Competency Plan

The purpose of this plan is to verify physician competency in the initial resuscitation of the trauma patient of those physicians who are not current in ATLS in accordance with IDPH Rules and Regulations.

Memorial Hospital’s Competency Plan is a diverse, multi-part plan that verifies competency of skills, knowledge, and tracks specific outcomes through our Peer Review process.

1. Successful completion of a written competency is completed annually. This competency was developed utilizing the ATLS curriculum and focuses on initial resuscitation principles.

2. Designated ED attending physicians validate trauma skill competencies. Competencies were derived from the objectives and procedures of the initial treatment and resuscitation of the trauma patient as determined by the ATLS curriculum. This annual competency may include, but is not limited to:

a. Airway management

b. Intubation

c. Chest tube insertion

d. DPL

e. Needle thoracentesis

f. Other

3. Trauma Surgeon outcome measure will be reviewed quarterly by the Trauma Medical Director, plus completing surgical site infection rate. The Emergency Department Medical Director or the ED physician designee reviews physician competencies. The Trauma Coordinator maintains physician competency in the EMS office.

4. Physician specific outcomes are addressed through a multi-disciplinary Trauma Patient Care Committee (PCC) and a Physician Peer Review Committee. Any staff member or physician involved in the care of the patient throughout the patient’s stay in the hospital may refer cases to the multidisciplinary Trauma PCC. The Trauma PCC on a random basis also reviews cases, even when there are no specific referrals or requests for review. The Trauma Patient Care Committee meets on a bi-monthly basis. Questions and issues related to the care provided by an individual physician or trauma surgeon are investigated and discussed by the full panel of physicians on the committee. Based upon results of the review by the Trauma PCC, cases may be referred to the hospital-wide Physician Peer Committee. The individual physician involved may be asked to attend the Peer Review Committee meeting to address questions or concerns regarding the care provided to the patient. The quality of care provided by the physician is then rated using a specified number system. The Regional Director of Quality Management maintains a tracking system of cases in the peer review process. The Peer Review Committee may recommend follow-up action to the Medical Executive Committee for any case leveled at a 3 or 4. When trended data indicates that a medical staff member has incurred three level 3’s or two level 4’s within a 12-month period, focused review may be recommended. The review process of the Trauma PCC and the Physician Peer Review Committee evaluates the entire spectrum of physician care. The Peer Review Committee reports to the Medical Executive Committee. The complete Peer Review Process Plan is available on site for further review upon request.

5.

Refer to Section 515.2040(h)(4)

The Memorial Hospital Trauma Service and Medical Staff feel the Competency Plan we are proposing will validate the physicians’ competency in trauma care when a current ATLS is not maintained. The Competency Plan is comprised of three subsections. See following page for complete Competency Plan.

¨ A written competency based on the ATLS curriculum, validates the Physician’s knowledge of the current standards in trauma care.

¨ A practical component will validate competency of the ED Physician’s skills, according to current standards in trauma care. The Trauma Physicians will be reviewed quarterly on surgical site infection rates by the Trauma Medical Director with the assistance of Quality Management/Infectious Disease Departments.

¨ Through the multi-disciplinary Trauma Patient Care Committee (PCC) an ongoing review of all reportable and all Category 1and 2 trauma patients will be in place in insure competent care is given to all trauma patients.

Through this process we feel our physician’s current knowledge and skills to care for the trauma patient can be validated as competent. The trauma care given by our physicians will be evaluated continuously by the Trauma PCC and if necessary by the Physician Peer Review Process, in order to maintain that competent care is given at Memorial Hospital.