Addendum ADraft 101117

RUTHERFORD REGIONAL MEDICAL CENTER MEDICAL STAFF ADDENDUM A (DRAFT 10-11-17)
ADDENDUM A – PROFESSIONAL PERFORMANCE

REVIEW CRITERIA & QUALITY INDICATORS
This Addendum A is adopted in connection with the Medical Staff Professional Performance Review
Policy (Bylaws Appendix “E”). The definitions and terminologies of the Medical Staff Bylaws and Professional
Performance Review Policy apply to this addendum and proceedings hereunder.
SECTION 1: PURPOSE
This Addendum A defines the type types of data, including review criteria and quality indicators, to be collected
for ongoing and focused professional practice evaluations. This data is used in the assessment of a practitioner’s
or AHP’s clinical competence and professional behavior. Results of professional performance reviews are
considered during credentialing/recredentialing and are used by the Medical Executive Committee and Service
Chiefs to help determine when corrective action or other intervention may be appropriate. The Quality Director
or his/her designee is responsible for coordinating and facilitating review activities and forwarding cases to the
designated Service Chief or his/her designee, as appropriate, per the criteria/indicators for review identified in
this Addendum A chosen by each Service.
This Addendum A is a supplement to the Medical Staff Professional Performance Review Policy (Bylaws
Appendix “E”). It is not intended that this Addendum A supersede any provisions of the Medical Staff Bylaws or
Professional Performance Review Policy.
SECTION 2: ONGOING PROFESSIONAL PRACTICE EVALUATION (OPPE)
2.1 Ongoing Professional Practice Evaluation (OPPE) is a screening process for evaluating all practitioners
and AHPs holding clinical privileges so as to identify those who may be providing an unacceptable
quality of care. Each Service Chief shall maintain and regularly update sets of measures and/or
indicators that serve to screen in an ongoing manner the competence of each of his/her Service members
holding clinical privileges. Furthermore, each Service Chief shall determine the minimum volume of
clinical activity that a member of his/her Service must achieve so as to generate sufficient material data
upon which to evaluate current competence. Services may utilize metrics that are specific to each
practitioner’s or AHP’s scope of practice (e.g. providers who perform consultations and do not provide
daily oversight of patient care may have different metrics than hospitalists). This ongoing process
determines whether additional focused evaluation is warranted, allows potential problems with a
practitioner’s or AHP’s performance to be identified and resolved as soon as possible, and fosters a more
efficient, evidence-based privilege renewal process. The OPPE monitoring and evaluation process is not
considered a restriction or limitation on a practitioner’s or AHP’s exercise of clinical privileges and does
not entitle the practitioner or AHP to the procedural rights afforded by the Medical Staff Fair Hearing
Plan or Medical Staff Bylaws Section 5.4, as applicable.
2.2 As one purpose of OPPE is to determine when greater scrutiny of a practitioner’s or AHP’s activity is
warranted, it utilizes three types of indicators to identify triggers for Focused Professional Performance
Evaluation (FPPE). Furthermore, when possible, these indicators are linked back to one or more of the
six competencies listed in Section 7.1 of the Medical Staff Professional Performance Review Policy
(Bylaws Appendix “E”).
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2.2(a) “Rate Indicators” identify outcomes or process steps that are aggregated for statistical analysis.
They provide insight into the number of events that have occurred compared to number of
opportunities for that event to have occurred. Thus, a rate indicator has a numerator and
denominator and is expressed as a percentage, frequency, average, rank, or ratio. A target range
is established for each rate indicator based on benchmark data or internal targets.
2.2(b) “Rule Indicators” represent standards, generally recognized professional guidelines, or accepted
medical practices where individual variation does not, in and of itself, directly cause adverse
patient outcomes. While the existence of such rules generally implies that non-compliance is a
defect, rare or isolated deviations from such rules may be insignificant and may be justified in
selected cases. A threshold number of violations for each rule, based on the criticality of the rule,
determines whether further follow-up is needed and of what kind.
2.2(c) “Review Indicators” identify significant individual events or situations that require focused
analysis to assess the effectiveness and appropriateness of the care provided. Generally, a review
indicator measures relatively broad outcomes that may or may not relate to practitioner or AHP
performance; it should flag a case, event, or situation for detailed analysis when the actual (or
potential) outcome for the patient is serious and too complex to be understood by measuring
how frequently such an outcome occurs.
2.3 At least annually, each Service Chief shall submit a written report detailing his/her Service’s OPPE
measures/indicators and minimum volume standards (if applicable) to the MEC for its approval.
2.4 No less frequently than every six (6) months, each Service Chief shall monitor performance on these
measures/indicators for each member of his/her Service holding clinical privileges. In performing this
monitoring, the Service Chief shall determine whether the practitioner’s or AHP’s activity is satisfactory
or whether it warrants the initiation of a Triggered FFPE FPPE (see below).
2.4(a) Criteria that would lead the Service Chief to recommend FFPE FPPE include, but shall not be
limited to:
(1) Insufficient clinical activity with regards to one or more specific privileges;
(2) Rate concerns where the practitioner’s or AHP’s performance on standardized metrics
breaches a threshold that is either established prospectively or that stands out
retrospectively when considering the body of work of the Service as a whole;
(3) Rule violations where the practitioner or AHP repeatedly breaches accepted standards of
practice in a manner that cannot be satisfactorily rationalized on clinical grounds; and/or
(4) Review of specific untoward events that generate concerns regarding clinical practice
and any of the six competencies.
2.4(b) If the Service Chief determines that the practitioner’s or AHP’s activity warrants further
evaluation, he/she shall follow the protocol for a Triggered FPPE (see below).
2.5 The Service Chief, assisted by the Quality & Resource Management (QRM) Department, shall make a
written report of each practitioner’s and AHP’s OPPE results at least every six (6) months, or more often
at the Service Chief’s discretion or as requested by the MEC. The Service Chief shall submit copies of
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this report to the MEC, to the practitioner or AHP, and to the Medical Staff Credentialing Office for
placement in the practitioner’s or AHP’s quality file. The Service Chief’s report shall address the
practitioner’s or AHP’s activity data and the practitioner’s or AHP’s performance in each of the six
