OPPE Dokter Di RS - English

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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.
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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:
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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
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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
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
Serves as oversight committee for medical staff performance
improvement activities;
ii.
Reviews findings of ongoing practice review, specifically as it
pertains to cases scored a 4 or 5 and takes actions as
appropriate;
iii. Considers all documented cases, which meet the criteria for
review, at the time of renewing, revising, limiting or revoking
existing privileges.
iv. Recommends a Focused Professional Practice Evaluation
when indicated.
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v.
Reports and recommends to the Board of Directors regarding

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

a. Definition - The individual whose performance is being reviewed.
b. Responsibility
i.
Provides a response to all cases scored 3, 4 or 5, or for any
case requested.
ii.
Reviews Ongoing Professional Practice Feedback Reports
when received.
iii.
Participates in Focused Professional Practice Evaluation
process when indicated.
IV.
Method for Selecting Reviewer Panels, Including Specific
Circumstances
1. Assignments
a. The Quality Director will identify a peer screener utilizing the roster
provided by the Medical Staff Office and in collaboration with the
Department Chairperson.
b. If the Department Chairperson is the individual being reviewed, the
Chief of Staff will determine the peer screener and may recommend
an alternative peer review panel.
2. Conflict of Interest -Within the context of the review process, a conflict of
interest will preclude an individual from making a performance review
determination in the evaluation of the performance of another practitioner. A
conflict of interest may exist if the reviewer has significant financial interest in
the hospital or direct professional or personal involvement in the case under
evaluation. In those cases the Department Chairperson or Chief of Staff will
assign an alternate peer screener. If necessary, hospital legal counsel may
be contacted to assist in identifying a review process that will minimize
conflict of interest.
3. Special Peer Review Panels - If requested by the Chief of Staff, MEC or
Department Chairperson, a special panel of peers may be assigned to review
the case.
a. External Review - External performance review is required under the
following circumstances:
a. Conflict of Interest - The review may not be conducted by any peer on
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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
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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)
3
4
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)
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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.
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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
X
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
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Form 1000

Indicator/Criteria
Case
Mgt.
Review
HIM
MSO
Quality
Dept.
MRR
Group
CME
Comm.
Complaints from
Patients/Family
Education
Dept.
UR
PT.
Rep
IC Pract.
Pharm
Adm/
Dept
Practice Based
Learning
Improvements
Illegible Orders
sent for Review
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
*Utilization Data
Report (eg TATs,
proper admission
status)
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
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
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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
Status Active Reporting Period: 4th Qarter 2008
Q4
Q3
Q2
Q1
Q4
Q3
2008
2008
2008
2008
2007
2007
.
Q2
2007
Ytd Dept
Data
Ytd Natl
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
Medical/Clinical
Knowledge
Hospital CME Hours

New Training or
Experience
Board Certification
Renewal/Initial
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
10
10
*
Yes
100%
Interpersonal and
Communication Skills
Patient Family/Staff
April 2008
21
ACCEPTED
Form 2000
Indicator/Criteria
Written positive
feedback
Complaints from
Patients/Families
Trigger

.
Q4
Q3
Q2
Q1
Q4
Q3
2008
2008
2008
2008
2007
2007
Yes
3 or More
Yes
.
Q2
2007
Yes
Ytd Dept
Data
Ytd Natl
Data
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
Indicator/Criteria
Trigger

.
Q4
Q3
Q2
Q1
Q4
Q3
2008
2008
2008
2008
2007
2007
.
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
*
*
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
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
April 2008
24
ACCEPTED
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
April 2008
25
ACCEPTED
Form 1000

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
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
Case
Mgt.
Review
HIM
MSO
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
X
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
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
Professionalism
Meetings
Attended
Complaints
related to
Professionalism
from Staff
Case
Presentation
Teaching an
Educational
Program

X
X
Adm - Administration
April 2008
28
ACCEPTED
Form 2000

Department of Anesthesia.
.
Practitioner ID # 9288 Last Appointment Date July 07
.
Indicator
Trigger
Q4
2008
Q3
2008
Q2
2008
Q1
2008
Q4
2007
Q3
2007
Q2
2007
Re-intubation in OR or
PACU
1 or More
Anesthesia Incidents
(Broken Teeth)
MI within 48 hours post
anesthesia
Pneumothorax from
CDIRECTOR Line
Insertion
1 or More
1 or More
1 or More
*
*
Ytd
Dept
Data
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
Interpersonal and
Patient/Family/Staff
Written positive
feedback
Complaints from
Patients/Families
Yes
*
3 or more
Yes
0
Yes
1
April 2008
N/A
Not Available
Not Available
29
ACCEPTED
Form 2000

