professional practice evaluation: a look into one critical ... · –tjc –diversity statement...

Professional Practice Evaluation: A Look Into One Critical Access

Hospital’s Peer Review Program

Kristen L. Rifenbark, MSA, CPHRM, CPPSRisk, Document & Patient Safety Coordinator

Scheurer Hospital989.453.4469 [email protected]

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Conflict of Interest Disclosure

Kristen L. Rifenbark does not have any real or apparent conflict(s) of interests or vested interest(s) that may have a direct bearing on the subject matter of the continuing education activity.

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Learning Objectives

This presentation will enable participants to:

1. Describe the requirements of The Joint Commission's Professional Practice Evaluation standards.

2. Illustrate how Scheurer’s Professional Practice Evaluation (PPE) Program works.

3. Describe how the PPE process compliments an Enterprise Risk Management Program.

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Acronyms

• ACGME – American College of Graduate Medical Education• ASHRM – American Society for Healthcare Risk

Management• CAH – Critical Access Hospital• CoPs – Conditions of Participation• COS – Chief of Staff• CRNA – Certified Registered Nurse Anesthetist• ED – Emergency Department• EP – Elements of Performance• ERM – Enterprise Risk Management • FPPE – Focused Professional Practice Evaluation

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Acronyms, continued

• HFAP – Healthcare Facilities Accreditation Program • MEC – Medical Executive Committee• NP – Nurse Practitioner• OPPE – Ongoing Professional Practice Evaluation• PA – Physician Assistant• PPE – Professional Practice Evaluation

– Name Alert ~ NOT Personal Protective Equipment

• QI – Quality Improvement Department• SD – Standard Deviation• TJC – The Joint Commission

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Poll Questions

• Raise your hand if you have an established PPE program.

• Raise your hand if you are a critical access hospital.

• Raise your hand if PPE is your favorite!

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Background

• 25 bed Critical Access Hospital (CAH)– Note: All standards I’ll describe are for CAHs

• Approximately 130 members on our Medical Staff – Includes 50ish teleradiologists

• Active Staff and Medical Executive Committee (MEC) Composition– 1 pediatrician– 6 family practice– 1 internist– 1 radiologist

• 2 full time Certified Registered Nurse Anesthetists – No Anesthesiologists

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Objective # 1

Describe the requirements of The Joint Commission’s Professional

Practice Evaluation standards.

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The Joint Commission Standards July 2017

• MS.06.01.05

– The decision to grant or deny a privilege(s), and/or to renew an existing privilege(s), is an objective, evidence‐based process.

• MS.08.01.01

– The organized medical staff defines the circumstances requiring monitoring and evaluation of a practitioner’s professional performance.

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The Joint Commission Standards July 2017, continued

• MS.08.01.03– Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing privilege prior to or at the time of renewal.

• MS.09.01.01– The organized medical staff, pursuant to the medical staff bylaws, evaluates and acts on reported concerns regarding a privileged practitioner’s clinical practice and/or competence.

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Within these 4 standards there are a total of 27 Elements of Performance.

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Within these 4 standards there are a total of 27 Elements of Performance.

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Healthcare Facilities Accreditation Program Standards 2017

• Chapter 5, Staffing

– 05.01.28 – Ongoing Professional Practice Evaluation (OPPE)

– 05.01.29 – Focused Professional Practice Evaluation (FPPE)

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05.01.28 OPPEOPPE information is factored into the decision to maintain existing privilege(s), to revise existing privilege(s), and/or to revoke an existing privilege prior to or at the time of renewal.

05.01.29 FPPEThe organized medical staff defines the circumstances requiring additional, focused monitoring and evaluation of a practitioner’s professional performance.

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Objective # 2

Illustrate how Scheurer’s Professional Practice Evaluation (PPE) Program works.

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PPE and Peer Review

• Our “hard core” PPE program started in April, 2011

• Previously had physician profiles

• Previously had a Peer Review process for “problem” cases

• No routine chart review

– Exception: Physician Assistants (PA) and Nurse Practitioners (NP)

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Responsibilities

• Oversight– Medical Executive Committee

– Who ultimately “owns” PPE? (MS.09.01.01, EP 1)

• Coordination– Quality Improvement Department – in policy

– Risk Management – in practice

• All Medical Staff– In Bylaws

– In contracts

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At ScheurerPPE is the responsibility of the organized Medical Staff. Coordination and all processes to accomplish PPE are carried out and conducted by the Quality Improvement Department; the Medical Staff are asked to participate as needed.

PPE is therefore “owned” by the Medical Staff and in practice by the Quality Improvement Department. In some facilities this is accomplished by the Medical Staff Office.

