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Proposed Policies (Attachment No. 2) - Page 107 of 231 Professional Practice Evaluation PolicyProposed Policies (Attachment No. 2) - Page 108 of 231 PROFESSIONAL PRACTICE EVALUATION POLICY (PEER REVIEW) ‘TABLE OF CONTENTS PAGE OBJECTIVES, SCOPE OF POLICY, COLLEGIAL EFFORTS, DEFINITIONS, AND ACRONYMS 1 LA Objectives... 1 1B Scope of Policy : 1 LC Collegial Efforts and Progressive Steps 2 1D General Terms. 2 LE Definitions.. m2 LF Acronyms... 4 PPE TRIGGERS..... 4 2A Specialty-Specitic Triggers . on 2.8 Hospital Quality & Patient Safety Department Triggers 4 2.C Reported Concerns .. on (1) Reported Concerns from Practitioners or Hospital Employees. 4 (2) Anonymous Reports 5 (3) Follow-up with Individual Who Filed Report. a (4) Unsubstantiated Reports or False Reports. 5 (5) Sharing Reported Concerns with Relevant Practitioner. 5 (6) _ Self-Reporting.... 6 2.0 Other PPE Triggers. 6 NOTICE TO AND INPUT FROM THE PRACTITIONER. 3.A Opportunity for Input 3.8 Manner of Providing Input. 3.C__ Failure to Provide Requested Input INTERVENTIONS TO ADDRESS IDENTIFIED CONCERNS. 4.4 Informational Letter. 4.8 — Educational Letter. 4.C —_ Collegial Intervention... 4.0 Performance Improvement Plan ("PIP"). (1) General eens (2) Input. (3) Voluntary Nature of PIPs (4) Ongoing Assessment of PIP Results. (5) Reporting Obligations (6) Participation in PIPs by Partners.STEP-BY-STEP PROCESS. Proposed Policies (Attachment No. 2) - Page 109 of 231 PAGE (7) PIP OpIONS. ror (a) Additional Education/CME. {b) Prospective Monitoring... (c) Indicators Checklist....... ancint (6) Second Opinions/Consultations {e) Concurrent Proctoring.... (Participation in a Formal Evaluation/Assessment Program . (g) Additional Training.. (h) Educational Leave of Absence or Determination to Voluntarily Refrain from Practicing during the PPE Process. 12 a Other... 12 S.A General Principles.. (1) Time Frames for Review . vo (2) Request for Additional information or Input... (3) No Further Review or Action Required... (4) Exemplary Care i: (5) Referral to the Medical Executive Committee (6) __ Role of Department Chairs in PPE Process . 5.B PPE Support Staff wnnnmmnnnn (a) Review... (2) Determination......... (3) Preparation of Case for Physician RevieW wu. . (4) Referral of Case to Leadership Councilor Clinical Specialty Reviewer... 16 5.C Leadership Council. v7 (1) Review. i: 7 2) Determinations and interventions. 5.D Clinical Specialty Reviewers (1) REVIEW. aren (2) Reports. rane BE PEC. (1) Review of Prior Determinations o (2) Cases Referred to the PEC for Further Review 19 (a) Review... (6) Determinations and interventions PRINCIPLES OF REVIEW AND EVALUATION os 20 6.A Incomplete Medical Records... 68 Forms... so 6. External Reviews... 6.0 Findings and Recommendations Supported by Evidence-Based Research/Clinical Protocols or Guidelines...Proposed Policies (Attachment No. 2) - Page 110 of 231 PAGE 6.£ System Process Issues. seo a 6.F Tracking of Reviews sen 2 6.6 Educational Sessions/Dissemination of Educational Information... a (2) General Principles... a (2) Rules for Educational Sessions. 2 6H Confidentiality. 2B (2) Documentation 2B (2) PPE Communications. os 23 (3) Practitioner Under Review. . son 24 61 Conflict of Interest Guidelines ..nsnnnnninnninnnnnnne 24 PROFESSIONAL PRACTICE EVALUATION REPORTS... DA 7.4 Practitioner Professional Practice Evaluation History Reports... 24 25 7.8 Reports to Medical Executive Committee and Board. 7.C Reports on Request. APPENDIX A: Performance Issues That Trigger Informational Letters APPENDIX B: Performance Improvement Plan Options ~ Implementation Issues Checklist APPENDIX C: Conflict of Interest GuidelinesProposed Policies (Attachment No. 2) - Page 111 of 231 PROFESSIONAL PRACTICE EVALUATION POLICY (PEER REVIEW) 1. OBJECTIVES, SCOPE OF POLICY, COLLEGIAL EFFORTS, DEFINITIONS, AND ACRONYMS LA 18 Objectives. The primary objectives of the Professional Practice Evaluation ("PPE") process of Mission Hospital are to: (a) (2) 3) establish a positive, educational approach to performance issues and a culture of continuous improvement for individual Practitioners, which includes: (a) fairly, effectively, and efficiently evaluating the care being provided by Practitioners, comparing it to established patient care protocols and benchmarks whenever possible; and (b) providing constructive feedback, education, and performance improvement assistance to Practitioners regarding the quality, appropriateness, and safety of the care they provide; effectively disseminate lessons learned and promote education sessions so that all Practitioners in a relevant specialty area will benefit from the PPE process and also participate in the culture of continuous improvement; and, promote the identification and resolution of system process issues that may adversely affect the quality and safety of care being provided to patients (e.g., protocol or policy revisions that are necessary; addressing patient handoff breakdowns or communication problems). Scope of Policy. a ‘The Hospital's PPE process includes several related but distinct components: (a) The PPE process described in this Policy is used when questions or concerns are raised about a Practitioner's clinical competence. This process has traditionally been referred to as “peer review.” {b) The process used to confirm an individual's competence to exercise newly granted Privileges is described in the FPPE Policy to Confirm Practitioner Competence and Professionalism (New Members/New Privileges). The process used to evaluate a Practitioner's competence on fan ongoing basis is described in the Ongoing Professional Practice Evaluation (OPPE) Policy. (c) Concerns regarding a Practitioner's professional conduct or health status shall be reviewed in accordance with the Medical Staff Professionalism Policy or Practitioner Health Policy, respectively.1c 10. LE Proposed Policies (Attachment No. 2) - Page 112 of 231 (4) If a matter involves both clinical and behavioral concerns, the Chairs of the Leadership Council and the Professional Evaluation Committee ("PEC’) shall coordinate the reviews. The behavioral concerns may either be: () addressed by the Leadership Council pursuant to the Professionalism Policy, with a report to the PEC; or (i) addressed by the PEC pursuant to this Policy, with the provisions in the Professionalism Policy being used for guidance. (2) This Policy applies to all Practitioners who provide patient care services at the Hospital Collegial Efforts and Progressive Steps. This Policy encourages the use of collegial efforts and progressive steps to address issues that may be identified in the PPE process. The goal of those efforts is to arrive at voluntary, responsive actions by the Practitioner. Collegial efforts and progressive steps may include, but are not limited to, Informational Letters, counseling, informal discussions, education, mentoring, Educational Letters of counsel or guidance, sharing of comparative data, and Performance Improvement Plans, as outlined in this Policy. All collegial efforts and progressive steps set forth in this Policy are part of the Hospital's confidential Professional Practice Evaluation and Professional Review Activities. These efforts are encouraged, but are net mandatory, and shall be within the discretion of the relevant Clinical Specialty Reviewer, Leadership Council, and PEC. General Terms. All of the terms set forth in Article 1 ("GENERAL") of the Medical Staff Credentials Policy apply to this Policy, including all provisions addressing: (2) Definitions (for Capitalized terms used in this Policy); (2) Headings and Footnotes; (3) Delegation of Administrative and Medical Staff Leadership Functions; (4) Confidentiality and Peer Review Protection; (5) Substantial Compliance; and (6) Indemnification of Practitioners. Definitions. \n addition to the “Definitions” set forth in the Medical Staff Credentials Policy, these terms, when capitalized in this Policy, will have the following meanings: ASSIGNED REVIEWER means a Physician appointed by a Clinical Specialty Reviewer, the Leadership Council, or the PEC to review and assess the care provided in a particular case, complete the POR, AR, Ad Hoc Committee Case Review Form, and report back to the individual or committee that assigned the review. As requested, an Assigned Reviewer may also serve as a consultant to an individual or committee conducting @ review, without the need for the Assigned Reviewer to complete a review form.Proposed Policies (Attachment No. 2) - Page 113 of 231 AUTOMATIC RELINQUISHMENT/AUTOMATIC RESIGNATION of Membership and/or Clinical Privileges are administrative actions that occur by operation of the Credentials Policy and/or this Policy and do not involve any subjective determinations about Practitioners’ competence or conduct. Accordingly, they do not entitle the Practitioner to a hearing or appeal. Automatic Relinquishment is temporary (subject to terms of reinstatement set forth in the applicable policy}, while Automatic Resignation is final. Both result in the immediate and complete loss of both Membership and Clinical Privileges, upon Notice to the Practitioner, unless less comprehensive terms for the relinguishment or resignation are specified in the relevant policy (e.g,, “relinquishment of admitting Privileges”) CLINICAL SPECIALTY REVIEWER means a Physician or committee appointed by the Leadership Council to perform the functions set forth in this Policy for @ particular department or specialty. Clinical Specialty Reviewers receive cases for review, obtain Input from Assigned Reviewers or Pre-Determined Reviewers as needed, complete the CSR Case Review Form, and forward the review form to the PEC for its determination. Clinical Specialty Reviewers shall serve at least two-year terms, and may be reappointed for additional terms. The Leadership Council may choose to appoint more than one Clinical Specialty Reviewer for 2 department or specialty, depending on its size and volume of cases. PPE SUPPORT STAFF means the clinical and non-clinical staff who support the Professional Practice Evaluation processes. This may include, but is not limited to, staff from the quality department, medical staff office, human resources, and/or patient safety department. PPE Support Staff will be deemed to act at the request of, and on behalf of, the Medical Staff Committees and Hospital Committees if they conduct Professional Review Activity, take any action in support of Professional Review Activity including gathering Information and preparing documentation, or attend a meeting of a Hospital Committee or Medical Staff Committee: (i) at the specific request or invitation of the Committee or its Chair; (ii) at the specific request or invitation of an individual who has been authorized to