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AHP Peer Evaluation Subcommittee

Administration:  Denise Stancil, 924-9055
Co-Chairs:  Tucker Gleason, PhD, and Gary Cuccia, CRNA

The Allied Health Professionals Peer Evaluation Subcommittee (AHPPES) is responsible for overseeing the ongoing evaluation of the adequacy and quality of professionals services, as well as the competency and qualifications for professional AHP privileges.  Regular reports and recommendations for follow-up action are made to the Credentials Committee and Allied Health Professionals Subcommittee for further consideration.  All proceedings, minutes, records and reports of the AHPPES process are privileged and confidential to the full extent authorized by Virginia Code 8.01-581.17 and are also exempted from production under Section 2.2-3705.1(1) of the Virginia Freedom of Information Act. 

The AHP Peer Evaluation Subcommittee Shall:
a.  Assure that the AHP Peer Review Evaluation is conducted in a manner that is objective, equitable and consistent. The Subcommittee shall require that (i) performance review is based on  pre-selected indicators; (ii) reviews are performed by subcommittee in accordance with established procedure that has been reviewed and recommended for approval by the Professional Practice Evaluation Subcommittee; (iii) follow up is conducted in accordance with procedures approved by the Credentials Committee and reported to the Medical Center Operating Board Quality Subcommittee;

b. Regularly review the results of FPPE and OPPE reports on individual AHP practitioners;

c.  Make recommendations to the Credentials Committee regarding the status of the FPPE and OPPE process in the clinical departments and by the Medical Directors/Managers within the Medical Center and outreach practices;

d.  Make recommendations to the clinical departments and Medical Directors/Managers with the Medical Center and outreach practices as to how they could improved the AHP FPPE and OPPE processes.

e.  Review the results of all AHP FPPE and OPPE processes which result in recommendations for restriction of AHP privileges or practice.

f.  Submit an annual report to the Credentials Committee concerning compliance with the requirements of Medical Center Policy 0280.

g.  Review and recommend revisions of Medical Center policy regarding AHP Professional Practice Evaluations periodically or as required by regulations or accrediting bodies;

h.  Maintain confidentiality of AHP Professional Practice Evaluation data, documents and work products;

i.  Develop processes to measure and then investigate as relevant and available global triggers as stated in Policy 0280 and outlined below:
- in a report in writing describing concerns related to the ability of a practitioner to provide safe quality patient care, submitted as described below;
- morbidity measures; unexpected serious injury, sentinel events (as defined by the Joint Commission), if the root cause analysis suggests the event may have been precipitated by cognitive or behavioral deficits of the practitioner
- excessive number of patient complaints as determined by a departmental quality evaluation
- quality report trends and patters involving concerns about a practitioners performance, including professional behavior (based upon nature and number of concerns)
- concerns about practitioner health or fitness to practices as determined by the department chair, division chief or physician wellness program
- pharmacy interventions about a practitioner's prescribing compared to peers (number and nature of intervention concerning allergies/intolerance, drug-drug interactions or weight-based/cumulative dosing)
- aggregate rate of medical record deficiencies as compiled through electronic authentication audits
-  cases that deviate significantly from established clinical practice or operational standards/guidelines established by the Quality, Patient care or Credentials Committees, e.g., usage of restraints, anticoagulants, DVT/PE prophylaxis, informed consent, infection control policies and procedures, new privileges and low volume practitioner policies
- cases determined through departmental quality/peer review group to warrant FPPE completion
- initiation of an investigation by the Department of Health Professionals or an action taken by the Virginia Baord of Medicine, the Virginia Board of Dentistry or the Virginia Board of Psychology and based upon the nature of the complaint and the action taken;

Department/Division or Medical Center Unit Specific:
- benchmark standards or an unfavorable trend, or
- other triggers as specifically defined by the department chair, division chief or medical director within the Medical Center or outreach practice.

Gary Cuccia, CRNA, Co Chair Anesthesiology
Tucker Gleason, PhD, Co Chair Otolaryngology
Kathryn Cathcart, PA Neurology
David Strider, ACNP Surgery
Matthew Robertson, ACNP Surgery
Yvonne Newberry, FNP OB/GYN
Tom Szabo, PA Neurosurgery
Lynn Fleming, JD General Counsel
Denise Stancil Clinical Staff Office
Stephanie Allen Clinical Staff Office