Oppe Fppe Toolkit

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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 practitioner’s 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 practitioner’s 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 Form—Page 67
 Medical Staff Case Review Tool---Page 68
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Ongoing Professional Practice Evaluation

EXAMPLE POLICY
JC Standards: MS.4.40 and MS.4.45
Purpose
1. To clearly define the process utilized for facilitating the continuous evaluation of each
practitioner's professional practice;
2. To define the type of data (criteria/indicators) to be collected for the ongoing
professional practice evaluation. (Note: The criteria defined for Ongoing Professional
Practice Evaluation, will be utilized as screening triggers for a possible Focused
Professional Practice Evaluation).
3. To ensure the information resulting from the ongoing professional practice
evaluation is used to determine whether to continue, limit or revoke any existing
privileges;
4. To define the process for collecting, investigating, and addressing clinical practice
concerns, including the process utilized to identify trends that impact Quality of care
and patient safety;
5. To ensure reported concerns regarding a privileged practitioner's professional
practice are uniformly investigated and addressed as defined by hospital
policy and applicable law;
6. To define those circumstances in which an external review or focused review
may be necessary; and
7. To define the medical staff's leadership role in the organization's performance
improvement activities related to practitioner performance and ensure that when
the findings are relevant to an individual's performance, the findings in the ongoing
evaluations of competence are in accordance with recognized standards.
Scope
This policy applies to all Medical Staff and Allied Health Professionals privileged through
medical staff mechanisms at the hospital.
Definitions
 Focused Professional Practice Evaluations (Focused Review) - A time-
limited evaluation of practitioner competence in performing a specific
privilege. This process is implemented for:
 All newly requested privileges and
 Whenever a question arises regarding a practitioner's ability to provide
safe, high quality patient care.
 Ongoing Professional Practice Evaluation - A documented summary of

ongoing data collected for the purpose of assessing a practitioner's clinical
competence and professional behavior. The information gathered during this
process factors into decisions to maintain, revise or revoke existing privilege
(s).
 Practitioner - For purposes of this policy, practitioner is defined as individuals

with Medical Staff or Allied Health privileges.
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Policy
1. The information used in the ongoing professional practice evaluation
may be acquired through the following:
a. Periodic chart review;
b. Direct observation;
c. Monitoring of diagnostic and treatment techniques; and
d. Feedback from other individuals involved in the care of the
patient, including consulting physicians, assistants at surgery,
nursing and administrative personnel.
2. Reported concerns regarding privileged practitioner's professional
performance will be uniformly investigated and addressed as
defined by the organization and applicable law.
3. Relevant information from the practitioner performance review process
will be integrated into performance improvement initiatives and will be
utilized to determine whether to continue, limit or revoke existing
privileges.
4. If there is uncertainty regarding the practitioner's professional
performance, the course of action defined in the medical staff bylaws
for further evaluation should be followed. It is not intended that this
policy supersede any provisions of the Medical Staff Bylaws. If the
performance of the practitioner is sufficiently egregious, the Chief of
Staff or CEO shall determine, within his/her sole discretion, whether
the provisions of this policy need not be followed, whereupon the
provisions of the Bylaws, and not this policy, shall govern.
5. The activities of the ongoing professional practice evaluation are
considered privileged and confidential.
Procedure
A. Screening
1. Quality Director, or designee will perform concurrent and retrospective chart

review using medical staff approved screening criteria.
2. Any individual (including patient/family, medical staff, allied health
professional or hospital staff) may report any concerns regarding the
professional performance of a practitioner.
3. When appropriate, feedback sheets will be provided to key leaders in the
hospital.
B. Criteria/Indicators
1. Criteria/indicators will include triggers and fall generally into the following
six areas of general competence:
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a. Patient care;
b. Medical/clinical knowledge;
c. Practice-based learning and improvement;
d. Interpersonal and communication skills;
e. Professionalism; and
f. System-based practice.
2. Criteria/indicators for referral will include review of the following:

a. Inpatient, outpatient, ED and ambulatory cases will be
screened for the presence of predefined criteria/indicators;
b. Events associated with a practitioner exceeding his/her clinical
privileges.
3. Criteria/indicators may be added or deleted at the recommendation of the

