Download PROJECT GOALS

OPPE
Ongoing professional practice evaluation is the process the hospital and medical
staff use to identify negative practice trends that may impact the quality of
patient care and safety. When negative trends or isolated incidents are
identified, the medical staff needs to determine what intervention should be
taken.
Prior to, or at the time of reappointment, information collected as a result of
OPPE is utilized in the decision to maintain current privileges, or revise/revoke an
existing privilege.
The ongoing professional practice evaluation process must be clearly defined and
must contribute to and support the evaluation of each practitioner’s professional
practice. There must be a written policy and procedure. The medical staff must
determine and approve what performance data is to be collected. Joint
Commission requires certain information be evaluated as part of the medical
staff’s PI. This includes use of medications, use of blood and blood components,
operative and other procedures, appropriateness of clinical practice patterns,
significant departures from established patterns of clinical practice, autopsy
criteria, quality of the medical history and physical exams, medical assessment
and treatment of patients, sentinel events, and patient safety data.
The medical staff must use the information it receives from ongoing professional
practice evaluation in its determination to continue, limit, or revoke any existing
privileges.
Ongoing Professional Practice Evaluation
Data collected and reported on practitioner specific
report every 3, 6 or 9 months
Care Meets
Expectation
Improvement Opportunity
Identified
Care Does Not Meet
Expectation
Implement FPPE Process
Flowchart
Communicate results & track
thru 24 month cycle.
Maintain in Practitioner
Quality File
Department Chief or Chief of
Staff communicates improvement
opportunity to involved
Practitioner via letter
Medical Staff
Review Process
Possible OPPE Outcomes
TIPS for Implementing OPPE
1.
Start by listing your medical staff departments and/or sub-specialties
2.
Identify general measures that apply to everyone and specialty-specific
measures that apply to a specific specialty. Start with those measures
you are already monitoring & have data available.
3.
Meet with key medical staff leaders to determine if the list is adequate
and if it’s not, fill in the gaps. Ensure you are collecting data that
relates to what individual practitioners are privileged to perform.
4.
Seek approval of the criteria by the appropriate medical staff leaders
and/or committees.
5.
Implement practitioner-specific profiles from your defined indicators.
6.
Define your periodic timeframe for reporting the profile, i.e. every 3, 6
or 9 months.
7.
Develop a reporting process to and from the Department Chair or
Committee and the Quality Department.
8.
Set up a process for practitioner feedback when results of ongoing or
focused evaluation are reported.
9.
Create a tracking tool for OPPE & FPPE.
10.
Maintain the practitioner specific report and associated feedback in the
practitioner’s quality file.
11.
To determine frequency of reporting, consider
identifying the total number of practitioners that
need to be evaluated, then determine what
frequency would be manageable for reviews.
For example, it might not be feasible for large
departments to do reviews quarterly. It might be
easier to do half of the reviews each quarter so
that everyone is evaluated every six months.
Selecting Medical Staff Indicators
1.
Whenever possible, use data that is already collected and/or is
easily obtained.
2.
Select measures that relate to services and improvement
opportunities at your facility.
3.
Assure that measures are pertinent to the specialty of the
practitioner and his/her requested privileges.
4.
Group very similar activities together from the practitioner list of
privileges. It is not reasonable to expect a competency evaluation
of every requested privilege.
5.
Assign responsibility for data collection to those department
directors responsible for the data i.e., HIM, Pharmacy, Case
Management, Infection Control, etc.
6.
Don’t select too many measures, but assure that you have
enough to truly evaluate the physician’s performance.
REMEMBER:
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The process must be fair – indicators for the same privilege are
managed the same way for all practitioners with that privilege.
Clearly define/specify all indicators so that everyone understands what
is being measured and how it is to be measured.
Various medical specialty boards have specialty-specific defined criteria
for performance monitoring. Research these to determine if any may be
pertinent and useful for your facility.
When serious issues arise, or are identified through routine OPPE or
FPPE, medical staff leaders need to know asap.
Good Versus Negative Data
 Data should not be limited to only negative or outlier data
 Good performance data should be also considered
 Capture zero data. Zero data is data and can indicate good
performance. For example:
o No returns to OR
o No complaints
o No complications or infections
Low-Volume & No-Volume Practitioners
Options include:
1.
The practitioner may submit their quality profile from other
facilities for use at reappointment
2.
Hospitalists may complete the reappointment profile for the PCP’s
for whom they accept admissions
3.
Practitioner may submit copies of office records for review by
medical staff committees
4.
Peer recommendation from a practitioner in the same
professional discipline
Don’t forget – if a practitioner does not exercise privileges,
he/she is not subject to the requirements of OPPE and FPPE.
