Appendix F_HSWLSCTD 2024-001_Peer Review.pdf

Commanding Officer United States Coast Guard Health, Safety, and Work-Life Service Center

300 E. Main Street Suite 1000 Norfolk, VA 23510-9109 Staff Symbol: (h) Phone: (757) 628-4787 Fax: (757) 628-4337

HSWLSCTD 2024-001

26 January 2024

HEALTH, SAFETY AND WORK-LIFE SERVICE CENTER TECHNICAL DIRECTIVE

2024-001

Subj: PEER REVIEW FOR MEDICAL, DENTAL, PHARMACY AND REGIONAL

BEHAVIORAL HEALTH PROVIDERS

Ref: (a) Coast Guard Medical Manual, COMDTINST M6000.1(series)

(b) Medical Quality Assurance (MQA) and Clinical Quality Management in the Military

Health System (MHS), DoDM 6025.13

1. PURPOSE. This publication provides standardized technical directives (TD) issued by the Health, Safety, and Work-Life Service Center (HSWL SC) that addresses the peer review process under Operational Medicine (OPMED) as part of the healthcare quality improvement/assurance activities.

2. ACTION. This TD publication applies to the HSWL organizational elements at all Coast Guard (CG) healthcare facilities. HSWL SC retains the authority to provide technical direction over all HSWL organizational elements. This TD is used to clarify policy that falls under the responsibilities and authorities of the HSWL SC OPMED.

3. AUTHORIZED RELEASE. Internet Release is Authorized.

4. UNIT INSTRUCTION AFFECTED. None.

5. DISCUSSON (or) BACKGROUND. In striving to continuously improve quality of care and promote more effective and efficient utilization of facilities and services, an accredited organization maintains an active, integrated, organized, peer-based program of quality management and improvement that links the peer review process, quality improvement activities, and risk management in an organized, systematic way. The Coast Guard peer review program maintains an active and organized process for review of clinical services that is integrated into the quality management and improvement program, creating a system that promotes open dialogue and provides objective feedback on the provision of care. The provisions of this TD are intended to ensure that all privileged and/or credentialed personnel performing clinical care participate in a peer review program. This

TD is intended to standardize the peer review program within medical/dental and to discuss the tools in place to help evaluate peer reviews for the medical/dental community.

In general, providers of the same category should provide peer review for other providers in that category. In other words, medical officers should review other medical officers;

regional behavioral health providers (RBHP) should evaluate other RBHP and so forth.

6. DISCLAIMER. This guidance is not a substitute for applicable legal requirements, nor is it itself a rule. It is intended to provide technical guidance for Coast Guard personnel and is not intended nor does it impose legally binding requirements on any party outside the Coast Guard.

7. MAJOR CHANGES. None.

8. SCOPE AND AUTHORITIES. It is recommended the reader become familiar with the instructions, publications, technical directives, and forms cited throughout this technical directive.

9. ENVIRONMENTAL ASPECT AND IMPACT CONSIDERATIONS. The Office of Environmental Management, Commandant (CG-47) reviewed this TD and the general procedures contained within and determined that this policy falls under the Department of Homeland Security (DHS) categorical exclusion A3. This TD will not result in any substantial change to existing environmental conditions or violation of any applicable federal, state, or local laws relating to the protection of the environment. It is the responsibility of the action proponent to evaluate all future specific actions resulting from this policy for compliance with the National Environmental Policy Act (NEPA), other applicable environmental requirements, and the U.S. Coast Guard Environmental Planning Policy, COMDTINST 5090.1 (series).

10. DISTRIBUTION. No paper distribution will be made of this TD. Unit Instructions/TDs are stored locally on the HSWL SC SharePoint page at https://uscg.sharepoint-mil.us/sites/hswlsc/SitePages/Unit%20Directives.aspx.

11. RECORDS MANAGEMENT CONSIDERATIONS. This TD has been thoroughly reviewed during the directives clearance process and it has been determined there are no further records scheduling requirements, in accordance with Federal Records Act, 44 U.S.C. 3101 et seq., National Archives and Records Administration (NARA) requirements, and the Information and Life Cycle Management Manual, COMDTINST M5212.12 (series). This policy does not have any significant or substantial changes to existing records management requirements.

