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YNHH

Policy-Focused Professional Practice Evaluation

Purpose

To set forth the policy for conducting focused professional practice evaluation:

(1) when there is concern about a currently privileged practitioner's ability to provide safe, high quality patient care as identified through the peer review/ongoing professional practice review process, or

(2) for the evaluation of privilege specific competence of all new medical staff members and new privileges for existing members of the Medical Staff

Scope

All Members of the Medical Staff and "Affiliated Health Care Professionals"

Policy

It is the Policy of Yale-New Haven Hospital to conduct appropriate monitoring of the care delivered by its Medical Staff and Affiliated Medical Staff and to promote safety and high quality health care for its patients.

The practice of members of the Medical and Affiliated Medical Staff will be monitored on an ongoing basis, consistent with the Policy regarding Peer Review/Ongoing Professional Practice Evaluation. Ongoing evaluation may identify patterns, outcomes, complications or other indicators associated with the practice of a specific individual which suggest the need for focused evaluation in accordance with this policy. Additionally, as of January 2008, privileges of all new members and newly approved privileges for existing members of the Medical Staff will require focused evaluation.

All findings and information associated with any Focused Professional Practice Evaluation shall be considered as confidential and protected under the Connecticut State Statutes regarding peer review activities. (Section 19a-25)

Related Policies

Medical Staff Policy / Proctoring
Medical Staff Policy / Peer Review/Ongoing Professional Practice Evaluation
Medical Staff Policy / Medical Staff Health

Procedure

A. CURRENTLY PRIVILEGED PRACTITIONERS

1. If at any time, concerns are raised relative to a practitioner's current clinical competence, practice behavior and/or ability to perform any of his/her privileges, a period of focused evaluation may be indicated. Examples include, but are not limited to: (1) information obtained from ongoing evaluation/peer review activities; (2) other evidence suggesting that a practitioner's performance does not fall within the accepted practice guidelines or standards of care; and (3) staff or patient/family complaints. A focused review may be triggered by a specific or single incident, a sentinel /adverse event, evidence of trends in clinical practice, or other circumstances indicating that patient safety may be compromised.

2. Such matters shall be brought to a representative of the Institutional Practice Quality and Peer Review Committee (IPQPRC). After consideration of the facts available, the IPQPRC shall designate an individual (i.e. Chief of Staff, Associate Chief of Staff, relevant Department Chief, Section Chief, Director of Quality Improvement) to conduct a focused evaluation as appropriate. Upon review of the findings, the IPQPRC may choose to refer the matter to the Credentials Committee of the Medical Board.

3. Focused evaluation may include, but is not limited to, one or more of the following:

  • Comparison of the practitioner's inpatient and outpatient complications / outcomes related to his/her peers
  • Retrospective or prospective chart review
  • Monitoring of clinical practice patterns
  • Proctoring (See Medical Staff Policy on Proctoring)
  • External Peer Review
  • Simulation
  • Discussion with other individuals involved in the care of the practitioner's patients relative to the substance of the focused review


4. External peer review will be solicited when the IPQPRC determines that an internal review would not be fair and objective when, for example, (1) the case(s) under review is/are not performed by any other member of the Medical Staff; (2) when there is concern regarding competition between the practitioner in question and the other practitioners on the Medical Staff who would be considered appropriate peers; or (3) other circumstances exist that could compromise the review.

5. The period of focused review is time limited. The duration and type of monitoring (see #3 above) required will be dependent upon the nature/severity of the situation under evaluation, the type of privilege(s) in question and the practitioner's overall activity level. The affected practitioner and his/her Chief/Associate Chief/Section Chief are informed of the duration of the review as well as the mechanisms that will be employed during the review.

6. The initial review period may be extended at the discretion of the IPQPRC or its appropriate designee based upon the extent to which sufficient information to evaluate the practitioner's performance has been obtained. Similarly, the initial method of evaluation may be expanded or supplemented with other methods as needed during the initial and any subsequent review periods.

7. Upon completion of the focused evaluation, significant findings shall be reported to the IPQPRC. The IPQPRC shall evaluate the results of the evaluation and make a recommendation. Recommendations may include, but are not limited to, the following:

  • No further action required
  • There are immediate threats to patient safety. In this case, the matter is referred to the Chief of Staff for consideration of summary suspension of relevant privileges, followed by referral to the Credentials Committee for further evaluation as necessary.
  • Impairment is suspected. In this case, the matter is referred to the Medical Staff Health Committee for review.
  • There are training / current competence issues. In this case, the matter is referred to the Credentials Committee for evaluation and subsequent recommendation to the Medical Board.

8. The recommendation of the IPQPRC or Credentials Committee, as applicable, is made to the Medical Board consistent with all other recommendations concerning medical staff status and privilege changes. The practitioner is also notified of the outcome of the evaluation and the requirements, if any, relative to future exercise of the privilege(s) in question.

9. Subsequent review following the completion of proctoring or any training required by the Credentials Committee shall occur to re-evaluate the practitioner's ability to exercise the privileges in question on an independent basis.

10. Any practitioner subject to proctoring, additional training, summary suspension or other limitations on his/her privileges shall be entitled to the Fair Hearing and Appeals process subject to the terms defined in the Medical Staff Bylaws.

