Sie sind auf Seite 1von 71

ACCEPTED

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.

ACCEPTED

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
April 2008

ACCEPTED

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.

April 2008

ACCEPTED

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

April 2008

ACCEPTED

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.
April 2008

ACCEPTED

Policy
1.

2.
3.

4.

5.

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.
Reported concerns regarding privileged practitioner's
professional performance will be uniformly investigated and
addressed as defined by the organization and applicable law.
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.
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.
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:
April 2008

ACCEPTED

a.
b.
c.
d.
e.
f.

Patient care;
Medical/clinical knowledge;
Practice-based learning and improvement;
Interpersonal and communication skills;
Professionalism; and
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

April 2008

ACCEPTED

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. Responsibilityi. 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.

April 2008

ACCEPTED

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.

ii.

Considers all documented cases which have been reviewed


and trigger (thresholds) parameters at the time of renewing,
revising, limiting, or revoking existing privileges.
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.
April 2008

ACCEPTED

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

April 2008

ACCEPTED

b.
c.
d.
e.

f.

V.

staff due to a potential conflict of interest that cannot be


appropriately resolved by the MEC or Board of Directors.
Lack of Internal Expertise - There is no peer on staff with similar or like
privileges in the specialty under review.
Ambiguity - There is confusion when internal reviews reach conflicting
or vague conclusions.
Litigation - When the hospital faces a potential medical malpractice
suit, corporate legal counsel or risk management may recommend
external review.
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.
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);
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
April 2008

10

ACCEPTED

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

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


Quality of care, treatment or services provided

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


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

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


of care; treatment or services provided (disease, or symptoms caused,
exacerbated or allowed to progress)

April 2008

11

ACCEPTED

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


of care, treatment or services provided
(longevity, and/or functional Quality of life shortened or adversely affected by
medical action or inaction)

April 2008

12

ACCEPTED

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

April 2008

13

ACCEPTED

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.

April 2008

14

ACCEPTED

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 welldocumented 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.
April 2008

15

ACCEPTED

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.

April 2008

16

ACCEPTED

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

April 2008

17

ACCEPTED

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.

April 2008

18

ACCEPTED

Form 1000

Indicator/Criteria List and Data Source Matrix


Emergency Department
Indicator/Criteria

Case
Mgt.
Review

HIM

M SO

Quality
Dept.

MRR
Group

CM E
Comm.

Education
Dept.

UR

PT.
Rep

IC Pract.

Pharm

Adm/
Dept

Patient Care
Acute MI Mgt
ASA Usage
Fibrinolytic
Therapy
Pneumonia
Blood Cultures
Antibiotic with 4
hours

X
X

Moderation Sedation
Reversal Rates

Medical/Clinical
Knowledge

Hospital Based
CMEs
New Training or
Experience
Board Cert-Initial
or Renewal

X
X

Interpersonal and
Communication
Skills
Pt/Family/Staff
Written Positive
Feedback

April 2008

18

ACCEPTED

Form 1000

Indicator/Criteria List and Data Source Matrix


Emergency Department
Indicator/Criteria

Case
Mgt.
Review

HIM

M SO

Quality
Dept.

MRR
Group

CM E
Comm.

Complaints from
Patients/Family

Education
Dept.

UR

PT.
Rep

IC Pract.

Pharm

Adm/
Dept

Practice Based
Learning
Improvements

Illegible Orders
sent for Review

Adherence to
NPSG:
Abbreviations
Universal
Protocol

Emergent Elder
Care Protocols

System Based
Practice

Medical Record
Delinquency
warnings

Number of
Suspensions for
Delinquency

April 2008

19

ACCEPTED

Form 1000

Indicator/Criteria List and Data Source Matrix


Emergency Department
Indicator/Criteria

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

Case
Mgt.
Review

HIM

M SO

Quality
Dept.

MRR
Group

CM E
Comm.

Education
Dept.