act on behalf of the Committee; or (i) pursuant to the terms of any of the Medical Staff Governance Documents or Hospital policy. PRE-DETERMINED REVIEWERS mean those Practitioners who are appointed by the Leadership Council or PEC to conduct case reviews and report their findings to the Clinical Specialty Reviewer, Leadership Council, or PEC. Pre-Determined Reviewers should be broadly representative of the specialties on the Medical Staff. Depending on volume, ‘more than one Pre-Determined Reviewer may be appointed in a department or specialty. Pre-Determined Reviewers will complete the PDR, AR, Ad Hoc Committee Case Review Form when asked to review a case, and upon request will meet with the individual or committee that assigned the review to discuss their findings and answer questions. They ‘may also serve as a consultant to an individual or committee conducting a review, without Clinical Specialty Reviewers may include, without limitation, department chairs or designee, division leads Cr designee, departmental or specialty committees, PEC members, Physician Advisors, Physician Quality Councils, or other individuals with experience in Professional Practice Evaluation,LF. Proposed Policies (Attachment No. 2) - Page 114 of 231 the need to complete a review form. Pre-Determined Reviewers shall serve one-year terms, and may be reappointed for additional terms. Acronyms. Definitions of the acronyms used in this Policy are: FPPE —_Focused Professional Practice Evaluation OPPE Ongoing Professional Practice Evaluation PIP Performance Improvement Plan PPE Professional Practice Evaluation (Peer Review) PEC Professional Evaluation Committee MEC Medical Executive Committee PPE TRIGGERS. The PPE process set forth in this Policy may be triggered by any of the following events: 2A, 28. 2. Specialty-Specific Triggers. Each department chair shall determine what occurrences and/or outcomes will be reported to the PPE Support Staff. Hospital Quality & Patient Safety Department Triggers. The Chief Medical Officer (or designee) shall determine what clinical issues or concerns identified through the Hospita’s Quality & Patient Safety Department will be reported to the PPE Support Staft Information reported by the Hospital Quality & Patient Safety Department to the PPE Support Staff shall not include any Patient Safety Work Product (PSWP]. Reported Concerns. (1) Reported Concerns from Practitioners or Hospital Employees. Any Practitioner Cor Hospital employee may report to the PPE Support Staff concerns related to: {a) the safety or quality of care provided to a patient by an individual Practitioner, which shall be reviewed through the process outlined in this, Policy; (b) professional conduct, which shall be reviewed and addressed in accordance with the Medical Staff Professionalism Policy; (c) potential Practitioner health issues, which shall be reviewed and addressed in accordance with the Practitioner Health Policy; (4) compliance with Medical Staff or Hospital policies, which shall be reviewed either through the process outlined in this Policy and/or in accordance with the Medical Staff Professionalism Policy, whichever the Leadership Council determines is more appropriate based on the policies at issue; or (e) a potential system or process issue which shall be referred to the appropriate individual, committee, or Hospital department for review.Proposed Policies (Attachment No. 2) - Page 115 of 231 Such referral shall be reported to the PEC, which shall monitor the matter, Until itis resolved. (2) Anonymous Reports. Practitioners and employees may report concerns anonymously, but all individuals are encouraged to identify themselves when making a report. This identification promotes an effective review of the concern because it permits the PPE Support Staff to contact the reporter for additional Information, if necessary. (3) Follow-up with individual Who Filed Report. The PPE Support Staff, PEC Chair and/or the Chief Medical Officer shall follow up with individuals who file a report by: {a) thanking them for reporting the matter and participating in the Hospital's culture of safety and quality care; (b) informing them that the matter will be reviewed in accordance with this Policy and that they may be contacted for additional information; (c) informing them that no retaliation is permitted against any individual ‘who raises a concern and to report any retaliation or any other incidents of inappropriate conduct; and (a) informing them that, due to confidentiality requirements under state law, no further information can be provided regarding the outcome of the review. (4) Unsubstantiated Reports or False Reports. If a report cannot be substantiated, r is determined to be without merit, the matter shall be closed as requiring no further review. False reports will be grounds for disciplinary action. Suspected false reports by Practitioners will be referred to the Leadership Council Suspected false reports by Hospital employees will be referred to human resources, (5) Sharing Reported Concerns with Relevant Practitioner. The substance of reported concerns may be shared with the relevant Practitioner as part of the review process outlined in Section 5, but neither the actual report nor the identity Of the individual who reported the concern or otherwise provided information about the matter will be provided to the Practitioner unless: {a) the individual specifically consents to the disclosure; {b) the Leadership Council determines that an exception must be made in a particular situation to ensure an appropriate review, in which case the individual in question will be notified; or (c) information provided by the individual is used to support an adverse Professional Review Action that results in a Medical Staff hearing,20. Proposed Policies (Attachment No. 2) - Page 116 of 231 6) Retaliation (as defined in the Medical Staff Professionalism Policy) by the Practitioner against anyone who is believed to have reported a concern or otherwise provided information about a matter is inappropriate conduct and will be addressed by the Leadership Council through the Professionalism Policy. Self-Reporting. Practitioners are encouraged to self-report their cases, as appropriate, to the PPE Support Staff. This includes self-reporting any case the Practitioner believes would be an appropriate subject for an educational session as described in Section 6 of this Policy. Self-reported cases will be reviewed as, outlined in this Policy. A notation will be made that the case was self-reported. Other PPE Triggers. In addition to specialty-specific triggers and reported concerns, other events that may trigger PPE include, but are not limited to, the following: ie} 2) @) (a) (5) (@) ” identification by a Medical Staff committee or work group of a clinical trend or specific case or cases that require further review. The review and deliberations of such a committee or work group and any documentation prepared are confidential peer review information and shall be used and disclosed only as set forth in this Policy; patient complaints that are referred by the patient representative and that require physician review, as determined by the PPE Support Staff (in consultation with the PEC Chairperson or the Chief Medical Officer); cases identified as quality risks that are referred by the risk management department. However, confidential information generated pursuant to this Policy may not be disclosed as part of any risk management activities; Unresolved issues of medical necessity referred through the utilization management committee, case management department, compliance officer, or otherwise referrals from the serious safety event review team or sentinel events involving an individual Practitioner's professional performance; @ Department Chair's determination that Ongoing Professional Practice Evaluation (“OPE”) data reveal a practice pattern or trend that requires further review as described in the OPPE Policy; and when a threshold number of Informational Letters identified in Appendix A is reached, or when a trend of noncompliance is otherwise identified with: (i) Medical Staff Rules and Regulations or other policies; or (ii) adopted clinical protocols, order sets or pathways, or other quality measures, based either on the overall number of Informational Letters sent to the Practitioner or based on other relevant factors.Proposed Policies (Attachment No. 2) - Page 117 of 231 NOTICE TO AND INPUT FROM THE PRACTITIONER. An opportunity for Practitioners to provide ‘meaningful input into the review of the care they have provided is an essential element of an educational and effective process. 3.8 Opportunity for Input. (2) Ifany questions or concerns are identified about the care provided in a case under review, the Practitioner will be notified of the questions or concerns and offered ‘an opportunity to provide input prior to the review being completed and any final determination made. The notice to the Practitioner shall include a time frame for the Practitioner to provide the requested input. (2) This prior notice and opportunity for input will always occur during the initial assessment of a case if any questions or concerns are identified, but subsequent levels of review may also seek input from the Practitioner if necessary or helpful to the review. (3) Prior notice and an opportunity to provide input are not required before an Informational Letter is sent to a Practitioner, as described in Section 4.A of this Policy. 3.8 Manner of Providing Input. (1) The Practitioner shall provide input through a written description and explanation of the care provided, responding to any specific questions posed in the notice. (2) Upon the request of either the Practitioner or the person or committee conducting the review, the Practitioner shall also provide input by meeting with appropriate individuals (as determined by the individual or committee conducting the review) to discuss the issues. (3) As part of a request for input pursuant to this Policy, the person or committee requesting input may ask the Practitioner to provide a copy of, or access to, medical records from the Practitioner's office. Failure to provide such copies or access will be viewed as a failure to provide requested input. 