Combined OPPE/FPPE Policy and Procedure
POLICY AND PROCEDURE
I.
SECTION
PAGE 1 OF 4
DATE
SUPERSEDES
MANUAL Medical Staff Office
APPROVED BY
Governing Board
SUBJECT OPPE/FPPE
WRITTEN BY
Medical Executive Committee
PURPOSE:
To define, determine, maintain, and evaluate the competency of members of the medical staff
and advanced practice professionals, who are members of the allied health professional staff, to
provide care, treatment, and service in accordance with the credentialing and privileging
processes and requirements of the medical staff.
This policy refers to the records and proceedings of the medical staff, which has the
responsibility of evaluation and improvement of the quality of care rendered in the hospital. The
records and proceedings of the medical staff that relate to this policy in any way are protected
from discovery pursuant to [state evidence statutes].
II.
POLICY:
All members of the medical staff and advanced practice professionals, who are members of the
allied health professional staff, will be required to meet six general competencies and will be
subject to a focused professional practice evaluation and an ongoing professional practice
evaluation process.
III.
TERMS:
A.
General competencies:
There are six areas of general competencies. These general competencies were developed by
the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of
Medical Specialties (ABMS) joint initiative and adopted by The Joint Commission. The areas of
general competencies include:
1. Patient care
Practitioners are expected to provide patient care that is compassionate, appropriate, and
effective for the promotion of health, prevention of illness, treatment of disease, and care at
the end of life.
2. Medical/clinical knowledge
Practitioners are expected to demonstrate knowledge of established and evolving
biomedical, clinical, and social sciences and the application of their knowledge to patient
care and the education of others.
3. Practice-based learning environment
Practitioners are expected to be able to use scientific evidence and methods to investigate,
evaluate, and improve patient care practices.
4. Interpersonal and communication skills
Practitioners are expected to demonstrate interpersonal communication skills that enable
them to establish and maintain professional relationships with patients, families, and other
members of the healthcare team.
5. Professionalism
Practitioners are expected to demonstrate behaviors that reflect a commitment to
continuous professional development, ethical practice, and understanding and sensitivity to
diversity and a responsible attitude toward their patients, their profession, and society.
6. Systems-based practice
Practitioners are expected to demonstrate both an understanding of the contexts and
systems in which healthcare is provided and the ability to apply this knowledge to improve
and optimize healthcare.
B.
FPPE:
FPPE is an intensified assessment of data or events, which relate to the performance or
behavior of a specific practitioner holding clinical privileges. The purpose of a focused review is
to determine whether the practitioner’s performance or behavior meets the minimum standard of
behavior or clinical care as is established by the medical staff. FPPE is not considered an
investigation as defined in the medical staff bylaws and is not subject to rights afforded in an
investigation. If an FPPE results in an action plan to recommend a formal investigation, the
process outlined in the medical staff bylaws will be followed. This process may be triggered:
1. When a practitioner has the credentials to suggest competence, but additional information or
a period of evaluation is needed to confirm competence in Doctors Hospital of Manteca’s
setting.
2. If questions arise regarding a currently privileged practitioner’s ability to provide safe, highquality patient care as documented by reports from others.
3. Practitioners may undergo proctoring (per policy) upon the granting of initial privileges
and/or when additional/new privileges are granted.
C.
OPPE:
OPPE is the continuous evaluation of the practitioner’s professional performance in order to
identify and resolve any potential problems with a practitioner’s performance. It allows the
medical staff to identify professional practice trends that impact on quality of care and patient
safety on an ongoing basis and provides an evaluation of an individual practitioner’s
performance and includes opportunities to improve patient care based on recognized standards.
OPPE uses multiple sources of information for individual evaluation, and practitioners are
provided with feedback for personal improvement or confirmation of personal achievement
related to the effectiveness of their professional, technical, and interpersonal skills in providing
patient care.
OPPE information is one of the factors considered in the decision to allow a practitioner to
maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing privilege
prior to or at the end of the initial appointment/reappointment period. OPPE includes, but is not
limited to, review of the following:
1.
2.
3.
4.
5.
6.
7.
8.
Direct observation
Individual case review/peer review results/incident or occurrence reports
Review of aggregate data
Compliance with hospital policies, medical staff bylaws and medical staff rules and
regulations
Clinical standards and the use of rates compared against established benchmarks or
norms
Results of any required monitoring/proctoring
Utilization data
Core measures compliance
9.
IV.
Other relevant indicators as determined by the medical staff
PROCEDURE
A.