UR

PT.
Rep

IC Pract.

Pharm

Adm/
Dept

*Provided as an attachment with the Ongoing Professional Practice Evaluation

Professionalism
Meetings
Attended
Complaints
related to
Professionalism
from Staff
Case
Presentation
Teaching an
Educational
Program
HIM Health Information Management
MSO Medical Staff Office
MRR Medical Record Review Group
UR- Utilization Review
PT Rep = Patient Representative

X
X
X
X
IC Pract Infection Control Practitioner
Adm Administration/Department

April 2008

20

ACCEPTED

Form 2000

Ongoing Professional Practice Evaluation - Evidence Based Data

Indicator/Criteria

Trigger

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
Q4
Q3
Q2
Q1
Q4
Q3
2008
2008
2008
2008
2007
2007

.
Q2
2007

Ytd Dept
Data

Yt d Nat l
Data

Patient Care
Acute MI Management
Percent receiving ASA
upon arrival (except for
acceptable
contraindications)
Fibrinolytic Therapy
within 30 minutes or
documented
contraindications
Pneumonia
Blood Cultures
Antibiotic within 4 hours
Moderation Sedation
Reversal Rates

Below
95%

96%

97%

100%

97%

98%

99%

95%

92%

93%

Below
95%

96%

97%

96%

96%

95%

97%

95%

94%

93%

Below
95%
Below
95%
Greater
than 5%

99%

96%

96%

99%

97%

95%

96%

95%

97%

90%

96%

97%

95%

96%

97%

95%

97%

94%

3%

3%

4%

3%

5%

4%

4%

2%

Not Available

Medical/Clinical
Knowledge

Hospital CME Hours


New Training or
Experience

Board Certification
Renewal/Initial

10

10

*
Yes

100%

Interpersonal and
Communication Skills

Patient Family/Staff

April 2008

21

ACCEPTED

Form 2000

Ongoing Professional Practice Evaluation - Evidence Based Data

Indicator/Criteria

Written positive
feedback
Complaints from
Patients/Families

Trigger

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
Q4
Q3
Q2
Q1
Q4
Q3
2008
2008
2008
2008
2007
2007
Yes

Yes

.
Q2
2007

Ytd Dept
Data

Yt d Nat l
Data

Yes

3 or More
1

5 or More

Not Available

3 or More
Less than
90%
Less than
5%

0
N/A

2
100%

3
N/A

2
N/A

3
90%

4
100%

5
N/A

3
90%

Not Available
Not Available

2%

3%

5%

5%

9%

10%

10%

6%

Not Available

3 or More

Not Available

1 or More

Not Available

Practice Based
Learning Improvements

Illegible Orders sent for


Review

Adherence to National
Patient Safety Goals:
Abbreviations

Universal Protocol, as
applicable
Emergent Elder Care
Protocols (% patients
inappropriately
discharged)

System Based
Practice

Medical Record
Delinquency
Number of Suspensions
for Delinquency
Warnings
* Utilization Data Report

April 2008

22

ACCEPTED

Form 2000

Ongoing Professional Practice Evaluation - Evidence Based Data

Indicator/Criteria

Trigger

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
Q4
Q3
Q2
Q1
Q4
Q3
2008
2008
2008
2008
2007
2007

.
Q2
2007

Ytd Dept
Data

Yt d Nat l
Data

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

Professionalism

Meetings Attended

Complaints related to
Professionalism from
Staff
Case Presentation
Teaching an Education
Program

1 or More

*
*

0
1

0
0

1
0

0
1

0
0

0
0

1
1

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
Mgt.
Review

HIM

MS O

Quality
Dept.

MRR
Group

CME
Comm.

Educatio
n
Dept.

UR

PT.
Rep

IC
Pract.