Scheurer Bylaws excerpt:SECTION 6. PROFESSIONAL PRACTICE EVALUATION Professional Practice Evaluation (PPE) shall be conducted on each Practitioner who is appointed to the Medical Staff and Allied Health Personnel with clinical privileges. The Medical Executive Committee shall provide oversight for the PPE process including the review and approval of the Hospital PPE policy that further defines the process and methodology. Core areas of competency includes, but is not limited to: patient care, medical/clinical knowledge, practice‐based learning and environment, communication and interpersonal skills, professionalism, system based practice, and activity (volume).

A period of focused review, referred to as Focused Professional Practice Evaluation (FPPE) shall occur when a Practitioner is initially appointed to the Medical Staff or an Allied Health Personnel is granted clinical privileges, new or modified clinical privileges are granted, and when members return from a Leave of Absence. FPPE may also be used when the Medical Executive Committee determines more frequent or intensive monitoring and evaluation is necessary based on findings identified from ongoing review. FPPE shall also be used in the event a Volunteer Licensed Independent Practitioner is authorized to provide patient care during a disaster situation. Whenever feasible, FPPE shall be completed within 72 hours of the practitioner’s arrival to assist the Chief of Staff or designee and/or the Chief Executive Officer or designee in determining whether authorization should continue beyond 72 hours. Ongoing Professional Practice Evaluation (OPPE) is the routine monitoring and evaluation of competency for current members of the Medical Staff and Allied Health Personnel.

Contract Excerpt Samples from Scheurer:Sample 1: Peer Review. Physician shall cooperate with and participate in Hospital’s peer review and/or quality assurance programs, as may be adopted from time to time, and abide by any decisions and recommendations of such peer review or quality assurance programs.

Sample 2: Physician shall cooperatively and meaningfully participate in utilization review, quality improvement, peer review, record review and risk management activities of Hospital and its medical staff.

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Areas of Core Competency

• From Accreditation Council for Graduate Medical Education (ACGME) (MS.06.01.05, EP 8)

• Patient Care• Medical/Clinical Knowledge• Practice‐Based Learning and Improvement• Interpersonal and Communication Skills• Professionalism

– TJC – Diversity statement – MS.06.01.03

• System‐Based Practice

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“1n, 2002, the ACGME launched a competency initiative called the Outcome Project. As a result of this project, ACGME identified six ACGME Core Competencies to be used by GME programs to evaluate their residents in training. Each competency is made up of different milestones residents are required to master at key stages of their medical training.”

Source: http://www.ecfmg.org/echo/acgme‐core‐competencies.html

Scheurer’s PolicyPatient 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 at support care at the end of life.

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

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.

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 the health care team.

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. The Joint Commission considers diversity to include race, culture, gender, religion, ethnic background, sexual preference, language, mental capacity and physical disability. (MS.06.01.03)

System‐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.

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Focused Professional Practice Evaluation

• New Practitioners (MS.08.01.01, EP 1)

• New Privileges (MS.08.01.01, EP 1)

• Return from Leave of Absence

–Who tracks this?

• OPPE Identifies a Need (MS.08.01.01, EP 6)

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Examples of Leave of Absences:

1. Practitioner goes on an extended mission trip.2. Maternity leaves

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FPPE, continued

• Monitoring Period (MS.08.01.01, EP 3)

– Date practitioner has activity thru end of current eval period

• Criteria for Reviews (MS.08.01.01, EP 3 & 5)

– Spelled out in policy

• QI Request Reviews

– For significant concerns identified by QI

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Ongoing Professional Practice Evaluation

• Every 6 months– TJC = at least every 9 months/more frequently than annually

– HFAP =at least 3 times during the two‐year appointment cycle

• OPPE or FPPE but not both

• Monitoring (Introduction to standard MS.08.01.03)– Retrospective chart review

– Clinical measures

– Complaints

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Evaluation

• Chief of Staff reviews findings from OPPE and FPPE– The Practitioner Profile

– Determines if practitioner demonstrates competency for clinical privileges granted (MS.08.01.03, EP 1)• MEC is informed and approves

• The practitioner is informed

– Does not demonstrate competency or has not had enough volume to eval (MS.08.01.01, EP 6 & MS.08.01.03, EP 3)• COS documents action plan

• Takes to MEC for decision

• The practitioner is informed

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The Struggle Bus is Real!