12. FORMS. All forms referenced in this TD are available on the HSWL SC Quality

Improvement SharePoint (CG Portal) page under the QI Coordinator Toolbox https://uscg.sharepoint-mil.us/sites/hswlsc/hswl-service-center-quality-improvement-https://uscg.sharepoint-mil.us/sites/hswlsc/SitePages/Unit%20Directives.aspx https://uscg.sharepoint-mil.us/sites/hswlsc/SitePages/Unit%20Directives.aspx https://uscg.sharepoint-mil.us/sites/hswlsc/hswl-service-center-quality-improvement-site/Quality%20Improvement%20Tools/Forms/AllItems.aspx?id=%2Fsites%2Fhswlsc%2Fhswl%2Dservice%2Dcenter%2Dquality%2Dimprovement%2Dsite%2FQuality%20Improvement%20Tools%2FPeer%20Review&viewid=9429d4fc%2D8aad%2D488e%2D93da%2De5e48113d373 site/Quality%20Improvement%20Tools/Forms/AllItems.aspx?id=%2Fsites%2Fhswlsc%2Fh swl%2Dservice%2Dcenter%2Dquality%2Dimprovement%2Dsite%2FQuality%20Improvem ent%20Tools%2FPeer%20Review&viewid=9429d4fc%2D8aad%2D488e%2D93da%2De5e 48113d373.

13. REPORTS. None.

14. REQUEST FOR CHANGES. Recommendations for improvements to this TD are encouraged and should be submitted to HSWL SC (om); 300 East Main Street; Suite 1000;

Norfolk, VA 23510-9109.

JOSE D. MARTIS

Captain, U. S. Coast Guard

COMMANDING OFFICER CG HSWL SC

https://uscg.sharepoint-mil.us/sites/hswlsc/hswl-service-center-quality-improvement-site/Quality%20Improvement%20Tools/Forms/AllItems.aspx?id=%2Fsites%2Fhswlsc%2Fhswl%2Dservice%2Dcenter%2Dquality%2Dimprovement%2Dsite%2FQuality%20Improvement%20Tools%2FPeer%20Review&viewid=9429d4fc%2D8aad%2D488e%2D93da%2De5e48113d373 https://uscg.sharepoint-mil.us/sites/hswlsc/hswl-service-center-quality-improvement-site/Quality%20Improvement%20Tools/Forms/AllItems.aspx?id=%2Fsites%2Fhswlsc%2Fhswl%2Dservice%2Dcenter%2Dquality%2Dimprovement%2Dsite%2FQuality%20Improvement%20Tools%2FPeer%20Review&viewid=9429d4fc%2D8aad%2D488e%2D93da%2De5e48113d373 https://uscg.sharepoint-mil.us/sites/hswlsc/hswl-service-center-quality-improvement-site/Quality%20Improvement%20Tools/Forms/AllItems.aspx?id=%2Fsites%2Fhswlsc%2Fhswl%2Dservice%2Dcenter%2Dquality%2Dimprovement%2Dsite%2FQuality%20Improvement%20Tools%2FPeer%20Review&viewid=9429d4fc%2D8aad%2D488e%2D93da%2De5e48113d373 https://uscg.sharepoint-mil.us/sites/hswlsc/hswl-service-center-quality-improvement-site/Quality%20Improvement%20Tools/Forms/AllItems.aspx?id=%2Fsites%2Fhswlsc%2Fhswl%2Dservice%2Dcenter%2Dquality%2Dimprovement%2Dsite%2FQuality%20Improvement%20Tools%2FPeer%20Review&viewid=9429d4fc%2D8aad%2D488e%2D93da%2De5e48113d373

THIS PAGE INTENTIONALLY LEFT BLANK

Enclosure (1) to HSWLSCTD 2024-001

HEALTH, SAFETY, AND WORK-LIFE

SERVICE CENTER OPERATIONAL MEDICINE

PEER REVIEW PROCESS GUIDE

Health, Safety, and Work-Life Service Center (HSWL SC) United States Coast Guard

300 East Main Street Norfolk, VA 23510

Table of Contents

Introduction

Overview

Purpose

Roles and Responsibilites

Administration

Medical

Dental

Appendices

Appendix A: CQA Self-Registeration Quick Guide

Appendix B: Provider Quick Guide

Appendix C: Locating Note in MHS Genesis

Appendix D: Do Not Use Abbreviations

Appendix E: Dental Officer Peer Review Instrument

Appendix F: Dental Officer Peer Review Score Sheet

Introduction

To establish an integrated, electronic, and standardized Peer Review process under Operational Medicine to allow for quality improvement (QI) across the enterprise.

