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EFFECTIVE DATE: 7/23/09

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SUBJECT: PROFESSIONAL PRACTICE EVALUATION POLICY SCOPE Applies to all members of the CHRISTUS Santa Rosa Hospital Medical and Allied Health Professional Staffs. POLICY I.

It is the policy of CHRISTUS Santa Rosa Hospital Medical Staff to establish a systematic process to define, determine, maintain, and evaluate the competency of members of the Medical and Allied Health Professional Staffs. Competency includes the ability to provide care, treatment, and services in accordance with the credentialing and privileging processes and requirements of the Medical Staff.

II.

It is the policy of the Medical Staff to ensure that there is sufficient information available to confirm the current and ongoing competency of practitioners granted privileges in order to comply with statutory and regulatory requirements regarding ongoing professional practice evaluation (OPPE) and focused professional practice evaluation (FPPE).

III.

Indications/criteria/triggers will be developed, implemented, and monitored by the Medical Board and Facility Credentials and Medical Executive Committees on an ongoing basis as part of the Medical Staff’s peer review activities.

PROCEDURE I.

GENERAL COMPETENCY EVALUATION (GCE) Applicants and members of the medical staff must satisfactorily exhibit the general competencies at the time of appointment and reappointment. The general competencies of the practitioner can be ascertained in several ways: A.

Peer references that affirmatively attest to the general competencies of the practitioner, along with a positive recommendation for appointment or reappointment to the medical staff.

B.

The decision of the Department, Credentials Committee, and the Medical Executive Committee (MEC) that the practitioner exhibits the general competencies based on the practitioner’s relevant education, training and experience and known information about the practitioner’s performance.

C.

Specific information that may arise out of ongoing and/or focused evaluation of a practitioner that affirmatively or adversely speaks to that practitioner’s general competencies. A practitioner who is unable to satisfactorily exhibit the general competencies outlined in this policy may be subject to the focused evaluation of his or her professional practice, as described in this policy.

PRIMARY FUNCTION: MEDICAL STAFF

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EFFECTIVE DATE: 7/23/09

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SUBJECT: PROFESSIONAL PRACTICE EVALUATION POLICY Six general competencies**: 1. Patient Care Practitioners are expected to provide patient care that is compassionate, appropriate & effective for promotion of health, prevention of illness, treatment of disease, & care at end of life. 2. Medical/Clinical Knowledge Practitioners are expected to demonstrate knowledge of established & evolving biomedical, clinical &social sciences, and the application of their knowledge to patient care and the education of others. 3. Practice-based Learning & Improvement Practitioners are expected to be able to use scientific evidence and methods to investigate, evaluate, and improve patient care practices. 4. Interpersonal & Communication Skills Practitioners are expected to demonstrate interpersonal & communication skills that enable them to establish & maintain professional relationships w/patients, families, & other members of health care teams. 5. Professionalism Practitioners are expected to demonstrate behaviors that reflect commitment to continuous professional development, ethical practice, understanding and sensitivity to diversity, & responsible attitude toward their patients, their profession, & society. 6. Systems Based Practice Practitioners are expected to demonstrate both an understanding of contexts & systems in which health care is provided, & ability to apply this knowledge to improve and optimize health care. Developed by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) joint initiative. II.

FOCUSED PROFESSIONAL PRACTICE EVALUATION (FPPE) Focused professional practice evaluation is a process whereby the privilege/procedure-specific competence of a practitioner who does not have sufficient documented evidence of competently performing the requested privilege at the organization is evaluated. This process may also be used when a question arises regarding a currently privileged practitioner’s ability to provide safe, highquality patient care for which he or she possesses current privileges. FPPE is a time-limited period during which an organization evaluates and determines the practitioner's professional performance. FPPE will be performed under the following circumstances: 

For all practitioners initially granted clinical privileges

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SUBJECT: PROFESSIONAL PRACTICE EVALUATION POLICY 

The practitioner has not yet performed the procedure for which he or she seeks privileges at your organization in the past



There is a concern regarding the practitioner's current competency, either due to data from an ongoing professional practice evaluation or because the practitioner has not exercised the privilege in question for an extended period of time

When a practitioner is granted privileges for the first time, either at initial appointment or as a current member of the medical staff, he or she will undergo an initial period of focused evaluation called concurrent supervision or retrospective review. A focused review of a practitioner’s performance may also occur when issues are identified that may affect the provision of safe, high-quality medical care. The following criteria may trigger the need for a focused evaluation: A. B.