3.C Failure to Provide Requested Input. (2) Ifthe Practitioner fails to provide input requested by a Clinical Specialty Reviewer within the time frame specified, the review shall proceed without the Practitioner's input. The reviewer shall note the Practitioner's failure to respond to the request for input in the reviewer's report to the Leadership Council or PEC regarding the assessment performed. (2) If the Practitioner fails to provide input requested by the Leadership Council or PEC within the time frame specified, the Practitioner will be required to meet with the Leadership Council to discuss why the requested input was not provided. Failure of the Practitioner to either meet with the Leadership Council or provideProposed Policies (Attachment No. 2) - Page 118 of 231 the requested information prior to the meeting will result in the Automatic Relinquishment of the Practitioner’ Clinical Privileges until the information is provided. If the Practitioner fails to provide input requested by the Leadership Council or PEC within ninety (90) Days of the Automatic Relinguishment, the Practitioner's Medical Staff Membership and Clinical Privileges will be deemed to have been Automatically Resigned. (See Section 1.£ for additional information about Automatic Relinguishment/Resignation.) The Leadership Council may extend any time frame set forth in this Section and establish a new deadline, iit determines that a Practitioner would be unable to comply due to: (1) liness; (2) previously scheduled travel; or (3) other extenuating circumstances. INTERVENTIONS TO ADDRESS IDENTIFIED CONCERNS. When concerns regarding a Practitioner's clinical practice are identified, the following interventions may be implemented to address those an Informational Letter. ‘The PEC shall identify specific performance issues that can be successfully addressed through the use of Informational Letters, without the need to immediately proceed with more formal review under this Policy. The performance issues that may lead to an Informational Letter are often referred to as “rate and rule” measures, Informational Letters are a non-punitive, educational tool to help Practitioners self- correct and improve their performance through the use of feedback, ‘As determined by the PEC, performance issues that may be addressed via Informational Letters include, but are not limited to, noncompliance with: ‘+ specific provisions of the Medical Staff Rules and Regulations or Hospital or ‘Medical Staff policies; + an adopted protocol, without appropriate documentation in the medical record as to the reasons for not following the protocol; * core or other quality measures; or © care management/utilization management requirements. Appendix A includes: (2) alist of issues that may result in an informational Letter being sent; (2) the number of violations that must occur before an Informational Letter will be sent; and (3) the number of Informational Letters in an OPPE period that will lead to further review under this Policy. In these situations, the PPE Support Staff shall prepare an Informational Letter reminding the Practitioner of the applicable requirement and offering assistance to the Practitioner in complying with it. The purpose of this feedback is to increase awareness of the48 ac 40 Proposed Policies (Attachment No. 2) - Page 119 of 231 requirement and permit the Practitioner to improve his/her practice on a self- improvement basis. However, nothing in this Policy prohibits any authorized individual or committee from forgoing the use of an Informational Letter and responding to a particular incident in some other manner as warranted by the circumstances. ‘Accopy of the Informational Letter shall be placed in the Practitioner's confidential file. It shall be considered when the individual requests renewal of Membership and/or Clinical Privileges, as well as in the assessment of the Practitioner's competence to exercise the Clinical Privileges granted. ‘A matter shall be subject to review by the Leadership Council in accordance with Section 5 of this Policy if: (i) the threshold number of Informational Letters to address a particular type of situation is reached as described in Appendix A; or (i) a trend of noncompliance is otherwise identified based on the overall number of Informational Letters sent toa Practitioner or other relevant factors, even if none of the thresholds for a particular category in Appendix A are met. Informational Letters may be signed by the following Medical Staff Leaders and Administrative Leaders: & department chair, a Clinical Specialty Reviewer, the Chair of the PEC, or the Chief Medical Officer. Individuals named in the preceding sentence shall bbe copied on any Informational Letter that they do not personally sign. Educational Letter. An Educational Letter may be sent to the Practitioner involved that describes the opportunities for improvement that were identified in the care reviewed and offers specific recommendations for future practice. A copy of the Educational Letter willbe included in the Practitioner's file along with any response that he or she would like to offer, Educational letters may be sent by: The Leadership Council or the PEC. The Department Chair and PEC will be copied on any Educational Letter that is sent to a Practitioner. Collegial intervention. Collegial Intervention means a face-to-face discussion between the Practitioner and one or more Medical Staff Leaders. If the Collegial Intervention results from a matter that has been reported to the PPE Support Staff and reviewed through this Policy, it shall be followed by a letter that summarizes the discussion and, when applicable, the expectations regarding the Practitioner's future practice in the Hospital. A copy of the follow up letter will be included in the Practitioner's file along. with any response that the Practitioner would like to offer. A Collegial intervention may be personally conducted by: One or more members of the Leadership Council or PEC, or these committees may facilitate an appropriate and timely Intervention by one or more designees (including, but not limited to, a Department Chair or a Clinical Specialty Reviewer). The department chair, Leadership Council, and PEC shall be informed of the substance of any Collegial Intervention and the follow-up letter, regardless of who conducts or facilitates it. Performance Improvement Plan ("PIP").Proposed Policies (Attachment No. 2) - Page 120 of 231 ay 2) 3) (a) 6) General. The PEC may determine it is necessary to develop a PIP for the Practitioner. To the extent possible, a PIP shall be for a defined time period or for a defined number of cases. The plan should specify how the Practitioner's ‘compliance with, and results of, the PIP will be monitored. One or more members Of the PEC should personally discuss the PIP with the Practitioner to help ensure a shared and clear understanding of the elements of the PIP. The PIP will aso be presented in writing, with a copy being placed in the Practitioner's file, along with any statement the Practitioner would like to offer. Input. As deemed appropriate by the PEC, the Practitioner may have an opportunity to provide input into the development and implementation of the PIP, The Department Chair shall also be asked for input regarding the PIP, and shall assist in implementation of the PIP as may be requested by the PEC. Voluntary Nature of PiPs. If a Practitioner agrees to participate in a PIP developed by the PEC, such agreement will be documented in writing. If a Practitioner disagrees with the need for a PIP developed by the PEC, the Practitioner is under no obligation to participate in the PIP. In such case, the PEC cannot compel the Practitioner to agree with the PIP. Instead, the PEC will refer the matter to the Medical Executive Committee for its independent review and action pursuant to the Medical Staff Credentials Policy. ‘Ongoing Assessment of PIP Results. (a) All PIPs will stay on the PEC’s agenda and be periodically assessed by the PEC so the PEC can determine whether any modifications to the PIP are appropriate. Such modifications may include, but are not limited to, additional education, monitoring requirements, or a decision that the elements of the PIP have been satisfied and no additional action is needed. The PEC will obtain input from the Practitioner before making any modification to a PIP other than a determination that the elements of the PIP have been satisfied. (b) Assessment of the PIP by the PEC will continue until the PEC determines that either: (i) concerns about the Practitioner's practice have been adequately addressed; or (il) the Practitioner is not making reasonable progress toward completion of the PIP in a timely manner, in which case the PEC shall refer the matter to the Medical Executive Committee for its independent review pursuant to the Medical Staff Credentials Policy. (c) The PEC will communicate with the Practitioner: (i) periodically regarding the Practitioner's progress under the PIP; and to any referral of the matter to the Medical Executive Committee. Reporting Obligations. Most PIPs that are developed by the PEC will not require a report to any state licensing board or to the National Practitioner Data Bank. However, the PEC must assess this reporting issue with each PIP, If the PEC determines that any element of a PIP must be reported, the resulting report will 10Proposed Poli (6) 7 es (Attachment No. 2) - Page 121 of 231 be shared with the Practitioner first. The report will explicitly state that the Hospital does not consider the PIP to be a disciplinary matter and, to the extent applicable, that the Practitioner is working constructively with the PEC to address the issues identified and to improve the care provided, Participation in PiPs by Partners. Consistent with the conflict of interest guidelines set forth in this Policy, partners and other individuals who are affiliated in practice with the Practitioner may participate in PIPs through chart review and monitoring, proctoring, and providing second opinions, but may not be the sole reviewers. In any such instance, these individuals shall comply with the standard procedures that apply to all other individuals who participate in the PPE process, such as the use of Hospital forms and the requirements related to confidentiality. PIP Options. A PIP may include, but is not limited to, the following (used individually or in combination): (a) Additional Education/CME which means that, within a specified period of time, the Practitioner must arrange for education or CME of a duration and type specified by the PEC. The educational activity/program may be chosen by the PEC or by the Practitioner. If the activity/program is, chosen by the Practitioner, it must be approved by the PEC. If necessary, the Practitioner may be asked to voluntarily refrain from exercising all or some of his or her Clinical Privileges or may be granted an educational leave of absence while undertaking such additional education. (b) Prospective Monitoring which means that a certain number of the Practitioner's future cases of a particular type will be subject to a focused review (e.g, review of the next 10 similar cases performed or managed by the Practitioner). (c]__ Indicators Checklist which means that the Practitioner must (i) research the medical