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Enhancing OPPE/FPPE Process in Novant Health

Learn about the evolution, challenges, and progress of the OPPE/FPPE process at Novant Health, covering data sources, thresholds, and statistical reporting. Discover how the process was streamlined and improved by transitioning from Excel to statistical reporting tools. Gain insights into the basics of OPPE and FPPE, as well as the innovative Echo-OPPE Module. Follow the journey of implementing new data storage methods and cycle checklists to ensure efficient tracking and reporting. Join the transformation and optimization journey at Novant Health.

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Enhancing OPPE/FPPE Process in Novant Health

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  1. OPPE / FPPE Uniform Process Larry Thacker, CPMSM Business Systems Analyst

  2. Statistics about Novant Health

  3. Current State of Novant Health • Presence in NC, VA and GA • 13 Facilities • 3 joint venture Ambulatory Surgery Centers • 2 Ambulatory Surgery Centers • Joint venture acute care facility with UVA • 4,600 +/- Credentialed providers • 4,100 +/- in OPPE / FPPE Process • 300 + Physician Practices • 6 Medical Staff Offices • 1 Central Verification Office OPPE / FPPE Process

  4. Early Beginnings Applies to both OPPE and FPPE

  5. In the Beginning • Early Decisions • Went to visit The Joint Commission at their headquarters • Clearly from the early stage TJC wanted to provide freedom • Left decisions to the facilities and the organized medical staff • A subcommittee was established • VPMA, Chief of Staff, Dept Chairs, MSO, CVO, Legal, Clinical Improvement and Regulatory • Basic indicators and thresholds were established • OPPE Data Range – 6 months • FPPE Data Range – 2, quarterly reports • Process was watched over the first 12 months OPPE / FPPE Process

  6. Challenges and Progress • Identifying the data sources and reporting mechanisms • How to store and track the data in a useful uniform format • Excel was where we looked first • Developed a spreadsheet with 100+ workbooks • First we saw a dramatic improvement in the number of medical record delinquent days dropped over 13,000 + days • Educating the providers and staff • Employee resources • How to handle the providers with issues OPPE / FPPE Process

  7. Challenges and Progress • Thresholds were to liberally applied • Red on the forms made the provider see RED • Providers didn’t like being AVERAGE • Solution was 50 shades of OPPE / FPPE • Data periods Changed • Reporting time frame changed • Discovered very early our data ranges needed to be extended • Moved to 8 month OPPE reporting periods • Moved to 2, four month reporting period for FPPE • Reduced the number of Nursing / Clinical Staff Feedbacks OPPE / FPPE Process

  8. Challenges and Progress • Identified quickly Excel wasn’t the solution • Statistical reporting was very difficult due to the provider being in OPPE and FPPE (stored in different spreadsheets) • Reappointment timeline • Push – Pull relationship • Dimension Data • EMR did not resolve • Delinquency days • Timeliness of signing records • EMR did resolve : • STD (Sign, Date and Time) itemsEcho– OPPE Module • Echo – OPPE Module • since 2010 have processed over 27,000 OPPE/FPPE reports OPPE / FPPE Process

  9. Data Applies to both OPPE and FPPE

  10. Novant Health: Enter Presentation Title in Footer Menu

  11. Data Sources – “Fingers in all things data” • Sample Size • Sample Size project • H&P, Unsigned Consents, STD, TO/VO • Monthly reports by facility • Peer Review • Peer Review Policy • Activity Data • Imports ran by the BSA’s for Dimensions (HL7) • Others have to enter manually • Nursing / Clinical Staff Feedbacks • Collected in OPPE once every 24 months • Collected during the 2nd period of FPPE unless improvement needed has been identified • HIM • Medical record delinquencies • Suspensions EPIC / Dimension • Data will still occur for the data indicators Always looking for other data sources Always looking to improve the process through automation OPPE / FPPE Process

  12. OPPE Basics

  13. OPPE • Who is in OPPE • A Practitioner • Who holds at least one or more clinical privileges • On staff longer than 8 months • Not currently in a FPPE • Reports are generated for each Medical Staff Office • Based 5 Primary Specialty cycles OPPE / FPPE Process

  14. OPPE / FPPE Process

  15. FPPE Basics

  16. FPPE Basics • Who is in FPPE • Any practitioner that would meet any one of the following requirements: • New Practitioner with one or more clinical privileges • Existing practitioner who has requested an additional privilege • Improvement needed threshold(s) met during OPPE process • Referral from Credentials Committee, Med Exec or BOT • Reports are generated based the month placed into FPPE • FPPE reporting is performed on 2, four month cycles • 8 months is a complete FPPE process unless one additional 4 month period is necessary to sync with the OPPE cycle • Possibility of an adjustment cycle to synchronize with the OPPE cycle • Could be placed into an extended FPPE if improvement has not been demonstrated or addition of privilege • Extended FPPE cycle can not go beyond 24 months OPPE / FPPE Process

  17. OPPE / FPPE Process

  18. See Larry and Robin Run!!! OPPE / FPPE Process

  19. Echo OPPE Module Applies to both OPPE and FPPE

  20. Wish Came True • THE OPPE Module OPPE / FPPE Process

  21. Data Storage • Parts of ECHO involved • Checklists • OPPE / FPPE cycle checklist – MSO (Who, What and When) • Tracks OPPE or FPPE with a Reporting Mechanism Checklist • When placed into OPPE or FPPE • What OPPE cycle the practitioner is in • When the Nursing / Clinical Staff Feedback is due • Who is the Primary Reviewer (Dept Chair or Section Chief) • Who is the Chief of Staff or Credentials Chair • When the last data audit was performed on the individual provider • Nursing / Clinical Staff Feedback moving to an automated Survey Module • Peer Review • Medical Record Status (delinquencies and suspensions) • QA Review (all other provider indicators) • Population (activity and procedural data) OPPE / FPPE Process

  22. We, as a team have processed over 27,000OPPE and FPPE since January 2010! OPPE / FPPE Process

  23. Forms and Committee Reports Applies to both OPPE and FPPE

  24. OPPE / FPPE Process

  25. OPPE / FPPE Process

  26. OPPE / FPPE Process

  27. OPPE / FPPE Process

  28. What the Future Holds

  29. Future Goals Automation • Nursing / Clinical Staff Feedbacks • SURVEY MODULE • Providers able to log in and view OPPE / FPPE forms • Provider Navigator • Online Chair Review Provider Assessment Portal • Peer Review Portal • HL7 Module live population data • Online Application • Additional Indicators • Changes to the process • Updated FPPE policy 2015 • Notification of any new data source • Uniform Additional Privilege Checklist • Customized privilege line • Uniform By-Laws • Uniform staff status OPPE / FPPE Process

  30. Questions

  31. OPPE / FPPE Process

  32. Larry Thacker, CPMSM lrthacker@novanthealth.org OPPE / FPPE Process

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