competencies listed in Section 7.1 of the Medical Staff Professional Performance Review Policy
(Bylaws Appendix “E”). A sample provider performance report format appears in Section 7, below.
2.6 OPPE for Low-Volume Practitioners & AHPs
Due to the nature of certain specialties (e.g. dermatology, rheumatology, or psychiatry) or to the style of
an individual’s particular practice (e.g. splitting his/her patient load amongst two or more facilities), a
practitioner’s or AHP’s volume of clinical activity at the Hospital may be insufficient to be evaluated
effectively by the standard OPPE approach described above. If a practitioner’s or AHP’s activity upon
any routine OPPE review is insufficient to generate enough data to perform an effective evaluation of
ongoing competency, the practitioner or AHP shall be notified that his/her activity falls below the
necessary threshold. If the practitioner’s or AHP’s volume is insufficient to be evaluable, he/she has the
following options:
2.6(a) The practitioner or AHP may petition the Service Chief to consider alternative information
demonstrating clinical competency. Such alternative information may include OPPE data from
another hospital where he/she has significant volume relating to the privileges being exercised at
the Hospital, similar data from a managed care plan, and/or an evaluation from a chief of service
and/or peer references specific to the privileges being exercised at the Hospital. For an office-
based practitioner or AHP without privileges at another hospital, a billing report from his/her
office practice of the types (diagnoses) and numbers of patients seen may also be submitted for
the Service Chief’s consideration.
2.6(b) The practitioner or AHP may petition the Service Chief for a waiver of the OPPE requirement;
provided, however, that such a waiver may be granted only in rare circumstances where the
needs of the Hospital so require (e.g., in order to assure adequate on-call coverage), and only
with the approval of the MEC and the Governing Board, based on a written justification for the
waiver from the Service Chief.
2.6(c) The practitioner or AHP may elect to voluntarily relinquish or limit the clinical privileges in
question.
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SECTION 3: FOCUSED PROFESSIONAL PRACTICE EVALUATION (FPPE)
3.1 Focused Professional Practice Evaluation (FPPE) is a more intensive process of evaluation applied to
practitioners and AHPs deserving greater scrutiny. Such practitioners and AHPs include all those granted
new clinical privileges and those for whom questions of performance and/or competency have been
triggered by OPPE or from other sources. The FPPE monitoring and evaluation process is not considered
a restriction or limitation of a practitioner’s or AHP’s exercise of clinical privileges and does not entitle
the practitioner to the procedural rights afforded by the Medical Staff Fair Hearing Plan or Medical Staff
Bylaws Section 5.4, as applicable.
3.2 Each practitioner’s or AHP’s FPPE plan shall be developed by his/her Service Chief (or his/her
designee) in accordance with the following guidelines. In developing the FPPE plan, the Service Chief
shall consider the practitioner’s or AHP’s specialty, the array of requested privileges, the extent of
professional experience, and the various evaluation methods available. For a practitioner or AHP
requesting one or more new clinical privileges, the Service Chief shall formulate an appropriate FPPE
plan before the new privilege(s) is/are exercised. Each FPPE plan shall be approved by the Medical
Executive Committee.
3.3 As all practitioners and AHPs are assigned to one or more clinical Services based upon specialty,
training, and the privileges to be exercised, FPPE plans shall generally be standardized across each
specialty, to the extent that members of that specialty exercise a similar array of privileges and must
demonstrate equivalent minimal competency. For sub-specialization, there may be greater specificity in
the FPPE requirements, but these, too, shall generally be standardized within the subspecialty. The array
of monitored cases shall be representative of the appointee’s anticipated activity and scope of practice,
with monitoring designed to assess competency across a range of comparable clinical activities and,
when applicable, comparable procedure types.
3.4 The practitioner’s or AHP’s extent of prior experience shall be considered when determining the
approach and the extent of the FPPE needed to assess current competence. The practitioner’s or AHP’s
experience may fall into one of the following categories, which are listed along with their minimum
suggested monitoring requirements:
3.4(a) Recent Graduate: A recent (within 3 years) graduate from a training program, who has requested
privileges for which competency should have been attained in the training program, shall
undergo a full FPPE evaluation.
3.4(b) Affiliated Provider: An active practitioner or AHP on the medical staff or AHP staff of another
LifePoint Health System hospital who has:
(1) Documented experience exercising the requested privilege(s);
(2) Successfully completed a period of FPPE, if he/she was appointed subsequent to the
implementation of the FPPE process; and
(3) Had no triggers identified as the result of an OPPE.
An Affiliated Provider, based upon the judgment of the relevant Service Chief and the Medical
Executive Committee, may require minimal FPPE. Reciprocal Evaluation (described below),
alone, may be sufficient. If concerns exist regarding the relative infrequency with which the
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candidate has been exercising the requested privilege(s), more intensive FPPE shall be required.
3.4(c) Experienced Provider: An active practitioner or AHP on the medical staff or AHP staff of a
hospital not affiliated with the LifePoint Health System who has:
(1) Documented experience exercising the requested privilege for more than five (5) years;
(2) Successfully completed a period of FPPE, if he/she was appointed subsequent to the
implementation of the FPPE process; and
(3) Had no triggers identified as the result of an OPPE.
An Experienced Provider, based upon the judgment of the relevant Service Chief and the
Medical Executive Committee, may require minimal FPPE. If concerns exist regarding the
relative infrequency with which the candidate has been exercising the requested privilege(s)
elsewhere, more intensive FPPE shall be required.
3.4(d) Other Provider: All practitioners and AHPs who do not meet the definitions of the categories
above.
Other Providers shall require a full FPPE, as defined by the respective Service and the Medical
Executive Committee. The full FPPE shall be comprised of various evaluation methods listed
below as deemed applicable.
3.5 Evaluation Methods
Several types of evaluation methods may be utilized to determine clinical competence. These include:
3.5(a) Prospective Case Evaluation (PCE): Prospective presentation of a case, including the anticipated
treatment plan, prior to the actual rendering of care, so as to evaluate the critical thinking
surrounding the case, the diagnostic process, and the ability to formulate an appropriate
treatment plan;
3.5(b) Concurrent Case Evaluation (CCE): Real-time observation of a procedure or concurrent,