Pharm

Adm/
Dept

Patient Care

Re-intubation in
OR or PACU
Anesthesia
incidents (broken
teeth)
MI within 48
hours post
anesthesia
Pneumothorax
from Cen-line
insertion

X
X
X

Medical/Clinical
Knowledge

Hospital Based
CMEs
New Training or
Experience
Board Cert-Initial
or Renewal

X
X

Interpersonal and
Communication
Skills

April 2008

26

ACCEPTED

Form 1000

Indicator/Criteria List and Data Source Matrix


Anesthesia Department
Indicator/Criteria

Case
Mgt.
Review

HIM

MS O

Quality
Dept.

MRR
Group

CME
Comm.

Educatio
n
Dept.

UR

PT.
Rep

IC
Pract.

Pharm

Adm/
Dept

Pt/Family/Staff
Written Positive
Feedback
Complaints from
Patients/Family

Practice Based
Learning
Improvements

Illegible Orders
sent for Review

Adherence to
NPSG: labeled
meds

Abbreviations

Universal
Protocol

System Based
Practice

Med Record
Delinquency
Warnings
Number of
Suspensions for
Delinquency

X
X

April 2008

27

ACCEPTED

Form 1000

Indicator/Criteria List and Data Source Matrix


Anesthesia Department
Indicator/Criteria

Case
Mgt.
Review

HIM

MS O

Quality
Dept.

MRR
Group

CME
Comm.

Educatio
n
Dept.

UR

PT.
Rep

IC
Pract.

Pharm

Adm/
Dept

X
*Utilization data
Report
*Provided as an attachment with the Ongoing Professional Practice Evaluation.

Professionalism

Meetings
Attended
Complaints
related to
Professionalism
from Staff
Case
Presentation
Teaching an
Educational
Program

HIM Health Information Management


MSO Medical Staff Office
MRR Medical Record Review Group
UR- Utilization Review
PT Rep = Patient Representative

X
X
IC Pract Infection Control Practitioner
Adm - Administration

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
2008

Q3
2008

Q2
2008

Q1
2008

Q4
2007

Q3
2007

Q2
2007

Ytd
Dept
Data

Ytd Na tl
Data

Re-intubation in OR or
PACU

1 or More

Not Available

Anesthesia Incidents
(Broken Teeth)
MI within 48 hours post
anesthesia
Pneumothorax from
CDIRECTOR Line
Insertion

1 or More

Not Available

1 or More

Not Available

1 or More

Not Available

*
*

Medical/Clinical
Knowledge

Hospital CME Hours


New Training or
Experience
Board Certification
Renewal/Initial

Yes

Interpersonal and
Communication Skills

Patient/Family/Staff
Written positive
feedback
Complaints from
Patients/Families

*
3 or more

Yes
0

Yes
1

April 2008

N/A

Not Available

Not Available

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
2008

Q3
2008

Q2
2008

Q1
2008

Q4
2007

Q3
2007

Q2
2007

Ytd
Dept
Data

Ytd Na tl
Data

Practice Based
Learning Improvements

Illegible Orders sent for


Review
Adherence to National
Patient Safety Labeled
Medication
Abbreviations

5 or more

Not Available

3 or more

10

14

Not Available

3 or more

Not Available

Universal Protocol, as
applicable

Less than
90%

100%

100%

100%

95%

95%

85%

90%

92%

Not Available

Below
90%

95%

90%

100%

100%

95%

90%

100%

92%

Not Available

3 or more

Not Available

1 or more

Not Available

System Based Practice

Documentation of
appropriate pre-and
post anesthesia
assessments
Medical Record
Delinquency
Number of Suspensions
for Delinquency
*Utilization Data Report

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

Professionalism

Meetings Attended

April 2008

Not Available

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

Complaints related to
Professionalism from
Staff
Case Presentation
Teaching an Education
Program

Q4
2008

Q3
2008

Q2
2008

Q1
2008

Q4
2007

Q3
2007

Q2
2007

Ytd
Dept
Data

2 or more

*
*

0
0

0
1

1
1

0
0

0
0

0
0

0
0

Ytd Na tl
Data
Not Available

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:
June 1, 2007

October, November, December 2008

Physician Number : 9288

Date:

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
Mgt.
Review

HIM

MSO

Quality
Dept.