Medical Executive Committee, Department Chairperson, and/or
Department Credentials Committee.
4. The applicable Medical Staff Department and the MEC will approve
indicator criteria and trigger (threshold) parameters.
5. The list of criteria/indicators will be reviewed on an ongoing basis and in

conjunction with this policy.
III. Definitions and Responsibilities
1. Screener
a. Definition - Quality Director, or designee
b. Responsibility - If a case meets the screening indicator criteria, the

screener will refer to a peer screener.
2. Quality Director/Designee
a. Definition - Individual responsible for coordinating and facilitating
review activities
b. Responsibility -
i. Identifies appropriate peer screeners utilizing the roster
provided by Medical Staff Office and collaborates with the
Department Chairperson to determine appropriate peer screener
if necessary;
ii. Provides medical record to be reviewed to the peer screener;
iii. Trends data related to individual practitioner performance for

cases scored 0,1 or 2 by the peer screener;
iv. Forwards to the designated Department Chairperson or Peer
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Review Panel, as appropriate, all cases scored a 3,4 or 5 by the

peer screener;
v. Provides periodic summary reports (Ongoing Professional

Practice Feedback Reports) on an ongoing basis to individual
practitioners, Department Chairpersons. Summary Reports will
be shared with Department Credentials Committee and MEC
and patterns/trends identified. The summary reports for review
by Department chairs will include the documentation of the
peer reviewers. The Department chair is looking for trends
based on the review by peers. Utilization review data, as
appropriate, will also be provided.
3. Peer Screener
a. Definition - Practitioner from the same discipline and with essentially
equal qualifications as the individual under review (for example,
physician and physician, dentist and dentist, etc).
b. Responsibility-
i. Reviews the medical record for the case and assigns a score of
0-5 on the Professional Practice Review Form and returns the
completed form to the Quality Director; and
ii. Documents on the form pertinent findings to support the

assigned review score, and identifies opportunities for
improvement and recommends any need for further
action/intervention.
4. Department Chairperson
a. Definition - Defined in Medical Staff Bylaws/Rules/Regs.
b. Responsibility
i. Retains final responsibility for practitioner performance within
the Department;
ii. Assigns Peer Review Panels, as appropriate;
iii. Provides summary reports to the MEC, on practitioner
performance activities;
iv. May send any questionable determinations for further review
or may
v. request an external review;
vi. Facilitates and provided oversight of any recommended
actions/interventions; and
vii. Presents cases findings as appropriate at medical staff
committee meetings as part of the performance improvement
process.
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viii. Reviews the Ongoing Professional Practice Feedback Reports

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

a. Definition - Defined in Medical Staff Bylaws
b. Responsibility -
i. Considers all documented cases which have been reviewed
and trigger (thresholds) parameters at the time of renewing,
revising, limiting, or revoking existing privileges.
ii. Recommends a Focused Professional Practice Evaluation when
indicated
7. Medical Executive Committee

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

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

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

Circumstances
1. Assignments
a. The Quality Director will identify a peer screener utilizing the roster
provided by the Medical Staff Office and in collaboration with the
Department Chairperson.
b. If the Department Chairperson is the individual being reviewed, the

Chief of Staff will determine the peer screener and may recommend
an alternative peer review panel.
2. Conflict of Interest -Within the context of the review process, a conflict of

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

Department Chairperson, a special panel of peers may be assigned to review
the case.
a. External Review - External performance review is required under the

following circumstances:
a. Conflict of Interest - The review may not be conducted by any peer on
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staff due to a potential conflict of interest that cannot be appropriately

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

scored a 3, 4 or 5 or when trends exceed threshold parameters on
established indicator criteria. The trend reports will be provided on the
Ongoing Professional Practice Feedback reports.
2. All action/follow-up/requests for interventions will be in a written

response or meeting with the involved practitioner.
3. All correspondence will be confidential.
4. Copies of letters and notifications will be kept on file.
VI. Interventions
Depending upon the findings of the ongoing professional practice review,
interventions may be implemented. The criteria utilized to determine the type of
intervention includes severity, frequency of occurrence and trigger (thresholds)
level exceeded. Interventions include, but may not be limited to, proctoring,
focused review and corrective action.
VII. Effectiveness of Review Process

1. Consistency - Cases meeting the criteria for reviewable circumstances will
undergo review, conducted according to this defined procedure.
2. Timeliness
a. Routine Performance Review - Time review initiated to time case
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closed should closely adhere to a 60-day timeframe. However, there

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

supported by rationale that specifically address the issues for which the
review was conducted, including, as appropriate, reference to the
literature and relevant clinical practice guidelines.
4. Balanced - Minority opinions and views of the individual under review are
to be considered and recorded.
5. Useful - The results of review activities are to become part of the

practitioner's Quality profile and to be used for credentialing and
privileging decisions and, as appropriate, in performance improvement
activities.
6. Ongoing - The review conclusions are tracked over time, and actions
based on review conclusions are monitored for effectiveness by the
Medical Executive Committee.
Scoring
SCORE DEFINITION
0 No problem with process*/documentation/acts of omission or commission** or

Quality of care, treatment or services provided
1 Minor problem with process*/documentation/acts of omission or commission** or

