St. Mark's Hospital - January 24, 2018

Effective December 20, 2017, the Medical Executive Committee and Board of Trustees approved the following new Medical Staff policies:

1 — Professional Practice Evaluation

This policy establishes the overall framework for peer review.

This policy:

  • Establishes a Leadership Council consisting of the Medical Staff President, Immediate Past Medical Staff President, Quality Improvement Council Chair and the Chief Medical Officer. The council oversees the peer review processes, and directly addresses issues of professionalism and practitioner health
  • Describes the role and function of support staff, clinical specialty reviewers and the Quality Improvement Council (QIC).
  • Establishes criteria for professional practice evaluation and defines requirements for notice and notification
  • Establishes principles of review and evaluation, defines the process and time lines for review and outlines interventions to address identified concerns
  • Establishes reporting for oversight accountability

2 — FPPE Policy to Confirm Practitioner Competence and Professionalism (New Members / New Privileges)

This policy establishes the process for Focused Professional Practice Evaluation (FPPE) for practitioners granted new privilege to confirm competence and professionalism.

This policy:

  • Declares requirement for FPPE for initial privileging, consistent with Joint Commission standards, and defines acceptable evidence
  • Defines process for development of clinical activity requirements
  • Describes the process for gathering FPPE data on clinical practice and professionalism
  • Describes voluntary withdrawal of privileges as alternative to completing FPPE for initial privileges
  • Defines the review and approval process for FPPE for initial privileges
  • Defines process for deemed voluntary withdrawal of privileges for failure to satisfy clinical activity requirements
  • Defines process to address failure to complete FPPE for initial privileging prior to renewal of privileges

3 — Ongoing Professional Practice Evaluation (OPPE)

This policy establishes the process for Ongoing Professional Practice Evaluation (OPPE) consistent with Joint Commission standards.

This policy:

  • Defines how universal and specialty-specific data elements are determined and approved
  • Describes the frequency and content of reports to practitioners and to reviewers
  • Defines acceptable performance, and addresses various issues, such as insufficient volume, etc.

4 — Professionalism

This policy provides the framework addressing issues of professional conduct to arrive at voluntary, responsive actions by the practitioner to constructively resolve concerns, and avoid disciplinary action.

The policy:

  • Defines professionalism, allowing practitioners to express opinions, disagreement or constructive criticism in a professional manner and in an appropriate forum
  • Establishes expectations for professional conduct to support a culture of patient safety
  • Establishes general guidelines and provides examples of inappropriate conduct
  • Establishes reporting pathways for inappropriate conduct and initial review
  • Defines how input is obtained from practitioners
  • Defines the Leadership Council procedure, including the process for developing a Performance Improvement Plan and how to address practitioner refusal.
  • Establishes criteria for referral to the MEC
  • Establishes the review process for reports of identify-based harassment

5 — Practitioner Health

This policy provides the framework for assisting practitioners in addressing health issues so they may practice safely and competently.

The policy:

  • Establishes requirement that practitioners maintain physical, cognitive and mental health sufficient to carry out privilege in a safe and competent manner
  • Provides examples of significant health issues, and warning signs of potential health issues
  • Establishes the duty to self-report, and the duty of others to report concerns that a practitioner may be practicing while having a health issue
  • Exempts treating practitioners from reporting, but advises the treating practitioner to encourage the practitioner to self-report
  • Defines the initial evaluation process, including information gathering, feedback to the reporter and initial assessment of the practitioner
  • Declares the process for addressing an immediate threat to patient safety
  • Outlines Leadership Council process for assessment, interim safeguards, establishment of a treatment program and various options for resumption of practice after treatment
  • Declares process for referral to the MEC for practitioner refusal or non-compliance with a voluntary plan

6 — Leave of Absence

This policy provides the framework for granting both temporary and regular leaves of absence to address gaps in a required credential (such as a job transition), health issues, outside assignments of an extended duration, etc. as a preferred alternative to suspension and resignation.

The policy:

  • Defines temporary Leave of Absence
    • Up to 180 days or end of current appointment, whichever first
    • Establishes criteria for immediate and automatic (gap in licensure, prof liability insurance or PA delegation)
    • Establishes criteria for department chair invoked
    • Terminates when issue is resolved or at end of current appointment, whichever occurs first
    • No committee action required
    • Criteria for “Deemed Request for regular Leave of Absence”
    • Criteria for “Deemed Request for Voluntary Resignation”
  • Defines regular Leave of Absence
    • Up to 1 year (unless exception made by Board of Trustees)
    • Requested by practitioner or department chair
    • Reapplication required on return
    • Establishes requirement for summary statement on reapplication
    • Establishes criteria for physical, mental, cognitive or chemical dependency evaluation on reapplication

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