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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
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
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
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
*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
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
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
3 or More 0 2 0 0 1 0 0 5 Not Available
Number of Suspensionsfor DelinquencyWarnings
1 or More 0 0 0 0 0 0 0 0 Not Available
* Utilization Data Report X
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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
*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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April 2008 26
Form 1000
Indicator/Criteria List and Data Source MatrixAnesthesia Department
Indicator/Criteria CaseMgt.
Review
HIM MSO QualityDept.
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
Medical/ClinicalKnowledge
Hospital BasedCMEs
X X
New Training orExperience
X
Board Cert-Initialor Renewal
X
Interpersonal andCommunicationSkills
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April 2008 27
Form 1000
Indicator/Criteria List and Data Source MatrixAnesthesia Department
Indicator/Criteria CaseMgt.Review
HIM MSO QualityDept.
MRRGroup
CMEComm.
EducationDept.
UR PT.Rep
ICPract.
Pharm Adm/Dept
Pt/Family/StaffWritten PositiveFeedback
X
Complaints fromPatients/Family
X X
Practice BasedLearningImprovements
Illegible Orderssent for Review
X
Adherence toNPSG: labeledmeds
Abbreviations X
UniversalProtocol
X
System BasedPractice
Med RecordDelinquencyWarnings
X
Number ofSuspensions forDelinquency
X
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April 2008 28
Form 1000
Indicator/Criteria List and Data Source MatrixAnesthesia Department
Indicator/Criteria CaseMgt.Review
HIM MSO QualityDept.
MRRGroup
CMEComm.
EducationDept.
UR PT.Rep
ICPract.
Pharm Adm/Dept
*Utilization dataReport
X
*Provided as an attachment with the Ongoing Professional Practice Evaluation.
Professionalism
MeetingsAttended
X
Complaintsrelated toProfessionalismfrom Staff
X
CasePresentation
X
Teaching anEducationalProgram
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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April 2008 29
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
1 or More 0 0 0 1 0 0 0 2 Not Available
Anesthesia Incidents(Broken Teeth)
1 or More 0 0 0 0 1 0 0 2 Not Available
MI within 48 hours postanesthesia
1 or More 0 0 0 0 0 0 0 0 Not Available
Pneumothorax fromCDIRECTOR LineInsertion
1 or More 0 0 0 0 0 0 0 0 Not Available
Medical/ClinicalKnowledge Hospital CME Hours * 0 2 3 0 0 5 5
New Training or
Experience
*
Board CertificationRenewal/Initial
Yes
Interpersonal andCommunication Skills
Patient/Family/StaffWritten positivefeedback
* Yes Yes N/A Not Available
Complaints fromPatients/Families
3 or more 0 0 0 1 0 0 0 2 Not Available
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April 2008 30
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 42008
Q 32008
Q 22008
Q 12008
Q 42007
Q 32007
Q 22007
YtdDept
Data
Ytd NatlData
Practice BasedLearning Improvements Illegible Orders sent for
Review
5 or more 0 0 2 3 3 5 5 3 Not Available
Adherence to NationalPatient Safety LabeledMedication
3 or more 3 4 9 10 8 9 14 5 Not Available
Abbreviations 3 or more 3 0 2 0 2 0 4 3 Not Available
Universal Protocol, asapplicable
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
3 or more 0 0 0 0 1 0 0 2 Not Available
Number of Suspensionsfor Delinquency
1 or more 0 0 0 0 0 0 0 0 Not Available
*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
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April 2008 31
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 42008
Q 32008
Q 22008
Q 12008
Q 42007
Q 32007
Q 22007
YtdDept
Data
Ytd NatlData
Complaints related toProfessionalism fromStaff
2 or more 0 0 0 0 0 0 0 1 Not Available
Case Presentation * 0 0 1 0 0 0 0
Teaching an EducationProgram
* 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
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April 2008 32
Form 3000Periodic Report
Ongoing Professional Practice EvaluationDepartment of Surgery / Anesthesia
Reporting Period October, November, December 2008
Number of Members 15
Members Listed Below Exceeded the Trigger for Evaluation# 9288 .# _______________# _______________
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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April 2008 33
Form 4000DEPARTMENT 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 reviewedthe 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. 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 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
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April 2008 34
Form 1000
Indicator/Criteria List and Data Source MatrixSurgery Department
Indicator/Criteria CaseMgt.
Review
HIM MSO QualityDept.
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
New Training orExperience
X
Board Cert-Initial orRenewal
X
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April 2008 35
Form 1000
Indicator/Criteria List and Data Source MatrixSurgery Department
Indicator/Criteria CaseMgt.Review
HIM MSO QualityDept.
MRRGroup
CMEComm.
