OPPE and professional conduct

The definition of OPPE can be expanded beyond traditional case review to include multiple and relevant performance dimensions. The following is an excerpt from a column written by William K. Cors, MD, MMM, FACPE, chief medical officer, Pocono Health System; East Stroudsburg, Pennsylvania, on how to use professional conduct as a metric to assess an employed physician’s performance:

Every hospital and medical staff must address how professional conduct issues will be handled. A best practice is to have a medical staff/hospital professional conduct policy that defines in advance who will handle these challenges and how. When professional conduct concerns involve an employed physician, many hospitals are moving to intimately involving the employer from the start.

Reasons for this include a generally more advanced expertise on the part of the employer to investigate and handle conduct issues; better leverage on the part of the employer to effectively deal with conduct issues; and clarity to avoid the employed physician facing “double jeopardy” from being subjected to both a medical staff process and an employer process. The reality is that most medical staffs are not very comfortable dealing with professional conduct issues. They often gladly will turn this over to the employer to handle. But you cannot just assume this to be the case.

Your policy needs to state what you actually will do and how and by whom. It cannot be left to chance. A further best practice is that the policy should state that regardless of who performs the investigation/intervention, all information should be stored in the MSSD quality file as generally this will provide peer review protection for all information therein. Additionally, it will be readily available for the MSSD in preparing OPPE reports.

So while the expectation for appropriate professional conduct is the same for everyone, the process of investigating, validating, and dealing with deviation from the policy may differ for the employed physician.

Source: Medical Staff Briefing