ongoing evaluation of a treatment plan and/or the care as it is rendered;
3.5(c) Retrospective Case Evaluation (RCE): The review of a case after care has been rendered, which
may include feedback from other personnel involved in the care of the patient, chart review,
and/or evaluation of outcomes or work product; and
3.5(d) Reciprocal Evaluation: When a practitioner or AHP has insufficient clinical activity to permit
effective evaluation at the Hospital relevant to a particular privilege, evidence of successful
evaluation from another facility may be acceptable. This alternative process, known as
Reciprocal Evaluation (RE), shall be used on a limited basis and is acceptable only under the
following conditions:
(1) The practitioner or AHP is responsible for identifying the alternate facility from which
information may be obtained and for ensuring that representatives of the alternate
facility provide the requested information.
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(2) The monitor(s) at the alternate facility must have privileges at a LifePoint Health
System hospital or, if lacking such privileges, is/are qualified to serve in the capacity of
monitor as judged by the Service Chief. Such determination may require submission of
documentation verifying the proposed monitors’ credentials.
(3) The practitioner or AHP must authorize the alternate facility to release copies of his/her
case evaluations or to provide a summary of monitored activities. The practitioner or
AHP must release the alternate facility, including its practitioners and monitor(s), from
claims potentially arising from such release.
(4) Each monitor from the alternate facility must complete an observation evaluation
summary form or other documentation acceptable to the Hospital and submit it to the
Hospital’s Credentials Office.
(5) The alternate facility must provide the Hospital with a copy of the clinical privileges
that have been granted to the practitioner or AHP being evaluated.
It is within the discretion of the Service Chief to determine whether the observation performed
at the alternate facility satisfies the objectives of this policy. The Service Chief’s decision may
be reviewed by the MEC and may be overruled by the MEC.
3.6 FPPE For Newly Privileged Practitioners
3.6(a) This subsection pertains both to providers granted initial clinical privileges and to current
clinical privilege holders who have been granted additional clinical privileges.
3.6(b) When a practitioner or AHP has been granted new clinical privileges, he/she shall be notified in
writing by the Credentials Committee of the FPPE requirement. The notification shall indicate
this policy’s general monitoring requirements and shall direct the practitioner or AHP to contact
his/her Service Chief to develop the specific monitoring plan before exercising the new
privileges.
3.6(c) When the practitioner or AHP is ready to commence exercising the new clinical privilege at the
Hospital, he/she shall notify the Service Chief who shall coordinate monitoring. If the FPPE plan
involves prospective or concurrent monitoring, the Service Chief shall designate the monitor(s)
so as to facilitate scheduling of the cases to be evaluated. It shall be the practitioner’s or AHP’s
responsibility to work with the monitor(s) so as to ensure that he/she complies with and
completes the monitoring requirements.
3.6(d) As soon as the practitioner or AHP begins exercising the new privileges, all of his/her work is
subject to evaluation until the FPPE has been completed and competency evaluated.
3.6(e) To satisfy as one of the practitioner’s or AHP’s required procedural cases, the practitioner or
AHP must be the proceduralist of record.
3.6(f) When a practitioner or AHP has completed the requisite numbers of cases for evaluation and/or
has satisfied other specified requirements of the monitoring plan, he/shall notify the Service
Chief.
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3.6(g) Evaluations shall be documented on standardized forms and returned to the Credentials Office
for placement in the confidential peer review portion of the practitioner’s or AHP’s credentials
file. The Credentials Office will notify the Service Chief of receipt of these forms. The
Credentials Office shall maintain all completed evaluation forms on file. These forms shall be
treated as confidential, peer review, quality assurance documents.
3.6(h) For cases being prospectively or concurrently evaluated, prior to the procedure or treatment, the
monitor shall review the history, work-up, and indications that have led to the planned treatment.
This review may include a presentation by the practitioner or AHP.
3.6(i) Retrospective case evaluations for episodic volume shall be completed within one (1) week
following each patient discharge, or, for high volume, within one (1) week of completion of all
requisite cases.
3.6(j) Concurrent or prospective case evaluations shall be completed within one (1) week of the
monitoring activity.
3.6(k) Once all of the professional performance reviews pertaining to a practitioner or AHP have been
received by the Service Chief, he/she shall review the evaluations and, when necessary, converse
with the monitor(s), to determine whether:
(1) The practitioner’s or AHP’s performance is deemed satisfactory, and the period of FPPE
should be ended;
(2) The period of FPPE should be extended;
(3) Action should be taken to improve performance; or
(4) The practitioner’s or AHP’s privileges should be limited or revoked.
3.6(l) The Service Chief shall report his/her recommendation to the Credentials Committee. If the
Service Chief’s recommendation is to limit or revoke any portion of the practitioner’s or AHP’s
privileges, the Service Chief also shall submit his/her findings and recommendations to the MEC
at its next meeting where a determination will be made whether to accept the Service Chief’s
recommendations with or without modification or to take alternative action. If the MEC’s
decision is to limit or revoke any portion of the practitioner’s or AHP’s privileges, the
practitioner or AHP has the following options:
(1) The practitioner or AHP may voluntarily consent to the limitation or relinquishment of
the relevant privileges. This request for limitation or relinquishment of privileges shall
be handled in accordance with the Medical Staff Bylaws. This limitation or
relinquishment of privileges shall be deemed reportable to other facilities and to
regulatory agencies under state and federal law.
(2) The practitioner or AHP may choose to challenge the MEC’s decision by invoking the
procedural rights afforded by the Medical Staff Fair Hearing Plan or Medical Staff
Bylaws Section 5.4, as applicable.
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3.6(m) If the practitioner or AHP has not completed the requisite number of cases for review within
three (3) months of commencing the FPPE period, the Service Chief shall grant the practitioner
or AHP a three (3)-month extension. If, after another three (3) months, the practitioner’s or
AHP’s activity still has not met the requisite case volume, consideration shall be given to
recommending withdrawal of the relevant privilege(s) due to insufficient volume. At his/her
discretion, the Service Chief may elect to extend the period of FPPE for up to two (2) additional
three (3)-month intervals, for a total FPPE period of one (1) year. If the practitioner or AHP has
not completed the requisite number of cases within one (1) year, the practitioner or AHP shall be
given an opportunity to:
(1) Voluntarily relinquish the relevant privilege(s) and have his/her FPPE period ended;
(2) Voluntarily request a change of status to one which has no clinical privileges and to have
his/her FPPE period ended;
(3) Resign his/her Medical Staff or AHP Staff appointment and relinquish all clinical
privileges; or
(4) Be granted a waiver of the FPPE requirement, which shall only be considered under the
conditions stipulated in subsection C2(f14) 3.6(n) below.
If the practitioner or AHP does not voluntarily select one of these options, the Service Chief
shall recommend termination of the FPPE period and the relevant clinical privileges. As this
termination is being effected based solely on the lack of sufficient volume to perform an
effective evaluation of the practitioner’s or AHP’s competency, it shall not be deemed an adverse
action, and the practitioner or AHP shall not be afforded the procedural rights afforded by the
Medical Staff Fair Hearing Plan or Medical Staff Bylaws Section 5.4, as applicable.
3.6(n) If the practitioner or AHP has been undergoing FPPE for one (1) year, but during that period
his/her volume of activity has been insufficient to permit an effective evaluation of competency,
then the Service Chief may recommend waiving the FPPE requirement, rather than terminate the
clinical privileges; provided, however, that such a waiver may be granted only in rare
circumstances where the needs of the Hospital so require (e.g., in order to assure adequate on-
call coverage), and only with the approval of the MEC and the Governing Board, based on a
written justification for the waiver from the Service Chief.
3.7 Triggered FPPE
3.7(a) This subsection pertains to all practitioners and AHPs with clinical privileges at the Hospital.
3.7(b) For all current members of the Medical Staff and AHP Staff, each Service Chief shall maintain
standard sets of event types and/or thresholds that serve as triggers for the initiation of an FPPE.
These event types and thresholds shall be reviewed by the respective Service Chiefs at least
annually, updated as necessary, and then submitted for approval by the MEC and the Governing
Board.
3.7(c) A Triggered FPPE may also result from findings of the OPPE, as explained above, or by other
information or events that are brought to the attention of the Service Chief, Chief of Staff, or
Chief Medical Officer. Other events that may warrant consideration of a Triggered FPPE
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include, but are not limited to:
(1) Specific questions of clinical competence, patient care and treatment, or case
management;
(2) Inappropriate, disruptive, or undermining behavior as referenced in the Medical Staff