General competencies:
Initial applicants for privileges and all members of the medical staff must meet the general
competencies outlined in this policy at the time of initial appointment and granting of privileges
at reappointment. A practitioner who is unable to satisfactorily exhibit the general competencies
outlined in this policy may be subject to the focused evaluation of his or her professional
practice as noted in this policy. The general competencies of the practitioner can be verified in
the following ways:
1. Verification regarding each practitioner’s current California licensure, training, experience,
competence, and ability to perform the requested privileges in accordance with the medical
staff bylaws.
2. Information from peer references that affirmatively attest to the general competencies of the
practitioner. Peer recommendations must be obtained from a practitioner preferably in the
same professional discipline as the applicant with personal knowledge of the applicant’s
ability to practice.
3. Information obtained from performing background checks, verification of any actions taken
by any licensing board or other healthcare organization, reports to the National Practitioner
Data Bank, and verification of any sanctions.
4. The recommendation of the department chair or designee and the Medical Executive
Committee (MEC) that the practitioner exhibits the general competencies based on the
practitioner’s relevant education, training, experience, and known information about the
practitioner’s current performance.
5. Specific information that may arise out of ongoing and/or focused evaluation of a practitioner
that affirmatively or adversely speaks to that practitioner’s general competencies.
B.
FPPE:
FPPE will occur under the following circumstances:
1.
Privileges requested at initial appointment or requests for additional privileges: All medical
staff members granted initial privileges will undergo a period of proctoring as determined by
the individual clinical department in which the practitioner is assigned. Refer to the
Proctoring Policy and Specialty Specific Proctoring Guidelines for specific requirements.
2.
Focused review: A focused review of a practitioner’s performance will occur if it is identified
that there may be a significant practitioner-specific issue related to patient care or safety.
Refer to the Peer Review Policy, located in the Departmental P.I. Plan, and medical staff
bylaws.
3.
Circumstances requiring evaluation from an external source: At times, there may be need
for an outside evaluation to occur. Refer to the Peer Review Policy.
4.
Discussion with others: Reports from other individuals involved in the care of a patient (e.g.,
consulting physicians, assistants at surgery, nursing or administrative personnel).
6.
OPPE: Significant findings as a result of the OPPE process.
C.
OPPE:
Every eight months, and at the time of reappointment, a summary of the following information
will be made available to the department chair or designee in order to perform the OPPE
process. If a trend of unsatisfactory patient care or management is identified, the department
chair or designee will recommend that a focus review be conducted in accordance with medical
staff bylaws.
1.
Peer review process: A Practitioner Profile will be generated in order to identify if there are
practitioners with a trend of unsatisfactory patient care and management.
2.
Results of peer review: Utilizing indicators selected by medical staff clinical departments,
cases will be forwarded for peer review.
3.
Crimson reports: A Crimson report, where available, will be generated to identify
practitioners with an unfavorable variance regarding the expected length of stay, expected
complication rate, or the expected mortality rate.
4.
Results of proctoring: The results of proctoring, if any, will be compiled and reviewed.
5.
Medical staff required monitoring: Quality peer indicators, results of blood review, mortality
review, operative and invasive procedure review, per departmental-specific criteria, will be
reviewed in order to determine whether focus review is indicated.
6.
Compliance with core measures: The organization collects data related to compliance with
the Core Measures.
Triggers: The two triggers that will be used to indicate a need for performance monitoring to
further assess current competence are:
1. Identification of a significant single event/sentinel event.
2. Identification of a trend of performance deficiencies. A trend will be considered to be met if
four or more cases for the same type of review with a rating of Q2, Q3, U2, U3, B2, or B3 are
identified.
Conflict of interest: A member of the medical staff who is asked to perform an FPPE may have a
conflict of interest if he or she is unable to render an unbiased opinion due to either involvement
in the patient’s care or a relationship with the practitioner involved, whether as a direct
competitor or a partner. It is the reviewer’s obligation to disclose the potential conflict to the
department chair. Department chairs are responsible for determining whether the conflict would
prevent the individual from participating and the extent of that participation, if allowed.
Individuals determined to have a conflict may be present during the FPPE; however, they will
recuse themselves from voting on any recommendation.
Confidentiality: Data, records, documents, and knowledge, including but not limited to minutes
and case review materials collected for or by hospital departments, individuals, or committees
assigned with the responsibility of performing the functions delineated in this policy are
confidential and are not public record. The information shall be used by department chairs and
designated medical staff departments and committees, including appointed ad hoc committees,
only in the exercise of the assigned functions of the department or committee.
Approved:
Medical Executive Committee, [Date]
Governing Board, [Date]
Source: Doctors Hospital of Manteca, 2015. Used with permission.
From The FPPE Toolbox: Field-Tested Documents for Credentialing, Competency, and Compliance, Second
Edition, ©2015 HCPro