Profile: 2017 CRC Excellence in Medical Staff Collaboration Award winners

The 2017 CRC Excellence in Medical Staff Collaboration Award winners are... 
Raechel Rowland, RN, LSSGB, and Thomas Rohs, MD
Ascension Borgess Health in Kalamazoo, Michigan

Register for HCPro's September 12th webinar for practical takeaways and tools from Ascension’s OPPE and FPPE overhaul.

Editor’s note: This profile is part of the special 2017 CRC contest coverage, a collaboration between Credentialing Resource Center JournalMedical Staff Briefing, and Credentialing Resource Center Daily. Check back in throughout Winners’ Week to learn more about this year’s CRC Achievement Awards and CRC Symposium Case Study Competition winners.   

How do you make OPPE and FPPE more than just an item on the regulatory compliance checklist? Although it has been 10 years since The Joint Commission released its ongoing and focused professional practice evaluation standards, organizations are still struggling to develop meaningful processes that have true meaning, enhance practitioner performance and patient safety, and garner medical staff support.

In the hopes of meeting the aforementioned goals, Ascension Borgess Health in Kalamazoo, Michigan, spent the last year revamping its OPPE and FPPE processes.

“We have made changes in our approach and increased our collaboration globally across the organization,” says Raechel Rowland, RN, LSSGB, medical staff quality specialist for Ascension Borgess Health. “The most significant effect of this program build is we are completing FPPE more timely and accurately; physician leaders have a better understanding of why and how we complete FPPE; we are in full compliance with the Joint Commission standards; and we have eliminated much rework and non–value-added work.”

The organization’s efforts and successes will be celebrated next month at the 2017 Credentialing Resource Center Symposium, held April 6–7, in Austin, Texas, where Rowland will accept the 2017 CRC Excellence in Medical Staff Collaboration award on behalf of herself and Thomas Rohs, MD, Ascension Borgess’ chief of staff and trauma services medical director and physician champion of the OPPE/FPPE overhaul.

“Developing a successful, electronic database for tracking meaningful OPPE and FPPE data benefits the organization and the population it serves,” says Jennifer Svetlecic, MD, FCCP, system director of medical staff development at St. Luke’s Health System in Kansas City, Missouri. Svetlecic is also a member of the eight-person expert panel that selected Rowland and Rohs as the collaboration category winners in the 2017 CRC Achievement Awards, a prestigious new platform for recognizing excellence in the medical staff services and leadership fields.

Laying the groundwork

Ascension Borgess’ journey to upgrade its professional practice evaluation processes started with creating the position of medical staff quality specialist and hiring Rowland, who was charged with reviewing the current process for improvement opportunities and with converting the process from paper to electronic. A recent Joint Commission survey pushed the hospital to improve its physician performance evaluation process.

Rowland started by conducting a gap analysis and current state flow map, which she weaved into an A3 diagram, a Lean Six Sigma tool for mapping out problems and solutions. From there, she leveraged other Lean principles (e.g., a future state map, a cycle time algorithm and escalation process, and a root cause analysis) in creating an extensive FPPE and OPPE policy and a clinical indicators summary tool.

“The biggest barrier we identified in the process was that our providers were getting a blank paper form to fill out with no data available,” says Rowland. “They wanted an at-a-glance scorecard to aid in making thorough and safe evaluations of provider performance.

“As a strong provider advocate, I felt an electronic process would be faster and respect the busy schedules of our providers to facilitate OPPE/FPPE completion.”

 Rowland also recognized that quality data collection needed to be reorganized to avoid duplicative work and promote interdisciplinary communication. The organization hired an outside consultant to help it compile a master data list detailing sources, collectors, and collection tools. Rowland also worked with the hospital’s chief information officer to make sure the electronic data sources could interface with the hospital’s EHR.

Gaining buy-in

Once Rowland created a road map, she began the hard part—getting physicians to buy into the process. This is where Rohs played a crucial role, becoming the physician champion for OPPE and FPPE.

“Having a proactive approach [to OPPE and FPPE] is best for patient safety purposes,” says Rohs. “When done right, FPPE can be a catalyst for process improvement and better outcomes. I partnered with Raechel to share the merits of streamlining the process. I also shared the milestones of the program build so our providers would know we were moving forward to make the process better.”

Rowland met with every department chief/chair to ask them to be a part of the solution. She attended department meetings and gave a presentation to help physician leaders understand the requirements of FPPE and OPPE.

“Our approach to physician engagement is to celebrate our providers for their talents and strengths first. The evaluation process is based on process improvement; it is not meant to be punitive,” says Rowland. “I am extremely passionate about process improvement, and I strive to help that passion catch fire with our physician champions.”

She also met weekly with Rohs to continually review and make necessary changes to the A3 diagram, which she considers a living document. “Dr. Rohs truly championed this process and made sure the provider chairs and chiefs understood the importance of meeting with me. Additionally, our chief medical officer, Robert Hill, backed the importance of their oversight. Many physician leaders were very excited about this coming to fruition and willingly gave their input.”

Rowland now has doctors coming to her with questions about how to complete the evaluations—instead of ignoring them. Since premiering the new process, her list of delinquent evaluations has diminished from 48 entries to seven.

The broader impact

In addition to improving Ascension Borgess’ OPPE and FPPE processes, Rowland and Rohs’ work also drove improvement in the physician onboarding process. As is the case in many organizations, providers were filling out duplicative forms for the medical staff services, health information management, and human resources departments. This duplication was brought to light at Ascension when the chief information officer conducted an analysis to see what data sources interacted with the organization’s EHR. Multiple sources of the same information were identified. This inspired Rowland to revive the organization’s physician onboarding committee and give them the charge of streamlining and enhancing the onboarding process. The committee is now focusing on eliminating redundant work, customizing orientation for providers, and adding two physician liaisons to help new providers navigate their beginning months with the organization.

Ascension Borgess is already working on version 2.0 of its processes. The hospital is beginning a second iteration of the electronic templates for FPPE. It is also building the FPPE process for telemedicine and remote, contractual providers. Additionally, Ascension Borgess is developing standardized forms for three tiers of FPPE: new provider, new credential, and standard of care opportunity. Standardizing the professional practice evaluation process across the Ascension health system is a future, high-level goal.

“We still have more work to do, but we have come an incredible distance. I am extremely proud of my team and the engagement of our physician leadership. I want to celebrate my team for all the hard work and proactive work that we have completed,” says Rowland. 

Editor's note: To see the Lean Six Sigma tools that Ascension used to redesign its physician performance evaluation process, click here.

About the 2017 CRC Contests

The 2017 CRC Symposium Case Study Competition and the 2017 CRC Achievement Awards are two inaugural contests recognizing MSPs and medical staff leaders who have made exceptional strides in their organization and the broader professional community. Winners, who were selected by a panel of esteemed industry experts, will be honored at the 2017 CRC Symposium, held April 6–7 in Austin, Texas.