Medical Staff Peer Review Policy

THE CHRIST HOSPITAL POLICY NUMBER 1.09.101

ADMINISTRATIVE POLICIES Page 1 of 10

POLICY TITLE: ONGOING PROFESSIONAL PRACTICE EVALUATION

APPROVED BY: MEDICAL EXECUTIVE COMMITTEE

ORIGINATED BY: MEDICAL STAFF SERVICES & QUALITY MANAGEMENT SERVICES

REVISED/REVIEWED: 6/2013

PURPOSE

The purpose of Ongoing Professional Practice Evaluation (OPPE) is to ensure that the hospital, through the activities of its medical staff, assesses a practitioner’s clinical competence and professional behavior on an ongoing basis. OPPE information is factored into the decision to maintain existing clinical privilege(s), to revise), or to revoke an existing clinical privilege prior to or at the time of renewal.

GOALS

I. To create an ongoing, systemic, data based process for the medical staff to evaluate practitioner performance and maintain accountabilities for addressing opportunities for improvement.

II. To identify and resolve performance problems.III. To create a positive peer case review culture by recognizing practitioner excellence as well as identifying

improvement opportunities through a process that is clearly defined, fair, efficient and useful.

SCOPE

This policy addresses the OPPE of practitioners who are currently exercising privileges as Practitioners under the evaluation of the medical staff. It also addresses the Focused Professional Practice Evaluation (FPPE) of those practitioners that arise from concerns identified by OPPE.

During OPPE and peer case review processes under this policy, the practitioner is NOT considered to be “under investigation” for the purposes of reporting requirements under the Healthcare Quality Improvement Act.

This policy does NOT address FPPE required to establish current competency of newly appointed practitioners, practitioners applying for new privileges or practitioners returning to active practice after a prolonged period of inactivity per FPPE policy number 1.09.102.

RESPONSIBILITY

Primary Responsibility: Medical Staff Quality Committee (MSQC) Chair, Department Directors, Division Chiefs and Medical Staff. Oversight Responsibility: MSQC, Medical Executive Committee (MEC)Facilitator Responsibility: Medical Staff Services and Performance Improvement Registered Nurses, Quality Management Services Data Support: Clinical Data Center Staff, Decision Support, and IS&T.

DUTIES AND RESPONSIBLITIES

I. MSQC Chair:A. Assurance that Department Directors / Division Chiefs review OPPE Profiles at least twice within a twelve

month period and perform the subsequent follow-up per the process outlined in this policy. B. Assist department directors with improvement plans when required. C. Track responses for requests for improvement, review the plans for adequacy and report to MSQC.D. Report to MEC regarding practitioner improvement plans developed and any instance where a plan was not

developed when requested, perceived to be inadequate or not accepted by the provider.II. Department Director:



A. Evaluation of OPPE profiles and the subsequent follow-up per the process outlined in this policy. The director may appoint a designee under the oversight of the MSQC if a conflict of interest is present.

B. Develops improvement plans with the assistance of the MSQC Chair or designee when required.C. At the time of reappointment, the Department Director / Division Chief will review the past two years of

OPPE and FPPE data (if applicable) and document the interpretation and any improvement activities for each indicator that required follow-up.

III. Medical Staff: A. The primary responsibility of the medical staff during the OPPE process is to understand their data relative to

their peers’, to recognize OPPE as a starting point for identifying improvement opportunities and is used to understand differences in performance relative to expectations.

IV. MSQC/MEC: A. The oversight of the OPPE Process is described in the MSQC Charter. The MEC has oversight of MSQC

activity. V. MEDICAL STAFF SERVICES:

A. Coordinate use of OPPE information into the credentialing and FPPE processes. VI. PERFORMANCE IMPROVEMENT REGISTERED NURSES/QMS:

A. Facilitate Peer Case Review process for review indicators and coordination of outcome data into OPPE profile.

VII. CLINICAL DATA CENTER STAFF: A. Assembles Rule and Rate indicator data from data systems, Decision Support &/or IS&T for inclusion into

OPPE profiles. B. Coordinate all types of indicator data into the OPPE Profile based on the current OPPE profile metrics.

POLICY

The MSQC evaluates and recommends for approval to MEC the hospital-wide OPPE indicators on an annual basis. In addition, each department evaluates and recommends their department-specific performance indicators, targets and thresholds on an annual basis to MSQC for review and recommendation to MEC for approval.