Encourage “Refer and Follow” privileges!
Peer Recommendations
A peer recommendation is a statement provided in support of an applicant’s request for
appointment / reappointment and/or privileges by a practitioner in the same
professional discipline as the applicant. Peer recommendations are typically obtained
from prior training program directors, department chairs, chiefs of staff, or others
familiar with the applicant’s professional history and current clinical competence.
Friends, neighbors, and relatives are not appropriate sources for peer
recommendations. Peer recommendations should include reference to the applicant’s
competence and ability to perform the privileges requested.
Joint Commission Requirements for Peer Recommendations
The medical staff must use peer recommendations in its consideration of
recommendations for appointment and initial granting of privileges. Peer
recommendations may be used to recommend individuals for the renewal of clinical
privileges when insufficient practitioner-specific data are available. The peer must be
an appropriate practitioner in the same professional discipline as the applicant with
personal knowledge of the applicant. In situations where there is no peer available for
a specific category or LIP, it may be necessary to obtain a reference from a physician
with essentially equal qualifications who is familiar with the LIP’s performance. For
example, a pediatrician could provide a reference for a pediatric nurse practitioner, or
an internist could provide a reference for an adult nurse practitioner. The
recommendation should come from someone in the same clinical specialty.
Peer recommendations must address the practitioner’s relevant training and experience,
current competence, and any effects of health status on privileges being requested.
Approved sources for peer recommendations include:
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a reference letter(s), written documentation, or a documented telephone
conversation(s) about the applicant from a peer(s) who is knowledgeable about
the applicant’s professional performance and competence;
a department or major clinical service chairperson who is a peer; or
the medical staff executive committee.
Additionally, peer recommendations must include evaluation of the applicant’s medical
knowledge, technical and clinical skills, clinical judgment, communication skills,
interpersonal skills and professionalism.
An example of a peer recommendation letter is located in the Credentialing software
system.
XYZ Hospital
Medical Staff OPPE/FPPE Practice Evaluation
SAMPLE Peer Recommendation Form
Practitioner Name:
Evaluation Period:
Instructions:
Since you have had limited patient contacts at XYZ Hospital, or we have no/limited access to your patient volume, please
have a peer, or, if applicable, the (1) department chair, (2) division chief, (3) credentialing committee chair, or (4)
sponsoring physician (AHP’s) from your primary hospital affiliation or practice affiliation complete this form and return to
Medical Staff Services. Deadline for completion is 30 days from receipt. Thank you for your assistance.
EVALUATION
FACTOR
C - Comments
YES
NO
C
Technical and Clinical Skills
1. Patient assessments are comprehensive, accurate and current.
2. Demonstrated clinical competence and judgment.
3. Appropriate and timely utilization of consultants.
Medical and Clinical Knowledge
4. Demonstrates knowledge of basic and discipline-specific medicine.
5. Timely ordering, appraisal, and follow-up of diagnostic tests.
Interpersonal & Communication Skills
6. Fosters a therapeutic and ethical relationship with patients/families.
7. Fosters a collegial and ethical relationship with members of the healthcare team.
8. Timely, appropriate, and effective communication that facilitates continuity of care and
consistency of treatment plan when assuming care of patients and when handing off to the next
practitioner.
9. Effective as a member of the interdisciplinary healthcare team.
Professionalism
10. Responsive, accountable, and committed to patients, the hospital, and the healthcare team.
11. Demonstrates ethical principles: provision/withholding of clinical care, confidentiality, informed
consent, and clinical practices.
12. Practitioner has the physical/mental ability to safely render care.
13. Satisfaction:  No comments on file  Comments on file: # positive____# negative____
14. Approximate Volume: _________ Number of Mortalities__________ Average LOS______(days)
COMMENTS:
Evaluation completed by:
Printed Name / Signature
Title
Date
Sample Practitioner Profiles
Using the OPPE Practitioner Profile at
Reappointment
CONTENT
In order to utilize the OPPE Practitioner Profile in lieu of the current Reappointment Profile,
the tool must include at least the following elements:
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Practitioner Name
Specialty or Department
Staff status/category
Volume / activity data
Department/committee attendance compliance (if required)
Evidence of CME (if required)
Resource Utilization Data (may provide data advantage report)
Core Measures Compliance Data (may provide MD specific report from system)
Quality Data, including
o Blood usage appropriateness
o Medication use
o Complication data
o HIM data
o Risk Management / Safety
Data elements may be customized for your individual facility and may include more
elements as desired or specified by the medical staff. All profiles must include data
representation of at least the above topics.