Bylaws and Appendices; or
(3) Violations of applicable ethical standards as referenced in the Medical Staff Bylaws,
Rules & Regulations, and Policies & Procedures; or the Hospital Bylaws.
3.7(d) A quality concern regarding a practitioner or AHP may be raised by members of the Medical
Staff or AHP Staff, Nursing staff, other hospital staff; patients, family members, or others; or
through the Hospital’s and Medical Staff’s performance improvement activities.
3.7(e) Each time a trigger-event occurs or a trigger-threshold is breached, a standardized process to

address the situation shall be implemented:
(1) Investigation
(a) The Service Chief or his/her designee shall conduct a prompt investigation to
understand the circumstances. The investigation shall include a discussion with
the practitioner or AHP.
(b) Based on the findings of the investigation, the Service Chief or his/her designee
shall determine whether the situation warrants (a) no action; (b) the
implementation of a Triggered FPPE directed at the concerns raised by the
investigation; or (c) corrective action. If corrective action is warranted, it shall
be initiated in accordance with the Medical Staff Bylaws and Appendices.
(2) Triggered FPPE Plan Implementation
(a) If, based upon the findings of the investigation, the Service Chief or his/her
designee determines that a Triggered FPPE directed at the concerns raised by
the investigation is warranted, he/she shall formulate an FPPE plan and review
it with the practitioner or AHP, who may provide input into developing the plan.
The plan may involve prospective, concurrent, or retrospective case evaluation,
as defined above. If the Triggered FPPE plan involves prospective or concurrent
monitoring, the Service Chief shall designate the monitor(s) so as to facilitate
scheduling of the cases to be evaluated. It shall be the practitioner’s or AHP’s
responsibility to work with the monitor(s) so as to ensure that he/she complies
with and completes the monitoring requirements.
(b) The practitioner or AHP may opt to comply with the plan or to voluntarily
relinquish or limit the privilege(s) in question.
(c) Depending on the cause of the Triggered FPPE and whether the resulting plan
constitutes a restriction or limitation on privileges, the institution of the plan or
the voluntary relinquishment of privileges may necessitate reporting to other
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facilities or regulatory agencies in accordance with state and federal law.
(d) The Service Chief shall present the Triggered FPPE plan to the MEC for its
approval at its next meeting. The Medical Executive Committee may modify the
plan.
(e) Failure of the practitioner or AHP to promptly comply with the Triggered FPPE
plan or to provide an alternative acceptable to the Service Chief and MEC shall
trigger corrective action in accordance with the Medical Staff Bylaws.
(f) Once the Triggered FPPE plan is instituted, its completion shall follow the
FPPE process for newly privileged practitioners and AHPs, described above,
except that it shall be completed within 30 days. The MEC has discretion to
extend the Triggered FPPE period (as described below).
(3) Triggered FPPE Results & Conclusions
(a) Triggered FPPE results shall be documented in writing by the Service Chief and
submitted to the MEC. A copy of this documentation shall be submitted to the
Credentials Office for placement in the confidential peer review portion of the
practitioner’s or AHP’s credentials file. This documentation shall be treated as
confidential, peer review, quality assurance material.
(b) For cases being prospectively or concurrently evaluated, prior to the procedure
or treatment, the monitor shall review the history, work-up, and indications that
have led to the planned treatment. This review may include a presentation by
the practitioner or AHP.
(c) Retrospective case evaluations shall be completed within one (1) week
following each patient discharge.
(d) Concurrent or prospective case evaluations shall be completed within one (1)
week of the monitoring activity.
(e) Once all of the professional performance reviews pertaining to the practitioner
or AHP have been received by the Service Chief, he/she shall review the
evaluations and, when necessary, converse with the monitor(s), to determine
whether:
1. The practitioner’s or AHP’s performance is deemed satisfactory and the

period of Triggered FPPE should be ended;
2. The period of Triggered FPPE should be extended;
3. Action should be taken to improve performance; and/or
4. The practitioner’s or AHP’s privileges should be limited or revoked.
(f) The Service Chief shall submit his/her findings and recommendations to the
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MEC at its next meeting where a determination will be made whether to accept
the Service Chief’s recommendations with or without modification or to take
alternative action.
(g) If the MEC’s decision is to limit or revoke any portion of the practitioner’s or
AHP’s privileges, the practitioner has the following options:
1. The practitioner may voluntarily consent to the limitation or

relinquishment of privileges. This request for limitation or
relinquishment of privileges shall be handled in accordance with the
Medical Staff Bylaws. This limitation or relinquishment of privileges
shall be deemed reportable to other facilities and to regulatory agencies
under state and federal law.
2. The practitioner or AHP may challenge the MEC’s decision by invoking

the procedural rights afforded by the Medical Staff Fair Hearing Plan or
Medical Staff Bylaws Section 5.4, as applicable.
(h) If, after 30 days, the Triggered FPPE has not been concluded, the reason(s) shall
be presented at the next meeting of the MEC where a determination will be
made whether to extend the Triggered FPPE period for another 30 days or to
take alternative action.
3.8 FPPE For Temporary & One-Case Privileges
Special requirements for supervision and reporting may be imposed upon any provider who has been
granted temporary or one-case clinical privileges. Notice of any failure by the provider to comply with
such special requirements may result in immediate termination of privileges. In general, all of the
clinical activities of a practitioner or AHP exercising temporary or one-case privileges shall be subject to
FPPE, following identically the process for newly privileged practitioners and AHPs.
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SECTION 4: QUALITY ASSESSMENT–PERFORMANCE IMPROVEMENT–RISK

MANAGEMENT (QAPIRM) PROCEDURE
4.1 Primary Non-Provider Screening
4.1(a) Hospital admissions are screened for medical necessity, appropriateness of setting, and quality
of care within the first working day of the admission by non-provider reviewers utilizing criteria
approved by the Medical Staff. Review is performed at intervals as outlined in the Hospital’s
Utilization Review Plan.
4.1(b) When peer review is required as indicated by criteria, the medical record and peer review form
are prepared by the Quality & Resource Management (QRM) Department for review by a
practitioner or AHP (as applicable) member of the appropriate Service.
4.2 Secondary Provider Review (Peer Review)
4.2(a) The reviewing practitioner or AHP reviews the medical record and documents on the peer
review form his/her conclusions and recommendations, including, but not limited to, the
following:
(1) Confirmation of referral
(2) Assessment of the event and assignment of a standard of care rating in accordance with
the rating scale set forth in Section 11.1 of the Medical Staff Professional Performance
Review Policy (Bylaws Appendix “E”)
(3) Identification of other issues. The reviewer may identify other issues and request
additional review. The medical record will be forwarded to the appropriate Service(s)
for further review.
4.3 Standard of Care Assignment
When a standard of care assignment of a 3A, 3B, 3C or 4 is made, the provider reviewer will record
his/her determination and goal(s)/reason(s) as indicated on the peer review form. If a 3A or 4 assignment
is made, the QRM Department will notify the practitioner or AHP of the determination by letter.
4.4 Review & Appeal of Standard of Care Assignment
4.4(a) The practitioner or AHP may review his/her peer review form. He/She can, if desired, request a
meeting or can provide a written response to the appropriate Service regarding the assignment of
care. If the practitioner or AHP wishes to meet with the Service, he/she must contact the QRM
Department in writing within three weeks of the notification of the assignment of care. The
QRM department will make arrangements for the practitioner or AHP to meet with the Service.
If the practitioner or AHP wishes to make a written response to the Service, the response must
be received by the QRM Department within three weeks of the notification of the assignment of
care. The QRM Department will forward the practitioner’s or AHP’s response to the Service.
4.4(b) If the practitioner or AHP does not notify the QRM Department in writing of his/her desire to
meet with the Service within the three week time frame and does not provide a written response
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to the Service within the three week time frame, the standard of care assignment will be entered
into the practitioner’s or AHP’s profile.
4.4(c) If the practitioner or AHP meets with and/or provides a written response to the Service, the
Service will review the information and either confirm the original assignment or make a new
assignment. The practitioner or AHP will be notified of the Service’s determination in writing by
the Service Chief.
4.4(d) It the practitioner or AHP disagrees with the Service’s standard of care assignment, he/she may
request a review by the MEC. The practitioner or AHP must have met in person with the
appropriate Service before he/she can appeal the case to the MEC.
(1) The Chief of the appropriate Service (or designee) and the practitioner or AHP will be
asked to attend the next MEC meeting. After reviewing the presentations of the
practitioner or AHP and Service Chief (or designee), the MEC will be responsible for
making the final determination and standard of care assignment. The MEC may consult
one or more experts, either on the Medical Staff or outside the Medical Staff. All
requests and recommendations for outside review must be approved by Administration.
The MEC will notify the practitioner or AHP and the appropriate Service in writing of
its final determination.
4.5 Service Responsibilities
Implementation of recommendations, continued monitoring, and resolution of the issue(s) identified by

