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SRH Peer Review

SRH Peer Review. Project Overview. Project goal and Aim : The establishment of a centralized committee for improving physician performance on an individual and aggregate level is to accomplish the following goals: Improve patient outcomes Enhance physician performance

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SRH Peer Review

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  1. SRH Peer Review

  2. Project Overview • Project goal and Aim: • The establishment of a centralized committee for improving physician performance on an individual and aggregate level is to accomplish the following goals: • Improve patient outcomes • Enhance physician performance • Increase efficiency of the process for the medical staff • Support medical staff educational goals through referrals of interesting cases to CME conferences • Efficient use of physician and quality staff resources • Start date: • January 2006

  3. Project Overview • Project charter or brief description • The Physician Excellence Committee (PEC) will be responsible for evaluating and improving physician performance in the following areas: • Technical Quality: Skill and judgment related to effectiveness and appropriateness in performing the clinical privileges granted • Service Quality: Ability to meet the customer service needs of patients and other care caregivers • Patient Safety/Patient Rights: Cooperation with patient safety and rights, rules and procedures • Resource Use: Effective and efficient use of hospital clinical resources • Relations: Interpersonal interactions with colleagues, hospital staff and patients. • Citizenship: Participation and cooperation with medical staff responsibilities

  4. Project Overview • Members of the Committee • Medical Staff President • Chair of Credentialing • Medical Director • Chief Nursing Officer • Director of Performance Outcome Services or Designee • Clinical Data Coordinator/ex-officio without vote • CEO/ex-officio without vote • Nine members reflective of the current Medical Staff • At large members of the MEC may attend as guests • Serve a three year term • Monthly meetings • Attendance required at least two thirds of the meetings • Reports to the Medical Executive Committee

  5. Success Factors & Lessons Learned • Keys to success • Medical Staff Involvement – one on one meetings with Chairman of each department to explain the process and the indicators for each department • Letting the Departments decide on their own indicators and what the targets should be • Barriers to success • Communication gap about clinical indicators and acceptable targets • Collection of all data elements – not one source for all indicators • Lessons learned • Getting the right physicians on the committee • Reporting formats and how best to explain what the committee is collecting and what it means

  6. Next Steps • Development of a database to house all of the aggregate data and information • Incorporating all of the chosen indicators into the collection and reporting steps of the process

  7. Contact Information • Leisa Butler, RHIA, CPHQ Self Regional Healthcare 1325 Spring Street Greenwood, SC 29646 864-725-4746 lbutler@selfregional.org

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