Ongoing professional practice evaluations

OPPE will become effective on January 1, 2007. The Joint Commission is not prescriptive on what you must evaluate, nor are they delineating the frequency you have to conduct the monitoring. It is up to the individual institution what to monitor and how to do it, and may include: the review of operative or other clinical procedures performed, and their outcomes based on pertinent results; patterns of blood use; requests for tests and procedures; length of stay patterns; mortality rates; risk management data; and the practitioner's use of consultants, pharmaceuticals, and other treatment modalities.

Instead of a credentialing and privileging process that gathers subjective information for use at initial appointment and reappointment, OPPE pushes the industry towards a more objective and evidence based privileging process. More than likely you already have a variety of departments collecting individual data on physicians in your facility. However, education will be needed for:

-          Medical service professionals and medical staff leaders regarding where to obtain the data (such as the appropriate departments)

-          Those who possess the data (quality and clinical departments, for example) to explain why it is needed by the medical staff office and how to present it in a format that is effective for use in making credentialing and privileging decisions

The expectation is that hospitals use data to evaluate practitioners and, if necessary, intervene if there are issues that impact the provision of safe patient care.  If there is insufficient data upon which to make a decision regarding privileges, additional appropriate steps should be taken to determine if the practitioner is eligible, or to proctor for a period of time.

In summary, hospitals need make sure that data and information are gathered and used as the basis for the decision to continue, limit, or revoke practitioner specific clinical privileges.