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OPPE-FPPE Physician Performance Toolkit

Contributed by

LifePoint Hospitals Brentwood, TN

Leading Practices Library


Organizations submit practices to The Joint Commission that they have found to be leading practices, with permission to share them with other organizations. The Joint Commission makes these leading practices available to organizations that may wish to examine their applicability to their particular circumstances. Please understand that The Joint Commission can make no representations as to the results that any organization can expect from their use or adaptation of a leading practice to their particular circumstances.

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LifePoint Physician Performance Toolkit*


Introduction: Credentialing is now an ongoing process that involves continuous evaluation of a practitioners performance using an evidence -based approach that is fairly and consistently applied using criteria appropriate to the specialty area of practice and request privileges. Physician profile data should be robust, include comparisons, and lead to informed decision-making around granting or denial of privileges. Definitions: Ongoing Professional Practice Evaluation - A documented summary of ongoing data collected for the purpose of assessing a practitioner's clinical competence and professional behavior. The information gathered during this process factors into decisions to maintain, revise or revoke existing privilege (s). Focused Professional Practice Evaluations (Focused Review) - A time-limited evaluation of practitioner competence in performing a specific privilege. This process is implemented for: All newly requested privileges and Whenever a question arises regarding a practitioner's ability to provide safe, high Quality patient care Practitioner Individual with Medical Staff or Allied Health privileges.

Core Competencies: Patient Care Medical/Clinical Knowledge Practice-Based Learning and Improvement Interpersonal and communication skills Professionalism System-Based Practice Steps for implementing OPPE: Identify all current criteria for each specialty/subspecialty Identify applicable core competencies (may meet more than one) Identify the gaps Meet with key medical staff leaders to complete the criteria/indicators Complete a matrix for data sources to connect the data to Quality and Medical Staff Office Define periodic timeframe for review Implement * Toolkit adapted from McKenna & Associates Presentation and other resources

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Steps for Developing An Evidence Based Ongoing Professional Practice Evaluation

Step One Complete a worksheet for each department and sometimes subspecialties within the department based on what is already being measured. Compare the list to the practitioners privilege list for specialties and subspecialties assigned to that department. You must be collecting data that relates to what they are privileged to perform. Step Two If the list is inadequate, meet with the Department Chair or other appropriate medical staff member to add appropriate indicators. Develop a matrix of data source. Again, using privilege list to make sure the data represents what the members are privileged to do. Step Three Seek approval of the criteria by the appropriate medical staff leaders and/or committees. Step Four Create the profiles from the indicator worksheet. Step Five Define your periodic timeframe for reporting the profile i.e. 3 months or 6 months. Step Six Develop a standard report format to and from the Department Chair to the Quality Department or appropriate Quality group based on your structure. Step Seven Set up a process for the feed back to reach the database (file) of the individuals being considered for reappointment.

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Toolkit Contents
Sample OPPE Policy Page 4 Sample FPPE Policy-- Page 13 Description of Forms -- Page 17 Toolkit Example Forms: Emergency Department Page 19 Anesthesia Department Page 26 Surgery Department Page 34 Radiology Department Page 42 Physician Assistant Surgery Department Page 50

Appendix Examples of Evaluation Sheet for Surgical PA Page 58 Example Indicators Page 60 Sample Privilege Criteria-- Page 64 Sample Proctor Review FormPage 67 Medical Staff Case Review Tool---Page 68

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Ongoing Professional Practice Evaluation EXAMPLE POLICY JC Standards: MS.4.40 and MS.4.45 Purpose
1. To clearly define the process utilized for facilitating the continuous evaluation of each practitioner's professional practice; 2. To define the type of data (criteria/indicators) to be collected for the ongoing professional practice evaluation. (Note: The criteria defined for Ongoing Professional Practice Evaluation, will be utilized as screening triggers for a possible Focused Professional Practice Evaluation). 3. To ensure the information resulting from the ongoing professional practice evaluation is used to determine whether to continue, limit or revoke any existing privileges; 4. To define the process for collecting, investigating, and addressing clinical practice concerns, including the process utilized to identify trends that impact Quality of care and patient safety; 5. To ensure reported concerns regarding a privileged practitioner's professional practice are uniformly investigated and addressed as defined by hospital policy and applicable law; 6. To define those circumstances in which an external review or focused review may be necessary; and 7. To define the medical staff's leadership role in the organization's performance improvement activities related to practitioner performance and ensure that when the findings are relevant to an individual's performance, the findings in the ongoing evaluations of competence are in accordance with recognized standards.