EducationDept.
UR PT.Rep
ICPract.
Pharm Adm/Dept
Interpersonal andCommunicationSkills
Pt/Family/StaffWritten PositiveFeedback
X
Complaints fromPatients/Family
X X
Practice BasedLearningImprovements
Illegible Orderssent for Review
Adherence toNPSG:
X
Abbreviations X
Universal Protocol X
System BasedPractice History & Physical
Current/updated
X X
Informed ConsentSurgery
X
Submits SSI report
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April 2008 36
Form 1000
Indicator/Criteria List and Data Source MatrixSurgery Department
Indicator/Criteria CaseMgt.Review
HIM MSO QualityDept.
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
Teaching anEducationalProgram
X
HIMHealth Information Management IC PractInfection Control PractitionerMSOMedical Staff Office Adm - AdministrationMRRMedical Record Review GroupUR- Utilization Review
PT Rep = Patient Representative
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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
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
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
2 or More 2 0 0 1 0 0 1 3 Not Available
Medical/ClinicalKnowledge
Hospital CME Hours * 0 4 5 0 0 3 4
New Training orExperience
*
Board CertificationRenewal/Initial due 8/07
Yes 100%
Interpersonal andCommunication Skills
Patient Family/Staff * Yes Yes
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April 2008 38
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
Indicator Trigger Q 42008
Q 32008
Q 22008
Q 12008
Q 42007
Q 32007
Q 22007
YtdDept
Data
Ytd NatlData
Written positivefeedback
Complaints fromPatients/Families
3 or more 0 0 2 0 0 0 1 4
Practice BasedLearning Improvements Illegible Orders sent for
Review
5 or more 1 2 1 0 0 1 2 6 Not Available
Adherence to NationalPatient Safety Goals:
Abbreviations 3 or more 0 0 2 3 4 4 6 3 Not Available
Universal Protocol, asapplicable
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
*Utilization Data Report X
*provided as an attachment with the Ongoing Professional Practice Evaluation.
Professionalism
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April 2008 39
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
Indicator Trigger Q 42008
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
Complaints related toProfessionalism fromStaff
1 or more 0 0 0 0 0 0 0 4
Case Presentation * 1 1 1
Teaching an EducationProgram
*
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
Form 3000Periodic Report
Ongoing Professional Practice EvaluationDepartment 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 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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April 2008 41
Form 4000DEPARTMENT DIRECTOR RESPONSE
DEPARTMENT OF SURGERY
Reporting Period: October, November, December 2008Date: June 1, 2007
Physician Number : 2207 .
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 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 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
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April 2008 42
Form 1000
Indicator/Criteria List and Data Source MatrixRadiology Department
ndicator/Criteria CaseMgt.
Review
HIM MSO QualityDept.
MRRGroup
CMEComm.
EducationDept.
UR PT.Rep
ICPract.
Pharm Adm/Dept
Patient Care
Percent ofAgreement forover-reads
X
ProceduralComplications
X
ModerateSedation-reversal rates
X
Medical/ClinicalKnowledge
Hospital BasedCMEs
X X
New Training orExperience
X
Board Cert-Initialor Renewal
X
nterpersonal andCommunicationSkills
Pt/Family/StaffWritten PositiveFeedback
X
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April 2008 43
Form 1000
Indicator/Criteria List and Data Source MatrixRadiology Department
ndicator/Criteria CaseMgt.Review
HIM MSO QualityDept.
MRRGroup
CMEComm.
EducationDept.
UR PT.Rep
ICPract.
Pharm Adm/Dept
Complaints fromPatients/Family
X
Practice BasedLearningmprovements
Critical ValuesTimeliness
X
Abbreviations X
UniversalProtocol
X
System BasedPractice History &
Physical forappropriateprocedures
X
Documentationof appropriateanesthesiaassessment formoderatesedation
X
*Utilization DataReport
X
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April 2008 44
Form 1000
Indicator/Criteria List and Data Source MatrixRadiology Department
ndicator/Criteria CaseMgt.Review
HIM MSO QualityDept.
MRRGroup
CMEComm.
EducationDept.
UR PT.Rep
ICPract.