Quality of care, treatment or services provided (patient outcome not affected)
2 Problem with process*/documentation/acts of omission or commission** or Quality

of care, treatment or services provided (potential for adverse consequence)
Problem with process*/documentation/acts of omission or commission**, or Quality
3 of care; treatment or services provided (disease, or symptoms caused,
exacerbated or allowed to progress)
Problem with process*/documentation/acts of omission or commission**, or Quality
4 of care, treatment or services provided
(longevity, and/or functional Quality of life shortened or adversely affected by
medical action or inaction)
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5 Death attributable to acts of omission or commission** or Quality of care, treatment

or services provided
 Includes, but is not limited to delays in care, treatment and services provided
 ** Includes, but is not limited to disruptive behavior
IX. Performance Improvement
1. Members of the medical staff are involved in activities to

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

understanding those special circumstances of practitioner
performance, which require further evaluation.
3. When findings of this process are relevant to an individual's

performance, the medical staff is responsible for determining their
use in ongoing evaluation of a practitioner's competence, in
accordance with the JC standards on renewing or revising clinical
privileges.
Supporting Policies/Procedures
 Disruptive Behavior Policy
 Patient Complaint/Grievance Policy
 Impaired Practitioner Policy
 Focused Professional Practice Evaluation Policy
 Medical Staff Bylaws
 Fair Hearing Plan
 Allied Health Grievance Policy
References
JC CAMH - MS.4.40 and MS.4.45
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FOCUSED PROFESSIONAL PRACTICE EVALUATION POLICY

Purpose
To establish a systematic process to evaluate and confirm the current
competency of practitioners’ performance of privileges at ______________
hospital. This process is known as focused professional practice evaluation
(―FPPE‖ or ―focused evaluation‖).
Definition of FPPE
Focused professional practice evaluation is defined as a time-limited period
during which the organization evaluates and determines a practitioner’s
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 practitioner’s
circumstance using the following guidelines:
1. New applicant.
a. Peer recommendations from previous institutions will be confirmed by the
department chair.
b. Performance indicators, or aggregate data, within the department will be

monitored.
c. FPPE peer evaluations by the department chair and one other active staff
member will be completed within 3 months of initiation of clinical activity. The
department chair should seek input from colleagues, consultants, nursing
personnel, and administration.
d. Procedure and clinical activity logs will be reviewed from either previous
institutions or training programs.
 If current competency from previous institution is well-documented
through case logs of activity within recent year, then no additional
monitoring is required.
 If current competency and adequate clinical activity is not well-
documented from previous institution, then a higher level of focused
evaluation will be necessary for this type of applicant. Specifically,
concurrent chart review, proctoring, or simulation should occur to fully
evaluate the ability to perform requested privileges. The focused
evaluation plan will be determined by the department chair with
approval of the credentials committee.
2. New privilege for existing staff member.

