McLeod Health

Ongoing Professional Practice

Evaluation
&
Focused Professional Practice
Evaluation
(OPPE & FPPE)
C. Dale Lusk, MD
Stacy Holley RN, MSN
 Objectives

 Define Ongoing Professional Practice

Evaluation (OPPE).

 Define Focused Professional Practice

Evaluation (FPPE).
 Objectives

 Understand the types of data utilized for

OPPE and FPPE.

 Understand how data from OPPE/FPPE

can improve practice and quality of patient
care.
Framework for Professional Practice
Evaluation
 Accreditation Council Graduate Medical
Education (ACGME) Six General
Competencies

 The Joint Commission adapted general

competencies in MS.06.01.03 for
credentialing.
 Six General Competencies

1. Patient Care
2. Medical & Clinical Knowledge
3. Practice-based Learning & Improvement
4. Interpersonal & Communication Skills
5. Professionalism
6. System-based Practice

Accreditation Council for Graduate

Medical Education (ACGME)
 Patient Care

 Practitioners are expected to provide

patient care that is compassionate,
appropriate, and effective for the
promotion of health, prevention of illness,
treatment of disease, and care at the end
of life.
(Assessment, Outcomes/Core measure data, clinical
competence and judgment)

The Joint Commission

 Medical/Clinical Knowledge

 Practitioners are expected to demonstrate

knowledge of established and evolving
biomedical, clinical, and social sciences,
and application of their knowledge to
patient care and the education of others.

(Knowledge of basic medicine, discipline specific medicine,

board certification, CMEs)

The Joint Commission

 Practice Based Learning &
Improvement
 Practitioners are expected to be able to
use scientific evidence and methods to
investigate, evaluate, and improve patient
care practices.

(Evaluates care practices & improves as needed, clinical

research, workgroup/committees, core measures).

The Joint Commisssion

 Interpersonal & Communication
Skills
 Practitioners are expected to demonstrate
interpersonal and communication skills
that enable them to establish and
maintain professional relationships with
patients, families, and other members of
the health care team.

(Relationships with patients, families, and other health care

team members)

The Joint Commission

 Professionalism

 Practitioners are expected to demonstrate

behaviors that reflect a commitment to
continuous professional development,
ethical practice, an understanding and
sensitivity to diversity, and a responsible
attitude toward their patients, their
profession, and society.
(Behavior, staff meeting attendance, respects diversity)

The Joint Commission

 Systems-based Practice

 Practitioners are expected to demonstrate

both an understanding of the contexts and
systems in which health care is provided,
and the ability to apply this knowledge to
improve and optimize health care.

(Utilizes resources, referrals, works with interdisciplinary

team).

The Joint Commission

 Ongoing Professional Practice
Evaluation
 The Joint Commission requires OPPE.

 MS.08.01.03

 OPPE-Purpose: document summary of

ongoing data collected to assess clinical
competence and professional behavior.
 OPPE
 Assist in determining whether to continue,
limit, or revoke existing privileges.

 Allows organization to identify practice

trends -» quality of care & patient safety.

 Identification of practice trends may

require intervention.
 TJC Intent of OPPE

 Ensure performance data for practitioners

with privileges is reviewed on an ongoing
basis, rather than at the two year
reappointment process
 OPPE

 Currently use an OPPE process at

reappointment.

 Occurs yearly or every 2 years.

 The Joint Commission requires OPPE more

frequently than at reappointment time.
 OPPE

 OPPE –evaluation for maintaining

privileges.

 Accomplish using several data sources.

 OPPE Data Sources
 Could include the following:
-periodic chart review
-direct observation
-monitoring of diagnostic and treatment
techniques
-discussions with other individuals
involved in the care of the patient
-Internal data sources, e.g. Midas,
Premier, Quality data
 Components to OPPE
Profiles

Additional
Data
OPPE Department
Indicators

Competencies
 Practitioner Profiles

 Premier Clinical Advisor™

 Profile sent to practitioners every 6

months.

 Data is administrative (coded) data.

 Practitioner Profile

 Use profile data as “directional” data.

 Represents a summary of performance

and resource utilization.

 Profiles have “drill down” capability.

 Profile Contents
 Case count-identifies practitioner role
 Mortality
 LOS
 Resource use
 Evidence-based care (AMI, HF, PN, PR & SCIP)
 Outcomes (Observed/Expected)
 Hospital Acquired Conditions & Patient Safety
Indicators
 Additional Data for OPPE
 ACGME General Competencies
 Medical Records-Admission & Hospital
Suspensions
 Legibility
 Unapproved Abbreviation Use
 Blood Utilization
 Operative Procedures and Other Procedures
 Triggers/Fall outs
 Department Data for OPPE

 Each department tasked to identify

department-specific indicators to
monitor.

 IMPORTANT Component-profiles are

not department specific-need
meaningful parameters for depts.
 Department Data

 Need involvement from all

departments

 Input will ensure measurement of the

“right” thing.
 Who sees OPPE data?

