vii . The reviews , supporting documentation and final determinations will be tracked in the Renown- approved peer review tool . viii . Pertinent information regarding Professional Practice Evaluation activities will be maintained in the Physician ’ s / APP ’ s Quality file and incorporated into the evaluation of current competence during the reappointment process .
5 . RULE AND RATE INDICATORS a . Rule Violations ( System / Documentation Issues ): Rule violations occur when a required processes or documentation is not performed . As the compliance is binary , i . e . yes or no , the PRC or QPRC Chair will determine if a rule violation occurred without further QPRC discussion . A letter of guidance or reprimand will be sent to the Physician / APP . Repeated rule violations will be escalated to QPRC discussion for consideration of progressive steps . b . Rates ( Frequency / Statistical analysis ): Rates of adverse clinical outcomes are utilized when they are timely , reliable , pertinent , and more appropriate than case reviews . Appropriate rates include known complications or situations not entirely under the control of the Physician / APP such as readmission rates , post-operative hemorrhage or venous thromboembolism . No specific patient records are evaluated initially , unless warranted . As possible and applicable , rates will be provided with the rates of the section , hospital , Renown Health system , or national rates or benchmarks to allow comparison and screen for potential concerning variations . The intent of rate monitoring is to identify opportunities for constructive intervention to achieve optimal outcomes and avoid future significant adverse outcomes . c . Notification and Escalation : A letter of inquiry / guidance will be sent to the Physician / APP when a rule violation or significant variation from an expected rate occurs . Repeated rule violations ( as defined in Appendix A ) or rate variations that do not improve or are of particularly serious concern will warrant a more thorough review of the practitioner ’ s care by the QPRC .
6 . External Case Reviews a . External case review will involve the use of a Physician / APP consultant with similar training who is not a member of the Medical / APP staff . b . An external peer review will be conducted when the QPRC or MEC has determined one or more of the following : i . The Medical Staff does not possess adequate the required expertise to evaluate the concerns ; ii . The only Physicians / APPs on staff with the specialty expertise have or would be perceived to have a significant conflict of interest ; iii . No determination can be made based on internal conflicting assessments ; or iv . There is concern that the outcome of the review may invoke a fair hearing or legal actions . c . External review may be requested by the Physician / APP under review , the QPRC , the Medical Staff Leadership ( Chief of Staff , Department Chair ), VP of Quality , or the Hospital ’ s Senior Leadership ( CEO , CMO / VPMA or CNO ). External Case review requests must be approved by one of the following : i . The MEC ; ii . The QPRC ; or iii . A consensus of the CMO / VPMA , the Chief of Staff , and the Chair of the QPRC . d . Professional External Review will be coordinated only with Renown-contracted companies . e . Role of the VP of Quality and Quality Director : i . The VP of Quality and / or Quality Director will coordinate with the QCs and PRC to initiate the appropriate Renown-approved contract with the external reviewer prior to releasing any medical records . A copy of the medical records will be prepared and sent in a manner that is HIPAA compliant utilizing certified mail or secure electronic communication .