As Healthcare institutes are striving to create a successful quality and patient safety environment along with multifaceted approach that systematically reviews overall systems and processes, they also require a standardized framework for evaluating individual practitioner performance on a routine basis..
Hospitals have established a privilege process, which is backed up with hospital credentialing process. As these two processes evolve, there are two required elements of competency assessment that are mandated by The Joint Commission (TJC) and JCI which are: Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE).
In today’s busy healthcare industry, medical staff leaders often encounter situations that don’t fit squarely into traditional evaluation frameworks, such as telehealth, low-volume or part time practitioners, and the growing ranks of advanced practice professionals. With a series of factors at play, it can be difficult to take the proper steps to ensure effective peer review.
is the evaluation framework of ongoing data collection for the purpose of evaluating a practitioner’s behaviors, professional growth, and clinical results. The information gathered during this process is factored into decisions to maintain privilege and or performance improvement activities. The process of ongoing professional practice evaluation is further helpful in reducing variation within a department/service through comparisons among peers and through comparisons with external benchmark practices and published research and clinical results.
Focused Professional Practice Evaluation (FPPE) is one step further to OPPE, where more specific and time-limited monitoring of a provider’s practice performance is conducted to evaluate the privilege-specific competence of the practitioner, who lacks documented evidence of independently performing the requested privilege(s) at the organization.
FPPE is initiated in below common situations:
a) when a provider is initially granted practice privileges
b) when new privileges are requested for an already privileged provider
c) when performance non-conformance involving a privileged provider are identified (through the OPPE process or by any other means such as complaints, sentinel events or significant variation from standard practice.
The FPPE process must be well -written and consistently implemented for all situations identified above. The performance monitoring process must be clearly defined and include, at a minimum, the following:
criteria (data) for conducting performance evaluations.
monitoring plan specific to the set criteria.
duration of performance monitoring.
Determine if monitoring by an external source is required.
Data Collection: Though OPPE/FPPE is quantitative data rich process, qualitative criteria (data) should also considered when designing the process, limiting to quantitative data may only represent the presence or absence of information but may not reflect the quality of the information reviewed.
Qualitative Data: Qualitative or ‘categorical’ data, may be described as data that ‘approximates and categorize’ and is often non-numerical in nature collected through observations, discussion with other individuals, chart review, monitoring of diagnostic and treatment techniques, etc.
Quantitative Data: generally, refers to data that are numerical quantities such as measurements, counts, percentage compliant, ratios, thresholds, intervals, time frames, etc.
Examples of Physician related quantitative data: Length of stay trends/Post-procedure infection rates/Dating/timing/signing entries/Presence/absence of required information (H & P, SOAP etc)/Scores of compliances with core measures, Clinical pathways etc.
Data Sources: The data source used for the FPPE process must include practitioner activities performed at the organization where privileges have been requested. This may include activities performed at any location that falls under the organization’s operated hospitals.
Off-site proctoring: documented evidence of FPPE at alternative hospital In multi-hospital systems where each hospital operates independently, numbers, data from those entities may be used to supplement local data.
Low-volume Practitioners: When practitioner activity at the hospital level is low or limited, supplemental data may be used from another organization where the practitioner holds the same privileges. The use of supplemental data may NOT be used in lieu of a process to capture local data also determine the supplemental data’s relevance, timeliness, and accuracy.Who reviews is clearly defined
Medical Director? Department chairs? A committee? (credentials/peer review?) Designated individual(s)?
Large number of data points and KPIs to address long list of specialties thru manual data analysis: If you are still using “hard copy or excel OPPE template”, you are likely struggling to perform meaningful OPPE and FPPE. If a privilege list for a typical specialist includes 60-80 privileges, how do you track current competence for each? For 100+ doctors in a facility?
The Joint Commission (TJC) gives suggestion here: “While the evaluation process would require an evaluation of each new privilege it could be possible to group very similar activities together and then evaluate a set number of any mix of the privileges, for example, any ten from the group will be evaluated to determine competence for the whole group, but you cannot just look at one privilege from the group.” (FAQs, October 2008)
Applying FPPE and OPPE inconsistently across providers as manual system don’t give accurate or real time comparisons: A hospital must be able to measure and report the number of procedures performed or cases managed that fall under each line on the procedure privilege list, something most hospitals cannot do with adequate accuracy in a manual process. So, even if there is an adverse event, is it one of two (1:2, or 50%) or (1:400, or 0. 4%)? Without a denominator for the equation, how can a “fall out” case say anything meaningful about the presence, absence, or trend of errors?
Reporting capabilities and data collections are inefficient and time-consuming thru manual data entry: Data required for an OPPE framework is collected/generated by different points in a hospital such a medication error from Pharmacy members, surgical site infection from related members or chart audit results from audit team, now breaking down this data and registering them against individual doctor member on a event or monthly basis is observed a tough or inadequate process in manual data entry
Delay in review of incident reporting or performance metrics available if those process is manual : Measures, such as patient satisfaction, medical records completion, blood usage, and drug usage etc requires individual case reviews as the primary mechanism for assessing competence for most privileges on the list, a manual data processing will cause delay from reviewing performance metrics.
Paper-based processes without charts utilized are leading into Conflict and trust “issues: Any attempt to alter a physician’s privilege as incompetent or to compare of a particular privilege based on inadequate data, including charges of bias is a rough road, especially when data proofs/sources are imperfect, most of the manual OPPE process lack provision for real time information to individual physicians, and only provides a sheet with fall out or compliances instances on a periodical basis, with no track of data origin or related patient details. This leads to conflict and trust issues among medical staff.
Consider investing in software that maintains the structure needed; yet allows for the flexibility required. AccreHealth technologies integrate KPIs, OPPE and FPPE process AccreHealth technologies manage end to process of OPPE/FPPE from data capturing to internal or external benchmark comparison, with a meaningful and detailed dashboard, which address all your data analysis needs.
The frequency & Reviews should be handled consistently for all providers.
Define the methods utilized for collecting data and identify KPIs that can contribute.
Establish guidelines of how FPPE/OPPE is used for re-credentialing and bench marking -List all possible outcome actions and next steps.
Feedback to providers should be consistent and timely regardless of the outcome.
Digitize the process
By Admin | Posted on April 26, 2021
By Admin | Posted on April 7, 2021