literature and government publications; (i) identify evidence-based guidelines that address when a test or procedure is medically-indicated; and (ii) prepare a checklist, flow chart, or similar document that can be used to document in the medical record the medical necessity and appropriateness of a test or procedure for a specific patient. (4) Second Opinions/Consultations which means that before the Practitioner proceeds with a particular treatment plan or procedure, the Practitioner must obtain a second opinion or consultation from a Medical Staff Member or other Practitioner who has been approved by the PEC. If there is any disagreement about the proper course of treatment, the Practitioner must discuss the matter further with individuals identified by the PEC before proceeding further. The Practitioner providing the second opinion/consultation must complete a Second Opinion/Consultation Report form for each case, which shall be reviewed by the PEC. aProposed Policies (Attachment No. 2) - Page 122 of 231 e) (f (e) (hy “ Concurrent Proctoring which means that a certain number of the Practitioner's future cases of a particular type (e.g., the Practitioner's next five vascular cases) must be personally proctored by a Medical Staff ‘Member or other Practitioner who has been approved by the PEC, or by another appropriately qualified individual (for example, a physician external to the organization), as approved by the PEC. The proctor must be present during the relevant portions of the operative procedure or must personally assess the patient and be available throughout the course of treatment. Proctors must complete the appropriate review form, which shall be reviewed by the PEC. Participation in a Formal Evaluation/Assessment Program which means that, within a specified period of time, the Practitioner must enroll in a program approved by the PEC that is designed to identify specific deficiencies, if any, in the Practitioner's clinical practice. The Practitioner ‘must then complete the assessment program within another specified time period. The Practitioner must execute a release to allow the PEC to communicate information to, and receive information from, the selected assessment program. If necessary, the Practitioner may be asked to voluntarily refrain from exercising all or some of his or her Clinical Privileges or may be granted an educational leave of absence while undertaking such formal assessment. Additional Training which means that, within a specified period of time, the Practitioner must complete additional training in a program approved by the PEC to address any identified deficiencies in his or her practice. ‘The Practitioner must execute a release to allow the PEC to communicate information to, and receive information from, the selected program. The Practitioner must successfully complete the training within another specified period of time. The director of the training program or appropriate supervisor must provide an assessment and evaluation of the Practitioner's current competence, skill, judgment, and technique to the PEC. If necessary, the Practitioner may be asked to voluntarily refrain from exercising all or some of his or her Clinical Privileges or may be granted an educational leave of absence while undertaking such additional training. Educational Leave of Absence or Determination to Voluntarily Refrain from Practicing during the PPE Process which means that the Practitioner voluntarily agrees to a leave of absence ("LOA") or to temporarily refrain from some or all clinical practice while the PPE process continues. During the LOA or the period of refraining, a further assessment of the issues will be conducted or the Practitioner will complete an education/training program of a duration and type specified by the PEC. Other elements not specifically listed may be included in a PIP. The PEC has wide latitude to tailor PIPs to the specific concerns identified, always 2Proposed Policies (Attachment No. 2) - Page 123 of 231 with the objective of helping the Practitioner to improve his or her clinical practice and to protect patients. ‘Additional guidance regarding PIP options and implementation issues is found in Appendix B. 5. STEP-BY-STEP PROCESS. This Section describes each step in the PPE process. S.A General Principles. (1) Time Frames for Review. (a) (b) (C) (a) fe) General. The time frames specified in this Section are provided only as guidelines. However, all participants in the process shall use their best efforts to adhere to these guidelines, withthe goal of completing reviews, {rom initial identification to final disposition, within ninety (90) Days. Pre-Determined Reviewers and Assigned Reviewers. Pre-Determined Reviewers and Assigned Reviewers are expected to submit completed review forms to the Clinical Specialty Reviewer, Leadership Council, or the PEC, depending on who assigned the review, within fourteen (14) Days of the review being assigned, Clinical Specialty Reviewers. Clinical Specialty Reviewers are expected to complete their reviews within fourteen (14) Days of the review being assigned to them or within fourteen (14) Days of the Clinical Specialty, Reviewer's receipt of the findings of a Pre-Determined Reviewer or ‘Assigned Reviewer, whichever is later. Leadership Council. The Leadership Council is expected to conduct its review and arrive at a determination or intervention within thirty (30) Days. External Reviewers. If an external review is sought pursuant to Section 6.C of this Policy, those involved will use their reasonable efforts to take the steps needed to have the report returned within thirty (30) Days of the decision to seek the external review (e.g., by ensuring that relevant information is provided promptly to the external reviewer, and that the contract with the external reviewer includes an appropriate deadline for the review). (2) Request for Additional Information or put. At any point in the process outlined in this Section, information or input may be requested from the Practitioner whose care is being reviewed as described in Section 3 of this Policy, or from any other Practitioner or Hospital employee with personal knowledge of the matter. (8) No Further Review or Action Required. \f, at any point in this process, a determination is made that there are no clinical issues or concerns presented in 13Proposed Policies (Attachment No, 2) - Page 124 of 231 (4) (5) (6) the case that require further review or action, the matter shall be closed. A report of this determination shall be made to the PEC. If information was sought from the Practitioner involved, the Practitioner shall also be notified of the determination Exemplary Care. |f the Leadership Council or PEC determines that a Practitioner provided exemplary care in a case under review, the Practitioner should be sent a letter recognizing such efforts. Referral to the Medical Executive Committee. (a) Referral by the Leadership Council or PEC. The Leadership Council or PEC may refer a matter to the Medical Executive Committee if: (i) it determines that a PIP may not be adequate to address the issues identified; (ii) the individual refuses to participate in a PIP developed by the PEC; (ili) the Practitioner fails to abide by a PIP; or (iv) the Practitioner falls to make reasonable and sufficient progress ‘on completing a PIP. (b) Pursuant to the Credentials Policy. This Policy outlines collegial and progressive steps that can be taken to address clinical concerns about a Practitioner. However, a single incident or pattern of care may be of such concern that more significant action is required. Therefore, nothing in this Policy precludes an immediate referral of a matter to the Medical Executive Committee pursuant to the Credentials Policy when deemed necessary under the circumstances. (0) Notice of Referral, The Practitioner shall be notified of any referral to the Medical Executive Committee. (4) Review by Medical Executive Committee. The Medical Executive Committee shall conduct its review in accordance with the Credentials, Policy. Role of Department Chairs in PPE Process. Active participation of Department Chairs is an essential element of an effective PPE process, Even if a Department Chair does not serve as the Clinical Specialty Reviewer under this Policy, the Department Chair nonetheless plays an important role in the PPE process by: {a) overseeing the Department's development of specialty-specific triggers for reviews under this Policy: 4Proposed Policies (Attachment No. 2) - Page 125 of 231 (b) ( (a) e) G) () participating with the Leadership Council and the PEC in Collegial Interventions with Department members; advising the PEC in the development of effective PIPs for Department members and assisting in their implementation; reviewing copies of Informational Letters, Educational Letters, follow-up letters to Collegial Intervention, and composite reports of cases of Department members reviewed through the process. If the Department Chair has any concern regarding the disposition of a case involving a member of the Department, the Chairperson shall document those concerns and forward them to the PEC Chairperson for review under this, Policy; consulting with the Leadership Council regarding the selection of one or ‘more Clinical Specialty Reviewers and Pre-Determined Reviewers for the Department; recommending to the PEC in writing, through the PEC Chair, ‘modifications to make the PPE process more effective and efficient; and working with PPE Support Staff to present educational case review sessions as described more fully in Section 6.G of this Policy. 5.B PPE Support Staff. ay Review. All cases or issues identified for PPE shall be referred to the PPE Support Staff, who will log the matter in some manner that facilitates the subsequent tracking and analysis of the case (e.g., a confidential database or spreadsheet). All family members and/or non-provider staff must sign and date the Acknowledge of Purpose of Interview Form. The PPE Support Staff will then review the referral, with such reviews to include, as necessary, the following: (a) (b) {o) (a) (e) the relevant medical record; interviews with, and information from Hospital employees, Practitioners, patients, family, visitors, and others who may have relevant information, including the Practitioner’s employer if that Practitioner is employed by the Hospital or a Hospital-related entity; consultation with relevant Medical Staff or Hospital personnel; other relevant documentation; and the Practitioner's Professional Practice Evaluation history. 