On-Demand Learning Lab: Administrative Foundations of Practitioner Peer Review-Handout June 2023 Learning Lab

Handout June 2023 Learning Lab

Pdf Summary

Southwest Healthcare’s Professional Practice Evaluation (PPE) policy establishes how the Medical Staff assesses and improves the competence and professional performance of individual practitioners. The Medical Executive Committee (MEC) delegates oversight to the Multi-Specialty Quality Review Committee (MSQRC), which meets generally monthly, reports to the MEC, and ultimately to the Board of Governors. The policy is conducted under peer review protections of the federal Health Care Quality Improvement Act and California Evidence Code 1157, with strict confidentiality and limited access to provider-specific files.<br /><br />PPE includes three components: Focused Professional Practice Evaluation (FPPE), Ongoing Professional Practice Evaluation (OPPE), and individual record (peer) review. Evaluations align with the ACGME six competencies (patient care, medical knowledge, practice-based learning, communication, professionalism, systems-based practice). Conflicts of interest must be disclosed; conflicted reviewers are excluded from deliberations.<br /><br />FPPE is time-limited (typically 3–6 months) and used for new applicants/new privileges (proctoring) or when concerns arise from case review, OPPE trends, or sentinel/near-miss events. FPPE may involve chart review, direct observation, simulation, interviews, event monitoring, data review, or requesting physical/psychological exams. Findings are summarized to the MEC; the practitioner can respond; outcomes range from no concerns to education, monitoring/proctoring, sharing best practices, or corrective actions up to privilege modification/discipline per bylaws.<br /><br />OPPE is routine monitoring at least every nine months. Department-specific profiles are approved by the MEC/Board and reviewed by Department Chairs. “Triggers” include point thresholds for peer review variations and professionalism, medication events, documentation suspensions, privacy breaches, and 10% deviation from benchmarks. MSQRC reviews summaries and may initiate FPPE.<br /><br />Peer review is coordinated by Quality staff and MSQRC, with accelerated review for significant safety events, defined indicators for automatic review, standardized scoring, and potential actions including letters, trending, referrals (e.g., Professional Behavior Committee), FPPE, or external peer review when needed.

Keywords

Professional Practice Evaluation (PPE)

Focused Professional Practice Evaluation (FPPE)

Ongoing Professional Practice Evaluation (OPPE)

Medical Executive Committee (MEC)

Multi-Specialty Quality Review Committee (MSQRC)

peer review confidentiality

Health Care Quality Improvement Act (HCQIA)

California Evidence Code 1157

ACGME six competencies

proctoring and privilege monitoring