Transcript MEDICAL STAFF CHAPTER HIGHLIGHTS

How to Avoid Being Cited for FPPE and OPPE
Processes During Your Next TJC Survey
Tuesday, April 16, 2013
John R. Rosing, MHA, FACHE
Vice President and Principal
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Speaker
John R. Rosing, MHA, FACHE
Vice President and Principal Patton
Healthcare Consulting
262-242-3631
[email protected]
www.pattonhc.com
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Learning Objectives
• Identify the FPPE and OPPE Elements of
Performance (EP) that are most troublesome
• Dissect the new FAQs on FPPE and OPPE
• Discuss strategies and best practices to
comply with the FPPE and OPPE EPs
• Learn how to create a meaningful and
efficient process for conducting FPPE and
OPPE on Advance Practice RNs and Physician
Assistants as applicable
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Focused Professional
Practice Evaluation (FPPE)
• MS.08.01.01, EP 5, A – The triggers that
indicate the need for performance monitoring
are clearly defined.
– Where will you point the surveyor to read these?
• EP 8, A, D, The measures employed to resolve
performance issues are clearly defined.
– Where will you point the surveyor?
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Ongoing Professional Practice
Evaluation (OPPE)
• MS.09.01.01, EP 1, A, D – The hospital
has a clearly defined process for
collecting, investigating and addressing
clinical practice patterns.
– Where will the surveyor be pointed to read?
• When did you start OPPE?
• How often do you produce the data?
• Who reviews the data?
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Hospital Clinical Staff
Medical Staff
Prior to New Standards
Prior to hire
• Interview
• Verification of license, training, experience
• Recommendations
Prior to appointment:
• Interview – not required
• Verification of license, training, experience
• Recommendations
Upon hire:
• Orientation
• Probationary period, during which there is a
determination of competence
Upon hire:
• Orientation – limited at best
• “Provisional status”
• No review until 1 or 2 years
Annually:
• Performance evaluation
• Review of skills
• Goals
Reappointment:
• Every two years
• Assumed to functioning well if there was no
bad news
• Little data, especially for non-admitters
Suspected performance problems
• Investigation
• Corrective action plan
• Termination
Suspected performance problems:
• Investigation
• Corrective action plan
• Termination
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Hospital Clinical Staff
Medical Staff
New Standards
Prior to hire:
• Interview
• Verification of license, training,
experience
• Recommendations
Prior to appointment:
• Interview – not required
• Verification of license, training,
experience
• Recommendations
Upon hire:
• Orientation
• Probationary period, during which there
is a determination of competence
Focused Professional Practice
Evaluation (FPPE):
• Required for all privileges
Annually:
• Performance evaluation
• Review of skills
• Goals
Ongoing Professional Practice
Evaluation (OPPE):
• More frequently than every 12 months
• Data driven using department
indicators
Suspected performance problems:
• Investigation
• Corrective action plan
• Termination
Focused Professional Practice
Evaluation Investigation (FPPE):
• Corrective action plan
• Limitation or revoking of privileges
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FPPE: Part of the Problem…
Words Matter and These are Confusing!
• EP 2 they say criteria; do they mean indicator?
• EP 3 bullet 1 they say criteria; do they mean circumstances?
• EP 5 they say trigger; do they mean special cause variation
or data point(s) above/below a threshold?
• EP 7 they say criteria; do they mean methods used?
• EP 8 & 9 they say measures employed; do they mean
actions taken?
• Be careful to understand how FPPE EP 1 differs from
Provisional Status or old-fashioned notion of Proctoring
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“Fine Line Between Criteria and Triggers”
FAQ January 2013
• Triggers are “single events” or “practice trends” that are
“obvious issues”
– E.g., “infection rates, sentinel events, perhaps complaints,
(and) other events that aren’t sentinel”
What????
• Criteria are “performance issues,” such as
o Any outlier issue identified from OPPE data collection
o A growing number of longer lengths of stay than other practitioners
o Small number of admissions or procedures over an extended period of time
that raise the concern of continued competence
o Returns to surgery
o Frequent or repeat readmission suggesting possibly poor or inadequate initial
management/treatment
o Patterns of unnecessary diagnostic testing/treatments
o Failure to follow approved clinical practice guidelines--may or may not indicate
care problems but why the variance
(and then oddly, the FAQ repeats the final three issues, apparently a “failure to edit properly” sentinel event)
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OK, Help Me Understand FPPE!
