Ongoing Professional Practice Evaluation Focused Professional Practice Evaluation

1. Ongoing Professional Practice Evaluation& Focused Professional PracticeEvaluation (OPPE & FPPE) C. Dale Lusk, MD Stacy Holley RN, MSN

2. Objectives Define Ongoing Professional Practice Evaluation (OPPE). Define Focused Professional Practice Evaluation (FPPE).

3. Objectives Understand the types of data utilized for OPPE and FPPE. Understand how data from OPPE/FPPE can improve practice and quality of patient care.

4. Framework for Professional Practice Evaluation Accreditation Council Graduate Medical Education (ACGME) Six General Competencies The Joint Commission adapted general competencies in MS.06.01.03 for credentialing.

5. Accreditation Council for Graduate Medical Education (ACGME) Six General Competencies Patient Care Medical & Clinical Knowledge Practice-based Learning & Improvement Interpersonal & Communication Skills Professionalism System-based Practice

6. The Joint Commission Patient Care Practitioners are expected to provide patient care that is compassionate, appropriate, and effective for the promotion of health, prevention of illness, treatment of disease, and care at the end of life. (Assessment, Outcomes/Core measure data, clinical competence and judgment)

7. The Joint Commission Medical/Clinical Knowledge Practitioners are expected to demonstrate knowledge of established and evolving biomedical, clinical, and social sciences, and application of their knowledge to patient care and the education of others. (Knowledge of basic medicine, discipline specific medicine, board certification, CMEs)

8. The Joint Commisssion Practice Based Learning & Improvement Practitioners are expected to be able to use scientific evidence and methods to investigate, evaluate, and improve patient care practices. (Evaluates care practices & improves as needed, clinical research, workgroup/committees, core measures).

9. The Joint Commission Interpersonal & Communication Skills Practitioners are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families, and other members of the health care team. (Relationships with patients, families, and other health care team members)

10. The Joint Commission Professionalism Practitioners are expected to demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity, and a responsible attitude toward their patients, their profession, and society. (Behavior, staff meeting attendance, respects diversity)

11. The Joint Commission Systems-based Practice Practitioners are expected to demonstrate both an understanding of the contexts and systems in which health care is provided, and the ability to apply this knowledge to improve and optimize health care. (Utilizes resources, referrals, works with interdisciplinary team).

12. Ongoing Professional Practice Evaluation The Joint Commission requires OPPE. MS.08.01.03 OPPE-Purpose: document summary of ongoing data collected to assess clinical competence and professional behavior.

13. OPPE Assist in determining whether to continue, limit, or revoke existing privileges. Allows organization to identify practice trends -� quality of care & patient safety. Identification of practice trends may require intervention.

14. TJC Intent of OPPE Ensure performance data for practitioners with privileges is reviewed on an ongoing basis, rather than at the two year reappointment process

15. OPPE Currently use an OPPE process at reappointment. Occurs yearly or every 2 years. The Joint Commission requires OPPE more frequently than at reappointment time.

16. OPPE OPPE �evaluation for maintaining privileges. Accomplish using several data sources.

17. OPPE Data Sources Could include the following: -periodic chart review -direct observation -monitoring of diagnostic and treatment techniques -discussions with other individuals involved in the care of the patient -Internal data sources, e.g. Midas, Premier, Quality data

18. Components to OPPE

19. Practitioner Profiles Premier Clinical Advisor� Profile sent to practitioners every 6 months. Data is administrative (coded) data.

20. Practitioner Profile Use profile data as �directional� data. Represents a summary of performance and resource utilization. Profiles have �drill down� capability.

21. Profile Contents Case count-identifies practitioner role Mortality LOS Resource use Evidence-based care (AMI, HF, PN, PR & SCIP) Outcomes (Observed/Expected) Hospital Acquired Conditions & Patient Safety Indicators

22. Additional Data for OPPE ACGME General Competencies Medical Records-Admission & Hospital Suspensions Legibility Unapproved Abbreviation Use Blood Utilization Operative Procedures and Other Procedures Triggers/Fall outs

23. Department Data for OPPE Each department tasked to identify department-specific indicators to monitor. IMPORTANT Component-profiles are not department specific-need meaningful parameters for depts.

24. Department Data Need involvement from all departments Input will ensure measurement of the �right� thing.

25. Who sees OPPE data? Data is incorporated into performance improvement activities. Considered privileged and confidential, Quality/Peer review material.