• Low or No Volume

• For PPE – use your own data and information (Intro to MS.08.01.01)

• For Credentialing – use your data and others’ data (MS.08.01.03, EP 3)

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Low/No Volume Providers

• Review continues for another 6 months

• Two year privilege period (MS.08.01.03, EP 3)

–MEC determines if privileges should be granted again

–May use info from other hospitals/facilities

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I can not claim that our process/position on Low/No Volume Providers is perfect or even correct by any means. All I can say is that we take baby steps and try to improve as much as we can each round.

Previously, we required practitioners who rented space for clinical reasons to be Medical Staff members. In April 2017 we modified the Bylaws to state that if the practitioner is not clinically treating any of our (Scheurer’s) patients they are not required to become a Medical Staff member. This was a huge step forward for us as many of the practitioners who only rent space from us never see our patients and therefore have no/low volume during the PPE process.

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Practitioner Profiles

• Used at reappointment time (MS.08.01.03, EP 3)

• Given to Medical Staff Office to include in privileging packet

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Sample Practitioner Profile – Family Practice

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Introduction to MS.08.01.03 gives samples that can be used in the practitioner profiles

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Introduction to MS.08.01.03

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Sample PPE Sign Off Form

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MS.08.01.01, EP 8 & 9

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3 Standard Deviations

32Inpatient Readmissions

MS.08.01.01, EP 4

Scheurer believes that 3 standard deviations is an objective way to determine if the criteria is in or out of range.

Measures:BU (172)Inpatient readmissions (176)ED returns (3296)ED Throughput Time – Arrival to discharge (99 minutes)ED Time to first physician contact (13 minutes)

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Your Turn!

• What “easy” measures can you use?

–Mandated measures

– Attendance

– Customer complaints

• Remember…zero (0) is a value!

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Your Turn!

• Write down 3‐5 people you can gather information from.

• Ideas– Customer Service

– Quality Improvement

– Medical Records

– Medical Staff Office

– Human Resources

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Types of Case Review – Routine

• Retrospective Chart Review 5 cases for most

• CRNA

–Mix of type of anesthesia

– Procedures inside and outside the OR

– Reviewer = another CRNA

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Types of Case Review – Routine, continued

• Emergency Department– Mix of patient age and high risk diagnoses – I.e. asthma, diabetes, COPD, CHF, pneumonia, abdominal or chest pain, fever in children, etc.

– Reviewer = Board certified ED to board certified ED or internal med/family practice to internal med/family practice

• Inpatient, observation, Long Term Care– 5 cases total, at least one from each service, if available – Mixed ages and high risk diagnoses– Reviewer = Internal med/family practice to internal med/family practice

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• Surgeons

–Mix of inpatient/outpatient procedures, varying ages and types of procedures, high risk

– Reviewer = physician within same specialty i.e. general surgeon to general surgeon

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• Blood Utilization– All units are reviewed each quarter– Outside criteria, as determined by Medical Director, sent to ordering practitioner for more comments

– Medical Director determines level of concern

• Clinics– 5 cases = 1 child and 4 adults– High risk diagnoses i.e. COPD, asthma, diabetes, CHF, well‐child visits

– Reviewers = midlevels to midlevels and physicians to physicians

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• Radiology

– 20‐25 cases of mixed modalities

– Selected randomly Diagnostic Imaging Department

– External reviewer due to only one radiologist on staff

• Coming to a hospital near you, Trauma Reviews!

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Michigan Department of Health and Human ServicesLevel IV Criteria Quick Reference Guide, 10.1.2015

See the following sections: • The Role of a Trauma Facility in a Trauma System • Performance Improvement

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Types of Case Review – Expedited

• Chart reviews• Patient or staff concerns relating to quality of care

(MS.09.01.09, EP 1 & EP 2)– If referred from patient or staff = COS review to determine if it

qualifies– If referred from another Medical Staff member, Hospital

President or QI System Leader no COS review needed

• Sentinel Event• OPPE suggests reason for concern (MS.08.01.01, EP 2 and

MS.08.01.01, EP 5)• QI Committee reviews not meeting criteria

– I.e. inpatient readmissions, returns to ED, etc.

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Case Reviews

• Completed in a “timely” manner

– Usually 2 weeks to 1 month

• Coordinated by QI staff

• Results are recorded in the period in which the review was completed

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Example – Results Recorded in Period Received

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Start End

PPE Round 1 10.1.2016 3.31.2017

PPE Round 2 4.1.2017 9.30.2017

Case # 105 Peer Review 3.17.2017 5.5.2017

Case # 105 Recorded in PPE Round 2 Profile

Results recorded within period review was completed – example

• Concern comes to QI on 3.17.2017.• QI processes concern according to policy, starting Peer Review process.• QI sends chart to peer reviewer on 3.28.17 with a due date from the peer reviewer

of 4.14.17.• QI receives peer reviewer’s comments on 4.13.17.• QI sends de‐identified comments to original practitioner on 4.17.17 with due date

of 5.1.2017.• Original practitioner returns comments on 5.5.2017.• QI records completed peer review case on round 2’s profiles.