Pharm Adm/Dept
*Provided as an attachment with the Ongoing Professional Practice EvaluationProfessionalism
Meetings Attended X
Complaintsrelated toProfessionalismfrom Staff
X
CasePresentation
X
Teaching anEducationalProgram
X
HIMHealth Information Management IC PractInfection Control PractitionerMSOMedical Staff Office Adm - AdministrationMRRMedical Record Review GroupUR- Utilization ReviewPT Rep = Patient Representative
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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
Indicator Trigger Q 42008
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
New Training orExperience
*
Board CertificationRenewal/Initial due
8/2007
Yes 100%
Interpersonal andCommunication Skills
Patient Family/StaffWritten positivefeedback
* Yes Yes Yes
Complaints fromPatients/Families
3 or more 0 0 0 1 0 0 0 2
Practice BasedLearning Improvements
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April 2008 46
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
Indicator Trigger Q 42008
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
Adherence to NationalPatient Safety Goals:
Abbreviations 3 or more 0 0 0 0 2 2 1 2
Universal Protocol, asapplicable
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%
*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 toProfessionalism fromStaff
1 or more 0 0 0 0 0 0 0 2
Case Presentation * 1
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April 2008 47
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
Indicator Trigger Q 42008
Q 32008
Q 22008
Q 12008
Q 42007
Q 32007
Q 22007
YtdDept
Data
Ytd NatlData
Teaching an EducationProgram
* 1
Reviewed and approved by Dept. of Radiology 1/15/07Reviewed and approved by Medical Executive Committee 2/11/07
* information only
ACCEPTED
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April 2008 48
Form 3000Periodic Report
Ongoing Professional Practice EvaluationDepartment of Radiology
Reporting Period October, November, December 2008
Number of Members 10
Members Listed Below Exceeded the Trigger for Evaluation# 2244 .# _______________# _______________
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
ACCEPTED
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April 2008 49
Form 4000DEPARTMENT DIRECTOR RESPONSE
DEPARTMENT OF RADIOLOGY
Reporting Period: October, November, December 2008Date: June 1, 2007
Physician Number : 2244 .
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 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 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
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April 2008 50
Form 1000
Indicator/Criteria List and Data Source MatrixAllied HealthPA
ndicator/Criteria CaseMgt.
Review
HIM MSO QualityDept.
MRRGroup
CMEComm.
EducationDept.
UR PT.Rep
ICPract.
Pharm Adm/Dept
Corrections toH&P X
Feedback onaseptictechnique
X X
Feedback onsurgical skills
X X
Medical/ClinicalKnowledge
CE Hours X X
New Training orExperience
X
nterpersonal andCommunicationSkills
Feedbackrelated tocommunicationskills
X
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April 2008 51
Form 1000
Indicator/Criteria List and Data Source MatrixAllied HealthPA
ndicator/Criteria CaseMgt.Review
HIM MSO QualityDept.
MRRGroup
CMEComm.
EducationDept.
UR PT.Rep
ICPract.
Pharm Adm/Dept
Complaints fromPatients/Family X
Practice BasedLearningmprovements
Illegible Orderssent for Review
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
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April 2008 52
Form 1000
Indicator/Criteria List and Data Source MatrixAllied HealthPA
ndicator/Criteria CaseMgt.Review
HIM MSO QualityDept.
MRRGroup
CMEComm.
EducationDept.
UR PT.Rep
ICPract.
Pharm Adm/Dept
Feedbackrelated toProfessionalismfrom Staff
X X
*Provided as an attachment with the Ongoing Professional Practice Evaluation.
HIMHealth Information Management IC PractInfection Control PractitionerMSOMedical Staff Office AdmAdministration/DepartmentMRRMedical Record Review GroupUR- Utilization ReviewPT Rep = Patient Representative
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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
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
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
New Training orExperience
* Yes newortho
systemInterpersonal andCommunication Skills
Feedback related tocommunication skills
Score of 2 orless
3 3 3 3 3 3 3 3 Not Available
Complaints fromPatients/Families
2 or more 0 0 0 1 0 0 0 3 Not Available
Practice BasedLearning Improvements Illegible Orders sent for 2 or more 0 0 0 0 0 0 0 2 Not Available
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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
Indicator Trigger Q 42008
Q 32008
Q 22008
Q 12008
Q 42007
Q 32007
Q 22007
YtdDept
Data
Ytd NatlData
Review
Adherence to NationalPatient Safety Goals:
Abbreviations
3 or more 0 0 2 3 4 5 4 3 Not Available
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
*Utilization Data Report X
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
*Provided as an attachment with the Ongoing Professional Practice Evaluation.
* Information onlyReviewed 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 55
Form 3000Periodic Report
Ongoing Professional Practice EvaluationDepartment of SurgerySubspecialty PA
Reporting Period October, November, December 2008
Number of Members 12
Members Listed Below Exceeded the Trigger for Evaluation# 2143 .# _______________# _______________
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
ACCEPTED
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April 2008 56
Form 4000DEPARTMENT 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 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 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 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
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APPENDIX
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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.
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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: ______________________
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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)
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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
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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
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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
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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
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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.
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(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.
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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 #______________________
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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:
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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:___________________________________________________________
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Recommended