1.0Scope

This Policy applies to the Medical Staff of the Hospital and affiliated clinics

2.0Purpose

2.1To ensure that the hospital, through the activities of its medical staff,(1) identifies professional practice trends that impact quality of care and patient safety by assessing the ongoing professional practice of individuals granted privileges and (2) when necessary, uses the results of such assessments, to perform focused professional practice evaluations (FPPE) and to assist medical staff members and APS in providing safe, high quality patient care.

3.0General policy

Scope

This policy addresses the ongoing evaluation of practitioners who are currently exercising privileges as either a member of the medical staff or as a LIP under the evaluation of the medical staff and includes focused evaluation of those practitioners that arise from concerns identified by the ongoing evaluation process.

Definitions:

Ongoing Professional Practice Evaluation(OPPE)- The routine, ongoing monitoring and evaluation of competency for medical staff members and APS.

Focused Professional Practice Evaluation(FPPE)- The establishment and confirmation of an individual practitioner’s current competency at the time when he/she requests new privileges, and is also used to evaluate and monitor concerns based on OPPE or other processes.

3.1Selection of Practitioner Performance Measures for OPPE

Practitioner performance measures will be selected that are appropriate to the practitioner’s specialty, are reflective of practitioner performance, and are attributable to individual practitioners whenever possible. These measures will utilize multiple sources of data described in the Medical Staff Indicator List. Whenever appropriate, the indicators should be linked to specific privileges or privilege groups.

3.1.1 The MEC has approved the professional and clinical indicators for which ongoing professional practice evaluation will be measured which may include, but are not limited to the following:

3.1.1.1Aggregate utilization data
3.1.1.2Patient Experience indicators with provider care
3.1.1.3Clinical Guideline adherence indicators
3.1.1.4Division or section specific clinical indicators
3.1.1.5Documentation related indicators
3.1.1.6Aggregate Clinical outcome data

3.2Thresholds for Focused Professional Practice Evaluation (FPPE)

If the results of Ongoing Professional Practice Evaluation indicate a potential significant issue with practitioner performance based on indicator data exceeding medical staff thresholds or targets,the Section Chief, Division Chief, Chair of Credentials Committee or Chair of Peer Review Committeemay initiate a FPPE to determine whether there is a problem with current competency for either specific privileges or for more global dimensions of performance. These potential issues may be the result of individual case review or data from rule or rate indicators.

3.3OPPE Report and Practitioner Performance Feedback Plan

The best approach to improve practitioner performance is to provide practitioners with data on their general competencies on a regular basis though a Practitioner Feedback Report (PFR). The same report will be used by medical staff leaders as the OPPE report for systematic measurement, evaluation and follow-up.

  1. OPPE reports will be generated more frequently than every 12 months, with an overall plan to be done every 9-11 months.
  2. Once established, the report will be distributed to Section Chiefs for all practitioners with privileges on the medical staff. The data will be kept confidential to the individual practitioner and appropriate medical staff leaders (i.e. Division Chiefs, Section Chiefs, Credentials Committee, MEC, and Medical Staff Officers).
  3. The OPPE report is to be used to identify improvement opportunitiesand is not considered definitive until further evaluation, including FPPEif appropriate, is used to understand differences in performance relative to expectations, and discussed with the practitioner involved. During this process of Collegial Intervention, the practitioner is not considered to be “under investigation” for the purposes of reporting requirements under the Healthcare Quality Improvement Act.
  4. Low volume providers- when the OPPE report has limited informationrelated to low activity, the Section Chief can determine if a request should be made to the low volume provider for quality related data from another organization that the provider has privileges at. In addition, the Chief may determine to continue privileges with the plan to concurrently review all admissions/procedures performed to ensure quality is being maintained. At the time of reappointment, when insufficient practitioner specific data is available, then peer references and recommendations can be used to assist in the determination.
  5. The report may contain indicators for feedback purposes only that will not be used in reappointment decisions (e.g. LOS). The MEC, with input from the Division and Section chiefs, Clinical Excellence Quality Safety Committee and the Credentials committee will determine which indicators are used for reappointment decisions.
  6. When indicators are added to the report over time, the medical staff should be informed with sufficient lead time prior to the use of any new indicators in credentialing and privileging decisions.