Note: The start and end times for the PPE Rounds were determined based on Scheurer’s Medical Staff reappointment cycle times of January and July so that 4 rounds of PPE would be available for each reappointing provider at their reappointment time.MS.08.01.03, EP 3

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Case Reviews, continued

• 3 level rating system– Level 1 – No Concern

• Case managed and documented properly.

– Level 2 – Minor Concern • A. Case was managed appropriately, but documentation not adequate.

• B. Medical management deviated from the norm, but not likely to cause a significant adverse outcome.

– Level 3 – Major Concern• Medical management deviated from the norm and likely contributed to a significant adverse outcome or had the potential to contribute to a significant adverse outcome.

• Most valuable – comments!

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In Scheurer’s PPE Program, only Level 3s require review of the case to close the loops with one exception.

Exception: Level 2s and Level 3s for mid‐level practitioners go to their supervising physician or clinical advisor for additional review and oversight.

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Example – OPPE to FPPE Case

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OPPE suggests reason for concern example

Example from Scheurer

Concern from ED that one practitioner was prescribing opioids inappropriately to patients (too many, for chronic pain, etc.) to Quality Improvement Department.

QI request specific patient names from ED relating to concern. ED provides names to QI. QI prepares charts and PPE paperwork and sends to COS. COS determined Peer Review was warranted based on the charts and the concerns. QI receives info back from COS and forwards to a Peer Reviewer. Peer Reviewer determines some Level 2s and some Level 3s and returns to QI. QI de‐identifies Peer Reviewer and sends to original practitioner. Original practitioner dictates additional information into his thought process for each case. QI forwards additional information along with Peer Reviewer’s information to COS for

review. COS reviews all available info and determines that FPPE should begin and determines an

Action Plan for correction. COS presents information and suggestion for Action Plan to MEC. MEC approves Action Plan. QI presents Action Plan to department (who will assist in monitoring) and original

physician. Action Plan consists of education and 3 month monitoring period for all cases where a

prescription narcotic is given to determine if it meets our standards. COS actively reviews cases that department has questions on or believes may have fallen

out of compliance. After 3 month period, COS determines that Action Plan was effective and FPPE ends. MEC and original practitioner notified by COS that FPPE has ended as it appears the issues

have been corrected by the original practitioner.

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Peer Review Protections

• All forms are stamped with Peer Review statutes

• MEC meetings – PPE is separated

• Profiles and chart reviews kept in QI file

– Only available to those who have a need to know

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Peer Review and PPE information is NOT held in the practitioner’s credentialing file. This is in an effort to uphold Michigan peer review statute protections.

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Professional Practice Evaluation aka Peer Review

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Professional Practice Evaluation aka Peer Review

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Professional Practice

Evaluation

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Tips and Recommendations

• Keep it simple

• Continually improve

• Automate as much as possible

• Seek support and assistance from others

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During each round of PPE, make improvements to the process and the program so that it doesn’t become overwhelming.

Automate as much as possible in Excel or your PPE database.

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Easy Peasy!

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3.20.2018

“Brand” Recognition

• Use the same type/color of envelope every time.• Use the same labels every time.• Providers complete the review and return to QI in the same envelope.• Important info on envelope includes:

• Due Date• Confidential• Contact Info for QI

• QI process down to a science:• Labels for every practitioner and generic ones for those who aren’t sent many• Saves time• Maintains brand recognition

• Brand recognition applies to:• Providers• Other staff (they know to deliver to practitioner and not to open on their behalf)• HIMS – sometimes the practitioners leave with other chart requests from HIMS so

HIMS knows to send these back to QI

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Objective # 3

Describe how the PPE process compliments an Enterprise Risk

Management Program.

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Enterprise Risk Management

• According to ASHRM

• “Enterprise Risk Management (ERM) in healthcare promotes a comprehensive framework for making risk management decisions which maximize value protection and creation by managing risk and uncertainty and their connections to total value.”

• 8 domains

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Operational Human Capital

Clinical/Patient Safety Legal/Regulatory

Strategic Technology

Financial Hazard

Source: http://www.ashrm.org/resources/pdf/ERM‐Tool_final.pdf

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Operational

• Adverse Event Management

• Credentialing and staffing

• Documentation

• Chain of command

• Deviation from practice

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The business of healthcare is the delivery of care that is safe, timely, effective, efficient, and patient‐centered within diverse populations. Operational risks relate to those risks resulting from inadequate or failed internal processes, people, or systems that affect business operations. Included are risks related to: adverse event management, credentialing and staffing, documentation, chain of command, and deviation from practice.