the QAPIRM procedure are the responsibilities of the respective Services.
4.6 Record-keeping
All peer review forms along with data relating to the practitioner or AHP, Service, and overall trend
analysis are maintained by the QRM Department. Access to profile data is limited and protected as
confidential as outlined in the Hospital Performance Plan, Section VII.
SECTION 5: PROTECTION FROM LIABILITY
5.1 All members of the Governing Board of Trustees, the Medical Staff, the AHP Staff, Hospital personnel,
and others assisting in Medical Staff professional performance review, peer review, and performance
improvement processes shall have immunity from any civil liability to the fullest extent permitted by
state and federal law when participating in any activity described in the Medical Staff Professional
Performance Review Policy and this Addendum A.
SECTION 6: QUALITY INDICATORS
6.1 The following table contains examples of OPPE quality indicators. Service Chiefs are not limited to
these quality indicators and may adopt/develop other quality indicators as needed, subject to MEC
approval. Service Chiefs may adopt the “Accept Target” (Acceptable Performance Target) thresholds as
FPPE triggers, or they may establish other FFPE FPPE triggers, subject to MEC approval.
13
OPPE Quality Indicators
Competency Indicator Excell Accept

# Service Indicator Type Comment
Category Description Target Target
Interpersonal HCAHPS - Provider
1 & Communi– All Services explains so Pt can Patient survey Rate 100% 78%
cation Skills understand
Interpersonal
HCAHPS - Provider
2 & Communi– All Services Patient survey Rate 100% 81%
listens to Pt
cation Skills
Interpersonal HCAHPS - Provider
3 & Communi– All Services treats Pt with Patient survey Rate 100% 88%
cation Skills courtesy & respect
Hospital staff/medi-
Interpersonal Recommended
cal staff survey Hospital staff/medi-
4 & Communi– All Services Rate 100% ≥80% by JCAHO
ratings of good or cal staff survey
cation Skills surveyor
better
Interpersonal
Validated patient/
5 & Communi– All Services Rule 0/yr 2/yr
family complaints
cation Skills
Interpersonal
Validated provider
6 & Communi– All Services Rule 0/yr 2/yr
behavior incidents
cation Skills
Medical/ Continually meets
7 Clinical All Services Board certification Medical Staff Rule yes yes
Knowledge Bylaws requirement
Medical/ Continuing educa–
Category 1 CME for
8 Clinical All Services tion credits relevant Rate ≥30/yr ≥20/yr
physicians
Knowledge to privileges
Patient Care Documented phar-
9 All Services Rate <10/yr <20/yr
– Appropriate macy interventions
Patient Care
10 All Services Medication error Review 0/yr 1-2/yr
– Appropriate
Unexpected signi-
ficant adverse drug
Patient Care
11 All Services reaction potentially Review NA 0/yr
– Appropriate
related to medica-
tion prescribing
Patient Care OP-29 Appropriate
12 All Surgical Rate 100% >90%
– Appropriate follow-up endo
OP-30 Avoidance of
Patient Care
13 All Surgical inappropriate use Rate 100% >90%
– Appropriate
endo
Tissue discrepancy
Patient Care
14 All Surgical between pre- and Rate 0/yr ≤2/yr
– Appropriate
post-op diagnosis
Unplanned change
Patient Care in anesthesia
15 Anesthesia Rate 0/yr ≤2/yr
– Appropriate delivery mode
(spinal to general)
14

Patient Care
16 OB/GYN C-Section rate Rate <24% <32%
– Appropriate
Scheduled induc-
Patient Care tions before 39
17 OB/GYN Review 0/yr ≤2/yr
– Appropriate weeks w/out appro-
priate indications
HBIPS-4 Multiple
Patient Care
18 Psychiatry anti-psychotics @ Rate 100% 95%
– Appropriate
d/c
HBIPS-5 Multiple
Patient Care
19 Psychiatry anti-psychotics @ Rate 100% 95%
– Appropriate
d/c w/ justification
Significant compli-
cations of medical
Patient Care procedures result-
20 All Medical Review NA NA
– Effective ing in additional
intervention or
prolonged stay
# Billed harms
Patient Care
21 All Services (COGNOS data Rate 0/yr ≤3/yr
– Effective
with NSHN review)
# Billed infections
Patient Care
22 All Services (COGNOS data Rate 0/yr ≤3/yr
– Effective
with NSHN review)
# Procedures
Patient Care
23 All Services resulting in Rate 0/yr ≤2/yr
– Effective
complication
Patient Care # unanticipated

24 All Services Rate 0/yr ≤2/yr
– Effective perforations
% Patients receiv-
Patient Care ing reversal agent
25 All Services Rate ≤5% ≤10%
– Effective for conscious
sedation
Patient Care DVT occurring dur-
26 All Services Rate 0% ≤10%
– Effective ing hospitalization
Patient Care Hospital-acquired
27 All Services Rate NA 0/yr
– Effective decubitus
Patient Care Meditech average Service Service
28 All Services Rule
– Effective LOS Specific Specific
Readmission <31
Patient Care days for condition
– Effective within the same
DRG MDC
Patient Care Readmission <31
– Effective days for DVT
15

Significant event
Patient Care Risk management not covered by
31 All Services Review NA NA
– Effective referral other review
indicators
Risk-adjusted Index = Observed
Patient Care observed to expect- Complications/Expe
32 All Services Rate <0.9 <1.3
– Effective ed complications cted Complications
Index by DRG Ratio
Risk-adjusted
Index = Observed
Patient Care observed to
33 All Services Mortality/Expected Rate <0.9 <1.3
– Effective expected mortality
Complications Ratio
index by DRG
Severity-adjusted Subcategorized by
Patient Care
34 All Services average LOS payer type if Rate <0.9 <1.3
– Effective
variance by DRG appropriate
Significant tissue Prior treatments
discrepancy include biopsies,
between pre and excisions, radiation
Patient Care
35 All Services post op diagnosis in therapy or chemo– Review NA NA
– Effective
the absence of therapy. Excludes
treatment prior to appendectomies &
surgery needle biopsies
Patient Care Unanticipated
36 All Services Review 0/yr ≤2/yr
– Effective Cardiac Arrest/MI
Patient Care Unanticipated
– Effective Mortality
Unplanned inpatient
Patient Care admission d/t
– Effective complication of
procedure
Patient Care Unplanned return to

