Professional Performance Evaluation FPPE & OPPE Presented by John Pastrano, BBA, CPMSM, CPCS Washington Association of Medical Staff Services April 24, 2019

Privileging Historically… Verification of training Residency / Fellowship CME Credentialing Standards Numbers criteria Previous Chair/Faculty/Peer confirmation

Joint Commission 2007 FPPE Professional Practice Evaluation OPPE

JC Medical Staff Standards MS.08.01.01 Focused Professional Practice Evaluation The organized medical staff defines the circumstances requiring monitoring and evaluation of a practitioner’s professional performance.

…and JC Medical Staff Standards MS.08.01.03 Ongoing Professional Practice Evaluation Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing privilege prior to or at the time of renewal.

Joint Commission 2007 FPPE Professional Practice Evaluation OPPE

What is FPPE? Process whereby the organization evaluates the privilege-specific competence of the practitioner who does not have documented evidence of competently performing the requested privilege at the organization

Concept External performance data cannot be used for own privileging purposes Concept - CMS does not allow privileging by proxy Sharing Compromises Peer Protection

What is OPPE? Routine monitoring of current competency for current Medical Staff members

Isn’t this the same as Peer Review? The process by which a practitioner, or committee of practitioners, examines the work of a peer and determines whether the practitioner under review has met accepted standards of care in rendering medical services.

Components of Peer Review Focused Professional Practice Evaluation Ongoing Professional Practice Evaluation Individual Case Review Proctor / Consult

Individual Case Review The process outlined for peer review of a particular case identified with a potential quality of care issue.

Peer Review Peer - Any practitioner who possesses the same or similar knowledge and training in a medical specialty as the practitioner whose care is the subject of review.

Peer Review Examples of Peers: Emergency Medicine / Internal Med / Family Med Pediatrics / Family Practice General Surgery / Gynecology / Urology Orthopedics / Neurosurgery Pathology Radiology

Peer Review More Examples of Peers: Anesthesiology Dentist / Oral Surgeon Cardiology / Internal Medicine Interventional Cardiology Nurse Practitioner / PA – same or physician CRNA – same or physician

Scope of FPPE & OPPE Applies to all credentialed / privileged members of the Medical Staff and Allied Health Practitioners.

Scope of FPPE & OPPE Exception: No-volume providers with medical staff membership and without clinical privileges per Joint Commission clarification are exempt from the Ongoing Professional Performance Evaluation and Focused Professional Practice Evaluation requirements contained within this document.

Purpose of FPPE & OPPE To assure that the hospital, through the activities of its medical staff, assess the ongoing professional practice and competence of its medical staff, conducts professional practice evaluations, and uses the results of such assessments and evaluations to improve professional competence, practice, and the quality of patient care.

Purpose of FPPE & OPPE To define those circumstances in which an external review or focused review may be necessary. To address identified issues in an effective and consistent manner.

Purpose of FPPE & OPPE “Professional Practice Evaluation” is considered an element of the peer review process and the records and proceedings relating to this policy are confidential and privileged to the fullest extent permitted by applicable law.

Gather data as physician uses privileges FPPE…. Dept Chair reviews data and makes an informed decision re: continuing or concluding FPPE Gather data as physician uses privileges Analyze Data

Initiation of FPPE Upon initial appointment When a new privilege is requested by an existing practitioner When a question arises through the OPPE process, individual case review, or other peer review process regarding a currently privileged practitioner’s ability to provide safe, high-quality patient care

Initiation of FPPE Example: When a trigger is exceeded and preliminary review indicates a need for further evaluation.

Gather data related to questions or concerns FPPE based on concern…. MS leadership makes an informed decision re: continuing or removing privilege(s) Gather data related to questions or concerns Panel of peers reviews data to determine if variations in practice are acceptable/appropriate

What is Initiated? FPPE is not considered an investigation as defined in the Medical Staff Bylaws and is not subject to the bylaws provisions related to investigations. If FPPE results in an action plan to perform an investigation, the process identified in the Medical Staff Bylaws would be followed.

Timeframe for Collection & Reporting Must be time-limited, defined by: A specific period of time, and/or A specific volume (number of procedures/admissions)

Other FPPE considerations May take into account previous experience in determining the approach, extent, and time frame: Recent graduate from training program affiliated with the facility (data available) Recent graduate from a training program at another facility (data not available)

Other FPPE considerations May take into account previous experience in determining the approach, extent, and time frame: Practitioner with regular experience exercising the requested privilege of fewer than two years on another medical staff Regular experience exercising the requested privilege of more than five years at another medical staff

Other FPPE considerations Should begin with the first admission / procedure Should (optimally) be completed with 3 months, or a suitable period based upon volume Period may be extended as necessary but may not extend beyond the first biennial reappointment

FPPE Methods Chart review - concurrent and/or retrospective Simulation Discussion with the practitioner and/or other individuals involved in care Dependent AHPs – review or proctoring by the sponsoring physician Internal or external peer review

FPPE Methods Communicate with the Practitioner Cause for the focused monitoring Anticipated duration Specific mechanism by which monitoring will occur (i.e. chart review, proctoring, etc.)