Scope

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

Definitions Focused Professional Practice Evaluations (Focused Review) - A timelimited 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 4

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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 5

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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

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Review Panel, as appropriate, all cases scored a 3,4 or 5 by the peer screener; v. Provides periodic summary reports (Ongoing Professional Practice Feedback Reports) on an ongoing basis to individual practitioners, Department Chairpersons. Summary Reports will be shared with Department Credentials Committee and MEC and patterns/trends identified. The summary reports for review by Department chairs will include the documentation of the peer reviewers. The Department chair is looking for trends based on the review by peers. Utilization review data, as appropriate, will also be provided.

3. Peer Screener a. Definition - Practitioner from the same discipline and with essentially equal qualifications as the individual under review (for example, physician and physician, dentist and dentist, etc). b. 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.

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viii. Reviews the Ongoing Professional Practice Feedback Reports and meets with individual practitioners when trends or suboptimal performance is identified. ix. Implements a Focused Professional Practice Evaluation when indicated. 5. Peer Review Panel a. Definition - The Peer Review Panel consists of practitioners assigned by the Department Chairperson, and may include others as designated the MEC. b. Responsibility i. Reviews cases (scored a category 3, 4 or 5) or when threshold parameters are exceeded; ii. Documents a final score on reviewed cases (unless case forwarded for external review); and iii. The Peer Review Panel minutes will reflect findings, conclusions, recommendations, and actions taken. Minutes will also reflect if any additional action is indicated. iv. Recommends a Focused Professional Practice Evaluation when indicated. 6. Department Credentials Committee a. Definition - Defined in Medical Staff Bylaws b. Responsibility i. 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 8

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v.

Reports and recommends to the Board of Directors regarding Ongoing Professional Practice Review and Focused Professional Practice Evaluation activities, as appropriate.

8. Individual Under Review a. Definition - The individual whose performance is being reviewed. b. Responsibility i. Provides a response to all cases scored 3, 4 or 5, or for any case requested. ii. Reviews Ongoing Professional Practice Feedback Reports when received. iii. Participates in Focused Professional Practice Evaluation process when indicated.

IV. Method for Selecting Reviewer Panels, Including Specific Circumstances 1. Assignments a. The Quality Director will identify a peer screener utilizing the roster provided by the Medical Staff Office and in collaboration with the Department Chairperson. b. If the Department Chairperson is the individual being reviewed, the Chief of Staff will determine the peer screener and may recommend an alternative peer review panel. 2. Conflict of Interest -Within the context of the review process, a conflict of interest will preclude an individual from making a performance review determination in the evaluation of the performance of another practitioner. A conflict of interest may exist if the reviewer has significant financial interest in the hospital or direct professional or personal involvement in the case under evaluation. In those cases the Department Chairperson or Chief of Staff will assign an alternate peer screener. If necessary, hospital legal counsel may be contacted to assist in identifying a review process that will minimize conflict of interest. 3. Special Peer Review Panels - If requested by the Chief of Staff, MEC or Department Chairperson, a special panel of peers may be assigned to review the case.
a. External Review - External performance review is required under the

following circumstances: a. Conflict of Interest - The review may not be conducted by any peer on April 2008

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b. c. d. e.

f.

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

V.

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

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closed should closely adhere to a 60-day timeframe. However, there may be circumstances when this timeline is exceeded due to external review process. The time frame should be adhered to as reasonable. b. Fast Track Review - Circumstances may arise in which the review process must be expedited. This includes cases meeting the organization's sentinel event definition. In other cases, the determination for fast-tracking may be left to the discretion of the Chief of Staff, Department Chairperson or Medical Executive Committee and corporate Quality Director. The timeframe for a Fast Track Review should not exceed 45 days from the time the event is determined to be a sentinel event. This time frame should be adhered to as reasonable. 3. Defensible - The conclusions reached during the review process are to be supported by rationale that specifically address the issues for which the review was conducted, including, as appropriate, reference to the literature and relevant clinical practice guidelines. 4. Balanced - Minority opinions and views of the individual under review are to be considered and recorded. 5. Useful - The results of review activities are to become part of the practitioner's Quality profile and to be used for credentialing and privileging decisions and, as appropriate, in performance improvement activities. 6. Ongoing - The review conclusions are tracked over time, and actions based on review conclusions are monitored for effectiveness by the Medical Executive Committee.

