The organized medical staff defines the circumstances requiring monitoring and evaluation of...

(1)

The organized medical staff develops and consistently implements criteria to be used for evaluating the performance of physicians or other licensed practitioners when issues affecting the provision of safe, high-quality patient care are identified.

(2)

A period of focused professional practice evaluation is implemented for all initially requested privileges.

(3)

The performance monitoring process is clearly defined and includes each of the following elements: - Criteria for conducting performance monitoring - Method for establishing a monitoring plan specific to the requested privilege - Method for determining the duration of performance monitoring - Circumstances under which monitoring by an external source is required

(4)

The triggers that indicate the need for performance monitoring are clearly defined. Note: Triggers can be single incidents or evidence of a clinical practice trend.

(5)

Criteria are developed that determine the type of monitoring to be conducted.

(6)

The measures employed to resolve performance issues are clearly defined.

(7)

The measures employed to resolve performance issues are consistently implemented.