4.0OPPE/FPPE Procedure

4.1Responsibility for Indicator Data Evaluation of OPPE

The evaluation of OPPE data will be conducted on an ongoing basis by the appropriate Division or Section chiefs under the oversight of the Peer Review Committee based on either rate or rule indicators that exceed the defined thresholds.

4.2FPPE for Case Reviews

If the findings of the Peer Review Committee on an individual case review, or a series of case reviews, raises concerns regarding the need for practitioner improvement, the following procedure will be used for FPPE:

  • The Peer Review Committee Chair will communicate the potential practitioner’s improvement opportunities to the appropriate division and section chief.
  • The Division Chief, with the assistance of the Peer Review Committee Chair or designee, and if requested, the Section Chief, will determine if additional data is needed or if the current data indicates an improvement plan should be developed.
  • If additional data is needed, the Division Chief with the assistance of the quality staff will define the additional data study and submit it to the Chair of Peer Review for approval. This plan may include the need for an outside review of cases. Per MS Bylaws Article 5: outside peer review will be used when, in the judgment of the Medical Staff President, or President of CMMC, acting on behalf of the Medical Staff, there is not adequate expertise within the Hospital, there may be a conflict of interest, or in any other situation where the Medical Staff President or President of CMMC decides that outside peer review would be in the best interests of the safe and effective operations of the Hospital.
  • If an improvement plan is required, it will be developed and monitored as described below.

4.3Routine OPPE Reporting and Follow-up

4.3.1Practitioners may review their personalized OPPE report. Results are open for 30 day review/comment period. No response after thirty days is considered acceptance.

4.3.2If Division Chief or Section Chief determines that a practitioner has outliers that warrant further review, they will communicate with the practitioner about the OPPE report and document the outcomes of the conversation. The intent of the communication is to review the OPPE report and to determine if additional information is needed to explain the variance.

4.3.3Chiefs will review the OPPE report within 30 days of distribution andsign off on a recommendation to either (1) continue privileges unchanged, (2) determine provider no longer needs privileges usually related to volume of activity, (3) recommend collegial intervention and/or FPPE process be started to address any potential concerns

4.3.4Improvement Plan Accountability

  • If an improvement plan is needed, the Division Chief or Section Chief, with the assistance of the Peer Review Committee Chair and or VP Quality & Patient Experience, will develop the improvement plan.
  • The Peer Review Committee Chair or VP Quality & Patient Experience will track responses for requests for improvement and review the improvement plan for adequacy.
  • The support staff will track results and report regularly on the status to the Peer Review Committee Chair and VP Quality & Patient Experience
  • The Peer Review Committee chair or VP Quality & Patient Experience will report to the MEC regarding actions taken to improve care and when any cases, where action was not taken when requested, or actions are perceived to be inadequate.

4.3.5If the results of the improvement plan monitoring indicate concerns regarding competency for specific privileges or maintaining membership, the Division Chief or Chair Peer Review Committee will inform the MEC of the need for a formal investigation or corrective action as determined by the Medical Staff Bylaws, article 7.

4.4Use of OPPE and FPPE at Reappointment

At time of reappointment, the Chief and medical staff leaders will use provider specific OPPE-FPPE and peer review results in making its recommendations to the Credentials Committee and/or MEC regarding the credentialing and privileging process and, as appropriate, in its performance improvement activities.

When insufficient practitioner specific data is available, the medical staff leaders will use other information available to them to make determination for renewal of privileges, including peer recommendations.

4.4.1 If unprofessional or disruptive conduct is identified as a possible issue, the Medical Staff Rules and Regulations governing Code of Conduct will be initiated as part of the OPPE.

5.0Document retention

Copies of the Confidential Peer Review Document and attachments will be maintained in the Medical Staff Office. Individual Providers’ quality files will contain summary information on the review activity and any relevant actions or decisions as an outcome of the review.

6.0References

This Policy refers to the current versions of the following:

  • CMMC Medical Staff Bylaws, Article 7 (Corrective Action);
  • CMMC Medical Staff Rules and Regulations, Section II (Code of Conduct).
  • The Joint Commission MS 08.01.01-.03

Effective: 5.17.2011

Reviewed:9/2012

Revised: 9/22/2014, 9/2017

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