OPPE and FPPE The new requirements - UNC Health Care

1 OPPE and FPPEThe new requirementsWhat are they and how do they relate to credentialing, privileges and reappointments?What s not new?Initial appointment for 1 yrReappointment of practitioners every 2 yrsWhat is new?Requirement that healthcare organizations collect competency data in an ongoing mannerJan 1, 2008 Ongoing professional Practice Evaluation (OPPE)Focused professional Practice Evaluation ( fppe )1stNEW CONCEPT: 6 General Competencies*Patient CareMedical/Clinical KnowledgePractice-based Learning & ImprovementInterpersonal & Communication SkillsProfessionalismSystems Based PracticeNEW STANDARD (2007): The integration of the 6 General Competencies* into the Credentialing & Privileging processes.*Developed by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) joint allow the organized medical staff to expand to a more comprehensive evaluation of a practitioner s professional Competency #1 -Patient CareFor Measures, consider.

2 ;Core Measures (CHF, P, MI data) ;SCIP Data;Results of cases referred to Peer Review Committee ;Report of diagnoses treated & procedures performed;Mortality RatesMedical Staff StandardsNew/Challenging _____General Competency #2 Medical/Clinical KnowledgeFor measures, consider ..;Continuing Medical Education (CME) activities attended;Board certification and recertification;Appropriateness of antibiotic usageMedical Staff StandardsNew/Challenging _____General Competency #3 Practice-based Learning & ImprovementFor Measures, consider ..;Continuing Medical Education (CME) hours related to specialty;Post-graduate training, preceptorships;Board certification;Education regarding pathways, protocols, best practices .. as a result of cases identified thru peer review Staff StandardsNew/Challenging _____General Competency #4 Interpersonal & Communication SkillsFor Measures, consider ..;Patient/Family Satisfaction Survey comments (complaints + compliments);Written complaints from peers and associates ( , case managers; ED staff);Inappropriate comments in medical records about other physicians;Monitoring of handwriting legibility.

3 ;Use of unacceptable abbreviations.;Timeliness of H&Ps and operative notes.;360 EvaluationsMedical Staff StandardsNew/Challenging _____General Competency #5 -ProfessionalismFor Measures, consider ..;Written complaints from peers and associates;Timeliness of H&Ps and Operative Reports;Medical record suspensions/delinquency;MS meeting attendance;Responsiveness to OR Call obligations;Compliance with MS Bylaws & Rules Timely answering of pages when on callGeneral Competency #6 Systems Based PracticeFor Measures, consider ..;Avoidable Days ;Average LOS ;Utilization of Resources;Clinical Pathways;On-time case starts in OR;Turn-over times in ORMedical Staff StandardsNew/Challenging _____Why do we need to measure physician competence?Patient SafetyQuality of CareTo report to the physician for his/her own use ..(If a hospital provides a physician with reliableperformance data, performance WILL CONTINUOUSLY IMPROVE!)_____Once you have the 6 General Competency measurements defined.

4 You can incorporate them into the remaining 2 new processes:OPPE and GeneralCompetencies;OPPE(OngoingProfessi onalPracticeEvaluation) fppe (FocusedProfessionalPracticeEvaluati on) _____OngoingProfessional Practice Evaluation (OPPE)STANDARD : OPPE information is factored into each decision to maintainexisting privilege(s), reviseexisting privilege(s), or revokeexisting privilege(s) prior to or at time of renewal. TRADITIONALC redentialing & PrivilegingProcedural and cyclical processes .. practitioners evaluated (1)when privileges are initially granted and(2)every 24 months thereafter [ , reappointment]. NEW! OPPEC ontinuous evaluation of practitioner s performance (more than yearly eval). Requires medical staff to conduct ongoing evaluation of eachpractitioner s performance. _____TJC: OPPE CRITERIA may include:_ Review of operative & other clinical procedure(s) performed and their outcomes _ Patternsof blood and pharmaceutical usage_ Requests for tests & procedures_ Length of stay patterns_ Morbidity & mortality data_ Practitioner s use of consultants_ Other relevant criteria as determined by Medical Staff The type of data to be collected is determined by individual departmentsInformationused in OPPE may be acquired thru:_ Periodic chart review_ Direct observation_ Monitoring of diagnostic and treatment techniques_ Discussion with other individuals involved in the care of each patient including consulting physicians, assistants at surgery, nursing, and administrative The organized medical staff evaluates and actsupon reported concerns regarding a privileged practitioner s clinical practice and/or competence.

