UNIVERSITY HOSPITAL
Medical Staff
Policy & Procedure
Policy Title:
Policy #:
Quality Case Analysis
MS-17
(Ongoing Professional Practice Evaluation-OPPE)
Effective Date
09-17-02
Approved by:
____________________________
Chief Medical Officer
____________
Date
Approval Authority:
MEC
Pages
5
Reviewed/Revised:
8/15/06
08/21/07
11/7/07
01/15/08
3/2014
OBJECTIVE:
Medical Staff case analysis is one mechanism to not only improve the quality of care at University Health Care
System but to also provide a mechanism for the ongoing evaluation of practitioner competency; in addition it
provides a consistent way to assess adequacy of professional health care practices and processes, including
system performance, medical management, care delivery and physician competence. Another avenue of
conducting ongoing practitioner evaluation is through utilization of the National Practitioner Data Bank’s
Proactive Disclosure Service.
SCOPE:
An issue for review may surface/be identified as a result of specific criteria identified by each medical staff
department (Medicine, Surgery, Cardiology, etc.) as well as other potential sources such as sentinel event
reports, variance reports, mortality and morbidity reviews, undesirable outcomes per Medical Staff criteria,
blood reviews, Pathology reports, Pharmacy reports, Medical Management reports, Infection Control reports,
Risk Management reports, or qualified concerns from ancillary departments. The Proactive Disclosure Service
offered by the National Practitioner Data Bank provides e-mail notifications within 24 hours of a data bank
report being filed making ongoing monitoring of practitioners possible.
PROCEDURE:

Sources of referral for case analysis may be:
1.
2.
3.
4.
5.
6.
7.
8.
Medical Staff Office
Case Management
Nursing
Medical Staff Department Chairs and/or medical staff department members
Risk Management
Pharmacy
Variance Reports
Other ancillary departments

Referrals from the above sources shall be forwarded to the Medical Staff Office for review.

The Case Analysis Referral Form is completed and forward it to the Chief Medical Officer or designee
for review to determine if the referred case requires further review.

If the CMO or designee determines the case requires further review, the case will be referred to the
Quality Case Analysis. A copy of the Case Analysis Referral Form is attached to this policy as
Addendum A.

Where issues of physician competencies arise, the physician involved will be notified of the review of
his/her case at which time he/she will be given the opportunity to provide additional documentation to
the Quality Case Analysis prior to a decision of final disposition.
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
A Quality Case Analysis has been formed to serve as the medical staff peer review committee The
members of this committee serve as the physician review panel and have been assigned by usual
processes outlined in the bylaws for committee assignment by Medical Executive Committee.

Once the case has been reviewed within the specified time frame the details of the review will be
entered into the PI database. A copy of the Case Analysis Referral Form will be sent to the
physician(s) involved in the case review and will become a part of the performance profile of the
physician(s).

The Physician Profile shall serve as the document for an ongoing physician peer review report card
and shall be reviewed as least semi-annually and at the time of reappointment. A physician profile
has been created for each physician with individual physician data, comparison data for all UH
physicians in the profiled physician’s specialty and, where available, an external benchmark or
performance target. (Addendum B)

The type of data to be collected is determined by individual departments and reviewed/revised as
appropriate with department chair.

For those low/no volume practitioners, he/she will be required to submit the name of a peer who
has directly observed his/her clinical activity at another location during the defined time period;
sign a new release form allowing the hospital to obtain the requested information; and the
designated peer will be asked to complete and return a low/no volume proctoring form to assess
the physician’s ongoing competency to the Medical Staff Office.

Information in the Performance Improvement database, physician's performance profile, or any
information submitted through the low/no volume proctoring form shall be accessible to individuals
appointed to conduct case analysis by University Health Care System Department Chief, Chief
Executive Officer, Medical Executive Committee, and Credentials Committee.

The Quality Case Analysis shall determine the disposition of the cases: trend or recommend to MEC
the initiation of formal Peer Review or external Peer Review

The physician involved in the review will be provided the opportunity to dispute questions of physician
performance or competence.

