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Hospital
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I.
[Insert Name of Manual]
No.
CO-5.006
Page:
1 of 6
Origination Date: 01-24-13; 03-29-12;
OPERATIVE AND INVASIVE 05-31-11; 02-17-09; 01-08-08; 11-24-03
PROCEDURES
Effective Date:
xx-xx-xx
APPROPRIATENESS REVIEW Retires Policy Dated:
xx-xx-xx
Previous Versions Dated:
xx-xx-xx
Hospital Medical Staff
Approval Dated:
xx-xx-xx
Hospital Governing Board
Approval Dated:
xx-xx-xx
Title:
SCOPE:
This policy applies to _________________________ (“Hospital”) and its Medical Staff.
II.
PURPOSE:
The purposes of this policy are to describe the minimum standards for prospective and
retrospective review of the appropriateness of operative and invasive procedures through
effective use of evidence-based clinical criteria, to appropriately and accurately identify trends
and patterns, and to monitor and improve the quality of care delivered to patients.
III.
POLICY:
Hospital will conduct systematic, reliable reviews of operative and invasive procedures. The
reviews shall be conducted as part of the peer review and quality processes set forth in the
Hospital’s Medical Staff Bylaws and state statutes. Hospital will report results of the reviews on
at least a quarterly basis to the Medical Executive Committee (MEC) and Governing Board.
Hospital will refer all cases which do not meet applicable criteria to the appropriate Medical
Staff committee for peer review.
IV.
PROCEDURE:
A.
Identification of Procedures
1.
Core Reviews
a.
Surgical / Invasive Procedures: Hospital will retrospectively
monitor a core set of surgical/invasive procedures according to the
schedule provided in Attachment A through SIMPlus, and
prospectively review Bariatric procedures utilizing the review
forms on A-1 and A-2.
b.
Cardiac Procedures (PCI, Valve, CABG, ICD, and Permanent
Pacemaker): Hospital will also prospectively and retrospectively
monitor cardiac procedures according to the listing provided in
Attachments B, B-1, B-2, B-3, B-4, and B-5.
[Insert
Hospital
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[Insert Name of Manual]
No.
CO-5.006
Page:
2 of 6
Origination Date: 01-24-13; 03-29-12;
OPERATIVE AND INVASIVE 05-31-11; 02-17-09; 01-08-08; 11-24-03
PROCEDURES
Effective Date:
xx-xx-xx
APPROPRIATENESS REVIEW Retires Policy Dated:
xx-xx-xx
Previous Versions Dated:
xx-xx-xx
Hospital Medical Staff
Approval Dated:
xx-xx-xx
Hospital Governing Board
Approval Dated:
xx-xx-xx
Title:
2.
Supplemental Reviews
At the direction of Hospital’s Medical Staff, Chief Medical Officer or
Director of Clinical Quality Improvement, Hospital also will monitor the
appropriateness of procedures new to the Hospital, selected high-risk,
high-volume, problem-prone or other procedures as identified and
prioritized by the organized Medical Staff. Such reviews may be
conducted on a prospective or retrospective basis.
3.
Annual Approval
On at least an annual basis, the MEC must approve the criteria and
schedules for the core sets of reviews as well as approve and prioritize any
supplemental operative and invasive procedures reviews.
4.
Additional Reviews
Additional reviews may be added as Attachments to this policy. Each new
review must include the following parameters:
B.
a.
effective date of review
b.
type of procedure to be reviewed
c.
type of review (prospective or retrospective or both)
d.
sample methodology, if different than the methodology described
in Section IV.C. of this policy
e.
evidence-based screening criteria
f.
reporting procedures, up to and including creation of Medical Staff
review committees as needed
Screening Criteria
Hospital will conduct all reviews using evidence-based clinical criteria, such as
INTERQUAL SIM PLUS criteria (“SIM PLUS”), INTERQUAL PROCEDURES
criteria (“Procedures”), American College of Cardiology/American Heart
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[Insert Name of Manual]
No.
CO-5.006
Page:
3 of 6
Origination Date: 01-24-13; 03-29-12;
OPERATIVE AND INVASIVE 05-31-11; 02-17-09; 01-08-08; 11-24-03
PROCEDURES
Effective Date:
xx-xx-xx
APPROPRIATENESS REVIEW Retires Policy Dated:
xx-xx-xx
Previous Versions Dated:
xx-xx-xx
Hospital Medical Staff
Approval Dated:
xx-xx-xx
Hospital Governing Board
Approval Dated:
xx-xx-xx
Title:
Association/Society for Cardiovascular Angiography and Interventions
guidelines, the Heart/Rhythm Society, or American Society for Metabolic and
Bariatric Surgery guidelines.
C.
1.
For procedures that are not included in SIM PLUS, the Medical Staff must
provide indications for screening criteria based upon review of
professional society guidelines and a consensus confirmed within the
appropriate Medical Staff committee. All such proposed additions must
be approved by the MEC prior to implementing the reviews.
2.
SIM PLUS criteria may be modified to reflect current national standards.
Any modification should be evidence-based and must be approved by the
appropriate Medical Staff committee and the MEC, with documentation of
such in meeting minutes. Any changes made to criteria should be done on
specified change dates (e.g., annually or semi-annually) so that data within
quarters of the year are comparable. Changing the criteria on an ad hoc
basis may make the historical data unusable.
3.