15Proposed Policies (Attachment No. 2) - Page 126 of 231 @ 3) a) Determination. After conducting their review, the PPE Support Staff (in consultation with the appropriate Clinical Specialty Reviewer, PEC Chair, or Chief Medical Officer when necessary) may: {a) determine that no further review is required and close the case; (b) send an Informational Letter as described in Section 4.A of this Policy; or (c) determine that further physician review is required. Preparation of Case for Physician Review. The PPE Support Staff shall prepare ‘cases that require physician review. Preparation of the case may include, as appropriate, the following: (a) completion of the appropriate portions of the applicable case review form; (b) as needed, modifying the case review form to reflect specialty-specific issues, as directed by a Clinical Specialty Reviewer, PEC Chair, or Chief Medical Officer; (c)___ preparation of a time line or summary of the care provided; (4) identification of relevant patient care protocols or guidelines; and (e) identification of relevant literature. Referral of Case to Leadership Council or Clinical Specialty Reviewer. {a) Cases shall be referred to the Leadership Council if they are administratively complex as described in this Section or if the PPE Support, Staff, in consultation with the appropriate Clinical Specialty Reviewer, PEC Chair, or Chief Medical Officer, determines that review by the Leadership Council would be appropriate. Administratively complex cases are defined as those: (1) that require immediate or expedited revie\ (2) that involve Practitioners from two or more specialties or Departments; (3) thatinvolve the Clinical Specialty Reviewer who would otherwise bbe expected to review the case; (4) that involve professional conduct; (5) that may involve a Practitioner health issue; 16Proposed Policies (Attachment No. 2) - Page 127 of 231 (6) that involve a refusal to cooperate with utilization oversight activities; (7) for which there are limited reviewers with the necessary clinical expertise; (8) where there is a trend or pattern of Informational Letters as described in Section 4.4 of this Policy; (9) where a pattern of clinical care appears to have developed despite prior attempts at Collegial Intervention/education; or (10) where a Performance Improvement Plan is currently in effect, or where prior participation in a Performance Improvement Plan does not seem to have addressed identified concerns. {) All other cases shall be referred to the appropriate Clinical Specialty Reviewer. 5.C Leadership Council. (2) Review. The Leadership Council shall review all matters referred to it, including all supporting documentation assembled by the PPE Support Staff. Based on its preliminary review, the Leadership Council shall determine whether any additional clinical expertise is needed fort to make an appropriate determination or intervention. If additional clinical expertise is needed, the Leadership Council may assign the review to one or more of the following, who shall evaluate the care provided, complete an appropriate case review form, and report their findings back to the Leadership Council (a) a Clinical Specialty Reviewer; (b) a Pre-betermined Reviewer; (c) an Assigned Reviewer; (d)_acommittee composed of such Practitioners; or (e)_anexternal eviewer, in accordance with Section 6.C ofthis Policy. The Leadership Council will then assess the matter and document its findings on the Leadership Council Case Review Form. (2) Determinations and interventions. ased on its own review and the findings of the other reviewers, if any, the Leadership Council may: v7Proposed Policies (Attachment No. 2) - Page 128 of 231 (a) determine that no further review or action is required; {b) send an Educational Letter; (c) conduct or facilitate a Collegial Intervention with the Practitioner; (d) refer the matter to one of the following for review and disposition: (i) PeC;or (ii) Medical Executive Committee; (e) address the matter through the Medical Staff Professionalism Policy of, in conjunction with the Health and Wellness Committee, through the Practitioner Health Policy; or (f) refer the matter for review under the appropriate Hospital or Medical Staff policy. 5.0 Clinical Specialty Reviewers. (1) Review. When a matter is referred to a Clinical Specialty Reviewer, the Clinical Specialty Reviewer shall either: (2) review it personally and complete the CSR Case Review Form; or (b) assign the review to any of the following, who shall evaluate the care provided, complete the PDR, AR, Ad Hoc Committee Case Review Form, and report his or her findings back to the Clinical Specialty Reviewer: (i) a Pre-Determined Reviewer; (ii) an Assigned Reviewer; or (iii) acommittee composed of such Practitioners. In all cases, Clinical Specialty Reviewers remain responsible for completing the CSR Case Review Form, (2) Reports. Clinical Specialty Reviewers shall report their findings to the Leaders! Council for determination if that committee requested the review. Otherwise, Clinical Specialty Reviewers shall report their findings to the PEC for determination, 5.E PEC. (1) Review of Prior Determinations. The PEC shall review reports from the PPE Support Staff and the Leadership Council for all cases where it was determined 18Proposed Policies (Attachment No. 2) - Page 129 of 231 2) that (i) no further review or action was required; or (ii) an Educational Letter or Collegial Intervention was appropriate to address the issues presented, If the PEC has concerns about any such determination, it may: @ (b) send the matter back to the Leadership Council with its questions or concerns and ask that the matter be reconsidered and findings reported back to it within fourteen (14) Days; or review the matter itself. Cases Referred to the PEC for Further Review. fa) (b) Review. The PEC shall consider review forms, supporting documentation, findings, and recommendations for cases referred to it by a Clinical Specialty Reviewer or the Leadership Council. The PEC may request that fone or more individuals involved in the initial review of a case attend the PEC meeting and present the case to the committee. Based on its review, the PEC shall determine whether any additional clinical expertise is needed to adequately identify and address concerns raised in the case. If additional clinical expertise is needed, the PEC may: (i) invite a specialist with the appropriate clinical expertise to attend ‘a PEC meeting as a guest, without vote, to assist the PEC in its review of issues, determinations, and interventions; (ii) assign the review to any Practitioner on the Medical Staff with the appropriate clinical expertise (e.g., a Clinical Specialty Reviewer, Pre-Determined Reviewer, or Assigned Reviewer); appoint a committee composed of such Practitioners; (iv) request @ department chair or committee or a Physician representative of the Quality and Patient Safety Committee to provide input; or (¥) arrange for an external review in accordance with Section 6.C of this Policy. Determinations and interventions. Based on its review ofall information obtained, including input from the Practitioner as described in Section 3 of this Policy, the PEC may: (i) determine that no further review or action is required; (i) send an Educational Letter; (ili) conduct or facilitate a Collegial Intervention with the Practitioner; 196. Proposed Policies (Attachment No. 2) - Page 130 of 231 (iv) develop a Performance Improvement Plan; (v) refer the matter to the Leadership Council; or (vi) refer the matter to the Medical Executive Committee. PRINCIPLES OF REVIEW AND EVALUATION 6A 68 6c Incomplete Medical Records. One of the objectives of this Policy is to review matters and provide feedback to Practitioners in a timely manner. Therefore, ita matter referred for review involves a medical record that is incomplete, the PPE Support Staff shall notify the Practitioner that the case has been referred for evaluation and that the medical record must be completed within ten (10) Days. If the medical record is not completed within ten (10) Days, the Practitioner will be required to attend a meeting of the Leadership Council to explain why the medical record ‘was not completed. Failure of the individual to either attend this meeting or complete the medical record in question prior to that meeting will result in the Automatic Relinquishment of the Practitioner's Clinical Privileges until the medical record is completed. if the Practitioner fils to complete the medical record within thirty (30) Days of the Automatic Relinquishment, the Practitioner's Medical Staff Membership and Clinical Privileges will be deemed to have been Automatically Resigned. (See Section 1. for additional information about Automatic Relinquishment/Resignation.) ‘The ten (10}-Day time frame set forth in this Section applies only to medical records that are necessary for a review being conducted pursuant to this Policy. The time frame set forth in this Section supersedes any other time frames for the completion of medical records as may be set forth in the Medical Staff Bylaws, Rules and Regulations, or other policy. ‘The Leadership Council may extend any time frame set forth in this section and establish a new deadline, if it determines that a Practitioner would be unable to comply due to: (1) illness; (2) previously scheduled travel; or (3) other extenuating circumstances. Forms. The PEC shall approve forms to implement this Policy. Such forms shall be developed and maintained by the PPE Support Staff, unless the PEC directs that another office or individual develop and maintain specific forms. Individuals performing a function pursuant to this Policy shall use the form currently approved by the PEC for that function. External Reviews. An external review may be appropriate if: (1) there are ambiguous or conflicting findings by internal reviewers; (2) the clinical expertise needed to conduct a review is not available on the Medical Staff; or (3) an outside review is advisable to prevent allegations of bias, even if unfounded. 