The purpose of this process guide is to describe how the Peer Review process will function across the HSWL utilizing an electronic system for all specialties under Operational Medicine with the exception of dental.

Roles and Responsibilities

HSWL SC Division of Operational Medicine (om) Clinical QI

• Responsible for the specific oversight of all aspects of this program.

• Responsible for giving technical and clinical guidance in the administration of the peer review program.

• Responsible for assigning monthly peer reviews to medical providers, regional behavioral health providers and pharmacy.

• Ensure that data is pulled redacted data quarterly or more frequently as needed, redacted, and delivered to regional practices through the clinic administrator and quality improvement coordinator for process improvement.

• Communicate rate of completion monthly to Health Services

Administrators.

• Responsible for setting up Supervisor Physician reviews as requested.

• Work with other providers not on this current evolution to create a peer review process within those specialty areas e.g., Physical Therapists, Regional Nurse Case Managers, and Ambulatory Nurses.

• Will forward feedback on the program to Commandant (CG-1K2) on an annual or as needed basis.

Overview

Purpose

Administration

Regional Managers (RMs) and Regional Directors (RDs)

• Ensure that this TD is promulgated to all clinics in their Regional Practice (RP).

• Responsible for ensuring that all providers in their RP participate in an active peer review program.

• Responsible for ensuring that the Health Services Administrators

(HSAs) and the Clinic QI Coordinators ensure full clinic participation in the program.

• For Dental Only:

o Will ensure in coordination with the Senior Dental

Executive (SDE) that at the beginning of each fiscal year or with the entry or departure of staff, a peer reviewer is assigned for each dentist in the RP.

o Coordinate with other RPs to achieve the above goal if in a solo practice location.

Health Services Administrators (HSAs)

• Ensure all medical and behavioral health providers (excluding dental) and pharmacists are enrolled into the Clinical Quality Assessment tool for managing and tracking Provider Peer Reviews (CQA) by checking the Provider Enrollment spreadsheet located on the HSWL SC QI SharePoint (CG Portal) page under the QI Coordinator Toolbox in the Peer Review (sharepoint-mil.us) folder.

• Provide data extracted from the peer review process quarterly for dissemination into the QI Focus Group (QIFG) and development of QI activities.

• Ensure that QI Coordinator spreadsheet located on the HSWL SC

QI SharePoint (CG Portal) page Peer Review (sharepoint-mil.us) is updated annually at the beginning of the fiscal year and as needed.

• Notify the HSWL SC Nurse Consultant and HSWL SC QI

Specialist when a QI Coordinator changes, or a provider leaves the Coast Guard.

• Ensure providers are completing their assigned peer reviews monthly by leveraging the SME and SDE to assist in ensuring compliance.

https://uscg.sharepoint-mil.us/sites/hswlsc/hswl-service-center-quality-improvement-site/Quality%20Improvement%20Tools/Forms/AllItems.aspx?id=%2Fsites%2Fhswlsc%2Fhswl%2Dservice%2Dcenter%2Dquality%2Dimprovement%2Dsite%2FQuality%20Improvement%20Tools%2FPeer%20Review&viewid=9429d4fc%2D8aad%2D488e%2D93da%2De5e48113d373 https://uscg.sharepoint-mil.us/sites/hswlsc/hswl-service-center-quality-improvement-site/Quality%20Improvement%20Tools/Forms/AllItems.aspx?id=%2Fsites%2Fhswlsc%2Fhswl%2Dservice%2Dcenter%2Dquality%2Dimprovement%2Dsite%2FQuality%20Improvement%20Tools%2FPeer%20Review&viewid=9429d4fc%2D8aad%2D488e%2D93da%2De5e48113d373 o Responsible for maintaining a binder marked confidential which will contain a copy of the peer reviews completed for dentists in their area of responsibility.

Clinic Quality Improvement Coordinator.

• Support the HSA with maintaining the Provider Enrollment spreadsheet.

• Assess and report on quarterly peer review data to the QIFG.

