Focused and Ongoing

Professional Practice Evaluations

Indiana Association for Healthcare Quality

Annual Educational Conference
April 30, 2009

Betty Brown, MBA, MSN, RN, CPHQ, FNAHQ

Chief Quality/Patient Safety Officer
Parkview Health – Northeast Indiana
 Objectives

 Define FPPE/OPPE.
 Determine the scope of the professional
practice evaluations.
 Understand the requirements as expected by
the Joint Commission surveyors.
 Review evaluation presentation tools.

4/30/2009 InAHQ
FPPE/OPPE 2
DEFINITION
 What is FPPE/OPPE?

FPPE and OPPE are professional practice

evaluations which are determined by your
medical staff for confirming competency
(focused) and for more routine monitoring of
all practitioners in a specialty (ongoing).

4/30/2009 InAHQ
FPPE/OPPE 4
 TJC Medical Staff Standards

 MS.08.01.01 Focused Professional Practice

Evaluation

The organized medical staff defines the circumstances

requiring monitoring and evaluation of a
practitioner’s professional performance.

4/30/2009 InAHQ
FPPE/OPPE 5
 When should FPPE occur?

 Initial privileging
 New privileging
 Triggers
 Unhappy trend
 Incident undetermined

4/30/2009 InAHQ
FPPE/OPPE 6
 And

 MS.08.01.03 Ongoing Professional Practice

Evaluation

Ongoing professional practice evaluation information

is factored into the decision to maintain existing
privilege(s), to revise existing privilege(s), or to
revoke an existing privilege prior to or at the time
of renewal.
4/30/2009 InAHQ
FPPE/OPPE 7
 What is the frequency of
OPPE?
 Every six (with leeway to nine months),
every member of the medical staff must be
evaluated for performance and then every 2
years for reappointment
Six months – six months – six months and then
reappointment time

4/30/2009 InAHQ
FPPE/OPPE 8
SCOPE
 Who must be privileged?

Any licensed, independent practitioner who

provides care, treatment or services must be
privileged to provide these services.

4/30/2009 InAHQ
FPPE/OPPE 10
 What about advanced practice?

 Physician Assistants and Advance Nurses –

if credentialed, they must have focused and
ongoing evaluations.

4/30/2009 InAHQ
FPPE/OPPE 11
 Who grants privileges?

 Medical staff recommends privileging

 Governance grants privileges

4/30/2009 InAHQ
FPPE/OPPE 12
 Temporary privileges – 2 types

 Temporary
 “I am an applicant and I want to work.”
 Application must be complete
 May then grant privileges for 120 days
 Locums
 Fits under urgent patient care needs
 Verification of license, competence, NPDB, insurance
 Not limited to 120 days

4/30/2009 InAHQ
FPPE/OPPE 13
 Core Privileging

 Defines a group of privileges defined for the

professional specialty
 May confer competency for the rest of the
areas, i.e., left hernia repair confers right
hernia repair
 If you have core privileging, outcomes can
be drawn from the core. Selecting a few
confers competency for the group.
4/30/2009 InAHQ
FPPE/OPPE 14
 Some clarifications…

 Labs are not considered care, treatment or

services.
 Imaging is not considered care, treatment or
services unless contrast is used.
 Outpatient pulmonary function test
(albuterol) must have privileges.

4/30/2009 InAHQ
FPPE/OPPE 15
 What about accepting external
performance evaluations?
 External performance data can not be used
for your privileging for credentialing
purposes
 The Joint Commission is surveying CMS
standards deemed. CMS does not allow
privileging by proxy.

4/30/2009 InAHQ
FPPE/OPPE 16
REQUIREMENTS
 FPPE may include…

 Chart review
 Monitoring clinical practice patterns
 Simulation
 Proctoring/direct observation
 External peer review
 Discussion with other individuals involved in the
care of each patient.
 Direct observation

4/30/2009 InAHQ
FPPE/OPPE 18
 OPPE may include…

 Review of operative procedures

 Pattern of blood and pharmaceutical usage
 Requests of tests and procedures
 Length of stay patterns
 Morbidity and mortality data
 Practitioner’s use of consultants
 Other relevant criteria as determined
4/30/2009 InAHQ
FPPE/OPPE 19
 Consider

 Some data applies to all

 There needs to be consideration of specific data for
different types of practitioners
 Requirement is for data on actual performance – the
good with the issues
 Pre-defined screening criteria is not sufficient to
meet the requirement for performance data on every
practitioner
4/30/2009 InAHQ
FPPE/OPPE 20
 Medical Staff Performance

 CMS requires that medical staff plans be

defined in writing.
 Performance Indicators must be established
that are appropriate to each physician.
 Components to be included are found in
 MS.05.01.01
 MS.05.01.03
4/30/2009 InAHQ
FPPE/OPPE 21
 Steps

1. Define indicators
2. Obtain department/leadership approval
3. Institute data inventory and method for data
collection
4. Establish reporting chain of command
5. Write the plan
6. Define focused evaluation
4/30/2009 InAHQ
FPPE/OPPE 22
 Steps continued

7. Define ongoing evaluation

8. Establish focused evaluation plans
9. Establish statistical analysis

4/30/2009 InAHQ
FPPE/OPPE 23
 The organized Medical Staff

 Determines whether to recommend to

continue, limit or revoke any existing
privileges at the time information is
analyzed.
 Based on analysis, several possible actions
could occur…

4/30/2009 InAHQ
FPPE/OPPE 24
 Determines practitioner is within desired
expectations – no further action
 Determine that issue exists requiring focused
review
 Revoke the privilege because it is not longer
required

4/30/2009 InAHQ
FPPE/OPPE 25
 Suspend the privilege which requires notifying the
practitioner that he/she will need to request
reactivation if he/she desires to reactivate
 Determine if zero performance triggers a focused
review
 Determine if the privilege should be continued
because the organization’s mission is to be able to
provide the privilege to its patients.

4/30/2009 InAHQ
FPPE/OPPE 26
 Challenges

Data collection is mostly manual

Increased performance measurement FTEs
Expertise in statistical analysis needed

4/30/2009 InAHQ
FPPE/OPPE 27
RESOURCES
 Questions…

4/30/2009 InAHQ
FPPE/OPPE 29