Case Study hysician performance data for the Obstetric Service at Community Hospital of the are provided in figure 14.4. Figure 14.5 gives an example of a physician profile an individual physician, Dr. Jones. The physician index summary for Dr. Doe, an RIGYN physician on the medical staff, is provided in figure 14.6. Using the physician dex summary, students should complete as much of the information as possible on the blank physician profile (figure 14.7 for Dr. Doe). They should identify what infor- mation cannot be obtained from the physician index. Then they should determine what other sources of hospital data would have to be essed to complete the physician profile for Dr. Doe. Finally, they should compare Dr. Doe's performance with the performance of the rest of the physicians on the Obstetric Service in the areas for which data are available. (See figure 14.4.) CASE STUDY QUESTIONS 1. How did Dr. Doe perform compared to the rest of the service? 2. Should Dr. Doe be reappointed to the medical staff? Why or why not? Profile Time Frame: From: To: yyyy 12/ 3yyyy PHYSICIAN PERFORMANCE RE PHYSICIAN 08/GYN GROUP OB/GYN Active UTILIZATION: 1,400/ 5,143 SERVICE CATEGORY 598 Procedures VBACs Blood Given 154 25 Admissions Patient Days Deliveries C-Sections 1,187 137 OUTCOMES: Comments: Category C-Section Rate VBAC Rate Nosocomial Inf Rate Surgical Wound Inf Rate Mortality Rate 154 21 137 11.5 % 11% 1.596 5 0.36% 0.84 % PERFORMANCE REVIEW: # Reviewed #Appropriate/% Comments: Category Surgical/Inv/Noninvasive Procedures Medication Use Blood Use Utilization Management Other Peer Review 60 140 25 140 140 58/96.7 % 139/99.3 % 25/100 % 135/95.7% 130/92.8 % DATA QUALITY: Clinical Pert. Comments: Data Quality Monitoring Delinquency (>21 days) Suspensions 75 7.7 % 2.6% RISK/SAFETY MANAGEMENT: Comments: Incidents reported by other professionals/ Administration Litigation 2/100 % 0.07% MEETING ATTENDANCE: 26 93 % 40 85% Medical Staff Meetings Committee Meetings Comments: I To: 12/31/yyyy COMMUNITY HOSPITAL OF THE WEST PHYSICIAN PERFORMANCE REVIEW SUMMARY FOR REAPPOINTMENT PHYSICIAN Bob Jones, M.D. Profile Time Frame: SERVICE OB/GYN From: CATEGORY 1/1/yyyy Active UTILIZATION: Admissions 175 Procedures 53 Patient Days 540 VBACs 28 Deliveries 145 Blood Given 2 C-Sections 22 OUTCOMES: Category Comments: C-Section Rate 15.2 % VBAC Rate 80 % Nosocomial Inf Rate 7.71 % Surgical Wound Inf Rate 3.8 % Mortality Rate 0.57 96 PERFORMANCE REVIEW: Category # Reviewed # Appropriate/% Comments: Surgical/Inv/Noninvasive Procedures 5/83 % Medication Use 10 8/80 % Blood Use 2/100 % Utilization Management 18 18/100 % Other Peer Review N/A DATA QUALITY: Data Quality Monitoring Comments: Delinquency > 21 days) 3 12.5% Suspensions 7 4.2 96 RISK/SAFETY MANAGEMENT: Incidents reported by Comments: other professionals/ 096 Administration 0.57% Litigation MEETING ATTENDANCE: Medical Staff Meetings 4 100 % Comments: 10 8 Committee Meetings 0 % Figure 14.5 (Continued) FOR COMPLETION BY SERVICE CHAIR OR CREDENTIALS COMMITTEE CHAT CATEGORY YES NO Comments: Has the applicant been considered for or subject to disciplinary action since last reappointment? Have the applicant's privileges or staff appointment been suspended, revoked, or diminished in any way, either voluntary or involuntary, since last reappointment? Are there any currently pending challenges to any licensure or registration or the voluntary relinquishment of such? Are there any physical or behavioral conditions or limitations? Has the applicant exhibited satisfactory professional performance? APPROVALS: APPROVED? REVIEWER SIGNATURE YES NO DATE Service Chair Credentials Chair Final Procedure OUTSOZZ Procedure Text Resection of uterus, open approach ure 14.6 Physician index summary for Dr. Doe Discharge Final tient Age LOS Status Diagnosis Diagnosis Text 523 Home N920 Excessive and frequent menstration with regular cycle 1428 Other cardiomyopathies 110 Essential (primary) hypertension