Medical Executive Committee updates September 2026

Effective Sept. 24, approved by the South Puget Sound Community Mission Board.

Centralia Hospital updates

• Scribes in the Hospital Setting – Revised

Centralia ongoing professional practice evaluation - New

Infectious Disease

• Number of Patients on IV Antibiotics vs number of missed notifications 

Neurology

• H&P Note Compliance Within 24 Hours of Admit Rate
• Peer Review Cases – 3 or more cases regarding the same situation/variance with a final recommendation of learning opportunity and/or 1 or more cases with the final recommendation as a Major Learning Opportunity and/or Inappropriate Care

Pediatric Cardiology

• Length of Stay O/E (Pediatrics 0-17 Yrs)
• Discharge Summary within 48 Hrs Rate

 Radiation Oncology

• 30-day Readmission O/E
• Post-operative hemorrhage or hematoma rate
• Peer Review Cases – 3 or more cases regarding the same situation/variance with a final recommendation of learning opportunity and/or 1 or more cases with the final recommendation as a Major Learning Opportunity and/or Inappropriate Care

Family Medicine

• Sepsis Orderset Utilized %
• Clinical Documentation Integrity (CDI) Response Rate

St. Peter Hospital updates

• Gynecology Privilege Request Form – Revised
• General Surgery Privilege Request Form – Revised
• Obstetrics Privilege Request Form – Revised
• Pediatric Cardiology Privilege Request Form – Revised
• Pediatrics Privilege Request Form – Revised
• Sports Medicine Privilege Request Form – Archived
• Focused Professional Practice Evaluation – New
• Supervision of Family Medicine Residents – Revised
• Pediatric Patients Requiring Procedures Policy - Revised

St. Peter ongoing professional practice evaluation - New

Gynecology

• 30-Day Readmission O/E Ratio
• Operative Note TAT – 48 Hr Compliance Rate

 Gynecology Oncology

• Patient Safety Indicated o5 (PSI 05) Retained Surgical Item or Unretrieved Device Fragment Count
• 30-Day Readmission O/E Ratio
• Hospital Acquired Condition (HAC 06) Cath Associated UTI 

Urogynecology & Reconstructive Surgery

• 30-Day Readmission O/E Ratio
• Post-operative hemorrhage or hematoma rate
• Peer Review Cases – 3 or more cases regarding the same situation/variance with a final recommendation of learning opportunity and/or 1 or more cases with the final recommendation as a Major Learning Opportunity and/or Inappropriate Care

Oral & Maxillofacial Surgery

• Discharge Summary within 48 Hours Rate
• Peer Review Cases – 3 or more cases regarding the same situation/variance with a final recommendation of learning opportunity and/or 1 or more cases with the final recommendation as a Major Learning Opportunity and/or Inappropriate Care

 Otolaryngology

• Operative Note TAT – 48 Hr Compliance Rate
• Peer Review Cases – 3 or more cases regarding the same situation/variance with a final recommendation of learning opportunity and/or 1 or more cases with the final recommendation as a Major Learning Opportunity and/or Inappropriate Care

 Pain Management

• Discharge Summary within 48 Hours Rate
• Peer Review Cases – 3 or more cases regarding the same situation/variance with a final recommendation of learning opportunity and/or 1 or more cases with the final recommendation as a Major Learning Opportunity and/or Inappropriate Care

 Plastic Surgery

• H&P Note Compliance Within 23 Hours of Admit Rate
• Operative Note TAT – 48 Hr Compliance Rate

 Radiation Oncology

• 30-day Readmission O/E
• Post-operative hemorrhage or hematoma rate
• Peer Review Cases – 3 or more cases regarding the same situation/variance with a final recommendation of learning opportunity and/or 1 or more cases with the final recommendation as a Major Learning Opportunity and/or Inappropriate Care

 Vascular Surgery

• 30-day Readmission O/E
• Post-operative hemorrhage or hematoma rate
• Peer Review Cases – 3 or more cases regarding the same situation/variance with a final recommendation of learning opportunity and/or 1 or more cases with the final recommendation as a Major Learning Opportunity and/or Inappropriate Care 

Family Medicine

• Mortality O/E Ratio
• Peer Review Cases – 3 or more cases regarding the same situation/variance with a final recommendation of learning opportunity and/or 1 or more cases with the final recommendation as a Major Learning Opportunity and/or Inappropriate Care

 Family Medicine with OB

• Post-partum hemorrhage rate
• H&P Note compliance within 24 hours of Admit Rate 

Palliative Care

• Discharge Summary within 48 hours rate
• H&P Compliance Note within 24 hours rate

Pediatrics

• Post-partum hemorrhage rate 

Pediatric Cardiology

• Length of Stay O/E (Pediatrics 0-17 Yrs)
• Discharge Summary within 48 Hrs Rate 

Certified Nurse Midwife

• H&P Note compliance within 24 hours of Admit Rate

 Obstetrics

• H&P Note compliance within 24 hours of Admit Rate