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Ongoing Professional Practice Evaluations - Update

Credentialing Resource Center Connection, September 25, 2008

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Anne Roberts, CPMSM, CPCS, is the director of medical affairs at Children's Medical Center of Dallas, where she oversees the medical administration, graduate medical education, and medical staff services departments.

Dear credentialing colleague:

In August 2008, The Joint Commission, published a new standards FAQ for the Comprehensive Accreditation Manual for Hospitals (CAMH), further clarifying the intent of the requirements for Ongoing Professional Performance Evaluations (OPPE). The response explains that organizations should be reviewing performance data for all practitioners on an ongoing basis to allow the practitioner to take steps towards personal performance improvement. Reviewing performance data only at the time of reappointment is a thing of the past – the decisions to grant, limit or revoke privileges are now made on a continuing basis through OPPE.

Furthermore, The Joint Commission requires organizations to have a clearly defined process which includes, (but is not limited to), the following elements:

• Individual(s) responsible for reviewing data: The FAQ gives an example indicating that, in a smaller organization, the department chair may serve as reviewer or the entire department may review the data at a department meeting. In larger organizations a full committee may conduct reviews, such as the Credentials Committee, MEC or special committee of the medical staff.
• How often the data is reviewed: An annual review is considered periodic and therefore not considered an ongoing review. The frequency of reviews should be established by the organization and should take place more than once per year, (i.e., every 3, 6 or 9 months).
• Documented Action: As the action taken during the review may involve continuing to grant, limit or revoke privileges, the clearly defined process should identify qualified decision-makers. Most organizations allow the department chair to make the decision when no action is needed at the time of OPPE. If, however, there is a recommendation to restrict or deny privileges, such recommendations are typically routed through the due process policy, as appropriate.
• Incorporating data in the credentialing file: It is important to determine how the data is incorporated into the credentialing files, including the process for review, action taken, and supporting data. Evidence to support how the determination was made to grant, limit, or revoke privileges should be included in the file.

Clarification was also added to reflect the organized medical staff’s responsibilities for determining whether the correct amount and type of data is being collected so as to make reviews meaningful. As the medical executive committee (MEC) acts on behalf of the organized medical staff, the MEC should routinely approve the data that is being collected and the method of review. Data should be collected on all practitioners, not just those with performance issues, and organizations are encouraged to remember that “zero data” is considered data. The Joint Commission specifically indicates that, “the fact that a practitioner doesn't fall out on pre-defined screening criteria, is not sufficient to meet the requirement for performance data on every practitioner.”

Click here to read this entire FAQ.

Remember, clear, effective communication is the key to success!

That's all for this week.

All the best,

Anne Roberts, CPMSM, CPCS

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