E119 Type 2 diabetes mellitus without complication D251 Intramural leiomyoma of the uterus Home 0334XXO Maternal care for disproportion of mixed maternal and fetal origin, not applicable or unspecified 0621 Secondary uterine inertia OUTCOZZ OUTROZZ OUT7OZZ Resection of cervix, open approach Resection of bilateral ovaries, open approach Resection of bilateral fallopian tubes, open c c approach of the uterus n 10DOOZ1 Extraction of products of conception, low cer- vical, open approach OU7C7ZZ 0411030 10907ZC Dilation of cervix, via natural or artificial opening Drainage of amniotic fluid, therapeutic from products of conception, via natural or artifi- cial opening Medican use n 0481 Z370 03421 Infection of amniotic sac and mem- branes, unspecified, third trimester, not applicable or unspecified ma Prolonged pregnancy Single live birth Maternal care for scar from previ ous cesarean delivery Single live birth Home OWNXZZ 2370 10EOXZZ ubac 109072C Division of female perineum, external approach Delivery of products of conception, external approach Drainage of amniotic fluid, therapeutic from products of conception, via natural or artifi- cial opening Reposition vagina, open approach Home N993 N9989 Prolapse of vaginal vault after It after OUSGOZZ hysterectomy Other postprocedural complications ODNGOZZ and disorders of the genitourinary system Release left large intestine, open approach (Continued on next Patient Age LOS Discharge Status Final Diagnosis N390 Procedure Text J9589 J9811 N3941 Y838 N994 Final Diagnosis Text Procedure Urinary tract infection, site not specified medication Other postprocedural complications and disorders of respiratory system, not elsewhere classified Atelectasis Urge incontinence Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure Essential (primary) hypertension Postprocedural pelvic peritoneal adhesions Maternal care for breech presenta 10DOOZ1 tion, not applicable or unspecified Infection of other part of genital tract in pregnancy, third trimester C Female pelvic inflammatory disease, unspecified Labor and delivery complicated by cord around neck, with compres- sion, not applicable or unspecified Single live birth Labor and delivery complicated 10EOXZZ by cord around neck, without compression, not applicable or unspecified 4 Home 0321XXO Extraction of products of conception, low cer vical, open approach 023593 N739 0691XXO Z370 06981X0 Home Delivery of products of conception, external approach Patient Age LOS Discharge Status Final Diagnosis N390 Procedure Text J9589 J9811 N3941 Y838 N994 Final Diagnosis Text Procedure Urinary tract infection, site not specified medication Other postprocedural complications and disorders of respiratory system, not elsewhere classified Atelectasis Urge incontinence Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure Essential (primary) hypertension Postprocedural pelvic peritoneal adhesions Maternal care for breech presenta 10DOOZ1 tion, not applicable or unspecified Infection of other part of genital tract in pregnancy, third trimester C Female pelvic inflammatory disease, unspecified Labor and delivery complicated by cord around neck, with compres- sion, not applicable or unspecified Single live birth Labor and delivery complicated 10EOXZZ by cord around neck, without compression, not applicable or unspecified 4 Home 0321XXO Extraction of products of conception, low cer vical, open approach 023593 N739 0691XXO Z370 06981X0 Home Delivery of products of conception, external approach 010013 C.Section Z370 110 099810 Pre-existing essential hyperten- sion complicating pregnancy, third trimester Single live birth Essential (primary) hypertension Abnormal glucose complicating pregnancy in 34 2 Home 10EOXZZ 2370 0700 Single live birth medias First-degree perineal laceration dur- ing delivery Surgical OHQ9XZZ 109072C 201 Delivery of products of conception, external approach Repair perineum skin, external approach Drainage