If a new requested privilege is significantly different from one’s 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 applicant’s 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
practitioner’s competency to perform specific clinical privileges or care related to
a specific patient, the proctor shall promptly notify the department chair.
Medical Staff’s 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 that—examples. Your facility
will need to develop your own comparisons and targets.
3. Sample documents should be used as a guideline for developing your own
unique documents that fit your healthcare organization. Make certain that you
use criteria that your hospital has adopted and you follow all of your state and
local laws.
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Form 1000
Indicator/Criteria List and Data Source Matrix
Emergency Department
Indicator/Criteria Case HIM MSO Quality MRR CME Education UR PT. IC Pract. Pharm Adm/
Mgt. Dept. Group Comm. Dept. Rep Dept
Review
Patient Care
Acute MI Mgt
 ASA Usage X
 Fibrinolytic X
Therapy
Pneumonia
 Blood Cultures X X
 Antibiotic with 4
hours X
Moderation Sedation
 Reversal Rates X
Medical/Clinical
Knowledge
 Hospital Based X
CME’s
 New Training or X
Experience
 Board Cert-Initial
or Renewal X
Interpersonal and
Communication
Skills
 Pt/Family/Staff
Written Positive X
Feedback
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Form 1000
Review
 Complaints from
Patients/Family X X
Practice Based
Learning
Improvements
 Illegible Orders X
sent for Review
 Adherence to X
NPSG:
Abbreviations
 Universal
Protocol X
 Emergent Elder
Care Protocols
System Based
Practice
 Medical Record
Delinquency X
warnings
 Number of
Suspensions for X
Delinquency
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Form 1000
Review
 *Utilization Data
Report (eg TATs,
proper admission
X
status)
*Provided as an attachment with the Ongoing Professional Practice Evaluation
Professionalism
Meetings
Attended
X
 Complaints
related to X
Professionalism
from Staff
 Case X
Presentation
 Teaching an
Educational X
Program
HIM – Health Information Management IC Pract – Infection Control Practitioner
MSO – Medical Staff Office Adm – Administration/Department
MRR – Medical Record Review Group
UR- Utilization Review
PT Rep = Patient Representative
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Form 2000
Ongoing Professional Practice Evaluation - Evidence Based Data
Department of Emergency Medicine.
Subspecialty if applicable N/A .
Practitioner ID # 0876 Last Appointment Date July 07 .
Status Active Reporting Period: 4th Qarter 2008
Indicator/Criteria Trigger Q4 Q3 Q2 Q1 Q4 Q3 Q2 Ytd Dept Ytd Nat’l
2008 2008 2008 2008 2007 2007 2007 Data Data
Patient Care
Acute MI Management
 Percent receiving ASA
upon arrival (except for Below 96% 97% 100% 97% 98% 99% 95% 92% 93%
acceptable 95%
contraindications)
 Fibrinolytic Therapy Below 96% 97% 96% 96% 95% 97% 95% 94% 93%
within 30 minutes or 95%
documented
contraindications
Pneumonia Below 99% 96% 96% 99% 97% 95% 96% 95% 97%
 Blood Cultures 95%
 Antibiotic within 4 hours Below 90% 96% 97% 95% 96% 97% 95% 97% 94%
95%
Moderation Sedation Greater
Reversal Rates than 5% 3% 3% 4% 3% 5% 4% 4% 2% Not Available
Medical/Clinical
Knowledge
 Hospital CME Hours * 5 0 0 10 0 5 10
 New Training or
Experience *
 Board Certification
Renewal/Initial Yes 100%
Interpersonal and
Communication Skills
 Patient Family/Staff *
April 2008 21
ACCEPTED
Form 2000
2008 2008 2008 2008 2007 2007 2007 Data Data
Written positive Yes Yes Yes
feedback
 Complaints from 3 or More
Patients/Families 1 0 1 0 1 1 1
Practice Based
Learning Improvements
 Illegible Orders sent for 5 or More 3 2 0 0 2 2 0 4 Not Available
Review
 Adherence to National
Patient Safety Goals:
 Abbreviations 3 or More 0 2 3 2 3 4 5 3 Not Available
 Universal Protocol, as Less than N/A 100% N/A N/A 90% 100% N/A 90% Not Available
applicable 90%
 Emergent Elder Care Less than
Protocols (% patients 5% 2% 3% 5% 5% 9% 10% 10% 6% Not Available
inappropriately
discharged)
System Based
Practice
 Medical Record 3 or More 0 2 0 0 1 0 0 5 Not Available
Delinquency
 Number of Suspensions 1 or More 0 0 0 0 0 0 0 0 Not Available
for Delinquency
Warnings
 * Utilization Data Report X
April 2008 22
ACCEPTED
Form 2000
2008 2008 2008 2008 2007 2007 2007 Data Data
*Provided as an attachment with the Ongoing Professional Practice Evaluation.
Professionalism
 Meetings Attended * 2 0 1 0 3 0 1
 Complaints related to 1 or More 0 0 0 0 0 0 0 4

Professionalism from
Staff
 Case Presentation * 0 0 1 0 0 0 1
 Teaching an Education * 1 0 0 1 0 0 1
Program
Reviewed and approved by Dept. of Emergency Medicine 1/15/07