PROCEDURE

OPPE Report1. The Clinical Data Center staff coordinates all type of indicator data, including volume data, Rate and Rule indicator

data and Peer Case Review indicator data into the OPPE Profile based on the current OPPE profile metrics. 2. The OPPE Profile metrics will continue to expand over time to allow a thorough evaluation of practitioner

performance. The profile shall encompass all hospital-wide indicators and specialty specific indicators. All specialty specific indicators recommended by each Department must be reviewed by MSQC and recommended for approval by MEC.

Practitioner Performance Feedback 3. Twice in a twelve month period, evaluation of OPPE profiles shall be conducted by the Department Director/Division

chief. The director may appoint a designee under the oversight of the MSQC if a conflict of interest is present. Medical Staff Services will notify the evaluator/reviewer when the OPPE Profiles are ready for review upon request by QMS.

4. The Department Director/Division chief will review the OPPE profiles of the department members within 30 days of notification and communicate with the practitioner those indicators rated ‘Needs Follow-up’ if: a. Any indicator has two sequential report periods in the Needs Follow-up categoryb. Any indicator has two out of four sequential report periods in the Needs Follow-up category

5. After follow-up, the Department Director/Division chief will document conclusions for each indicator and whether there is either a need for obtaining additional data or an improvement plan is required.

6. The MSQC Chair will follow-up with the Department Director/Division chief if no communication is received within 30 days of the report being distributed regarding areas that Need Follow-up.

7. If no indicators need follow-up, review again in six (6) months.

Improvement Plan Development8. The Department Director/Division chief, with the oversight of the MSQC Chair will determine if additional data is

needed or if the current data indicates an improvement plan should be developed.



9. If additional data is needed, the Department Director/Division chief, with the assistance of Quality Management, will define the additional data study.

10. Following the review of the additional data, the Department Director/Division chief will submit a report to the MSQC regarding whether an improvement plan is required.

11. If an improvement plan is required, the Department Director/Division chief will develop the improvement plan.

Improvement Plan Accountability 12. The MSQC Chair will track responses for requests for improvement, review the improvement plan for adequacy and

report to the MSQC on the adequacy of the improvement plan. 13. The MSQC Chair will report to the MEC regarding practitioner improvement plans developed and any instance where

a plan was not developed when requested, is perceived to be inadequate or not accepted by the provider. 14. If the results of the improvement plan monitoring indicate concerns regarding competency for specific privileges or

maintaining membership, the MSQC will inform the MEC of the need for consideration for FPPE.

Use of OPPE at Reappointment15. At the time of reappointment, the Department Director/Division chief will review the most current 24 months of

OPPE and FPPE data and document the interpretation and any improvement activities for each indicator that required follow-up during that period of time.

16. If the results of OPPE indicate a potential issue with practitioner performance, the MSQC, MEC or Department Director/Division chief may initiate a FPPE. Refer to FPPE Policy # 1.09.102.

17. Triggers that may initiate FPPE are described in the FPPE policy (Policy # 1.09.102). 18. In addition, a single serious or egregious case may also initiate FPPE.

See OPPE Process Flow Chart for further process/action flow, [Appendix A] of this policy

Types of indicators Different Types of indicators are utilized to identify potential quality concerns. The indicator type dictates the action required:

1. Rule indicators will have a letter sent based on the targets established by MSQC / MEC.2. Rate indicators are trended and assessed at appropriate time period relative to the target established by

MSQC /MEC.3. Review indicators will go to the assigned initial practitioner reviewer from the Department designated Peer

Case Review Committee(s).

The Peer Case Review Process is:

A. A member of the peer review committee performs the initial practitioner review of the medical record and prepares the case for presentation

B. Each case is taken to committee in summary format or for additional discussion. 1. Practitioners shall not participate in the outcome determination or sign off on his/her own cases. But may be

present during and hear the case discussions.2. The committee must reach outcome determinations by obtaining a consensus of members present. 3. If there are no issues identified, the final case rating remains as ‘Care Appropriate’ and a summary of these

cases is reported to MSQC.4. If a potential issue remains, a letter (can be certified) is sent to the practitioner responsible for the issue(s)

and a response is expected within fourteen (14) days (If the practitioner is not present to respond). 5. The case returns to the Department Peer Case Review Committee with the original case rating form and the

response from the practitioner. With or without a response from the practitioner, the committee then decides the final case rating and actions warranted by obtaining a group consensus.

C. Final Case Rating1. Final Case Rating of “Inappropriate” and IHI Harm Classification of 1-3 are included in reporting to MSQC /

MEC.2. Final Case Rating of “Inappropriate” and IHI Harm Classification of 4-6 are referred to MSQC, are included

in reporting to MSQC / MEC and are considered for FPPE. If FPPE needed, will be referred to FPPE Process (policy 1.09.102).

3. If the Department Peer Case Review Committee is unable to reach a final case rating the case is referred to the MSQC for determination.

