St. Peter August 2025 Med Exec Committee updates

August 26, 2025

Effective Aug. 28, the South Puget Sound Community Mission Board approved the following:

  • Obstetrics Privilege Request Form – Revised
  • Pediatric Cardiology Privilege Request Form – Routine Review
  • ARNP Inpatient Normal Newborns Privilege Request Form – Routine Review
  • Pediatric Privilege Request Form – Routine Review
  • Spinal Surgery Policy – Revised
  • First Surgical Assisting and Surgical Wound Closure – Revised
  • Gastrostomy Tube (G-tube), Percutaneous nephrostomy (PMC) tube & Suprapubic catheter (SPC) exchanges – New

 

Focused Professional Practice Evaluation (FPPE) Specialty Data IndicatorsNew

  • Emergency Medicine

Observed or Retrospective Review:

  • 3 Treatments for Adult Patients
  • 2 Treatments for Pediatric Patients
  • 2 Procedural Sedations
  • Code Management
  • 2 Procedures (Chest Tube, Lumbar Puncture, Line Placement, etc.)

 

  • Family Medicine

Observed or Retrospective Review:

  • 5 Adult Patient Care Managements
  • 2 Pediatric Patient Care Managements
  • 2 Newborn Patient Care Managements

 

  • Family Medicine with OB

Observed or Retrospective Review:

  • 2 OB admissions

Observed:

  • 2 Deliveries. After two months, conduct a retrospective review of all cases for standard of care management. Review must occur within the first 10 cases. Observations maybe performed by any provider with obstetrical privileges, including practice associates.

Proctored:

  • 10 Cesarean Sections

 

  • Pediatrics

Observed or Retrospective Reviews of:

  • 5 Inpatient Pediatrics Patient Care Encounters

 

Ongoing Professional Practice Evaluation (FPPE) Clinical Quality MeasuresNew

  • Emergency Medicine
  • Returns to Emergency Department within 72 hours with Hospital Admission Rate
  • ED Note Compliance Rate 72 hours 
  • General Surgery
  • Returns to Emergency Department within 72 hours with Hospital Admission Rate
  • Post operative wound infection after colorectal surgery

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CMO Message: August 2025