14 5 Not Available
Medication
Abbreviations 3 or more 3 0 2 0 2 0 4 3 Not Available

Universal Protocol, as Less than 100% 100% 100% 95% 95% 85% 90% 92% Not Available
applicable 90%
System Based Practice
Documentation of Below 95% 90% 100% 100% 95% 90% 100% 92% Not Available
appropriate pre-and 90%
post anesthesia
assessments
Medical Record 3 or more 0 0 0 0 1 0 0 2 Not Available
Delinquency
Number of Suspensions 1 or more 0 0 0 0 0 0 0 0 Not Available
for Delinquency
*Utilization Data Report X

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


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

April 2008 30
ACCEPTED

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 .
th
Status Active Reporting Period: 4 Qarter 2008
Indicator Trigger Q4 Q3 Q2 Q1 Q4 Q3 Q2 Ytd Ytd Na tl
2008 2008 2008 2008 2007 2007 2007 Dept Data
Data
Complaints related to 2 or more 0 0 0 0 0 0 0 1 Not Available
Professionalism from
Staff
Case Presentation * 0 0 1 0 0 0 0
Teaching an Education * 0 1 1 0 0 0 0
Program

Reviewed and approved by Dept. of Anesthesia 1/15/ 07


Reviewed and approved by Medical Executive Committee 2/11/07
* information only

April 2008 31
ACCEPTED

Form 3000
Periodic Report
Ongoing Professional Practice Evaluation
Department of Surgery / Anesthesia
Reporting Period October, November, December 2008

Number of Members 15

Members Listed Below Exceeded the Trigger for Evaluation


# 9 288 .
#
#

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

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

Sue Smith
Director of Medial Staff Affairs

April 2008 32
Form 4000
DEPARTMENT DIRECTOR RESPONSE
DEPARTMENT OF SURGERY/ANESTHESIA

Reporting Period: October, November, December 2008 Date:


June 1, 2007

Physician Number : 9288 .

As the Department Chair for Surgery and Chair of Anesthesia, we have


reviewed the results of the Ongoing Professional Practice Evaluation for the
above named physician. I have 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. The
practitioner has been informed that if the threshold is exceeded for two Quarters
or more during this reappointment cycle, a focus review will be initiated based
on the Peer Review Policy.

I reviewed the findings and discussed them with the practitioner. As a result,
I am recommending a focus professional practice review by the Peer
Review Committee for March, April, and May 2007. The results should be
forwarded to me as a part of the practitioners Quarterly review.

Comments:
The Physician was receptive to our discussion. W e also noted the willingness
to participate in the education of the staff and to participate in case presentation
and extended our thanks .

Dr. Ima Cutter


Department Chair Surgery
Dr. Sam Sleep
Chair of Anesthesia
ACCEPTED

Form 1000
Indicator/Criteria List and Data Source Matrix
Surgery Department

Indicator/Criteria Case HIM MSO Quality MRR CME Education UR PT. IC Pharm Adm/
Mgt. Dept. Group Comm. Dept. Rep Pract. Dept
Review
Patient Care
Organ Injury X
Prophyladic X X
antibiotic with one
hour to incision
Prophyladic
antibiotic
discontinued within
24 hrs
Compliance with
DVT prevention
Post wound X X
infection

Post- op ventilator X X
associated
pneumonia
Medical/Clinical
Knowledge
Hospital Based X X
CMEs
New Training or X
Experience
Board Cert-Initial or X
Renewal

April 2008 34
ACCEPTED

Form 1000
Indicator/Criteria List and Data Source Matrix
Surgery Department

Indicator/Criteria Case HIM MSO Quality MRR CME Education UR PT. IC Pharm Adm/
Mgt. Dept. Group Comm. Dept. Rep Pract. Dept
Review
Interpersonal and
Communication
Skills
Pt/Family/Staff X
Written Positive
Feedback
Complaints from X X
Patients/Family
Practice Based
Learning
Improvements
Illegible Orders X
sent for Review
Adherence to
NPSG:
Abbreviations X
Universal Protocol X
System Based
Practice
History & Physical X X
Current/updated
Informed Consent X
Surgery

