How to Avoid Being Cited for FPPE and OPPE Processes During Your Next TJC Survey

1. How to Avoid Being Cited for FPPE and OPPE Processes During Your Next TJC Survey Tuesday, April 16, 2013 John R. Rosing, MHA, FACHE Vice President and Principal The information provided in AHC Media Webinars does not, and is not intended to constitute medical or legal advice. Opinions, references and links provided by our speakers are provided for your convenience and do not represent our endorsement of such opinions, products or services.

2. Speaker John R. Rosing, MHA, FACHE • Vice President and Principal Patton Healthcare Consulting • 262-242-3631 • johnrosing@pattonhc.com • www.pattonhc.com

3. Learning Objectives Identify the FPPE and OPPE Elements of Performance (EP) that are most troublesome Dissect the new FAQs on FPPE and OPPE Discuss strategies and best practices to comply with the FPPE and OPPE EPs Learn how to create a meaningful and efficient process for conducting FPPE and OPPE on Advance Practice RNs and Physician Assistants as applicable

4. Focused Professional Practice Evaluation (FPPE) • MS.08.01.01, EP 5, A – The triggers that indicate the need for performance monitoring are clearly defined. • Where will you point the surveyor to read these? • EP 8, A, D, The measures employed to resolve performance issues are clearly defined. • Where will you point the surveyor?

5. Ongoing Professional Practice Evaluation (OPPE) • MS.09.01.01, EP 1, A, D – The hospital has a clearly defined process for collecting, investigating and addressing clinical practice patterns. • Where will the surveyor be pointed to read? • When did you start OPPE? • How often do you produce the data? • Who reviews the data?

8. FPPE: Part of the Problem…Words Matter and These are Confusing! • EP 2 they say criteria; do they mean indicator? • EP 3 bullet 1 they say criteria; do they mean circumstances? • EP 5 they say trigger; do they mean special cause variation or data point(s) above/below a threshold? • EP 7 they say criteria; do they mean methodsused? • EP 8 & 9 they say measures employed; do they mean actions taken? • Be careful to understand how FPPE EP 1 differs from Provisional Status or old-fashioned notion of Proctoring

9. “Fine Line Between Criteria and Triggers”FAQ January 2013 • Triggers are “single events” or “practice trends” that are “obvious issues” • E.g., “infection rates, sentinel events, perhaps complaints, (and) other events that aren’t sentinel” What???? • Criteria are “performance issues,” such as • Any outlier issue identified from OPPE data collection • A growing number of longer lengths of stay than other practitioners • Small number of admissions or procedures over an extended period of time that raise the concern of continued competence • Returns to surgery • Frequent or repeat readmission suggesting possibly poor or inadequate initial management/treatment • Patterns of unnecessary diagnostic testing/treatments • Failure to follow approved clinical practice guidelines--may or may not indicate care problems but why the variance (and then oddly, the FAQ repeats the final three issues, apparently a “failure to edit properly” sentinel event)

10. OK, Help Me Understand FPPE! Focused professional practice evaluation is defined as a time-limited period during which the organization evaluates and determines a practitioner’s professional performance of privileges. FPPE will occur in all requests for new privileges and when there are concerns regarding the provision of safe, high quality care by a current medical staff member, as recognized through the peer review process. LifePoint Hospitals, Brentwood TN

11. FPPE – For New Privileges (EP 1) &When A Cause for Concern is Spotted (formerly called Peer Review, EPs 2-9) • EP 1 is applied to all initially requested privileges • EPs 2-9 also apply to this exercise/period • (though they never stated this explicitly) • EPs 2-9 also apply when OPPE has identified a cause for concern; FPPE is then launched to evaluate if more formal monitoring, investigation, or corrective action is warranted

12. OK, Help Me Understand FPPE! • FPPE is an information gathering phase, not yet an adverse action • EP 2 and EP 7 require that criteria be developed. Better to think of it as…. • EP 2 requires development of clinical indicators • EP 7 requires a method to select the type of monitoring to be completed • EP 5 requires that triggers indicating the need for enhanced performance monitoring (i.e., an additional level of scrutiny) be defined • Triggers are single red flag incidents or evidence of a undesired practice trends within a particular criteria/indicator • E.g., elevated infection rates, delays in DX/TX, readmits, a significant SEA or incident report on LIP, validated staff or patient complaints, significant deviation or outlier from accepted norm, repeated failure to follow policy, or single egregious disruptive behavior

