Joint Commission Update
National Credentialing Forum
Ron Wyatt MD, MHA
Medical Director, Division of Health Care Improvement
Office of the Chief Medical Officer
The Joint Commission
John Herringer
Associate Director
Certified Yellow Belt--RPI
Standards Interpretation Group-Clinical
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San Diego, California
February 6, 2014
Objectives
2. Share best practices in the area of
OPPE/FPPE that participants can use in their
organizations.
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1. Briefly discuss the Joint Commission
standards that relate to credentialing,
privileging and OPPE and FPPE of Licensed
Independent Practitioners.
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Source: IHI Forum 2012
Competing Demands on LIP Time
Organization
Regulatory
Joint Commission
OPPE
Clinic/Unit
Patient Needs
Optimize the patient
experience
Individual Physician
Professional Needs
MOC, CME
Source: University of Wisconsin Health
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Clinical care,
patient experience
and operational
performance
Credentialing and Privileging
Utilization of three concepts to allow the
organized medical staff to conduct a more
comprehensive evaluation of a practitioner’s
professional performance
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2007 MS Chapter introduced 3
new concepts
Process involving a series of activities
designed to collect, verify, and evaluate data
relevant to a practitioner’s professional
performance
Serves as a foundation for objective,
evidence-based decisions regarding
appointment to the medical staff, and
recommendations to grant or deny initial and
renewed privileges
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Joint Commission
Credentialing and Privileging
The ACGME and the ABMS jointly developed six areas in
which a physician must be competent:
The six competencies are a recommended framework by
The Joint Commission…not a requirement
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• Patient Care
• Medical/Clinical Knowledge
• System Based practice
• Practice based learning
• Communication skills
• Professionalism
Credentialing and Privileging
• Focused
• Ongoing
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Professional
Practice
Evaluation
Purpose
 Align competency expectations to those used by ACGME
training programs
 OPPE
– Require organizations to review performance data for all
practitioners with privileges on an ongoing basis rather than
the two year reappointment process and thus allow them to
take the appropriate steps to improve performance on a
more timely basis
– Require organizations to establish a process to evaluate the
specific competence of all practitioners who do not have
documented evidence of competency performing the
privileges at the organization (e.g. new appointees, new
privileges for current staff)
– Process to evaluate a current privileged practitioner’s ability
to provide safe, high quality patient care.
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 FPPE
OPPE Expectations
EP1 - There is a clearly defined process in place that
facilitates the evaluation of each practitioner’s
professional practice. (A)
 This clearly defined process must include but is not
limited to:
– Who will be responsible for reviewing the data?
–
–
–
–
Department and/or Department Chair
Credentials Committee
Medical Executive Committee (MEC)
Special Committee of the Medical Staff (e.g. “aka peer review”)
– The frequency must be defined in the policy (e.g. 3,6,9 months)
– IMPORTANT- Once every 12 months is periodic rather than
ongoing!
– How are the data incorporated into the credential files?
– This data need not be continuously stored in the credential file
– However, the decision resulting from the review, whether it be to
take an action or continue the privilege, would need to be
documented and included in the practitioner’s credential file
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– How often are the data reviewed?
OPPE Expectations
– The type of data collected is the organization’s choice
– The data should be tailored to specialties and/or
practitioners
– The six areas of “General Competencies” may be used
as a template for data stratification – but not required
–
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EP2 – The type of data to be collected is determined
by the individual departments and approved by the
organized medical staff (A)
– The type of data to be collected and the approval
process needs to be defined
– Data
Examples
of
Data
OPPE Expectations
 Discussion with other individuals involved in the
care of each patient - other practitioners, NP, PA,
Surgical Assistants, Nursing, Ancillary Support
Staff
 Prospective Analysis – treatment conferences
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Ongoing Chart Review
Direct Observation
Peer Evaluations
Monitoring of diagnostic and treatment
techniques
 Data collection must be completed for all
practitioners who are Medical or Professional Staff
MembersActive, Courtesy, Consulting, Allied Health, etc.
 Zero data are in fact data – a zero rate may be good
for complications but not good in that the practitioner
has not performed a procedure in the last two years
 There is no requirement that the data must be
provided to the practitioner, and ….
 The data and analysis does not need to be
contained in the credential file
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Data Analysis
 When possible, display the performance of one
practitioner against the performance of the others.