Submits SSI report

April 2008 35
ACCEPTED

Form 1000
Indicator/Criteria List and Data Source Matrix
Surgery Department

Indicator/Criteria Case HIM MSO Quality MRR CME Education UR PT. IC Pharm Adm/
Mgt. Dept. Group Comm. Dept. Rep Pract. Dept
Review
to ICP monthly
*Utilization Data X
Report
*Provided as an attachment with the Ongoing Professional Practice Evaluation,
Professionalism
Meetings attended X
Complaints related X
to Professionalism
from Staff
Case Presentation X
Teaching an
Educational X
Program
HIM Health Information Management IC Pract Infection Control Practitioner
MSO Medical Staff Office Adm - Administration
MRR Medical Record Review Group
UR- Utilization Review
PT Rep = Patient Representative

April 2008 36
ACCEPTED

Form 2000
Ongoing Professional Practice Evaluation - Evidence Based Data
Department of Surgery .
Subspecialty if applicable N/A .
Practitioner ID # 2207 Last Appointment Date July 07 .
th
Status Active Reporting Period: 4 Qarter 2008
Indicator Trigger Q4 Q3 Q2 Q1 Q4 Q3 Q2 Y td Yt d Nat l
2008 2008 2008 2008 2007 2007 2007 Dept Data
Data
Patient Care
Organ Injury 1 or More 0 0 0 1 0 0 0 2 Not Available
Prophyladic antibiotic Less than 95% 97% 100% 98% 96% 95% 98% 97% 98%
within 1hr prior to 95%
surgical incision
Prophyladic antibiotic Less than 95% 94% 90% 80% 85% 78% 75% 90%
discontinued within 24 95%
hrs
Compliance with DVT Less than 93% 99% 84% 82% 88% 43% 22% 88%
prevention 90%
Post-op wound Infection Less than .5% 0 1% 1% 0 0 0 1.0% 1.0%
2% of total
cases
Post-op ventilator 2 or More 2 0 0 1 0 0 1 3 Not Available
associated pneumonia
Medical/Clinical
Knowledge
Hospital CME Hours * 0 4 5 0 0 3 4
New Training or *
Experience
Board Certification Yes 100%
Renewal/Initial due 8/07
Interpersonal and
Communication Skills
Patient Family/Staff * Yes Yes

April 2008 37
ACCEPTED

Form 2000
Ongoing Professional Practice Evaluation - Evidence Based Data
Department of Surgery .
Subspecialty if applicable N/A .
Practitioner ID # 2207 Last Appointment Date July 07 .
th
Status Active Reporting Period: 4 Qarter 2008
Indicator Trigger Q4 Q3 Q2 Q1 Q4 Q3 Q2 Y td Yt d Nat l
2008 2008 2008 2008 2007 2007 2007 Dept Data
Data
Written positive
feedback
Complaints from 3 or more 0 0 2 0 0 0 1 4
Patients/Families
Practice Based
Learning Improvements
Illegible Orders sent for 5 or more 1 2 1 0 0 1 2 6 Not Available
Review
Adherence to National
Patient Safety Goals:
Abbreviations 3 or more 0 0 2 3 4 4 6 3 Not Available

Universal Protocol, as Less than 100% 100% 100% 98% 100% 96% 95% 96% Not Available
applicable 90%
System Based Practice
History & Physical Less than 100% 100% 95% 100% 100% 100% 100% 98% Not Available
Current 100%

Informed Consent Less than 100% 100% 100% 98% 100% 100% 100% 95% Not Available
100%
Submits SSI report to <3 3 3 3 3 3 3 2 2.4 Not Available
ICP monthly
*Utilization Data Report X

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


Professionalism

April 2008 38
ACCEPTED

Form 2000
Ongoing Professional Practice Evaluation - Evidence Based Data
Department of Surgery .
Subspecialty if applicable N/A .
Practitioner ID # 2207 Last Appointment Date July 07 .
th
Status Active Reporting Period: 4 Qarter 2008
Indicator Trigger Q4 Q3 Q2 Q1 Q4 Q3 Q2 Y td Yt d Nat l
2008 2008 2008 2008 2007 2007 2007 Dept Data
Data
Meeting Attended * 3 3 2 3 1 3 3
Complaints related to 1 or more 0 0 0 0 0 0 0 4
Professionalism from
Staff
Case Presentation * 1 1 1
Teaching an Education *
Program

Reviewed and approved by Dept. of Surgery 1/15/07


Reviewed and approved by Medical Executive Committee 2/11/07

April 2008 39
ACCEPTED

Form 3000
Periodic Report
Ongoing Professional Practice Evaluation
Department of Surgery
Reporting Period October, November, December 2008

Number of Members 75

Members Listed Below Exceeded the Trigger for Evaluation


# 2207 .
#
#

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

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

Sue Smith
Director of Medial Staff Affairs

April 2008 40
Form 4000
DEPARTMENT DIRECTOR RESPONSE
DEPARTMENT OF SURGERY

Reporting Period: October, November, December 2008


Date: June 1, 2007

Physician Number : 2207 .

