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Administrative Policies and Procedures
OPPE for Low Volume/No Volume Practitioners
Policy Number:
Origination Date:
Medical Staff President:
Chief Executive Officer:
Board President:
Page 1 of 7
Reviewed:
Revised:
Purpose
This Low/No Volume Practitioner policy is designed to provide guidance to the medical staff, management,
and governing board of Centennial Medical Center in pursuing the following three goals:
1. Protect patients by ensuring all providers are only granted privileges for which they have
demonstrated current competence;
2. Meet legal and regulatory requirements;
3. Build and maintain strategic relationships between the hospital and providers who rarely or never
practice within the organization.
This policy will address, at least in part, how the hospital will maintain and support productive,
collaborative relationships between the hospital and Low/No Volume Practitioners (practitioners with
less than three (3) patient contacts during the evaluation period) in a manner that supports the
hospital in fulfilling its mission, and vision.
Definitions
Types of Low/volume practitioners:
There are four fundamental types of Low/No Volume Practitioners:
1. Practitioners with adequate clinical activity elsewhere relevant to requested hospital privileges
either at another accredited hospital or accredited free standing surgical or accredited ambulatory
center (e.g. partial admitter, covering group consultant, ambulatory procedurist)
2. Practitioners actively practicing in an acute care related specialty but with a reduced scope of
practice resulting in inadequate care/clinical activity relevant to hospital privileges (e.g. primary
care practitioners using hospitalists for all, or the vast majority, of inpatient care)
3. Practitioners actively practicing in a specialty that does not typically provide care in an acute care
setting (e.g. dermatologists)
4. Practitioners not actively practicing for prolonged time period who are seeking reinstatement of
privileges (e.g. prolonged leave of absence, early retirement). These practitioners will be placed
under co-management privileges until current competence is established for independent
privileges.
Direct Patient Care: Documenting in the medical record, writing orders, performing examinations or
procedures
Levels of privileges
 Independent: Practitioners who, by license or hospital/medical staff policy, currently hold
independent privileges and have sufficient external or internal evidence of current competence for
the Board to grant independent privileges.
 Continuity of Care (alt.: Active Affiliate): Practitioners who, by license or hospital/medical staff
policy, are eligible for independent privileges but choose not to request privileges to participate in
direct patient care. Such practitioners are authorized to refer patients to the hospital, order
outpatient ancillary studies, and follow patients through their hospital stay including
communication with care providers.
Page 1 of 7
Facility logo
Administrative Policies and Procedures
OPPE for Low Volume/No Volume Practitioners
Policy Number:
Origination Date:
Medical Staff President:
Chief Executive Officer:
Board President:

Page 2 of 7
Reviewed:
Revised:
Co-management: Practitioners who, by license or hospital/medical staff policy, are eligible for
independent privileges and wish to participate in direct patient care but do not have evidence of
current clinical competence (e.g. practitioner returning form a prolonged leave of absence or
practicing predominately outpatient care and wishes to retain specific inpatient privileges with
insufficient data to demonstrate current competence). Care provided within the scope of comanaged privileges must be overseen by a practitioner with those independent privileges who
assumes the ultimate responsibility for the care of such patients. The data obtained during comanagement may be used to provide evidence of current competence if independent privileges are
eventually requested. The hospital may also determine FPPE should be conducted for an
appropriate time frame if independent privileges are granted.
Policy
Centennial Medical Center grants Low/No Volume Practitioners only those independent privileges for which
adequate evidence of the practitioner’s current clinical competence is provided and to use other privileging
levels to maintain an appropriate relationship with the medical staff. This policy will be pursued in parallel
with the goal of building and maintaining productive, collaborative relationships between the hospital and
providers in the community whose practice includes little or no volume of clinical care at the hospital in a
manner that supports the hospital in fulfilling its mission, and vision.
Procedure
Guidelines for Determining Information Needs
In evaluating Low/No Volume Practitioners for OPPE or reappointment, the following guidelines will be
applied:
 The assignment of a practitioner to a specific medical staff membership category will be made
consistent with the medical staff bylaws and the medical staff’s desire to enfranchise practitioners who
fulfill an important strategic role supporting the mission of the medical staff and the hospital through
granting these practitioners the rights of membership.
 Practitioners will be encouraged to seek the level of privilege independence best suited for their
current practice setting and ability to demonstrate current clinical competence.
 The burden to produce adequate information to establish current clinical competence for maintenance
of privileges through OPPE or at reappointment is the responsibility of the practitioner, including
assisting the hospital in obtaining needed information from other practice settings. If information is not
provided that, in the sole discretion of the hospital, is needed to assess current competence for specific
privileges, the practitioner’s request for those specific privileges reappointment or maintenance of
those privileges through OPPE will be considered incomplete and will not be processed.
 For practitioners seeking each level of privilege, the following information will be required:
 Independent privileges: data and references to establish current competence during OPPE and
reappointment based in the nature of the type of Low/No Volume Practitioner. The methods most
appropriate for the privileges requested for each type of Low/No Volume Practitioner are described
below in Methods section.
 Continuity of Care (Active Affiliate) privileges: only information necessary to meet the appropriate
membership criteria and appropriate professional references for reappointment unless any reported
incidents or events related to the six competencies raises concerns. The hospital is not obligated to
Page 2 of 7
Facility logo
Administrative Policies and Procedures
OPPE for Low Volume/No Volume Practitioners
Policy Number:
Origination Date:
Medical Staff President:
Chief Executive Officer:
Board President:

