Clinical Performance Enhancement


‹ Back to Q&A


Our facility has an optometrist that comes on-site on a regular basis for patient care. Does standard C-02 Clinical Performance Enhancement require that the optometrist receive a clinical performance review?

Although it is good practice to have a clinical performance review for all providers with direct patient care, the standard does not require that an optometrist be part of this review.
— From CorrectCare Volume 30 Issue 4, Fall 2016


Is a clinical performance enhancement review required for part-time and per-diem nurses and subcontracted nurses?

The Clinical Performance Enhancement standard (C-02) requires that the clinical performance of the facility’s direct patient care clinicians and RNs and LPNs is reviewed at least annually. The intent of the standard is to enhance patient care through peer review of the individuals’ practice, and therefore it applies to all nurses regardless of the number of hours worked per week.
— From CorrectCare Volume 29, Issue 4, Fall 2015


Since registered dental hygienists are licensed practitioners, do they require the clinical performance enhancement reviews discussed in standard C-02? If so, would the supervisor within the same discipline be a dentist or a dental hygienist? Most dental hygienists do not have supervisors who are also registered dental hygienists. Also, the standard does not specify whether midlevel providers are reviewed by the physician or whether another supervisory midlevel provider would conduct those reviews.

While clinical performance review of dental hygienists is good practice, technically it is not required by the NCCHC standards. If you opt to conduct the reviews, a dentist could do that since, as you noted, hygienists do not normally have a peer supervisor. Concerning the reviews of midlevel providers, which are required by the standard, those can be completed by the physician.
— From CorrectCare Volume 29, Issue 2, Spring 2015


In reviewing the 2014 Standards, we noted that the peer reviews must now be done on all RN and LPN staff nurses. Does an independent party have to do the reviews, or can we have the nurses do the opposite shift?

Standard C-02 requires that a clinical performance enhancement process evaluates the appropriateness of services delivered by all direct patient care clinicians as well as RNs and LPNs. The addition of RNs and LPNs was new in the 2014 jail and prison Standards, and the definition of direct patient care clinicians was clarified as follows: all licensed practitioners providing medical, dental and mental health care, including physicians, dentists, midlevel practitioners and qualified mental health professionals (see definition in book).

Reviews are normally conducted by supervisors within the same discipline. For example, if you have more than one MD, the responsible physician would conduct the review of the facility MD. So if you have a director of nursing, he/she would review the nurses. If the responsible physician or DON also provides clinical care, he/she must also be reviewed. Reviews may be accomplished through a memorandum of agreement with an outside practitioner, by contracting with an outside group such as a medical school or hospital, or through the regional or corporate system.
— From CorrectCare Volume 28, Issue 4, Fall 2014


I’m not very clear on the difference between a clinical performance enhancement review (C-02 Clinical Performance Enhancement) and an annual performance review. Can you please explain this?

A clinical performance enhancement review is focused on the quality of the clinical care provided; a health professional’s work is reviewed by another professional of at least equal training in the same general discipline, such as the review of the facility’s physicians by the responsible physician. An annual performance review might address areas such as punctuality, teamwork, attitudes, goals, etc.; those types of reviews do not apply to this standard.
— From CorrectCare Volume 23, Issue 4, Fall 2009


Is our obstetrician/gynecologist required to have a clinical performance enhancement review under the Clinical Performance Enhancement standard (C-02)?

This standard requires the clinical performance of a facility’s primary care clinicians to be reviewed at least annually. Primary care clinicians are all licensed practitioners (including medical physicians, psychiatrists, dentists, midlevel practitioners and PhD-level psychologists) who provide primary care on a regular basis. Therefore, this standard does not require an ob/gyn or any other specialist that is not considered a primary care clinician to receive a clinical performance enhancement review.
— From CorrectCare Volume 23, Issue 1, Winter 2009


This question concerns the new standard for peer review. We are a small jail, average daily population about 200, in a rural area. We understand that our consulting psychiatrist now needs an annual review of her performance at the jail, but she is the only psychiatrist who works at the jail in our area. Can our licensed psychiatric social worker do her review?

You are referring to important standard C-02 Clinical Performance Enhancement, which is new to the 2003 jail and prison Standards and included in the 2004 juvenile Standards. To quote from the discussion section: “The intent of this standard is to enhance patient care through peer review of the clinicians’ practice. The clinical performance enhancement review process is neither an annual performance review nor a clinical case conference process. It is a professional practice review focused on the practitioner’s clinical skills; its purpose is to enhance competence and address areas in need of improvement.

Facilities in which the practitioner (in your case, the psychiatrist) is the sole representative of a profession is actually one of the situations the standards revision committee wanted to address. The standard’s intent is to promote the professional exchange of ideas and practice that can occur only with another professional of equal or more advanced training and experience in the same discipline. So, while medical physicians can review other medical physicians and midlevel practitioners, only psychiatrists should be reviewing psychiatrists.

So, what are you to do? Is there a community psychiatrist in private practice willing to do such a review? Will a state medical school provide such services? Ideally, the performance review is a face-to-face meeting, but telephone reviews following sample record reviews might be an option. Exchange of written materials may not be best, but it could work. Yet another possibility is the use of a university telemedicine program, if one is available.

Failing all of the above, you should note that NCCHC has designated this standard as “important” (as opposed to “essential”) so noncompliance should not affect your accreditation status.

For more details about compliance, see the Spotlight on the Standards that deals with this standard.
— From CorrectCare Volume 18, Issue 2, Spring 2004