As the Department Chair for Surgery, I have reviewed the results of the Ongoing
Professional Practice Evaluation for the above named physician. I have 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. The
practitioner has been informed that if the threshold is exceeded for two Quarters
or more during this reappointment cycle, a focus review will be initiated based
on the Peer Review Policy.

I reviewed the findings and discussed them with the practitioner. As a result,
I am recommending a focus professional practice review by the Peer
Review Committee for March, April, and May 2007. The results should be
forwarded to me as a part of the practitioners Quarterly review.

Comments :
W e reviewed the current ventilator management pathway and discussed
areas for improvement .

Dr. Ima Cutter


Department Chair for Surgery
ACCEPTED

Form 1000
Indicator/Criteria List and Data Source Matrix
Radiology Department

Indicator/Criteria Case HIM MSO Quality MRR CME Education UR PT. IC Pharm Adm/
Mgt. Dept. Group Comm. Dept. Rep Pract. Dept
Review
Patient Care

Percent of X
Agreement for
over-reads
Procedural X
Complications

Moderate X
Sedation-
reversal rates
Medical/Clinical
Knowledge
Hospital Based X X
CMEs
New Training or X
Experience
Board Cert-Initial X
or Renewal
Interpersonal and
Communication
Skills
Pt/Family/Staff X
Written Positive
Feedback

April 2008 42
ACCEPTED

Form 1000
Indicator/Criteria List and Data Source Matrix
Radiology Department

Indicator/Criteria Case HIM MSO Quality MRR CME Education UR PT. IC Pharm Adm/
Mgt. Dept. Group Comm. Dept. Rep Pract. Dept
Review
Complaints from X
Patients/Family
Practice Based
Learning
Improvements
Critical Values X
Timeliness
Abbreviations X
Universal X
Protocol
System Based
Practice
History & X
Physical for
appropriate
procedures
Documentation X
of appropriate
anesthesia
assessment for
moderate
sedation
*Utilization Data X
Report

April 2008 43
ACCEPTED

Form 1000
Indicator/Criteria List and Data Source Matrix
Radiology Department

Indicator/Criteria Case HIM MSO Quality MRR CME Education UR PT. IC Pharm Adm/
Mgt. Dept. Group Comm. Dept. Rep Pract. Dept
Review
*Provided as an attachment with the Ongoing Professional Practice Evaluation
Professionalism
Meetings Attended X
Complaints X
related to
Professionalism
from Staff
Case X
Presentation
Teaching an
Educational X
Program
HIM Health Information Management IC Pract Infection Control Practitioner
MSO Medical Staff Office Adm - Administration
MRR Medical Record Review Group
UR- Utilization Review
PT Rep = Patient Representative

April 2008 44
ACCEPTED

Form 2000
Ongoing Professional Practice Evaluation - Evidence Based Data
Department of Radiology .
Subspecialty if applicable N/A .
Practitioner ID # 2244 Last Appointment Date July 07 .
th
Status Active Reporting Period: 4 Qarter 2008
Indicator Trigger Q4 Q3 Q2 Q1 Q4 Q3 Q2 Y td Yt d Nat l
2008 2008 2008 2008 2007 2007 2007 Dept Data
Data
Patient Care
Percent of Agreement 95% or 98% 99% 100% 100% 98% 100% 100% 97%
for Over-reads less

Procedural 2 or more 0 0 0 1 0 0 0 1
Complications
Moderate Sedation Greater 2% 0% 0% 1% 1% 0% 0% 2.5%
Reversal Rate than 5%
Medical/Clinical
Knowledge
Hospital CME Hours * 4 2 2 0 0 3 3
New Training or *
Experience
Board Certification Yes 100%
Renewal/Initial due
8/2007
Interpersonal and
Communication Skills
Patient Family/Staff * Yes Yes Yes
Written positive
feedback
Complaints from 3 or more 0 0 0 1 0 0 0 2
Patients/Families
Practice Based
Learning Improvements