of amniotic fluid, therapeutic from products of conception, via natural or artifi- cial opening Delivery of products of conception, external approach Division of female perineum, external approach Resection of uterus, open approach Home 080 10EOXZZ Encounter for full-term uncompli- cated delivery Single live birth 2370 OW8NXZZ 36 3 Home 00889 N9489 Resection of cervix, open approach medication F329 N920 D252 D251 R112 D251 Other complications following an OUTSOZZ ectopic and molar pregnancy Surco Other specified conditions associ- OUTCOZZ ated with female genital organs and menstrual cycle Major depressive disorder, single episode, unspecified Excessive and frequent menstration with regular cycle Subserosal leiomyoma of uterus Intramural leiomyoma of the uterus Nausea with vomiting, unspecified Intramural leiomyoma of the uterus OUTSOZZ Suriyenly OUTCOZZ Calculus of gallbladder with other OUT2OZZ cholecystitis without obstruction OUT7OZZ De Home Resection of uterus, open approach Resection of cervix, open approach Resection of bilateral ovaries, open approach K8018 medicator Resection of bilateral fallopian tubes, open approach (Continued on next page) Figure 14.6 (Continued) Patient Age LOS Discharge Status Final Diagnosis N800 D259 N393 Diagnosis Text Endometriosis of uterus Leiomyoma of uterus, unspecified Stress incontinence (female)(male) Final Procedure OTSDOZZ OUQGOZZ OFT44ZZ Procedure Text Reposition urethra, open approach Repair vagina, open approach Resection of gallbladder, percutaneous endo- scopic approach 2 N816 03421 Home 3E033VJ Rectocele Maternal care for scar from previ ous cesarean delivery Single live birth Z370 10903ZC Introduction of other hormone into periph- eral vein, percutaneous approach Drainage of amniotic fluid, therapeutic from products of conception, percutaneous approach Delivery of products of conception, external approach 06981XO 10EOXZZ 099810 0329xxo Labor and delivery complicated by cord around neck, without compression, not applicable or unspecified Abnormal glucose complicating pregnancy Maternal care for malpresentation of fetus, unspecified, not applicable or unspecified Third-degree perineal laceration during delivery Maternal care for other specified fetal problems, third trimester, not applicable or unspecified Single live birth 22 2 Home 0702 OKQMOZZ Repair perineum muscle, open approach 0368930 ODQROZZ Repair anal sphincter, open approach Z370 10EOXZZ Delivery of products of conception, external approach Extraction of products of conception, low cer- vical, open approach 37 14 Home 076 10DOOZ1 Abnormality in fetal heart rate and rhythm complicating labor and delivery Deep phlebothrombosis in preg. nancy, third trimester 02233 OUL73ZZ Occlusion of bilateral fallopian tubes, percu taneous approach 099013 042113 0321XXO 060140 Anemia complicating pregnancy. third trimester Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture, third trimester Maternal care for breech presenta- tion, not applicable or unspecified Preterm labor third trimester with preterm delivery third trimester, not applicable or unspecified Supervision of elderly multigravida, third trimester Other specified pregnancy related conditions, third trimester Other specified diseases of blood and blood-forming organs Rash and other nonspecific skin 009523 026893 D7589 R21 Z370 Z302 06981XO Home W8NXZZ eruption Single live birth Encounter for sterilization Labor and delivery complicated by cord around neck, without compression, not applicable or unspecified Pyrexia during labor, not elsewhere classified Single live birth Division of female perineum, external approach 0752 3E033VJ 2370 10903ZC Introduction of other hormone into periph- eral vein, percutaneous approach Drainage of amniotic fluid, therapeutic from products of conception, percutaneous approach Drainage of amniotic fluid, therapeutic from products of conception, via natural or artifi- cial opening 22 2 Home 06981XO 