SIM PLUS criteria use patient-specific characteristics and tissue analysis
to retrospectively evaluate the appropriateness of surgical and invasive
procedures. Procedures criteria are used to support reviewers’ decisions
about the appropriateness of surgical and invasive procedures
prospectively, and may be used when negative trends by surgeon or
procedure are identified through retrospective review.
Sampling Methodology
Unless otherwise instructed, Hospital will use the following sampling
methodology for all reviews to assure that all physicians are adequately
represented in the sample:
1.
For each identified procedure, select at least 10% of cases for each
physician per month;
2.
For physicians identified on previous reviews as having a volume of 3
standard deviations or higher above the state or national mean, select at
least 20% of cases for each physician per month;
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D.
[Insert Name of Manual]
No.
CO-5.006
Page:
4 of 6
Origination Date: 01-24-13; 03-29-12;
OPERATIVE AND INVASIVE 05-31-11; 02-17-09; 01-08-08; 11-24-03
PROCEDURES
Effective Date:
xx-xx-xx
APPROPRIATENESS REVIEW Retires Policy Dated:
xx-xx-xx
Previous Versions Dated:
xx-xx-xx
Hospital Medical Staff
Approval Dated:
xx-xx-xx
Hospital Governing Board
Approval Dated:
xx-xx-xx
Title:
3.
For a sample pool with less than or equal to 3 cases, abstract all of the
cases;
4.
Perform a minimum of 3 abstractions per physician per procedure per
month; and
5.
Perform a maximum of 20 abstractions per physician per procedure per
month.
Review Process
The process for review of operative and invasive procedures includes an initial
review, and if necessary, a secondary review.
1.
Initial Review
The initial review is completed by a non-physician, utilizing the medicalstaff approved criteria (SIM PLUS or other). If documentation in the
record does not support the indication for the procedure, the case is to be
completed as “not met” prior to contacting the physician for supporting
documentation to enable trending by procedure and/or physician for
inadequate documentation.
2.
E.
Secondary Review
a.
Secondary review may be completed by a non-physician upon
receipt of documentation from the physician’s office or other
location.
b.
If additional documentation is not obtained or does not meet the
indications for the procedure, secondary review shall be completed
by an appropriate peer physician or committee. Secondary review
is complete upon final determination of the case meeting or failing
to meet the approved criteria.
Timely Completion
1.
Prospective Reviews
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[Insert Name of Manual]
No.
CO-5.006
Page:
5 of 6
Origination Date: 01-24-13; 03-29-12;
OPERATIVE AND INVASIVE 05-31-11; 02-17-09; 01-08-08; 11-24-03
PROCEDURES
Effective Date:
xx-xx-xx
APPROPRIATENESS REVIEW Retires Policy Dated:
xx-xx-xx
Previous Versions Dated:
xx-xx-xx
Hospital Medical Staff
Approval Dated:
xx-xx-xx
Hospital Governing Board
Approval Dated:
xx-xx-xx
Title:
Each prospective review must be completed before a procedure is
performed. In the event of an emergency, appropriateness will be
documented immediately after the procedure is completed.
2.
Retrospective Reviews
Abstractions for any given month should be completed within 3 months of
the close of that month.
F.
Reporting
On at least a quarterly basis, the CEO shall cause a report to be given to the
Medical Executive Committee and the Governing Board. Each report will include
the following:
1.
Results by physician and by procedure;
2.
Identification of trends or patterns noted for that quarter by physician and
by procedure; and
3.
Listing of all cases not meeting criteria by physician.
The MEC shall address any patterns or trends identified in a review according to
the peer review and quality processes set forth in the Hospital’s Medical Staff
Bylaws and state statutes.
G.
Auditing and Monitoring
Quality Management shall audit adherence to this policy during the
Comprehensive Clinical Audits.
H.
Enforcement
All Hospital Staff and Medical Staff Members whose responsibilities are affected
by this policy are expected to be familiar with the basic procedures and
responsibilities created by this policy. Failure to comply with this policy will be
subject to appropriate performance management pursuant to all applicable
policies and procedures, including the Medical Staff Bylaws, Rules and
Regulations.
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V.
[Insert Name of Manual]
No.
Page:
6 of 6
Origination Date: 01-24-13; 03-29-12;
OPERATIVE AND INVASIVE 05-31-11; 02-17-09; 01-08-08; 11-24-03
PROCEDURES
Effective Date:
xx-xx-xx
APPROPRIATENESS REVIEW Retires Policy Dated:
xx-xx-xx
Previous Versions Dated:
xx-xx-xx
Hospital Medical Staff
Approval Dated:
xx-xx-xx
Hospital Governing Board
Approval Dated:
xx-xx-xx
Title:
REFERENCES:
- 42 CFR 482.21
VI.
CO-5.006
ATTACHMENTS:
- Attachment A: Surgical/Invasive Appropriateness Monitoring Schedule
- Attachment A-1: Bariatric Criteria Form for Medicare Patients
- Attachment A-2: Bariatric Criteria Form for Self-Pay Patients
- Attachment B: Cardiac Procedures Appropriateness Review
- Attachment B-1: PCI Indications Documentation Tool
- Attachment B-2: Valve Indications Documentation Tool
- Attachment B-3: CABG Indications Documentation Tool
- Attachment B-4: ICD Documentation Tool
- Attachment B-5: Permanent Pacemaker Documentation Tool
- Attachment C: External Cardiovascular Review Form
- PCI Indications Reference Tool
- Valve Indications Reference Tool
- CABG Indications Reference Tool
- Diagnostic Coronary Angiography Reference Tool