April 2008 45
ACCEPTED

Form 2000
Ongoing Professional Practice Evaluation - Evidence Based Data
Department of Radiology .
Subspecialty if applicable N/A .
Practitioner ID # 2244 Last Appointment Date July 07 .
th
Status Active Reporting Period: 4 Qarter 2008
Indicator Trigger Q4 Q3 Q2 Q1 Q4 Q3 Q2 Y td Yt d Nat l
2008 2008 2008 2008 2007 2007 2007 Dept Data
Data
Critical Value 1 or more 2 0 0 1 0 0 0 5
Timeliness exceeding
Adherence to National
Patient Safety Goals:

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

Universal Protocol, as Less than 100% 100% 96% 95% 92% 90% 90% 95%
applicable 90%

System Based Practice


History & Physical for Less than 100% 100% 95% 100% 100% 100% 100% 100%
appropriate procedures 100%
Documentation of Less than 95% 100% 96% 100% 100% 90% 85% 95%
appropriate anesthesia 100%
assessment for
moderate sedation
*Utilization Data Report X
*Provided as an attachment with the Ongoing Professional Practice Evaluation.

Professionalism
Meetings attended * 2 2 2 2 0 1 2
Complaints related to 1 or more 0 0 0 0 0 0 0 2
Professionalism from
Staff
Case Presentation * 1

April 2008 46
ACCEPTED

Form 2000
Ongoing Professional Practice Evaluation - Evidence Based Data
Department of Radiology .
Subspecialty if applicable N/A .
Practitioner ID # 2244 Last Appointment Date July 07 .
th
Status Active Reporting Period: 4 Qarter 2008
Indicator Trigger Q4 Q3 Q2 Q1 Q4 Q3 Q2 Y td Yt d Nat l
2008 2008 2008 2008 2007 2007 2007 Dept Data
Data
Teaching an Education * 1
Program

Reviewed and approved by Dept. of Radiology 1/15/ 07


Reviewed and approved by Medical Executive Committee 2/11/07
* information only

April 2008 47
ACCEPTED

Form 3000
Periodic Report
Ongoing Professional Practice Evaluation
Department of Radiology
Reporting Period October, November, December 2008

Number of Members 10

Members Listed Below Exceeded the Trigger for Evaluation


# 2 244 .
#
#

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

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

Sue Smith
Director of Medial Staff Affairs

April 2008 48
Form 4000
DEPARTMENT DIRECTOR RESPONSE
DEPARTMENT OF RADIOLOGY

Reporting Period: October, November, December 2008


Date: June 1, 2007

Physician Number : 2244 .

As the Department Chair for Radiology, I have reviewed the results of the
Ongoing Professional Practice Evaluation for the above named physician. I
have 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. The
practitioner has been informed that if the threshold is exceeded for two Quarters
or more during this reappointment cycle, a focus review will be initiated based
on the Peer Review Policy.

I reviewed the findings and discussed them with the practitioner. As a result,
I am recommending a focus professional practice review by the Peer
Review Committee for March, April, and May 2007. The results should be
forwarded to me as a part of the practitioners Quarterly review.

Comments:

Dr. Patty Picture


Department Chair
Department of Radiology
ACCEPTED

Form 1000
Indicator/Criteria List and Data Source Matrix
Allied Health PA

Indicator/Criteria Case HIM MSO Quality MRR CME Education UR PT. IC Pharm Adm/
Mgt. Dept. Group Comm. Dept. Rep Pract. Dept
Review
Corrections to
H&P X

Feedback on X X
aseptic
technique
Feedback on X X
surgical skills

Medical/Clinical
Knowledge
CE Hours X X

New Training or X
Experience

Interpersonal and
Communication
Skills
Feedback X
related to
communication
skills

April 2008 50
ACCEPTED

Form 1000
Indicator/Criteria List and Data Source Matrix
Allied Health PA

Indicator/Criteria Case HIM MSO Quality MRR CME Education UR PT. IC Pharm Adm/
Mgt. Dept. Group Comm. Dept. Rep Pract. Dept
Review
Complaints from
Patients/Family X