26. Who sees OPPE data? Individual practitioners Department Chiefs (6 month & reappt) Credentials Committee view data at reappointment, unless concerns prior to reappointment. MEC, if intervention warranted.

27. Maintaining Documentation OPPE data will be maintained in the practitioner�s Quality File.

28. Please note: A government or accreditation entity could also request to view the quality file or credentials file of a practitioner, i.e. CMS, The Joint Commission.

29. Practice Trends Trends identified will be discussed with the Department Chair. (Credentials Committee if needed) Recommendations for Follow-up

30. Triggers Can be a single incident Evidence of a clinical practice trend Indicators described in the Medical Staff Peer Review Policy.

31. Fall outs Department indicators Exceed set threshold Significant difference in performance compared to peer group on profile Exceed threshold on profile

32. Follow-up Triggers and Fall outs handled by same process as practice trends. Dept. Chief -� Credentials Committee -� MEC

33. Focused Professional Practice Evaluation FPPE- time limited evaluation of practitioner competence in performing a specific privilege. Required by The Joint Commission MS.08.01.01

34. FPPE Time limited evaluation, i.e., 3 months, 6 months. Confirm competency Applies in three situations

35. FPPE Situations New applicants Existing practitioners requesting new privilege Practitioners when concerns arise

36. FPPE Data Sources Proctoring- prospective, retrospective or concurrent. Peer review data Internal data sources (Sentinel event data, quality data, etc.)

37. FPPE Data Sources Chart review by physician or non-medical staff Monitoring clinical practice patterns External peer review

38. The FPPE Process

39. FPPE Plan Individualized plan Based on privileges requested, experience Dept. Chief develops plan Credentials Committee reviews plan

40. FPPE Plan Plan includes: - what will be evaluated - timeframe - sources of data

41. Duration of FPPE Time limited Will depend on: privileges of concern practitioner's overall activity level nature and severity of the situation

42. Duration New applicants- goal is to complete within three months. Will allow for additional evaluation period (if needed) prior to the end of 12 month provisional period.

43. FPPE Evaluation Framework for evaluation based on ACGME General Competencies Patient Care, Medical & Clinical Knowledge, Practice-based Learning & Improvement, Interpersonal & Communication Skills, Professionalism, System-based Practice Evaluate specific aspects of each competency

44. Other components Medical Records-Admission & Hospital Suspensions Legibility Unapproved Abbreviation Use Blood Utilization Operative Procedures and Other Procedures Mortality

45. FPPE Evaluation Documentation Satisfactory or Unsatisfactory Trends identified Data source used for evaluation

46. Evaluation Completed by the Dept. Chief Reviewed by Credentials Committee Completion, Expand timeframe, or Intervention

47. Completion & Approval Satisfactory Completion of FPPE Not satisfactorily completed: must make recommendations, i.e. supplemental plan, revoke privileges.

48. Completion & Approval Credentials Committee Medical Executive Committee Reviews evaluation- and recommendations, if applicable

49. Who sees FPPE data? Practitioner Dept. Chief Credentials Committee MEC

50. Maintaining Documentation FPPE plan and evaluation will be maintained in the practitioner�s Quality File. Approval documentation will be maintained in the Credentials File. Available at reappointment.

51. Please note: A government or accreditation entity could also request to view the quality file or credentials file of a practitioner, i.e. CMS, The Joint Commission.

52. FPPE -� OPPE Successful completion of the FPPE process leads to OPPE. Practitioner will progress to ongoing evaluation.

53. OPPE & FPPE Does not apply to affiliate staff members or no volume practitioners. Must have privileges for OPPE/FPPE Eventually will include mid-level providers in the process.

54. OPPE & FPPE Provide feedback to identify opportunities for improvement Information to assist in the reappointment process Assure quality evidence- based care being provided.

55. Questions? Stacy Holley, RN, MSN Quality Improvement Specialist Clinical Outcomes 777-5490 sholley@mcleodhealth.org Susan Pickle, RN AVP Clinical Effectiveness 777-5141 spickle@mcleodhealth.org

56. References Accreditation Council for Medical Graduate Education (ACGME). (1999). ACGME Outcome Project. Retrieved September 9, 2010, from http://www.acgme.org/outcome/comp The Joint Commission (TJC). Standard MS.06.01.03, Standard MS.08.01.01, Standard MS.08.01.03.