Ongoing professional practice evaluation (OPPE), a mandated process by The Joint Commission to evaluate and monitor the competency, professional behavior, and performance of practitioners, can often feel a bit overwhelming. To aid you in executing your OPPE process, one of our November featured research pieces answered a number of questions your fellow HBI Cost & Quality Academy members have been asking on this topic. Here are four key insights from this research about improving OPPE processes:
1) Select Appropriate Evaluation Metrics
A major area for improvement in the OPPE process for many hospitals and health systems is ensuring that the right general and department-specific evaluation metrics are chosen. Organizations have found success by focusing general competency metrics on interpersonal communication, practice-based learning, professionalism, and systems-based practice. Example metrics include mortality, readmissions, infection rates, and compliance with evidence-based protocols and CMS and TJC standards.
2) Create Specific Committees and Delegate Tasks
Another effective strategy for enhancing the OPPE review process is establishing specific committees and appointing relevant personnel to lead the identification and review process. Generally, department chairs, designees, or division chiefs are chosen to recommend the evaluation metrics for their individual departments. Then, a peer review committee made up of medical staff approves these metrics, often with input from a medical executive committee. These same groups and individuals are typically involved in actually carrying out the OPPE evaluation and making final recommendations as well.
There are exceptions to this process—some organizations include their chief medical officer in reviews, and others have created committees specifically to carry out the review process (e.g., a Medical Staff Performance Improvement Committee).
3) Carry Out Reviews Frequently
Though TJC standards require evaluations to occur more than once every 12 months, most organizations conduct reviews every six to nine months. Other organizations are more ambitious, carrying out reviews every six to eight months.
4) Tailor the Review Process for Low- or No-Volume Providers
Reviewing the performance of low- or no-volume practitioners is a complicated endeavor because data is often absent. But to comply with TJC standards, organizations need to establish a procedure for collecting data for these practitioners anyway. Strategies to do so include:
- Aggregating data from a practitioner’s practice at other facilities
- Increasing their clinical activity levels
- Requesting a reduction in privileges
Certain organizations have taken a more creative approach. Syosset Hospital, for instance, has offered these providers an extended time period to increase their volume. If they fail to do so, they can request to become adjunct staff.
To learn more about the OPPE process, check out the featured research piece and this case study about re-credentialing and privileging low- and no-volume providers. To gain access to this information on our online members-only portal—and to our analyst team that can answer custom research requests—join our membership community today.
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