Follow this detailed recipe for meeting the Joint Commission’s standard for OPPE.
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| Henry Johnson, M.D. |
Building a physician profile that will meet the Joint Commission’s standard for Ongoing Professional Practice Evaluation (OPPE) and its six competencies, while also meeting the needs of your most important customer—your medical staff—is much like cooking a fine meal. It begins with planning the menu, requires picking the best ingredients, and ends with creating the final product.
What Customers Need and Expect
Start by understanding what your customers need and want as a final product. Your hospital’s most important external customers are the local department of health, which grants the hospital license; CMS, which permits Medicare participation; and the Joint Commission, which grants voluntary accreditation that also serves CMS’ needs. Meeting Joint Commission standards for the medical staff generally covers any state or federal standards, so let’s focus first on the Joint Commission standards.
In 2007, the Joint Commission rolled out OPPE, a new and continuous approach to physician evaluation. To perform ongoing evaluation, hospitals need a profile for each physician that is updated at an interval determined by the medical staff. Six months is a reasonable interval, and it is the minimum amount of time before changes will show in the practice profile of a busy clinician. The content of the profile must measure six competencies originally created by the Accreditation Council for Graduate Medical Education and now incorporated into the Joint Commission standards (see figure 1 below).
As important as accreditation and licensure is, do not forget your primary internal customer, the medical staff. Profiles must be created by and for the medical staff, while also meeting Joint Commission requirements. You may find that your physicians have very discerning tastes and that they look for profiles that go well beyond accreditation requirements.
Data Selection and Testing
In preparing for the profiles, go “shopping” for data very carefully. Consider all data sources, but realize that each source has its advantages and potential problems (see figure 2 below).
Note that the measures of structure, such as the presence of intensivists in the ICU, are easy to obtain, hard to change and often more an attribute of the hospital than of a practitioner. Process and outcome measures are good for profiles, especially when they are evidence-based. Event reports, case reviews and personal evaluations are standbys and essential additions to process and outcome measures. Finally, surveys are becoming essential in the new world of the six competencies, where measurement of “interpersonal and communication skills” and “professionalism” requires surveying staff and physicians.
Once data are selected, they should be checked for three characteristics:
Building the Profile
Building the profile, like cooking a meal, must take the menu requests into account, then put all the ingredients (data) together in a way to meet our customers’ expectations. With this in mind, aggregating measures by the Joint Commission’s six competencies helps focus on the intent of the categories as well as create a clear picture of compliance at the time of the survey.
Although we think of profiles as being for individual physicians, profiles can be built by department, division or physician group. This is helpful for overall system improvement and for profiling groups of physicians—such as hospitalists—when issues of physician attribution may make individual profiles less useful.
How many types of profiles do you need? Profiles will vary by specialty; here is a short list of specialties that warrant their own profile:
The number and type of profiles will depend on your hospital’s service lines and the nature of your medical staff.
Avoid Getting Burned in the Kitchen
Here are four pitfalls to recognize and avoid in the profiling process:
Volume: Chances are that half of your physicians care for 95 percent of your admissions, while the other half have very low volume. Who should get a profile, and at what point do we shift to a different form of periodic evaluation?
Solution: Create a volume cutoff (perhaps 20 cases per year), create profiles for only the higher volume physicians, and find an alternative form of profiling for the lower volume physicians. Remember that you need to do OPPE on all physicians regardless of their volume, but the low-volume profiles should be designed for low-volume physicians. Beware of a one-size-fits-all profile that prints zeros for half the medical staff.
Attribution: For certain physician groups (hospitalists, for example), one patient is often cared for by multiple physicians during one admission, making assignment of one physician per discharge difficult.
Solution: Create the profile for the whole group, and have the head of the group analyze the results, aiming toward overall improvement. At the same time, create profiles for each physician, with an emphasis on survey data and whatever volume data look valid.
Search for the “perfect metric”: Physicians may want to collect and report measures that, while valid, accurate and reliable, require extensive resources to collect, including chart review, direct data entry or phone follow-up.
Solution: Don’t wait for perfection. Rather, design a profile you can afford to run. Then, distinct from your OPPE process, build more advanced metrics for processes in key areas of the hospital, such as the cardiac catheterization lab or interventional radiology, with an eye toward overall system improvement.
Acceptance by physicians: Regardless of the effort put into creating profiles, they must be accepted by the medical staff in order to work. Common complaints are that the data are inaccurate or not severity adjusted.
Solution: Be sure the measures are valid, accurate and reliable. Adjust mortality and length of stay for severity.
Presentation Matters
How the profiling process is introduced is critical to its success. Begin the profiling process with a small group of high-volume physicians in a leadership role who are responsible for the quality of care delivered by physicians in their departments. Have the best information available—not only at reappointment, but also continually.
The first profiles should be of the leaders—and their input should be used to improve the profiles. Then when the profiles are extended to all physicians, leaders can stand together and say, “We profiled ourselves, and we approve these profiles.”
Preparing for Future Profiling
Most likely your first profiles will be on paper, delivered or reviewed with physicians on an ongoing basis. Deliver the reports at an interval you determine, probably about every six months, initially keeping it simple.
As your profiles mature and cover all of your active staff, move toward secure, on-demand electronic delivery, perhaps in scorecard format over your secure intranet in the hospitals.
Henry Johnson, M.D., M.P.H., is the medical director of the MIDAS+ software division of ACS Healthcare Solutions and a quality practice seminar presenter for the American Society for Quality (ASQ).
For more information on physician profiling from ASQ, please visit www.asq.org/healthcareqps.
Figure 1: The Six Competencies in the Joint Commission Standards
Patient Care |
Medical/Clinical Knowledge |
Practice-based Learning and Improvement |
Interpersonal and Communication Skills |
Professionalism |
Systems-based Practice |
Figure 2: Potential Data Sources by Category
| Category | Examples of Sources | Pros | Cons |
| Structure |
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| Process |
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| Outcomes |
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| Case Reviews |
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| Surveys |
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| Event Reports | Reports of events |
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| Personal Evaluations |
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