10907ZC Labor and delivery complicated by cord around neck, without compression, not applicable or unspecified (Continued our next page igure 14.6 (Continued) Discharge Patient AgeLOS Status Final Diagnosis 0752 Procedure Text Delivery of products of conception, external approach Repair perineum subcutaneous tissue and fas- cia, open approach 0701 Z370 009523 422 Home Z370 0701 Dilation of cervix, via natural or artificial opening Delivery of products of conception, external approach Repair perineum subcutaneous tissue and fas- cia, open approach Resection of uterus, open approach Resection of cervix, open approach Resection of bilateral ovaries, open approach Resection of bilateral fallopian tubes, open approach Release large intestine, ope approach 673 Home Final Diagnosis Text Procedure Pyrexia during labor, not elsewhere 10EOXZZ classified Second-degree perineal laceration OJQBOZZ during delivery Single live birth Supervision of elderly multigravida, 007C7ZZ third trimester Single live birth 10EOXZZ Second-degree perineal laceration OJQBOZZ during delivery Postmenopausal bleeding OUTSOZZ Other giant cell arteritis OUTCOZZ Dehydration OUT2OZZ Intramural leiomyoma of the uterus OUT7OZZ Polyp of corpus uteri ODNEOZZ Postprocedural pelvic peritoneal adhesions Personal history of venous throm- bosis and embolism Unspecified asthma, uncomplicated Excessive bleeding in the premeno. OUTSOZZ pausal period Iron deficiency anemia secondary to OUTCOZZ blood loss (chronic) Intramural leiomyoma of the uterus OUT2OZZ Other noninflammatory disorders OUT7OZZ of ovary, fallopian tube and broad ligament N950 M316 E860 0251 N840 N994 28671 J45909 N924 Resection of uterus, open approach Home D500 Resection of cervix, open approach D251 N838 Resection of bilateral ovaries, open approach Resection of bilateral fallopian tubes, open approach N830 N9489 Home 0328XXO 10907ZC Follicular cyst of ovary Other specified conditions associ- ated with female genital organs and menstrual cycle Maternal care for other malpresen- tation of fetus, not applicable or unspecified Single live birth Retained placenta without hemorrhage Prolonged pregnancy Drainage of amniotic fluid, therapeutic from products of conception, via natural or artifi- cial opening 2370 0730 10EOXZZ 0481 OW8NXZZ 10D 1021 Delivery of products of conception, external approach Division of female perineum, external approach Extraction of products of conception, retained, via natural or artificial approach Delivery of products of conception, external approach 22 2 Home 06981X0 10EOXZZ Labor and delivery complicated by cord around neck, without compression, not applicable or unspecified Single live birth Z370 10907ZC Drainage of amniotic fluid, therapeutic from products of conception, via natural or artifi- cial opening Division of female perineum, external approach OW8NXZZ 25 2 Home 0328xx0 Maternal care for other malpresen- tation of fetus, not applicable or unspecified Single live birth Z370 OW8NXZZ 10EOXZz Division of female perineum, external approach Delivery of products of conception, external approach Introduction of other hormone into periph. eral vein, percutaneous approach 3E033VJ jure 14.6 (Continued) atient Age LOS Discharge Status Final Diagnosis Diagnosis Text Final Procedure 10907ZC 31 2 Home 0701 10EOXZZ Second-degree perineal laceration during delivery Single live birth 2370 OJQBOZZ Procedure Text Drainage of amniotic fluid, therapeutic from products of conception, via natural or artifi- cial opening Delivery of products of conception, external approach Repair perineum subcutaneous tissue and tas cia, open approach Drainage of amniotic fluid, therapeutic from products of conception, percutaneous approach Resection of uterus, open approach Resection of cervix, open approach Resection of bilateral ovaries, open approach 10903ZC 403 Home N802 D259 E119 OUTSOZZ OUTCOZZ OUT2OZZ N736 OUT7OZZ 323 Home 0321XXO 10000Z1 Resection of bilateral fallopian