4/25/2017 Your Facility Name Focused and Ongoing Professional Practice Evaluation (F/OPPE) for Medical Staff & Allied Health Professionals Facility Name Last Update: _________ Revised

Professional Practice Evaluation is a Medical Staff-led initiative 4/25/2017 What is the Goal of Professional Practice Evaluation? Professional Practice Evaluation is a Medical Staff-led initiative to establish performance expectations and ensure that patient care meets appropriate standards Facility Name Last Update: _________ Revised

Last Update: _________ 4/25/2017 Why F/OPPE? For the Safety of our Patients The Medical Staff Leadership and the Governing Board have approved this process to ensure physician competency and high quality care for our patients, and to ensure (your facility name) providers are the best they can be. Facility Name Last Update: _________ Revised

Last Update: _________ 4/25/2017 What is FPPE? FPPE is the acronym for Focused Professional Practice Evaluation and it is to validate competency at (your facility name) using the hospital’s resources, equipment, environment, staff, etc. FPPE occurs at initial appointment, a new privileges request, or if a question arises regarding current privileges. Facility Name Last Update: _________ 4 Revised 4

Last Update: _________ 4/25/2017 What is OPPE? OPPE is the acronym for Ongoing Professional Practice Evaluation. It is the ongoing review of your performance here at (your facility name), to validate your competency, and to identify professional practice trends. Again, using the hospital’s resources, equipment, environment, staff, etc. OPPE review is conducted in 8 month cycles, and in order to maintain privileges at (your facility name) the Medical Staff requires providers to complete 3 patient encounters every 8 months Facility Name Last Update: _________ 5 Revised 5

Professional Practice Evaluation 4/25/2017 Newly appointed physician / AHP or new privilege request Focused and Ongoing Professional Practice Evaluation Physician & AHP Ongoing Evaluation OPPE Cycle 3/ 3rd 8 month review OPPE Cycle 2/ 2nd 8 month review OPPE Cycle1/1st 8 month review FPPE first 3 months or # of cases specified, but not to exceed 6 months. Issue of Competency: When questions of competency arise regarding a provider’s current privileges. Peer Evaluation/Chart Review Credentials Committee Once the specified number of cases has been reviewed, FOR VERBAL PRESENTATION What is FPPE/OPPE? FPPE/OPPE is one process with 2 phases: The FPPE phase is called the Focused Professional Practice Evaluation and the OPPE phase is the Ongoing Professional Practice Evaluation. They are part of the Joint Commission regulations that require all licensed practitioners to be evaluated based on their ability to provide safe, high quality patient care. 2. The process evaluates the competency of licensed professionals through the collection, analysis, and reporting of quality data throughout the appointment and reappointment cycles. At Centennial, FPPE is complete within 6 months of privilege(s) granted. OPPEs are conducted in 8 month cycles. 3. The process begins when a provider is first appointed to the hospital. In the FPPE phase, There is an initial 3 month review of activity and if there is no activity a letter is sent to the new provider to remind them to utilize the services of Centennial. Then, at the 6 month FPPE evaluation, the results are presented to this committee for recommendation to maintain, revise, or revoke privileges and/or membership. The Vice-Chairs can recommend to continue to monitor performance during the next 8 months if there are no quality of patient care concerns. Also, at this point in the process the Vice-Chairs make the recommendation to continue to monitor for activity if there hasn’t been any and to maintain privileges. The Recommendations are sent through to the Credentials Committee, the MEC, and the Governing Board for Final Approval. THE FPPE Phase happens only once during the first 6 months unless a focused review is opened. 4. A focused Review is open when a provider requests a new privilege, or if there has been an adverse event, or complaints by a patient, family member or hospital staff about the provider. The results of the focused review is presented to the Peer Evaluation Chart Review Committee for discussion/recommendation/and action. 5. The OPPE phase, A provider will remain in the OPPE phase as long as he or she is part of the Medical Staff in good standing. Evaluations are completed every 8 months throughout the two year credentialing cycle. This allows for any potential problems or trends in performance, quality of care, or patient safety to be addressed and resolved early on instead of finding problems at the end of a two year reappointment cycle. The goal of OPPE is to continuously review all licensed practitioner files on a regular basis (every 8 months here at Centennial) to reduce the chance of a problem occurring and not being resolved in a timely manner. Medical Executive Committee Reappointed/ Privileges Granted/Maintained – Physician/ AHP Notified NOT Reappointed/ Privileges NOT Granted / Maintained – Physician/AHP Notified Governing Board Revised

Specialty Specific Indicators 4/25/2017 Specialty Specific Indicators Facility Name Last Update: _________ 7 Revised 7

Initially Granted “Core” Privileges (Focused Review) Triggers 4/25/2017 Department Specific Indicator Samples DEPARTMENT FPPE Initially Granted “Core” Privileges (Focused Review) Triggers OPPE Indicators Anesthesiology Review of 5 representative anesthesiology cases/charts, including adequacy of H&P, progress notes, consultation, and operative reports for EBM-SCIP: On-Time Prophylactic Antibiotic EBM-SCIP: Pts on BB Therapy Pre-Admin Received BB during Preoperative Unanticipated Dental Injury   Unexpected Re-intubation Failed Intubation Unexpected Transfer to ICU Due to Anesthesia Complication Facility Name Last Update: _________ 8 Revised 8

Last Update: _________ 4/25/2017 Analytics Application Source for severity adjusted analytics for OPPE Provides drill down access to case detail Self evaluation of patient care performance Resource for benchmarks and best practice data Care cost analysis to review utilization trends Facility Name Last Update: _________ 9 Revised 9

Last Update: _________ 4/25/2017 FPPE Documentation Complete the form provided to help us document your first 3 cases ______________________________________ Your Name (Please Print) Patient Name Date of Birth Medical Record Number Account Number Date of Service(s) Facility Name Last Update: _________ 10 Revised 10

Last Update: _________ 4/25/2017 Remember... 5 patient encounters in the first 3 months If you are a part of a group practice, please notify your scheduler to rotate you to (your facility name) until you acquire 3 patient encounters within the first 3 months. Facility Name Last Update: _________ 11 Revised 11

Last Update: _________ 4/25/2017 FPPE/OPPE Q & A Questions about FPPE or OPPE? Is there anyone who will have a problem with meeting 3 cases in the first 3 months for FPPE? Facility Name Last Update: _________ 12 Revised 12