News and Views for Healthcare Accreditation Professionals

Archive for July, 2012

TJC holds Medical staffs for having data to support OPPE

I recently asked a question of SIG about what hospitals should do if they had no data to support OPPE.  This generally occurs with low volume, or no volume.  I had suspected this would be a problem in that no actual data would be available to support the conclusion of competency.  I also asked for further details on their position on the “Good Standing” letters.  Here is how the conversation went:

Question: If a physician does not complete his/her initial focused review because of lack of volume (or no volume), and the focused review period has been extended for two years, and still there is no volume, can the hospital depend on a “letter of good standing” as sufficient information to grant the physician reappointment (with no OPPE data either)? Thank you.

Answer: Based on your example, the letters would not be able to serve as a substitute for OPPE data or for low or no volume providers. There  is also no FPPE completed so OPPE would not be able to be accomplished. It is not uncommon for organizations to simply inform the practitioner that they either need to find a way to meet/complete the FPPE requirements, or consider removing them from staff, or placing them in a status that does not require FPPE/OPPE – however, this would also mean that they would have no privileges to treat patients.  The letter referenced that only states “in good standing “ for OPPE is not adequate.  There needs to be evidence of privilege-specific competency.

FAQ: For practitioners who have been granted clinical privileges at an organization,  every organization must collect data for the ongoing professional practice evaluation (OPPE) related to performance within its own organization.  OPPE would not apply if the practitioner has membership only with no clinical privileges.  Any information received from another organization can only be used as supplemental information and not in lieu of collecting organization specific data or evaluating performance within the organization.

Prior to sharing such information between organizations, even with the practitioner’s consent, organizations should obtain legal advice on whether such sharing would affect the protections provided by any applicable State peer review statute.

The OPPE standard will not fully address the issue of the low or no volume practitioner.  Organizations must collect data, even data showing zero performance.  At each review point, e.g. quarterly or every six months, the medical staff and governing body would use the data, however, limited, to determine whether to continue, limit, or revoke any existing privileges.

At the two year reappointment if the organization determines it has insufficient practitioner specific data, then per standard MS.07.01.03 EP 2 “Upon renewal of privileges, when insufficient practitioner-specific data are available, the medical staff obtains and evaluates peer recommendations.

Comment:  Since peer recommendations are obtained for all providers, it would seem on the surface that organizations would love to just say that a peer recommendation could substitute for performance data.  Stay tuned for more interpretations.



TJC has reversed its previous (years ago) opinion.  Currently they REQUIRE that unauthenticated verbal and telephones that are unsigned at 30 days be included in the delinquent medical record count.  Be aware that CMS does not allow for the luxurious “50%” delinquency rate, but actually mandates NO delinquent medical records.

Delinquencies have resulted in termination notices being issued.