tubes, open approach Extraction of products of conception, low cer. vical, open approach Introduction of other therapeutic substance into epidural space, percutaneous approach 0745 Endometriosis of fallopian tube Leiomyoma of uterus, unspecified Type 2 diabetes mellitus without complication Female pelvic peritoneal adhesions (postinfective) Maternal care for breech presenta tion, not applicable or unspecified Spinal and epidural anesthesia- induced headache during labor and delivery Endocrine, nutritional and meta- bolic diseases complicating preg- nancy, third trimester Hypothyroidism, unspecified Single live birth Prolapse of vaginal vault after hysterectomy 3E053GC 099283 E039 Z370 N993 4 Home OUQGOZZ Repair vagina, open approach J9811 Atelectasis OJQCOZZ Repair pelvic region subcutaneous tissue and fascia, open approach Reposition urethra, open approach OTSDOZZ N393 110 E039 M129 R112 K5900 0322XXO 2 Home Stress incontinence (female)(male) Essential (primary) hypertension Hypothyroidism, unspecified Arthropathy, unspecified Nausea with vomiting, unspecified Constipation, unspecified Maternal care for transverse and oblique lie, not applicable or unspecified Delayed and secondary postpartum hemorrhage Other specified trauma to perineum and vulva Single live birth 10907ZC 0722 10EOXZZ Drainage of amniotic fluid, therapeutic from products of conception, via natural or artifi- cial opening Delivery of products of conception, external approach Repair vulva, external approach 07182 OUOMXZZ 2370 OW8NXZZ 10D0726 Division of female perineum, external approach Extraction of products of conception, vac- uum, via natural or artificial opening Resection of uterus, open approach 54 3 Home C541 OUTSOZZ 1340 Malignant neoplasm of endometrium Nonrheumatic mitral (valve) insufficiency Incomplete uterovaginal prolapse Stress incontinence (female)(male) OUTCOZZ Resection of cervix, open approach N812 N393 OUT2OZZ OUT7OZZ Resection of bilateral ovaries, open approach Resection of bilateral fallopian tubes, open approach N950 N801 N800 Postmenopausal bleeding Endometriosis of ovary Endometriosis of uterus OUQGOZZ OTSDOZZ Repair vagina, open approach Reposition urethra, open approach (Continued on next page) Figure 14.6 (Continued) Discharge LOS Status Patient Age Final Procedure Procedure Text Final Diagnosis E669 T502X55 Diagnosis Text Obesity, unspecified Adverse effect of carbonic anhy. drase inhibitors, benzothiadiazides and other diuretics, sequela Preterm labor third trimester with preterm delivery third trimester, not applicable or unspecified Single live birth 191 Home 060140 10907ZC 2370 10EOXZZ Drainage of amniotic fluid, therapeutic from products of conception, via natural or artifi- cial opening Delivery of products of conception, external approach Division of female perineum, external approach 0411030 OWBNXZZ 0321XXO 10000Z1 Extraction of products of conception, low cer vical, open approach Z370 0702 Home OKOMOZZ Repair perineum muscle, open approach 06981X0 Infection of amniotic sac and mem- branes, unspecified, third trimester, not applicable or unspecified Maternal care for breech presenta tion, not applicable or unspecified Single live birth Third-degree perineal laceration during delivery Labor and delivery complicated by cord around neck, without compression, not applicable or unspecified Single live birth Encounter for full-term uncompli- cated delivery Single live birth ODQROZZ Repair anal sphincter, open approach 2370 080 21 2 Home OW8NXZZ Z370 10EOXZZ Division of female perineum, external approach Delivery of products of conception, external approach 1090720 3E033V) Drainage of amniotic fluid, therapeutic from products of conception, via natural or artifi- cial opening Introduction of other hormone into periph- eral vein, percutaneous approach Delivery of products of conception, external approach Home 00943 10EOXZZ 009523 0700 Supervision of pregnancy with grand multiparity, third