MRR
Group

CME
Comm.

Education
Dept.

UR

PT.
Rep

IC
Pract.

Pharm

Adm/
Dept

Patient Care

Organ Injury

Prophyladic
antibiotic with one
hour to incision
Prophyladic
antibiotic
discontinued within
24 hrs
Compliance with
DVT prevention
Post wound
infection

Post- op ventilator
associated
pneumonia

Medical/Clinical
Knowledge

Hospital Based
CMEs
New Training or
Experience
Board Cert-Initial or
Renewal

X
X

April 2008

34

ACCEPTED

Form 1000

Indicator/Criteria List and Data Source Matrix


Surgery Department
Indicator/Criteria

Case
Mgt.
Review

HIM

MSO

Quality
Dept.

MRR
Group

CME
Comm.

Education
Dept.

UR

PT.
Rep

IC
Pract.

Pharm

Adm/
Dept

Interpersonal and
Communication
Skills

Pt/Family/Staff
Written Positive
Feedback
Complaints from
Patients/Family

Practice Based
Learning
Improvements

Illegible Orders
sent for Review
Adherence to
NPSG:
Abbreviations

Universal Protocol

System Based
Practice

History & Physical


Current/updated
Informed Consent
Surgery

X
X

Submits SSI report

April 2008

35

ACCEPTED

Form 1000

Indicator/Criteria List and Data Source Matrix


Surgery Department
Indicator/Criteria

Case
Mgt.
Review

HIM

MSO

Quality
Dept.

MRR
Group

CME
Comm.

Education
Dept.

UR

PT.
Rep

IC
Pract.

Pharm

Adm/
Dept

to ICP monthly
X
*Utilization Data
Report
*Provided as an attachment with the Ongoing Professional Practice Evaluation,

Professionalism

Meetings attended
Complaints related
to Professionalism
from Staff
Case Presentation
Teaching an
Educational
Program

HIM Health Information Management


MSO Medical Staff Office
MRR Medical Record Review Group
UR- Utilization Review
PT Rep = Patient Representative

X
X
X
IC Pract Infection Control Practitioner
Adm - Administration

April 2008

36

ACCEPTED

Form 2000

Indicator

Trigger

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
Q4
Q3
Q2
Q1
Q4
Q3
Q2
2008
2008
2008
2008
2007
2007
2007

Y td
Dept
Data

Yt d Nat l
Data

Patient Care

Organ Injury
Prophyladic antibiotic
within 1hr prior to
surgical incision
Prophyladic antibiotic
discontinued within 24
hrs
Compliance with DVT
prevention
Post-op wound Infection
Post-op ventilator
associated pneumonia

1 or More
Less than
95%

0
95%

0
97%

0
100%

1
98%

0
96%

0
95%

0
98%

2
97%

Not Available
98%

Less than
95%

95%

94%

90%

80%

85%

78%

75%

90%

Less than
90%
Less than
2% of total
cases
2 or More

93%

99%

84%

82%

88%

43%

22%

88%

.5%

1%

1%

1.0%

1.0%

Not Available

*
*

Medical/Clinical
Knowledge

Hospital CME Hours


New Training or
Experience
Board Certification
Renewal/Initial due 8/07

Yes

100%

Interpersonal and
Communication Skills

Patient Family/Staff

Yes

Yes

April 2008

37

ACCEPTED

Form 2000

Indicator

Written positive
feedback
Complaints from
Patients/Families

Trigger

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
Q4
Q3
Q2
Q1
Q4
Q3
Q2
2008
2008
2008
2008
2007
2007
2007