D. Process for MSQC Referral



1. PI Nurse will complete the ‘Presentation of Peer Review Case to MSQC’ form and submit to PI Manager for the next MSQC meeting. MSQC Chair will be notified of case specifics, provider response and committee concerns.

2. MSQC Chair presents case or invites Peer Review Committee chair to present case to MSQC. 3. MSQC determination and recommended actions are documented on Case Rating Form.

E. The Christ Hospital standard is that the medical record is completed within 30 days of the patient’s discharge. As

long as key elements facilitating peer case review (i.e. H&P, consultation notes, procedural reports, discharge summary) are present case review should proceed. Additional information can be requested from the practitioner(s) during the review process.

F. Immediate Reviews: When an issue has been identified and needs concurrent or prompt review, a Performance Improvement Nurse will contact the appropriate Department Director. The Department Director will review the case and provide feedback to the PI Nurse within 72 hours.

G. Retrospective Reviews: PI Nurses will facilitate peer case review through the Department Peer Case Review Committee. The process must be concluded within 90 days from the date the chart is reviewed by the PI Nurses.

H. External Reviews: 1) The VP/CMO, the MEC or the MSQC may request external review 2) Consideration for External Review can be made under the following circumstances:

1) Department Peer Case Review Committee is unable to reach a final case rating2) The Department Director has concerns for bias or conflict of interest3) Specialty reviewer unavailable internally

3) The MSQC Chair shall report results of external review to the VP/CMO, the MEC and the MSQC. A written letter of the review results shall also be issued to the practitioner. All paperwork associated with the review must be returned to the PI Nurse within 30 days of receipt.

I. Case Rating Forms: The Case Rating Form is the one form to be utilized to document the Peer Case Review process. The top portion will be completed by the PI Nurse. The PI Nurses will make every effort to ensure each case rating form is completed at the time of the review. If a form is incomplete, it will be returned to the reviewer to be completed immediately.

See Peer Case Review Process Flow Chart for further process/action flow, [Appendix B] of this policy

PROCEDURE FOR PROTECTING CONFIDENTIAL OPPE INFORMATION AND DOCUMENTS:

1. Attach the following statutory language to all OPPE documentation; i.e. minutes, agendas, and attachments.

a. “These documents are used by and/or prepared for use by a peer review committee, within the scope and functions of a peer review committee, for the purpose of reviewing professional qualifications and/or activities of health care providers, pursuant to Ohio Revised Code 2305.24, 2305.25, 2305.252 and 2305.253, and are privileged and confidential. Documents are not to be copied or distributed to unauthorized individuals.”

2. E-mail communication of confidential OPPE proceedings or documentation must be encrypted and include statutory language statement noted in item #1.

3. Email Communication of Peer Case Review Responses by practitioners is prohibited.

4. All proceedings and records within the scope of these quality review activities are confidential and members of the Department attending the meeting in which peer case review is conducted, serving as a peer case reviewer, working for or on behalf of the Department or providing information to the Department for peer case review activities are entitled to confidentiality according to Ohio Revised Code Section 2305.252.

5. Store all OPPE documentation in confidential, protected areas. (Quality Management Services department or Medical Staff Services department)



6. OPPE information in a practitioner’s quality file is available only to authorized individuals who have a legitimate need to know this information based on their responsibilities. The [Chief Medical Officer / Vice President of Medical Affairs] will ensure that only authorized individuals have access to individual provider quality files and that the files are reviewed under the supervision of the manager of medical staff services or designee for the following individuals:

a) The specific providerb) Members of the MEC and/or department chairs and credentials committeec) Vice President of Medical Affairs/Chief Medical Officer, medical staff services

professionals, quality director, and quality staff members supporting the peer review process

d) Individuals surveying for accrediting bodies with appropriate jurisdiction (e.g., The Joint Commission or state/federal regulatory bodies)

7. OPPE data will be retained for seven (7) years, unless the case involves minors; whose would need to be retained for twenty (20) years.

OVERSIGHT AND REPORTING OF OPPE ACTIVITY:

1. A written annual report to the MSQC will include a summary of all indicators including coded physician-specific information and action taken. This report will be due two weeks’ prior to the meeting date. This report will be forwarded to the MEC per the MSQC reporting structure.

DEFINITIONS

Ongoing Professional Practice Evaluation (OPPE) is a document summary of ongoing data collected for the purpose of assessing a practitioner’s clinical competence and professional behavior. Through this process, practitioners receive feedback for potential personal improvement or confirmation of personal achievement related to the effectiveness of their professional practice in all practitioner competencies.

