Ensure professional practice evaluation program effectiveness
Once the OPPE/FPPE program is fully designed and implemented, an oversight committee must ensure that the various steps of the process occur as expected and that practitioners adhere to the procedures. An ineffective (but common) approach to program oversight is having the medical staff quality committee, peer review committee, or credentials committee review all OPPE reports. This approach duplicates the work of medical staff leaders, who have already reviewed the reports. It is far more effective for the dedicated clinical staff to manage the review process at the departmental level and to assist the division/section and departmental leaders in ensuring that the OPPE process is carried out accordingly.
Best practices for the OPPE/FPPE oversight committee or medical staff quality committee include the
following:
- Periodically performing sample audits of each specialty’s or department’s activities to ensure compliance with procedures
- Assessing whether the OPPE/FPPE program is providing effective, relevant, and meaningful support for the evaluation of ongoing clinical competence
- Recommending modifications in program configuration, procedures, and training of participants who might improve the effectiveness or efficiency of the program
Many organizations discretely forward results of the OPPE review to the MEC and/or board of directors. However, although these stakeholders may need to know individual OPPE results when a privileging action is required, it is not productive to forward detailed results to them. In their capacity as a governing body, the MEC and board of directors are most concerned with ensuring that there are effective systems in place to measure and monitor clinical competence and that there are criteria outlining what should occur when further review or action is needed. When an identified issue calls for FPPE, the MEC and/or board may also provide rationale for the move and should strive to foster collaboration across the organization. To those ends, the MEC and board should receive periodic reports from them medical staff quality committee in conjunction with the OPPE/FPPE task force regarding the results of their assessment of the program’s efficiency and effectiveness.