206D ee oF 6G Proposed Policies (Attachment No. 2) - Page 131 of 231 {An external review may be arranged by the Leadership Council or PEC, in consultation with the Chief Executive Officer or Chief Medical Officer. Those arranging for an external review shall first seek to identify an appropriate internal expert within HCA, such as a specialist at another HCA hospital. If decision is made to obtain an external review, the Practitioner involved shall be notified of that decision and the nature of the external Findings and Recommendations Supported by Evidence-Based Research/Clinical Protocols or Guidelines. Whenever possible, the findings of reviewers and the PEC shall be supported by evidence-based research, clinical protocols, or guidelines. ‘System Process Issues. Quality of care and patient safety depend on many factors in addition to Practitioner performance. If system processes or procedures that may have adversely affected, or could adversely affect, outcomes or patient safety are identified through the process outlined in this Policy, the issue shall be referred to the appropriate Hospital department or committee and/or the PPE Support Staff. The referral shall be reported to the PEC and will stay on the PEC’s agenda until it determines, based on reports from the Hospital department or individuals charged with addressing the system issue, that the issue has been resolved. Tracking of Reviews. The PPE Support Staff shall track the processing and disposition of matters reviewed pursuant to this Policy. The Clinical Specialty Reviewers, Leadership Council, and PEC shall promptly notify the PPE Support Staff of their determinations, interventions, and referrals. Educational Sessions/Dissemination of Educational Information. (1) General Principles. (a) Educational sessions as described in this section, as well as the dissemination of educational information through other mechanisms, are integral parts of the peer review process and assist Practitioners in continuously improving the quality and safety of the care they provide. These activities will be conducted in a manner consistent with their confidential and privileged status under the North Carolina peer review protection law and any other applicable federal or state law. {b) Cases that reflect exemplary care, unusual clinical facts, or would be of educational value for any other reason, shall be referred to the appropriate department chair for discussion during an educational session or for the dissemination of “lessons learned” in some other () Medical staff Members, Practitioners, residents, medical students, and appropriate Hospital personnel are encouraged to participate in educational sessions in order to assess and continuously improve the care they provide, 2Proposed Policies (Attachment No. 2) - Page 132 of 231 @) (a) Educational sessions may also serve as a triage mechanism for the review process set forth in this Policy in certain circumstances. If any case is. identified in an educational session that: (may raise questions or concerns with the clinical practice or professional conduct of an individual Practitioner; and (ii) has not already been reviewed as part of the process set forth in this Policy; the case should be referred for review in accordance with this Policy to evaluate whether the potential concern has merit, and to address any concerns that exist. Following the conclusion of that review process, the case may be referred back to the department chair for purposes of conducting an educational session as described in this section. Rules for Educational Sessions. (a) (b) ic) (a) te) (A (e) For purposes of this section, “educational sessions” include morbidity and mortality conferences and any other session conducted in a manner, designed to promote quality assessment and improvement. Educational sessions will be supported and facilitated by the PPE Support Staff, whenever possible. ‘Any Practitioner whose care of a patient will be reviewed in a session shall be notified at least seven (7) Days prior to the educational session. Such Practitioners shall be encouraged to attend and participate in the discussion, Information identifying specific Practitioners shall be removed prior to any presentation, unless the Practitioner requests otherwise or it is impossible to de-identify the information, Al individuals who attend routine educational sessions that occur in designated specialty areas shall sign a Confidentiality Agreement annually All attendees at an educational session will also be required to sign 2 confidentiality reminder for each session (e.g., as part of the sign-in process}. In addition, a confidentiality reminder should be made verbally at the beginning of each session. Minutes are not required to be kept for educational sessions, but each session will have a standardized agenda that includes: 26H Proposed Policies (Attachment No. 2) - Page 133 of 231 ‘=a header in large, bold print identifying the agenda as a “Confidential Peer Review Document,” and a reference to the North Carolina peer review statute (Patient Safety and Quality Improvement Act (42 CFR Part 3) and NC General Statute 90- 21.22A, NCG.S. 131-76, NC G.S. 131-95 and NC G.S. 1316-97.2, as well as other federal laws); © the date of the educational session; + cases reviewed (i., medical record numbers); and © participants involved, All such agendas shall be filed securely in confidential PPE Support Staff files Confidentiality. Maintaining confidentiality is a fundamental and essential element of an effective professional practice evaluation process. Therefore, in addition to the Confidentiality and Peer Review Protection provisions set forth in the Medical Staff Credentials Policy (including Section 1.D. of that Policy), the following terms shall apply’ a) (2) Documentation. All documentation that is prepared in accordance with this Policy shall be maintained in appropriate Medical Staff files and subject to the protections and restrictions on access and disclosure that apply to Professional Practice Evaluation and Professional Review Activities (as set forth in the Credentials Policy and other relevant Hospital and Medical Staff policy). PPE Communications. Communications among those participating in the PPE processes, including communications with reviewers and the individual Practitioner involved, should be conducted in a manner reasonably calculated to assure privacy. {a) Telephone and in-person conversations shall take place in private at appropriate times and locations to minimize the risk of a breach of confidentiality (e.g., conversations should not be held in Hospital hrallways). (b) Hospital e-mail may be used to communicate between individuals participating in the Professional Practice Evaluation process, including with those reviewing a case and with the Practitioner whose care is being reviewed. For all e-mails, a standard convention, such as “Confidential PPE Communication,” shall be utilized in the subject line of such e-mail Except as set forth below, personal e-mail accounts shall not be used other than to direct recipients to check their Hospital e-mail. If an individual who is participating in a review under this Policy does not have ‘a Hospital e-mail account, e-mails may be sent to a private account, but 23Proposed Policies (Attachment No. 2) - Page 134 of 231 ‘only if: (i) the e-mail is encrypted; and (I) the individual is the only person ‘who has access to the private account. Notwithstanding this subsection, e-mail should not be utilized to present a PIP to a Practitioner. As noted previously in this Policy, one or more members of the PEC should personally discuss the PIP with the Practitioner and present a copy to the Practitioner in person. (c)__Allcorrespondence (whether paper or electronic) shall be conspicuously marked with the notation “Confidential Peer Review,” “Confidential PPE Communication” or words to that effect. (d) Before any correspondence is sent to a Practitioner whose care is being reviewed (whether paper or electronic), a text message may be sent ora phone call may be attempted as a courtesy to alert the Practitioner that the correspondence is being sent and how it will be sent. The intent of any such text message or phone call is to make the Practitioner aware of the correspondence and avoid any deadline being missed. Whenever such a text message or phone call is utilized, a notation to that effect should be made on the copy of the applicable correspondence ‘maintained in the Practitioner's confidential file or in another peer review database. (ce) Ifitis necessary to e-mail medical records or other documents containing a patient’s protected health information, Hospital policies governing compliance with the HIPAA Security Rule shall be followed. (4) Practitioner Under Review. The Practitioner under review must maintain all information related to the review in a strictly confidential manner. The Practitioner may not disclose information to, or discuss it with, anyone outside of the Professional Review Activities of the Hospital and Medical Staff without first obtaining the permission of the Leadership Council, except for any legal counsel ‘who may be advising the Practitioner. 6.1 Conflict of interest Guidelines. To protect the integrity of the review process, all those Involved must be sensitive to potential conflicts of interest. It is also important to recognize that effective peer review involves “peers” and that the PEC does not make any recommendations that would adversely affect the Clinical Privileges of a Practitioner (which is only within the authority of the Medical Executive Committee and Governing. Board). As such, the conflict of interest guidelines outlined in the Medical Staff Credentials Policy shall be used in assessing and resolving any potential conflicts of interest that may arise under this Policy. For reference purposes, those conflict of interest Buidelines are summarized in Appendix C. PROFESSIONAL PRACTICE EVALUATION REPORTS. 7.4 Practitioner Professional Practice Evaluation History Reports. A Practitioner history report showing all cases that have been reviewed for a particular Practitioner within the 24Proposed Policies (Attachment No. 2) - Page 135 of 231 past two years and their dispositions shall be generated for each Practitioner for consideration and evaluation by the appropriate department chair and the Credentials Committee at the time of considering the Practitioner's RRFC and Application for renewal of Membership and/or Clinical Privileges. 7.8 Reports to Medical Executive Committee and Board. The PPE Support Staff shall prepare reports at least annually showing the aggregate number of cases reviewed through the PPE process and the dispositions of those matters. 7.€ Reports on Request. The PPE Support Staff shall prepare reports as requested by the Leadership Council, department chair, PEC, Medical Executive Committee, Hospital ‘management, or the Board. ‘Adopted by the Medical Executive Committee on , 2023. Adopted by the Board on 2023, 25Proposed Policies (Attachment No. 2) - Page 136 of 231 ‘APPENDIX A, PERFORMANCE ISSUES THAT TRIGGER INFORMATIONAL LETTERS. This Appendix lists specific performance issues that can be successfully addressed by Practitioners via Informational Letters as described in Section 4.A of this Policy, rather than a more formal review. More formal review is required if a threshold number indicated below is reached within an OPPE period, or if a pattern or trend of noncompliance with Medical Staff Rules and Regulations or other policies, adopted clinical protocols, or other quality measures is otherwise identified This Appendix may be modified by the PEC at any time, without the need for approval by the Medical Executive Committee or Board. However, notice of any revisions shall be provided by the PEC to the Medical Executive Committee and the Medical Staff. The following may be addressed by Informational Letters: (1) First time violations of: (a) Hospital Health and Safety Guidelines (e.g. mandatory masking during OVID); (b) Rules and Regulations as may be identified by the PEC; (2) First time failure to follow clinical protocol without documentation of MDF; (3) First time failure to complete required documentation components (e.g. procedural consent; Suicide risk ORL) a 2eso01.a 4050-0029-1666, v.2Proposed Policies (Attachment No. 2) - Page 137 of 231 ‘APPENDIX B PERFORMANCE IMPROVEMENT PLAN OPTIONS IMPLEMENTATION ISSUES CHECKLIST ‘TABLE OF CONTENTS PAGE Additional Education/CME.. Pa Prospective Monitoring ea Indicators Checklist 3 Second Opinions/Consultations.... 