trimester Supervision of elderly multigravida, third trimester First-degree perineal laceration dur ing delivery Single live birth Encounter for sterilization Encounter for full-term uncompli- cated delivery Single live birth Z370 2302 080 1 Home OW8NXZZ 2370 10EOXZZ 10907ZC Division of female perineum, external approach Delivery of products of conception, external approach Drainage of amniotic fluid, therapeutic from products of conception, via natural or artifi- cial opening Delivery of products of conception, external approach Home 06981XO 10EOXZZ Labor and delivery complicated by cord around neck, without compression, not applicable or unspecified Single live birth 2370 109072C 099824 Drainage of amniotic fluid, therapeutic from products of conception, via natural or artifi- cial opening Division of female perineum, external approach Division of female perineum, external approach 201 Home Streptococcus B carrier state compli- OW&NXZZ cating childbirth Preterm premature rupture of OW8NXZZ membranes, unspecified as to length of time between rupture and onset of labor, third trimester 042913 14.6 (Continued) Discharge LOS Status nt Age Final Diagnosis 076 Final Procedure 10EOXZZ Procedure Text Delivery of products of conception, external approach 0601480 0691XXO 099824 34 3 Home Z370 0321XXO 10DOOZ1 Diagnosis Text Abnormality in fetal heart rate and rhythm complicating labor and delivery Preterm labor third trimester with preterm delivery third trimester, not applicable or unspecified Labor and delivery complicated by cord around neck, with compres- sion, not applicable or unspecified Streptococcus B carrier state compli- cating childbirth Single live birth Maternal care for breech presenta tion, not applicable or unspecified Full-term premature rupture of membranes, unspecified as to length of time between rupture and onset of labor Smoking (tobacco) complicating pregnancy, third trimester Single live birth Encounter for sterilization Maternal care for other malpresen- tation of fetus, not applicable or unspecified Abnormality in fetal heart rate and rhythm complicating labor and delivery Extraction of products of conception, low cer- vical, open approach Occlusion of bilateral fallopian tubes, percu- taneous approach 04292 OUL73ZZ 099333 2370 2302 0328XXO Home 10EOXZZ Delivery of products of conception, external approach 076 OHQ9XZZ Repair perineum skin, external approach 06981xo 06981X0 Drainage of amniotic fluid, therapeutic from products of conception, via natural or artifi- cial opening 0700 Labor and delivery complicated 10907ZC by cord around the neck without compression, not applicable or unspecified First-degree perineal laceration dur- OUJD7ZZ ing delivery Single live birth Abnormal glucose complicating 10907ZC pregnancy Inspection of uterus and cervix, via natural or artificial opening Z370 099810 Home 2370 Single live birth 10EOXZZ Drainage of amniotic fluid, therapeutic from products of conception, via natural or artifi- cial opening Delivery of products of conception, external approach Division of female perineum, external approach 060140 0403xxo Extraction of products of conception, low for ceps, via natural or artificial opening 009513 07589 Preterm labor third trimester with W8NXZZ preterm delivery third trimester, not applicable or unspecified Polyhydramnios, third trimester, not 1000723 applicable or unspecified Supervision of elderly primigravida, third trimester Other specified complications of labor and delivery Vomiting, unspecified Secondary uterine inertia Unspecified placental disorder, third trimester Incomplete uterovaginal prolapse OUT97ZZ R1110 0621 04393 Home N812 D252 N840 Subserosal leiomyoma of uterus Polyp of corpus uteri OUQGOZZ OJQCOZZ Resection of uterus, via natural or articial opening Repair vagina, open approach Repair pelvic region subcutaneous tissue and fascia, open approach Drainage of bladder with drainage device, open approach (Continued on