Focused professional practice evaluation is defined
as a time-limited period during which the
organization evaluates and determines a
practitioner’s professional performance of
privileges. FPPE will occur in all requests for new
privileges and when there are concerns regarding
the provision of safe, high quality care by a current
medical staff member, as recognized through the
peer review process.
LifePoint Hospitals, Brentwood TN
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FPPE – For New Privileges (EP 1) &
When A Cause for Concern is Spotted
(formerly called Peer Review, EPs 2-9)
• EP 1 is applied to all initially requested privileges
• EPs 2-9 also apply to this exercise/period
– (though they never stated this explicitly)
• EPs 2-9 also apply when OPPE has identified a cause
for concern; FPPE is then launched to evaluate if
more formal monitoring, investigation, or corrective
action is warranted
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OK, Help Me Understand FPPE!
•
•
FPPE is an information gathering phase, not yet an adverse action
EP 2 and EP 7 require that criteria be developed. Better to think of it as….
– EP 2 requires development of clinical indicators
– EP 7 requires a method to select the type of monitoring to be completed
•
EP 5 requires that triggers indicating the need for enhanced performance
monitoring (i.e., an additional level of scrutiny) be defined
– Triggers are single red flag incidents or evidence of a undesired practice
trends within a particular criteria/indicator
• E.g., elevated infection rates, delays in DX/TX, readmits, a significant SEA
or incident report on LIP, validated staff or patient complaints, significant
deviation or outlier from accepted norm, repeated failure to follow
policy, or single egregious disruptive behavior
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Example of FPPE EP 7
Method to Select a Type of
Monitoring to be Conducted
Correlate to These
Specialties
Observation/ Monitoring of Diagnostic
and Treatment Techniques
Surgery, OB/GYN, Emergency
department, hospitalists
Chart review
Internists, pediatricians
Outcome data
Endoscopy, cardiac caths
Over-reads
Imaging, pathology, some cardiology
privileges
Discussion with knowledgeable staff
Any department
Outside experts
When there is no local peer or when
there is a conflict
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FPPE Indicator Examples
Types of Data
• Hard Data – Process / Outcome Indicators
– Individual events or trends of noncompliance
with administrative or clinical norms
• Timeliness, completeness, legibility, pertinence, dating,
timing of clinical record entries, complete medication
orders
• LOS, Readmission, Core Measures
• Mortality and Morbidity
• Surgical Complications
• Perception Data
– Peer, supervisor, patient feedback
• e.g., team player, good technical skills, good
communicator, no disruptive behavior
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OK, Help Me Understand FPPE!
• EP 8 & 9 the measures (i.e., actions) taken to resolve
performance issues are clearly defined and
consistently implemented.
– Here I recommend you simply refer to the provisions within
the investigation, corrective action, hearing and appeal
section of medical staff bylaws. (E.g., education, counseling,
mentoring. impairment program, remediation program,
suspension, revocation of membership and/or privileges )
• If indicated, define the method for establishing a
monitoring plan including the roles of the review
committee, department chair, and MEC
– Again, make reference to the investigation, corrective
action, hearing and appeal section medical staff bylaws
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FPPE EPs 3 and 4: Clearly Define the Process
to Include These Elements; Apply Consistently
• Criteria (circumstances?) for performance monitoring
– (Consider the LifePoint definition)
• Method for establishing monitoring plan specific to
the requested privilege
– (Consider the Table shown for EP 7)
• Method for determining duration
– Time period for high volume, number/stats for low volume
• Circumstances warranting external review
– Conflict of interest, lack of internal expert, ambiguity, etc.
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OPPE – More Straightforward
(So says me!)
• Routine monitoring of current competency
• Quality must be defined in a measurable way
– What is it you do? (dimensions of performance)
– When what you do is done well, what does that
look like? (benchmarks, targets)
– Do you look like that? (outcomes)
• Feedback is provided whether answered
“yes” or “no,” and over time, the norm of
performance for the individual and cohort
group improves.