• Ensure the HSA is aware of any difficulties with enrolling providers in to the CQA system or late reviews.

o Work with the HSA to maintain the completed peer review binder.

Senior Medical Executives (SMEs) and Directors.

• First level dispute resolution should there be a disputed assessment that is not resolved between peers.

• Dispute resolution will be assigned by the HSWL SC Operational Medicine as needed based on location of reviewee.

• Ensure providers are completing their reviews in a timely manner.

Medical, RBHP and Pharmacy Peers (Reviewers).

• Ensure properly enrolled into the CQA system to receive charts to review. See Appendix (A) on self-registration. If a team is not selected, the provider cannot be approved in the system. Use the guidelines below to identify what team you should be enrolled in.

https://informatics.med.ds.osd.mil/CQA/(S(zxhl3tnuhjxc5h2peenx v2do))/Security/Default.aspx o Enrollment Categories:

Physicians, PAs (non-RBHP) and NPs (non-RBHP):

select team CG Medical

RBHP providers: select team CG Regional

Behavioral Health Providers

Medical https://informatics.med.ds.osd.mil/CQA/(S(zxhl3tnuhjxc5h2peenxv2do))/Security/Default.aspx https://informatics.med.ds.osd.mil/CQA/(S(zxhl3tnuhjxc5h2peenxv2do))/Security/Default.aspx

Pharmacists: select team CG Pharmacist

• Will be assigned two (2) charts to review at the end of each month in the CQA system. See Appendix (B) for Provider Quick Guide.

• CQA is anonymous so please be honest regarding your review.

• Charts should be fully reviewed each month to ensure that the reviewee receives timely feedback to initiate practice improvements if needed.

• Peers will communicate departures from the standard of care or suggestions for improvement directly to the reviewee within the system.

• Peer review is a confidential process that is protected under law. It is the peer’s responsibility to keep the peer review process confidential and to not share specific reviews with anyone not identified as having a need to know by this instruction.

• Cases where unsafe practices may be occurring and there is no satisfactory resolution following a discussion with the technical supervisor and reviewee, shall be brought to the attention of the appropriate HSWL SC technical authority under Operational Medicine.

• Reviewee will acknowledge all reviews in accordance with Appendix (B).

• Keys to Success:

o The number provided for the reviewer is the FIN number.

The MHS Genesis search box places that item towards the bottom of the search options. See Appendix (C).

o If you cannot locate a specific note, please reach out to the HSWL SC Nurse Consultant for assistance or reassignment.

DO NOT just answer “No” to each item or “N/A”. This can impact the reliability of the tool and create a potential privileging question for your peer.

o Appendix (D) contains a list of “do not use abbreviations”.

Please review and adopt those guidelines.

Reviewees under Medical, RBHP, Pharmacy.

• Providers reviewed under the CQA process should take suggestions and feedback seriously to help with clinical self-improvement.

• Providers shall respond to any feedback within the system in the space provided. If no dispute, select acknowledge.

• Providers who notice issues with care that may be difficult to resolve should bring these to the attention of the HSWL SC (om).

Senior Dental Executives (SDEs).

• Will assist the RM/RD in assigning every dentist in their RP a peer to review ten (10) charts yearly.

o Assignments will be made by the end of October of each year and as needed due to the transfer of a dentist into or out of the RP.

o Shall be completed by the end of the fiscal year each year.

• Will contact the HSWL SC (om-de) with questions or concerns about the program.

• SDEs will ensure that the peer review process is completed and will provide copies of the peer reviews to HSWL SC (om-de).

Dental Peers (Reviewers).

• Peer reviews will be conducted on ten (10) dental health records and should contain recent patient treatment from the previous twelve (12) months.

• Reviews must be documented in a binder marked confidential and maintained by the HSA and QI Coordinator by the end of each fiscal year. See Appendix (E) and (F) for questionnaire and sample sheet.

• Records should consist of the following: Four (4) T-2 exams, one

(1) sick-call, five (5) procedures (e.g., operative/restorative, prosthodontic, endodontic, oral surgery, or periodontal treatment), and at least one (1) referral case. Technical guidance will be provided by the HSWL SC om-de.

• If the reviewee is not on the EHR system, pertinent forms from each record are to be photocopied and mailed as per instructions to the reviewer. Forms should include current dental health history questionnaire, dental progress notes (SF-603/A forms), supporting consultations/referrals and reports, informed consent forms, etc.

