HFAP adds standards for monitoring competence
The Healthcare Facilities Accreditation Program (HFAP) has released new standards for OPPE and FPPE for critical access hospitals and acute care hospitals. Effective January 1, 2015, the medical staff is required to develop a process for evaluation of practitioners who have been granted privileges by the governing body, HFAP announced earlier this week.
For OPPE, Medical Staff Standard 03.15.01 in the Acute Care Hospital manual states that the medical staff is required to periodically conduct an evaluation of the member’s competence. The medical staff is expected to identify performance measures including both administrative and clinical indicators.
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Administrative indicators may include the number of admissions, volume of procedures, mortality rate, patient safety measures, patient complaints, compliance with medical records expectations, and others.
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Each department is also expected to identify appropriate clinical indicators to determine the current competence of the medical staff. HFAP recommends that the total number of performance measurements be kept to a minimum, especially while the process is under development.
By January 1, 2015, the medical staff must:
- Have evidence that a formal assessment process is under way
- Have identified at least two to three clinical indicators plus two to three administrative indicators.
“It is understood that facilities will require additional time to produce the first round of practitioner-specific reports,” HFAP stated.
According to standard 03.15.02, FPPE consists of additional, focused monitoring and evaluation of a practitioner’s professional performance. The FPPE allows the medical staff to monitor performance of an individual for a defined period of time, based on three indications:
- All new privileges granted by the board upon initial appointment
- All new/additional privileges granted by the board, following initial appointment
- Identification of issues affecting the provision of safe, high-quality patient care
In the Critical Access Hospital manual, these Medical Staff standards are 05.01.28 OPPE and 05.01.29 FPPE.
Source: HFAP