PART II: What is Ongoing Professional Practice Evaluation?
By Judy Courtemanche and Charles Milano, MD
Introduction
Last month in Part I, we discussed Focused Professional Practice Evaluation (FPPE), the first of two key concepts to measure professional performance. This month, we’ll discuss Ongoing Professional Practice Evaluation (OPPE). (If you missed Part I, you can download a PDF with both parts of the article here.)
Let’s review the background for these concepts. Two years ago, The Joint Commission (TJC) introduced the concept of Professional Practice Evaluation in the form of two key Medical Staff standards: MS.4.30 Focused Professional Practice Evaluation and MS.4.40 Ongoing Professional Practice Evaluation. The concepts required organizations to review their current process for assuring physician competence at initial appointment, when new privileges were requested, when trigger events occurred, and in an ongoing manner. In essence, the organization would assess performance initially and measure performance in an ongoing manner to assure appropriate performance to maintain approved privileges. These standards were effective in January of 2008.
Inherent in the concepts are expectations that organizations engage in performance measurement for various aspects of medical staff practice competencies as outlined in MS.4.00. General competencies for medical staff include: 1) Patient Care, 2) Medical/Clinical Knowledge, 3) Practice-based Learning and Improvement, 4) Interpersonal and Communication Skills, 5) Professionalism, 6) Systems-based Practice. Additionally, medical staff performance improvement, such as patient safety, medical management, medication use, and others, as noted in MS.3.10 – MS.3.20, would be considered. Thus, routinely, organizations would utilize data, such as morbidity and mortality data, as in MS.4.15, analysis in MS.4.20, focused professional practice evaluation in MS.4.30, and MS.4.40 ongoing professional practice evaluation for reappointment decisions.
Ongoing Professional Practice Evaluation
The Joint Commission defines ongoing professional practice evaluation as “a document summary of ongoing data collected for the purpose of assessing a practitioner’s clinical competence and professional behavior. The information gathered during this process factored into decisions maintain, revise or revoke existing privilege(s) prior to or at the end of the two-year license and privilege renewal cycle.”
You might think of OPPE as the process for maintaining privileges. The privileging process is a systematic process that includes processing an application, developing and approving procedure lists, evaluating applicant specific data and information, recommending privileges to the governing body and notifying the applicant and others of the decision. Inherent in this process is the foundation for privileging that is based on medical staff criteria for privileging and monitoring the use of privileges for quality and patient safety. The basic criteria for privileging includes relevant education and training, current licensure and required certifications, data on current performance of requested privileges, peer or faculty recommendations, and evidence of the ability to perform requested privileges. Basic privileging combined with FPPE and OPPE creates a three step process: first, privileges are approved based on criteria. Second, the practitioner undergoes the medical staff’s focused evaluation process to assure initial performance of privileges and organization expectations, and third, the provider meets ongoing performance expectations through OPPE.
What Criteria should be used for OPPE?
The criteria for OPPE should address desired and required elements of performance, although the medical staff has significant latitude in determining the criteria used to maintain privileges. Consideration should be given to performance that seeks to improve quality and patient safety. For example, organizations may review morbidity, mortality and length of stay patterns, data which is readily available through MedPAR or Medicare discharge criteria. Measurement of core measures, disease specific or organization specific patient care initiatives can be used. Traditional medical staff reviews of operative and other clinical procedures performed, their outcomes, patterns of blood and pharmaceutical usage, requests for tests and procedures, practitioner’s use of consultants, and other relevant criteria as determined by the organized medical staff.
Organizations may utilize proactive strategies by integrating changing quality requirements, such as Present on Admission initiatives, CMS Never Events, and Value-based Purchasing or Pay for Performance Plans into their initial focused professional practice process and their OPPE. In addition, state requirements or other national initiatives, such as Healthy People 2010 or Government Performance Results Act (GPRA) could be used.