A summary of case analysis activities will be presented at a minimum of annually to the Quality Case
Analysis.
This policy is not intended to and does not establish the only route by which issues may be brought to the
Medical Staff Executive Committee for action under Article IXX of the Medical Staff Bylaws. Background
information regarding external and peer review is attached as Addendum C. No failure to comply with this
policy shall prejudice the ability of the Medical Staff Executive Committee to make any recommendation as
described at Article III Part C Section III of the Medical Staff Bylaws or prejudice the ability of the Governing
Body to take final action as described in Article IXX of the Medical Staff Bylaws.
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ADDENDUM A
CASE ANALYSIS REFERRAL
Date Assigned:
Assigned To:
M.R. #
Age
Sex:
__M
__F
E.R.
Admission
_Y
__N
Adm Date
Physician/Practitioner:
D/C Date
Consultants:
Reason for Review:
Reported Concern
Specify:________________________
Patient Complaint
Specify:________________________
Quality of Care Concern
Specify:________________________
Litigation Risk
Specify:________________________
Medical Necessity
Specify:________________________
Sentinel Event
Specify:________________________
Other
Specify:________________________
Summary of Event/Key issues for physician :
To be completed by Physician Reviewer:
COMMUNICATION/HANDOFFS
Yes
Are there indications that communication problems or
breakdowns between or among care givers or hospital
departments contributed or could have contributed to
an adverse outcome?
If yes, please explain:
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No
Na
SYSTEM IMPROVEMENT
Yes
No
Na
Are there indications that system processes or procedures
contributed or could have contributed to an adverse outcome
for the patient?
If yes, please explain including the identification of any process changes or rules that need to be created
or enforced to minimize the reoccurrence of this event? Please summarize below.
COMPLICATONS
Yes
No
Na
Were complications recognized and managed appropriately?
If no, please explain
ASSIGNMENT OF CASE DISPOSITION:
_____________________________________________________________________
√
Outcome
√
Morbidity & Mortality Category
0-Variation from criteria/indicator; case found
No Injury
acceptable after review (no issues)
1-Variation
caused
by
inadequate
Injury: ___Minor ___Moderate
documentation (no issues)
___Major
2-Variation is unusual (However, professional
Modification of Care ___Increased LOS
opinion & current practice vary regarding
this issue. No major quality issues.)
3-Variation unexpected (Summary of care will
Modification of Care ___Higher Level of
be presented to the Quality Case Analysis
Acuity
Committee
4-Variation unacceptable (Summary of care will
be presented to the Quality Case Analysis
Committee
Death
Physician Reviewer's Printed Name: ___________________________________________
Signature: ____________________________________________
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Addendum B
MEASURES & CRITERIA
UNIVERSITY HOSPITAL PHYSICIAN PROFILER
GENERAL
Each profile displays physician displays individual physician data, peer norm, benchmark and peer
benchmark- see definitions below. The descriptions of the content for the majority of provider profiles are
included below; other profile data may also be added when indicated to include cost detail, cost index,
charge detail, charge index, payer volume and core measures. Additional reports are attached to the
profile to include procedures, consults and physician’s contribution to core measure outcomes that do not
meet guidelines.
LOS INDEX, MORTALITY INDEX, COMPLICATION INDEX, READMISSION INDEX
NORM
Norm represents how the physician is performing
compared to the National Average on the specific
metric. This displays as an observed to expected
ratio or index.
Peer Norm represents how the other physicians
included in the profile are performing compared to
the National Average on the specific metric.
PEER NORM
BENCHMARK
Benchmark represents how the physician is
performing compared to the Top Ten percent
Benchmark group selected on the Measures screen.
Peer Benchmark represents how the other physicians
included in the profile are performing compared to
the Top Ten Percent Benchmark group selected on
the Measures screen.
PEER BENCHMARK
LOS Detail-Norm
CASE LOAD
Average LOS
The case load for the physician and peer group.
Average length of stay for the physician and peer
group.
Average Norm or Benchmark
The average length of stay we would have expected
for these patients at the rate of the U.S. National
average or selected benchmark.
Opportunity
Opportunity is calculated by subtracting the average
LOS from the average norm (expected LOS as
compared to the US National average)

A number greater than one indicates an area
for improvement and is represented in red.
 A number less than one indicates a strength
and is presented in green.
 A value of exactly one indicates a
performance level of the National Average or
Benchmark.