Y td
Dept
Data

Yt d Nat l
Data

3 or more

Illegible Orders sent for


Review
Adherence to National
Patient Safety Goals:
Abbreviations

5 or more

Not Available

3 or more

Not Available

Universal Protocol, as
applicable

Less than
90%

100%

100%

100%

98%

100%

96%

95%

96%

Not Available

Practice Based
Learning Improvements

System Based Practice

History & Physical


Current

Less than
100%

100%

100%

95%

100%

100%

100%

100%

98%

Not Available

Informed Consent

100%

100%

100%

98%

100%

100%

100%

95%

Not Available

Submits SSI report to


ICP monthly
*Utilization Data Report

Less than
100%
<3

2.4

Not Available

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

Professionalism

April 2008

38

ACCEPTED

Form 2000

Indicator

Trigger

*
1 or more

Meeting Attended
Complaints related to
Professionalism from
Staff
Case Presentation
Teaching an Education
Program

*
*

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
Q4
Q3
Q2
Q1
Q4
Q3
Q2
2008
2008
2008
2008
2007
2007
2007
3
0

3
0

2
0

3
0

1
0

3
0

3
0

Y td
Dept
Data

Yt d Nat l
Data

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
Mgt.
Review

HIM

MSO

Quality
Dept.

MRR
Group

CME
Comm.

Education
Dept.

UR

PT.
Rep

IC
Pract.

Pharm

Adm/
Dept

Patient Care

Percent of
Agreement for
over-reads
Procedural
Complications

X
X

Moderate
Sedationreversal rates

Medical/Clinical
Knowledge

Hospital Based
CMEs
New Training or
Experience
Board Cert-Initial
or Renewal

X
X

Interpersonal and
Communication
Skills

Pt/Family/Staff
Written Positive
Feedback

April 2008

42

ACCEPTED

Form 1000

Indicator/Criteria List and Data Source Matrix


Radiology Department
Indicator/Criteria

Case
Mgt.
Review

HIM

MSO

Quality
Dept.

MRR
Group

CME
Comm.

Education
Dept.

UR

PT.
Rep

IC
Pract.

Pharm

Adm/
Dept

Complaints from
Patients/Family

Practice Based
Learning
Improvements

Critical Values
Timeliness

Abbreviations

Universal
Protocol

System Based
Practice

History &
Physical for
appropriate
procedures
Documentation
of appropriate
anesthesia
assessment for
moderate
sedation
*Utilization Data
Report

April 2008

43

ACCEPTED

Form 1000

Indicator/Criteria List and Data Source Matrix


Radiology Department
Indicator/Criteria

Case
Mgt.
Review

HIM

MSO

Quality
Dept.

MRR
Group

CME
Comm.

Education
Dept.

UR

PT.
Rep

IC
Pract.

Pharm

Adm/
Dept

*Provided as an attachment with the Ongoing Professional Practice Evaluation

Professionalism

Meetings Attended
Complaints
related to
Professionalism
from Staff
Case
Presentation
Teaching an
Educational
Program

X
X

X
X
HIM Health Information Management
MSO Medical Staff Office
MRR Medical Record Review Group
UR- Utilization Review
PT Rep = Patient Representative

IC Pract Infection Control Practitioner


Adm - Administration

April 2008

44

ACCEPTED

Form 2000

Indicator

Trigger

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
Q4
Q3
Q2
Q1
Q4
Q3
Q2
2008
2008
2008
2008
2007
2007
2007

Y td
Dept
Data

Yt d Nat l
Data

Patient Care

Percent of Agreement
for Over-reads

95% or
less

Procedural
Complications
Moderate Sedation
Reversal Rate

2 or more

Greater
than 5%

98%

99%

100%

100%

98%

100%

100%

97%

2%

0%

0%

1%

1%

0%

0%

2.5%

Medical/Clinical
Knowledge

Hospital CME Hours


New Training or
Experience
Board Certification
Renewal/Initial due
8/2007

*
*

Yes

100%

Interpersonal and
Communication Skills

Patient Family/Staff
Written positive
feedback
Complaints from
Patients/Families

*
3 or more

Yes
0

Yes
0

Yes
0

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
Q4
Q3
Q2
Q1
Q4
Q3
Q2
2008
2008
2008
2008
2007
2007
2007