B. NEW MEMBERS OF THE MEDICAL STAFF & NEWLY REQUESTED PRIVILEGES

New Members of the Medical Staff

1. A period of focused evaluation is required for all new members of the Medical Staff and is accomplished through review of all hospital-based outpatient procedures and all inpatient admissions. Outpatient and inpatient episodes of care are reviewed by screening all coded medical record descriptors for specific "complication codes" listed in standard coding texts. The physician-specific rate of the codes for all episodes of care is compared to peer physicians from the same specialty or sub-specialty. Focused evaluation for individuals who practice in hospital-based specialties whose performance cannot be measured through the mechanism described above will entail monitoring through appropriate Hospital and Medical Staff Committees.

2. The duration of focused review shall be for a minimum of three months or until at least five episodes of care are available for review. The period of focused evaluation shall not exceed two years, unless extended by practitioner request (see #6 and #7 below). If there are no outliers identified upon the completion of the focused evaluation described in #1, the evaluation shall be deemed complete.

3. If statistical outliers are identified through the evaluation described in #1, focused evaluation shall continue and expand to encompass , but not be limited to, one or more of the following:

  • Retrospective or prospective chart review
  • Prospective monitoring of clinical practice patterns
  • Proctoring
  • External Peer Review
  • Simulation
  • Discussion with other individuals involved in the care of the practitioner's patients

4. Focused evaluation as outlined in #3 above will be conducted by a medical staff leader (Chief, Associate Chief, Section Chief, Associate Section Chief) or a designee of the IPQPRC.

5. If at any time during the focused evaluation a question arises as to the practitioner's competence to exercise the affected privileges and there is concern about imminent threat to patient safety, review by the relevant medical staff leader with input from the Chief of Staff or the Director of Quality Improvement, as applicable, shall occur to determine the appropriateness of continuing to allow the practitioner to exercise the privilege(s) in question. Additional performance monitoring requirements (from #3 above) may be put into place and #6 - #10 as described under "Currently Privileged Practitioners" above will be followed.

6. At the end of the period of focused evaluation described in #1 above, in the event that the practitioner's activity at YNHH has not been sufficient to appropriately evaluate his/her competence either:
a. the practitioner shall voluntarily resign the relevant privilege(s), or
b. the practitioner shall submit a written request for an extension of the period of focused evaluation, or
c. if the practitioner has significant volume of the privileges in question at another local hospital, external peer references specific to the procedures will be obtained

8. In situations in which the practitioner does not voluntarily resign the relevant privilege(s), he/she may request an extension of the focused evaluation period by providing a letter of explanation describing the circumstances suggesting that an extension is appropriate.

The period of focused evaluation for individuals who are approved in advance for a leave of absence shall be automatically extended for the duration of the leave of absence.

Existing Members of the Medical Staff

1. A period of focused evaluation is also required for all existing members of the Medical Staff who have been approved for new privileges. Focused evaluation is accomplished through review of all hospital-based outpatient procedures and all inpatient admissions. Outpatient and inpatient episodes of care are reviewed by screening all coded medical record descriptors for specific "complication codes". The physician-specific rate of the codes for all episodes of care is compared to peer physicians from the same specialty or sub-specialty. Focused evaluation for individuals who practice in hospital-based specialties whose performance cannot be measured through the mechanism described above will entail monitoring through appropriate Hospital and Medical Staff Committees.

2. The duration of focused review shall be for a minimum of three months or until at least five episodes of care are available for review. The period of focused evaluation shall not exceed two years unless extended by practitioner request (see #7 and #8 below). If there are no statistical outliers identified upon the completion of the focused evaluation described in #1, the evaluation period shall be deemed complete.

3. If statistical outliers are identified through the evaluation described in #1, focused evaluation shall continue and expand to encompass, but not be limited to, one or more of the following:

  • Retrospective or prospective chart review
  • Prospective monitoring of clinical practice patterns
  • Proctoring
  • External Peer Review
  • Simulation
  • Discussion with other individuals involved in the care of the practitioner's patients

4. Focused evaluation as outlined in #3 above will be conducted by a medical staff leader (Chief, Associate Chief, Section Chief, Associate Section Chief) or a designee of the IPQPRC.

5. If at any time during the focused evaluation a question arises as to the practitioner's competence to exercise the affected privileges and there is concern about imminent threat to patient safety, review by the relevant medical staff leader with input from the Chief of Staff or the Director of Quality Improvement, as applicable, shall occur to determine the appropriateness of continuing to allow the practitioner to exercise the privilege(s) in question. Additional performance monitoring requirements (from #3 above) may be put into place and #6 - #10 as described under "Currently Privileged Practitioners" above will be followed.

6. At the end of the period of focused evaluation described in #1 above, in the event that the practitioner's activity at YNHH has not been sufficient to appropriately evaluate his/her competence for the relevant privilege(s), either: 

a.  the practitioner shall voluntarily resign the relevant privilege(s), or 
b.  the practitioner shall submit a written request for an extension of the period of focused
evaluation, or
c. if the practitioner has significant volume of the privileges in question at another local hospital, external peer references specific to the procedures will be obtained

7. In situations in which the practitioner does not voluntarily resign the relevant privilege(s), he/she may request an extension of the focused evaluation period by providing a letter of explanation describing the circumstances suggesting that an extension is appropriate.

The period of focused review for individuals who are approved in advance for a leave of absence shall be automatically extended for the duration of the leave of absence.

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