– Effective ICU within 48 hrs
% Surgical Site In-

Patient Care
40 All Surgical fections by selected Rate <5% <10%
– Effective
surgical procedures
% Surgical/proce-
Patient Care dural complications
41 All Surgical Rate <0.9% <1.3%
– Effective identified by ICD-9
996.0-999.9
% Unanticipated
return to surgery for
Patient Care
42 All Surgical removal of foreign Rate <0.9% <1.3%
– Effective
body, hematoma, or
hemorrhage
16

% Unplanned repair
of an organ during
Patient Care operative procedure
43 All Surgical Rate <5% <10%
– Effective including laceration,
puncture, tear, or
perforation
Perioperative
Patient Care
44 All Surgical mortality excluding Review NA NA
– Effective
palliative care
Significant intra or As defined by ICD-
Patient Care
45 All Surgical post procedural 10 codes or severity Review NA NA
– Effective
complication adjusted data
Unplanned read-
mission ≤ 30 days Rate exclusions
Patient Care
46 All Surgical of inpatient proce- surgical infections, Review NA NA
– Effective
dure for problems inclusions
related to procedure
Unplanned return to
Patient Care
47 All Surgical surgery during Review NA NA
– Effective
same admission
Unscheduled
Patient Care admission following
48 All Surgical Review NA NA
– Effective outpatient surgery
with >48 hr stay
Events include
aspiration, aware-
ness under anes-
thesia, broken,
% Patient safety-
chipped tooth or
Patient Care related events for
49 Anesthesia bridge, eye trauma, Rule 0/yr ≤2/yr
– Effective patients undergoing
corneal abrasions,
anesthesia
failed epidural spi-
nal/general, hypo-
thermia, prolonged
muscle paralysis
% patients having
routine procedures
under general
Patient Care
50 Anesthesia anesthesia being Rate 0/yr ≤2/yr
– Effective
discharged from
PACU beyond 4
hours
Patient Care
51 Anesthesia Dental trauma Rate 0/yr ≤2/yr
– Effective
Patient Care Intubation-related
– Effective trauma
17

Major perioperative
Patient Care complications of
53 Anesthesia Review NA NA
– Effective patient undergoing
anesthesia
Patient Care Perioperative
– Effective aspiration
Patient Care Peripheral nerve
55 Anesthesia Rate 0/yr 1/yr
– Effective trauma
Unplanned admis-
Patient Care sion of Outpt w/in
– Effective 24 hrs surgery d/t
anes complication
Patient Care Unplanned
– Effective reintubation
Patient Care Unrecognized
– Effective difficult airway
%Clinically verified
significant discrep-
Patient Care Emergency ancy between radi-
59 Rate <5% <11%
– Effective Service ology over reads
and ED provider
reading
Clinically verified
discrepancy
Patient Care Emergency
60 between radiology Rate 0/yr ≤2/yr
– Effective Service
over reads and ED
provider reading
ED return by
patients w/in 48
Patient Care Emergency hours resulting in
61 Rate 0/yr ≤2/yr
– Effective Service death or an admis-
sion to a critical
care unit
% Birth trauma as
Patient Care
62 OB/GYN defined by ICD-10 Rate 0% ≤10%
– Effective
codes
% C-Section with
Patient Care post-C-section
63 OB/GYN Rate <0.9% <1.3%
– Effective length of Stay >4
days
Patient Care 3rd & 4th degree
64 OB/GYN Rate 0% ≤10%
– Effective lacerations
Patient Care Hospital-acquired
65 OB/GYN Review NA NA
– Effective infection
18

Return to OR for
Patient Care
66 OB/GYN bleeding or retained Review NA NA
– Effective
placenta
Patient Care Subsequent ED
– Effective visit w/in 72 hours
Patient Care Transfer from OB to
– Effective ICU
Patient Care Unplanned/emer-
– Effective gent C-section
% Major diagnostic
Patient Care discrepancies
70 Pathology Review 0% <5%
– Effective between initial and
final reports
% Minor diagnostic
Patient Care discrepancies
71 Pathology Review <10% <25%
– Effective between initial and
final reports
% Major diagnostic
discrepancies
Patient Care
72 Pathology between pathologist Review 0% <5%
– Effective
and outside
reviewer
% Minor diagnostic
discrepancies
Patient Care
73 Pathology between pathologist Review <5% <10%
– Effective
and outside
reviewer
Patient Care % Asthma patients
74 Pediatrics Rate <0.9% <1.3%
– Effective readmitted ≤7 days
# Addendums
Patient Care
75 Radiology (change course of Rate 0/yr 3/yr
– Effective
treatment)
% Mammography
Patient Care false neg. cases
76 Radiology Rate 0% <5%
– Effective subcategorized by
age group
Patient Care
77 Radiology Overreads with CT Rate 0/yr 3/yr
– Effective
Patient Care Overreads with
78 Radiology Rate 0/yr 3/yr
– Effective mammography
Patient Care
79 Radiology Overreads with MRI Rate 0/yr 3/yr
– Effective
19

– Effective nuclear medicine
– Effective ultrasound
Interventional
Patient Care
82 Radiology procedure Rate <2.5% <5%
– Effective
complications
Practice-
# Inpatients not
Based
83 All Services seen every 24 Rule 0/yr ≤2/yr
Learning &
hours
Improvement
Practice- # of Category 3
Based (confirmed w/
Learning & expected
Improvement improvement)
Practice-
# of Category 4
Based
85 All Services (unexpected w/ Review 0/yr ≤2/yr
Learning &
potential risk)
Improvement
Practice-
Based Blood utilization
86 All Services Rule 1/yr ≤3/yr
Learning & non-compliance
Improvement
Practice-
IMM-2 influenza
Based
87 All Services vaccination (1st & Rate 100% ≥95%
Learning &
4th Qtr only
Improvement
Practice-
Based
88 All Services SEP-1 sepsis Rate 100% ≥95%
Learning &
Improvement
Practice-
Based Total # transfusion
Learning & cases for review
Improvement
Practice-
Urinary catheter
Based
90 All Services removed on POD1 Rate 100% ≥90%
Learning &
or POD2
Improvement
Practice-
Based VTE-8 hospital-
Learning & acquired DVT/PE
Improvement
20

Practice-
Adherence to
Based
92 Anesthesia AORN guidelines Review 100% ≥60%
Learning &
for local anesthesia
Improvement
Practice-
Based Emergency AMI–Aspirin on
93 Rate 100% ≥90%
Learning & Service arrival
Improvement
Practice-
Based Emergency OP–Door to EKG
94 Rate <4 min ≤7 min
Learning & Service w/in 10 minutes
Improvement
Practice- Emergency
OP–Head CT/MRI
Based Service & <45
95 stroke w/in 45 min Rate 45 min
Learning & Radiology min
of arrival
Improvement Service
Practice-
OP–Median transfer
Based <60 <70
96 All Services time for acute Rate
Learning & min min
coronary
Improvement
Practice-
OP–Pain manage-
Based Emergency <30 ≤33
97 ment for long bone Rate
Learning & Service min min
fracture
Improvement
Practice-
Patient seen by
Based Emergency
98 provider w/in 20 Rate 100% ≥90%
Learning & Service
minutes
Improvement
Practice-
Based Hematology- Cancer stage
99 Rate 100% ≥90%
Learning & Oncology documented
Improvement
Practice-
STK-1 stroke Pt
Based
100 Medicine receives VTE Rate 100% ≥95%
Learning &
prophylaxis
Improvement
Practice-
Based STK-4 thrombolytic
101 Medicine Rate 100% ≥95%
Learning & therapy
Improvement
Practice-
STK-5 antithrom-
Based
102 Medicine botic therapy by Rate 100% ≥95%
Learning &
end of day 2
Improvement
Practice- Anatomic pathology
Based report missing
103 Pathology Random audit Rule 0/yr ≤2/yr
Learning & applicable cancer
Improvement checklist
21

