POLICY TITLE : Quality , Professional Practice and Peer Review ( Renown ) CATEGORY : Acute Care Facilities ,
ORIGINATION DATE : November 12 , 2024
Medical Staff SUB-CATEGORY : Medical Staff PUBLICATION DATE : November 12 , 2024 APPLICABLE FACILITIES : Renown Regional Medical Center , Renown South Meadows Medical Center , Renown Rehabilitation Hospital
SCOPE This policy applies to all Physicians ( MDs / DOs , Dentists , Podiatrists ) and Advanced Practice Providers ( APPs ) granted clinical privileges at Renown hospitals . This policy and the practices of the Medical Staff are consistent with the Nevada State Peer Review Statutes .
PURPOSE This policy defines the organizational structure , including the processes and procedures , of the Medical Staff by which it fulfills its Board of Directors ( BOD ) -delegated responsibility to ensure the quality and safety of the medical care provided by privileged providers , i . e . physicians and APPs . This responsibility includes ongoing and focused professional practice evaluations and other performance improvement functions .
The Medical Executive Committee ( MEC ) has delegated these responsibilities to the multi-specialty Quality , Professional Practice , and Peer Review Committee ( QPRC ). Quality , safety and professional practice oversight will be conducted in alignment with High Reliability Organization ( HRO ) principles and with the promotion of a Just Culture . In contrast , the MEC has delegated Initial Focused Professional Practice Evaluation to the Credentials Committee .
POLICY 1 . Quality , Professional Practice , and Peer Review Committee ( QPRC ): a . Responsibilities and Reporting : The QPRC is responsible for Professional Practice Evaluation as delegated by the MEC . In turn , the QPRC may authorize other medical staff committees , departments , or sections to perform peer review activities . Summary reports of such activities must be submitted to the QPRC at least twice a year . The QPRC will provide its own summary reports to the MEC and BOD at least quarterly . b . Membership and voting rights : A quorum will consist of at least three ( 3 ) physician voting members . i . QPRC Chair ( Physician ) ( voting ) ii . Physician members , at least three ( 3 ), from a cross-section of specialties ( voting ) iii . APP member ( s ), one ( 1 ) or two ( 2 ) members , of which one would preferably be a nurse practitioner ( voting ) iv . Chief Medical Officer / Vice President of Medical Affairs ( CMO / VPMA ), Chief Nursing Officer or senior nurse leader designee , VP of Quality , Quality Director , Legal services , and other senior executive members as invited ( non- voting ) v . Peer Review Coordinator ( non-voting ), and vi . Medical Staff Services representative ( non-voting ) c . Appointment of Committee Chair and Members : The committee chair and members will be appointed by the Chief of Staff in consultation with the MEC .
2 . Professional Practice Evaluation for privileged physicians and APPs will use an objective peer review