Reviewed and approved by Medical Executive Committee 2/11/07
 Information only
April 2008 23
ACCEPTED
Form 3000
Periodic Report
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 practitioner’s 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 practitioner’s 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 HIM MSO Quality MRR CME Educatio UR PT. IC Pharm Adm/
Mgt. Dept. Group Comm. n Rep Pract. Dept
Review Dept.
Patient Care
 Re-intubation in X
OR or PACU
 Anesthesia X
incidents (broken
teeth)
 MI within 48 X
hours post
anesthesia
 Pneumothorax X
from Cen-line
insertion
Medical/Clinical
Knowledge
 Hospital Based X X
CME’s
Experience
 Board Cert-Initial X
or Renewal
Interpersonal and
Communication
Skills
April 2008 26
ACCEPTED
Form 1000
Review Dept.
 Pt/Family/Staff X
Written Positive
Feedback
 Complaints from X X
Patients/Family
Practice Based
Learning
Improvements
sent for Review
 Adherence to
NPSG: labeled
meds
 Abbreviations X
 Universal X
Protocol
System Based
Practice
 Med Record X
Delinquency
Warnings
 Number of X
Suspensions for
Delinquency
April 2008 27
ACCEPTED
Form 1000
Review Dept.
 *Utilization data X
Report
Professionalism
 Meetings
X
Attended
 Complaints X
related to
Professionalism
from Staff
 Case X
Presentation
 Teaching an
Educational X
Program
MSO – Medical Staff Office Adm - Administration
April 2008 28
ACCEPTED
Form 2000
Department of Anesthesia.
Indicator Trigger Q4 Q3 Q2 Q1 Q4 Q3 Q2 Ytd Ytd Nat’l
2008 2008 2008 2008 2007 2007 2007 Dept Data
Data
 Re-intubation in OR or 1 or More 0 0 0 1 0 0 0 2 Not Available
PACU
 Anesthesia Incidents 1 or More 0 0 0 0 1 0 0 2 Not Available
(Broken Teeth)
 MI within 48 hours post 1 or More 0 0 0 0 0 0 0 0 Not Available
anesthesia
 Pneumothorax from 1 or More 0 0 0 0 0 0 0 0 Not Available
CDIRECTOR Line
Insertion
Medical/Clinical
Knowledge
 New Training or *
Experience
 Board Certification Yes
Renewal/Initial
Interpersonal and
 Patient/Family/Staff * Yes Yes N/A Not Available
Written positive
feedback
 Complaints from 3 or more 0 0 0 1 0 0 0 2 Not Available
Patients/Families
April 2008 29
ACCEPTED
Form 2000
2008 2008 2008 2008 2007 2007 2007 Dept Data
Data
Practice Based
 Illegible Orders sent for 5 or more 0 0 2 3 3 5 5 3 Not Available
Review
Patient Safety Labeled 3 or more 3 4 9 10 8 9 14 5 Not Available
Medication
 Abbreviations 3 or more 3 0 2 0 2 0 4 3 Not Available
 Universal Protocol, as Less than 100% 100% 100% 95% 95% 85% 90% 92% Not Available
applicable 90%
System Based Practice
 Documentation of Below 95% 90% 100% 100% 95% 90% 100% 92% Not Available
appropriate pre-and 90%
post anesthesia
assessments
 Medical Record 3 or more 0 0 0 0 1 0 0 2 Not Available
Delinquency
 Number of Suspensions 1 or more 0 0 0 0 0 0 0 0 Not Available
for Delinquency
 *Utilization Data Report X

Professionalism
 Meetings Attended * 1 2 1 3 1 5 2 Not Available
April 2008 30
ACCEPTED
Form 2000
2008 2008 2008 2008 2007 2007 2007 Dept Data
Data
 Complaints related to 2 or more 0 0 0 0 0 0 0 1 Not Available
Staff
 Case Presentation * 0 0 1 0 0 0 0
 Teaching an Education * 0 1 1 0 0 0 0
Program
Reviewed and approved by Dept. of Anesthesia 1/15/07

* information only
April 2008 31
ACCEPTED
Form 3000
Periodic Report
Department of Surgery / Anesthesia

# 9288 .
# _______________
# _______________
Sue Smith
April 2008 32
ACCEPTED
Form 4000
DEPARTMENT OF SURGERY/ANESTHESIA
Reporting Period: October, November, December 2008 Date:

June 1, 2007
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 practitioner’s 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 HIM MSO Quality MRR CME Education UR PT. IC Pharm Adm/
Mgt. Dept. Group Comm. Dept. Rep Pract. Dept
Review
Patient Care
 Organ Injury X
 Prophyladic X X
antibiotic with one
hour to incision
 Prophyladic
antibiotic
discontinued within
24 hrs
 Compliance with
DVT prevention
 Post – wound X X
infection
 Post- op ventilator X X
associated
pneumonia
Medical/Clinical
Knowledge
CME’s
Experience
 Board Cert-Initial or X
Renewal
April 2008 34
ACCEPTED
Form 1000
Surgery Department
Review
Interpersonal and
Communication
Skills
Written Positive
Feedback
 Complaints from X X
Patients/Family
Practice Based
Learning
Improvements
sent for Review
Adherence to
NPSG:
 Abbreviations X
 Universal Protocol X
System Based
Practice
 History & Physical X X
Current/updated
 Informed Consent X
Surgery
 Submits SSI report
April 2008 35
ACCEPTED
Form 1000
Surgery Department
Review
to ICP monthly
 *Utilization Data X
Report
*Provided as an attachment with the Ongoing Professional Practice Evaluation,
Professionalism
Meetings attended X
 Complaints related X
to Professionalism
from Staff
 Case Presentation X
 Teaching an
Educational X
Program
April 2008 36
ACCEPTED
Form 2000
Department of Surgery .
2008 2008 2008 2008 2007 2007 2007 Dept Data
Data
Patient Care
 Organ Injury 1 or More 0 0 0 1 0 0 0 2 Not Available
 Prophyladic antibiotic Less than 95% 97% 100% 98% 96% 95% 98% 97% 98%
within 1hr prior to 95%
surgical incision
 Prophyladic antibiotic Less than 95% 94% 90% 80% 85% 78% 75% 90%
discontinued within 24 95%
hrs
 Compliance with DVT Less than 93% 99% 84% 82% 88% 43% 22% 88%
prevention 90%
 Post-op wound Infection Less than .5% 0 1% 1% 0 0 0 1.0% 1.0%
2% of total
cases
 Post-op ventilator 2 or More 2 0 0 1 0 0 1 3 Not Available
associated pneumonia
Medical/Clinical
Knowledge
Experience
 Board Certification Yes 100%
Renewal/Initial due 8/07
Interpersonal and
 Patient Family/Staff * Yes Yes
April 2008 37
ACCEPTED
Form 2000
2008 2008 2008 2008 2007 2007 2007 Dept Data
Data
Written positive
feedback
 Complaints from 3 or more 0 0 2 0 0 0 1 4
Patients/Families
Practice Based
Review
 Abbreviations 3 or more 0 0 2 3 4 4 6 3 Not Available
 Universal Protocol, as Less than 100% 100% 100% 98% 100% 96% 95% 96% Not Available
applicable 90%
 History & Physical Less than 100% 100% 95% 100% 100% 100% 100% 98% Not Available
Current 100%
 Informed Consent Less than 100% 100% 100% 98% 100% 100% 100% 95% Not Available
100%
 Submits SSI report to <3 3 3 3 3 3 3 2 2.4 Not Available
ICP monthly
*provided as an attachment with the Ongoing Professional Practice Evaluation.

Professionalism
April 2008 38
ACCEPTED
Form 2000
2008 2008 2008 2008 2007 2007 2007 Dept Data
Data
 Meeting Attended * 3 3 2 3 1 3 3
 Complaints related to 1 or more 0 0 0 0 0 0 0 4
Staff
 Case Presentation * 1 1 1
 Teaching an Education *
Program
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
Review
Patient Care
 Percent of X
Agreement for
over-reads
 Procedural X
Complications
 Moderate X
Sedation-
reversal rates
Medical/Clinical
Knowledge
CME’s
Experience
 Board Cert-Initial X
or Renewal
Interpersonal and
Communication
Skills
Written Positive
Feedback
April 2008 42
ACCEPTED
Form 1000
Review
 Complaints from X
Patients/Family
Practice Based
Learning
Improvements
 Critical Values X
Timeliness
 Abbreviations X
 Universal X
Protocol
System Based
Practice
 History & X
Physical for
appropriate
procedures
 Documentation X
of appropriate
anesthesia
assessment for
moderate
sedation
Report
April 2008 43
ACCEPTED
Form 1000
Review
*Provided as an attachment with the Ongoing Professional Practice Evaluation
Professionalism
Meetings Attended X
 Complaints X
related to
Professionalism
from Staff
 Case X
Presentation
 Teaching an
Educational X
Program
April 2008 44
ACCEPTED
Form 2000
Department of Radiology .
2008 2008 2008 2008 2007 2007 2007 Dept Data
Data
Patient Care
 Percent of Agreement 95% or 98% 99% 100% 100% 98% 100% 100% 97%
for Over-reads less
 Procedural 2 or more 0 0 0 1 0 0 0 1
Complications
 Moderate Sedation Greater 2% 0% 0% 1% 1% 0% 0% 2.5%
 Reversal Rate than 5%
Medical/Clinical
Knowledge
Experience
 Board Certification Yes 100%
Renewal/Initial due
8/2007
Interpersonal and
 Patient Family/Staff * Yes Yes Yes
Written positive
feedback
 Complaints from 3 or more 0 0 0 1 0 0 0 2
Patients/Families
Practice Based
April 2008 45
ACCEPTED
Form 2000
2008 2008 2008 2008 2007 2007 2007 Dept Data
Data
 Critical Value 1 or more 2 0 0 1 0 0 0 5
Timeliness exceeding
 Abbreviations 3 or more 0 0 0 0 2 2 1 2
 Universal Protocol, as Less than 100% 100% 96% 95% 92% 90% 90% 95%
applicable 90%

