Kendall L. Stewart, MD, MBA, DFAPA August 17, 2009 Physician Peer Review1,2,3 A Practical Approach to the Focused Professional Practice Evaluation (FPPE) Process A Presentation for Pomerene Hospital Physician Leaders Kendall L. Stewart, MD, MBA, DFAPA August 17, 2009 1I hope to offer a practical perspective you can use to design and deploy your own effective peer review process. 2I’m going to describe our process as an example; I’m certain you can learn from our mistakes. 3I have a lot of peer review scars to show from my years of involvement in this process.

Why do exceptional physicians insist on participating in a vigorous peer review process? We want our patients to receive exceptional care. We aspire to be lifelong learners. During our long years of training, we have learned that experience-based learning is the best kind. The people, payers and regulators we serve expect us to do it. The Joint Commission requires us to do it.1 After mastering the information in this presentation, you will be able to Give three reasons why exceptional physicians participate in a peer review process, Identify three things that might launch the peer review process. Explain the purpose and intent of the Joint Commission’s Focused Professional Practice Evaluation (FPPE) process. (This is the new term for Peer Review.) Design the key steps in your own FPPE (Peer Review) process. 1I hired a vocal physician critic as our internal Joint Commission consultant.

What is a Focused Professional Practice Evaluation1 (FPPE)? Allows the medical staff to focus an evaluation on a specific aspect of a practitioner’s performance Used in two circumstances: Additional information or a period of evaluation is needed to confirm competence Questions arise during the course of the Ongoing Professional Practice Evaluation (OPPE) 1This was formerly known as peer review.

What is the intent of a Focused Professional Practice Evaluation (FPPE)?1 There are two categories of issues that will trigger the FPPE process: All new practitioners and all existing practitioners who receive new privileges must undergo this process. (There are no exceptions.) All concerns that arise in the OPPE process or any other “peer review” will trigger this process. The components of the FPPE process include (but are not limited to): Criteria for conducting performance evaluations Method for establishing the monitoring plan specific to the requested privilege Method to determining the duration of performance monitoring Circumstances under which monitoring by an external source is required The duration of the FPPE process need not be for 12 months. A peer review process that is based only on untoward outcomes will not meet the intent of this standard. The bottom line principles for the FPPE process are: The process must be defined The process must be consistently implemented as defined All new privileges (new applicants and new privileges for existing applicants) must be reviewed in accordance with the defined process 1The Joint Commission Website

What triggers the SOMC Department of Medicine FPPE (peer review) process?1 Readmissions with related diagnoses within 72 hours Unplanned transfers to the ICU within 24 hours of admission Unexpected mortalities or adverse outcomes Cases referred from Risk Management Cases referred at the request of other committees, physicians or staff 1Naturally you will want to identify your own credible triggers.

What is the SOMC FPPE process for performance issues?1 Something triggers a review. Nurse reviewer summarizes the case. Peer review committee screens the case. Improvement plan monitored. Improvement documented. Documentation filed. Physician input obtained. Yes Concern? No Opportunity identified. Improvement plan detailed. Yes Concern? No No further action is needed. Documentation is filed appropriately. 1The SOMC Peer Review Process, Revised, May 2008

We must be willing confront each other. What natural barriers to effective peer review must exceptional physicians overcome? We must be willing confront each other. We must invite and accept constructive feedback. We must pursue evidence-based, protocol-driven medical practices. We must invest the necessary time, energy and study. We must acknowledge our own shortcomings. We must modify our behaviors as a result of what we learn.1 1I received some critical feedback from a nursing aide about my patients’ satisfaction with the food.

In summary, what elements must be present to create an effective peer review process? A sustained organizational commitment One or more physician champions A simple, understandable process A respected, detail-oriented infrastructure expert A fair, consistent, transparent process. A passionate commitment to not waste physicians’ time An appeals process that makes sense Strong protection from discovery and liability1 An ongoing professional practice evaluation process (OPPE) that is fair and transparent Good food 1The Ohio statutes are among the strongest in the nation.

Where can you learn more?1 Learn more about The Joint Commission’s Focused Professional Practice Evaluation (FPPE) at http://www.jointcommission.org/AccreditationPrograms/Hospitals/Standards/09_FAQs/MS/Focused_Professional_Practice.htm. Learn more about The Joint Commission’s Ongoing Professional Practice Evaluation (OPPE) at http://www.jointcommission.org/AccreditationPrograms/CriticalAccessHospitals/Standards/09_FAQs/MS/Ongoing_Professional_Practice_Evaluation.htm. Review a helpful overview from The Greeley Company at http://www.greeley.com/pdf/TGC-MC57458_PeerReview-0607.pdf. Read the interesting Wikipedia entry on Medical Peer Review at http://en.wikipedia.org/wiki/Medical_peer_review. 1Please visit www.KendallLStewartMD.com to download related white papers and presentations.

How can you contact me?1 Kendall L. Stewart, M.D. VPMA and Chief Medical Officer Southern Ohio Medical Center President & CEO The SOMC Medical Care Foundation, Inc. 1805 27th Street Waller Building Suite B01 Portsmouth, Ohio 45662 740.356.8153 StewartK@somc.org KendallLStewartMD@yahoo.com www.somc.org www.KendallLStewartMD.com 1Speaking and consultation fees benefit the SOMC Endowment Fund.

 Safety  Quality  Service  Relationships  Performance  Are there other questions? www.somc.org  Safety  Quality  Service  Relationships  Performance 