Ongoing Professional Practice Evaluation Oppe Stanford

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Ongoing professional practice evaluation oppe stanford

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Summary

This policy applies to: Date Written or Last
 Stanford Health Care Revision: March 1, 2016
Name of Policy:
Ongoing Professional Practice Evaluation (OPPE)
Page 1 of 6
Departments Affected:
All Departments
I. 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, modify or revoke existing
clinical privilege(s). It is also used when appropriate to recommend further
evaluation such as a Focused Professional Practice Evaluation (FPPE)

II. POLICY STATEMENT
OPPE is conducted for each practitioner every nine months. The review is
performed by the Service Chief or designee. Each service evaluates and
recommends their service-specific performance targets and thresholds. The
Service Chief or designee evaluates and recommends service-based OPPE
indicators at least every three years

III. DEFINITIONS
A. Ongoing Professional Practice Evaluation (OPPE) is a 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 improvement or confirmation of achievement related to the
effectiveness of their professional practice in all practitioner competencies

B. Focused Professional Practice Evaluation (FPPE) is the focused evaluation of
practitioner competence in performing a specific privilege or privileges. This
process is implemented whenever a question arises regarding a practitioner’s
ability to provide safe, high-quality patient care as identified through OPPE or
other processes. (See Medical Staff and APP Professional Practice Evaluation
policy)
C. Practitioner Competencies
The medical staff has determined that for purposes of defining its expectations of
performance, measuring performance, and providing performance feedback it will
use the American College of Graduate Medical Education Framework outlined
below, whenever possible

D. 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

This policy applies to: Date Written or Last
 Stanford Health Care Revision: March 1, 2016
Name of Policy:
Ongoing Professional Practice Evaluation (OPPE)
Page 2 of 6
Departments Affected:
All Departments
E. 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

F. 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

G. 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

H. 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

I. 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

J. 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. Potential conflicts of interest are outlined in the
Conflict of Interest for Medical Staff policy. It is the obligation of the reviewer to
disclose to the Care Improvement Committee (CIC) Chair or Chief of Staff, in
advance, the potential conflict. It is the responsibility of the CIC Chair or Chief of
Staff to determine, on a case-by-case basis, if a potential conflict is substantial
enough to prevent the individual from completing the review. The determination
of the CIC Chair or Chief of Staff will prevail in any disagreement regarding the
existence of a conflict

IV. SCOPE
A. This policy addresses the OPPE of practitioners who are currently exercising
clinical privileges at SHC. Concerns identified by OPPE may be referred to the
CIC for appropriate action or may be considered through the reappointment
process

This policy applies to: Date Written or Last
 Stanford Health Care Revision: March 1, 2016
Name of Policy:
Ongoing Professional Practice Evaluation (OPPE)
Page 3 of 6
Departments Affected:
All Departments
B. During OPPE under this policy, the practitioner is NOT considered to be
“under investigation” for the purposes of reporting requirements

C. This policy does NOT address the Initial Focused Professional Practice
Evaluation (IFPPE) 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 (refer to SHC Policy
‘Initial Focused Professional Practice Evaluation (IFPPE) for New Providers,
New Privileges)

V. RESPONSIBILITY
A. Primary Responsibility: Service Chief
B. Oversight Responsibility: Medical Executive Committee (MEC)
C. Facilitator Responsibility: Medical Staff Services
D. Data Support: Quality Patient, Safety and Effectiveness Department (QPSED)
VI. DUTIES AND RESPONSIBILITIES
A. Chief of Staff:
1. Assures that Service Chiefs review OPPE Reports at least every nine
months and perform the subsequent follow-up per the process outlined in
this policy
2. Assist Service Chiefs with improvement plans when required
B. Service Chief or designee:
1. Evaluates OPPE reports and the subsequent follow-up per the process
outlined in this policy
2. Develops improvement plans when required
3. At the time of reappointment, reviews the past two years of OPPE and
FPPE data (if applicable) for individual providers and considers findings
in the re-credentialing process
C. Medical Staff:
1. 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 that it is used
to understand differences in performance relative to expectations

D. Medical Staff Services Department:
This policy applies to: Date Written or Last
 Stanford Health Care Revision: March 1, 2016
Name of Policy:
Ongoing Professional Practice Evaluation (OPPE)
Page 4 of 6
Departments Affected:
All Departments
1. Coordinates use of OPPE information into the credentialing and FPPE
processes
E. Quality Improvement:
1. Assembles indicator data from data systems for inclusion into OPPE
reports
2. Coordinates all types of indicator data into the OPPE reports based on
the current department OPPE metrics
VII. PROCESS/PROCEDURE
A. OPPE Report
1. The Quality Department staff coordinates all types of indicator data,
including volume data for the OPPE report based on the current OPPE
metrics

