1. Ongoing Professional Practice Evaluation Joel T. Patterson, MD University of Texas Medical Branch

2. Ongoing Professional Practice Evaluation (OPPE) Joint Commission requirement in place since 2008 Requires hospitals to document data collection on credentialed staff on an ongoing basis rather then at the two year reappointment process Allows hospitals to take steps to improve performance on a more timely basis

3. History of the Joint Commission Components of OPPE UTMB system of data collection Concerns about the future Overview

4. Ernest A. Codman, M.D. “end results system” Morbidity and mortality Kicked off staff at MGH End Result Hospital

5. Joint Commission 1913American College of Surgeons 1917Minimum Standards for Hospitals »89/692 passed 19503,200 hospitals achieve approval 1951American College of Physicians, American Hospital Association, American Medical Association, and Canadian Medical Association join with the ACS to form the Joint Commission on Accreditation of Hospitals (JCAH)

6. Joint Commission 1965SSA Act of 1965: hospitals accredited by JCAH are “deemed” to be in compliance with conditions for participation 1987JCAHO formed, publishes “Agenda for Change” 1990’ssentinel event, pain assessment, performance measures

7. Joint Commission 2000’sNational Patient Safety Goals, Universal Protocol, stroke center certification, certification programs for lung reduction surgery, LVAD, and COPD, etc. 2006Joint Commission – “helping health care organizations help patients”

8. Joint Commission Hospitals Hospices Home care agencies Health care delivery networks Long term care facilities Ambulatory health care organizations Mental health services organizations

10. OPPE Clearly defined process that includes but is not limited to: 1. who is responsible for reviewing data 2.how often data are reviewed 3. process for using data to continue, limit, or revoke privileges 4. how data are to be incorporated into credentialing files

11. Data All practitioners, not just those with performance issues 1.chart review 2.direct observation 3.monitoring of diagnostic and treatment techniques 4.evaluation of practitioner by others involved in the care of the patient

12. Action Practitioner performing well, no further action warranted Focused evaluation Revoking the privilege because it is no longer required Suspending the privilege Zero performance should trigger a focused review whenever the practitioner performs the privilege Privilege continues because the organization mission is to be able to provide the privilege to its patients

13. Our Process at UTMB Activity –Inpatient discharges –Outpatient visits –Procedures Performance –Competencies –Not specifically mandated by Joint Commission

14. Performance Patient Carecore measures Medical KnowledgeCME PBLIQI participation Communicationpatient services Professionalismdocumentation SBPmedical records

15. Concerns Future clarification regarding more specific expectations How will data be used Inappropriate use of peer review protections Core credentialing Economic credentialing

16. Value Proposition VALUE = QUALITY/COST