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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