Navigating through Peer Review Standards
Back in 2008, The Joint Commission (TJC) developed standards for evaluating practitioners’ professional performance as part of the process of maintaining practice privileges within a healthcare organization. The standards include both Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) with a facility that is accredited by TJC. OPPE will identify performance improvement for practitioners, use data for the continuation of practice privileges, and monitor professional proficiency.
TJC requires that performance data be gathered, and that the provider be evaluated more frequently than once a year. TJC considers annual evaluations to be “periodic,” not “ongoing.” Individual medical staff departments define the information collected and is approved by the organized medical staff. All providers must be evaluated, not just providers with performance issues. Mining performance data and developing comprehensive report cards for practitioners is extremely time-consuming. Developing processes through strategic planning and workflow automatization of data will create a seamless method for OPPEs.
When administering OPPEs, TJC requires the following to be clearly defined:
- Consistent metrics and measurements
- Define the reviewers
- Determine indicators/triggers/issues
- Develop a process
- Results for credentialing
- Application to all privileged practitioners
Consistent Metrics and Measurements
What information should be included in a performance report? Performance reports are a comprehensive collection of the provider’s activity. The primary section of a performance report must be aligned with the privileges that are granted to the provider, associating the activity/procedure with the privileges granted to the provider. Monitoring clinical practice patterns and chart reviews will achieve this goal. External peer reviews and discussing patient care are also avenues for measurement.
Other performance sections to report include professionalism, communication skills, and overall staff interaction. Developing performance reports can be cumbersome. Develop policies and procedures that are focused and manageable for the medical staff. Charts and graphs will provide accurate communication tools for performance reports.
Clearly defining reviewers will establish stability within reporting. The Joint Commission recommends reviewers be department chairs so there is knowledge of the reviewee. Committees also provide a broad knowledge of skills to assist in the review process.
The Joint Commission defines triggers as unacceptable levels of performance within defined criteria. The criteria may include several events occurring, several peer reviews with adverse determinations, elevated infection rates, an increasing number of returns to surgery, and failure to follow approved clinical practice guidelines. Once triggers are defined, the best practice is to maintain standardization through documentation.
Develop a Process
The first step in developing a process is determining the length of time for the review process. OPPE is ongoing and must be performed more than once a year. Streamlining this process through automation with patient records will eliminate manual processing of data collection. Gathering information into a single source database will ease the process of developing performance reports. MD-Staff can integrate with all Applied Statistic & Management, Inc modules including MD-Stat. Syncing patient records from Electronic Medical Record (EMR) systems such as Epic, Cerner, and Meditech, is seamless. MD-Stat handles all types of data, whether it’s streaming data, manually uploaded, exported automatically, or manually entered. MD-Stat provides direct interfaces through an HL7 ADT Interface and Patient Demographics Importer.
HL7 Interface: An interface to connect between EMR data (patient visits, diagnosis, mortality rate, and length of stay). Each of these can be turned into indicators and put on a provider’s report card. EMR data can also be used to create peer reviews.
Patient Demographic Importer: For users who do not have an HL7 Interface, medical offices can manually upload EMR data with spreadsheets. This process can be automated!
The second step in developing a process is to define the measures to resolve performance issues. While we would like to have no problems in performance, it is best to prepare for situations and eliminate when possible. Developing education programs, offering counseling and mentoring opportunities will provide a stable foundation for improvement. In some cases, suspension, and revocation of membership and/or privileges are required. Medical offices’ priority is patient safety!
Results for Credentialing
Once all data is collected and presented, the results are associated with credentialing. Establishing thresholds for performance improvement and determining proctoring assignments need to be completed. There are many challenges when determining if a provider should be proctored. Those challenges include not only the provider, but also the proctor, staff, and patients. Developing the process of proctoring with consistent metrics will eliminate confusion and concern. When outcomes are measurable, then processes can be trusted and followed.
Application to all Privileged Providers
Yes, all on-staff providers must have ongoing reviews. Consistent monitoring will prevent any developing issues and provide time for resolutions. Share the information with the provider. Reviewing reports with the provider will help to improve performance. And remember, there is no warm body syndrome when it comes to patient care!
Where to Begin?
Embrace technology to ease the collection of data! Implementing a single source of truth software such as MD-Staff for credentialing and privileging, along with MD-Stat for peer reviews, will create efficiencies and accurate data migration. MD-Stat provides a range of built-in and customizable charts and reports that can help your organization analyze data, find problems, and make valuable decisions. MD-Stat can process and validate your data sources process, saving you the hassle of complicated data transformations.