1. SRH Peer Review

2. 2 Project Overview Project goal and Aim : Project goal and Aim : The establishment of a centralized committee for improving physician performance on an individual and aggregate level is to accomplish the following goals: The establishment of a centralized committee for improving physician performance on an individual and aggregate level is to accomplish the following goals: Improve patient outcomes Improve patient outcomes Enhance physician performance Enhance physician performance Increase efficiency of the process for the medical staff Increase efficiency of the process for the medical staff Support medical staff educational goals through referrals of interesting cases to CME conferences Support medical staff educational goals through referrals of interesting cases to CME conferences Efficient use of physician and quality staff resources Efficient use of physician and quality staff resources Start date: Start date: January 2006 January 2006

3. 3 Project Overview Project charter or brief description Project charter or brief description The Physician Excellence Committee (PEC) will be responsible for evaluating and improving physician performance in the following areas: The Physician Excellence Committee (PEC) will be responsible for evaluating and improving physician performance in the following areas: Technical Quality: Skill and judgment related to effectiveness and appropriateness in performing the clinical privileges granted Technical Quality: Skill and judgment related to effectiveness and appropriateness in performing the clinical privileges granted Service Quality: Ability to meet the customer service needs of patients and other care caregivers Service Quality: Ability to meet the customer service needs of patients and other care caregivers Patient Safety/Patient Rights: Cooperation with patient safety and rights, rules and procedures Patient Safety/Patient Rights: Cooperation with patient safety and rights, rules and procedures Resource Use: Effective and efficient use of hospital clinical resources Resource Use: Effective and efficient use of hospital clinical resources Relations: Interpersonal interactions with colleagues, hospital staff and patients. Relations: Interpersonal interactions with colleagues, hospital staff and patients. Citizenship: Participation and cooperation with medical staff responsibilities Citizenship: Participation and cooperation with medical staff responsibilities

4. 4 Project Overview Members of the Committee Members of the Committee Medical Staff President Medical Staff President Chair of Credentialing Chair of Credentialing Medical Director Medical Director Chief Nursing Officer Chief Nursing Officer Director of Performance Outcome Services or Designee Director of Performance Outcome Services or Designee Clinical Data Coordinator/ex-officio without vote Clinical Data Coordinator/ex-officio without vote CEO/ex-officio without vote CEO/ex-officio without vote Nine members reflective of the current Medical Staff Nine members reflective of the current Medical Staff At large members of the MEC may attend as guests At large members of the MEC may attend as guests Serve a three year term Serve a three year term Monthly meetings Monthly meetings Attendance required at least two thirds of the meetings Attendance required at least two thirds of the meetings Reports to the Medical Executive Committee Reports to the Medical Executive Committee

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6. 6 Success Factors & Lessons Learned Keys to success Keys to success Medical Staff Involvement – one on one meetings with Chairman of each department to explain the process and the indicators for each department Medical Staff Involvement – one on one meetings with Chairman of each department to explain the process and the indicators for each department Letting the Departments decide on their own indicators and what the targets should be Letting the Departments decide on their own indicators and what the targets should be Barriers to success Barriers to success Communication gap about clinical indicators and acceptable targets Communication gap about clinical indicators and acceptable targets Collection of all data elements – not one source for all indicators Collection of all data elements – not one source for all indicators Lessons learned Lessons learned Getting the right physicians on the committee Getting the right physicians on the committee Reporting formats and how best to explain what the committee is collecting and what it means Reporting formats and how best to explain what the committee is collecting and what it means

7. 7 Next Steps Development of a database to house all of the aggregate data and information Development of a database to house all of the aggregate data and information Incorporating all of the chosen indicators into the collection and reporting steps of the process Incorporating all of the chosen indicators into the collection and reporting steps of the process

8. 8 Contact Information Leisa Butler, RHIA, CPHQ Leisa Butler, RHIA, CPHQ Self Regional Healthcare Self Regional Healthcare 1325 Spring Street Greenwood, SC 29646 864-725-4746lbutler@selfregional.org