The medical staff meets these requirements through assimilation of data sources and monitoring performance that relates to the privileges awarded. Criteria can be broad for performance issues that may affect the medical staff privileges as a whole, such as the quality of assessments, implementation of universal protocol procedures, or the documentation issues of dating, timing, and signing entries or use of dangerous abbreviations. Criteria can also be specific to focus measurement on specialty privileges. For example, a cardiologist who treats patients with acute myocardial infarctions (AMI) or congestive heart failure (CHF) could have criteria for OPPE that includes core measure requirements for AMI and CHF. An orthopedic surgeon who performs joint surgery could have criteria that include core measures for infection prevention based on the Surgical Care Improvement Project (SCIP). Criteria for performance of privileges must be defined and data must be used in the ongoing privileging process.
Monitoring
The medical staff collects data through observation, record review, and monitoring of diagnostic and treatment techniques. Additional information may be obtained through discussion with other professional staff involved in care, consulting with physician assistants involved in surgery, interviewing nursing and administrative staff. Accreditors do not determine what criteria is used or how data is collected, but do require that relevant information obtained from the ongoing professional practice evaluation is integrated into performance improvement activities, which may include FPPE.
While working with organizations to structure their OPPE process, we find that performance measurement systems are not readily available within their budget constraints, making much data collection a manual process and thus labor intensive and time consuming. Manual extraction of measures from medical records is an onerous task at best. Thus leadership understanding of these concepts and support is needed to implement a process that works and meets budgetary expectations.
How do you satisfy these Standards?
Medical staff leaders, Chiefs, Department Directors and others must consider performance when privileging. They define criteria for performance measurement and review performance data in an ongoing manner to identify potential performance issues and prevent potential patient harm. Under this process, privileges are awarded only when there is performance data to assure quality and safety.
Ongoing professional practice evaluation must be defined:
| Must Define | Examples |
| 1. Who reviews the data? | - Chair of department
- Credentials committee
- Others
|
| 2. How often data is reviewed? | - Annually is periodic - does not meet OPPE
- Monthly, quarterly
- Every six months
|
| 3. How will data be used to continue, limit or revoke privileges? | - Analyze to determine if quality or safety issue
- Designate who makes recommendations
- Designate who takes action
|
| 4. How will data be incorporated into credential file? | - Data summaries go to quality file
- Quality file is reviewed for reappointment
|
| 5. What data will be collected? | - Include all providers
- Failure to fall out of pre-screening criteria does not meet this requirement
- Department specific data maybe used
- Need to know if specific privileges are not being performed
|
| 6. What methods are used for data collection | - Record review
- Direct observation
- Interview
- Discussion
|
| 7. How is the information derived from data collection and analysis used to determine privileges? | - Revoke privileges when no longer needed
- Suspend the privilege for quality, safety concern or no data
|
What to Expect During Survey Process
Surveyors need to know that you have an OPPE process in place that addresses the three elements of performance relevant to MS.4.40. This means you have a clearly defined process in place to facilitate the evaluation of each practitioner’s professional practice. You also need to determine what data is collected by individual departments and approved by the medical staff. Lastly, you need to determine how information resulting from OPPE continues, limits, or revokes any existing privileges.
Questions surveyors may ask include:
- Describe your OPPE process?
- Who does it apply to?
- Who is responsible for reviewing the data?
- What data is collected?
- How often is data reviewed?
- Can you show me a file where decisions were made based on the ongoing review of data?
- Are there any departments that have not defined their data to be collected?
- Under what conditions would privileges be revoked? Limited? Suspended?
- When privileges are suspended due to zero performance, is FPPE recommended?
- May I see a file of a practitioner where a privilege was revoked? Limited? Suspended?
For more information on OPPE, contact Courtemanche & Associates at 704-573-4535.
Standards Referenced - Crosswalk – 2008 to 2009:
| 2008 Standard | 2009 Standard |
| MS.3.10 | MS.05.01.01 |
| MS.3.20 | MS.05.01.03 |
| MS.4.00 | MS.06.01.01 |
| MS.4.15 | MS.06.01.05 |
| MS.4.20 | MS.06.01.07 |
| MS.4.30 | MS.08.01.01 |
| MS.4.40 | MS.08.01.03 |