 Data is incorporated into performance

improvement activities.

 Considered privileged and confidential,

Quality/Peer review material.
 Who sees OPPE data?
 Individual practitioners

 Department Chiefs (6 month & reappt)

 Credentials Committee view data at

reappointment, unless concerns prior to
reappointment.

 MEC, if intervention warranted.

 Maintaining Documentation

 OPPE data will be maintained in the

practitioner’s Quality File.
 Please note:

 A government or accreditation entity

could also request to view the quality
file or credentials file of a practitioner,
i.e. CMS, The Joint Commission.
 Practice Trends

 Trends identified will be discussed with

the Department Chair. (Credentials
Committee if needed)

 Recommendations for Follow-up

 Triggers

 Can be a single incident

 Evidence of a clinical practice trend

 Indicators described in the Medical

Staff Peer Review Policy.
 Fall outs

 Department indicators
 Exceed set threshold

 Significant difference in performance

compared to peer group on profile
 Exceed threshold on profile
 Follow-up

 Triggers and Fall outs handled by same

process as practice trends.

 Dept. Chief -» Credentials Committee -»

MEC
 Focused Professional Practice
Evaluation
 FPPE- time limited evaluation of
practitioner competence in performing a
specific privilege.

 Required by The Joint Commission

 MS.08.01.01
 FPPE

 Time limited evaluation, i.e., 3 months,

6 months.

 Confirm competency

 Applies in three situations

 FPPE Situations

 New applicants

 Existing practitioners requesting new

privilege

 Practitioners when concerns arise

 FPPE Data Sources

 Proctoring- prospective, retrospective or

concurrent.

 Peer review data

 Internal data sources (Sentinel event

data, quality data, etc.)
 FPPE Data Sources

 Chart review by physician or non-medical

staff

 Monitoring clinical practice patterns

 External peer review

The FPPE Process
Approval
Evaluation
Plan
 FPPE Plan

 Individualized plan

 Based on privileges requested, experience

 Dept. Chief develops plan

 Credentials Committee reviews plan

 FPPE Plan

 Plan includes:
- what will be evaluated
- timeframe
- sources of data
 Duration of FPPE

 Time limited
Will depend on:
 privileges of concern

 practitioner's overall activity level

 nature and severity of the situation

 Duration

 New applicants- goal is to complete within

three months.

 Will allow for additional evaluation period

(if needed) prior to the end of 12 month
provisional period.
 FPPE Evaluation

 Framework for evaluation based on

ACGME General Competencies
Patient Care, Medical & Clinical Knowledge, Practice-
based Learning & Improvement, Interpersonal &
Communication Skills, Professionalism, System-based
Practice

 Evaluate specific aspects of each

competency
 Other components
 Medical Records-Admission & Hospital
Suspensions
 Legibility
 Unapproved Abbreviation Use
 Blood Utilization
 Operative Procedures and Other
Procedures
 Mortality
FPPE Evaluation Documentation

 Satisfactory or Unsatisfactory

 Trends identified

 Data source used for evaluation

 Evaluation

 Completed by the Dept. Chief

 Reviewed by Credentials Committee

 Completion, Expand timeframe, or

Intervention
 Completion & Approval

 Satisfactory Completion of FPPE

 Not satisfactorily completed: must make

recommendations, i.e. supplemental plan,
revoke privileges.
 Completion & Approval

 Credentials Committee

 Medical Executive Committee

 Reviews evaluation- and

recommendations, if applicable
 Who sees FPPE data?

 Practitioner

 Dept. Chief

 Credentials Committee

 MEC
 Maintaining Documentation

 FPPE plan and evaluation will be

maintained in the practitioner’s Quality
File.
 Approval documentation will be
maintained in the Credentials File.

 Available at reappointment.
 Please note:

A government or accreditation
entity could also request to
view the quality file or
credentials file of a
practitioner, i.e. CMS, The Joint
Commission.
 FPPE -» OPPE

 Successful completion of the FPPE process

leads to OPPE.

 Practitioner will progress to ongoing

evaluation.
 OPPE & FPPE

 Does not apply to affiliate staff members

or no volume practitioners.

 Must have privileges for OPPE/FPPE

 Eventually will include mid-level providers

in the process.
 OPPE & FPPE

 Provide feedback to identify opportunities

for improvement

 Information to assist in the reappointment

process
 Assure quality evidence- based care being
provided.
 Questions?
 Stacy Holley, RN, MSN
Quality Improvement Specialist
Clinical Outcomes
777-5490
sholley@mcleodhealth.org

 Susan Pickle, RN AVP

Clinical Effectiveness
777-5141
spickle@mcleodhealth.org
 References
1. Accreditation Council for Medical Graduate Education (ACGME).
(1999). ACGME Outcome Project. Retrieved September 9,
2010, from http://www.acgme.org/outcome/comp
2. The Joint Commission (TJC). Standard MS.06.01.03, Standard
MS.08.01.01, Standard MS.08.01.03.