Understanding OPPE: Peer review by any other name
by William K. Cors, MD, MMM, FACPE, chief medical quality officer at Pocono Health System in East Stroudsburg, Pennsylvania
The amount of confusion and controversy around the concept of ongoing professional practice evaluation (OPPE) is both surprising and unnecessary. The confusion and controversy are surprising because it has been seven years since The Joint Commission dropped that term into our lexicon. The confusion and controversy are unnecessary because many medical staffs seem to struggle with understanding what is actually required—or, if they do understand what is required, they struggle with implementing a structure and process to actually produce the desired outcome, which is to make every practitioner the best he or she can be.
Let’s begin this series by addressing what is required. In 2007, The Joint Commission employed the term ongoing professional practice evaluation (OPPE) in its then-standard MS.4.40 (now standard MS.08.01.03). The elements of performance under this standard require that there be a clearly delineated process in place that facilitates the evaluation of each practitioner’s professional practice; that data collected is approved by individual departments and approved by the organized medical staff; and that information from this process is used to determine whether to continue, limit, or revoke any existing privileges.
Cutting to the chase, OPPE is just another name for peer review. To have an effective peer review process is to have met the OPPE standard. While many MSPs and physicians feel that a lot of this is new, truth be told, it is not. Peer review has been around since the first time two physicians discussed a case together. The reemphasis on the importance of peer review may be recent, but the concept most certainly is not.
Regardless of what agency accredits your organization, all U.S. hospitals must conform to the CMS Conditions of Participation (CoP), which require an organized medical staff. The organized medical staff exists to carry out the accountability of the governing board to ensure quality of care, which in turn is primarily dependent on the individuals granted privileges in the organization. The CoPs emphasize the need to determine current competency for all privileges granted. The organized medical staff accomplishes this through competency determination across the tenure of a practitioner at the organization, including credentialing, privileging, proctoring (focused professional practice evaluation, or FPPE), and peer review (OPPE).
What might be causing some confusion for medical staffs is the traditional perception that peer review means only “case review.” The reality is that physician performance and determination of current competency is much more than that very narrow concept. A contemporary definition of peer review is the ongoing evaluation of an individual physician’s performance for all relevant performance dimensions using all appropriate and relevant sources of practitioner performance data that are available. For example, the technical quality of care certainly is important, but just as important are medical knowledge; decision-making; judgment; ability to communicate clearly; documentation that is timely, accurate, and appropriate; and interactions with others that are professional at all times.
The Joint Commission suggests using the Accreditation Council for Graduate Medical Education’s six competencies as a framework for OPPE. These include patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and behavior, and systems-based practice. Many medical staffs bristled when The Joint Commission made this suggestion, questioning how the competency of residents could possibly be applied to a seasoned active staff medical attending. (Note: The second part of this series will attempt to answer that concern.)
Earlier this year another accreditation agency, the Healthcare Facilities Accreditation Program (HFAP), introduced new OPPE standards as well. Its standard 05.01.28 recommends performance measures that include both clinical and administrative indicators. Clinical indicators should be department specific and appropriate. HFAP listed an example of the obstetrics and gynecology department having a set goal of reducing the number of non–medically necessary deliveries before 39 weeks. Administrative indicators suggested included number of admissions, volume of procedures, mortality rate, safety measures, patient complaints, and compliance with medical record expectations.
Like proctoring, OPPE/peer review can be as simple or as complex a process as the organization makes it. A word of caution right up front is that any attempt to institute a new and complex process in one fell swoop more often than not ends up as a failed initiative. Sometimes it is because the scope of the project is too ambitious to achieve traction and growth. Alternatively, the required high degree of collaboration between medical staff and hospital leadership might not be present, leaving no way to realistically determine the capabilities, resources, and data requirements necessary to ensure a successful program. HFAP offered organizations sage advice about its new OPPE standard when it stated, “It is highly recommended that the total number of performance measures is kept to a minimum, especially when the process is under development.” This is advice worth heeding regardless of your accreditation agency.
It is important to remember that OPPE/peer review is a process, and like any other process it should be clearly delineated in a policy that is objective and applied equally. If emotions can run high concerning the proctoring of a physician’s privileges, then the ongoing evaluation of competency through a peer review process can go positively nuclear if not handled effectively. A lot depends on the culture of your medical staff and the history of attempts at peer review in your organization.
It should be noted that many physicians regard peer review as nothing more than an ill-conceived attempt to limit autonomy and question individual judgment, wherein the favored are favored and the outcasts are cast out. This tainted view may stem from medical school and residency where morbidity and mortality sessions (which, by the way, are not truly a peer review function) often resulted in a severe dressing down by a borderline sadistic professor. Given the emotional baggage that accompanies this subject, it is critically important to have a very clear structure and process delineated in policy (and action) that is evidence-based, equally applied, and led by credible leaders of the medical staff. Sources for effective peer review policies include the book Effective Peer Review: Third Edition, by Robert J. Marder, MD, available from HCPro, a division of BLR.
When all is said and done, nothing beats credible and educated physician leaders. If your organization is continuing to struggle with OPPE/peer review, it’s time to invest in the education, training, and development of physician leaders to become subject matter experts on this topic for your organization.
Physicians often think that “peer review” is something we just know how to do, but nothing could be further from the truth. It is a fairly complex subject, but with appropriate resources, physician leaders can master it. Whether it’s books, webinars, conferences, or all the above, the investment will help tremendously in implementing a successful structure and process for OPPE/peer review.