Practice-
Based SUB-1 alcohol use
104 Psychiatry Rate 100% ≥95%
Learning & screening
Improvement
Practice- Radiology reports
Based contain documenta-
105 Radiology Rate 100% ≥90%
Learning & tion of fluoroscopy
Improvement times
Profession- Committee meeting
106 All Services Rate ≥90% ≥50%
alism attendance
Profession- Service meeting
107 All Services Rate 90% ≥50%
alism attendance
Instances of de-
Profession-
108 All Services layed consultation > Rule 0/yr ≤2/yr
alism
24 hrs
Validated incidents
Profession-
109 All Services of inappropriate Rule 0/yr ≤2/yr
alism
provider behavior
% Charts contain
Systems- essential elements Essential elements
110 Based All Services (e.g. H&P, operative listed in med staff Rule 100% ≥90%
Practice reports, progress rules & regs
notes)
Non-adherence to Validated observa-
Systems-
standard infection tions by infection
111 Based All Services Rule ≤6/yr ≤12/yr
control precautions control program
Practice
– hand hygiene designees
Systems-
Antibiotic order
112 Based All Services Rule 100% ≥90%
includes indication
Practice
Blood component
Based on med staff
Systems- use not meeting
approved criteria for
113 Based All Services appropriateness Rule ≤1yr ≤3/yr
PRBCs, platelets,
Practice criteria (excluding
FFP, cryoprecipitate
autologous units)
Systems-
Crossmatch-to-
114 Based All Services Rate ≤1.3 ≤2
transfusion ratio
Practice
Discharge summary
Systems-
dictated/written w/in
30 days of
Practice
discharge
Systems- H&P completion
116 Based All Services w/in 24 hrs of Rule 100% ≥90%
Practice admission
22

Systems-
Initial restraint order
signed w/in 24 hrs
Practice
The 2 staff may be
Medication order
2 pharmacists, a
Systems- unreadable as vali-
pharmacist and a
118 Based All Services dated by 2 licensed Rule ≤2/yr ≤6/yr
nurse, a nurse and
Practice staff at the time
a respiratory thera-
order is needed
pist, etc.
Systems- PRN medication
119 Based All Services order includes Rule 100% ≥95%
Practice qualifier
Systems-
Use of prohibited
120 Based All Services Rule ≤2/yr ≤3/yr
abbreviation
Practice
Systems- Restraint renewal
121 Based All Services order signed each Rule 100% ≥95%
Practice calendar day
Systems- Suspensions for
122 Based All Services delinquent medical Rule 0/yr ≤2/yr
Practice records
Validated incidents
of provider non-
Systems- compliance with
123 Based All Services Presurgical/Invasive Rule 0/yr ≤2/yr
Practice Procedure safety
policies and
procedures
Systems- Validated procedure
124 Based All Services start time delays Rule 0/yr ≤2/yr
Practice due to provider
Systems-
Immediate post-op
125 Based All Surgical Rule 100% ≥90%
report completion
Practice
Systems- Improper utilization
126 Based All Surgical of urgent/emergent Rule 0/yr ≤5/yr
Practice OR cases
Validated incidents
non-compliance
Systems-
pre-procedure
127 Based All Surgical Rule 0/yr ≤2/yr
safety policies and
Practice
procedures (e.g.
time outs)
Systems-
Post-anesthesia
128 Based Anesthesia Rate 100% ≥90%
note completed
Practice
23

Systems- Pre-induction
129 Based Anesthesia assessment Rate 100% ≥90%
Practice completed
Validated Incidents
Systems-
of non-participation
130 Based Anesthesia Rule 0/yr ≤2/yr
in pre-procedure
Practice
time-outs
Systems- HBIPS-2 Hours of
131 Based Psychiatry physical restraint Rate 100% ≥95%
Practice use
Systems-
HBIPS-3 Hours of
132 Based Psychiatry Rate 100% ≥95%
seclusion
Practice
Systems- HBIPS-6 Post d/c
133 Based Psychiatry continuing care plan Rate 100% ≥95%
Practice created
HBIPS-7 Post d/c
Systems-
care plan
134 Based Psychiatry Rate 100% ≥95%
transmitted to next
Practice
care level
Systems-
135 Based All Services Inpatient suicides Review NA 0/yr
Practice
24
SECTION 7: PROVIDER PERFORMANCE REPORTS
7.1 Written reports of practitioner and AHP OPPE results are periodically prepared by Service Chiefs, with
the assistance of the Quality & Resource Management (QRM) Department, as described in Section 2,
above. These reports use the following format, modified as necessary to accommodate the information
required for each Service and provider.
25
Sample Provider Performance Report

Provider: Service: Period: Period: Period:
Activity Data Signatures: Bi-annual Reviews

Inpatient Admissions:
Consults: _________________________________________________ ______________
Service Chief Signature Date
Procedures:
_________________________________________________ ______________
Chief of Staff Signature Date
Data Volumes Excel. Accept. Cumula-

