National Credentialing Forum Research Study Results: Physician Competency Assessment and OPPE Mark A. Smith, MD, MBA, FACS Clinical Assistant Professor of Surgery University of California, Irvine March 2, 2017 © Mark Allan Smith 2016

Disclosures Consulting agreement- Morrisey/Healthstream Stock owned- Immunomedics

Method Survey conducted using Survey Monkey Sent using Definitive Healthcare database to all identified Physician Executives (CMO, CIO, etc.), Medical Staff Professionals, Quality Professionals Submissions were anonymous although respondents were given the opportunity to receive the raw data results

Explanation of Data Total Number of Responses- 465 Not all questions had a response; therefore, there is a varying response rate for a given question- reported as total known Unknown is the number of unanswered questions Percent for Total Known and Unknown given matched against 465 Percent for answers given matched against Total Known for that question © Mark Allan Smith 2016

Survey Respondent’s Position NUMBER PERCENT Chief of Staff 5 1.5% CMO 46 14.2% Department/Division/Service Line Chair 16 4.9% MSP 126 38.9% Other 75 23.2% Quality Director 56 17.3% Total Known 324 69.7% Unknown 141 30.3%

Survey Organization Types NUMBER PERCENT Health System 36 11.1% Hospital Regional (Tertiary referral), Teaching 26 8.0% Hospital, Academic 40 12.3% Hospital, Community, Non-teaching 120 37.0% Hospital, Community, Teaching 62 19.1% Hospital, Regional (Tertiary referral), Non-teaching 12 3.7% Medical Group 2 0.6% Other Total Known 324 69.7% Unknown 141 30.3% © Mark Allan Smith 2016

© Mark Allan Smith 2016

Survey Organization’s Bed Size NUMBER PERCENT Less than 100 beds 78 24.1% 100- 250 beds 73 22.6% 250- 500 beds 85 26.3% 500- 1000 beds Greater than 1000 beds 9 2.8% Total Known 323 69.5% Unknown 142 30.5% © Mark Allan Smith 2016

© Mark Allan Smith 2016

Number of Credentialed Physicians PERCENT Less than 50 19 6.5% 50- 100 16 5.4% 100- 250 55 18.7% 250- 500 76 25.9% 500- 1000 79 26.9% 1000- 2500 41 13.9% Greater than 2500 8 2.7% Total Known 294 63.2% Unknown 171 36.8% © Mark Allan Smith 2016

© Mark Allan Smith 2016

Number of Credentialed APPs PERCENT Less than 50 88 31.0% 50- 100 74 26.1% 100- 250 67 23.6% 250- 500 43 15.1% 500- 1000 11 3.9% 1000- 2500 0.0% Greater than 2500 1 0.4% Total Known 284 61.1% Unknown 181 38.9% © Mark Allan Smith 2016

© Mark Allan Smith 2016

Total Number of Credentialed Practitioners PERCENT Less than 50 15 5.2% 50- 100 12 4.2% 100- 250 47 16.4% 250- 500 67 23.4% 500- 1000 66 23.1% 1000- 2500 Greater than 2500 13 4.5% Total Known 286 61.5% Unknown 179 38.5% © Mark Allan Smith 2016

© Mark Allan Smith 2016

Survey Organization- Public or Private? NUMBER PERCENT Public 158 50.1% Private 157 49.8% Total 315 67.7% Not Specified 150 32.3% © Mark Allan Smith 2016

© Mark Allan Smith 2016

Survey Organization- For Profit or Not-For-Profit? NUMBER PERCENT For Profit 49 15.0% Not For Profit 278 85.0% Total 327 70.3% Not Specified 138 29.7%

Frequency of OPPE Reviews NUMBER PERCENT Every 6 months 269 58.9% Every 8 months 103 22.5% Other 85 18.6% Total 457 98.3% Unknown 8 1.7%

Method of Collecting OPPE Data NUMBER PERCENT Completely manual 54 11.8% Mostly manual, some automatic 158 34.5% Equal manual and automatic 97 21.2% Mostly automatic, some manual 130 28.4% Completely automatic 19 4.1% Total 458 98.5% Unknown 7 1.5%