Indicator

Trigger

Critical Value
Timeliness
Adherence to National
Patient Safety Goals:

1 or more
exceeding

Abbreviations

3 or more

Universal Protocol, as
applicable

Less than
90%

100%

100%

96%

95%

92%

90%

90%

95%

100%

100%

100%

100%

100%

100%

100%

90%

85%

95%

2
0

0
0

1
0

2
0

Y td
Dept
Data

Yt d Nat l
Data

System Based Practice

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

Professionalism

Meetings attended
Complaints related to
Professionalism from
Staff
Case Presentation

*
1 or more

2
0

2
0

2
0

April 2008

46

ACCEPTED

Form 2000

Indicator

Trigger

Teaching an Education
Program

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
Q4
Q3
Q2
Q1
Q4
Q3
Q2
2008
2008
2008
2008
2007
2007
2007

Y td
Dept
Data

Yt d Nat l
Data

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

Corrections to
H&P

Feedback on
aseptic
technique
Feedback on
surgical skills

Case
Mgt.
Review

HIM

MSO

Quality
Dept.

MRR
Group

CME
Comm.

Education
Dept.

UR

PT.
Rep

IC
Pract.

Pharm

Adm/
Dept

X
X

Medical/Clinical
Knowledge

CE Hours

New Training or
Experience

Interpersonal and
Communication
Skills

Feedback
related to
communication
skills

April 2008

50

ACCEPTED

Form 1000

Indicator/Criteria List and Data Source Matrix


Allied Health PA
Indicator/Criteria

Case
Mgt.
Review

HIM

MSO

Quality
Dept.

MRR
Group

CME
Comm.

Education
Dept.

Complaints from
Patients/Family

UR

PT.
Rep

IC
Pract.

Pharm

Adm/
Dept

Practice Based
Learning
Improvements

Illegible Orders
sent for Review

Adherence to
NPSG:
Abbreviations

X
X

Universal
Protocol

System Based
Practice

Timeliness of
H&Ps
Dating and
Timing of entries
*Utilization Data
Report

X
X

Professionalism

April 2008

51

ACCEPTED

Form 1000

Indicator/Criteria List and Data Source Matrix


Allied Health PA
Indicator/Criteria

Case
Mgt.
Review

HIM

MSO

Quality
Dept.

MRR
Group

CME
Comm.

Education
Dept.

X
Feedback
related to
Professionalism
from Staff
*Provided as an attachment with the Ongoing Professional Practice Evaluation.
HIM Health Information Management
MSO Medical Staff Office
MRR Medical Record Review Group
UR- Utilization Review
PT Rep = Patient Representative

UR

PT.
Rep

IC
Pract.

Pharm

Adm/
Dept
X

IC Pract Infection Control Practitioner


Adm Administration/Department

April 2008

52

ACCEPTED

Form 2000

Indicator

Trigger

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
Q4
Q3
Q2
Q1
Q4
Q3
Q2
2008
2008
2008
2008
2007
2007
2007

Y td
Dept
Data

Yt d Nat l
Data

Patient Care

Corrections to H&P

Feedback on aseptic
technique
Feedback on surgical
skills

*
*

10

4
Yes new
ortho
system

16

Score of 2 or
less
2 or more

2 or more

2 or more
H&Ps with
corrections
1 or more
breaks
Below 4
rating on
feedback

1.2

Not Available

3.5

Not Available

Not Available

Not Available

Not Available

Medical/Clinical
Knowledge

CE Hours
New Training or
Experience

Interpersonal and
Communication Skills

Feedback related to
communication skills
Complaints from
Patients/Families

Practice Based
Learning Improvements

Illegible Orders sent for

April 2008

53

ACCEPTED

Form 2000

Indicator

Trigger

Review
Adherence to National
Patient Safety Goals:
Abbreviations
Universal Protocol,
as applicable