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OPPE – Types of Data
• Hard Data – Process / Outcome Indicators
– Individual events or trends of noncompliance
with administrative or clinical norms
• e.g., timeliness, completeness, legibility, pertinence, dating,
timing of clinical record entries, complete medication orders
• LOS, Readmission, Core Measures
• Mortality and Morbidity
• Surgical Complications
• Perception Data
– Peer, supervisor, patient feedback
• e.g., team player, good hand hygiene, good
technical skills, good communicator
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OPPE: Sources of Information
• Physician profiles (besides the departmental
indicators, they should include volume data,
generic indicators and utilization data)
• Cases that went to peer review
• Colleague feedback
• Knowledgeable hospital staff (unit managers,
QI/Risk management staff, administration)
• Observation and personal interaction
• Complaints and malpractice suits
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OPPE: Bottom Line
• Apply to each physician/LIP prior to reappointment
• Departments determine the type of data, approved by MS
• For low volume renewals use peer recommendations that
include the 6 general competencies
– Upstream and Downstream from the applicant
• Report negative/outlier and good performance data
• Define process to include who reviews the data/how often
• Data informs decision to renew, limit or revoke privileges
• Also applies to AHP with privileges (PA and APNP)
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The 6 General Competencies
1. Patient care.
2. Medical and clinical knowledge
3. Practice-based learning and improvement
4. Interpersonal and communication skills
5. Professionalism
6. Systems-based practice
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FPPE and OPPE
• Are applicable to mid-level physician
assistants and advance practice nurse
practitioners depending on their
scope of practice in your state and in
your hospital.
• If APRN/PA provide “medical level
services” (a CMS term – DX and TX
decisions) then FPPE and OPPE apply.
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What should advanced practice professional competency assessments include?
The Joint Commission requires organizations to determine competence through a defined process for
every practitioner who provides care in the facility. When it comes to advanced practice professionals
(APP) who are credentialed and privileged through the medical staff process, Joint Commission
standards require the medical staff office to evaluate competency in a similar manner to physicians.
In addition to evaluating the various elements of the job description, this overall performance review
should include information that indicates that the:






APP has sound clinical skills
APP has good judgment
APP has demonstrated overall adequate professional performance
Physician understands the APP is working under his or her direct supervision
Supervising physician’s insurance policy provides coverage for the acts of the APP
Physician retains the overall responsibility for all the actions of his or her APP
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OPPE & FPPE – In Summary
Documents Reviewed by Surveyors
•
Focused Professional Practice Evaluation – initial
– Who will be conducting the review?
• Department chair or his/her delegate; MEC; Credentials Committee
– What are the criteria (indicators) used per specialty?
– What method are used?
• Periodic chart review
• Direct observation
• Monitoring of diagnostic and treatment techniques
• Discussion with other individuals involved in the care of each patient
including consulting physicians, assistants at surgery, nursing, and
administrative personnel
– Duration is addressed?
• May be individualized. Someone with 10 years experience may
require less than someone directly from residency
• Should cover the scope of privileges, though similar privileges may
lumped together
– Circumstances when an external expert required are defined?
– Documentation that the review occurred is in the file?
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OPPE & FPPE
Documents Reviewed by Surveyors
•
Focused Professional Practice Evaluation – Stemming from OPPE
– What are the triggers?
• Single incident
• Evidence of a clinical practice trend
– Who decides that an investigation is needed?
– Who will be conducting the review?
• Department chair or his/her delegate; MEC; Credentials Committee
– Method to be used is defined?
• Periodic chart review
• Direct observation
• Monitoring of diagnostic and treatment techniques
• Discussion with other individuals involved in the care of each patient
including consulting physicians, assistants at surgery, nursing, and
administrative personnel
– Duration is defined?
– Conclusions are documented and in the file?
• No action; education and further monitoring; revoking or limiting privileges
– Circumstances when an external expert required are defined?
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OPPE & FPPE
Documents Reviewed by Surveyors
• Policy and procedures, including definition of terms,
OPPE, FPPE initial, FPPE stemming from OPPE.
• Ongoing Professional Practice Evaluation:
– How is the information displayed? Most organizations are creating
–
–
–
–
physician profiles, using both volume, generic and department
specific indicators
Who is responsible? Usually the department chair or section chief.