.
.
Indicator
Trigger
Q4
2008
Q3
2008
Q2
2008
Q1
2008
Q4
2007
Q3
2007
Q2
2007
Ytd
Dept
Data
Ytd Natl
Data
Practice Based

Review
Patient Safety Labeled
Medication
Abbreviations
5 or more
Not Available
3 or more
10
14
Not Available
3 or more
Not Available
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
Professionalism
Meetings Attended
April 2008
Not Available
30
ACCEPTED
Form 2000

.
.
Indicator
Trigger
Staff
Case Presentation
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 Natl
Data
Not Available
Reviewed and approved by Dept. of Anesthesia 1/15/07

* information only
April 2008
31
ACCEPTED
Form 3000
Periodic Report
Department of Surgery / Anesthesia
# 9288
.
# _______________
# _______________
Sue Smith
April 2008
32
ACCEPTED
Form 4000
Reporting Period:
June 1, 2007

DEPARTMENT OF SURGERY/ANESTHESIA
October, November, December 2008
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:
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

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

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
X
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

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
April 2008
36
ACCEPTED
Form 2000
Indicator
Trigger

Department of Surgery .
.
.
Q4
Q3
Q2
Q1
Q4
Q3
Q2
2008
2008
2008
2008
2007
2007
2007
Ytd
Dept
Data
Ytd Natl
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
Yes
Yes
April 2008
37
ACCEPTED
Form 2000
Indicator
Written positive
feedback
Complaints from
Patients/Families
Ytd
Dept
Data
Ytd Natl
Data
3 or more

Review
Abbreviations
5 or more
Not Available
3 or more
Not Available
applicable
Less than
90%
100%
100%
100%
98%
100%
96%
95%
96%
Not Available
Practice Based
Trigger

.
.
Q4
Q3
Q2
Q1
Q4
Q3
Q2
2008
2008
2008
2008
2007
2007
2007
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
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
Meeting Attended
Staff
Case Presentation
Program
*
1 or more
*
*

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

April 2008
39
ACCEPTED
Form 3000
Periodic Report
Department of Surgery
# 2207
.
# _______________
# _______________
Sue Smith
April 2008
40
ACCEPTED
Form 4000

DEPARTMENT OF SURGERY
Date: June 1, 2007
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:
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

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
X
Interpersonal and
Communication
Skills
Pt/Family/Staff
Written Positive
Feedback
April 2008
42
ACCEPTED
Form 1000

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
X
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
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

April 2008
44
ACCEPTED
Form 2000
Indicator
Trigger

Department of Radiology .
.
.
Q4
Q3
Q2
Q1
Q4
Q3
Q2
2008
2008
2008
2008
2007
2007
2007
Ytd
Dept
Data
Ytd Natl
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
Written positive
feedback
Complaints from
Patients/Families
*
3 or more
Yes
0
Yes
0
Yes
0
Practice Based
April 2008
45
ACCEPTED
Form 2000
Indicator
Trigger

.
.
Q4
Q3
Q2
Q1
Q4
Q3
Q2
2008
2008
2008
2008
2007
2007
2007
Ytd
Dept
Data
Critical Value
Timeliness
1 or more
exceeding
Abbreviations
3 or more
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
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
X
Ytd Natl
Data
Professionalism
Meetings attended
Staff
Case Presentation
*
1 or more
2
0
2
0
2
0
April 2008
46
ACCEPTED
Form 2000
Indicator
Trigger
Program

.
.
Q4
Q3
Q2
Q1
Q4
Q3
Q2
2008
2008
2008
2008
2007
2007
2007
Ytd
Dept
Data
Ytd Natl
Data
Reviewed and approved by Dept. of Radiology 1/15/07

* information only
April 2008
47
ACCEPTED
Form 3000
Periodic Report
Department of Radiology
# 2244
.
# _______________
# _______________
Sue Smith
April 2008
48
ACCEPTED
Form 4000

DEPARTMENT OF RADIOLOGY

Date: June 1, 2007
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:
Comments:
________________________________________________________________
Dr. Patty Picture

Department Chair
Department of Radiology
April 2008
49
ACCEPTED
Form 1000

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

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

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
PT.
Rep
IC
Pract.
Pharm
Adm/
Dept
X

