REVIEW / APPROVAL SUMMARY REVIEW / REVISION DATES PRIOR TO POLICY TECH : N / A COMMENTS :
LAST REVIEW DATE : 11 / 12 / 24 |
NEXT REVIEW DATE : 11 / 12 / 26 |
APPROVAL BODY ( IES ): Peer Review |
APPROVAL DATE : 11 / 12 / 24 |
Committee ( QPRC ), MEC |
Appendix A : Indicators for Referral
The Indicators for Referral are a set of events that trigger a possible peer review . These indicators are reviewed annually by the Medical Staff and may be revised in the interim by a Medical Staff approved process . The listed indicators should be considered for inclusion in OPPE and other professional practice evaluations . These are recommendations and not requirements .
A . General Indicators ( i . e ., applicable to all specialties )
1 . Case Review : a . Sentinel events ; b . Questionable care or deviation from Generally Accepted Practice ( GAP ); c . Missed or significantly delayed diagnosis ; d . Undesirable trend or practice pattern ; e . Unplanned transfer to a higher level of care ; f . Unplanned readmissions within 30 days ; g . Failure to respond in a timely fashion ; h . Unexpected death , i . e ., death with low severity-adjusted level , ( e . g ., 1 or 2 ). i . Exclusion considerations : 1 . admission for palliative care / hospice care . ii . Inclusion criteria for mod-high severity-adjusted level : 1 . potential delay in diagnosis or treatment ; 2 . unplanned removal / injury of an organ during a procedure ; 3 . unintended lack of treatment of significant metabolic or hemodynamic abnormalities ; 4 . complaints and / or grievances concerning quality of care ; 5 . Physician / APP , committee , administrative , nursing or staff referrals ; 6 . notices of lawsuits or claims involving Physicians / APPs .
2 . Rule Indicators ( No . in parenthesis indicates threshold for escalation to QPRC for consideration of progressive steps ): a . non-compliance with Medical Staff Bylaws , Policies , Guidelines or Protocols ( 3 ); b . Inadequate or missing required documentation : i . History & Physical or History & Physical procedural update ( 3 ); ii . Consultation ( 3 ); iii . Progress Note ( 3 ); iv . Operative Note ( 3 ); v . Discharge Summary ( 3 ).
3 . Rate Indicators :