There is aggregate, valid, practitioner-specific data that demonstrates a significant adverse variation from internal or external benchmarks of performance. There is a problematic pattern or trend identified as a result of the ongoing professional practice evaluation of the practitioner.

C.

There is a complaint or quality-of-care concern raised against the practitioner that is of a serious nature.

D.

There is evidence of behavior, health, and/or performance issues that carries an immediate threat to the health and safety of the patient, public, or other members of the health care team (see Bylaws, Summary Suspension Process).

The evaluation shall begin with the applicant’s first 5 (five) admissions or performance of the newly requested privilege. The evaluation can be accomplished by chart review, monitoring clinical practice patterns, proctoring, direct observation, external peer review, and discussions with other practitioner’s involved in the care of specific patients (e.g., consulting physicians, assistants at surgery, nursing staff, or administrative personnel). Evaluations shall be performed by the respective Department Chairman/Vice Chairman, Section Chief, VPMA, or their designee. The Medical Staff Office shall provide each evaluator with the Professional Practice Evaluation Form. (See Attachment A) Evaluations shall be submitted to the Medical Staff Office at least every six months, with their results being presented to MEC at their next scheduled meetings.

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SUBJECT: PROFESSIONAL PRACTICE EVALUATION POLICY

Concerns regarding a practitioner’s clinical practice and/or competence shall be acted upon immediately. III.

ONGOING PROFESSIONAL PRACTICE EVALUATION (OPPE) Ongoing professional practice evaluation is the continuous evaluation of the practitioner’s professional performance, rather than an episodic evaluation. It is intended to identify and resolve potential performance issues as soon as possible, as well as foster a more efficient, evidence-based privilege renewal process. Ongoing professional practice evaluation allows the organization to identify professional practice trends that may impact the quality of care and patient safety. Early identification of problematic performance allows for timely intervention. Ongoing professional practice evaluation results should be shared with the practitioners on a regular basis. OPPE indicators chosen by departments may include, but not necessarily be limited to, the following areas:                 

Performance of operative and/or invasive procedures and their outcomes Communication with professionals and patients Patterns of blood and/or pharmaceutical usage Requests for tests and procedures Length-of-stay patterns Morbidity and mortality data Practitioner use of consultants Complaints received from patients, families, or staff and/or unusual occurrences (usually from RM Event Reporting System) Other relevant indicators as determined by the Medical Staff Patient Tracers Malpractice Claims Compliance with Core Measures Unprofessional Behavior Infection Rate Blood Utilization Medical Record suspensions, appropriate completion and legibility Responsiveness with professionals and patients

Ongoing evaluation information is factored into the decision to maintain an existing privilege, to modify an existing privilege, or to revoke an existing privilege prior to or at the time of reappointment. Information resulting from this evaluation is used to determine whether to continue, limit or revoke an existing privilege. The evaluation may be obtained through, but is not limited to, the following:

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EFFECTIVE DATE: 7/23/09

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SUBJECT: PROFESSIONAL PRACTICE EVALUATION POLICY       

Concurrent and/or targeted medical record review Direct observation Monitoring/proctoring Discussion with other practitioner’s involved in the care of specific patients Data collected and assessed through quality improvement indicators and triggers Sentinel event data Any applicable peer review data

Ongoing data review and findings about practitioner practice and performance will be evaluated by the Medical Board, and Credentials and Medical Staff Executive Committees and will be utilized to assess the quality of care of each practitioner at time of reappointment or any time additional privileges are requested. Patterns, trends or issues identified will be addressed for further review, correction action and/or additional monitoring, as necessary. Practitioners who do not admit/utilize the hospital with adequate frequency for assessment or are in a specialty that does not provide inpatient hospital care shall be responsible for providing alternative information for review that will allow an informed decision regarding professional practice evaluation. APPROVALS: ______ Don Beeler, FACHE - CEO ______ James C. Martin, M.D. - CMO