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Medical Executive Committee updates September 2026

Published Date

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