Exit this survey Medical Staff Peer Evaluation Form This provider has identified you as a current member of the PSPH Medical Staff and as a peer who has specific knowledge of the provider's practice and quality care. On the provider's behalf, please complete the following assessment form. Responses will be automatically routed to the:Providence St. Peter Hospital Medial Staff Services Question Title * 1. Applicant Name: Question Title * 2. Peer Reference Name: Question Title * 3. Degree: Question Title * 4. Specialty: Question Title * 5. How long have you known the applicant? Question Title * 6. Completion of this evaluation is based on the following approximate time period? Last two years From: Month/Year - Month/Year Question Title * 7. How are you acquainted with the applicant? (Check all that apply.) Medical business or professional partner Post Graduate training Referral Source Specialty Peer Other Professional Peer Affiliation Question Title * 8. With what frequency did you observe the work with the applicant? (check one) Almost Daily Many Times a Week Several Times per Week Several Times per Month Several Times per Year Question Title * 9. To your knowledge, has this practitioner exhibited any disruptive behavior? Yes No Question Title * 10. To your knowledge, is there any physical or mental condition, including possible dependence on drugs or alcohol, which would affect this practitioner's ability in carrying out responsibilities to patients? Yes No Question Title * 11. Do you recommend this provider for medical staff membership or other affiliation status? Yes No Question Title * 12. Is this provider qualified by training and experience to be approved for all privileges requested? (See attached request for privileges.) If no, please comment. Yes No Question Title * 13. Please evaluate the applicant for the following?Patient Care Excellent Good Fair Unsatisfactory No Knowledge Provides care with compassion Provides care with compassion Excellent Provides care with compassion Good Provides care with compassion Fair Provides care with compassion Unsatisfactory Provides care with compassion No Knowledge Provides clinically appropriate care Provides clinically appropriate care Excellent Provides clinically appropriate care Good Provides clinically appropriate care Fair Provides clinically appropriate care Unsatisfactory Provides clinically appropriate care No Knowledge Considerate of patient's family/friends Considerate of patient's family/friends Excellent Considerate of patient's family/friends Good Considerate of patient's family/friends Fair Considerate of patient's family/friends Unsatisfactory Considerate of patient's family/friends No Knowledge Availability/timeliness Availability/timeliness Excellent Availability/timeliness Good Availability/timeliness Fair Availability/timeliness Unsatisfactory Availability/timeliness No Knowledge Patient Outcomes Patient Outcomes Excellent Patient Outcomes Good Patient Outcomes Fair Patient Outcomes Unsatisfactory Patient Outcomes No Knowledge Question Title * 14. Medical Knowledge Excellent Good Fair Unsatisfactory No Knowledge Basic medical/clinical knowledge Basic medical/clinical knowledge Excellent Basic medical/clinical knowledge Good Basic medical/clinical knowledge Fair Basic medical/clinical knowledge Unsatisfactory Basic medical/clinical knowledge No Knowledge Knowledge in specialty Knowledge in specialty Excellent Knowledge in specialty Good Knowledge in specialty Fair Knowledge in specialty Unsatisfactory Knowledge in specialty No Knowledge Technical Skills Technical Skills Excellent Technical Skills Good Technical Skills Fair Technical Skills Unsatisfactory Technical Skills No Knowledge Appropriate use of resources Appropriate use of resources Excellent Appropriate use of resources Good Appropriate use of resources Fair Appropriate use of resources Unsatisfactory Appropriate use of resources No Knowledge Question Title * 15. Practice-Based Learning and Improvement Excellent Good Fair Unsatisfactory No Knowledge Medical knowledge is up-to-date Medical knowledge is up-to-date Excellent Medical knowledge is up-to-date Good Medical knowledge is up-to-date Fair Medical knowledge is up-to-date Unsatisfactory Medical knowledge is up-to-date No Knowledge Timely, appropriate use of consultants Timely, appropriate use of consultants Excellent Timely, appropriate use of consultants Good Timely, appropriate