 The hospital’s responsibility is to collect and display
the data in such a manner that the medical staff can
make decisions about performance – “Actionable
Information”
 Action is taken as issues arise, not just at the twoyear reappointment
 When possible, let one page “tell the story” of a
physician, or a department
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Organizing and Displaying
OPPE Data
Take Home Points
Periodically (at least at reappointment)
it’s helpful to generate the volumes of
each procedure or DRG to assure the
medical staff that there are not areas of
‘zero volume’ creeping into categories
of privileges
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In OPPE, you’re only capturing data on
a few indicators or flags of quality.
FPPE
– EP1 A period of focused professional practice is
implemented for all initially requested privileges
– EP3 The performance monitoring process is
clearly defined and includes each of the following:
– Criteria for conducting performance monitoring
– Method for establishing a monitoring plan
specific to the requested privilege
– Method for determining the duration of
performance monitoring
– Circumstances under which monitoring by an
external party is required
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New Privileges
Focused Review for New Privileges
Example – electronic data
Various categories of privileges can move
out of FPPE while leaving other privileges
still to be reviewed under FPPE once
exercised –
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Though all privileges must be part of the
review, the medical staff can review those
completed during the FPPE period and
assess them as equivalent to those not
yet exercised, and therefore OK…. or not
Focused Review for New Privileges
Example – electronic data
– Mortality and morbidity
– Surgical outcomes and events
– Length of Stay and Readmissions
– Volumes of each procedure or each DRG
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Think about using broad clinical
indicators that capture the population
served by this practitioner – tie to each
privilege
The OPPE-FPPE Connection
EP2 The organized medical staff develops
criteria to be used for evaluating the
performance of practitioners when issues
affecting the provision of safe, high quality
patient care are identified
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– This EP links OPPE performance findings with
the processes defined in FPPE
Focused Review for New Privileges
You would at least want to check on their
progress as often as OPPE.
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FPPE should occur quicker than OPPE (e.g.,
it shouldn’t last a year if OPPE is done every
6 months), BUT a new practitioner often
doesn’t build a practice fast enough, or touch
on all categories of their privileges soon
enough, to really capture the essence of their
practice
Focused Review for New Privileges
Example chart review
–
–
–
–
–
–
–
H & P timeliness? Required elements?
Progress notes regularly?
Required op notes?
Signatures on verbal orders?
Discharge summary?
Presence of Do Not Use abbreviations?
You decide
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Define what is reviewed in a record by
a non-LIP if that will be part of the
FPPE:
Focused Review for New Privileges
Example chart review
– Quality of H & P?
– Quality of progress notes?
– Specialty-specific documentation?
– Addressing abnormal diagnostics?
– Appropriateness of procedures?
– You decide
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Define what peer LIPs review in the
record that touch on practice quality
Focused Review for New Privileges
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For privileges new to the facility, the
medical staff may have to go to an
outside source for some safety and
quality benchmarks – “evidence based”
Focused Review for New Privileges
Describe the process in general terms (does not have
to be in bylaws)
 What kinds of data are you able to evaluate (your menu) –
Outcomes? Complications? Clinical management? Technique?
 Who evaluates – Section Chief, MEC, Credentialing
Committee?
 How long (quantity of procedures, admissions, or length of
time)
 How the decision will be conveyed to the LIP
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 What Method of evaluation is available to you (your menu) chart review, direct observation, statistical review, proctoring?
In Summary
FPPE is a brief period of looking at the basic
safety and competence in exercising ALL
privileges for new medical staff members
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OPPE is an ongoing period of looking at just
a few indicators of quality for EACH
practitioner – it touches on something he/she
does, but not everything
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Questions?
For Standards/NPSG question:
– 630-792-5900, Option 6 or
– http://www.jointcommission.org/Standards/
OnlineQuestionForm/
Pat Adamski
Ron Wyatt
– 630-792-5922
– rwyatt@jointcommission.org
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– 630-792-5964
– padamski@jointcommission.org
The Joint Commission Disclaimer Statement
 These slides are only meant to be cue points, which
were expounded upon verbally by the original
presenter and are not meant to be comprehensive
statements of standards interpretation or represent
all the content of the presentation. Thus, care should
be exercised in interpreting Joint Commission
requirements based solely on the content of these
slides.
 These slides are copyrighted and may not be further
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original presenter or The Joint Commission.
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 These slides are current as of January 26, 2014.
The Joint Commission reserves the right to change
the content of the information, as appropriate.