Clinical Staff Office
 

Professional Practice Evaluation Subcommittee

Contacts

Administration:  Carole Wagonhurst, Coordinator, Clinical Staff Office
Chair:  Christian Chisholm, M.D., Obstetrics & Gynecology

Charge

The Professional Practice Evaluation Committee (PPEC) is a committee responsible for overseeing the process of reviewing, evaluating and making recommendations as to the adequacy and quality of professional services, as well as the competency and qualifications for professional staff privileges.  All proceedings, minutes, records and reports of the Professional Practice Evaluation process are privileged and confidential to the full extent authorized by Virginia Code 8.01-581.17 and are also exempted from production under Section 2.2-3705.1(1) of the Virginia Freedom of Information Act.    The Professional Practice Evaluation Committee shall:

a.   Assure that the Professional Practice Evaluation is conducted in a manner that is objective, equitable and consistent.  The Committee shall require that (1) case selection is done by use of pre-selected indicators; (ii)  review of cases is performed by committee in accordance with established procedure that has been approved by the Credentials Committee, (iii) follow-up is conducted in accordance with procedures approved by the Credentials Committee and reported to the Medical Center Operating Board Quality Subcommittee;

b. Review regularly and at random, the results of FPPE and OPPE on individual practitioners;

c.  Make recommendations to the Credentials Committee regarding the status of the FPPE and OPPE process in the clinical departments.

d.  Make recommendations to the clinical departments as to how they could improve the FPPE and OPPE processes.

e. Review the results of all FPPE and OPPE processes which result in recommendations for restriction of privileges or practice.

f. Submit an annual report to the Credentials Committee concerning compliance with the requirements of Medical Center Policy 0279.

g. Review and recommend revisions of Medical Center policy regarding Professional Practice Evaluations periodically or as required by regulations or accrediting bodies;

h.  Maintain confidentiality of Professional Practice Evaluation data, documents and work products.

I. Investigate global triggers as stated in Policy 0279 and outlined below:
(i) a report in writing describing concerns related to the ability of a practitioner to provide safe quality patient care, submitted as described below;
(ii) mortality measures: Unexpected death, death in low mortality diagnosis-related groups, severity-adjusted mortality index +2 SD from peer group mean, assignation of preventable or potentially preventable death upon mortality review.
(iii) morbidity measures. Unexpected serious injury, new onset peri-procedural myocardial infarction, neurologic injury or renal failure (based on number and nature as compared to peers), aggregate complication rate for invasive procedures + 2 SD from peer group mean.
(iv) sentinel events (as defined by Joint Commission) if the root cause analysis suggests the event may have been precipitated by cognitive or behavioral deficit of the practitioner.
(v) excessive number of patient complaints as determined by Departmental QI evaluation;
(vi) quality report trends and patterns involving concerns about a practitioner's performance, including professional behavior (based on nature and number);
(vii) concerns about practitioner health or fitness to practice as determined by the Department Chair, Division Chief or the Physician Wellness Program;
(viii) pharmacy interventions about a practitioner's prescribing compared to peers (number and nature of intervention concerning allergies/intolerance, drug-drug interactions or weight-based/cumulative dosing);
(ix) concerns about patterns/trends in rate-based indicators in the quarterly Physician Dashboard, e.g. (a) unplanned readmission within 30 days for complication or incomplete management of problem during previous admission (allocation to the appropriate attending physician), (b) use frequency of reversal agents, (c) severity adjusted length of stay indices, (d) cost per cases indices, or (3) F09/DBN rates, with + 2 SD from peer group or department mean;
(x) aggregate rate of medical record deficiencies as compiled through electronic authentication audits;
(xi) cases that deviate significantly from established clinical practice or operational standards/guidelines established by the Quality, Patient Care or Credentials Committee, e.g. usage of restraints, anticoagulants, DVT/PE prophylaxis, informed consent, infection control policies and procedure, new privilege and low volume practitioner policies;
(xii) cases determined through departmental quality/peer review group to warrant FPPE
(xiii) initiation of an investigation by the Department of Health professionals or an action taken by the Virginia Board of Medicine, the Virginia Board of Dentistry or the Virginia Board of Psychology and based upon the nature of the complaint and the action taken.

Department or Division specific:
(i) any area of competency regularly reviewed as a component of an Ongoing Professional Practice Evaluation for which an individual practitioner is outside the Clinical Department or Division benchmark standards, or for whom an unfavorable trend is noted over two cycles of the Ongoing Evaluation; or
(ii) other triggers as specifically defined by the Clinical Department Chair or Division Chief for that Department or Division.

Attendance will be kept for meetings of the Professional Practice Evaluation Committee.  Members who do not maintain attendance at 50% of the meetings over a six month period will be replaced.

Meetings: The Professional Practice Evaluation Committee shall meet monthly or as otherwise deemed necessary by the Chair of the Committee but not less than quarterly.

Membership:
The Chair and voting members shall be appointed by the President of the Clinical Staff and Vice President and Chief Executive Officer of the Medical Center and shall include representatives from the Credentials Committee.   The Professional Practice Evaluation Committee shall report jointly to the Credentials Committee.

Staff support will be provided by the Clinical Staff Office.

Voting Members

Christian Chisholm, M.D., Chair Obstetrics & Gynecology
Reid Adams, M.D. Surgery
Robert S. Gibson, M.D. President, Clinical Staff
Diane Pappas, M.D. Pediatrics
Catherine A. Leslie, M.D. Psychiatry
Clint Merritt, MD
General Medicine/Hospitalist
C. Edward Rose, M.D. Medicine
Jason Sheehan, M.D. Neurosurgery
Scott Syverud, M.D. Chair, Credentials Committee
John D. Voss, M.D. Medicine
Gilbert Upchurch,Jr.,  M.D. Surgery
Jeff Young, M.D. Chief, Quality
Non Voting Members

Stephanie Allen Director, Clinical Staff Office
Tracey Hoke, MD Chief, Quality & Performance Improvement
Stacy Crowell Director, Quality & Performance Improvement
Fred Jung, RN, PhD, CPHQ Administrator, Quality & Performance Improvement
Lynne Fleming, Esq
General Counsel