What are the key elements needed to meet the Ongoing Professional Practice Evaluation (OPPE) requirements?

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Any examples are for illustrative purposes only.

Intent

OPPE identifies professional practice trends that may impact the quality and safety of care and applies to all practitioners granted privileges via the Medical Staff chapter requirements. A well-designed process supports early detection and response to performance issues that could negatively impact patient outcomes.

Goals
The goals include:

A qualitative and quantitative data-driven process to identify performance trends that may require taking steps to improve performance (e.g. implementing an FPPE review).
Establishing an objective, data-driven foundation for making re-privileging decisions.

Design

clearly-defined process that includes elements, such as:

Responsibilities for data review, as defined by the medical staff that may include:
- Department chair or the department as a whole
- Credentialing committee
- Medical Executive Committee
- Special committee of the organized medical staff
Frequency of review
The process for using data for decision-making
The decision process resulting from the review (continue/limit/deny privilege)

Frequency of Review

The organized medical staff defines the frequency for data collection. However, the timeframe for review of the data cannot exceed every 12 months.

Data

Qualitative and quantitative criteria (data) that has been approved by the medical staff, should be designed into the process. For example, limiting criteria to quantitative data may only represent the presence or absence of information but may not reflect the quality of the information reviewed. Consider the following:

Qualitative Data

Qualitative or 'categorical' data, may be described as data that 'approximates and characterizes' and is often non-numerical in nature. This type of data may be collected through methods of observations, discussion with other individuals, chart review, monitoring of diagnostic and treatment techniques, etc.

Examples(^) may include, but are not limited to:

• Description of procedures performed
• Periodic Chart Review

o   quality/accuracy of documentation
o   appropriateness of tests ordered / procedures performed
o   patient outcomes

•   Types of patient complaints
•   Code of conduct breaches
•   Peer recommendations
•   Discussion with other individuals involved in the care of patient(s), e.g. consultants, surgical assistants, nursing, administration, etc.

When the data being collected is related to the quality of performance, e.g., appropriate management of a patient's presenting condition, or the quality of the performance of a procedure, then the organized medical staff should determine that someone with essentially equal qualifications would review the data.

Quantitative Data

Quantitative data often reflects a certain quantity, amount or range and are generally expressed as a unit of measure. Contrasted with qualitative data, quantitative data generally relates to data in the form of numerical quantities such as measurements, counts, percentage compliant, ratios, thresholds, intervals, time frames, etc.

Examples(^) may include, but are not limited to:

Length of stay trends
Post-procedure infection rates
Periodic Chart Review
Dating/timing/signing entries
T.O./V.O. authenticated within defined time frame
Presence/absence of required information (H & P elements, etc)
Number of H & P / updates completed within 24 hours after inpatient admission/registration
Compliance with medical staff rules, regulations, policies, etc.
Documenting the minimum required elements of an H & P / update.
Compliance with core measures

^ Note: The manner in which such data is captured could represent either – or both – qualitative and quantitative information.

Data Sources

The data source used for the OPPE process must include practitioner activities performed at the organization where privileges have been requested. This may include activities performed at any location that falls under the organization's single CMS Certification Number (CCN). For example, if an organization operates two hospitals that fall under the same CCN number, data from both hospital locations may be used.

Multi-hospital Systems
In multi-hospital systems where each hospital operates independently under separate CMS Certification Numbers (CCN), data from those entities may be used to supplement local data.

Low-volume Practitioners
When practitioner activity at the 'local' level is low or limited, supplemental data may be used from another CMS-certified organization where the practitioner holds the same privileges. The use of supplemental data may NOT be used in lieu of a process to capture local data. Organizations choosing to use supplemental data should assess and determine the supplemental data's relevance, timeliness, and accuracy.

Examples where supplemental data could be used may include, but are not limited to:

activity is limited to periodic on-call coverage for other physicians or groups
occasional consultations for a clinical specialty

Consistent with the "Medical Staff" chapter, the medical staff must develop policies and procedures which ensure oversight of local data and the use of supplemental data.

OPPE for non-inpatient areas

Privileges need to be granted to anyone providing a medical level of care, i.e., making medical diagnoses or medical treatment decisions, in any setting that is included within the scope of the hospital survey. The settings can include inpatient, on-campus outpatient, off campus clinics, hospital owned physician office practices, etc.
OPPE applies to any privileges granted to be exercised in any setting and/or location included within the scope of the hospital survey. The privileges are often the same as those for inpatient care, treatment, and services, therefore, separate privileges based on 'location' would not be required. If the non-inpatient settings do not have the same clinical record system or information technology, collecting data may be more difficult, but if the privileges are the same, the data collected should be the same.

Using the Data in Decision-making

The information resulting from the evaluation needs to be used to determine whether to continue, limit, or revoke any existing privilege(s) at the time the information is analyzed. Based on the analysis, several possible actions could occur, for example:

determining that the practitioner is performing well or within desired expectations and that no further action is warranted
determining that a performance issues exists and requires a focused evaluation – see MS.08.01.01 EP 5.
revoking the privilege because it is no longer required
suspending the privilege, which suspends the data collection, and notifying the practitioner that if they wish to reactivate it, they must request a reactivation

Evidence of these determinations would need to be available at the time data is reviewed.

Manual: Hospital and Hospital Clinics

Chapter: Medical Staff MS

Last reviewed by Standards Interpretation: February 04, 2022