Practice Based
Learning
Improvements
Illegible Orders X
sent for Review
Adherence to
NPSG:
Abbreviations X

Universal X X X
Protocol

System Based
Practice
Timeliness of X
H&Ps
Dating and X
Timing of entries
*Utilization Data X
Report

Professionalism

April 2008 51
ACCEPTED

Form 1000
Indicator/Criteria List and Data Source Matrix
Allied Health PA

Indicator/Criteria Case HIM MSO Quality MRR CME Education UR PT. IC Pharm Adm/
Mgt. Dept. Group Comm. Dept. Rep Pract. Dept
Review
Feedback X X
related to
Professionalism
from Staff
*Provided as an attachment with the Ongoing Professional Practice Evaluation.
HIM Health Information Management IC Pract Infection Control Practitioner
MSO Medical Staff Office Adm Administration/Department
MRR Medical Record Review Group
UR- Utilization Review
PT Rep = Patient Representative

April 2008 52
ACCEPTED

Form 2000
Ongoing Professional Practice Evaluation - Evidence Based Data
Department of Surgery .
Subspecialty if applicable Allied Health/PA.
Practitioner ID # 2143 Last Appointment Date .
th
Status Active Reporting Period: 4 Qarter 2008
Indicator Trigger Q4 Q3 Q2 Q1 Q4 Q3 Q2 Y td Yt d Nat l
2008 2008 2008 2008 2007 2007 2007 Dept Data
Data
Patient Care
Corrections to H&P 2 or more 0 0 0 3 1 0 0 1.2 Not Available
H&Ps with
corrections
Feedback on aseptic 1 or more 0 0 1 0 0 0 0
technique breaks
Feedback on surgical Below 4 4 4 4 4 4 4 3 3.5 Not Available
skills rating on
feedback
Medical/Clinical
Knowledge
CE Hours * 10 4 6 0 8 16 0
New Training or * Yes new
Experience ortho
system
Interpersonal and
Communication Skills
Feedback related to Score of 2 or 3 3 3 3 3 3 3 3 Not Available
communication skills less
Complaints from 2 or more 0 0 0 1 0 0 0 3 Not Available
Patients/Families
Practice Based
Learning Improvements
Illegible Orders sent for 2 or more 0 0 0 0 0 0 0 2 Not Available

April 2008 53
ACCEPTED

Form 2000
Ongoing Professional Practice Evaluation - Evidence Based Data
Department of Surgery .
Subspecialty if applicable Allied Health/PA.
Practitioner ID # 2143 Last Appointment Date .
th
Status Active Reporting Period: 4 Qarter 2008
Indicator Trigger Q4 Q3 Q2 Q1 Q4 Q3 Q2 Y td Yt d Nat l
2008 2008 2008 2008 2007 2007 2007 Dept Data
Data
Review
Adherence to National 3 or more 0 0 2 3 4 5 4 3 Not Available
Patient Safety Goals:
Abbreviations
Universal Protocol, Less than 100% 100% 100% 100% 95% 90% 95% 95% Not Available
as applicable 90%

System Based Practice


Timeliness of H&P 2 or more 0 1 1 0 2 0 1 4 Not Available
Dating and timing of Less than 90% 90% 90% 85% 80% 80% 75% 80% Not Available
entries 90%
*Utilization Data Report X
Professionalism
Meeting Attended * 0 3 2 0 2 2 2 Not Available
Feedbacks related to Score of 2 or 3 3 3 3 3 3 3 3 Not Available
Professionalism from less
Staff
*Provided as an attachment with the Ongoing Professional Practice Evaluation.

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

April 2008 54
ACCEPTED

Form 3000
Periodic Report
Ongoing Professional Practice Evaluation
Department of Surgery Subspecialty PA Reporting
Period October, November, December 2008

Number of Members 12

Members Listed Below Exceeded the Trigger for Evaluation


# 2 143 .
#
#

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

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

Sue Smith
Director of Medial Staff Affairs

April 2008 55
Form 4000
DEPARTMENT DIRECTOR RESPONSE
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 Physicians
Assistants we have reviewed the results of the Ongoing Professional Practice
Evaluation for the above named allied health member. We have 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. The
practitioner has been informed that if the threshold is exceeded for two Quarters
or more during this reappointment cycle, a focus review will be initiated based
on the Peer Review Policy.

