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New Service-Specific Indicators for Ongoing Professional Practice Evaluation

Christy Sandborg, MD
Christy Sandborg, MD

At Lucile Packard Children’s Hospital, all members of the Medical Staff are reappointed every two years, unless they choose to resign. Traditionally, this process has involved the review of a set of quality and competency indicators that were uniform from service to service, such as readmission within 72 hours, unexpected return to surgery or unanticipated death. While some of these indicators remain, a new process for reappointment is being developed that adheres to new Joint Commission standards and reflects service-specific indicators, in order to present a more refined picture of physician competency.
This process, called Ongoing Professional Practice Evaluation (OPPE), is factored into the decision to maintain, revise or revoke an existing privilege to practice at Lucile Packard Children’s Hospital. OPPE allows the Medical Staff to identify professional practice trends that impact quality of care and patient safety. This program for continuous monitoring incorporates information into performance improvement activities and allows for evaluation of each physician’s professional practice.
OPPE includes six areas of physician competency, with indicators in each category chosen by individual departments working with the Quality Management department. The categories, with some examples of specific indicators developed by one or more services at Packard Children’s, include:
Patient care—reviewed cases based on patient complaints, referrals from other departments/committees, significant clinician-reported events through incident reports, emails or phone calls; sentinel events or near misses; patient death

Medical knowledge—hours of Continuing Medical Education per year and attendance at Grand Rounds

Practice-based learning—each service to choose an indicator based on an established protocol or published evidence-based practice standard

Interpersonal communication—confirmed behavior problems documented by patient complaints, incident reports, or reports from clinicians; accommodations documented on patient satisfaction surveys or hospital awards system

Professionalism—involvement in medical staff activities, such as attendance at medical staff meetings or attendance at standing medical staff committees, including Medical Board, Care Improvement, Credentials, Critical Care, Ethics, HIMS, Pediatric OR, Quality Improvement, Perinatal Care, Pharmacy & Therapeutics, and Physician Well-Being
System-based learning—compliance with medical record documentation through LINKS
OPPE quality indicators are rate based, rule based or review based. Rate-based indicators identify cases that are aggregated for statistical analysis. Services establish a target range for each indicator, such as patient care that results in transfer to the ICU, return to surgery or readmission.
A rule-based indicator represents a general rule that is accepted and where variation does not directly cause adverse patient outcomes. For each service, a threshold is established, such as noncompliance with hand washing, with isolation or with universal precautions, or professionalism standards for discharge summaries and chart delinquencies. Physicians must be informed of every infraction.
Review-based indicators, or cases that warrant a full review, are defined as significant events that would ordinarily require analysis by a physician peer to determine cause, effect and severity. These include cases in which there has been a significant patient complaint, a sentinel event, a significant incident report, and/or referral from a clinician (may be identified at Morbidity and Mortality conferences as needing peer review).
When established thresholds are exceeded, the Peer Review Committees may request a Focused Professional Practice Evaluation (FPPE) to assess why a practitioner’s performance is different than his/her peers’. Results of the FPPE are reported back to the Peer Review Committee. The committee will review the results and determine whether further action is needed.
Packard Children’s rigorous process of competency evaluation is a key aspect of our Joint Commission accreditation and sustains our standard of excellence.


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