MSPs will find familiar concepts in new HFAP requirements

New OPPE and FPPE standards for acute care and critical access hospitals accredited by the Healthcare Facilities Accreditation Program (HFAP) may look somewhat familiar to many hospitals. Most facilities conduct competence assessment and peer evaluation in one form or another. Now, however, they must implement structured ongoing and focused processes for assessing physician competence to stay HFAP-accredited. The new standards, took effect in January 2015.

OPPE Requirements

Staffing standard 03.15.01 in the Acute Care Hospital Manual and standard 05.01.28 in the Critical Access Hospital Manual call for OPPE information to be factored into the decision to maintain or revise existing privileges prior to or at the time of renewal.

The medical staff must develop and approve an OPPE plan that is applicable to all practitioners with privileges granted by the governing body, according to the standard. The plan must be clearly defined, and it must address 12 items, including:

1. Reasons for an OPPE program
2. Identification of performance indicators specific to each department of the medical staff
3. Data collection methods
4. Individual(s) responsible for data collection
5. Sources of data
6. Frequency of data collection
7. Methods for evaluation and analysis of data
8. Confidentiality and security of data
9. Individuals who may access practitioners’ professional practice data
10. Explanation that data will be used as a measure of competency and will be reviewed at time of reappointment to determine eligibility
11. Evaluation of low-volume practitioners
12. Triggers for additional, focused monitoring

The standard calls for data to be collected on an ongoing basis and summarized at least three times during each two-year appointment cycle. HFAP recommends that individual data reports be distributed to the practitioners.

At least every two years, the medical staff must identify and approve performance measurements specific to the services provided by the practitioners. Examples of performance measures include:

• Administrative data, such as number of admissions, number of consultations, number of weeks on Surgery Suspension List, or medical record delinquency rate.
• Clinical indicators, such as core measures (heart failure, acute myocardial infarction, pneumonia, stroke, etc.), Surgical Care Improvement Project, returns to surgery, surgical infection rate, procedural complication data, cesarean section births when not medically necessary, or turnaround time for simple or complicated autopsy reports.

FPPE requirements

Under Staffing standard 03.15.02 in the Acute Care Hospital Manual and standard 05.01.29 in the Critical Access Hospital Manual, the medical staff must define circumstances requiring additional, focused monitoring and evaluation of a practitioner’s professional performance.

The medical staff bylaws must address:

• The period of FPPE implemented for all new privileges granted by the board either on initial appointment or for requests for additional privileges.
• The criteria for evaluating the performance of practitioners when issues affecting the provision of safe, high-quality patient care are identified.

The medical staff bylaws clearly define the professional practice evaluation process and addresses:

• Criteria (triggers) for conducting focused performance monitoring
• Methods for determining the duration of focused performance monitoring
• Indications for an external reviewer

The department chair is responsible to assign the focused evaluation. The focused evaluation may be defined as either a period of time (e.g., six months) or a specific number of cases. The focused evaluation may be extended, as defined in the bylaws.

Data sources for the focused evaluation are defined and may include chart review, direct observation, simulation, or discussion with others involved in the care of each patient.

The medical staff bylaws define unacceptable levels of performance that trigger the need for focused performance monitoring. Triggers may be a single incident or evidence of a clinical practice trend.

The medical staff bylaws must specify the measures employed to resolve performance issues. These measures must be consistently implemented and may include necessary education, proctoring/assisting for a defined privilege, counseling, physician/practitioner assistance programs, or suspension specific privileges.

The improvement plan must be documented and include requirements, who is accountable, and how improvement will be measured and documented.

FPPE outcomes must be documented and analyzed, and processes developed to allow the practitioner to review findings and submit opinions.