1. 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

2. Disclosures Consulting agreement- Morrisey/Healthstream
Stock owned- Immunomedics

3. 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

4. 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

5. 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%

7. 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

8. © Mark Allan Smith 2016

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

10. © Mark Allan Smith 2016

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

12. © Mark Allan Smith 2016

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

14. © Mark Allan Smith 2016

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

16. © Mark Allan Smith 2016

17. 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

18. © Mark Allan Smith 2016

19. 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%

21. 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%

23. 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%

25. 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%

27. 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%

29. 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%

31. 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%

33. 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%

35. 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%

37. 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%

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

41. 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%

43. 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%

45. 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%

47. 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

49. 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

51. 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%

53. 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

55. 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%

57. 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%