GENERAL ONGOING PROFESSIONAL PRACTICE EVALUATION ...

GENERAL ONGOING PROFESSIONAL PRACTICE EVALUATIONName: ____________________________________Data source(s)(in addition to credentialing file review)IndicatorAcceptableNeedsImprovementUnacceptableNot Observed/Not ApplicableTRENDPATIENT CARE:1. Clinical Assessment of Patients2. Quality of Patient Management Plans3. Clinical Competence and Judgement4. Appropriate and Timely Use ofConsultants5. Responds to Pages and Concerns;Availability6. Patient/Family Education IncludingDischarge Instructions7. Medication Management8. Supports National Patient Safety GoalsInitiatives9. Admissions and Assigned Level of CareAppropriate10. Follows Accepted ManagementGuidelines/Standards of CareComments:Recommendations:MEDICAL KNOWLEDGE1. Basic Medical Knowledge2. Medical Knowledge – Specialty-Specific3. CME Requirements Satisfied4. Participates Willingly and Effectively inthe Education of Medical Students andResidents1

GENERAL ONGOING PROFESSIONAL PRACTICE EVALUATIONName: ____________________________________AcceptableNeedsImprovementUnacceptableNot Observed/Not ApplicableTREND5. Appropriate use of Laboratory andImaging ServicesComments:Recommendations:INTERPERSONAL ANDCOMMUNICATION SKILLS:1. Relationship with Medical Staff andHospital Staff2. Clarity of Records3. Histories and Physical ExamDocumentation Complete and Timely4. Progress Notes Documentation Completeand Timely5. Collaborates with SBAR Method6. Uses Approved Standardized Orders(When Appropriate)7. Signs Orders in a Timely FashionComments:Recommendations:PROFESSIONALISM:1. Respectful of Others2. Collegial, Courteous, Pleasant, Positivewith all Staff, Patients, and Families3. Compassionate4. Accountable for Personal Behavior andActions5. Maintains Patient Confidentiality6. Maintains Confidentiality in all PeerReview Processes7. Follows Ethical Principles at all Times8. Adheres to the Medical Staff By-Laws,Rules and Regulations, and Policies.2

GENERAL ONGOING PROFESSIONAL PRACTICE EVALUATIONName: ____________________________________9. Quarterly Medical Staff, Committee,Department Meeting Participation andAttendance10. Participates Cooperatively andConstructively in Peer Review Activities,Case Reviews, RCA’s11. Press Ganey Patient Satisfaction ScoresAcceptableNeedsImprovementUnacceptableNot Observed/Not ApplicableTREND12. Follows Admission Processes and PoliciesComments:Recommendations:UTILIZATION MANAGEMENT/QUALITYOF CARE:1. Adjusted LOS2. Maintains Legible Records3. Blood Usage4. Discharge Summaries Complete andTimely5. Re-Admission Rate6. Cooperates with Discharge PlanningProcess; Discharge to Appropriate Level ofCare7. Ancillary Utilization (appropriate SocialService, Respiratory Therapy, PhysicalTherapy)8. Appropriate and Timely Attention toLifesaving Orders/Advance Directives9. Appropriately Completes Imaging andLaboratory Requests/Pre-Authorization10. Appropriate Documentation11. Cooperates With CDI; Query SystemComments:Recommendations:3

GENERAL ONGOING PROFESSIONAL PRACTICE EVALUATIONName: ____________________________________CONDUCT1. Incident Reports2. Unusual Occurrence Reports3. Staff/Patient/Family ComplaintsComments:Recommendations:MORBIDITY & MORTALITYIncluding:“Never Events” as defined by CMS, BCBSM“Sentinel Events” as defined by TJCMedication Errors□ None requiring review Mortalities reviewed: ______________Resuscitations reviewed: _________ Targeted reviews: _______________________________________________________________□ No adverse outcomes □ Medical management appropriate. Noquality issues_______________________________________________________Minor adverse outcomes: ___ Major adverse outcomes: ___Care appropriate: ___ Care appropriate: _________________________________________________________Medical management controversial: ___Medical management inappropriate: ___Comments:Recommendations:FOCUSED REVIEW/ACTIONIncluding:FPPEPEER ReviewsSuspension/Privilege Restrict______________________________________________________________________________________________________________Comments:Recommendations:PHYSICIAN SIGNATURE:______________________________________________________4

GENERAL ONGOING PROFESSIONAL PRACTICE EVALUATIONName: ____________________________________EVALUATION COMPLETED BY: ______________________________________________________Chief Medical Officer______________________________________________________DateEVALUATION REVIEWED BY:_____________________________________________________Department ChairDepartment of _____________________________________________________________________________________________DateEVALUATION APPROVED BY: ______________________________________________________Chief of Staff______________________________________________________DateEVALUATION REVIEWED WITH: ____________________________________________________Practitioner_____________________________________________________Date5