10.07.01.22

.22 Practitioner Performance Evaluation.

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 hospitalís 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 patientís 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.