2. The OPPE metrics will continue to be refined over time to allow a
thorough evaluation of practitioner performance. The report will
encompass hospital-wide indicators and specialty specific indicators

3. At the time of reappointment, the Service Chief will review the most
current 24 months of OPPE and FPPE data and document the
interpretation and any improvement activities for each practitioner

B. Practitioner Performance Feedback
1. Every nine months, evaluation of OPPE reports will be conducted by
the Service Chief or designee. A designee may be appointed if a conflict
of interest is present. The Medical Staff Services Department will notify
the evaluator/reviewer when the OPPE reports are ready for review

2. The Service Chief will review the OPPE reports of the practitioners on
that service within 30 days of notification and communicate any
opportunities for improvement to the practitioner. This process may
trigger a FPPE

3. The Service Chief will document conclusions based on this review

Reviewer conclusion options are:
a) Acceptable Performance
b) Recommend FPPE
This policy applies to: Date Written or Last
 Stanford Health Care Revision: March 1, 2016
Name of Policy:
Ongoing Professional Practice Evaluation (OPPE)
Page 5 of 6
Departments Affected:
All Departments
4. The Medical Staff Services Department will follow-up with the Service
Chief if no communication is received within 30 days of the report being
distributed regarding practitioners who need an FPPE

5. If no follow-up is required, review will occur again in nine months

C. Improvement Plan Development
1. The Service Chief will determine if additional data are needed, if
performance is acceptable or if a FPPE is needed

2. If additional data are needed, the Service Chief, with the assistance of
QPSED, will define the additional evaluation

3. Following data review, if an improvement plan is required, the Service
Chief will develop the improvement plan

4. If the results of the improvement plan monitoring indicate concerns
regarding competency for specific privileges or maintaining medical staff
membership, the Service Chief will inform the CIC of the need for
consideration for FPPE

VIII. CONFIDENTIALITY
A. The following statutory language will be added to all OPPE documentation;
i.e. minutes, agendas, and attachments

1. “All OPPE documents are confidential and protected under California
Evidence Code 1156, 1157.”
B. E-mail communication of confidential OPPE proceedings or documentation
must be encrypted and include statutory language

C. OPPE electronic or paper documentation will be kept in confidential, protected
areas. (QPSED or Medical Staff Services department)
D. OPPE information will be stored in a practitioner’s quality file that is available
only to authorized individuals who have a legitimate need to know this
information based on their responsibilities. Files may be reviewed only under the
supervision of the manager of the Medical Staff Services Department or designee

E. OPPE data will be retained permanently

This policy applies to: Date Written or Last
 Stanford Health Care Revision: March 1, 2016
Name of Policy:
Ongoing Professional Practice Evaluation (OPPE)
Page 6 of 6
Departments Affected:
All Departments
IX. OVERSIGHT AND REPORTING OF OPPE ACTIVITY:
A written annual report to the MEC will include a summary of all OPPE actions
and compliance with this policy. The Director of the Medical Staff Services
Department will produce and present this report

A. REFERENCES:
1. The Joint Commission Hospital Accreditation Manual 2016, Medical
Staff Chapter MS.08.01.03.SHC Medical Staff Bylaws and Rules and
Regulations
2. SHC Policy Initial Focused Professional Practice Evaluation (IFPPE)
for New Providers, New Privileges
B. APPROVALS
Care Improvement Committee – 4/16
Medical Executive Committee – 4/16
Board of Directors – 4/16
“This document is intended for use by staff of Stanford Hospital & Clinics

No representations or warranties are made for outside use. Not for outside reproduction
or publication without permission.”

PROCESS/PROCEDURE . A. OPPE Report. 1. The Quality Department staff coordinates all types of indicator data, including volume data for the OPPE report based on the current OPPE …

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Frequently Asked Questions

What is ongoing professional practice evaluation oppe?

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.

Does oppe apply to all practitioners?

Any examples are for illustrative purposes only. OPPE identifies professional practice trends that may impact the quality and safety of care and applies to all practitioners granted privileges via the Medical Staff chapter requirements.

What is focused professional practice evaluation fppe?

The Joint Commission (TJC) mandates both Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) in order for a provider to receive privileges with a healthcare organization that is accredited by The TJC.

How do you ensure your oppe and fppe programs meet or exceed standards?

To assist in creating or updating your OPPE and FPPE program to meet or exceed minimum standards, ensure that your policies and procedures address the following considerations: 1. Standardize the frequency of performing evaluations. 2. Handle reviews consistently for all providers. 3.