Regulation .22 Practitioner Performance Evaluation.
Regulation .22 Practitioner Performance Evaluation.LinkCopy Citation
A.
Consistent with the standards of the Joint Commission for focused and ongoing professional performance evaluations, the hospital shall establish a practitioner performance evaluation process that objectively evaluates the performance of each member of the medical staff.
B.
The hospital’s practitioner performance evaluation process shall include a review of care which shall:
(1)
Be undertaken for cases:
(a)
Chosen at random; and
(b)
With unexpected adverse outcomes;
(2)
Be based on objective review standards;
(3)
Include a review of the appropriateness of the plan of care for the patient, particularly any medical procedures performed on the patient, in relation to the patient’s condition; and
(4)
Be conducted by members of the medical staff, or at the discretion of the hospital, by external reviewers, who:
(a)
Are of the same specialty as the member of the medical staff under review;
(b)
Have been trained to perform practitioner performance evaluation; and
(c)
Are not otherwise associated with the case under review.
C.
A hospital shall take into account the results of the practitioner performance evaluation process for a member of the medical staff in the reappointment process.