Scoring
SCORE

DEFINITION
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) 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)

0 1 2 3 4

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

Includes, but is not limited to delays in care, treatment and services provided ** Includes, but is not limited to disruptive behavior IX. Performance Improvement 1. Members of the medical staff are involved in activities to measure, assess, and improve performance on an organization wide basis, including the ongoing professional practice review process defined herein. 2. The review process involves monitoring, analyzing, and understanding those special circumstances of practitioner performance, which require further evaluation. 3. When findings of this process are relevant to an individual's performance, the medical staff is responsible for determining their use in ongoing evaluation of a practitioner's competence, in accordance with the JC standards on renewing or revising clinical privileges. Supporting Policies/Procedures Disruptive Behavior Policy Patient Complaint/Grievance Policy Impaired Practitioner Policy Focused Professional Practice Evaluation Policy Medical Staff Bylaws Fair Hearing Plan Allied Health Grievance Policy References JC CAMH - MS.4.40 and MS.4.45

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FOCUSED PROFESSIONAL PRACTICE EVALUATION POLICY


Purpose To establish a systematic process to evaluate and confirm the current competency of practitioners performance of privileges at ______________ hospital. This process is known as focused professional practice evaluation (FPPE or focused evaluation). Definition of FPPE Focused professional practice evaluation is defined as a time-limited period during which the organization evaluates and determines a practitioners professional performance of privileges. FPPE will occur in all requests for new privileges and when there are concerns regarding the provision of safe, high quality care by a current medical staff member, as recognized through the peer review process. This process includes an assessment for proficiency in the following six areas of general competencies: 1. Patient care. 2. Medical and clinical knowledge 3. Practice-based learning and improvement 4. Interpersonal and communication skills 5. Professionalism 6. Systems-based practice Information for this evaluation may be derived from the following: 1. Discussion with other individuals involved in the care of each patient (e.g. consulting physician, assistants in surgery, nursing, or administrative personnel) 2. Chart review 3. Monitoring clinical practice patterns 4. Proctoring 5. Simulation 6. External peer review Responsibilities The department chair (or division chief) shall be responsible for overseeing the evaluation process for all applicants or staff members assigned to their department or division. The credentials committee is charged with the responsibility of monitoring compliance with this policy. It accomplishes this by receiving regular status reports on the progress of all practitioners undergoing focused evaluation as well as any issues or problems involving the implementation of this policy.

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Performance of FPPE The type of focused professional performance evaluation to be used will be determined by the department chair based on the individual practitioners circumstance using the following guidelines: 1. New applicant. a. Peer recommendations from previous institutions will be confirmed by the department chair. b. Performance indicators, or aggregate data, within the department will be monitored. c. FPPE peer evaluations by the department chair and one other active staff member will be completed within 3 months of initiation of clinical activity. The department chair should seek input from colleagues, consultants, nursing personnel, and administration. d. Procedure and clinical activity logs will be reviewed from either previous institutions or training programs. If current competency from previous institution is well-documented through case logs of activity within recent year, then no additional monitoring is required. If current competency and adequate clinical activity is not 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.

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4. When a privilege is used infrequently. The department should determine a minimum number of cases to be performed to maintain proficiency. This should be denoted in the delineation of privileges plan. If the minimum amount is not being met, then the department chairman will establish a plan for focused evaluation. Duration of FPPE FPPE shall begin with the applicants first admission or performance of the newly requested privilege. Each department/division will determine the number of cases or charts to be reviewed. FPPE for new applicants should be completed by 3 months. This will allow for further evaluation, if indicated, prior to the end of the initial appointment cycle. All proctoring activity, summaries, and reports need to be completed prior to the end of the 12 month initial appointment cycle. If the FPPE has not been completed, then unrestricted privileges will not be granted. Supervision of FPPE Assignment of focused professional practice evaluations will be the responsibility of the department chair or division chief. The chair/chief may appoint active staff members to complete the appropriate tasks. Division consultants and medical directors should be utilized. It is recommended that each department establish a panel of proctors. Proctor Qualifications If proctoring is required, the following guidelines should be used: 1. Proctors must be in good standing of the active medical staff of MHMH. 2. The proctor must have unrestricted privileges to perform any procedure to be concurrently observed. 3. Proctors will be mutually agreed upon between the department chair and the physician being proctored. 4. The proctor may be a member of the same practice group as the physician being proctored. Responsibilities of Proctors 1. Proctor shall directly observe the procedure being performed, concurrently observe medical management or retrospectively review the completed medical record following discharge and will complete appropriate forms. 2. Ensure confidentiality of proctor results and forms. Submit completed forms to the medical staff office. 3. Submit a summary report at conclusion of proctoring period. 4. If at any time during the proctoring period the proctor has concerns about the practitioners competency to perform specific clinical privileges or care related to a specific patient, the proctor shall promptly notify the department chair. Medical Staffs Ethical Position on Proctoring Concurrent proctoring is one method of evaluation for competency for procedures that may be used. The proctor is not a mentor or a consultant. The proctor is an agent of the hospital. The proctor shall receive no compensation from any patient for this service. April 2008

