Credentialing & Privileging

OPPE: The who, what, where, and when

Credentialing Resource Center Insider, March 11, 2010

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Anne R. Buss, CPMSM, CPCS, is a medical staff consultant based in Fayetteville, AR.

Dear readers,

I wish that I could tell you in this very first sentence that I have something new and profound to say about the ongoing professional practice evaluation (OPPE). I don’t. Those of us who have been in medical staff services for almost any length of time recognize OPPE as performance review taken to a new level. The Joint Commission thinks looking at a provider’s performance every two years isn’t often enough. Thus, OPPE necessitates a process for ongoing evaluations. But how do we achieve such a great task? What MSPs need to focus on are answering the who, what, where, and when of the process. Sticking to those basic questions can make the OPPE process more manageable.

Who: Each facility needs to decide for itself who will review the data and what will be the first step in that review process. Who should be that who? The chief of a department or service line in large facilities, or the president of the medical staff in other facilities could be the who. Some healthcare organizations have quality departments that collect, analyze, and report that data to the credentials committee at reappointment. Other hospitals depend on the medical staff services department (MSSD) to pull clinical data from various sources and keep it in separate files in the MSSD. Most facilities have a multitude of measurement and screening tools already in place to collect this data, they just need to decide who to pass it on to.

What: After you’ve helped identify the who, you must determine what data to collect and what will happen to the data once it is gathered. Will it be clinical data abstracted from medical records, quality data collected through rule break and outcomes analysis, chart review, direct observation, peer review, or…. The possibilities are as varied as the healthcare facilities themselves. There should also be a means for review of systems and processes that help provide background details for the raw data.

For me, a huge part of the OPPE process is creating plans outlining what actions to take and who should take those actions in the following circumstances:

  • Data raises questions regarding the physician’s competency
  • Practitioner has positive competency data
  • Practitioner has zero data due to a lack of activity

    Again, there are multiple options for the types of action that could be taken, including additional education, proctoring, mentoring, suspending the privilege(s) with a notice to the provider, and/or determining if the provider is meeting expectations and that no further action is needed.

    In a way, it’s easier to learn from positive outcomes than from negative ones. If one member of a department performs a procedure with shorter OR time, has good outcomes, and results in a shorter length of stay for the patient, wouldn’t you think the practitioner’s peers might benefit from learning about his or her techniques? If a practitioner arrives at a diagnosis by using an unusual test or recognizing vague symptoms, wouldn’t you want every practitioner in that department to be aware of the outcome? We seem to focus on errors and events to prompt us to do better, but maybe it’s time for us to focus on the positive, too, when considering the data we’re collecting.

    Where: Where to store this data can also be as varied as the data itself. It does not have to be kept in the credentials file as long as it is available at the time for review. You can determine what data (and supplemental documents, as needed) to put in the credentials file at the time the OPPE data is reviewed. This data could be a colorful graph with detailed legends or something as simple as a statement noting what data was reviewed, who reviewed it, when it was reviewed, and the result of the review.

    When: How often this evaluation is done is the issue. The standard says ongoing. The timing may be as different as the process, depending on the needs of your facility. However, it is a best practice to compile OPPE reports twice per year so that there are four reports to review in a two year reappointment cycle.

    Alright, all you need to do now is put all of this in a plan, present it to your medical executive committee as a positive step toward excellence, get their approval and then move on to the next project. Be sure to let the rest of us know what is or isn’t working for your facility so we can all learn to master OPPE.

    Remember, those who are afraid to ask are afraid to learn.

    All the best,

    Anne R. Buss, CPMSM, CPCS



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