“How to do OPPE and FPPE with Minimal Resources”

PowerPoint PresentationAlaska Association of Medical Staff Services Anchorage, Alaska
“How to do OPPE and FPPE with Minimal Resources”
Not so long ago…..
Practitioners would go from appointment to reappointment to reappointment with little if any interim evaluation unless some significant quality issue was identified (usually do to a poor outcome or ‘near miss’).
What was the problem with this approach?
Not so long ago…..
Dr. Burroughs had the reputation of ordering too many CT scans in his emergency medicine practice and he received several letters to this effect in his confidential quality file.
What was the problem with this approach?
Quality Assurance-What’s the Problem?
“The maintenance of a desired level of quality through the search for and elimination of negative outliers or defects.”
Ten years ago…..
“The decision to grant or deny a privilege(s), and/or to renew an existing privilege(s) is an objective, evidence- based process.”
---The Joint Commission MS.06.01.05
What does this mean?
The ongoing measurement and assessment of clinical performance for all practitioners granted clinical privileges through the organized medical staff
Who does this include?
Furthermore,
MS.08.01.03: OPPE information is factored into the decision to maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing privilege prior to or at the time of renewal.
A2: The type of data to be collected is determined by individual departments and approved by the organized medical staff
Dimensions of Performance (ACGME, ABMS, The Joint Commission):
• Patient care • Medical/clinical knowledge • Practice-based learning and improvement • Interpersonal and communication skills • Professionalism • Systems-based practice
Patient Care:
Provide 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
Patient Care: • Effectiveness
• Appropriateness – Peer review cases rated care less than appropriate – Procedures/tests (e.g. CT) not meeting criteria
• Compassion – Patient/staff satisfaction
Medical Clinical Knowledge:
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
Medical Clinical Knowledge:
• Applying the knowledge – Retrospective or concurrent review
• Compliance with use of Evidence-based Medicine –Physician-relevant core/SCIP measures –Compliance with medical staff order sets (e.g.
DTV) – Observation/Testing
Practice-Based Learning and Improvement:
Use scientific evidence and methods to investigate, evaluate, and improve patient care practices
Practice Based Learning and Improvement:
• Improvement – Excellent/improvement scores on feedback report
(e.g. rate of conversions from reds/yellows to greens)
• Information technology use – Noncompliance with use of physician electronic
medical record tools (e.g. CPOE)
Interpersonal and Communication Skills:
Demonstrate interpersonal and communication skills that establish and maintain professional relationships with patients, families, and other members of the health care teams
• Written communication – Documentation audits (e.g. Timeliness of H&Ps, OP
reports, discharge summaries Date/Time of entries, Illegible orders)
– Suspensions for delinquent records • Verbal communication
– Patient satisfaction with physician communication – Collegial satisfaction with consultations
• Cooperation – Incident reports of non-cooperation
Professionalism:
Professionalism:
call schedule or unresponsiveness to requests for evaluation (medical screening exam)
Systems-Based Practice:
Demonstrate both an understanding of the contexts and systems in which healthcare care is provided, and the ability to apply this knowledge to improve and optimize health care.
Systems-Based Practice:
• Cost effectiveness and optimal resource utilization – Severity-adjusted average LOS – Avoidable days due to physician – Pharmacy cost per case – Cost per case – Late starts for 1st case in OR due to surgeon
• Patient safety – Validated reported incidents of non-compliance with
safety policies (e.g. time outs, infection precautions) – Hand washing observation data
Step 1: Articulate Key Performance Expectations within each Dimension of Performance
Patient Care: When available, utilize evidence based guidelines as recommended by Departments and approved by the MEC Professionalism and Interpersonal and Communication Skills: Respond to requests for consultation in a timely and professional manner
Step 2: Create Relevant Performance Indicators/Metrics
Source of performance metrics: • Agency for Healthcare Research and Quality • National Quality Forum (national guideline
clearinghouse) • National Healthcare Quality Report • National Committee for Quality Assurance • CMS/The Joint Commission • Professional Societies
So many Metrics-Which do we Pick?