14. FPPE Indicator ExamplesTypes of Data • Hard Data – Process / Outcome Indicators • Individual events or trends of noncompliance with administrative or clinical norms • Timeliness, completeness, legibility, pertinence, dating, timing of clinical record entries, complete medication orders • LOS, Readmission, Core Measures • Mortality and Morbidity • Surgical Complications • Perception Data • Peer, supervisor, patient feedback • e.g., team player, good technical skills, good communicator, no disruptive behavior

15. OK, Help Me Understand FPPE! • EP 8 & 9 the measures (i.e., actions) taken to resolve performance issues are clearly defined and consistently implemented. • Here I recommend you simply refer to the provisions within the investigation, corrective action, hearing and appeal section of medical staff bylaws. (E.g., education, counseling, mentoring. impairment program, remediation program, suspension, revocation of membership and/or privileges ) • If indicated, define the method for establishing a monitoring plan including the roles of the review committee, department chair, and MEC • Again, make reference to the investigation, corrective action, hearing and appeal section medical staff bylaws

16. FPPE EPs 3 and 4: Clearly Define the Process to Include These Elements; Apply Consistently • Criteria (circumstances?) for performance monitoring • (Consider the LifePoint definition) • Method for establishing monitoring plan specific to the requested privilege • (Consider the Table shown for EP 7) • Method for determining duration • Time period for high volume, number/stats for low volume • Circumstances warranting external review • Conflict of interest, lack of internal expert, ambiguity, etc.

17. OPPE – More Straightforward (So says me!) • Routine monitoring of current competency • Quality must be defined in a measurable way • What is it you do? (dimensions of performance) • When what you do is done well, what does that look like? (benchmarks, targets) • Do you look like that? (outcomes) • Feedback is provided whether answered “yes” or “no,” and over time, the norm of performance for the individual and cohort group improves.

18. OPPE – Types of Data • Hard Data – Process / Outcome Indicators • Individual events or trends of noncompliance with administrative or clinical norms • e.g., timeliness, completeness, legibility, pertinence, dating, timing of clinical record entries, complete medication orders • LOS, Readmission, Core Measures • Mortality and Morbidity • Surgical Complications • Perception Data • Peer, supervisor, patient feedback • e.g., team player, good hand hygiene, good technical skills, good communicator

19. OPPE: Sources of Information • Physician profiles (besides the departmental indicators, they should include volume data, generic indicators and utilization data) • Cases that went to peer review • Colleague feedback • Knowledgeable hospital staff (unit managers, QI/Risk management staff, administration) • Observation and personal interaction • Complaints and malpractice suits

20. OPPE: Bottom Line • Apply to each physician/LIP prior to reappointment • Departments determine the type of data, approved by MS • For low volume renewals use peer recommendations that include the 6 general competencies • Upstream and Downstream from the applicant • Report negative/outlier and good performance data • Define process to include who reviews the data/how often • Data informs decision to renew, limit or revoke privileges • Also applies to AHP with privileges (PA and APNP)

21. The 6 General Competencies 1. Patient care. 2. Medical and clinical knowledge 3. Practice-based learning and improvement 4. Interpersonal and communication skills 5. Professionalism 6. Systems-based practice

22. FPPE and OPPE • Are applicable to mid-level physician assistants and advance practice nurse practitioners depending on their scope of practice in your state and in your hospital. • If APRN/PA provide “medical level services” (a CMS term – DX and TX decisions) then FPPE and OPPE apply.

25. OPPE & FPPE – In SummaryDocuments Reviewed by Surveyors • Focused Professional Practice Evaluation – initial • Who will be conducting the review? • Department chair or his/her delegate; MEC; Credentials Committee • What are the criteria (indicators) used per specialty? • What method are used? • 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 personnel • Duration is addressed? • May be individualized. Someone with 10 years experience may require less than someone directly from residency • Should cover the scope of privileges, though similar privileges may lumped together • Circumstances when an external expert required are defined? • Documentation that the review occurred is in the file?