4 Concurrent Proctoring wrn eter 7 Formal Evaluation/Assessment Program. sen 10 Additional Training.ncmnnn re nu Educational Leave of Absence or Determination to Voluntarily Refrain from Practicing during the PPE Process 2 “Other onsen B Note: Issues related to the development and monitoring of Performance Improvement Plans ("PIPs") are described in Section 4.0 of the PPE Policy. The Implementation Issues Checklists in this Appendix may be used by the PEC to effectuate PIPs. Checklists may be used individually or in combination with one another, depending on the nature of the PIP. A copy of a completed Checklist may be provided to the Practitioner who is subject to the PIP, so that the PEC and the Practitioner have a shared and clear understanding of the elements of the PIP. While Checklists may serve as helpful guidance to the PEC and the Practitioner, there is no requirement that they be used. Failure to use a Checklist or to answer one or more questions on a Checklist will not affect the validity of a PIP.Proposed Policies (Attachment No. 2) - Page 138 of 231 PIP OPTI Additional Education/CME (Wide range of options) ieee Scope of Additional Education/CME Be specific what type? D_Acceptable programs include: PEC approval required before Practitioner enrolls. Program approved! Date of approval: Timeframes Practitioner must enrol by CME must be completed by: Who pays for the CME/course? Practitioner subject to PIP O Medical staff Hospital Combination: Documentation of completion must be submitted to PEC. OD Date submitted ‘Additional Safeguards will the individual be asked to voluntarily refrain from exercising relevant Clinical Privileges until completion of additional ‘education? yes ONo Follow-Up After CME has been completed, how will monitoring be done to be sure that concerns have been addressed/practice has. Improved? (Focused prospective monitoring? Proctoring?)Proposed Policies (Attachment No. 2) - Page 139 of 231 era Ec Prospective Monitoring ‘Scope af Monitoring How many cases are subject to review? (100% focused review of next X cases (e.g,, obstetrical cases, laparoscopic surgery).) 2 What types of cases are subject to review? Based on Practitioner's practice patterns, estimated time for ‘completion of monitoring? bees monitoring include more than review of medical record? Ces CINo If yes, what else does it include? Review to be done: | O Post-discharge During admission Review to be done by: PPE Support Staff Clinical Specialty Reviewer Department Chair Chief Medicol officer {it applicable] Other: ooooo Must Practitioner notify reviewer of cases subject to requirement? (Yes CONo Other options? Documentation of Review General Case Review Form Specific form developed for this review General summary by reviewer Other: coco ‘Results of Monitoring who will review results of monitoring with Practitioner? TD Afier each wise After total of cases subject to review (unless sooner discussions are necessary based on case findings)Proposed Policies (Attachment No. 2) - Page 140 of 231 rae (ee) Indicators Checklist (Research the medical literature, identify evidence-based guidelines addressing when a test or procedure is medically indicated, and develop a Checklist that can be included in the medical record to document medical necessity and appropriateness.) Completion of the Checklists OCheckists will be developed for the following procedures (in order of priority, if more than one): The Practitioner will consult with the following subject matter experts in developing the Checklists: o ‘The following PEC member wil serve as the point of contact to assist the Practitioner with questions about the Checklists (The first draft of the Checklists will be submitted to the PEC by: ( The PEC will submit the Checklists to the following Individuals/eommittees for their review and comment, prior to final approval by the PEC: The target date for final completion of the Checklists is ‘Additional Safeguards C1 Until the Checklists have been approved, what steps will be taken to ‘monitor the medical necessity/appropriateness of the Practitioner's tests/procedures? o Will the individual be asked to voluntarily refrain from exercising relevant Clinical Privileges until the Checklists have been approved? yes ONo Follow-Up Once Checklists are completed and being used to document medical necessity/appropriateness of the Practitioner's procedures/tests for individual patients, describe the monitoring of completed Checklists that will occur (who will moniter, how often, and who will discuss with Practitioner):Proposed Policies (Attachment No. 2) - Page 141 of 231 PIP OPTION (eer Second Opinions/ Scope cf Second Opinons/onsaatons boos Catia iat types of cases are subject to the second opinions/consultaions (Before the Practitioner proceeds with a particular treatment plan or procedure, he or she Q__ How many cases are subject to the second opinions/consultations? obtains a second opinion or consultation.) (This is not a “restriction” | Based on practice patterns, estimated time to complete the second of privileges that ‘opinions/consultations? triggers a hearing and reporting, if implemented correctly.) Must consultant evaluate patient in person prior to treatment/procedure? yes ONo ‘Responsibilities of Practitioner Notify consultant when applicable patient is admitted or procedure Is scheduled and ensure that a information necessary to provide Consultation is available in the medical record (H&P, results of diagnostic tests, etc). What time frame for notice to consultant is practical and reasonable (e.g, two days prior to scheduled, elective procedure)? (2 Hf consultant must evaluate patient prior to treatment, inform. patient that consultant will be reviewing medical record and wil examine patient.Proposed Policies (Attachment No. 2) - Page 142 of 231 ere (Ieee Second Opinions/Consultations (Before the Practitioner proceeds with a particular treatment plan or procedure, he or she obtains a second opinion or consultation.) (This is not a “restriction” of privileges that triggers a hearing and reporting, if implemented correctly.) (cont’d.) | Second Opinions/Consultations Af consultant must evaluate patient prior to treatment, include general progress note in medical record noting that consultant ‘examined patient and discussed findings with Practitioner. a Discuss proposed treatment/procedure with consultant. ‘Qualifications of Consultant Consultant must have Clinial Privileges in Possible candidates include: The following individuals agreed to act as consultants and were approved by the PEC (or designees) on: (date) Responsibilities of Consultant (Information provided by PEC; include discussion of legal protections for consultant.) Review medical record prior to treatment or procedure. D._Evaluate patient prior to treatment or procedure, if applicable. G_iscuss proposed treatment/procedure with physician.| Proposed Policies (Attachment No. 2) - Page 143 of 231 Bryan (Before the Practitioner proceeds with a particular treatment plan or procedure, he or she obtains a second opinion or consultation.) (This is not a “restriction” of privileges that triggers a hearing and reporting, ifimplemented correctly.) (cont’d.) Ices) Complete Second Opinion/Consultation Form and submit to PPE Support Staff (not for inclusion in the medical record). Disagreement Regarding Proposed Treatment/Procedure if consultant and physician disagree regarding proposed treatment/ procedure, consultant notifies one of the following so that an immediate meeting can be scheduled to resolve the disagreement ‘Chief Medical office (applicable) President of the Medica Staff PEC Chair Department Chair Other: ooocoo ‘Compensation for Consultant (consultant cannot bill for consuitation) No compensation, D_ Compensation by: Practitioner subject to PIP O Medical staff Hospital Combination ‘Results of Second Opinion/Consultations Who will review results of second opinion/consultations with Practitioner? After each case 1G _ After total # of cases subject to review (unless sooner discussions are necessary based on case findings) Q_ Include consultants’ reports in Practitioner's quality le Additional Safeguards will Practitioner be removed from some/all on-call responsibilities Luntl the second opinions/consultations are completed? Q1Yes NoPropo d Policies (Attachment No. 2) - Page 144 of 231 Tae ieee Concurrent Proctoring (A certain number of the Practitioner's future cases of a particular type (e.g., vascular cases, management of diabetic patients) must be directly observed.) (This is not a “restriction” of privileges that triggers a hearing and reporting, ifimplemented correctly.) ‘Scope of Proctoring (D What types of cases are subject to proctoring? (2 How many cases are subject to proctoring? Time Frames G_ Based on practice patterns, estimated time to complete the proctoring? Responsibilities of Practitioner Notify proctor when applicable patient is admitted or procedure is scheduled and ensure that all information necessary for proctor to evaluate case Is available in the medical record (H&P; results of diagnostic tests, etc) What time frame for notice to proctor is practical and reasonable (e.g,, two days prior to scheduled, elective procedure)? Procedures: inform patient that proctor will be present during procedure, may examine patient and may participate in procedure, and document patient's consent on informed consent form. Medical: if proctor will personally assess patient or will participate in patient's care, discuss with patient prior to proctor’s examination. Include general progress note in medical record noting that proctor ‘examined patient and discussed findings with Practitioner, if applicable. Agree that proctor has authority to intervene, if necessary. Discuss treatment/procedure with proctor.Proposed Policies (Attachment No. 2) - Page 145 of 231 eran MEI Qualifications of Proctor (PEC must approve) Concurrent Proctor must have Clinical Privileges in Proctoring (if proctor is not Member of Medical Staff, eredentil ond