Where would you start? 1. Regulatory quality-hardwire! 2. Strategic quality (physicians, management,
payers!, service, cost-effectiveness, safety, outcomes)
3. Calculate a return on investment (ROI) for strategic initiatives!
Step 3: Set Targets for each Performance Indicator/Metric
Setting appropriate targets is of strategic importance! You may choose targets based upon: • Internal data (historical) • External data and benchmarking (e.g. literature
and professional societies) • Quality databases (e.g. Premier) • Risk/Severity adjusted data
The Challenge with utilizing a single target: One target = two performance levels 1. Acceptable ____________________ 2. Unacceptable Issues: • No recognition of excellence (QA) • Focus on identifying low performers • Assumes everyone else is the same • No emphasis on improvement
A better approach: Two Targets Two targets = three performance levels 1. Excellent performance _____________________________ 2. Acceptable performance _____________________________ 3. Needs Follow Up Issues: • Recognizes excellence • Stimulates middle group to improve • Addresses marginal performance
Step 4: Classify all indicators/metrics
• Review- triggers a peer review every time (e.g. unexpected death in a low acuity patient)
• Rule- triggers a peer review when a critical number of occurrences is reached (e.g. number of validated conduct issues/year)
• Rate- triggers a peer review when a critical rate is reached (e.g. % of readmissions for the same dx within 72 hours)
Step 5: Prioritize all indicators/metrics and targets Patient Care: Risk adjusted mortality index for all DRGs (rate). Green target <0.9, Yellow target 0.9-1.1, Red target >1.1 Professionalism/Interpersonal and Communications Skills: Number of validated conduct reports/year (rule). Green target <2, Yellow target 2, Red target >2
Step 6: Create a weighted feedback report • Enable practitioners to self-manage and self-
correct (The Hawthorne Effect) • Recognize excellence (greens) • Stimulate improvement (reds and yellows) • Develop improvement plans (reds) • Discuss to identify system barriers • Provide data q 8 months for ongoing
assessment and reappointment
Balanced Scorecard- Inpatient PILLAR METRIC PEER AVG. GOAL Q1 Q2 Q3 Q4 YTD
MI: ASA/beta blocker at DC for AMI patients 91% 100% 93% 95% 95% 96% 95%
Pneumovax/influenza/BC
before ABX/ABX 93% 100% 90% 88% 86% 84% 87%
HF: ACE/ARB for LVSD 94% 100% 92% 96% 100% 100% 97% % Compliance c
evidence based order sets
74% 90% 90% 88% 88% 82% 86%
30-day readmit rate 18.40% 15% 12% 10% 14% 18% 15% % Pts risk
assessed/prophylaxed for DVT
81% 95% 90% 93% 95% 88% 92%
Treat you with courtesy and respect? (% Always) 68% 78% 92% 94% 93%
Listen carefully to you? (% Always) 69% 78% 96% 92% 94%
Explain things in a way you could undrstand?
(% Always) 71% 78% 88% 92% 90%
Peer review (0-100) 74 80 94 96 95 Nurse review (0-100) 68 80 96 100 98
% Medical records complete in 48 hours 78 90% 42% 46% 55% 62% 58%
DC summary to PCP within 24 hrs of DC 58% 90% 38% 36% 48% 58% 48%
Average LOS 4.6 4.1 4.25 5.2 4.78 4.2 4.4 Average LOS/CHF
admission 6.9 6.2 7.67 8.3 6.24 5.9 6.55
Cost per adjusted DC 7,198 7,000 6262 6849 6647 % Patients discharged by
noon 76% 90% 56% 62% 59%
TEAMWORK
FINANCE
QUALITY
SERVICE
KEY Meeting or exceeding goal Above peers avg., below goal At or below peer average
Outpatient
58%
70%
78%
82%
80%
42%
58%
74%
77%
76%
68%
74%
88%
92%
90%
88%
90%
98%
96%
97%
69%
80%
85%
86%
86%
SERVICE
How often did this doctor explain things in a way that was easy to understand?
66%
80%
49%
47%
48%
50%
48%
62%
80%
39%
42%
40%
52%
48%
How often did this doctor seem to know important information about your medical history?
68%
80%
48%
50%
49%
54%
52%
How often did this doctor show respect for what you had to say?