Focused Professional Practice Evaluation (FPPE) is the time limited evaluation of practitioner competence in performing a specific privilege. This process is implemented for all initially requests privileges and whenever a question arises regarding a practitioner’s ability to provide safe, high-quality patient care. (Policy # 1.09.102)

A peer is defined as an individual that is credentialed within the same specialty discipline and with the same scope of clinical privileges; an individual practicing in the same profession who has expertise in the appropriate subject matter under review. Resident review of credentialed Medical Staff members is not peer review.

Peer Case Review is an evaluation of a practitioner’s professional performance for all defined competency areas using multiple data sources. Case Review is a part of OPPE. It is separate from other processes such as: root cause analysis, hospital PI, M&M conferences, or clinical management conferences.

Practitioner An individual permitted by law and by the organization to provide care, treatment and services without direct supervision. A practitioner operates within the scope of his or her license, consistent with individually granted clinical privileges. This may include; physicians, oral and maxillofacial surgeons, dentists, podiatrists, physicians’ assistants and some Advanced Practice Registered Nurses (APRNs).

Practitioner Competencies: The medical staff has determined that for purposes of defining its expectations of performance, measurement of performance, and providing performance feedback for the Joint Commission General Competencies, it will use the American College of Graduate Medical Education Framework outlined below:

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.

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.

Practice-Based Learning and Improvement



Practitioners are expected to be able to use scientific evidence and methods to investigate, evaluate, and improve patient care practices.

Interpersonal and Communication Skills Practitioners are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families, and other members of health care teams.

Professionalism Practitioners are expected to demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity, and a responsible attitude toward their patients, their profession, and society.

Systems-Based Practice Practitioners are expected to demonstrate both an understanding of the contexts and systems in which health care is provided, and the ability to apply this knowledge to improve and optimize health care.

Conflict of Interest: A member of the medical staff requested to perform OPPE evaluation may have a conflict of interest if he or she may not be able to render a fair and constructive opinion. An absolute conflict of interest would result if the practitioner is the provider under review or a first-degree relative or spouse. Potential conflicts of interest may result if the practitioner is directly involved in the patient’s care but not related to the issues under review or a direct competitor, partner or key referral source. Potential conflicts may also result if the practitioner is involved in a perceived personal conflict with the practitioner under review.

It is the obligation of the reviewer to disclose to the MSQC, in advance, the potential conflict. It is the responsibility of the MSQC to determine on a case-by-case basis if a potential conflict is substantial enough to prevent the individual from participating.

IndicatorsA. A Review indicator is an unusual or unexpected actual or potential outcome requiring practitioner review to

determine appropriateness of practitioner careB. A Rule indicator is based on reported events, audits or abstracted data and is used for clinical practices or behavioral

policies that don’t require case review. The purpose is to automatically inform practitioners of non-compliance for each event through an educational letter. The goal is self-improvement and no follow-up is needed until the established target is exceeded.

C. Rate indicators are used for outcomes with some frequency of occurrence (not rare) for all practitioners for the procedure or condition. Typically are “known complication of disease” and are expressed as a percent or percentile.

Multi-Specialty: is the term used to describe the multiple specialty areas within the same professional licensure i.e. anesthesiology, cardiology, psychiatry, etc.

Multi-Discipline: is the term used to describe multiple disciplines working within the institution i.e. physicians, nurses, dietitians, physical therapists, respiratory therapists, etc.

A Peer Case Review Committee(s ) will be established for each Department and have an individual peer review plan. The plan will be developed in accordance to the Medical Staff Bylaws and Medical Organization and Function Manual. The plan will clearly state membership, determination of a quorum and actions that may be taken in the absence of a quorum, meeting frequency and all indicators to be utilized in addition to the Hospital-wide OPPE Profile metrics and case review indicators. The committee shall meet a minimum of four times per year (quarterly).

Attachment List:

APPENDIX A: OPPE Process Flow ChartAPPENDIX B: Case Review Process Flow Chart

REFERENCES:

1. HCPro, Inc. and The Greeley Company, The OPPE Done Right Seminar Workbook, HCPro, Inc., Peabody, MA, 2011.

2. The Joint Commission Accreditation of Health Care Organizations, Accreditation Program: Hospital, 2009, Chapter: Medical Staff, p. 164 – 165.

3. TCH Policy Number 1.09.102 – “Medical Staff Focused Professional Practice Evaluation”. 4. TCH Policy Number 1.8.100 – “Peer Review Process”.



5. TCH Medical Staff By Laws, Article II ‘Medical Staff Categories’; p.13.6. TCH Organization and Function Manual, p. 21-23

APPENDIX A





APPENDIX B