Entity That Collects OPPE Data NUMBER PERCENT Medical Staff 155 33.9% Quality Department 228 49.9% Medical Record Department 5 1.1% IT Department 7 1.5% Other 62 13.6% Total 457 98.3% Unknown 8 1.7%

Who Reviews and Signs Off OPPE Reports? NUMBER PERCENT CMO/VPMA 25 5.4% Credentials Committee 29 6.3% Department Chair 257 55.7% Division Chair 31 6.7% MEC 34 7.4% Peer Review Committee 21 4.6% Service Line Chair 19 4.1% Other 45 9.8% Total 461 99.1% Unknown 4 0.9%

How is the OPPE Review Documented? NUMBER PERCENT Batched Review/Sign off 116 25.3% Electronic log of reviews 31 6.8% Individual Report Sign off 294 64.2% Other 17 3.7% Total 458 98.5% Unknown 7 1.5%

How are the OPPE Reports Stored? NUMBER PERCENT Hard Copy 125 27.1% Electronically 166 35.9% Both 169 36.6% Other 2 0.4% Total 462 99.4% Unknown 3 0.6%

Who Manages Deficient Performance Identified by OPPE? NUMBER PERCENT CMO/VPMA 31 6.7% Credentials Committee 39 8.4% Department Chair 202 43.7% Division Chair 32 6.9% MEC 61 13.2% Peer Review Committee 58 12.6% Service Line Chair 13 2.8% Other 26 5.6% Total 462 99.4% Unknown 3 0.6%

OPPE Deficiency Reported by a Regulatory Body Within 3 Years? NUMBER PERCENT Yes 116 25.3% No 343 74.7% Total 459 98.7% Unknown 6 1.3%

Identified Patient Care Improvement Through OPPE NUMBER PERCENT Yes 107 23.7% No 158 35.0% Not Sure 187 41.4% Total 452 97.2% Unknown 13 2.8%

Is Dedicated Software Used for OPPE? NUMBER PERCENT Yes 161 35.1% No 298 64.9% Total 459 98.7% Unknown 6 1.3%

Does Your Organization Use Internal Software for Data Analytics? NUMBER PERCENT Yes 158 38.5% No 252 61.5% Total 410 88.2% Unknown 55 11.8%

Does Your Organization Use External Software for Data Analytics? NUMBER PERCENT Yes 189 44.4% No 237 55.6% Total 426 91.6% Unknown 39 8.4%

Do practitioners review their own OPPE reports? NUMBER PERCENT Yes 371 81.5% No 84 18.5% Total 455 97.8% Unknown 10 2.2%

IF yes, how is the OPPE report delivered to the practitioner? NUMBER PERCENT Hard Copy Delivered 211 56.9% Electronic Copy Delivered 107 28.8% Other 99 26.7% Total 371

Who Chooses the OPPE Metrics? NUMBER PERCENT Board of Directors/CEO 30 6.5% CMO/VPMA 88 18.9% Quality 190 40.9% Medical Staff 237 51.0% Clinical Departments/Chairs 199 42.8% Clinical Service Lines/Directors 41 8.8% Credentials Committee 82 17.6% Medical Staff Services 91 19.6% Peer Review Committee 86 18.5% Regulatory Agencies 26 5.6% Other 21 4.5% Total 465

Are your performance indicators classified using a model? NUMBER PERCENT Yes 161 35.9% No 288 64.1% Total 449 96.6% Unknown 16 3.4%

If yes, what model is used? NUMBER PERCENT Structure, Process, Outcome, Volume 60 33.0% Review, Rule, Rate, Volume 78 42.9% Other 44 24.2% Total 182

Does your organization use benchmarks for performance indicators? NUMBER PERCENT Yes 301 67.6% No 144 32.4% Total 445 95.7% Unknown 20 4.3%

Does your organization use statistical process control? NUMBER PERCENT Yes 167 38.3% No 269 61.7% Total 436 93.8% Unknown 29 6.2%