66%
80%
42%
38%
41%
40%
39%
GROWTH
52%
65%
24%
28%
26%
TEAMWORK
91%
100%
93%
95%
95%
96%
95%
93%
100%
90%
88%
86%
84%
87%
74%
90%
90%
88%
88%
82%
86%
81%
95%
90%
93%
95%
88%
92%
SERVICE
68%
78%
92%
94%
93%
69%
78%
96%
92%
94%
71%
78%
88%
92%
90%
TEAMWORK
78
90%
42%
46%
55%
62%
58%
58%
90%
38%
36%
48%
58%
48%
FINANCE
PILLAR
METRIC
Beta blocker for AMI
Antibiotics within 4 hours for CAP
EKG for syncope patients
How often did your physician keep you informed of treatment?
How often did your physician explain things so you could understand?
Door to doc time
TEAMWORK
58%
70%
78%
82%
80%
42%
58%
74%
77%
76%
68%
74%
88%
92%
90%
88%
90%
98%
96%
97%
69%
80%
85%
86%
86%
SERVICE
66%
80%
49%
47%
48%
50%
48%
62%
80%
39%
42%
40%
52%
48%
68%
80%
48%
50%
49%
54%
52%
66%
80%
42%
38%
41%
40%
39%
GROWTH
52%
65%
24%
28%
26%
TEAMWORK
91%
100%
93%
95%
95%
96%
95%
93%
100%
90%
88%
86%
84%
87%
74%
90%
90%
88%
88%
82%
86%
81%
95%
90%
93%
95%
88%
92%
SERVICE
68%
78%
92%
94%
93%
69%
78%
96%
92%
94%
71%
78%
88%
92%
90%
TEAMWORK
78
90%
42%
46%
55%
62%
58%
58%
90%
38%
36%
48%
58%
48%
FINANCE
PILLAR
METRIC
Door to doc time
TEAMWORK
Balanced Scorecard- Outpatient
KEY Meeting or exceeding goal Above peers avg., below goal At or below peer average
PILLAR METRIC PEER AVG. GOAL Q1 Q2 Q3 Q4 YTD
Patients c DM c LDL < 100 58% 70% 78% 82% 80%
Patients c DM c HgA1c < 7 42% 58% 74% 77% 76%
Patients c HTN c BP < 140/90 68% 74% 88% 92% 90%
Patients c DM c annual microalbumin 88% 90% 98% 96% 97%
Women 40-69 annual mammogram 84% 90% 94% 95% 95%
Patients over 65 c pneumovax 69% 80% 85% 86% 86%
66% 80% 49% 47% 48% 50% 48%
How often did this doctor listen carefully to you? 62% 80% 39% 42% 40% 52% 48%
68% 80% 48% 50% 49% 54% 52%
How often did this doctor show respect for what you had to
say? 66% 80% 42% 38% 41% 40% 39%
Likelihood of recommending (% tile) 46% 60% 8% 15% 12%
Overall rating of physician (% 9 or 10) 52% 65% 24% 28% 26%
Peer review 85.5 90 79 81 82 84 82 Staff review 72.3 85 66 64 68 67 66
Patients seen/day 19.7 22 23 24 21.4 22.5 22.6 Percent generic medication
use 76% 85% 74% 78% 76% 84% 80%
QUALITY
SERVICE
GROWTH
FINANCE
58%
70%
78%
82%
80%
42%
58%
74%
77%
76%
68%
74%
88%
92%
90%
88%
90%
98%
96%
97%
69%
80%
85%
86%
86%
SERVICE
66%
80%
49%
47%
48%
50%
48%
62%
80%
39%
42%
40%
52%
48%
68%
80%
48%
50%
49%
54%
52%
66%
80%
42%
38%
41%
40%
39%
GROWTH
52%
65%
24%
28%
26%
TEAMWORK
91%
100%
93%
95%
95%
96%
95%
93%
100%
90%
88%
86%
84%
87%
74%
90%
90%
88%
88%
82%
86%
81%
95%
90%
93%
95%
88%
92%
SERVICE
68%
78%
92%
94%
93%
69%
78%
96%
92%
94%
71%
78%
88%
92%
90%
TEAMWORK
78
90%
42%
46%
55%
62%
58%
58%
90%
38%
36%
48%
58%
48%
FINANCE
PILLAR
METRIC
Door to doc time
TEAMWORK
Outpatient
58%
70%
78%
82%
80%
42%
58%
74%
77%
76%
68%
74%
88%
92%
90%
88%
90%
98%
96%
97%
69%
80%
85%
86%
86%
SERVICE
66%
80%
49%
47%
48%
50%
48%
62%
80%
39%
42%
40%
52%
48%
68%
80%
48%
50%
49%
54%
52%
66%
80%
42%
38%
41%
40%
39%
GROWTH
52%
65%
24%
28%
26%
TEAMWORK
91%
100%
93%
95%
95%
96%
95%
93%
100%
90%
88%
86%
84%
87%
74%
90%
90%
88%
88%
82%
86%
81%
95%
90%
93%
95%
88%
92%
SERVICE
68%
78%
92%
94%
93%
69%
78%
96%
92%
94%
71%
78%
88%
92%
90%
TEAMWORK
78
90%
42%
46%
55%
62%
58%
58%
90%
38%
36%
48%
58%
48%
FINANCE
PILLAR
METRIC
Door to doc time
TEAMWORK
Above peers avg., below goal
