Are you on board with The Joint Commission's FPPE/OPPE requirements?
Are you on board with The Joint Commission's FPPE/OPPE requirements?
Collaborating with your medical staff key
She presents on the topic all the time because, she says, it's a tough one for hospitals — time- and data-intensive. And beyond being a challenge, Susan Mellott says many hospitals aren't doing it at all. In fact, she's made it a few minutes through presentations before realizing her audience doesn't even know what FPPE and OPPE stand for. For many hospitals that don't have electronic medical records, and even for those that do, the requirements can mean extensive data collection and data analysis that may seem impossible with the staff you have, experts say. But with some tips, you can make a process that seems laborious be manageable.
The acronyms — focused professional practice evaluation and ongoing professional practice evaluation, respectively — are not new, nor are The Joint Commission standards making them a mandatory process.
What does OPPE, FPPE mean?
"FPPE is really two different things," says Mellott, PhD, RN, CPHQ, FNAHQ, CEO/health care consultant, Mellott & Associates in Houston. "The first one is what's causing everyone the problems. When a new practitioner comes on staff, whatever privileges they get, I have to evaluate every single one of them for competencies awarded to the practitioner.
"If it's a new practitioner, you can give them the privileges and then you have to monitor them as they're doing them in your organization."
You must also conduct an FPPE (Standard MS.08.01.01) for medical staff members looking to be granted new or additional privileges to ensure competency. So essentially you grant the privilege and, after the FPPE, they are formally entitled to practice those privileges in the assigned facility.
The second part of FPPE focuses on one practitioner "who for some reason has fallen out of your monitoring or has had a complaint or something has happened that has made you want to focus on that one person," Mellott says.
For OPPE (Standard MS.08.01.03), the operative word is ongoing. Every practitioner's performance must be evaluated at least more often than once a year. The part that Joint Commission surveyors will look for is the determination made by the OPPE process — the decision to continue, limit, or revoke privileges.
Both FPPE and OPPE should be used for all practitioners within your organization that are privileged through your medical staff, Mellott says.
The Joint Commission requires a "defined process" for both forms of evaluation but allows the medical staff to determine which data are to be tracked and collected. "Your organization figures out the time frame; your organization figures out how you want this to be — i.e., observation? Do you want it to be from medical records? How do you want to gather the data?" These are the questions the quality department and the medical staff should answer.
Sources of information, Mellott says, may include:
- periodic chart review;
- direct observation;
- monitoring of diagnostic and treatment techniques;
- discussions with other staff involved in the care of each patient.
Identifying data to track
Evaluations must be specialty-specific. You can't look at, for example, mortality rates in each practitioner's evaluation; for some physicians — such as pathologists — that won't be applicable, says Vicki Searcy, vice president, consulting services at Morrisey Associates Inc. in Chicago. She suggests looking first at your facility's privilege delineation form "because that's what you're granting. So you need to look at your privileges and identify what kind of data are going to help you determine that somebody is competent." If the privilege forms are outdated or not carefully defined, she says, you have a difficult process in place. "And quite honestly," she says, "I think that's why a lot of places haven't done it."
Then take an inventory, which will come from a lot of areas within the hospital, on the data you are already collecting to see what you can use in this process, Searcy says. "Then look at your privilege forms and start matching up that data to your privilege forms," she says. Perform a gap analysis of what data elements you don't have that you need and determine how expensive and worthwhile it is to capture the missing data elements. Defining the data should be done in concert with the quality department and medical staff.
For OPPE, Mellott suggests the following as examples of data to collect:
- review of operative and other clinical procedure(s) performed and their outcomes;
- pattern of blood and pharmaceutical usage;
- requests for tests and procedures;
- length of stay patterns;
- morbidity and mortality patterns;
- practitioner's use of consultants;
- other relevant criteria as determined by the organized medical staff.
She also suggests:
- Start small, with a limited number of measures you are already collecting.
- Use a single profile per specialty, and try to keep it to one or two pages.
- Start with high-volume specialties.
- Involve the physicians in the specialties in the selection of the measures, their comparison data, etc.
The Joint Commission considers an annual evaluation to be periodic, so the OPPE must be done more often than once a year. Mellott suggests doing it every six months for each practitioner. "If you have the data systems in place to be able to produce that type of information at the time of reappointment, you ought to be able to produce it in the intervals between reappointments. But the problem is, until the standard went into effect and The Joint Commission appears to be more serious about it, I think a lot of hospitals were just scrambling once every two years to throw some data on a piece of paper. And now it's become something that you have to do more often than that. And so you really do have to have the systems in place to produce data," Searcy says.
Working with IT, medical staff
So the IT component — working to make sure your systems are speaking to one another and culling the data — is a challenge with regard to complying with the evaluation requirements. Beyond working with your IT department, OPPE and FPPE require collaboration between the quality and medical staff departments. Both Searcy and Mellott say who "owns" this process has been a subject of debate, but they assert that it must be a collaborative effort between the two.
"Historically, creating a profile for reappointment — that used to be the medical staff person's responsibility, and so what would happen is about every two years they'd go running around begging and borrowing data to put on this profile," Searcy says. "And so, in many organizations, quality doesn't think this is their job. And that's part of the problem.
"Because they're usually the people who have the data. The medical staff office doesn't have the data. The quality and the performance, they've got pieces of it. They know about somebody's malpractice history; if there's been behavioral problems, they'll know that. Some of the rate-based-type information that we're talking about that is necessary, it comes from quality or some other department. So that's where there really has to be a collaboration between quality and the medical staff office," she says.
The quality department can signal when a practitioner is outside where he or she should be on certain measures, but The Joint Commission, in its frequently asked questions, recommends that in smaller organizations, the department chair or the department as a whole review the OPPE data. In larger organization, it says, it could be the responsibility of the credentials committee, the MEC, or a special committee of the medical staff.
Searcy says the quality department must analyze the data; giving the medical staff raw data means nothing. She suggests the quality department flag instances where problems might be, such as a practitioner with higher mortality or complication rates, to help the medical staff when they review credentials file to make a determination. She says creating thresholds or rates to determine practitioners' trends is important, especially in larger facilities where a department chair may have 500 people in their department and 500 reports to review.
Though both Mellott and Searcy say many hospitals are not fulfilling the requirements of the FPPE and OPPE process, The Joint Commission's associate director, standards interpretation group, John Herringer, stresses the flexibility of the standards, saying, "We do see citations for the problem, but it's not of such a nature that it's rising to the most frequently cited standard."
What surveyors will be looking for
"I think the thing that is important to remember is we're very flexible," he says. "So [hospitals] can start small and grow the program as they get familiar with it and they obtain additional resources. So basically the surveyors will survey against whatever they've defined. If they have a small set of data, that's acceptable. If they have large set of data, that's acceptable."
Surveyors will ask about your process and for you to explain elements such as how often you look at the data and how, and who makes the decisions on whether to continue a privilege based on those data.
Surveyors, he says, "will look to see evidence of those decisions. And in the frequently asked questions that I have on the web site, I have clarified that they don't have to keep the actual data in every practitioner's file. As long as it's available at each review point so that you can compare the sets of data to look for any patterns or trends over time, they can keep the data outside of the file. But the information on the decision needs to be in there. And it needs to be documented."
Performance Evaluation ED Form
She presents on the topic all the time because, she says, it's a tough one for hospitals time- and data-intensive.Subscribe Now for Access
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