Page 3 of 7
Reviewed:
Revised:
obtain data to determine current competence either at reappointment or OPPE unless the hospital
is privileging the ambulatory competence.
Co-management: evidence of appropriate training experience, professional references, relevant
professional licensing criteria, and any information related to medical staff membership if
applicable for reappointment unless any reported incidents or events related to the six
competencies raise concerns.
Methods for Obtaining Current Clinical Competence Information for Low/No Volume Practitioners
requesting independent privileges
As indicated above, only practitioners with Independent and co-management privileges are required to
provide evidence of current clinical competence for the specific privileges requested. (See the Ongoing
Professional Practice Evaluation Worksheet) Outlined below are types of information and methods
for obtaining the data based on the type of Low/No Volume Practitioner. If there is insufficient data to
assess current clinical competence for a given privilege, the decision regarding a practitioner’s privileges
may depend significantly on information contained in professional references. When necessary, the
department/clinical service vice-chair, or designee may personally contact the references to assess
whether or not the information provided by the references is adequate to establish current competence for
the requested privileges.
1. Practitioners with adequate relevant clinical activity elsewhere
a. Volume data (external and internal) related to the acute care privileges requested
b. General Competencies data (external)
i. Patient Care
1. Results of peer review case reviews regarding number of cases determined with
care less than appropriate in the prior 2 years.
2. Mortality and complication rates (preferably risk adjusted) relevant to the
privileges requested. This may be provided as overall rates that encompass the
requested privileges or disease or procedure specific rates based on the capacity
of the providing organization.
3. For imaging specialties: Image interpretation accuracy data the prior 2 years
ii. Medical Knowledge (Compliance with Evidence Based Medicine):
1. Core Measure data relevant to the specialty for the prior 2 years
2. Blood use data relevant to the specialty and privileges
3. Protocol Compliance (if available)
iii. Communication and Interpersonal skills
1. Number of reported validated incidents of patient complaints
2. Number Medical Records suspensions
3. Patient Satisfaction with physician survey data (if available)
iv. Professionalism
1. Number of reported validated incidents of complaints regarding inappropriate
behavior
v. System based practice
1. Number of reported incidents of non-compliance with patient safety precautions
2. Optional: Length of stay or cost per adjusted day for high volume conditions
treated (preferably risk adjusted). This may be provided as overall rates that
Page 3 of 7
Facility logo
Administrative Policies and Procedures
OPPE for Low Volume/No Volume Practitioners
Policy Number:
Origination Date:
Medical Staff President:
Chief Executive Officer:
Board President:
Page 4 of 7
Reviewed:
Revised:
encompass the requested privileges or disease or procedure specific rates based
on the capacity of the providing organization.
c. All internal data available for the above competencies.
d. General Professional Reference Qualitative Evaluation: if sufficient data is not provided or
internally available for the general competencies, the hospital will request a professional
reference form be completed by a practitioner at the facility(s) with sufficient activity who has
reviewed that facility’s most recent OPPE report. (Ongoing Professional Practice Evaluation
Worksheet)
2. Practitioners actively practicing in an acute care related specialty with a reduced scope of practice still
requesting independent privileges.