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

References JC CAMH - MS.4.30

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Description of Forms in the Toolkit


Form 1000 Indicator/Criteria List and Data Source Matrix Each department and/or specialty needs indicators appropriate to the area of practice. The indicator/criteria for each department or division should be approved through the Medical Staff approval process. It will be important to identify the group accountable for providing the data so the data can be brought forward to the practitioner driven profile. Many of the indicator/ criteria will be consistent across the organization with the same data source. The ones that are approved for patient care are the ones that will change the most frequently from one department to another. Form 2000 Ongoing Professional Practice Evidence Based Data This form reflects the indicators/criteria presented for individual practitioners from the Departments/Divisions. The trigger level should be established by the medical staff. Form 3000 Periodic Report to the Department/Division Chair from the Quality Department This form provides an example of communication from the Quality Department or Medical Staff Office to the Department Chair/Division Chair outlining practitioners in their department or division that were at trigger levels. It will be important to your success that appropriate communication links are established and there is an appropriate action taken based on the trigger. Form 4000 Department/Division Responses Back to the Quality Department or Medical Staff Office This form provides an example of how the Department/Division chair starts to document the appropriate action taken based on the periodic review.

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

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Form 1000

Indicator/Criteria List and Data Source Matrix Emergency Department


Indicator/Criteria Case Mgt. Review HIM MSO Quality Dept. MRR Group CME 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 Moderation Sedation Reversal Rates Medical/Clinical Knowledge Hospital Based CMEs New Training or Experience Board Cert-Initial or Renewal X X X X X X X X

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

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Form 1000

Indicator/Criteria List and Data Source Matrix Emergency 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


Illegible Orders sent for Review X X

Adherence to NPSG: Abbreviations Universal Protocol Emergent Elder Care Protocols

System Based Practice


Medical Record Delinquency warnings Number of Suspensions for Delinquency

X X

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Form 1000

Indicator/Criteria List and Data Source Matrix Emergency Department


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

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

*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
IC Pract Infection Control Practitioner Adm Administration/Department

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

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Form 2000

Indicator/Criteria 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

Trigger

Department of Emergency Medicine. Subspecialty if applicable N/A . Practitioner ID # 0876 Last Appointment Date July 07 Status Active Reporting Period: 4th Qarter 2008 Q4 Q3 Q2 Q1 Q4 Q3 2008 2008 2008 2008 2007 2007

Ongoing Professional Practice Evaluation - Evidence Based Data


. Q2 2007 Ytd Dept Data Ytd Natl Data

Below 95% Below 95% Below 95% Below 95% Greater than 5%

96% 96%

97% 97%

100%

97%

98% 95%

99%

95% 95%

92% 94%

93% 93%

96%

96%

97%

99% 90% 3%

96% 96% 3%

96% 97% 4%

99% 95% 3%

97% 96% 5%

95% 97% 4%

96% 95% 4%

95% 97% 2%

97% 94% 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 *

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Form 2000

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 Status Active Reporting Period: 4th Qarter 2008 Q4 Q3 Q2 Q1 Q4 Q3 2008 2008 2008 2008 2007 2007
Yes 0 Yes 1

Ongoing Professional Practice Evaluation - Evidence Based Data


. Q2 2007 Ytd Dept Data Ytd Natl Data

Yes 1

3 or More

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

3 or More Less than 90% Less than 5%

0 N/A 2%

2 100% 3%

3 N/A 5%

2 N/A 5%

3 90% 9%

4 100% 10%

5 N/A 10%

3 90% 6%

Not Available Not Available Not Available

System Based Practice


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

3 or More 1 or More X

0 0

2 0

0 0

0 0

1 0

0 0

0 0

5 0

Not Available Not Available

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Form 2000

Indicator/Criteria

Trigger

Department of Emergency Medicine. Subspecialty if applicable N/A . Practitioner ID # 0876 Last Appointment Date July 07 Status Active Reporting Period: 4th Qarter 2008 Q4 Q3 Q2 Q1 Q4 Q3 2008 2008 2008 2008 2007 2007