Dental

• Current diagnostic panoramic and digital bitewing radiographs should either be provided on a compact disc (CD) if not on the EHR system or uploaded to the Dentrix Document Center. More information can be requested from the reviewee as needed.

• Reviewers will convey any findings by meeting directly in person or virtually with the reviewee. Findings will be documented on the Peer Review form.

• Both reviewer and reviewee will sign to acknowledge that the Peer Review form has been reviewed. All completed forms will be sent to the SDE for review and action as needed.

• Peer review is a confidential process that is protected under law. It is the peer’s responsibility to keep peer review documents confidential and to not discuss reviews with anyone not identified as needing to know by this instruction.

• Cases where unsafe practices are occurring and there is no satisfactory resolution following a discussion with the reviewee and SDE, shall be brought to the attention of the HSWL SC (om-de).

Privileged and Credentialed Dental Providers (Reviewees).

• Dental providers reviewed under the above process should take suggestions and feedback seriously to help with clinical self-improvement.

CQA

Self-Registration Quick Guide CAC Authentication Click the CQA link or copy and paste it in the address bar of your browser. The CQA web site will then open to the default page.

Acknowledge Access Statements If you do not already have an account, the CQA tool will automatically redirect you to the self-registration page.

A Clinical Quality Assessment Tool for managing and tracking Provider Peer Reviews

When prompted, select your Authentication Certificate, and click the OK button to go to the logon screen.

You may also need to enter your PIN.

Click the acknowledgement button to log in

Appendix (A) to HSWLSCTD 2024-001

Step 2, Roles and Provider Type If you provide patient care, check the Provider box. If you are the CQA Team administrator, check that box. Select a provider type from the dropdown (mandatory).

Verify your name and email address

Click to continue

Make the appropriate selections then click Next

Step 3, Select a Team Note: If you do not see your facility or parent facility on the dropdown list, please let us know using Contact Us on the far right of the menu.

Step 4, Find Your Name as it Appears in Genesis Enter any part of your name in the search box. If you are not a provider or your name isn’t found select ‘Skip Step’ to complete your registration request.

1. Select your facility from the drop-down.

2. Click Select to choose a team

Search and select your name as it appears in Genesis

When your Request is Completed If you selected a team, CQA will send the team administrator an email notification. If you did not select a team, be sure to let your team administrator know that you have registered.

Next Steps Your CQA Team administrator will verify your settings and approve your registration request. When you are assigned reviews to complete you will receive an automated message including the CQA link.

CQA

Provider Quick Guide Overview CQA is a CAC authenticated web application which provides for the unbiased evaluation of clinical encounters to help providers self-improve and increase the quality of care that patients receive.

CQA supports Joint Commission requirements and promotes fair, standards-based evaluations.

CQA promotes unbiased evaluation through the random selection of encounters of care which are then randomly assigned a reviewer from a pool of “like” practitioners on a team.

A team can consist of medical care providers from divergent facilities, providing the means for even the one deep specialist to be reviewed by their peers. Your team’s name may not be the same as your place of care.

Assignment of Peer Reviews When CQA generates assessments for a team, each assessment is randomly assigned* to a peer for review.

Reviewers may receive weekly email notifications when there are reviews that have not been completed.

CAC Authentication Click the CQA link or copy and paste it in the address bar of your browser. The CQA web site will then open to the default page.

A Clinical Quality Assessment Tool for managing and tracking Provider Peer Reviews

When prompted, select your Authentication Certificate, and click the “OK” button to go to the logon screen.

You may also need to enter your PIN.

Appendix (B) to HSWLSCTD 2024-001

Acknowledge Access Statements If you do not already have an account, the CQA tool will automatically redirect you to the self-registration page. Please see the CQA Self-Registration quick guide for more information.

Performing Peer Reviews For most providers the My Peer Reviews To do page will be your starting page. You can also get to it by clicking Peer Reviews to Do on the menu.

Click the acknowledgement button to log in

Click “Select” to start your peer review

TIP:

Reviews that you haven’t completed are shown by default. Use the dropdown to display more reviews

This is the Review encounter page of the CQA tool. The Provider, Encounter Date, Patient Name, and FIN are displayed at the top. Under that are the peer review questions, which are configurable locally and guided centrally.