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
Q4
Q3
Q2
Q1
Q4
Q3
Q2
2008
2008
2008
2008
2007
2007
2007

Y td
Dept
Data

Yt d Nat l
Data

3 or more

Not Available

Less than
90%

100%

100%

100%

100%

95%

90%

95%

95%

Not Available

0
90%

1
90%

1
90%

0
85%

2
80%

0
80%

1
75%

4
80%

Not Available
Not Available

0
3

2
3

2
3

2
3

Not Available
Not Available

System Based Practice

Timeliness of H&P
Dating and timing of
entries
*Utilization Data Report

2 or more
Less than
90%
X

Professionalism

*
0
3
2
Meeting Attended
Score of 2 or
3
3
3
Feedbacks related to
less
Professionalism from
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:
June 1, 2007

October, November, December 2008

Practitioner Number : 2143 (PA)

Date:

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
Poor

2
Fair

3
Average

4
Good

5
Excellent

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

2).

Professionalism
1
Poor

2
Fair

3
Average

4
Good

5
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

Unfamiliar with the steps of the operation;


Unable to recall or describe many operative steps

Instrument Handling
1

Makes tentative or awkward moves by


inappropriate used of instruments

Knowledge of Instruments
1

FreQently asks for wrong instruments or


used inappropriate instruments

Flow of the Operation


1

FreQently stopped operating and


seemed unsure of next move

Respect For Tissue


1

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 SelfTeaching 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:
Hosp/ MR #

Event
Indicator and Description
Date(s)

Source of Referral
_

Quality Indicator
Pattern of clinical or behavioral issues
Patient/Family complaint
Potential litigation (attorney requests record)

_ Nursing/other clinical staff concern


_ Other Medical Staff Member
QCC/Incident Report
Formal notice of litigation

Evaluation of Case
1)
2)
3)
4)
5)
6)
7)
8)
9)

Does the case represent a deviation from the standard of care for this patient population? No Yes*
Were the H&P, OP notes, and Progress notes adequate and timely? No* Yes
Were there any identifiable breakdowns in communication? No Yes*
Was judgment/decision making sound in this case? No* Yes
Were there any clinical process problems that contributed to the patient outcome? No Yes*
Could this incident have been readily prevented? No Yes*
Is there an educational opportunity? No Yes*
Was the management/documentation of the case a problem after the complication occurred? No Yes*
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
1
2
3
4
5
6
7

No problem or complication unrelated to quality/safety issue


Minor problem or complication
Problem with significant but temporary adverse affect on patient (example- extended LOS,
extra surgery, etc)
Problem with significant adverse affect on patient that is likely to be longer-term (ie pain, mobility,
dietary restrictions, other problems)
Problem as #3 but with permanent disability/significant injury
Death possibly related to quality/safety issue
Death likely related to quality/safety issue
Unknown outcome

Action by Committee
1
2
3
4
5
6
7
8
9
10
11
12
13
14

No action other than documentation in minutes and record for profile


Trend
Telephone or verbal discussion
Letter to practitioner with no request for response
Letter to practitioner with request for response
Counseling conversation between Chair & practitioner
Request practitioner to attend MSPR meeting to discuss case
Intensive review of
additional cases
Referred for review by outside reviewer
Referred for Root Cause Analysis
Classified as a Sentinel Event
Refer to Medical Staff Executive Committeeto assess potential disciplinary action
Refer to Hospital Patient Safety Team or IQC for concerns about hospital processes
Consider medical staff education session on topic:

Additional Actions
A
B
C
D

Mandatory consultation for specific type of cases as noted


Suspension of privileges-type/timeframe specified
Report to Data Bank
Other:_