At or below peer average
Step 7: Create an OPPE Policy and Procedure • Create a process to perform steps (1-6) • Who is accountable for each step? Who
provides oversight? • What data ‘counts’ for peer review and/or
reappointment? Who determines? • What addresses data integrity? • How does the MEC and BOT monitor?
Squeaky clean application:
Dr. Burroughs comes to you as a board certified emergency physician with no history of malpractice settlements or claims and excellent professional references.
What do you know about his clinical skills?
How would this have been handled seven years ago?
Focused Professional Practice Evaluation (FPPE): The more timely and focused assessment of a clinical practitioner clinical performance when exercising new privileges or when concerns are raised regarding existing privileges
The Scope of FPPE varies:
1. Practitioners who are new to the staff (broad evaluation)
2. Practitioners who request ‘new’ privileges outside of their ‘core’ (narrower evaluation)
3. Practitioners who have concerns raised with existing privileges (more specific evaluation)
The Type of FPPE varies:
1. Assessment of cognitive and procedural skills 2. May be prospective, concurrent, and
retrospective 3. May be reciprocal and preemptive 4. May utilize technology through tele-
proctoring, procedure recording, and simulation
Proctoring is NOT Precepting:
• Observational data • Objective criteria/scoring in different dimensions
(e.g. patient care, professionalism, communication etc.)
• Ideally, multiple proctors for balanced assessment
Potential Issues:
• Need for intervention in rare occurrences • Concerns with potential liability • Physicians don’t have the time (or want to be
paid!) • Communication to patients and staff • Surveyor specific proscriptions
FPPE Policy and Procedure: • Outline who is responsible for each step in the
process • Who designs and develops specialty specific
proctoring plans? • Who provides oversight and addresses potential
conflicts and conflicts of interest? • Should the proctor intervene if an adverse
outcome is likely to occur? • How does the MEC and BOT monitor and
indemnify?
How would you handle this issue today? The OR nurses report that Dr. Unpopular has a higher number of perforations during colonoscopy than her peers and that the medical staff should ‘do something about it.’
Questions, Discussion, and Wrap Up
Jon Burroughs, MD, MBA, FACHE, FAAPL [email protected];
603-733-8156
Slide Number 1
Ten years ago…..
Furthermore,
Patient Care:
Patient Care:
Step 1: Articulate Key Performance Expectations within each Dimension of Performance
Step 2: Create Relevant Performance Indicators/Metrics
So many Metrics-Which do we Pick?
Step 3: Set Targets for each Performance Indicator/Metric
The Challenge with utilizing a single target:
A better approach: Two Targets
Step 4: Classify all indicators/metrics
Step 5: Prioritize all indicators/metrics and targets
Step 6: Create a weighted feedback report
Balanced Scorecard- Inpatient
Balanced Scorecard- Outpatient
Slide Number 32
Slide Number 33
Squeaky clean application:
Proctoring is NOT Precepting:
Slide Number 43
Slide Number 44

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“How to do OPPE and FPPE with Minimal Resources”