TIP

Questions are in Yes, No, N/A format, as shown here.

Only one response can be selected per question.

Copy and paste the FIN into the Search box on the MHSG Home Page/Ambulatory Organizer and ensure that you have chosen ‘FIN’ as the search term before pasting the number.

Choose “Peer Review/QI” as your Relationship and click on the “OK” button to open the desired encounter.

The selected encounter opens. You can review a completed note by clicking on the encounter in the MPage Workflow (Light Menu) Documents component and review Medication Reconciliation (Green checkmark in front of Home Medications).

TIP

If unable to complete the review, you can click ‘Save Progress’ to save your answers and finish later

Answer each question in the CQA application, then click the “Continue” button to go to the Rate Encounter page

On the Rate Encounter page, you will select a rating and document your findings. It is always helpful to add comments. If a deficiency is found, then comments are required. If significant deficiencies are found, please notify the appropriate person within your department or clinic.

My Assessments Click ‘My Assessments’ on the menu to display reviews done on you.

3. Choose the appropriate rating based on your review from the ratings dropdown

Click “Select” to View and Acknowledge the Assessment

1. Explain the basis for your rating in the “Comments” text box

2. Complete the review by clicking either “Submit” or “Submit and Send Notification”, depending on the number and seriousness of deficiencies

Deficiencies that you noted are displayed in this area

TIP:

Unacknowledged assessments are displayed by default.

Use the filter dropdown to show more assessments.

The View and Acknowledge Assessment page shows the peer review results and allows you close out the review by acknowledging that you reviewed it. Alternatively, you may choose to dispute the results.

Peer review elements displayed include:

• FIN of the patient encounter

• Patient name

• Date of Service

• Assessment Rating

• Date the peer review was assigned (Assessment Generated)

• Date the peer review was completed

• Any deficiencies found (non-administrative questions answered “No”)

Check the acknowledged box and click “Submit”

Check the dispute box, document the reason for the dispute, and click “Submit”

OR

When your Request is Completed If you selected a team, CQA will send the team administrator an email notification. If you did not select a team, be sure to let your team administrator know that you have registered.

Next Steps Your CQA Team administrator will verify your settings and approve your registration request. When you are assigned reviews to complete you will receive an automated message including the CQA link.

Locating Note in MHS Genesis

Here is where you will enter the FIN number given to the reviewer for the chart.

You can verify the FIN number at the botom of the documenta�on here. Be aware, if the note is in italics, it was not finalized by the provider. Please look above for corresponding notes. It might have a different date.

The Joint Commission Official "Do Not Use" List This list is part of the Information Management standards

Does not apply to preprogrammed health information technology systems (i.e. electronic medical records or CPOE systems), but remains under consideration for the future

Organizations contemplating introduction or upgrade of such systems should strive to eliminate the use of dangerous abbreviations, acronyms, symbols and dose designations from the software.

Abbreviation Potential Problem Use Instead

U, u (unit) Mistaken for “0” (zero), the number “4” (four) or “cc” Write "unit"

IU (International Unit) Mistaken for IV (intravenous) or the number

10 (ten) Write "International

Unit"

Q.D., QD, q.d., qd (daily) Q.O.D., QOD, q.o.d, qod

(every other day) Mistaken for each other Period after the Q mistaken for "I" and the "O" mistaken for "I

Write "daily" Write "every other day

Trailing zero (X.0 mg)* Lack of leading zero (.X

mg) Decimal point is missed Write X mg Write 0.X mg

MS MSO4 and MgSO4 Can mean morphine sulfate or magnesium sulfate Confused for one another Write "morphine sulfate"

Write "magnesium sulfate"

*Applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on pre-printed forms.

*Exception: A “trailing zero” may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.

Development of the “Do Not Use” List In 2001, The Joint Commission issued a Sentinel Event Alert on the subject of medical abbreviations. A year later, its Board of Commissioners approved a National Patient Safety Goal requiring accredited organizations to develop and implement a list of abbreviations not to use. In 2004, The Joint Commission created its “Do Not Use” List to meet that goal. In 2010, NPSG.02.02.01 was integrated into the Information Management standards as elements of performance 2 and 3 under IM.02.02.01.