Ongoing Professional Practice Evaluation - Evidence Based Data


. Q2 2007 Ytd Dept Data Ytd Natl 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 * *

2 0 0 1

0 0 0 0

1 0 1 0

0 0 0 1

3 0 0 0

0 0 0 0

1 0 1 1 4

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

Information only

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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 # 0876 . # _______________ # _______________ 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

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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

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Form 1000

Indicator/Criteria List and Data Source Matrix Anesthesia Department


Indicator/Criteria Case Mgt. Review HIM MSO 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 X

Medical/Clinical Knowledge
Hospital Based CMEs New Training or Experience Board Cert-Initial or Renewal X X X X

Interpersonal and Communication Skills

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Form 1000

Indicator/Criteria List and Data Source Matrix Anesthesia Department


Indicator/Criteria Case Mgt. Review HIM MSO Quality Dept. MRR Group CME Comm. Educatio n Dept. UR PT. Rep
X X X

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 X X X X X

System Based Practice


Med Record Delinquency Warnings Number of Suspensions for Delinquency

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Form 1000

Indicator/Criteria List and Data Source Matrix Anesthesia Department


Indicator/Criteria Case Mgt. Review HIM MSO 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 X X

X X
IC Pract Infection Control Practitioner Adm - Administration

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

April 2008

28

ACCEPTED

Form 2000

Ongoing Professional Practice Evaluation - Evidence Based Data Department of Anesthesia. Subspecialty if applicable N/A . Practitioner ID # 9288 Last Appointment Date July 07 . Status Active Reporting Period: 4th Qarter 2008

Indicator
Re-intubation in OR or PACU Anesthesia Incidents (Broken Teeth) MI within 48 hours post anesthesia Pneumothorax from CDIRECTOR Line Insertion

Trigger
1 or More 1 or More 1 or More 1 or More

Q4 2008
0 0 0 0

Q3 2008
0 0 0 0

Q2 2008
0 0 0 0

Q1 2008
1 0 0 0

Q4 2007
0 1 0 0

Q3 2007
0 0 0 0

Q2 2007
0 0 0 0

Ytd Dept Data


2 2 0 0

Ytd Natl Data


Not Available Not Available Not Available Not Available

Medical/Clinical Knowledge
Hospital CME Hours New Training or Experience Board Certification Renewal/Initial * * 0 2 3 0 0 5 Yes 5

Interpersonal and Communication Skills


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

* 3 or more 0 0

Yes 0 1

Yes 0 0 0

N/A 2

Not Available Not Available

April 2008

29

ACCEPTED

Form 2000

Ongoing Professional Practice Evaluation - Evidence Based Data Department of Anesthesia. Subspecialty if applicable N/A . Practitioner ID # 9288 Last Appointment Date July 07 . Status Active Reporting Period: 4th Qarter 2008

Indicator

Trigger

Q4 2008

Q3 2008

Q2 2008

Q1 2008

Q4 2007

Q3 2007

Q2 2007

Ytd Dept Data


3 5 3 92%

Ytd Natl Data

Practice Based Learning Improvements


Illegible Orders sent for Review Adherence to National Patient Safety Labeled Medication Abbreviations Universal Protocol, as applicable Documentation of appropriate pre-and post anesthesia assessments Medical Record Delinquency Number of Suspensions for Delinquency *Utilization Data Report 5 or more 3 or more 3 or more Less than 90% Below 90% 3 or more 1 or more X 0 3 3 100% 0 4 0 100% 2 9 2 100% 3 10 0 95% 3 8 2 95% 5 9 0 85% 5 14 4 90% Not Available Not Available Not Available Not Available

System Based Practice


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

0 0

0 0

0 0

0 0

1 0

0 0

0 0

2 0

Not Available Not Available

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

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

April 2008

30

ACCEPTED

Form 2000

Ongoing Professional Practice Evaluation - Evidence Based Data Department of Anesthesia. Subspecialty if applicable N/A . Practitioner ID # 9288 Last Appointment Date July 07 . Status Active Reporting Period: 4th Qarter 2008

