Criterion 16: #49877

Finding
Compliance

The provider’s CME program is closely tied to performance improvement initiatives in the organization. For example, a recent hospital performance improvement and quality initiative was developed to reduce readmission rates for pneumonia and heart failure patients. Chart audits are being incorporated into a database that will be used for Joint Commission Ongoing Professional Practice Evaluation (OPPE) and performance improvement. This model will be refined and provide a model for future performance improvement activities. In addition, analysis of CME events is performed to determine the impact of each event on physician practice and to measure the multiyear trends in the number of activities addressing (1) changing and sustaining physician competence, (2) clinical performance, and (3) optimizing patient outcomes.