# COMAR Title 10 — Maryland Department of Health

## Subtitle 07 — Hospitals

### Chapter 01 — Acute General Hospitals and Special Hospitals

#### Regulation .22 Practitioner Performance Evaluation.

*COMAR 10.07.01.22*

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.