FORMAT
Aggregated Data Results
The OPPE practitioner profile must include a “roll-up” or total column that is formulated to
provide an ongoing calculation of practitioner performance over time.
Outcome of Review
The individual profile must include a means to document the outcome of the review. This
may be accomplished by including an outcome and sign-off section on the profile itself, or
by a separate form. The outcome of the review must be documented and maintained in
the practitioner’s quality file.
The profile requires approval by the medical staff and Board.
<ENTER FACILITY NAME>
Privileged and Confidential for Peer Review Purposes Only
Physician:
Professionalism
Current Health Screening:
Meeting Attendance:
Systems Based Practice
Admissions
Consults
Case Mix Index
Average Length of Stay
Failure to Meet Admission Criteria
Readm within 30 days (same Dx)
Suspension
Inappropriate Transfers
Communication
Validated Patient Complaint
Compliments
Validated Disruptive Incidents
Response to paging
Patient Care
Unexpected significant ADR's
Complications of mod. sedation
Do Not Use Abbreviations
Medical/Clinical Knowledge
Dating/Timing of entries
Verbal/Phone Order Authentication
Legibility
Delinquent H&P
Practiced-Based Learning and
Improvement
Core Measures - AMI
Core Measures - HF
Core Measures - PN
Core Measures - OP
Blood Use Not Meeting Criteria
Peer Review
Total # of cases reviewed
Indicator:
Indicator:
Status:
Sanctions:
Compliance with By-Laws/Rules & Regulations/Policies:
ENTER
ENTER
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Goal
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PERIOD
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OPPE PERIOD
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OPPE PERIOD
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Score:
Score:
Ongoing Professional Practice Evaluation
The information from Ongoing Professional Practice Evaluation has been reviewed and based on this review:
□ The practitioner is performing well or within desired expectations and no further action is warranted. It is
recommended that current privileges continue.
Review Period: _____ to ______ □ Issue(s) exist or triggers(s) met requiring a focused evaluation. The specific issue(s) is/are:
_______________________________________________________________________________________
□ Practitioner has had no activity for _____ months, notify practitioner and initiate focused review when
activity resumes.
Approval Signature:
Date
XYZ Regional Hospital
Physician Ongoing Professional Practice Evaluation
Med Staff
Info and
Performance
Color Key
Reporting Period
Provider Number
Licensure
Target
Paul Jones MD
Department / Status
Volume
n/a
n/a
n/a
n/a
n/a
Patient Care
Unplanned Returns to ER (same dx)
Invasive Procedure Complications
Individual Case Reviews Receiving Score 3 or >
Moderate Sedation-related Complications
QIO review
n/a
0
n/a
0
0
Adverse Drug reactions (known allergy or contra)
0
EKGs - Overread Interpretation
2nd
3rd
4th
TOTAL
50166
Emergency MD
Emergency Medicine / Active
No. ED Encounters
Admit %
Physician Consulted %
Number of AMAs
ED readm w/in 48h resulting in admission or death
Medical
Clinical
Knowledge
1st
n/a
X-Ray Variances %
<15%
Core Measures (Inpt: CHF)
Core Measures (Inpt: AMI)
100%
100%
Practice-Based
Learning and
Improvement
Core Measures (Inpt: PN)
100%
Core Measures (Outpt: AMI)
100%
Core Measures (Outpt: CP)
100%
Interpersonal &
Communication
Skills
# of validated disruptive physician complaints
0
# of validated patient complaints
0
VO/TO orders not signed w/in 48 hrs.
0

Emtala Issues
Professionalism
# of Suspensions/Days (Episodes/Days)
0
0

Systems
Based Practices
Exam Wait > 2 Hours
Avg Exam wait time
Length of Stay (LOS) > 6 Hours
Avg LOS
0
<30 min
0
<2
REVIEW AND RECOMMENDATION
The information from OPPE has been reviewed and based upon this review:
 The practitioner is performing within desired expectations. It is recommended that current privileges continue.
 Issue(s) exist or trigger(s) met requiring focused evaluation. The specific issue(s) is/are: ______________________________________________
 Practitioner has had no activity for _____ months, notify practitioner and initiate focused review when activity resumes.
Approval Signature:
Date:
Physician Quality Score Card
General Surgery
last name, first name, MD/DO/etc
active
Department of Surgery
Volume
GOAL
No. Admissions
No. Consults
Surgical cases
Average LOS
Case Mix Index
CARE INDICATOR
Core Measures
Mortality rate
Post -op complications
Surgical site infection
Readmission rate
Blood products usage outlier
Medication usage appropriate
Entries Dated and Timed
HA UTI
HA DVT
Peer Review Scoring 3 or above
2nd
QTR
2011
3rd QTR
2011
4th QTR
2011
4-Quarter
Summary
Comments
0
0
0
PATIENT CARE / PATIENT SAFETY
100.00%
#DIV/0!