next page) E049 Nontoxic goiter, unspecified OT9BOOZ Figure 14.6 (Continued) Discharge LOS Status 1 Home Patient Age 33 Final Diagnosis 0640xxo Final Diagnosis Text Procedure Obstructed labor due to incomplete 109072C rotation of fetal head, not appli- cable or unspecified First-degree perineal laceration dur- OHQ9XZZ ing delivery Single live birth 10EOXZZ Procedure Text Drainage of amniotic fluid, therapeutic from products of conception, via natural or artifi- cial opening Repair perineum skin, external approach 0700 2370 Delivery of products of conception, external approach Division of female perineum, external approach 302 Home 0328xxo Maternal care for other malpresen. OWBNXZZ tation of fetus, not applicable or unspecified 10D0723 0752 10EOXZZ Extraction of products of conception, low for- ceps via natural or artificial opening Delivery of products of conception, external approach Inspection of uterus and cervix, via natural or artificial opening 03421 Pyrexia during labor, not elsewhere classified Maternal care for scar from previ- ous cesarean delivery Single live birth Cystocele unspecified Rectocele OUJD7ZZ 67 3 Home Z370 N8110 N816 OUQGOZZ OJQCOZZ Repair vagina, open approach Repair pelvic region subcutaneous tissue and fascia, open approach Reposition urethra, open approach 813 Home N393 N815 N814 N841 N840 D251 Stress incontinence (female)(male) OTSDOZZ Vaginal enterocele Uterovaginal prolapse, unspecified OUTSOZZ Polyp of cervis uteri OUTCOZZ Polyp of corpus uteri OUTROZZ Intramural leiomyoma of the uterus OUT7OZZ Resection of uterus, open approach Resection of cervix, open approach Resection of bilateral ovaries, open approach Resection of bilateral fallopian tubes, open approach E119 OUQGOZZ Repair vagina, open approach 110 E785 OBO Type 2 diabetes mellitus without complication Essential (primary) hypertension Hyperlipidemia, unspecified Encounter for full-term uncompli- cated delivery Single live birth 26 2 Home 10EOXZZ 2370 3E033VJ OW8NXZZ Delivery of products of conception, external approach Introduction of other hormone into periph- eral vein, percutaneous approach Division of female perineum, external approach Repair perineum subcutaneous tissue and fas- cia, open approach Delivery of products of conception, external approach Home 0701 OJQBOZZ 099333 10EOXZZ Z370 C541 Second-degree perineal laceration during delivery Smoking (tobacco) complicating pregnancy, third trimester Single live birth Malignant neoplasm of endometrium Hypothyroidism, unspecified Unspecified ovarian cysts Hemoglobinuria 3 Home OUTSOZZ Resection of uterus, open approach E039 N8320 R823 OUTCOZZ OUT2OZZ OUT7OZZ Resection of cervix, open approach Resection of bilateral ovaries, open approach Resection of bilateral fallopian tubes, open approach Excision of pelvis lymphatic, open approach Reposition vagina, open approach 07BCOZZ OUSGOZZ 38 3 Home Home N993 50 3 Home N800 D500 Prolapse of vaginal vault after hysterectomy Endometriosis of uterus Iron deficiency anemia secondary to blood loss (chronic) Endometriosis of fallopian tube Endometriosis of ovary OUTSOZZ OUTCOZZ Resection of uterus, open approach Resection of cervix, open approach N802 N801 OUT2OZZ OUT7OZZ Resection of bilateral ovaries, open approach Resection of bilateral fallopian tubes, open approach Reposition urethra, open approach (Continued on next page) N393 Stress incontinence (female) (male) OTSDOZZ Figure 14.6 (Continued) Discharge LOS Status Patient Age Final Diagnosis N920 Procedure Text D251 N72 NB03 R102 E119 K449 Home 0410370 0752 Final Diagnosis Text Procedure Excessive and frequent menstration with regular cycle Intramural leiomyoma of the uterus Inflammatory disease of cervix uteri Endometriosis of pelvic peritoneum Pelvic and perineal pain Type 2 diabetes mellitus without complication Diaphragmatic hernia without obstruction of gangrene Oligohyramnios, third trimester, not OWNXZZ applicable or unspecified Pyrexia during labor, not elsewhere 1000723 classified Maternal care for other malpresen. 