©2018 The Joint Commission | May be copied and distributed | Department of Corporate Communications

Appendix (D) to HSWLSCTD 2024-001

Appendix (E) to HSWLSCTD 2024-001

Dental Officer Peer Review Instrument This Quality Assurance Document is protected under the provisions of 14 U.S.C. 645.

1. Chief Complaint/Reason for visit was documented.

1 Chief complaint/reason for visit was never documented in any entry 3 Chief complaint/reason for visit was documented in some entries 5 Chief complaint/reason for visit was documented in all entries N/A Non-applicable IL Illegible

2. Health history reviewed, signed, and positive entries addressed annually or when information changes.

1 No evidence that the health history was ever reviewed or updated as appropriate.

3 Some evidence that the health history was reviewed and/or updated.

5 The health history was reviewed/signed and updated as appropriate.

N/A Non-applicable IL Illegible

3. SOAP format is used for all annual dental exams and dental sick call entries.

1 SOAP format was never used.

3 SOAP format was used for some entries.

5 SOAP format was used for all entries.

N/A Non-applicable IL Illegible

4. Appropriate diagnostic tests performed (including diagnostic quality radiographs).

1 No appropriate diagnostic testing was performed.

3 Some appropriate diagnostic testing was performed.

5 All appropriate diagnostic testing was performed.

N/A Non-applicable IL Illegible

5. Diagnosis is recorded for each visit.

1 No diagnosis documented for any visit 3 Some visits had diagnosis documented.

5 All visits had diagnosis documented.

N/A Non-applicable IL Illegible

6. Treatment plan supports diagnosis (including perio) 1 None of the treatment plans support the diagnosis.

3 Some of the treatment plans support the diagnosis.

5 All of the treatment plans support the diagnosis.

N/A Non-applicable IL Illegible

This Quality Assurance Document is Protected under the provisions of 14 U.S.C. 645

Appendix (E) to HSWLSCTD 2024-001

7. Informed consent, such as the use of SF 522 (Request for Administration of Anesthesia and for Performance of Operations and Other Procedures), is used to assure adequate documentation.

1 Informed consent was not documented appropriately in all cases reviewed.

3 Informed consent was documented appropriately in some cases.

5 Informed consent was documented appropriately in all cases.

N/A Non-applicable IL Illegible

8. Procedures are documented with specific materials, type, and dose of anesthetic.

1 No procedures were documented with specific materials, type, and dose of anesthetic.

3 Some procedures were documented with specific materials, type, and dose of anesthetic.

5 All procedures were documented with specific materials, type, and dose of anesthetic.

N/A Non-applicable IL Illegible

9. Prescription drug utilization appropriate to diagnosis.

1 None of the prescription drugs utilized were appropriate.

3 Some of the prescription drugs utilized were appropriate.

5 All of the prescription drugs utilized were appropriate.

N/A Non-applicable IL Illegible

10. Controlled substance documentation was appropriate.

1 Controlled substance documentation was never appropriate.

3 Controlled substance documentation was sometimes appropriate.

5 Controlled substance documentation was always appropriate.

N/A Non-applicable IL Illegible

11. Opiate analgesics use was limited to post procedure pain relief.

1 None of the opiate analgesics were used solely for post procedure pain relief.

3 Some of the opiate analgesics were used solely for post procedure pain relief.

5 All of the opiate analgesics were used solely for post procedure pain relief.

N/A Non-applicable IL Illegible

12. All referrals are reviewed, and appropriate follow-up addressed.

1 None of the referrals were reviewed or had appropriate follow up addressed.

3 Some of the referrals were reviewed or had appropriate follow up addressed.

5 All of the referrals were reviewed and had appropriate follow up addressed.

N/A Non-applicable IL Illegible

Appendix (F) to HSWLSCTD 2024-001

Dental Officer Peer Review Score Sheet This Quality Assurance Document is protected under the provisions of 14 U.S.C. 645.

Record Number (First initial Last name + last 4) Item 1.

Item 2.

Item 3.

Item 4.

Item 5.

Item 6.

Item 7.

Item 8.

Item 9.

Item 10.

Item 11.

Item 12.

Appendix (F) to HSWLSCTD 2024-001

Findings/Comments:

1-

2-

3-

4-

5-

6-

7-

8-

9-

10-

Provider:__________________________________________________

Reviewer:_________________________________________________

Signature:_________________________________________________

Date Completed: ___________________________________________