5 Medical Staff StandardsNew/Challenging _____6 GeneralCompetencies;OPPE(OngoingProfessi onalPracticeEvaluation); fppe (FocusedProf essionalPracticeEvaluation) What happens when OPPE identifies a problem?FocusedProfessional Practice Evaluation ( fppe )Standard effective 1/1/08 Time limited period during which the organization evaluates and determines a practitioner s performance of privilegesMedical Staff StandardsNew/Challenging _____TJC requires use of an fppe process to confirm competency for ALL initially granted questions arise in the OPPE process related to competency. Triggers that indicate the need for performance monitoring must be is looking for CONSISTENT new appointmentsyAll new privileges for existing practitionersyAll practitioners returning from prolonged leave of absence*yOPPE triggers need for fppe **to be definedAlbert Einstein FPPEy3 month periodyProctoring of procedures/cases determined by chairyChart reviews of 5 casesyReports of admission activity, LOS, Mortalitity, HQIDyAt 3 mo, 6 core competencies ratedyEither continue fppe or go to OPPEA lbert Einstein OPPEyReports on practitioner specific datayOR chart review, minimum 5 charts by division chief or representativey6 month evaluation of 6 core competenciesStanford FPPEyEach medical staff dept shall assign proctors for all new applicants, additional privileges, low volume providersyProctoring.

6 Presentation of cases with planned RX, real time observation, chart reviews or interviews with others involved in careyOff-site proctoring: documented evidence of fppe at alternative hospital UC Davis: FPPEAll new staff in Anesthesia Dept have daily evaluations by residents/ CRNA s; information directed to Chair; all information collected and reviewed with faculty at 1 monthNorthwestern FPPEyDept fppe plans shall include 6 core competenciesySources: Personal interaction with practitioner (proctoring), 360 evaluations, chart review by non-medical staff based on pre-defined criteria, chart reviews by physicians, simulation, external peer reviewNorthwestern FPPEyNew to NMH but with >5 yrs experience: 1 month FPPEyNew to NMH but with <5 yrs experience: 3 months FPPEyPhysicians who completed residency or fellowship at NMH within 2 yrs: no fppe unless dictated by ChairOPPE/FPPEyRequired of all practitioners with privilegesyThis includes allied Health professionalsHow to document low-volume, no volume providers?

7 YFor both OPPE and FPPEyCompletion of competency assessment form by primary facilityLow volume/no volumeLow volume, No volumeyProviding name of peer who can provide professional reference and evaluation of current competence for performing privilegesySuccessful completion of CME or other assessment program sufficient to maintain competence for clinical privileges grantedNew Appointment or New PrivilegeCompetency Reappointment 1 yrReappointment q 2 yrs FPPEOPPEOPPE q 6 moFPPEPlan for improvement Privileging MythsI did my residency/fellowship; I am qualified for life in my specialtyPrivileging MythsyI did my residency/fellowship; I am qualified for life in my specialtyyCompetency = Have you done it recently and did you do it well?Privileging MythsyPrivileges are owned by LIP sPrivileging MythsyPrivileges are owned by LIP syPrivileges are grantedPrivileging MythsThere is a need to give honorary privileges to individuals who may not use themPrivileging mythsIf there is no documentation of competency, reappointment of those privileges is in jeopardyWhere are we?

8 YInitial steps for OPPEyPI/PS group has met with each chair to define 2 measures yQ 6 month evaluations for physiciansyFeedback to ChairsySoon Feedback to PractitioneryUltimately these reports to Credentials Committee, along with Chair s form for reappointmentWhere are we?y6 core competencies are used for reappointment yPolicies in place to allow fppe for any unsatisfactory evaluation{Chair s discretion for expedited vs nonexpedited reappointment {Need improved plan for follow-up at 6 months William R. Furman, Chair, Credentials Committee Office of Medical Staff Services 101 Manning Drive, CB#7600 UNC Hospitals Dear Dr. Furman: _____ s term of appointment and/or clinical privileges at UNC Hospitals will soon expire. As the Department Chair, I have evaluated his/her general competencies and performance during the period of most recent appointment and have discussed deficiencies (if any) noted on the following evaluation with him/her.}}

9 Areas of Evaluation Satisfactory Unsatisfactory* Patient Care/Clinical Skills _____ _____ Medical Knowledge _____ _____ Interpersonal & Communication Skills _____ _____ Professionalism: Practice within Scope of Delineated Privileges _____ _____ Professionalism: Relationships With: Patients: _____ _____ Peers & Trainees: _____ _____ Hospital Staff: _____ _____ Professionalism: Honesty, Integrity, Character, Ethical Behavior _____ _____ Practice-Based Learning & Improvement: Use of Consultation, Ancillary Services, and Hospital Resources _____ _____ Systems-Based Practice: Clinical Performance Report _____ _____ Systems-Based Practice: Compliance with JCAHO/OSHA requirements : General Safety, Tuberculosis and Infection Control Training _____ _____ System-Based Practice: Participation in Medical Staff Committees and Compliance with Bylaws, Rules and Regulations of The Medical Staff (as applicable) _____ _____ Health Status as it affects the Applicant s Ability to Perform His/Her Duties _____ _____ Where are we?

10 Y6 core competencies are used for reappointment yPolicies in place to allow fppe for any unsatisfactory evaluation{Chair s discretion for expedited vs nonexpedited reappointment {Need improved plan for follow-up at 6 monthsWork still to be doneyDefine department specific policies/measurements for fppe for initial appointmentsyRefine current OPPE measures and ultimately identify measures for 6 core competenciesyAssess every practitioner with privileges at UNC HospitalsyDefine how to assess specific privileges}}