Cells that are pale purple are statistically
significant.
The ratio between the actual LOS and the expected
LOS (as compared to the US National average)
 A number greater than one indicates an area
for improvement and is represented in red.
Index
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


A number less than one indicates a strength
and is presented in green.
A value of exactly one indicates a
performance level of the National Average or
Benchmark.
Cells that are pale purple are statistically
significant.
Lower limit
Complication Detail -Norm
CASE LOAD
Observed
The lower limit to calculate Statistical Significance.
Norm or Benchmark
The number of complications we would have
expected for these patients at the rate of the U.S.
National average or selected benchmark.
Opportunity
Opportunity is calculated by subtracting the observed
complications from the norm(expected complications
as compared to the US National average)
The case load for the physician and peer group.
The actual number of complications for the physician
and peer group. (list of defined complications
attached)

A number greater than one indicates an area
for improvement and is represented in red.
 A number less than one indicates a strength
and is presented in green.
 A value of exactly one indicates a
performance level of the National Average or
Benchmark.

Cells that are pale purple are statistically
significant.
The ratio between the actual complications and the
expected complications(as compared to the US
National average)
 A number greater than one indicates an area
for improvement and is represented in red.
 A number less than one indicates a strength
and is presented in green.
 A value of exactly one indicates a
performance level of the National Average or
Benchmark.
 Cells that are pale purple are statistically
significant.
Index
Lower limit
Upper limit
Mortality Detail -Norm
CASE LOAD
Observed
The lower limit to calculate Statistical Significance.
The upper limit to calculate Statistical Significance.
Norm or Benchmark
The number of mortalities we would have expected
for these patients at the rate of the U.S. National
average or selected benchmark.
Opportunity
Opportunity is calculated by subtracting the observed
mortality from the norm(expected mortality as
compared to the US National average)
The case load for the physician and peer group.
The actual number of mortalities for the physician
and peer group.
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
A number greater than one indicates an area
for improvement and is represented in red.
 A number less than one indicates a strength
and is presented in green.
 A value of exactly one indicates a
performance level of the National Average or
Benchmark.

Cells that are pale purple are statistically
significant.
The ratio between the actual mortality and the
expected mortality(as compared to the US National
average)
 A number greater than one indicates an area
for improvement and is represented in red.
 A number less than one indicates a strength
and is presented in green.
 A value of exactly one indicates a
performance level of the National Average or
Benchmark.
 Cells that are pale purple are statistically
significant.
Index
Lower limit
Upper limit
The lower limit to calculate Statistical Significance.
The upper limit to calculate Statistical Significance.
Readmission Detail -Norm
Cases
Index
Total number of cases that were readmitted by day
Readmission Index:
 An index of 1.0 indicates performance
equaling that of the compare group.
 An index of <1.0 indicates performance is
better than that of the compare group
 An index of >1.0 indicates performance is not
as good as the compare group.
Readmission the same day or as indicated-1-7, 8-14,
15-30, 1-30, 0-30 days from the day of discharge
Same day
1-7 day
8-14
15-30
1-30
0-30
Opportunity is calculated by subtracting the observed
complications from the norm(expected complications
as compared to the US National average)




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A number greater than one indicates an area
for improvement and is represented in red.
A number less than one indicates a strength
and is presented in green.
A value of exactly one indicates a
performance level of the National Average or
Benchmark.
Cells that are pale purple are statistically
significant.
Lower limit
Upper limit
The lower limit to calculate Statistical Significance.
The upper limit to calculate Statistical Significance.
DEFINITIONS
The Board delegates the oversight for the quality of patient care to the medical staff. Although peer review is
considered a medical staff function, it can be applied to other health care professionals at UHCS. The peer
review is an evaluation by unbiased peers (practitioners). No health care provider shall be required to perform
peer review outside of his/her area of expertise. A “peer” as described in the Medical Staff Bylaws is “a
professional health care provider as defined by Georgia law at Official Code of Georgia Section 31-7-131. The
legal term peer, in GA, includes any physician, dentist, podiatrist, psychologist, pharmacist, nurse, physical
therapist, occupational therapist, or health care faculty administrator licensed by the state of Georgia or any
other state.” All activities undertaken pursuant to this policy are considered confidential and protected from
disclosure in accordance with the Official Code of Georgia.
External review of the issue may be warranted in circumstances where there are not sufficient number of
peers able or willing to conduct the peer review or other factors exist which make external review desirable.
The decision to conduct an external review and the resources to be used shall be made by the CEO, Chief of
the Medical Staff and the Department Chairman. This decision shall be made within a reasonable time after
the need for an external review of the complaint is raised. The results of the external review shall be reported
to the Medical Executive Committee.
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