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

Trigger
2 or more * *

Q4 2008
0 0 0

Q3 2008
0 0 1

Q2 2008
0 1 1

Q1 2008
0 0 0

Q4 2007
0 0 0

Q3 2007
0 0 0

Q2 2007
0 0 0

Ytd Dept Data


1

Ytd Natl 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 # 9288 . # _______________ # _______________ 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

ACCEPTED

Form 4000

DEPARTMENT DIRECTOR RESPONSE DEPARTMENT OF SURGERY/ANESTHESIA October, November, December 2008 Date:

Reporting Period: June 1, 2007

Physician Number : 9288

As the Department Chair for Surgery and Chair of Anesthesia, we have reviewed the results of the Ongoing Professional Practice Evaluation for the above named physician. I have taken the following action: I reviewed the findings and no further action is needed at this time. I reviewed the findings and discussed them with the Practitioner. The practitioner has been informed that if the threshold is exceeded for two Quarters or more during this reappointment cycle, a focus review will be initiated based on the Peer Review Policy. I reviewed the findings and discussed them with the practitioner. As a result, I am recommending a focus professional practice review by the Peer Review Committee for March, April, and May 2007. The results should be forwarded to me as a part of the practitioners Quarterly review. Comments: The Physician was receptive to our discussion. We 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

April 2008

33

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 X X X

X X

X X

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 X X X

Practice Based Learning Improvements


Illegible Orders sent for Review Adherence to NPSG: Abbreviations Universal Protocol X

X X

System Based Practice


History & Physical Current/updated Informed Consent Surgery Submits SSI report

X X

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 X X X X
IC Pract Infection Control Practitioner Adm - Administration

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

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 . Status Active Reporting Period: 4th Qarter 2008 Q4 Q3 Q2 Q1 Q4 Q3 Q2 2008 2008 2008 2008 2007 2007 2007
0 95% 95% 93% .5% 2 0 97% 94% 99% 0 0 0 100% 90% 84% 1% 0 1 98% 80% 82% 1% 1 0 96% 85% 88% 0 0 0 95% 78% 43% 0 0 0 98% 75% 22% 0 1

Ytd Dept Data


2 97% 90% 88% 1.0% 3

Ytd Natl Data


Not Available 98%

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% Less than 95% Less than 90% Less than 2% of total cases 2 or More

1.0% Not Available

Medical/Clinical Knowledge
Hospital CME Hours New Training or Experience Board Certification Renewal/Initial due 8/07 * * 0 4 5 0 0 3 Yes 4 100%

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 . Status Active Reporting Period: 4th Qarter 2008 Q4 Q3 Q2 Q1 Q4 Q3 Q2 2008 2008 2008 2008 2007 2007 2007

Ytd Dept Data


4

Ytd Natl Data

3 or more

Practice Based Learning Improvements


Illegible Orders sent for Review Adherence to National Patient Safety Goals: Abbreviations Universal Protocol, as applicable History & Physical Current Informed Consent Submits SSI report to ICP monthly *Utilization Data Report

5 or more

Not Available

3 or more Less than 90% Less than 100% Less than 100% <3 X

0 100% 100% 100% 3

0 100% 100% 100% 3

2 100% 95% 100% 3

3 98% 100%

4 100% 100% 100% 3

4 96% 100% 100% 3

6 95% 100% 100% 2

3 96% 98% 95% 2.4

Not Available Not Available Not Available Not Available Not Available

System Based Practice


98% 3

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

Professionalism

April 2008

38

ACCEPTED

Form 2000

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

Trigger
* 1 or more * *

Ongoing Professional Practice Evaluation - Evidence Based Data Department of Surgery . Subspecialty if applicable N/A . Practitioner ID # 2207 Last Appointment Date July 07 . Status Active Reporting Period: 4th Qarter 2008 Q4 Q3 Q2 Q1 Q4 Q3 Q2 2008 2008 2008 2008 2007 2007 2007
3 0 3 0 2 0 1 3 0 1 1 0 3 0 3 0 1

Ytd Dept Data


4

Ytd Natl 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

ACCEPTED

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 : We reviewed the current ventilator management pathway and discussed areas for improvement . ________________________________________________________________ ________________.

Dr. Ima Cutter Department Chair for Surgery

April 2008

41

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 Moderate Sedationreversal rates X X X

Medical/Clinical Knowledge
Hospital Based CMEs New Training or Experience Board Cert-Initial or Renewal X X 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
X

IC Pract.