I reviewed the findings and discussed them with the practitioner. As a result,
I am recommending a focus professional practice review by the Peer
Review Committee 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 Surgery
Hope Floats, PA
Director of Physicians Assistant
APPENDIX
EXAMPLE
th
Evaluation of Surgical PA 4 Qarter 2008
Please rate the following individual
in the areas listed below:

1). Communication with staff/patients

1 2 3 4 5
Poor Fair Average Good Excellent

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

2). Professionalism

1 2 3 4 5
Poor 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 this
reporting period? If so, please provide details and any actions taken.
EXAMPLE
PA 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 5
Unfamiliar with the steps of the operation;
Unable to recall or describe many operative steps

Instrument Handling

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

Knowledge of Instruments

1 2 3 4 5
FreQently asks for wrong instruments or
used inappropriate instruments

Flow of the Operation

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

Respect For Tissue

1 2 3 4 5
FreQently used unnecessary force on tissue or
caused damage by inappropriate use of instruments

Physician Signature: Date:


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 facility
3. Assure that measures are pertinent to the specialty of the physician and
his/her requested privileges (some physicians may need a
combination form from 2 or more specialties)
4. Clearly define/specify all indicators so that everyone understands what
is being measured and how it is to be measured
5. Dont select too many measures, but assure that you have enough to truly
evaluate 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 or
unclear orders, dosing errors, ordering medications to which a patient has
a known 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)
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
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 ongoing
resuscitation @ 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
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
SAMPLE PRIVILEGE ELIGIBILITY CRITERIA
General Medical Staff Procedural Sedation Overview. Procedural sedation is
a drug-induced depression of consciousness during which patients respond
purposefully 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 patients
in 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 medical
staff appointee who is physically present. This policy does not apply to PCA
pumps, pain medication unrelated to IV procedural sedation, deep sedation or
any privilege credentialed to the medical staff.

General Medical Staff Procedural Sedation - Adult


Education: 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 procedural sedation 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 patients in the past 24 months. Reappointment Applicants must be able to
demonstrate that they have maintained competence by showing evidence that
he/she has administered procedural sedation for at least 5 patients in the past
24 months. If the physician has not performed 5 procedures in the past 24
months the physician is to be concurrently observed for the first 2 procedures.
(or)
Education: MD, DO, DDS, DMD or DPM. Minimum formal training: ACLS
Certification. The applicant must be concurrently observed for the first 3
cases. Reappointment: Current ACLS Certification. The applicant must be
able to demonstrate he/she has maintained competency by showing evidence
that he/she has administered procedural sedation for at least 5 patients in the
past 24 months. If the physician has not performed 5 procedures the
physician must be concurrently observed for the first 2 procedures.
(or)
Education: MD, DO, DDS, DMD or DPM. Minimum formal training: Successful
completion of XYZ Hospital MEC approved Procedural Sedation Self-Teaching
Module. The applicant must be concurrently observed for the first 3 cases.
Reappointment: Successful completion of XYZ Hospital MEC approved
Procedural Sedation Self-Teaching Module. The applicant must be able to
demonstrate he/she has maintained competency by showing evidence that
he/she has administered procedural sedation for at least 5 patients in the past
24 months. If the physician has not performed 5 procedures the physician must
be concurrently observed for the first 2 procedures.

General Medical Staff Procedural Sedation -


Pediatric
Education: 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 procedural sedation for pediatric
patients 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 in the past 24 months.
Reappointment Applicants must be able to demonstrate that they have
maintained competence by showing evidence that he/she has administered
procedural sedation for at least 5 pediatric patients in the past 24 months. If
the physician has not performed 5 pediatric procedures in the past 24 months

DEPARTMENT PRIVILEGE ELIGIBILITY CRITERIA: Ventilator Management


Included in basic privileges for Anesthesiology, Thoracic Surgery, Emergency
Medicine and Pulmonary Disease. Privileges in Cardiovascular Disease, Family
Practice, Internal Medicine, Neurosurgery, Pediatrics, General Surgery, Vascular
Surgery require documentation of management of 20 patients on ventilators
during an accredited residency or under the supervision of a physician skilled in
ventilator management. Required previous experience (also required for
reappointment): Satisfactorily managed four (4) patients on ventilator in past 24
months.