Provider Performance Data 6 Months 6 Months
Source /Data Target Target tive
Patient Care
Unplanned inpatient admission d/t complication of procedure QRM 0/yr ≤2/yr
# Billed infections (COGNOS data with NSHN review) QRM 0/yr ≤3/yr
Unanticipated mortality QRM 0/yr ≤2/yr
# of Category 3 peer reviews (moderate deviation of care) QRM 0/yr ≤3/yr
# of Category 4 peer reviews (not standard of care) QRM 0/yr ≤2/yr
Practice-Based Learning & Improvement
# Inpatients not seen every 24 hours QRM 0/yr ≤2/yr
Blood utilization noncompliance QRM 0/yr ≤3/yr
Total # transfusion cases for review QRM 0/yr ≤2/yr
SEP-1 sepsis QRM 100% ≥95%
VTE-8 hospital-acquired DVT/PE QRM 0% ≤6%
Systems-Based Practice
Crossmatch-to-transfusion ratio QRM ≤1.3 ≤2
Use of prohibited abbreviations QRM ≤2/yr ≤3/yr
H&P completion w/in 24 hours of admission QRM 100% >90%
Suspensions for delinquent medical records Med Rec 0/yr ≤2/yr
Interpersonal & Communication Skills
HCAHPS – Provider explains so Pt understands QRM 100% ≥78%
HCAHPS – Provider listens to Pt QRM 100% ≥81%
HCAHPS – Treats Pt with courtesy & respect QRM 100% ≥88%
Hospital staff survey ratings of good or better QRM 100% ≥80%
Validated patient/family complaints QRM 0/yr ≤2/yr
Validated provider behavior incidents Peers/Staff 0/yr ≤2/yr
Professionalism
Instances of delayed consultation >24 hrs Peers/Staff 0/yr ≤2/yr
Validated inappropriate behavior incidents Peers/Staff 0/yr ≤2/yr
Committee meeting attendance Credentials ≥90% ≥50%
Service meeting attendance Credentials ≥90% ≥50%
Medical/Clinical Knowledge
Achieve/maintain board certification Credentials Yes Yes
26
SECTION 8: ADOPTION & AMENDMENT OF ADDENDUM A
8.1 Development
The Medical Staff shall have the initial responsibility to bring before the Board a formulated, adopted
and recommended Addendum A which shall be effective when approved by the Board. The Medical
Staff shall exercise its responsibility in a reasonable, timely, and responsible manner, reflecting the
interest of providing patient care of recognized quality and efficiency and of maintaining a harmony of
purpose and effort with the CEO, the Board, and the community.
8.2 Adoption, Amendment, And Review
Addendum A may be amended or replaced at any regular Medical Staff meeting at which a quorum is
present and without previous notice, or at any special Medical Staff meeting at which a quorum is
present on notice, by a majority vote of those present and eligible to vote. Alternatively, the MEC may
amend or replace Addendum A on its own initiative but must promptly thereafter communicate such
action to the Medical Staff. The Medical Staff shall have the opportunity for retrospective review of any
Addendum A amendment or replacement adopted by the MEC and may either approve or reject it at any
subsequent Medical Staff meeting at which a quorum is present. Addendum A amendments and
replacements require Board approval. If the Medical Staff or MEC fails to act within a reasonable time
after notice from the Board to such effect, the Board may initiate revisions to Addendum A, taking into
account the recommendations of Medical Staff members. Addendum A shall be reviewed and revised as
needed, but shall be reviewed at least every two (2) years.
8.3 Documentation & Distribution Of Amendments
Amendments to Addendum A as set forth herein shall be documented by either:
(1) Appending to this Addendum A the approved amendment, which shall be dated and signed by
the Chief of Staff, the CEO, and the Chairperson of the Board and approved as to form by
Corporate Legal Counsel; or
(2) Restating Addendum A, incorporating the approved amendments and all prior approved
amendments which have been appended to Addendum A since its last restatement, which
restated Addendum A shall be dated and signed by the Chief of Staff, the CEO, and the
Chairperson of the Board and approved as to form by Corporate Legal Counsel.
8.4 Suspension, Supplementation, or Replacement
The Board reserves the right to suspend, override, supplement, or replace all or any portion of
Addendum A in the event of exigent and compelling circumstances affecting the operation of the
Hospital, welfare of its employees and staff, or provision of optimal care to patients. Should the Board
so suspend, override, supplement, or replace Addendum A, it shall consult with the Medical Staff at the
next regular staff meeting (or at a special called meeting as provided in the Medical Staff Bylaws), and
shall thereafter proceed as provided in subsection 8.2 (above) for adoption and amendment of Adden-
dum A. If an agreement with the Medical Staff cannot be reached, the Board shall have the ultimate
authority as to adoption and amendment of Addendum A, but shall exercise such authority unilaterally
only when the Medical Staff has failed to fulfill its obligations, and it is necessary to ensure compliance
with applicable law or regulation, or to protect the well being of patients, employees, or staff.
27
ADDENDUM A
ADOPTED & APPROVED:
MEDICAL STAFF:
By: _________________________________________ __________________________

Chief of Staff Date
BOARD OF TRUSTEES:
By: __________________________________________ __________________________

Chairperson Date
DLP RUTHERFORD REGIONAL HEALTH SYSTEM, LLC

D/B/A RUTHERFORD REGIONAL MEDICAL CENTER:
By: __________________________________________ __________________________

Chief Executive Officer Date
APPROVED AS TO FORM:
By: __________________________________________ __________________________

Legal Counsel for DLP Rutherford Regional Health Date
System, LLC d/b/a Rutherford Regional Medical Center
APPROVED:
By: __________________________________________ __________________________

Division President Date
28

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RUTHERFORD REGIONAL MEDICAL CENTER MEDICAL STAFF ADDENDUM A (DRAFT 10-11-17)

ADDENDUM A – PROFESSIONAL PERFORMANCE

SECTION 2: ONGOING PROFESSIONAL PRACTICE EVALUATION (OPPE)

2.6 OPPE for Low-Volume Practitioners & AHPs

SECTION 3: FOCUSED PROFESSIONAL PRACTICE EVALUATION (FPPE)

(1) Documented experience exercising the requested privilege(s);

(3) Had no triggers identified as the result of an OPPE.

(3) Had no triggers identified as the result of an OPPE.

3.5 Evaluation Methods

3.5(b) Concurrent Case Evaluation (CCE): Real-time observation of a procedure or concurrent,

3.6 FPPE For Newly Privileged Practitioners

(2) The period of FPPE should be extended;

(3) Action should be taken to improve performance; or

(4) The practitioner’s or AHP’s privileges should be limited or revoked.

3.7 Triggered FPPE

include, but are not limited to:

(2) Inappropriate, disruptive, or undermining behavior as referenced in the Medical Staff

3.7(e) Each time a trigger-event occurs or a trigger-threshold is breached, a standardized process to

(2) Triggered FPPE Plan Implementation

facilities or regulatory agencies in accordance with state and federal law.

(3) Triggered FPPE Results & Conclusions

1. The practitioner’s or AHP’s performance is deemed satisfactory and the

2. The period of Triggered FPPE should be extended;

3. Action should be taken to improve performance; and/or

4. The practitioner’s or AHP’s privileges should be limited or revoked.

1. The practitioner may voluntarily consent to the limitation or

2. The practitioner or AHP may challenge the MEC’s decision by invoking

3.8 FPPE For Temporary & One-Case Privileges

SECTION 4: QUALITY ASSESSMENT–PERFORMANCE IMPROVEMENT–RISK

4.1 Primary Non-Provider Screening

4.2 Secondary Provider Review (Peer Review)

(1) Confirmation of referral

4.3 Standard of Care Assignment

4.4 Review & Appeal of Standard of Care Assignment

4.5 Service Responsibilities

Implementation of recommendations, continued monitoring, and resolution of the issue(s) identified by

SECTION 5: PROTECTION FROM LIABILITY

SECTION 6: QUALITY INDICATORS

OPPE Quality Indicators

Competency Indicator Excell Accept

Competency Indicator Excell Accept

Patient Care # unanticipated

Competency Indicator Excell Accept

Patient Care Unplanned return to

% Surgical Site In-

Competency Indicator Excell Accept

Competency Indicator Excell Accept

Competency Indicator Excell Accept

Competency Indicator Excell Accept

Competency Indicator Excell Accept

Competency Indicator Excell Accept

Competency Indicator Excell Accept

Competency Indicator Excell Accept

SECTION 7: PROVIDER PERFORMANCE REPORTS

Sample Provider Performance Report

Activity Data Signatures: Bi-annual Reviews

Data Volumes Excel. Accept. Cumula-

SECTION 8: ADOPTION & AMENDMENT OF ADDENDUM A

8.2 Adoption, Amendment, And Review

8.3 Documentation & Distribution Of Amendments

Amendments to Addendum A as set forth herein shall be documented by either:

8.4 Suspension, Supplementation, or Replacement

By: _________________________________________ __________________________

By: _______________

By: ________________

By: ________________

By: ________________

By: ________________