use of consultants Fair Timely, appropriate use of consultants Unsatisfactory Timely, appropriate use of consultants No Knowledge Question Title * 16. Interpersonal and Communication Skills Excellent Good Fair Unsatisfactory No Knowledge Overall communication Overall communication Excellent Overall communication Good Overall communication Fair Overall communication Unsatisfactory Overall communication No Knowledge Verbal and written English fluency Verbal and written English fluency Excellent Verbal and written English fluency Good Verbal and written English fluency Fair Verbal and written English fluency Unsatisfactory Verbal and written English fluency No Knowledge Rapport with patients Rapport with patients Excellent Rapport with patients Good Rapport with patients Fair Rapport with patients Unsatisfactory Rapport with patients No Knowledge Communication with peers Communication with peers Excellent Communication with peers Good Communication with peers Fair Communication with peers Unsatisfactory Communication with peers No Knowledge Communication with hospital staff Communication with hospital staff Excellent Communication with hospital staff Good Communication with hospital staff Fair Communication with hospital staff Unsatisfactory Communication with hospital staff No Knowledge Ability to work with healthcare team Ability to work with healthcare team Excellent Ability to work with healthcare team Good Ability to work with healthcare team Fair Ability to work with healthcare team Unsatisfactory Ability to work with healthcare team No Knowledge Writes legibly Writes legibly Excellent Writes legibly Good Writes legibly Fair Writes legibly Unsatisfactory Writes legibly No Knowledge Question Title * 17. Professionalism Excellent Good Fair Unsatisfactory No Knowledge Ethical standards of treatment Ethical standards of treatment Excellent Ethical standards of treatment Good Ethical standards of treatment Fair Ethical standards of treatment Unsatisfactory Ethical standards of treatment No Knowledge Maintains patient confidentiality Maintains patient confidentiality Excellent Maintains patient confidentiality Good Maintains patient confidentiality Fair Maintains patient confidentiality Unsatisfactory Maintains patient confidentiality No Knowledge Maintains responsibility for patients Maintains responsibility for patients Excellent Maintains responsibility for patients Good Maintains responsibility for patients Fair Maintains responsibility for patients Unsatisfactory Maintains responsibility for patients No Knowledge Fulfills on-call duties Fulfills on-call duties Excellent Fulfills on-call duties Good Fulfills on-call duties Fair Fulfills on-call duties Unsatisfactory Fulfills on-call duties No Knowledge Sensitive to diversity Sensitive to diversity Excellent Sensitive to diversity Good Sensitive to diversity Fair Sensitive to diversity Unsatisfactory Sensitive to diversity No Knowledge Question Title * 18. Systems-Based Practice Excellent Good Fair Unsatisfactory No Knowledge Use of electronics in medicine Use of electronics in medicine Excellent Use of electronics in medicine Good Use of electronics in medicine Fair Use of electronics in medicine Unsatisfactory Use of electronics in medicine No Knowledge Familiarity with electronic medical record Familiarity with electronic medical record Excellent Familiarity with electronic medical record Good Familiarity with electronic medical record Fair Familiarity with electronic medical record Unsatisfactory Familiarity with electronic medical record No Knowledge Familiarity using protocol and practice guidelines Familiarity using protocol and practice guidelines Excellent Familiarity using protocol and practice guidelines Good Familiarity using protocol and practice guidelines Fair Familiarity using protocol and practice guidelines Unsatisfactory Familiarity using protocol and practice guidelines No Knowledge Complete, appropriate and timely medical record documentation Complete, appropriate and timely medical record documentation Excellent Complete, appropriate and timely medical record documentation Good Complete, appropriate and timely medical record documentation Fair Complete, appropriate and timely medical record documentation Unsatisfactory Complete, appropriate and timely medical record documentation No Knowledge Question Title * 19. Comments: Question Title * 20. Your Info Printed Name Phone: Email: Done