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					                             Medical Center of South Arkansas
                                                                                                                                                               Privileged and Confidential
                        Ongoing Professional Performance Evaluation                                                                                         for Peer Review Purposes Only

Physician #:                                                                    Specialty:                                                          Status:
Medical Staff Membership Requirements
Current Health Screening:                                               New Malpractice Claim or NPDB Report:                                Sanctions:
                                                    Goal 1Q09 2Q09 3Q09 4Q09 1Q10 2Q10 3Q10 4Q10 Jan                         Feb    Mar       Apr May      Jun   Jul    Aug     Sep     Oct   Nov   Dec
Meeting Attendance ( 25% of GMS/ 50% of other)
Volume                                              Goal 1Q09 2Q09 3Q09 4Q09 1Q10 2Q10 3Q10 4Q10 Jan                         Feb    Mar       Apr   May    Jun   Jul    Aug     Sep     Oct   Nov   Dec
Admissions
Consults
Procedures
Case Mix Index
Average Length of Stay                               3.8
Utilization Review                                  Goal 1Q09 2Q09 3Q09 4Q09 1Q10 2Q10 3Q10 4Q10 Jan                         Feb    Mar       Apr   May    Jun   Jul    Aug     Sep     Oct   Nov   Dec
Failure to Meet Admission Criteria                    0
Readmission within 30 days (same Dx)                  0
Inappropriate Transfers                               0
QIC Denial                                            0
Risk Management                                     Goal 1Q09 2Q09 3Q09 4Q09 1Q10 2Q10 3Q10 4Q10 Jan                         Feb    Mar       Apr   May    Jun   Jul    Aug     Sep     Oct   Nov   Dec
Validated Patient Complaint                           0
Validated Disruptive Behavior Incidents               0
Med Errors/ Near Misses                               0
Non-Compliance with Restraint Policy                  0
Pharmacy                                            Goal 1Q09 2Q09 3Q09 4Q09 1Q10 2Q10 3Q10 4Q10 Jan                         Feb    Mar       Apr   May    Jun   Jul    Aug     Sep     Oct   Nov   Dec
Do Not Use Abbreviations                              0
Antibiotic Use
Health Information Management                       Goal 1Q09 2Q09 3Q09 4Q09 1Q10 2Q10 3Q10 4Q10 Jan                         Feb    Mar       Apr   May    Jun   Jul    Aug     Sep     Oct   Nov   Dec
Non-Compliance with all H&P Elements
    Chief Complaint                                  0
    History of Present Illness                       0
    Past Medical History                             0
    Family History                                   0
    Social History                                   0
    System Review                                    0
    Physical Exam by body system                     0
    Impression                                       0
    Course of Action                                 0
Delinquent H&P                                       0
Delinquent Op report                                 0
Delinquent DC Summary                                0
Delinquent Medical Records                           0
Receipt of Reminder Letter                           0
Suspension                                           0
Illegibility of Medical Records                      0
Lab                                                 Goal 1Q09 2Q09 3Q09 4Q09 1Q10 2Q10 3Q10 4Q10 Jan                         Feb    Mar       Apr   May    Jun   Jul    Aug     Sep     Oct   Nov   Dec
C.T. Ratio 2009                                     <2.0
C.T. Ratio 2010                                     <2.0
Surgical Services                                   Goal 1Q09 2Q09 3Q09 4Q09 1Q10 2Q10 3Q10 4Q10 Jan                         Feb    Mar       Apr   May    Jun   Jul    Aug     Sep     Oct   Nov   Dec
Moderate Sedation
Mortality Review                                     0
Appropriateness of Surgery Review                  100%
H&P prior to Surgery                               100%
Surgical Site Infections                             0
Compliance with Core Measures                               see attached physician report card
Pathology                                          Goal 1Q09 2Q09 3Q09 4Q09 1Q10 2Q10 3Q10 4Q10 Jan                          Feb    Mar       Apr   May    Jun   Jul    Aug     Sep     Oct   Nov   Dec
Intra-Departmental Agreement                       100%
Extra-Departmental Agreement                       100%
Pre/Post/ Path Dx Discrepancies                      0
Perinatal Services                                 Goal 1Q09 2Q09 3Q09 4Q09 1Q10 2Q10 3Q10 4Q10 Jan                          Feb    Mar       Apr   May    Jun   Jul    Aug     Sep     Oct   Nov   Dec
C-Section Rate
Total Deliveries
Anesthesia Services                                Goal 1Q09 2Q09 3Q09 4Q09 1Q10 2Q10 3Q10                    4Q10 Jan       Feb    Mar       Apr   May    Jun   Jul    Aug     Sep     Oct   Nov   Dec
Pre Op Assessment Compliance                       100%
# of Reportable Complications                        0
Medical Services                                   Goal 1Q09 2Q09 3Q09 4Q09 1Q10 2Q10 3Q10                    4Q10 Jan       Feb    Mar       Apr   May    Jun   Jul    Aug     Sep     Oct   Nov   Dec
Hospital Acquired Infections                         0
Mortality Review                                     0
Compliance with Core Measures                               see attached physician report card
Interventional Cardiology                          Goal 1Q09 2Q09 3Q09 4Q09 1Q10 2Q10 3Q10                    4Q10 Jan       Feb    Mar       Apr   May    Jun   Jul    Aug     Sep     Oct   Nov   Dec
Cath Lab Complications                               0
Radiology                                          Goal 1Q09 2Q09 3Q09 4Q09 1Q10 2Q10 3Q10                    4Q10 Jan       Feb    Mar       Apr   May    Jun   Jul    Aug     Sep     Oct   Nov   Dec
Radiology Peer Review (# agreed/ total)            100%
Disconcordant Findings:

* for Teleradiologists, see attached Ongoing Evaluation from Nighthawk Radiology Services
Interventional Radiology                             Goal 1Q09 2Q09 3Q09 4Q09 1Q10             2Q10 3Q10 4Q10 Jan            Feb    Mar       Apr   May    Jun   Jul    Aug     Sep     Oct   Nov   Dec
Complications                                          0
Emergency Services                                   Goal 1Q09 2Q09 3Q09 4Q09 1Q10             2Q10 3Q10 4Q10 Jan            Feb    Mar       Apr   May    Jun   Jul    Aug     Sep     Oct   Nov   Dec
Radiology Discrepancies                                0
   Findings:
EKG Discrepancies                                      0
   Findings:
ED transfers to Acute Care Facilities                  0
   Reason for transfer:
Deaths in ED                                           0
   Dx/ DNR?/ DOS
Case Review                                          Goal 1Q09 2Q09 3Q09 4Q09 1Q10             2Q10 3Q10 4Q10 Jan            Feb    Mar       Apr   May    Jun   Jul    Aug     Sep     Oct   Nov   Dec
Total # of cases reviewed
Indicator:                                                                                     Score:                              Action:
Focused Professional Practice Evaluation
None

Peer Review Committee Recommendation:
Based on personal knowledge, observations, and review of the above quality assessment and improvement findings, the committee agrees this practitioner's privileges should be:


                                                   □ No Issues noted. Continuation of all privileges as delineated. Monitor on a quarterly basis.


                                                   □ Issue Noted:
                                                   __________________________________________________________________________________________________________________
                                                   Recommendation for Focused Review of:
                                                   __________________________________________________________________________________________________________________


         Chief of Department/ Peer Review Chairperson Signature                                                                                     Date

				
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posted:8/23/2011
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