a. Professional Reference Qualitative Evaluation for the general competencies from practitioners at
current practice settings and/or from physicians managing the practitioners patients in the
acute care setting (Ongoing Professional Practice Evaluation Worksheet)
b. General competencies specific internal and external data if available (rolling prior 2 years)
i. Patient Care
1. Internal results of any peer review case reviews regarding number of cases
determined with care less than appropriate
2. External outcomes data from non-acute setting for conditions treated or
procedures performed related to privileges requested
ii. Medical Knowledge
1. Internal results of any Core Measure, Blood use, data or Protocol Compliance
data relevant to the specialty
2. External process data from non-acute setting for conditions treated or procedures
performed related to privileges requested
3. Evidence of CME and/or maintenance of board certification relevant to the
privileges requested during the past 2 years
4. Evidence of relevant skills certification for procedures requested (if available)
iii. Communication and Interpersonal skills
1. Any internal reported validated incidents of patient complaints
iv. Professionalism
1. Any internal reported validated incidents of complaints regarding inappropriate
behavior
v. System based practice
1. Any internal reported validated incidents of non-compliance with patient safety
precautions
3. Practitioners actively practicing in a specialty that does not typically provide care in an acute care
setting (rolling prior 2 years)
a. General Professional Reference Qualitative Evaluation for the general competencies from
practitioners at current practice settings and referral sources (Ongoing Professional Practice
Evaluation Worksheet)
b. Any internal data relating to the general competencies as indicated above for practitioners with
reduced scope of practice.
Page 4 of 7
Facility logo
Administrative Policies and Procedures
OPPE for Low Volume/No Volume Practitioners
Policy Number:
Origination Date:
Medical Staff President:
Chief Executive Officer:
Board President:
Page 5 of 7
Reviewed:
Revised:
c. Data from non-acute setting for conditions treated or procedures performed related to
privileges requested (if available)
d. Evidence of CME and/or maintenance of board certification relevant to the privileges requested
during the past 2 years
e. Evidence of relevant skills certification for procedures requested (if available)
.
Page 5 of 7
Attachment A
ONGOING PROFESSIONAL PRACTICE EVALUATION WORKSHEET
CONFIDENTIAL PEER REVIEW DOCUMENT
From : (Medical Staff Member)
DEAR PRIMARY HOSPITAL:
Review Period: ___________ to ______________
The provider referenced above is a low-volume provider at (your facility). Please provide evaluation of this provider based upon demonstrated
performance compared to that reasonably expected of a physician with a similar level of training, experience and background as the one referred above;
evaluation should be based on personal knowledge and/or direct observation of the Department Chairperson. Additional documentation can be included
to document findings.
DEPARTMENT:____________________________________ SPECIALTY:_______________________________________
Department/Specialty Specific Criteria:__________________________________________________________________
__________________________________________________________________________________________
Total Admits/Procedures: __________________________________
Review of Competencies below
FACTOR
DATA SOURCE(s) in addition to QI File
Review
Patient Care
Provides 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. These measures may include:
Comparison of practitioner’s
complications/outcomes related to peers
EVALUATION
(*Requires further comment)
Satisfactory
Unsatisfactory*
Retrospective or prospective chart review
Comments:_________________________
Monitoring of clinical practice patterns
__________________________________
Proctoring

