Meaningful indicators are key to robust OPPE, FPPE processes
When The Joint Commission changed its language to focused and ongoing evaluations, some physicians at the hospital had a difficult time understanding that these "new" requirements were still peer review, according to Barbara Lewis Shelton, BS, MBA-HCM, RN, CPHQ, director of medical staff performance at Wayne Memorial Hospital. However, the biggest challenge wasn't in the terminology changes: It was figuring out what to measure and how. Like many other facilities, each medical staff department at Wayne initially came up with its own quality indicators (QI). "When we first started out, we had a lot of data that was just data," she says. "[The question was,] what do we do with it?"
Originally, the hospital's OPPE form was an uncomplicated, single-page document. It included activity and patient care in the six ACGME competencies, so surveyors could easily see that the organization was looking at all six—patient care, medical knowledge, interpersonal and communication skills, professionalism, practice-based learning and improvement, and systems-based practice.
Although elements of these six competencies are still incorporated, the new form has room for additional information and reflects its multiple uses. "Through the years, this has evolved. We call it 'professional practice reviews' now; we changed that last year," Shelton adds.
Today, Wayne conducts OPPE every eight months, and the Professional Practice Quality Report form includes three columns to accommodate three evaluation periods. "When I initially made the form, it only had one column. But then, when we started to do OPPE every eight months, I realized if I included a column for the first eight months, the second, and the third, then I wouldn't have to redo the form each time," says Shelton.
Some of the data doesn't change very much as the forms are populated, she notes. "You'll have the same basic information each time for physicians as well as patient satisfaction overall. In some of the data fields, it looks like a lot of information, but when we run the reports, the way the forms are set up gives us a lot of the data so we don't have to [search for it]."
Initial FPPE monitoring requirements vary for Wayne practitioners. In addition to completing the listed monitoring requirements, all department chairs or their designees complete a summary review of the evaluated physician at the end of the provisional year for use by one or more medical staff medical review committees. In some cases, the provisional year-end review may fulfill the FPPE requirements for medical staff privileges.
Check boxes on the Professional Practice Quality Report forms allow them to be used for OPPE or FPPE. The forms include activity data that is relevant to the practitioner profile; for example, the General Surgery profile includes inpatient admissions and observations, consults, transfusion episodes, and unplanned transfers to the ICU, among others.
Activity data is included because the hospital bylaws require minimum numbers of patients to meet the criteria of the medical staff section. Over time, the hospital has limited the activity data it measures to only the information pertinent to each department, according to Shelton.
Editor’s note: Check out Wednesday’s edition of CRC Daily to see Wayne Memorial Hospital’s OPPE form.