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Tips for creating your OPPE/FPPE policies
You don't have to start from scratch
It was a marriage of sorts, between two departments — credentialing and quality improvement. Two departments that hadn't known each other well before. Two departments that came together for a common goal.
Laura Culleny, RN, performance improvement clinical coordinator for AtlantiCare Regional Medical Center, recalls attending a session at a conference on the issue of The Joint Commission's requirement on ongoing professional practice evaluation (OPPE) and focused professional practice evaluation (FPPE). She happened to be sitting next to her center's director of credentialing. "And we just looked at each other and said, 'It looks like our departments have to get married to be able to focus on this,'" she says.
Often the departments would communicate when it was time for a provider to be reappointed, but they both realized it would take more communication and sharing to comply with OPPE and FPPE requirements.
They began their work and realized the groundwork already was there. The quality department already was collecting a lot of data. The question became, which of the data could it use?
At AtlantiCare, the quality management clinical coordinators are assigned to departments. One, for example, might work with the emergency department and critical care; another would be assigned to pediatrics. So the team began with a grid (see sample OPPE form). In the first column, they plugged in the general competencies The Joint Commission looks for:
Across the top, they added columns for indicators, measurement-review style, and triggers to begin FPPE. Each quality management clinical coordinator wrote indicators next to each competency in relation to his or her department or division. Then each coordinator recorded next to each competency which ones data were already collected on, where those data were obtained (i.e., internal reports, referrals, outside vendors). Then in another column, they entered what they thought would be an appropriate trigger — a trigger that might move the practitioner into a focused evaluation.
Getting buy in
Once the "skeleton" was created, the quality team presented it to senior leaders, including the vice president of medical affairs. "They were all very much on board with it. Not only because this was a Joint Commission requirement, but also because it was just good for the hospital," she says.
"A lot of times, especially if you have physicians who don't have a lot of volume at your hospitals, reappointment time comes and you don't have a lot of data. That also happens quite often with the allied health professionals. And so the organization was really on board with it because it was going to give us an opportunity to actually look at some of the data we were collecting more often than every two years," she says.
Culleny then presented the early grid at a credentials department meeting with all the department chairs. Explaining the requirement, she reviewed the indicators. "As far as the indicators went, we didn't want this to be another full reappointment every six months. So we asked them to take a look at the indicators that really made sense for their department to really get a good overall view of how your physicians are doing," she says. Culleny coined a term for the OPPE — "reappoint lite."
What is important for one department, she explained, might not be for another. For example, she says, for patient care, an OB might want to evaluate third- and fourth-degree laceration rates. But if you're evaluating an ED physician, you might want to look at whether antibiotics for pneumonia were given in a timely fashion.
After that presentation, she asked the department chairs to take the grids to their respective departments for feedback. She says they gave everyone a description of The Joint Commission requirements and "why we were doing this, why it was good not just to meet the requirements but for the hospital. We gave them the information that we are not really collecting anything we haven't always collected. It was just going to be that we were going to do it now on a six-month period and look at very specific, targeted areas. If a trigger was met to begin a focused evaluation, that just might be that that particular physician might need some extra education. Moving into an FPPE cycle is not meant to be a punitive thing. It is intended to be an opportunity for education geared toward performance improvement," she says.
And they approved it. She says there were a couple of changes. "For example, one of the triggers that we had was Cesarean rate above department average, and they said, 'Well then 50% of the people are going to hit the trigger.'
"So, for overall Cesarean rate we went to two standard deviations above the department mean, which was a more realistic measurement," she says.
The quality management team asked for input, or "wish list" items, as additional indicators but none were given. "We found out we were already collecting most of the data the chairs wanted to look at in one way or another," Culleny says.
FPPE: 'I want a new privilege'
When a practitioner wants to add a new privilege, he or she must go through an FPPE cycle. Culleny says at AtlantiCare, when a new privilege is requested, the chair of that department will determine what is needed to prove competence. For surgery, for example, that might be 10 observed surgeries. The request is then presented at the next credentials meeting, and if the observation is approved, then it goes to the medical executive committee for final approval. The quality department receives minutes from all of those meetings. Unlike before, where credentials might have some information and quality might have other data, now that communication is ongoing.
When a practitioner has low volume, for example for a surgeon, 10 cases might not be observed within the first FPPE cycle; the chair might then decide to extend the focused evaluation until the full 10 cases are completed. This would be a way to address low volume in a new practitioner, Culleny says.
For the OPPE, if a practitioner has low/no volume-no issues identified for three consecutive evaluations, at the next reappointment period, the credentials committee might consider whether privileges on the active medical staff are still appropriate, Culleny says. Visiting staff privileges might be a better fit.
Physicians would be notified of adverse peer review outcomes or complaints right away, but for things that are tracked and trended, such as documentation issues, the data are collected over time. A physician wouldn't be notified every time there's a documentation issue in an OPPE unless there are several within the six-month period, such as four instances. That doesn't mean he or she is put directly into FPPE, Culleny says. At the sixth-month mark, there is a sign-off sheet that prompts a letter to the physician. So at the next evaluation, the chair knows that physician received communication and can see if there has been an improvement.
Culleny's department has made the process as automated as possible. "So when we say, 'Let's run data on Dr. X for September to March, we just pop in the physician's ID number and the date range and all the data pretty much populate it.' It is difficult if you haven't at least attempted to automate some of it," she says.
Most of the report comes from the database filled by the quality department. For instance, Culleny says, they've put all the operative invasive reviews into a database so they don't have to sit with a spreadsheet and check yes and no.
"We actually have put our questions and answers to our operative invasive reviews into a database where we can just actually click on drop downs — yes, no, not applicable — so that actually populates its own report, which is part of this," she says. "You also don't want to reinvent the wheel. If you have some standard reports that support your data collection needs, by all means, use them."
The credentials committee approved a change from the six-month OPPE period for physicians to eight months to allow two rather than three ongoing evaluations between reappointment times. "By doing that, you can cut your workload by about 25%," she says.
"I think a lot of hospitals might start out really gung-ho and say, 'Let's do this every six months.' And then when you look at it, if you move it out to say, eight months, you're still doing it within the time frame required, but it's a little less labor intensive and also the reports themselves are a little more robust. Because they have a little more data in them," she says.
Culleny suggests if you're trying to build the process:
Of the latter, Culleny says she recently told an audience at a conference that oftentimes a lot of hospitals see the OPPE and FPPE process as a responsibility for the credentialing department. "But credentialing needs input from quality to be able to meet that requirement. And when it comes right down to it," she says, "we're all one organization. And I think that that's probably one of the biggest challenges that a lot of organizations face. They say, 'That's your work' and don't look at it as, 'This is our work.'"