UR

Adm Administration/Department
April 2008
52
ACCEPTED
Form 2000
Indicator
Trigger

Subspecialty if applicable Allied Health/PA.
Last Appointment Date
.
Q4
Q3
Q2
Q1
Q4
Q3
Q2
2008
2008
2008
2008
2007
2007
2007
Ytd
Dept
Data
Ytd Natl
Data
Patient Care
Corrections to H&P
Feedback on aseptic
technique
Feedback on surgical
skills
Medical/Clinical
Knowledge
CE Hours
New Training or
Experience
2 or more
H&Ps with
corrections
1 or more
breaks
Below 4
rating on
feedback
*
*
10
4
Yes new
ortho
system
16
Score of 2 or
less
2 or more
2 or more
1.2
Not Available
3.5
Not Available
Not Available
Not Available
Not Available
Interpersonal and
Feedback related to
communication skills
Complaints from
Patients/Families
Practice Based
April 2008
53
ACCEPTED
Form 2000
Indicator
Trigger
Review
Abbreviations
Universal Protocol,
as applicable

Subspecialty if applicable Allied Health/PA.
Last Appointment Date
.
Q4
Q3
Q2
Q1
Q4
Q3
Q2
2008
2008
2008
2008
2007
2007
2007
Ytd
Dept
Data
Ytd Natl
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
Timeliness of H&P
Dating and timing of
entries
2 or more
Less than
90%
X
Professionalism
*
0
3
2
Meeting Attended
Score of 2 or
3
3
3
Feedbacks related to
less
Staff
* Information only
Reviewed and approved by Dept. of Surgery 1/15/07
April 2008
54
ACCEPTED
Form 3000
Periodic Report
Department of Surgery Subspecialty PA
# 2143
.
# _______________
# _______________
Sue Smith
April 2008
55
ACCEPTED
Form 4000
Reporting Period:
June 1, 2007

DEPARTMENT OF SURGERY
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:
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 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)
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
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
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
65
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
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.
April 2008
66
ACCEPTED
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 ______________________________
April 2008
67
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:
April 2008
68
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
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:___________________________________________________________
April 2008
69

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ACCEPTED

Leading Practices Library

LifePoint Physician Performance Toolkit*

Focused Professional Practice Evaluations (Focused Review) - A

Steps for Developing An Evidence

Emergency Department Page 19

Anesthesia Department Page 26

Surgery Department Page 34

Radiology Department Page 42

Physician Assistant Surgery Department Page 50

Example Indicators Page 60

Sample Privilege Criteria-- Page 64

Sample Proctor Review FormPage 67

Medical Staff Case Review Tool---Page 68

Ongoing Professional Practice Evaluation

Ongoing Professional Practice Evaluation - A documented summary of

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

The information used in the ongoing professional practice evaluation

2. Criteria/indicators for referral will include review of the following:

Definitions and Responsibilities

Provides medical record to be reviewed to the peer screener;

iii. Trends data related to individual practitioner performance for

Review Panel, as appropriate, all cases scored a 3,4 or 5 by the

Provides periodic summary reports (Ongoing Professional

Documents on the form pertinent findings to support the

viii. Reviews the Ongoing Professional Practice Feedback Reports

Considers all documented cases which have been reviewed

7. Medical Executive Committee

Reports and recommends to the Board of Directors regarding

8. Individual Under Review

staff due to a potential conflict of interest that cannot be appropriately

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

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

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

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

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

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

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

FOCUSED PROFESSIONAL PRACTICE EVALUATION POLICY

4. When a privilege is used infrequently.

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

Description of Forms in the Toolkit

Form 1000 Indicator/Criteria List and Data Source Matrix

Form 2000 Ongoing Professional Practice Evidence Based Data

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

Form 4000 Department/Division Responses Back to the Quality

Indicator/Criteria List and Data Source Matrix

Indicator/Criteria List and Data Source Matrix

Indicator/Criteria List and Data Source Matrix

*Provided as an attachment with the Ongoing Professional Practice Evaluation

HIM Health Information Management

Ongoing Professional Practice Evaluation - Evidence Based Data

Department of Emergency Medicine.

Hospital CME Hours

Ongoing Professional Practice Evaluation - Evidence Based Data

Department of Emergency Medicine.

Illegible Orders sent for

Ongoing Professional Practice Evaluation - Evidence Based Data

Department of Emergency Medicine.

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

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

DEPARTMENT DIRECTOR RESPONSE

Reporting Period: October, November, December 2007