In our travels to help hospitals prepare for Joint Commission surveys, we find that many hospitals still have not yet met the expectations of the requirement for Ongoing Professional Practice Evaluation (OPPE). OPPE is an attempt to put some structure behind the process of evaluating clinical competence. A well-designed and compliant OPPE program is able to demonstrate, via data, that a physician with clinical privileges is competent in the exercise of those privileges. The second purpose of OPPE is to intervene in a timely manner when there is evidence that clinical expectations have not been met. While making an OPPE program work involves administrative planning and execution, the most important factor is engaging the leadership of the Medical Staff to ensure that the process is meaningful and that it fulfills its purposes.
OPPE generally involves five steps: design; gather data; aggregate, analyze and report; evaluate the data; and finally, act appropriately on the results. (If you don’t act on the findings, the rest of the process will be an expensive waste of time.) Many hospitals struggle with all of these steps. But, the steps that pose the most consistent challenges are the ones that involve physicians (design, evaluate, and act).
For example, a common problem regarding evaluation arises when hospitals decide to collect data that are easy to measure (e.g., financial data), but not very meaningful. The result is that the report looks nice on paper, but the Medical Staff can’t actually evaluate clinical performance. Even worse, the hospital runs the risk of teaching physicians that compliance on paper, rather than self-management, is the goal. What does that do to physician attitudes toward compliance, accreditation and other externally driven “quality” initiatives? By measuring meaningless data, hospitals teach physicians to disengage and view the evaluation efforts as busywork, not beneficial assessments of performance.
Ultimately, OPPE isn’t about satisfying The Joint Commission. It is about measuring the things that are important to patients, who trust that you are ensuring that your hospital’s Medical Staff is competent. Consequently, several principles should be considered when designing an OPPE program.
First, realize that one size doesn’t fit all. The American College of Cardiology, American College of Surgeons, and Society for Thoracic Surgery all came up with clinical indicators for their specialties. Just as these indicators can’t be applied to other specialties, different performance indicators are needed for different specialties within your hospital. This makes data gathering harder, but ensures that the data obtained is meaningful.
Consider including some non-medical indicators, such as important behavioral measures, in your OPPE, as well. For example, because monitoring for post-procedure infections is important, your ICP sends information requests to physicians involved in appropriate procedures. If your hospital is like most, physicians rarely return the forms to the ICP. Why not list number of eligible procedures, number of reports returned, and number of infections?
Another idea for measuring important indicators is to send questionnaires to patients about complications and satisfaction with physician follow-up, physician-provided education or informed consent. When you start to measure data like these, physicians pay attention, since they know it is important.
What do you do if physicians object? Remind them that they have nothing to fear; they are good doctors who provide excellent care to their patients. One or two disgruntled patients will not make a physician an outlier. But patient feedback, when reflected upon with a professional improvement mindset (rather than a defensive one), may identify opportunities to improve practice. After all, great patient care requires great communication as well as great clinical decision-making and skills.
OPPE was a breakthrough concept, and it remains an important one for ensuring quality patient care. It reminds us that hospitals grant clinical privileges to practitioners who can demonstrate their competence in using them. Creative approaches make OPPE a meaningful exercise. In the end, it’s not about making the OPPE process easy; hospitals are ultimately charged with creating a fair and reliable tool to protect patients.
