News and Views for Healthcare Accreditation Professionals

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.

Comments on: "TJC holds Medical staffs for having data to support OPPE" (1)

  1. I am concerned that the implementation of some recent healthcare laws has the effect of actually threatening patient safety and quality care vice helping. While patient complaints and staff concerns are important, I believe that they are being over valued by many community hospitals. Often we set up anonymous systems of reporting that are essentially misused by nurses, techs or administrators (or unstable patients/drug seekers) to attack doctors that challenge them. True aggressive or abusive behavior by a physician is a problem. However, without any objective standard, any minor complaint seems to qualify as a registered complaint. As with any interpersonal issues….misunderstanding and disagreements should be expected. (I could go on here based on years of experience as a pilot who instructs and evaluation crew resource management and aviation safety).
    Furthermore, the issue of tying government program funding for hospitals based on reviews patient satisfaction scores is quite flawed and further encourages hospitals to press medical staff to just please patients and not to provide quality care. It should be obvious how this behavior (motivated by profit and some misguided care concern) has been part of the epidemic abuse of prescription pain medication.
    The system of peer review was a valuable system to help physician train and maintain standards. However, it appears now to have moved to a “witch hunt” type system where hospitals are protecting themselves from legal attacks. Too me the overall process is now out of the control of the physicians, so it is no longer true “peer review” and is more akin to hospital risk management oversight. It is a system without clear standards and a sanctioned lack of due process. Why should anyone trust this type of system given all of the external pressures exerted? Why would any physician speak up or even challenge a nurse anymore? It should also be concerning that many physicians are happy to just follow along with given regulations, without much critical thought, as long as it lets them remain focused on practicing medicine and not executing administration. This results in a system where the true medicine providers are no longer in control of the process. To me this is quite dangerous to real patient safety…ala the cautionary tale of Dr. Semmelweis.

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