HospitalInspections.org

Based on interview and record review, the facility failed to ensure semiannual evaluations were completed for 1 of 3 physician records reviewed.

Failure to complete the performance evaluations as required potentitally puts patients at risk for harm from receiving care from a physician which may not have the required skill to perform their job safely.


Findings include:

1. The facility policy entitled "HMC (Harborview Medical Center) Ongoing Professional Practice Evaluation" effective 1/7/2010 and revised 3/2011 read in part "The ongoing provider performance review process at HMC assesses pertinent information including medical/clinical knowledge, technical and clinical skills, interpersonal and communication skills, professionalism, clinical judgement, patient satisfaction, and documentation requirements, as the data is available on an ongoing basis".

"Ongoing Professional Practice Evaluation (OPPE) attestations for all medical staff are sent to the Service Chief semiannually. The Service Cheif signs off acknowledging he/she has reviewed department specific quality and competency information to a satisfactory degree. Any quality or professionalism concerns are detailed on the OPPE attestation and followed up in subsequent reviews".

2. Physician #1 was an Associate Member of the Medical Staff. The physician was last reviewed in October 2015. Documentation revealed the physician had an "OPPE" evaluation only annually.

3. On 8/18/2016 at 9:00 AM the Medical Director (Staff A) stated the practice was to complete a "OPPE" attestation for active medical staff semiannually

3. The above information was verified with the Associate Director of Medical Staff Appointments (Staff B) and the Medical Director (Staff A) on 8/18/2016 at 9:30 AM.