Pharm

Adm/ Dept

Complaints from Patients/Family

Practice Based Learning Improvements


Critical Values Timeliness Abbreviations Universal Protocol X X X

System Based Practice


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

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 . Status Active Reporting Period: 4th Qarter 2008 Q4 Q3 Q2 Q1 Q4 Q3 Q2 2008 2008 2008 2008 2007 2007 2007
98% 0 2% 99% 0 0% 100% 0 0% 100% 1 1% 98% 0 1% 100% 0 0% 100% 0 0%

Ytd Dept Data


97% 1 2.5%

Ytd Natl Data

Patient Care
Percent of Agreement for Over-reads Procedural Complications Moderate Sedation Reversal Rate 95% or less 2 or more Greater than 5%

Medical/Clinical Knowledge
Hospital CME Hours New Training or Experience Board Certification Renewal/Initial due 8/2007 * * 4 2 2 0 0 3 Yes 3 100%

Interpersonal and Communication Skills


Patient Family/Staff Written positive feedback Complaints from Patients/Families * 3 or more 0 Yes 0 0 1 Yes 0 0 Yes 0 2

Practice Based Learning Improvements

April 2008

45

ACCEPTED

Form 2000

Indicator
Critical Value Timeliness Adherence to National Patient Safety Goals: Abbreviations Universal Protocol, as applicable

Trigger
1 or more exceeding

Ongoing Professional Practice Evaluation - Evidence Based Data Department of Radiology . Subspecialty if applicable N/A . Practitioner ID # 2244 Last Appointment Date July 07 . Status Active Reporting Period: 4th Qarter 2008 Q4 Q3 Q2 Q1 Q4 Q3 Q2 2008 2008 2008 2008 2007 2007 2007
2 0 0 1 0 0 0

Ytd Dept Data

Ytd Natl Data

3 or more Less than 90%

0 100%

0 100%

0 96%

0 95%

2 92%

2 90%

1 90%

2 95%

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.

100% 100%

100% 100%

100% 90%

100% 85%

100% 95%

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

April 2008

46

ACCEPTED

Form 2000

Indicator
Teaching an Education Program

Trigger
*

Ongoing Professional Practice Evaluation - Evidence Based Data Department of Radiology . Subspecialty if applicable N/A . Practitioner ID # 2244 Last Appointment Date July 07 . Status Active Reporting Period: 4th Qarter 2008 Q4 Q3 Q2 Q1 Q4 Q3 Q2 2008 2008 2008 2008 2007 2007 2007
1

Ytd Dept Data

Ytd Natl 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 # 2244 . # _______________ # _______________ 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

ACCEPTED

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

April 2008

49

ACCEPTED

Form 1000

Indicator/Criteria List and Data Source Matrix Allied Health PA Indicator/Criteria Case Mgt. Review HIM MSO Quality Dept. MRR Group
X X X X X

CME Comm.

Education Dept.

UR

PT. Rep

IC Pract.

Pharm

Adm/ Dept

Corrections to H&P Feedback on aseptic technique Feedback on surgical skills

Medical/Clinical Knowledge
CE Hours New Training or Experience X X X

Interpersonal and Communication Skills


Feedback related to communication skills X

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. UR PT. Rep
X

IC Pract.

Pharm

Adm/ Dept

Complaints from Patients/Family

Practice Based Learning Improvements


Illegible Orders sent for Review Adherence to NPSG: Abbreviations Universal Protocol X X

X X X

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. UR PT. Rep IC Pract. Pharm Adm/ Dept
X

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 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 . Status Active Reporting Period: 4th Qarter 2008 Q4 Q3 Q2 Q1 Q4 Q3 Q2 2008 2008 2008 2008 2007 2007 2007
0 0 4 0 0 4 0 1 4 1 0 4 0 0 4 0 0 3

Ytd Dept Data


1.2

Ytd Natl Data


Not Available

Patient Care
Corrections to H&P Feedback on aseptic technique Feedback on surgical skills 2 or more H&Ps with corrections 1 or more breaks Below 4 rating on feedback * * 3 0 4

3.5

Not Available

Medical/Clinical Knowledge
CE Hours New Training or Experience

10

4 Yes new ortho system 3 0

16

Interpersonal and Communication Skills


Feedback related to communication skills Complaints from Patients/Families Score of 2 or less 2 or more 3 0 3 0 3 1 3 0 3 0 3 0 3 3 Not Available Not Available

