An OPPE system for 'specialty-specific' metrics

A recent Joint Commission survey at my organization brought another topic to light that we need to address in this series: inclusion of practitioner performance metrics that are specific more to a particular specialty, department, service line, or privilege(s) that cross specialty lines.

This allows greater specific scrutiny of competency within a defined clinical domain. The metric chosen will obviously only apply to some subset of practitioners, but the specificity allows better definition for driving improvement and quality care in an area or a procedure or a privilege that is relevant to that department/section/service line. Examples might include the following:

Anesthesia: Rate of re-intubation; intra-operative mortality/morbidity; dental injuries; post-spinal headache rate

Medicine: Conformance with use of evidence-based admission order sets for heart failure or stroke; or community-acquired pneumonia

Cardiology: Door-to-intervention time for STEMI (S-T Elevation Myocardial Infarction).

Surgery: Number of fallouts on the surgical indicators for the AHRQ Patient Safety Indicators 90 (PSI 90) metrics that are part of the CMS Value Based Purchasing initiative; returns to OR for same condition within 72 hours; conformance with current Surgical Care Improvement Project (SCIP) measures.

Gynecology: Same as surgery indicators; robotic surgery complications requiring conversion to laparoscopic or open procedure; ureteral or visceral injury during surgery.

Obstetrics: Obstetric trauma (3rd or 4th degree lacerations); rate per 1,000 instrument-assisted vaginal deliveries; rate of early elective delivery (EED) before 39 weeks of gestation without medical or obstetrical indication.

Emergency medicine: Return to emergency department within 24 hours for same condition.

Colonoscopies: Perforation rate. (Note: this could apply to numerous specialties holding the same privilege for colonoscopy, including gastroenterology, general surgery, colorectal surgery, and family medicine.)

Pediatrics: Conformance with quality measures identified by Children's Health Insurance Program Reauthorization Act (CHIPRA).

As emphasized throughout this series, the choice of metric is up to your organization. There is no one size fits all. There is no one mandated list. The choice of metrics is yours but is dependent upon the answers to several fundamental organizational and cultural factors, including:

What is truly important to the medical staff in driving improvement in quality care and practitioner performance?

What challenges exist for which an objective OPPE program can help?

What is the organization capable of actually measuring? If you choose a metric, can you obtain the data?

Do you have the existing resources—human resources, information technology, data systems—to achieve what you have designed? If not, can you reasonably obtain those resources given organizational, financial, structural, and process restraints?

Is this something that is already being collected and can be adopted for OPPE?

Once this analysis has been performed, the five steps for implementation outlined in previous parts of the series can be brought to bear.

1.Expectation: The first step is to clearly define the expectation. Allowing for different medical staff structures as well as different ways of approaching clinical privileges, the statement of expectations can be as simple as:

All practitioners in the department (or section or service line or other functional structure) of surgery will actively participate and adhere to expectations on specialty (or privilege or procedures) performance metrics defined by the department and approved by the medical staff through its medical executive committee.

2.Indicator: The second step is to select an indicator that defines a clear measure of the expectation. "Specialty specific" indicators will be limited to a smaller subset of practitioners than the general indicators listed previously. A sample list was offered above; you can generate other options as well.

3.Targets: Targets are metrics that are defined to look at trends and overall aggregate performance of physicians against the selected indicator. There generally are no published targets for a specific indicator. Your medical staff will need to do the research and education to understand how to set targets that will be meaningful to improve physician performance in your organization. Particularly in this area, it will be important to set targets in advance to deal with the potential volume of data that will need to be evaluated. One possibility is:

Excellent performance: Full compliance with indicator over the last four "rolling" quarters

Acceptable performance: One episode of non-conformance over this time period

Unacceptable performance: Two or more episodes of non-conformance over this time period

4.Feedback: Once again, feedback and evaluation is essential to drive the success and credibility of any OPPE system. Your organization determines who reviews this data and how often. The ultimate goal is to ensure competency and to make recommendations to maintain, modify, restrict, or revoke a privilege(s). Although there is no current requirement to offer a formal report to the practitioner, it certainly makes sense to do so since you are collecting this data anyway. Your intent should be to help everyone be the best that they can be, and that means timely feedback (every 6?9 months) about performance.

5.Manage poor performance: The whole point of OPPE is that the medical staff evaluates performance data and makes a recommendation to continue, limit, or revoke existing privileges. Best practice here is to have a plan in advance of when poor performance needs to be managed. One possibility might look like this:

1 episode of non-conformance: Letter to practitioner and copy to file

2 episodes: Counseling with department chair and letter to file

3 episodes: Imposition of a new focused professional practice evaluation plan that might include prescribed CME and some type of additional proctoring

4 episodes or more: Evaluation by MEC whether any further limitation or revocation of privileges is warranted

Next month we will conclude this series on OPPE by reviewing key learning points and assessing whether your OPPE/peer review program has FACE. Until then, be the best you can be.