Performance Monitoring Criteria & Triggers Develop monitoring criteria Include specific performance elements Include thresholds or triggers Approved by the medical staff department/committee, MEC

Triggers Single egregious case Evidence of a practice trend Exceeding a threshold established for OPPE Patient / staff complaints Non-compliance with Bylaws, R&R Elevated infection, mortality Elevated complication rates Failure to follow approved clinical practice guidelines Unprofessional behavior or disruptive conduct

Conclusion of FPPE Findings reviewed by MEC or Department/Chair Decision and recommendation Move forward with OPPE Extend period and/or scope of FPPE Develop performance improvement plan Limit or suspend privilege(s)

Conclusion of FPPE Practitioner should be notified of performance outcome in writing Findings & outcome of FPPE Specific actions that need to be taken by Practitioner to address any quality concerns, including follow-up If FPPE is complete or will continue (w/period) If complete – move to OPPE

Conclusion of FPPE Activity/volume insufficient to meet FPPE, Practitioner may: Voluntarily resign privilege(s) Submit request for extending FPPE period Submit evidence of sufficient volume from another local facility w/ external peer reference Chair/Department/Committee may discretionarily extend FPPE NOTE: Practitioner is not entitled to a hearing/procedural rights for voluntary relinquishment

Performance Improvement Plan Plan drafted by Department/Chair/Committee Presented to MEC for approval Practitioner offered opportunity to address Committee and respond to findings Methods to resolve issues clearly defined Education / CME Proctoring and/or mentoring Counseling Practitioner assistance program Suspension or revocation of privilege(s)

Performance Improvement Plan MEC approved PI Plan Dept Chair and/or COS meet w/ Practitioner Agree – sign written document Does not agree – forward to MEC for resolution

OPPE …. Departments define data for areas of competency Medical/Clinical Knowledge Departments define data for areas of competency Patient Care Data collected regularly and collated by individual physician to identify opportunities for improving performance Interpersonal Skills Practice-Based Learning Professionalism Systems-Based Practice

OPPE Timeline for collection and reporting All practitioners with clinical privileges Every 3 to 6 months (discretion) No less than every 9 months

OPPE Indicators for Review Type of data to be collected and related thresholds or triggers is determined by medical staff committees/departments & approved by MEC Indicators may changes as appropriate Reviewed annually Do not limit data collection to negative/outlier trending data – consider good performance data

OPPE Indicators for Review Department selects 3 to 5 specialty-specific indicators MEC selects general indicators applicable to all practitioners Consider using ACGME “General Competencies” Patient care Medical/clinical knowledge Practice-based learning and improvement Interpersonal and communication skills Professionalism Systems-based practice

OPPE Indicators for Review Threshold/triggers for performance must be defined for select indicators Triggers define unacceptable levels of performance – may trigger FPPE

OPPE Indicators for Review Triggers to consider Defined number of events occurring Defined number of adverse outcomes Elevated infection, mortality, complication rates Sentinel events Low admissions/procedures over extended time Increased LOS compared to peers Increased returns to surgery Frequent unanticipated readmits for same issue Patterns of unnecessary diagnostic testing Failure to follow approved practice guidelines “Examples of Performance Measures & Triggers”

OPPE Results & Reporting Data Data are analyzed and reported to determine whether to continue, limit, or revoke any privilege(s) Outcome of evaluation must be documented and maintained in the Practitioners quality file At Completion of review period, OPPE results (practitioner profile report) is communicated to Practitioner & filed in quality file

Practice Data ….. Mortality Resource use Readmissions Avg LOS Patient Care Mortality Resource use Readmissions Avg LOS Process Measures Medical Records Board Certification CME / Certification Peer Discussion Medical/Clinical Knowledge Practice-Based Learning Interpersonal Communication & Skill Professionalism System-Based Practice

Challenges to Implementation Identifying meaningful FPPE / OPPE Education & compliance of Medical Staff Most data collection is manual (FTE) Software / IT support Restructure & training of support staff Urgency of implementation

Steps toward change and conformance… Dept Chairs define FPPE / OPPE indicators Obtain MEC & Board approval Identify data collection methodology Create data inventory / statistical analysis / reporting tool Establish reporting chain of command Write practice evaluation policy / plans

External Review MEC/COS/Dept Chair/Board may request external peer review External Reviewer – Board Certified same specialty Circumstances Eligible reviewers unable to serve No qualified Practitioner on Staff to review Litigation risk NOTE: Practitioner may not require Hospital to obtain external review

Review Form Type of data to be collected and related thresholds or triggers is determined by medical staff committees/departments & approved by MEC Indicators may changes as appropriate Reviewed annually Do not limit data collection to negative/outlier trending data – consider good performance data

What about temporary privileges? Temporary – Applicant Application must be complete May grant temporary privileges up to 120 days FPPE applicable Temporary – Non-applicant / Locums Fits under urgent patient care needs Verification of license, competence, NPDB, insurance Temporary privileges to care for patient (non-applicant) or up to 15 days (Locums)

Professional Performance Evaluation FPPE and OPPE Professional Performance Evaluation

THANK YOU! Contact Information: John Pastrano, BBA, CPMSM, CPCS Southern Belles and Beau Speaker Bureau Email: John.Pastrano@tenethealth.com