26. OPPE & FPPEDocuments Reviewed by Surveyors • Focused Professional Practice Evaluation – Stemming from OPPE • What are the triggers? • Single incident • Evidence of a clinical practice trend • Who decides that an investigation is needed? • Who will be conducting the review? • Department chair or his/her delegate; MEC; Credentials Committee • Method to be used is defined? • 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 personnel • Duration is defined? • Conclusions are documented and in the file? • No action; education and further monitoring; revoking or limiting privileges • Circumstances when an external expert required are defined?

27. OPPE & FPPEDocuments Reviewed by Surveyors • Policy and procedures, including definition of terms, OPPE, FPPE initial, FPPE stemming from OPPE. • Ongoing Professional Practice Evaluation: • How is the information displayed? Most organizations are creating physician profiles, using both volume, generic and department specific indicators • Who is responsible? Usually the department chair or section chief. • When is the review documented? Every six months? Eight months? (must be more often than 12 months) • What is documented? That the review occurred and that the practitioner is performing well or that an investigation is needed • Is the data shared with the LIP???? (Interesting question!)

28. Additional Resources Life Point Hospitals Toolkit http://www.nahq.org/uploads/apps/files/OPPE-FPPE_Toolkit.pdf FPPE and OPPE “BoosterPak” may be found on your Joint Commission Extranet site

29. Additional Medical Staff Issues

30. Telemedicine MS.13.01.01 - 3 Options • Originating site fully credentials and privileges the LIP. • Originating site privileges the LIP using the credentialing information from a TJC accredited organization. The LIP needs a license in the originating hospital’s state. • Originating site uses the credentialing and privileging decision of the distant site if: • The distant site is TJC accredited • The LIP has the privilege(s) at the distant site • The distant site must share the full list of LIP privileges • The originating site collects FPPE/OPPE data and shares with distant site (including adverse outcomes and complaints)

31. Telemedicine LD.04.03.09 • If either Option 2 or 3 is chosen, there must be a written agreement and EP 4 and 23 apply • EP 4 Leaders monitor performance expectations • EP 23 the agreement must • Label the distant site as a contractor • Specify that distant site will follow MS.06.01.01 – 06.01.13 • Specify that distant site complies with CMS CoP • Note that originating site governing body grants privileges based on originating site medical staff recommendation based on information provided by the distant site • Also, the medical staff bylaws must include a provision permitting such reliance on the distant site.

32. HISTORY AND PHYSICAL • MS.03.01.01, EP 6, A,D – “The organized medical staff specifies the minimal content of medical histories and physicals, which may vary by setting, level of care, tx and services”. • Problem: A long form, short form or “ad hoc” form that doesn’t meet your requirements • CMS now prohibits anything but a “comprehensive H&P” for ASC; • Same for Hospitals????

33. HISTORY AND PHYSICAL • EP 7, A – “The medical staff monitors the quality of H+P’s”. • Surveyors score failure to obtain within 24 hours or prior to surgery or missing update prior to surgery, then look for actions taken by MEC to improve. • If quality data indicates that indeed sometimes there are performance gaps, what do the minutes show for actions?

34. Sample H&P Bylaw LanguageMS.01.01.01 EP 3, EP 16 A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. The medical history and physical examination must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oromaxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy. An updated examination of the patient, including any changes in the patient's condition, be completed and documented within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination are completed within 30 days before admission or registration. The updated examination of the patient, including any changes in the patient's condition, must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oromaxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy.

35. MEDICAL STAFF ROLE IN PI • MS.05.01.01 – The medical staff is actively involved in the measurement, assessment, and improvement of the following: • Medical assessment and tx, use of medications, use of blood and components, operative reports and procedures, appropriateness of clinical practice patterns, significant departures from established patterns of practice, the use of criteria developed for autopsies. • Is there a routine schedule, standing agenda items, or other documentation that can be pointed to in the last 12 months?

36. TEMPORARY PRIVILEGES • MS.06.01.13, EP 1, A – Temporary privileges are granted to meet an important patient care need, or • EP 3, A – while awaiting MEC/Board review. • EP 6, A – Temporary privileges are granted for no more than 120 days • Not used when we are behind schedule • Not used for reappointment

37. QUESTIONS? JohnRosing@PattonHC.com 262-242-3631 Please visit and bookmarkwww.pattonhc.com