Department of Family Practice Privileges & Clinical Observation


Qualifications:
A. Privileges will be considered for physicians who have completed a Family
Practice residency program and are board certified or actively pursuing board
certification by a board approved by the ACGME or the AOA.
B. Hospital Experience: Applicants must demonstrate, to the satisfaction of
the Department of Family Practice, current clinical competence in an acute
care setting (within the past two years) for all privileges requested.
C. Physicians who qualify for medical staff appointment but cannot document
required current competency and/or recent hospital experience may apply for
Referring category status. Referring Category physicians may not admit patients,
treat, or write orders for patient care but are the physician is to be concurrently
observed for the first 2 pediatric procedures.
(or)
Education: MD, DO, DDS, DMD or DPM. Minimum formal training: PALS
Certification. The applicant must be concurrently observed for the first 3
cases. Reappointment: Current PALS Certification. The applicant must be
able to demonstrate he/she has maintained competency by showing evidence
that he/she has administered procedural sedation for at least 5 pediatric
patients in the past 24 months. If the physician has not performed 5 pediatric
procedures the physician must be concurrently observed for the first 2
pediatric procedures.
(or)
Education: MD, DO, DDS, DMD or DPM. Minimum formal training: Successful
completion of XYZ Hospital MEC approved Procedural Sedation Self-
Teaching Module. The applicant must be concurrently observed for the first 3
pediatric cases. Reappointment: Successful completion of XYZ Hospital MEC
approved Procedural Sedation Self-Teaching Module. The applicant must be
able to demonstrate he/she has maintained competency by showing evidence
that he/she has administered procedural sedation for at least 5 pediatric
patients in
the past 24 months. If the physician has not performed 5 pediatric procedures
the physician must be
concurrently observed for the first 2 pediatric procedures.

FAMILY PRACTICE DEPARTMENT ELIGIBILITY CRITERIA


A. ICU Admissions require a Family Practice physician to have the first 3
admissions retrospectively reviewed by a Family Practice physician with the
privilege.
B. OB deliveries require a Family Practice physician to have the first 3
deliveries retrospectively reviewed by a Family Practice or OB-GYN physician
with the privilege.

Department of Family Practice Cesarean Section Participation


Physician is required to obtain co-management by an NRP certified Pediatrician,
Neonatologist, or Neonatologist supervised NNP for a Family Practice physician
to participate/attend a cesarean section.

Department of Family Practice Level II Pediatric High Risk Privileges


Physician is required to obtain consultation and/or co-management by an
NRP certified Pediatrician, Neonatologist, or Neonatologist supervised NNP to
participate in the care of Level II newborns.
Observation The Family Practice may impose observation if it is determined
to be appropriate.
Patient Name

CONFIDENTIAL MR #

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 section
below)

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 or


attach additional sheets if additional space is needed)

Signature of observing physician

PLEASE RETURN COMPLETED FORM TO


Medical Staff Case Review Tool
Meeting Date:

Event
Hosp/ MR # Indicator and Description
Date(s)

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* Yes
3) Were there any identifiable breakdowns in communication? No Yes*
4) Was judgment/decision making sound in this case? No* Yes
5) 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:


Severity (Patient Outcome)
0 No problem or complication unrelated to quality/safety issue
1 Minor problem or complication
2 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 injury
5 Death possibly related to quality/safety issue
6 Death likely related to quality/safety issue
7 Unknown outcome

Action by Committee
1 No action other than documentation in minutes and record for profile
2 Trend
3 Telephone or verbal discussion
4 Letter to practitioner with no request for response
5 Letter to practitioner with request for response
6 Counseling conversation between Chair & practitioner
7 Request practitioner to attend MSPR meeting to discuss case
8 Intensive review of additional cases
9 Referred for review by outside reviewer
10 Referred for Root Cause Analysis
11 Classified as a Sentinel Event
12 Refer to Medical Staff Executive Committeeto assess potential disciplinary action
13 Refer to Hospital Patient Safety Team or IQC for concerns about hospital processes
14 Consider medical staff education session on topic:

Additional Actions
A Mandatory consultation for specific type of cases as noted
B Suspension of privileges-type/timeframe specified
C Report to Data Bank
D Other:_