10EOXZZ tation of fetus, not applicable or unspecified Attempted application of vacuum OHQ9XZZ extractor and forceps Second-degree perineal laceration 1001021 during delivery Labor and delivery mltd by cord around neck, without compression, not applicable or unspecified Single live birth Maternal care for othere known 3E033VJ or suspected poor fetal growth, third trimester, not applicable or unspecified Division of female perineum, external approach Extraction of products of conception, low for ceps, via natural or artificial opening Delivery of products of conception, external approach 0328xxo 0665 0701 Repair perineum subcutaneous tissue and fas- cia, open approach Extraction of products of conception, retained, via natural or artificial approach Introduction of other hormone into periph- eral vein, percutaneous approach 06981X0 2370 0365930 24 2 Home Introduction of other hormone into periph- eral vein, percutaneous approach 0752 Pyrexia during labor, not elsewhere classified 10903ZC 2302 Encounter for sterilization 10EOXZZ Drainage of amniotic fluid, therapeutic from products of conception, percutaneous approach Delivery of products of conception, external approach Division of female perineum, external approach 0328xxo Maternal care for other malpresen. OW8NXZZ tation of fetus, not applicable or unspecified Encounter for immunization OUJD7ZZ 223 10EOXZZ Inspection of uterus and cervix, via natural or artificial opening Delivery of products of conception, external approach Division of female perineum, external approach 2 Home 06981XO OW8NXZZ Labor and delivery complicated by cord around neck, without compression, not applicable or unspecified Single live birth Z370 3E033V) 10EOXZZ > 10903ZC Introduction of other hormone into periph- eral vein, percutaneous approach Delivery of products of conception, external approach Drainage of amniotic fluid, therapeutic from products of conception, percutaneous approach Introduction of other hormone into periph- eral vein, percutaneous approach Home 06981XO 3E033VJ Labor and delivery complicated by cord around neck, without compression, not applicable or unspecified Single live birth Z370 10EOXZZ OW8NXZZ Delivery of products of conception, external approach Division of female perineum, external approach Figure 14.7. Blank physician profile for case study COMMUNITY HOSPITAL OF THE WEST PHYSICIAN PERFORMANCE REVIEW SUMMARY FOR REAPPOINTMENT PHYSICIAN Dr Profile Time Frame: Doe From: SERVICE To: CATEGORY UTILIZATION: Admissions Procedures 71 Patient Days 124 VBACs Deliveries Blood Given C-Sections OUTCOMES: Category Comments: C-Section Rate VBAC Rate Nosocomial Inf Rate Surgical Wound Inf Rate Mortality Rate PERFORMANCE REVIEW: Category # Reviewed # Appropriate/% Comments: Surgical/Inv/Noninvasive Procedures Medication Use Blood Use Utilization Management Other Peer Review DATA QUALITY: Data Quality Monitoring Comments: Delinquency (>21 days) NA Suspensions RISK/SAFETY MANAGEMENT: Incidents reported by Comments: other professionals/ Administration NE Litigation MEETING ATTENDANCE: Medical Staff Meetings Committee Meetings NA IVA NA Comments: (Continued on next page) QI Toolbox Technique 371 Figure 14.7 (Continued) FOR COMPLETION BY SERVICE CHAIR OR CREDENTIALS COMMITTEE CHAIR CATEGORY YES NO Comments: Has the applicant been considered for or subject to disciplinary action since last reappointment? Have the applicant's privileges or staff appointment been suspended, revoked, or diminished in any way, either voluntary or involuntary, since last reappointment? Are there any currently pending challenges to any licensure or registration or the voluntary relinquishment of such? Are there any physical or behavioral conditions or limitations? Has the applicant exhibited satisfactory professional performance? APPROVALS: APPROVED? YES NO REVIEWER SIGNATURE DATE Service Chair Credentials Chair