Accurate & complete H&P
External peer review
__________________________________

All components of physical exam present
Simulation
__________________________________

Complete assessment and plans

Provides quality patient education

Competently performs medical and/or surgical
procedures delineated by privileges
Medical/Clinical Knowledge
Demonstrates knowledge of established and evolving
biomedical, clinical and social sciences, and applies
this knowledge to patient care and education of
others. These measures may include:
 Appropriate selection of diagnostic tests

Appropriate interpretation/analysis of results

Appropriate integration of H&P findings and
diagnostic studies to formulate a differential
diagnosis

Pharmacological knowledge

Appropriate ordering of therapeutics
Practice-Based Learning & Improvement
Uses scientific evidence and methods to investigate,
evaluate and improve patient care practices. These
measures may include:
 Applies evidence based medicine to clinical
decisions

Comparison of practitioner’s
complications/outcomes related to peers
Retrospective or prospective chart review
Awareness of quality improvement measures
and application to clinical practice
Facilitates the learning of students and other
healthcare professionals
__________________________________
__________________________________
Satisfactory
Unsatisfactory*
Comments:____________________
Monitoring of clinical practice patterns
Proctoring
__________________________________
External peer review
__________________________________
Simulation
Discussion(s) with other individuals involved in
the care of the practitioner’s patients relative to
the substance of the focused review
Overall integration of clinical information into
treatment planning


Discussion(s) with other individuals involved in
the care of the practitioner’s patients relative to
the substance of the focused review
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
Comparison of practitioner’s
complications/outcomes related to peers
Satisfactory
Unsatisfactory*
Retrospective or prospective chart review
Comments:_________________________
Monitoring of clinical practice patterns
__________________________________
Proctoring
External peer review
__________________________________
Simulation
__________________________________
Discussion(s) with other individuals involved in
the care of the practitioner’s patients relative to
the substance of the focused review
__________________________________
__________________________________
FACTOR
DATA SOURCE(s) in addition to QI File
Review
Interpersonal & Communication Skills
Demonstrates interpersonal and communication
skills that enable him/her to establish and maintain
professional relationships with patients, families and
other members of health care teams. These
measures may include:
 Communications and behaviors with patients
are effective and appropriate
Comparison of practitioner’s
complications/outcomes related to peers

Communications and behaviors with other
clinicians are effective and appropriate
Discussion(s) with other individuals involved in
the care of the practitioner’s patients relative to
the substance of the focused review

Demonstrates emotional resilience and stability,
adaptability, flexibility, and tolerance of
ambiguity and anxiety

Uses effective listening, nonverbal, explanatory,
interviewing, and writing skills to elicit and
provide information
Comments:_________________________
__________________________________
Proctoring
External peer review
__________________________________
Simulation
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________

Discussion(s) with other individuals involved in
the care of the practitioner’s patients relative to
the substance of the focused review
Satisfactory
Unsatisfactory*
Retrospective or prospective chart review
Comments:_________________________
Monitoring of clinical practice patterns
__________________________________
Proctoring
External peer review
__________________________________
Simulation
__________________________________
Systems-Based Practice
Understands the contexts and systems in which
health care is provided, and applies this knowledge to
improve and optimize health care. These measures
may include:
 Uses information technology resources to
support patient care decisions and patient
education
Comparison of practitioner’s
complications/outcomes related to peers

Discussion(s) with other individuals involved in
the care of the practitioner’s patients relative to
the substance of the focused review

Unsatisfactory*
Monitoring of clinical practice patterns
Comparison of practitioner’s
complications/outcomes related to peers
Practices cost-effective healthcare and resources
allocation that does not compromise quality of
care
Satisfactory
Retrospective or prospective chart review
Professionalism
Demonstrates behaviors that reflect a commitment
to continuous professional development, ethical
practice, understanding and sensitivity to diversity
and a responsible attitude toward patients, their
profession and society. These measures may include:
 Displays sensitivity and responsiveness to
patients’ culture, age, gender, and disabilities
Commitment to personal excellence and
ongoing professional development
EVALUATION
(*Requires further comment)
__________________________________
__________________________________
Satisfactory
Unsatisfactory*
Retrospective or prospective chart review
Comments:________________________
Monitoring of clinical practice patterns
__________________________________
Proctoring
External peer review
__________________________________
Simulation
__________________________________
Applies medical information and clinical data
systems to provide more effective, efficient
patient care
__________________________________
__________________________________
__________________________________
Based upon review and assessment of the results of the monitoring and evaluation activities, it is determined to recommend to:
Continue the privilege(s) unchanged
Direct Education: Review of the practitioner’s OPPE data indicates the opportunity for improvement. The Department ViceChair recommends additional education (comments are required)
Direct FPPE: Review of the practitioner’s OPPE data indicates a question about the practitioner’s competence. An FPPE is
recommended (comments are required)
Modify or Revoke an existing privilege: Review of the practitioner’s OPPE data indicates existing privileges should be
modified or revoked due to insufficient activity or failure to meet competency requirements (comments are required)
Comments:______________________________________________________________________________________________________________
Completed By: ____________________________________________________________________
Date: ___________________________
Primary Hospital Department Chair Signature: ____________________________________
Date: ___________________________
Primary Hospital please fax this completed form to (your name and phone number) (No coversheet is necessary)