OPPE standards catch some facilities out

What TJC says you should watch for

It seems like one of the more straightforward standards: to make sure that you regularly collect and review quality data from providers. And yet, surveyors do find issues with organizations. So what makes for a good “Ongoing Professional Practice Evaluation” policy? And what are the common problems that Joint Commission surveyors are finding?

HPR asked Ron Wyatt, MD, MHA, the medical director of the division of healthcare improvement and Carol Mooney, RN, MSN, the senior associate director of the department of standards interpretation, to weigh in on the topic.

Wyatt says the first thing to remember is that the standard is directly related to the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation. “What the Conditions of Participation say about the expectations for medical staff and their credentialing are what we based the standard on. This isn’t just some edict from us.” He says he has had to repeat that fact more than once during presentations.

He also emphasizes that this standard is directly related to providing high-quality safe care for patients. “Performance reviews have to be data driven, and that data should be used on an ongoing basis to evaluate the quality of care. You can use this standard to directly impact quality and patient safety. This is a roadmap for users to do that.”

Mooney says the biggest issue organizations have is creating a clearly defined process — who reviews, how often, what the parameters are for deciding to revoke privileges, and how data will be incorporated into the provider’s file. The specifics are up to the organization, she says. The Joint Commission doesn’t mandate something specific.

However, she does note that how often should be something more than once a year. “That’s periodic, not ongoing,” Mooney says.

Be sure to define the method of monitoring — direct observation, chart review, or a combination? Are you getting feedback from staff on professional behavior? If so, how is that gathered?

Wyatt says that organizations often feel as if The Joint Commission is just handing down these mandates and that it will tell them how to set something up. But that’s a mistake. “You have to set up your own process and then follow through with it,” he says. “It doesn’t have to be some complicated process. We just want to know that you are doing this, and that you are working to ensure high-quality safe patient care.”

Both the OPPE and the Focused Professional Practice Evaluation (FPPE) standards for those seeking new privileges offer opportunity for hospitals that use them to their fullest, Wyatt says. “Both of these standards will be important as quality impacts finances and reimbursement,” he notes. “Both will impact how you measure value, and done correctly, both OPPE and FPPE will allow you to collect measures that show value in decreasing waste. There will be fewer readmissions, fewer returns to surgery, and fewer hospital-acquired infections. You will be able to look at the data and see outliers. You will be able to coach them towards improvement.”

Readers can find out more information about the standards by looking for the BoosterPak called “Focused Professional Practice Evaluation/Ongoing Professional Practice Evaluation (FPPE/OPPE),” available at jointcommission.org.

For more information, contact:

• Carol Mooney, RN, MSN, Senior Associate Director, Department of Standards Interpretation, The Joint Commission, Oakbrook Terrace, IL. Email: cmooney@jointcommission.org.

• Ron Wyatt, MD, MHA, Medical Director, Division of Healthcare Improvement, The Joint Commission, Oakbrook Terrace, IL. Email: rwyatt@jointcommission.org.