 History & Physical for Less than 100% 100% 95% 100% 100% 100% 100% 100%
appropriate procedures 100%
 Documentation of Less than 95% 100% 96% 100% 100% 90% 85% 95%
appropriate anesthesia 100%
assessment for
moderate sedation
*Utilization Data Report X
Professionalism
 Meetings attended * 2 2 2 2 0 1 2
 Complaints related to 1 or more 0 0 0 0 0 0 0 2
Staff
 Case Presentation * 1
April 2008 46
ACCEPTED
Form 2000
2008 2008 2008 2008 2007 2007 2007 Dept Data
Data
 Teaching an Education * 1
Program
Reviewed and approved by Dept. of Radiology 1/15/07

* 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:
 I reviewed the findings and no further action is needed at this time.
I reviewed the findings and discussed them with the Practitioner. The
Comments:
________________________________________________________________
Dr. Patty Picture

Department Chair
Department of Radiology
April 2008 49
ACCEPTED
Form 1000
Allied Health – PA
Review
 Corrections to
H&P X
 Feedback on X X
aseptic
technique
 Feedback on X X
surgical skills
Medical/Clinical
Knowledge
 CE Hours X X
Experience
Interpersonal and
Communication
Skills
 Feedback X
related to
communication
skills
April 2008 50
ACCEPTED
Form 1000
Review
 Complaints from
Patients/Family X
Practice Based
Learning
Improvements
sent for Review
 Adherence to
NPSG:
 Abbreviations X
 Universal X X X
Protocol
System Based
Practice
 Timeliness of X
H&P’s
 Dating and X
Timing of entries
Report
Professionalism
April 2008 51
ACCEPTED
Form 1000
Review
 Feedback X X
related to
Professionalism
from Staff
MSO – Medical Staff Office Adm – Administration/Department
April 2008 52
ACCEPTED
Form 2000
Subspecialty if applicable Allied Health/PA.
Practitioner ID # 2143 Last Appointment Date .
2008 2008 2008 2008 2007 2007 2007 Dept Data
Data
Patient Care
 Corrections to H&P 2 or more 0 0 0 3 1 0 0 1.2 Not Available
H&P’s with
corrections
 Feedback on aseptic 1 or more 0 0 1 0 0 0 0
technique breaks
 Feedback on surgical Below 4 4 4 4 4 4 4 3 3.5 Not Available
skills rating on
feedback
Medical/Clinical
Knowledge
 CE Hours * 10 4 6 0 8 16 0
 New Training or * Yes new
Experience ortho
system
Interpersonal and
 Feedback related to Score of 2 or 3 3 3 3 3 3 3 3 Not Available
communication skills less
 Complaints from 2 or more 0 0 0 1 0 0 0 3 Not Available
Patients/Families
Practice Based
April 2008 53
ACCEPTED
Form 2000
Subspecialty if applicable Allied Health/PA.
Practitioner ID # 2143 Last Appointment Date .
2008 2008 2008 2008 2007 2007 2007 Dept Data
Data
Review
 Adherence to National 3 or more 0 0 2 3 4 5 4 3 Not Available
 Abbreviations
 Universal Protocol, Less than 100% 100% 100% 100% 95% 90% 95% 95% Not Available
as applicable 90%

 Timeliness of H&P 2 or more 0 1 1 0 2 0 1 4 Not Available
 Dating and timing of Less than 90% 90% 90% 85% 80% 80% 75% 80% Not Available
entries 90%
Professionalism
 Meeting Attended * 0 3 2 0 2 2 2 Not Available
 Feedbacks related to Score of 2 or 3 3 3 3 3 3 3 3 Not Available
Professionalism from less
Staff
* 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
DEPARTMENT OF SURGERY
Reporting Period: October, November, December 2008 Date:

June 1, 2007
Practitioner Number : 2143 (PA) .
As the Department Chair for Surgery, and the Director of the Physician’s
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
Comments:
________________________________________________________________.
Dr. Ima Cutter