#DIV/0!
0
0
#DIV/0!
0
0
0
0%
0
100%
#DIV/0!
0
0
0
# of Validated Disruptive Complaints
0
0
0
0
0
Department Chair comments:
Department Chair Signature
1st QTR
2011
Date
1st Qtr Ertapenem/ 2nd Qtr
Dronedarone/ 3rd Qtr Tolvaptan
Ongoing Professional Practice Evaluation Report
(To be included in Credential File)
Practitioner Name:
Department:
Time Period for Review: From: ____________
To: _________________
The information from Ongoing Professional Practice Evaluation has been reviewed and based
on this review:

The practitioner is performing well or within desired expectations and no further action
is warranted. It is recommended that current privileges continue.

Issue(s) exist or trigger(s) met requiring a focused evaluation. The specific issue(s)
is/are:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Practitioner has had no patient contact for ______ months, notify practitioner and
initiate focused review when activity resumes.

Other: _______________________________________________________________
________________________________________________________________
_____________________________________
Signature, Department Chair
Date
Optimally, these items
should be included on the
individual practitioner
OPPE Profile report.
OPPE Log – Department of Medicine
Physician
1st Reporting Period
2011
Sent & Filed
File Only/
No Data
2nd Reporting Period
2011
Sent & Filed
File Only/
No Data
3rd Reporting Period
2011
Sent & Filed
File Only/
No Data
4th Reporting Period
2011
Sent & Filed
File Only/
No Data
OPPE Log – Department of Surgery
Physician
1st Reporting Period
2011
Sent & Filed
File Only/
No Data
2nd Reporting Period
2011
Sent & Filed
File Only/
No Data
3rd Reporting Period
2011
Sent & Filed
File Only/
No Data
4th Reporting Period
2011
Sent & Filed
File Only/
No Data
Sample OPPE Letter
July 20, 2011
Keith Jones, MD
312 West Main Street
Franklin, TN 37067
RE:
Ongoing Professional Practice Evaluation (OPPE)
Dear Dr. Jones
A Joint Commission standard requires that we ensure our credentialed practitioners on staff
have the necessary skills and knowledge to provide quality patient care. In order to
successfully meet this standard, the medical staff of XYZ Hospital has implemented processes
for ongoing professional practice evaluation.
These evaluation processes allow XYZ Hospital to identify professional practice trends that
impact quality of care and patient safety. Relevant information obtained from the OPPE process
is integrated into performance improvement activities and is factored into the decision to either
maintain existing privileges, to revise existing privileges, or to revoke an existing privilege prior
to or at the time of reappointment. OPPE will be conducted every three to six months with
results reported in applicable medical staff committee(s). All practitioners will receive their
individual OPPE results. A copy will also be maintained in the practitioner quality file.
Attached is your individual performance analysis for the most recent reporting period. All data
elements are noted as satisfactory or in acceptable range. Please feel free to contact me if you
have any questions.
Sincerely:
Robert Matthews, MD
Chair, Department of Medicine
Cc:
Quality File
CONFIDENTIAL
Sample OPPE Letter –
FPPE Recommended
July 20, 2011
Keith Jones, MD
312 West Main Street
Franklin, TN 37067
RE:
Ongoing Professional Practice Evaluation (OPPE)
Dear Dr. Jones
A Joint Commission standard requires that we ensure our credentialed practitioners on staff
have the necessary skills and knowledge to provide quality patient care. In order to
successfully meet this standard, the medical staff of XYZ Hospital has implemented processes
for ongoing professional practice evaluation.
These evaluation processes allow XYZ Hospital to identify professional practice trends that
impact quality of care and patient safety. Relevant information obtained from the OPPE process
is integrated into performance improvement activities and is factored into the decision to either
maintain existing privileges, to revise existing privileges, or to revoke an existing privilege prior
to or at the time of reappointment. OPPE will be conducted every three to six months with
results reported in applicable medical staff committee(s). All practitioners will receive their
individual OPPE results. A copy will also be maintained in the practitioner quality file.
Attached is your individual performance analysis for the most recent reporting period. All data
elements have been reviewed by the Department of Surgery and are noted as satisfactory or in
acceptable range with the exception of your post-operative infection rate of 2.9. Please be
advised we will be conducting a focused review of your operative cases over the next six weeks.
Please feel free to contact me if you have any questions.
Sincerely:
Matthew Johnson, MD
Chair, Department of Surgery
Cc:
Quality File
CONFIDENTIAL