iv . The Physician / APP will be given fourteen ( 14 ) days from the date of the email , if there are no mitigating factors , to provide a written response ( e-mail ) to the QPRC . v . If a written response is not received in the required timeframe , the QPRC may complete its evaluation without the Physician ’ s / APP ’ s additional information . The QPRC may also invite Physicians / APPs to appear in person , in lieu of or in addition to a written response . d . QPRC Case Reviews : The QPRC will approve the consent agenda including all cases with “ no concern ”, unless the members of the QPRC request that a specific case be moved to the main agenda for further discussion . The QPRC will then review each case review with concerns or “ no concern ” pulled from the consent agenda . The QPRC will carefully consider the materials presented including the Physician ’ s / APP ’ s clarifying letter before making a final determination : i . Exemplary care ; ii . No improvement opportunity ; iii . Minor improvement opportunity ; iv . Moderate improvement opportunity ; or v . Major improvement opportunity . e . Safety Event Classification ( SEC ) and Coordination with Patient Safety ( Appendix C ): Renown Health ’ s journey to achieve zero preventable harm is dependent on the coordination between the Medical Staff and Hospital Quality Department to identify lessons learned from events of harm and near misses . These events represent opportunities to create an environment conducive to safe patient care . At the same time , the protections of peer review must be maintained . If when scoring case reviews , the QPRC determines that a deviation from Generally Accepted Practice ( GAP ) did occur , physician / APP related or not , and a serious , precursor or near miss safety event occurred , it will determine a SEC score . This score will be shared with the CMO / VPMA and the PRC . The information shared shall consist only of the SEC score without assignment of blame , i . e ., hospital process , equipment , nursing or physician / APP related . f . When an opportunity for improvement is identified , the QPRC will consider the Just Culture Algorithm ( Appendix D ) in making its determination and require one or more of the following actions , using the continuum of progressive steps ( Appendix E ): i . Acknowledgment letter of self-directed learning or intervention ; ii . Letter of guidance , counsel , warning or reprimand ; iii . Educational letter ; iv . Collegial interventions , which may include , but are not limited to , counseling , sharing of comparative data , monitoring , and additional training and education ; or v . For Cause Focused Professional Practice Evaluation ( FPPE )); may include , but not be limited to one or more of the following : a ) retrospective chart review ; b ) concurrent monitoring ; c ) second opinions or consultations ; d ) proctoring ; e ) structured education or CME ; or f ) formal psychological and competency assessment and / or training program . * FPPEs may be shared with the Department Chair and Practice Leadership as warranted to facilitate successful completion and ensure patient safety .
vi . Any FPPE that is non-voluntary , involves modification of privileges , provides grounds for a hearing , or requires reporting to the Board of Medical Examiners or National Practitioner Data Bank will require referral and approval by the MEC and will be addressed according to the Medical Staff Credentials Policy