Dept Chair Surgery
Hope Floats, PA
Director of Physician’s 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 2 3 4 5
Poor Fair Average Good Excellent
For a score of 2 or below, please provide examples:
2). Professionalism
1 2 3 4 5
Poor Fair Average Good Excellent
For a score of 2 or below, please provide examples:
3). Aseptic Technique
Has the individual had any reported breaks in sterile technique for this
reporting period? If so, please provide details and any actions taken.
April 2008 58
ACCEPTED
EXAMPLE
PA COMPETENCY EVALUATION
Operative Performance Rating Form
PA_______________________________________________
Please circle the number corresponding to the resident’s performance in each area,
irrespective of training level.
Knowledge of Operative Steps
1 2 3 4 5
Unfamiliar with the steps of the operation;
Unable to recall or describe many operative steps
Instrument Handling
1 2 3 4 5
Makes tentative or awkward moves by
inappropriate used of instruments
Knowledge of Instruments
1 2 3 4 5
FreQently asks for wrong instruments or
used inappropriate instruments
Flow of the Operation
1 2 3 4 5
FreQently stopped operating and
seemed unsure of next move
Respect For Tissue
1 2 3 4 5
FreQently used unnecessary force on tissue or
caused damage by inappropriate use of instruments
Physician Signature: ____________________ Date: ______________________
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. Don’t select too many measures, but assure that you have enough to truly
evaluate the physician’s 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 patient’s condition
 Mortality rates
 Meeting attendance
 CME’s 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 issues—may 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: _____________________
Event
Hosp/ MR # Indicator and Description
Date(s)
Source of Referral
_ __ Quality Indicator __ _ Nursing/other clinical staff concern
____Pattern of clinical or behavioral issues __ _ Other Medical Staff Member
____Patient/Family complaint ____QCC/Incident Report
____Potential litigation (attorney requests record) ____Formal notice of litigation
Evaluation of Case
1) Does the case represent a deviation from the standard of care for this patient population? No Yes*
2) Were the H&P, OP notes, and Progress notes adequate and timely? No* Yes
3) Were there any identifiable breakdowns in communication? No Yes*
4) Was judgment/decision making sound in this case? No* Yes
5) Were there any clinical process problems that contributed to the patient outcome? No Yes*
6) Could this incident have been readily prevented? No Yes*
7) Is there an educational opportunity? No Yes*
8) Was the management/documentation of the case a problem after the complication occurred? No Yes*
9) Is there a strong probability that this case will lead to litigation? No Yes*
*Explanation of any above noted deviations:

_______________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Reviewing physician signature and date:
April 2008 68
ACCEPTED
Severity (Patient Outcome)

0 No problem or complication unrelated to quality/safety issue
1 Minor problem or complication
2 Problem with significant but temporary adverse affect on patient (example- extended LOS, extra
surgery, etc)
3 Problem with significant adverse affect on patient that is likely to be longer-term (ie pain, mobility,
dietary restrictions, other problems)
4 Problem as #3 but with permanent disability/significant injury
5 Death possibly related to quality/safety issue
6 Death likely related to quality/safety issue
7 Unknown outcome
Action by Committee
1 No action other than documentation in minutes and record for profile
2 Trend
3 Telephone or verbal discussion
4 Letter to practitioner with no request for response
5 Letter to practitioner with request for response
6 Counseling conversation between Chair & practitioner
7 Request practitioner to attend MSPR meeting to discuss case
8 Intensive review of _____ additional cases
9 Referred for review by outside reviewer
10 Referred for Root Cause Analysis
11 Classified as a Sentinel Event
12 Refer to Medical Staff Executive Committee—to assess potential disciplinary action
13 Refer to Hospital Patient Safety Team or IQC for concerns about hospital processes
14 Consider medical staff education session on topic:
_________________________________________
Additional Actions
A Mandatory consultation for specific type of cases as noted______________
B Suspension of privileges-type/timeframe specified_____________________
C Report to Data Bank ____________________________________________
D Other:___________________________________________________________
April 2008 69

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Leading Practices Library

LifePoint Physician Performance Toolkit*

Introduction: Credentialing is now an ongoing process that involves continuous

 Focused Professional Practice Evaluations (Focused Review) - A

 Practitioner – Individual with Medical Staff or Allied Health privileges.

Steps for implementing OPPE:

Steps for Developing An Evidence

Sample OPPE Policy – Page 4

Sample FPPE Policy-- Page 13

Description of Forms -- Page 17

Toolkit Example Forms:

 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 Form—Page 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

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

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

3. Criteria/indicators may be added or deleted at the recommendation of the

5. The list of criteria/indicators will be reviewed on an ongoing basis and in

III. Definitions and Responsibilities

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

ii. Provides medical record to be reviewed to the peer screener;

iii. Trends data related to individual practitioner performance for

iv. Forwards to the designated Department Chairperson or Peer

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

v. Provides periodic summary reports (Ongoing Professional

ii. Documents on the form pertinent findings to support the

viii. Reviews the Ongoing Professional Practice Feedback Reports

6. Department Credentials Committee

7. Medical Executive Committee

v. Reports and recommends to the Board of Directors regarding

8. Individual Under Review

IV. Method for Selecting Reviewer Panels, Including Specific

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

2. Conflict of Interest -Within the context of the review process, a conflict of

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

a. External Review - External performance review is required under the

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

V. Notification Review Determinations

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

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

3. All correspondence will be confidential.

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

VII. Effectiveness of Review Process

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

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

5. Useful - The results of review activities are to become part of the

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

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

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

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

IX. Performance Improvement

1. Members of the medical staff are involved in activities to

2. The review process involves monitoring, analyzing, and

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

Physician Signature: Date: __