Practice Based Learning Improvements


Illegible Orders sent for 2 or more 0 0 0 0 0 0 0 2 Not Available

April 2008

53

ACCEPTED

Form 2000

Indicator
Review Adherence to National Patient Safety Goals: Abbreviations Universal Protocol, as applicable Timeliness of H&P Dating and timing of entries *Utilization Data Report

Trigger

Ongoing Professional Practice Evaluation - Evidence Based Data Department of Surgery . Subspecialty if applicable Allied Health/PA. Practitioner ID # 2143 Last Appointment Date . Status Active Reporting Period: 4th Qarter 2008 Q4 Q3 Q2 Q1 Q4 Q3 Q2 2008 2008 2008 2008 2007 2007 2007
0 100% 0 100% 2 100% 3 100% 4 95% 5 4 95%

Ytd Dept Data


3 95%

Ytd Natl Data


Not Available Not Available

3 or more Less than 90% 2 or more Less than 90% X

90%

System Based Practice


0 90% 1 90% 1 90% 0 85% 2 80% 0 80% 1 75% 4 80% Not Available Not Available

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

0 3

2 3

2 3

2 3

Not Available Not Available

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 # 2143 . # _______________ # _______________ 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

ACCEPTED

Form 4000

DEPARTMENT DIRECTOR RESPONSE DEPARTMENT OF SURGERY October, November, December 2008 Date:

Reporting Period: June 1, 2007

Practitioner Number : 2143 (PA)

As the Department Chair for Surgery, and the Director of the Physicians Assistants we have reviewed the results of the Ongoing Professional Practice Evaluation for the above named allied health member. We have taken the following action: I reviewed the findings and no further action is needed at this time. I reviewed the findings and discussed them with the Practitioner. The practitioner has been informed that if the threshold is exceeded for two Quarters or more during this reappointment cycle, a focus review will be initiated based on the Peer Review Policy. I reviewed the findings and discussed them with the practitioner. As a result, I am recommending a focus professional practice review by the Peer Review Committee for March, April, and May 2007. The results should be forwarded to me as a part of the practitioners Quarterly review.

Comments: ________________________________________________________________. Dr. Ima Cutter Dept Chair Surgery Hope Floats, PA Director of Physicians Assistant

April 2008

56

ACCEPTED

APPENDIX

April 2008

57

ACCEPTED

EXAMPLE Evaluation of Surgical PA 4th 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.

April 2008

58

ACCEPTED

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: ______________________

April 2008

59

ACCEPTED

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 enou gh 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)

April 2008

60

ACCEPTED

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

April 2008

61

ACCEPTED

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

April 2008

62

ACCEPTED

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

April 2008

63

ACCEPTED

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

April 2008

64

ACCEPTED

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.

April 2008

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ACCEPTED

(or) Education: MD, DO, DDS, DMD or DPM. Minimum formal training: Successful completion of XYZ Hospital MEC approved Procedural Sedation Self-Teaching Module. The applicant must be concurrently observed for the first 3 pediatric cases. Reappointment: Successful completion of XYZ Hospital MEC approved Procedural Sedation Self-Teaching Module. The applicant must be able to demonstrate he/she has maintained competency by showing evidence that he/she has administered procedural sedation for at least 5 pediatric patients in the past 24 months. If the physician has not performed 5 pediatric procedures the physician must be concurrently observed for the first 2 pediatric procedures. FAMILY PRACTICE DEPARTMENT ELIGIBILITY CRITERIA A. ICU Admissions require a Family Practice physician to have the first 3 admissions retrospectively reviewed by a Family Practice physician with the privilege. B. OB deliveries require a Family Practice physician to have the first 3 deliveries retrospectively reviewed by a Family Practice or OB-GYN physician with the privilege. Department of Family Practice Cesarean Section Participation Physician is required to obtain co-management by an NRP certified Pediatrician, Neonatologist, or Neonatologist supervised NNP for a Family Practice physician to participate/attend a cesarean section. Department of Family Practice Level II Pediatric High Risk Privileges Physician is required to obtain consultation and/or co-management by an NRP certified Pediatrician, Neonatologist, or Neonatologist supervised NNP to participate in the care of Level II newborns. Observation The Family Practice may impose observation if it is determined to be appropriate.

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ACCEPTED

Patient Name________________________________

CONFIDENTIAL
Surgical Care Proctoring Evaluation Form

MR #______________________

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 ______________________________

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ACCEPTED

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:

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ACCEPTED

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

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

Action by Committee

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:___________________________________________________________

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69