arant temporary privileges.) (A certain number of the | a Sees ae Practitioner's future | cases of a particular type | (e.g., vascular cases, management of diabetic | The following individuals agreed to act as proctors and were approved by the patients) must be PEC (or designees) on directly observed.) (date) (This is not a “restriction” of privileges that ‘esponsbities of Proctor (information provided by PEC; include discussion triggers a hearing of legal protections for proctor) and reporting, if implemented Review medical record and: correctly.) Procedure: Be present for the relevant portions of the procedure and be available post-op if complications arise. (cont’d.) Medical: Be available during course of treatment to discuss treatment plan, orders, lab results, discharge planning, etc, and personally assess, | patient, if necessary. DIntervene in care f necessary to protect patient and document such Intervention appropriately in medical record Discuss treatment plan/procedure with Practitioner. Document review as indicated below and submit to PPE Support Staff Documentation of Review (not for inclusion in the medical record) General Case Review Form Specific form developed for this PIP otherProposed Policies (Attachment No. 2) - Page 146 of 231 Tan eee Concurrent Proctoring (A certain number of the Practitioner's future cases of a particular type (e.g., vascular cases; | management of diabetic patients) must be directly observed.) (This is not a “restriction” of privileges that triggers a hearing and reporting, ifimplemented correctly.) (cont’d.) Compensation for Proctor (proctor cannot bill for review of medical record or ‘assessment of patient and cannot act as first assistant) O_ Nocompensation O._Compensation by: Practitioner subject to PIP ‘Medical Staff Hospital Combination ocoo Results of Proctoring D Whowill review results of proctoring with Practitioner? After each case _Ater total # of cases subject to review (unless sooner discussions are necessary based on case findings) 1D. Include proctor reports in Practitioner's quality file Additional Safeguards will Practitioner be removed from some/all on-call responsibilities until proctoring is completed? ClYes O1NoProposed Policies (Attachment No. 2) - Page 147 of 231 eT IMPLEMENTATION ISSUES Formal Evaluation/ Sites of oe lar Airset ron came area ceptable programs include: (Onsite multiple-day programs that may PEC approval required before Practitioner enrolls include formal testing, Program approves: simulated patient Date of approval: ccocotinters care (2 Who pays forthe evaluation/assessment? review.) Practitioner subject to PIP O Medical statt Hospital Combination: Practitioner's Responsibilities Sign release allowing PEC to provide Information to program if necessary) ‘and program to provide report of assessment and evaluation to PEC. 1D. Enrollin program by: Complete program by: ‘Additional Safeguards O. Willthe individual be asked to voluntarily refrain from exercising relevant Clinical Privileges until completion of evaluation/assessment program? yes No will practitioner be removed from some/sll on-call responsibilities until ‘completion of evaluation/assessment program? (1 Yes C1No Follow-Up Based on results of assessment, what additional interventions are necessary, if any? o How will monitoring ater assessment program/any additional interventions be conducted to be sure that concerns have been addressed/practice has improved? (Focused prospective review? Proctoring?) 10Proposed Policies (Attachment No. 2) - Page 148 of 231 Bxrae Weed Additional Training Boe ot Aaa e specfic~ what type? (Wide range of options from hands-on CME to simulation to repeat of | Acceptable programs include: residency or fellowship.) PEC approval required before Practitioner enrolls. Program approved Date of approval: Who pays forthe training? Practitioner subject to PIP Medical staff Hospital Combinatio Practitioner's Responsibilities Sign release allowing PEC to provide information to training program {if necessary) and program to provide detailed ‘evaluation/assessment to PEC before resuming practice. Enroll in program by: Complete program by: ‘Additional Safeguards Will the individual be asked to voluntarily refrain from exercising relevant Clinical Privileges until completion of additional training? yes ONo 2 Will Practitioner be removed from some/all on-call responsibilities ‘ntl completion of additional training? G1Yes C1No will LOA be used for the additional training? C1Yes C1 No. Follow-Up After additional training is completed, how will monitoring be conducted to be sure that concerns have been addressed/practice | has improved? (Focused prospective review? Proctoring?) uwProposed Policies (Attachment No. 2) - Page 149 of 231 xa eed Educational Leave of Absence | 9 Who may grant a formal LOA (it applicable? (Review Credentials | 7 Policy) | Determination to Voluntarily Refrain from Practicing during the PPE Process Will the individual be asked to voluntarily refrain from exercising relevant Clinical Privileges while the PPE process continues? yes ONo Specify the conditions for reinstatement from the LOA or for the resumption of practice following the decision to voluntarily refrain: Q_ What happens ifthe Practitioner agrees to LOA or to voluntarily refrain, but: does not return to practice at the Hospital? Will this be considered resignation in return for not conducting an investigation and thus be reportable? yes ONo moves practice across town? Must Practitioner notify other Hospital of educational leave of absence of the determination to voluntarily refrain from practicing? yes ONoProposed Policies (Attachment No. 2) - Page 150 of 231 yaa Mice “other” Wide latitude to utilize other | ideas as part of PIP, tailored to specific concerns. Examples: ‘+ Participate in an educational session at section or Department ‘meeting and assess colleagues’ ‘approach to case. + Study issue and present grand rounds. + Design and use informed consent {forms approved by PEC. *+ Design and use indication forms ‘approved by PEC. + Limit inpatient census. + Limit number of procedures in any ‘one day/black schedule. + No elective procedures to be performed after__ p.m. + Allpatient rounds done by certain time of day ~ timely orders, tests, Iength of stay concerns. + Personally see each patient prior to procedure (rather than using PA, NP, or APRN). * Personally round on patients ~ cannot rely solely on PA, NP, or APRN. + Utilize individuals from other specialties to assist in PIPS (e.9., cardiologist experiencing difficulties with TEE technical complications mentored by anesthesiologist).Proposed Policies (Attachment No. 2) - Page 151 of 231 ‘APPENDIX C CONFLICT OF INTEREST GUIDELINES | a oe Levels of Participation - _ Potential a Committee Member sean Confers | Provide | Reviewer faring | goard Information | Applicatior redentials | '&2dership 2 | AdHoe Panel | patcation/ | Credentiais | coinct” | PEC | ME’ | snvestigating ee N 8 a |r vn | wr Relevant - i 7 - if treatment | ¥** N R R Rik N nia Employment ; | relationship | y Y y Y Y Y ley, with hospital | : _ Significant | finanlal o | 3 Y Y y]r N nor |_telationship J _ | direct : at ve R vn | ow |r | Gosetriens| vy | y | y |_® eee | R History of | come | Y f Y fy fy ori oN Noir Provided under : review (but _ . | ‘ W u) N 2 not subject, af evew) - i fe Reviewed at ea Y y v aie wv [owe tabeatwe | y v v v w jw ie * A *relevant treatment relationship” exist: (1) if the individual participating ina review and the Practitioner are in a curtent patient-physican relationship; or (2) if the patient-physician relationship has terminated but the review process involves the health condition for which the Practitioner sought professional health services. > Hospitals with smaller MECS should evaluate the quorum requifements in the Medical staf Bylaws to determine ifthe recusal of MEC members will make it difficult to obtain a quorum. Ifs0, the Hospital should follow the amendment process In the Medical Staff Bylaws to either: (1) decrease the quorum requirement (e.g, to 25% or 33%); oF (2) adopt language stating: “Once a quorum is established, the business of the ‘meeting may continue and actions taken will be binding regardless of whether any subsequent recusal of members in accordance with the conflict of interest guidelines set forth in the Professional Practice Evaluation Policy (Peer Review) causes the number of individuals present at the meeting to fall below the umber required for a quorum.”Proposed Policies (Attachment No. 2) - Page 152 of 231 An individual may provide information that was not obtained through a treatment relationship. However, an individual may provide information that was obtained through a treatment relationship only after obtaining the Practitioner’s HIPAA-compliant authorization for the disclosure. (green “Y") means the Interested Member may serve in the indicated role; no extra precautions are necessary. {yellow *7") means the Interested Member may generally serve in the indicated role, Itis legally permissible for interested Members to serve in these roles because of the check and balance provided by the multiple levels of review and the fact that the Credentials Committee, Leadership Council, and PEC have no disciplinary authority. In addition, the Chair of the Credentials Committee, Leadership Council, or PEC always has the authority and diseretion to recuse a member in a particular situation if the Chair determines that the Interested Member's presence would inhibit the full and fair discussion of the issue before the committee, skew the recommendation or determination of the committee, or otherwise be unfair to the Practitioner under review. (red “N") means the individual may not serve inthe indicated role. (red *R") means the individual must be recused in accordance with the rules for recusal Rules for Recusal * Interested Members must leave the meeting room prior to the committee's or Board's final deliberation and determination, but may answer questions and provide input before leaving, * fan interested Member is recused on a particular issue, the recusal shall be specifically documented in the minutes. + Whenever possible, an actual or potential conflict should be raised and resolved prior to the meeting by the committee or Board chair, and the Interested Member informed of the recusal determination in advance. * No Medical Staff Member has the RIGHT to demand the recusal of an individual ~ that determination is within the discretion of the Medical Staff Leaders and Hospital Leadership, in accordance with these guidelines. © Voluntarily choosing to refrain from participating in a particular situation is not a finding for an admission of an actual conflict or any improper influence on the process,
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