Focused and Ongoing Professional Practice Evaluation FOPPE for

Focused and Ongoing Professional Practice Evaluation (F/OPPE) for Medical Staff & Allied Health Professionals Facility Name Last Update: _____

Professional Practice Evaluation is a Medical Staff-led initiative to establish performance expectations and ensure that patient care meets appropriate standards 2 Facility Name Last Update: _____

For the Safety of our Patients The Medical Staff Leadership and the Governing Board have approved this process to ensure physician competency and high quality care for our patients, and to ensure (your facility name) providers are the best they can be. Facility Name Last Update: _____ 3

FPPE is the acronym for Focused Professional Practice Evaluation and it is to validate competency at (your facility name) using the hospital’s resources, equipment, environment, staff, etc. FPPE occurs at initial appointment, a new privileges request, or if a question arises regarding current privileges. Facility Name Last Update: _____ 4

Ø OPPE is the acronym for Ongoing Professional Practice Evaluation. It is the ongoing review of your performance here at (your facility name), to validate your competency, and to identify professional practice trends. Again, using the hospital’s resources, equipment, environment, staff, etc. Ø OPPE review is conducted in 8 month cycles, and in order to maintain privileges at (your facility name) the Medical Staff requires providers to complete 3 patient encounters every 8 months Facility Name Last Update: _____ 5

Newly appointed physician / AHP or new privilege request FPPE first 3 months or # of cases specified, but not to exceed 6 months. Issue of Competency: When questions of competency arise regarding a provider’s current privileges. Once the specified number of cases has been reviewed, Focused and Ongoing Professional Practice Evaluation OPPE Cycle 3/ 3 rd 8 month review OPPE Cycle 2/ 2 nd 8 month review Physician & AHP Ongoing Evaluation OPPE Cycle 1/1 st 8 month review Peer Evaluation/Chart Review Credentials Committee Medical Executive Committee NOT Reappointed/ Privileges NOT Granted / Maintained – Physician/AHP Notified Governing Board Reappointed/ Privileges Granted/Maintained – Physician/ AHP Notified

Facility Name Last Update: _____ 7

DEPARTMENT Anesthesiology FPPE Initially Granted “Core” Privileges Review of 5 representative anesthesiology cases/charts, including adequacy of H&P, progress notes, consultation, and operative reports for EBM-SCIP: On-Time Prophylactic Antibiotic FPPE (Focused Review) Triggers Failed Intubation Unexpected Transfer to ICU Due to Anesthesia Complication EBM-SCIP: Pts on BB Therapy Pre-Admin Received BB during Preoperative OPPE Indicators EBM-SCIP: On-Time Prophylactic Antibiotic EBM-SCIP: Pts on BB Therapy Pre-Admin Received BB during Preoperative Unanticipated Dental Injury • Unexpected Reintubation Facility Name Last Update: _____ 8

Analytics Application Ø Source for severity adjusted analytics for OPPE Ø Provides drill down access to case detail Ø Self evaluation of patient care performance Ø Resource for benchmarks and best practice data Ø Care cost analysis to review utilization trends Facility Name Last Update: _____ 9

ØComplete the form provided to help us document your first 3 cases ___________________ Your Name (Please Print) Patient Name Date of Birth Medical Record Number Facility Name Last Update: _____ Account Number Date of Service(s) 10

Ø 5 patient encounters in the first 3 months Ø If you are a part of a group practice, please notify your scheduler to rotate you to (your facility name) until you acquire 3 patient encounters within the first 3 months. Facility Name Last Update: _____ 11

Ø Questions about FPPE or OPPE? Ø Is there anyone who will have a problem with meeting 3 cases in the first 3 months for FPPE? Facility Name Last Update: _____ 12