OPPE, FPPE, quality assurance systems, and core measures

In my last column on June 28, I discussed step one of practitioner credentialing, which entails creating a method for practitioners to request credentials and privileges. This column will focus on step two of the process, which requires medical staff leadership to develop processes for creating and using data to support granting or modifying those privileges. At this point, the focus moves from credentials, which are the documents and certifications required to obtain medical staff membership, to privileges, which are the things practitioners do for and to patients.

Privileges are requested and granted in three time-based modalities:

• New privileges to a new member of the staff
• New privileges added to a practitioner’s existing privilege list, such as new technologies or advanced techniques
• Renewal of privileges, usually at two year intervals

Let’s start with the first group, new applicants to the medical staff. Officially, a new applicant’s skills and quality of services are unknown to the hospital, even if he or she practices in a nearby hospital or city. Having obtained all the required credentials, the practitioner’s request to treat patients in your facility is now at hand. That privilege request should be formatted to the specialty involved, such as general surgery, orthopedics or internal medicine. Each specialty has a set of core privileges and specific privileges. As noted in a previous column, the core list is privileges exercised by all members of that specialty, and thus could be requested and supported as a block. The core would not include things that only some practitioners perform. For example, the core privileges for orthopedic surgery might include diagnosis of injuries and conditions of the skeletal system. Beyond that, the department of orthopedics may separate groups of procedures, such as spine, hand, trauma, etc. and allow each applicant to request them as deemed appropriate.

The general theme is that requests of competency clusters such as hand surgery should be supported by data, usually clinical experience and outcomes. Remember competency is measured by doing something often and doing it well. This may be from recent training as defined by the hospital, or experience elsewhere.  One goal of accreditation is to align data collection in all hospitals to support these privileges. Coding of groups of competency clusters begins at this stage and will be very important as the process continues. Once data is requested from applicable sources, it can be used to create a focused professional practice evaluation (FPPE).

As determined by the applicant’s department, the data is analyzed and used to support the privilege requests.  As needed, additional data can be obtained by proctoring or special analysis during the initial phase.  When the data phase is completed, and the applicant’s competency is verified, the organization can grant the practitioner appropriate privileges.
FPPE is also used on the second group mentioned above, a practitioner who already has privileges who seeks additional privileges not previously granted.  For example, a surgeon who does spine procedures who now seeks privileges to do hand procedures, or a surgeon who seeks privileges to use new technology such as robotic surgery. If determined that these are not logical extensions under the theory of competency clusters, then a FPPE is conducted.

At the time of reappointment—typically every two years—ongoing professional practice evaluation (OPPE) data is used to support privilege renewal. This data set, based on coding of competency clusters to establish experience, is matched to quality assurance data in areas such as complications, outcomes, complaints, and even length of stay.  At that point, the concept that doing things often and doing them well becomes the basis to support the granting of privileges.  Ongoing continuing medical education in areas targeted to delineate privileges is also an important factor in the process, as are CMS delineated core measures.

All of this work is aimed at our original goal: the practitioner is deemed to be competent to perform a procedure or activity that meets the standards set by the medical staff leadership and ultimately by the organization’s governance.

In the next installment, I will discuss the maintenance of the medical record, history and physicals, and information flow.

Richard Turbin, MD, FACPE, is a speaker for The Greeley Company's medical staff leadership national seminars and onsite education programs.