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Clinical/Patient Safety

• Delivery of care

• Evidence based practices

• Medication errors

• Hospital acquired conditions

• Serious safety events

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Risks associated with the delivery of care to residents, patients and other healthcare customers. Clinical risks include: failure to follow evidence based practice, medication errors, hospital acquired conditions (HAC), serious safety events (SSE), and others.


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Strategic

• Brand, reputation, competition

• Failure to adapt to changing times

• Health reform or customer priorities

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Risks associated with the focus and direction of the organization. Because the rapid pace of change can create unpredictability, risks included within the strategic domain are associated with brand, reputation, competition, failure to adapt to changing times, health reform or customer priorities. Managed care relationships/partnerships, conflict of interest, marketing and sales, media relations, mergers, acquisitions, divestitures, joint ventures, affiliations and other business arrangements, contract administration, and advertising are other areas generally considered as potential strategic risks.


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Financial

• Malpractice

• Litigation

• Insurance

• Growth in programs and facilities

• Corporate compliance (fraud and abuse)

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Decisions that affect the financial sustainability of the organization, access to capital or external financial ratings through business relationships or the timing and recognition of revenue and expenses make up this domain. Risks might include: costs associated with malpractice, litigation, and insurance, capital structure, credit and interest rate fluctuations, foreign exchange, growth in programs and facilities, capital equipment, corporate compliance (fraud and abuse), accounts receivable, days of cash on hand, capitation contracts, billing and collection.


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Human Capital

• Employee recruitment and selection, retention, turnover

• Staffing

• Absenteeism

• Fatigue

• Productivity

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This domain refers to the organization’s workforce. This is an important issue in today’s tight labor and economic markets. Included are risks associated with employee selection, retention, turnover, staffing, absenteeism, on‐the‐job work‐related injuries (workers’ compensation), work schedules and fatigue, productivity and compensation. Human capital associated risks may cover recruitment, retention, and termination of members of the medical and allied health staff.


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Legal/Regulatory

• Local, state and federal levels

• Licensure

• Accreditation

• CMS Conditions of Participation (CoPs)

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Risk within this domain incorporates the failure to identify, manage and monitor legal, regulatory, and statutory mandates on a local, state and federal level. Such risks are generally associated with fraud and abuse, licensure, accreditation, product liability, management liability, Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoPs) and Conditions for Coverage (CfC), as well as issues related to intellectual property.


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Technology

• Clinical diagnosis and treatment

• Training and education

• Electronic Health Records

• Meaningful Use

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This domain covers machines, hardware, equipment, devices and tools, but can also include techniques, systems and methods of organization. Healthcare has seen an explosion in the use of technology for clinical diagnosis and treatment, training and education, information storage and retrieval, and asset preservation. Examples also include Risk Management Information Systems (RMIS), Electronic Health Records (EHR) and Meaningful Use, social networking and cyber liability.


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Hazard

• Assets and their values

• Emergency Preparedness

• Emergency Credentialing including PPE (EM.02.02.13, EP 7)

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This ERM domain covers assets and their value. Traditionally, insurable hazard risk has related to natural exposure and business interruption. Specific risks can also include risk related to: facility management, plant age, parking (lighting, location, and security), valuables, construction/ renovation, earthquakes, windstorms, tornadoes, floods, fires.


EM.02.02.13“During disasters, the critical access hospital may grant disaster privileges to volunteer licensed independent practitioners. Note: A disaster is an emergency that, due to its complexity, scope, or duration, threatens the organization’s capabilities and requires outside assistance to sustain patient care, safety, or security functions.”

EP 7“Based on its oversight of each volunteer licensed independent practitioner, the critical access hospital determines within 72 hours of the practitioner’s arrival if granted disaster privileges should continue.”

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Objectives

Now, are you able to:

1. Describe the requirements of The Joint Commission’s Professional Practice Evaluation standards.

2. Illustrate how Scheurer’s Professional Practice Evaluation (PPE) Program works.

3. Describe how the PPE process compliments an Enterprise Risk Management Program.

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Questions?

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Thank you!

Kristen L. Rifenbark, MSA, CPHRM, CPPSRisk, Document & Patient Safety Coordinator

Scheurer Hospital989.453.4469 [email protected]

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professional practice evaluation: a look into one critical ... · –tjc –diversity statement...

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