Ongoing professional practice evaluation: An infrastructure for accountability.

Abstract

239 Background: As a national network of five hospitals treating patients fighting complex cancers, continuous monitoring of clinical staff competence is a priority. Recognizing an opportunity for an enhanced structure for ongoing professional practice evaluation (OPPE), a process mandated by The Joint Commission, the network set out to create heightened accountability, reliability and understanding of the review of performance data. Methods: Two work groups were established. The first was charged with the selection of meaningful specialty specific measures applicable to the oncology patient population. The second tasked to leverage resources expended using existing software and limiting the need for manual intervention. This group was responsible for creation and implementation of a consistent workflow with defined roles for physicians, medical staff operations and quality reviewers. Results: Over 50 subspecialties were mapped to over 250 selected metrics, with overlap when applicable to more than one specialty. A standard network-wide policy was approved by each center’s medical executive team. A workflow was clearly defined to include responsibilities associated with (pre-review) analyst role, service chief and credential committee. The use of the network’s reporting tool was standardized for OPPE as well as additional sources of quality data identified outside of the tool as needed, specifically for low volume and non-patient facing providers. A review calendar was created to guide the process on a rolling basis. Lastly, an OPPE Toolkit was created to govern and educate on the process that includes a pocket guide, Q&A, and on-boarding materials for physicians to understand their data relevant to metrics for which they are accountable. Conclusions: This systemic and timely evaluation of practitioner specific data supports improvement of practitioner performance and provides objective information for credentialing and privileging decisions across the network. Physicians’ visibility into their own data has increased. Automating the majority of efforts associated with OPPE has reduced the time associated with fulfilling this external requirement and resulted in full compliance.