When is the review documented? Every six months? Eight months?
(must be more often than 12 months)
What is documented? That the review occurred and that the
practitioner is performing well or that an investigation is needed
Is the data shared with the LIP???? (Interesting question!)
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Additional Resources
Life Point Hospitals Toolkit
http://www.nahq.org/uploads/apps/files/OPPE-FPPE_Toolkit.pdf
FPPE and OPPE “BoosterPak” may be found
on your Joint Commission Extranet site
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Additional Medical Staff Issues
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Telemedicine MS.13.01.01 - 3 Options
1. Originating site fully credentials and privileges the LIP.
2. Originating site privileges the LIP using the credentialing
information from a TJC accredited organization. The LIP
needs a license in the originating hospital’s state.
3. Originating site uses the credentialing and privileging
decision of the distant site if:
–
–
–
–
The distant site is TJC accredited
The LIP has the privilege(s) at the distant site
The distant site must share the full list of LIP privileges
The originating site collects FPPE/OPPE data and shares with
distant site (including adverse outcomes and complaints)
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Telemedicine LD.04.03.09
• If either Option 2 or 3 is chosen, there must be a
written agreement and EP 4 and 23 apply
– EP 4 Leaders monitor performance expectations
– EP 23 the agreement must
•
•
•
•
Label the distant site as a contractor
Specify that distant site will follow MS.06.01.01 – 06.01.13
Specify that distant site complies with CMS CoP
Note that originating site governing body grants privileges
based on originating site medical staff recommendation based
on information provided by the distant site
• Also, the medical staff bylaws must include a provision
permitting such reliance on the distant site.
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HISTORY AND PHYSICAL
• MS.03.01.01, EP 6, A,D – “The organized
medical staff specifies the minimal content of
medical histories and physicals, which may
vary by setting, level of care, tx and services”.
• Problem: A long form, short form or “ad hoc”
form that doesn’t meet your requirements
• CMS now prohibits anything but a
“comprehensive H&P” for ASC;
– Same for Hospitals????
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HISTORY AND PHYSICAL
• EP 7, A – “The medical staff monitors the
quality of H+P’s”.
• Surveyors score failure to obtain within 24
hours or prior to surgery or missing update
prior to surgery, then look for actions taken by
MEC to improve.
• If quality data indicates that indeed sometimes
there are performance gaps, what do the
minutes show for actions?
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Sample H&P Bylaw Language
MS.01.01.01 EP 3, EP 16
A medical history and physical examination be completed and documented for each
patient no more than 30 days before or 24 hours after admission or registration, but
prior to surgery or a procedure requiring anesthesia services. The medical history and
physical examination must be completed and documented by a physician (as defined in
section 1861(r) of the Act), an oromaxillofacial surgeon, or other qualified licensed
individual in accordance with State law and hospital policy.
An updated examination of the patient, including any changes in the patient's condition,
be completed and documented within 24 hours after admission or registration, but prior
to surgery or a procedure requiring anesthesia services, when the medical history and
physical examination are completed within 30 days before admission or registration. The
updated examination of the patient, including any changes in the patient's condition,
must be completed and documented by a physician (as defined in section 1861(r) of the
Act), an oromaxillofacial surgeon, or other qualified licensed individual in accordance
with State law and hospital policy.
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MEDICAL STAFF ROLE IN PI
• MS.05.01.01 – The medical staff is actively
involved in the measurement, assessment,
and improvement of the following:
– Medical assessment and tx, use of medications,
use of blood and components, operative reports
and procedures, appropriateness of clinical
practice patterns, significant departures from
established patterns of practice, the use of criteria
developed for autopsies.
• Is there a routine schedule, standing agenda
items, or other documentation that can be
pointed to in the last 12 months?
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TEMPORARY PRIVILEGES
• MS.06.01.13, EP 1, A – Temporary privileges
are granted to meet an important patient care
need, or
• EP 3, A – while awaiting MEC/Board review.
• EP 6, A – Temporary privileges are granted for
no more than 120 days
• Not used when we are behind schedule
• Not used for reappointment
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QUESTIONS?
[email protected]
262-242-3631
Please visit and bookmark www.pattonhc.com
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