i.
j.
k.
l.
Analyze and profile data regarding the measurement of patient treatment functions by service and practitioner, where appropriate;
Provide routine summaries of the above analyses and recommend process improvement when opportunities are identified;
Serve as an advisory group to the Hospital and medical staff pertaining to the choice of available medications; and
Establish standards concerning the use and control of investigational medication and of research in the use of recognized medication.
1.2.11 Practitioner Health a.
b.
c.
d.
e.
Evaluate the credibility of a complaint, allegation, or concern and establish a program for identifying and contacting practitioners who have become professionally impaired, in varying degrees, because of drug dependence( including alcoholism) or because of mental, physical, or cognitive impairment. Refer the practitioner to appropriate professional internal or external resources for evaluation, diagnosis, and treatment;
Establish programs for educating practitioners and staff to prevent substance dependence and recognize impairment;
Notify the impaired practitioner’ s Department Chief and the MEC whenever the impaired practitioner’ s actions could endanger patients;
Create opportunities for referral( including self-referral) while maintaining confidentiality to the greatest extent possible; and
Report to the MEC all practitioners providing unsafe treatment so that the practitioner can be monitored until his / her rehabilitation is complete and periodically thereafter.
1.2.12 Utilization Management a.
b.
c.
Study recommendations from medical staff members, quality assessment coordinators and others to identify problems in utilization and the review program;
Monitor the effectiveness of the review program and perform retrospective review in cases identified through the utilization management process;
Forward all unjustified cases in any review category to the appropriate Department or committee for review and action;
d. Review case-mix financial data and any other internal / external statistical data;
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