Making healthcare remarkable OPPE / FPPE Uniform Process Larry Thacker, CPMSM Business Systems Analyst Making healthcare remarkable Statistics about Novant Health Current State of Novant Health OPPE / FPPE Process Presence in NC, VA and GA 13 Facilities 3 joint venture Ambulatory Surgery Centers 2 Ambulatory Surgery Centers Joint venture acute care facility with UVA 4,600 +/- Credentialed providers 4,100 +/- in OPPE / FPPE Process Physician Practices 6 Medical Staff Offices 1 Central Verification Office 3 Making healthcare remarkable Early Beginnings Applies to both OPPE and FPPE In the Beginning OPPE / FPPE Process Early Decisions Went to visit The Joint Commission at their headquarters Clearly from the early stage TJC wanted to provide freedom Left decisions to the facilities and the organized medical staff A subcommittee was established VPMA, Chief of Staff, Dept Chairs, MSO, CVO, Legal, Clinical Improvement and Regulatory Basic indicators and thresholds were established OPPE Data Range 6 months FPPE Data Range 2, quarterly reports Process was watched over the first 12 months 5 Challenges and Progress OPPE / FPPE Process Identifying the data sources and reporting mechanisms How to store and track the data in a useful uniform format Excel was where we looked first Developed a spreadsheet with 100+ workbooks First we saw a dramatic improvement in the number of medical record delinquent days dropped over 13,000 + days Educating the providers and staff Employee resources How to handle the providers with issues 6 Challenges and Progress OPPE / FPPE Process Thresholds were to liberally applied Red on the forms made the provider see RED Providers didnt like being AVERAGE Solution was 50 shades of OPPE / FPPE Data periods Changed Reporting time frame changed Discovered very early our data ranges needed to be extended Moved to 8 month OPPE reporting periods Moved to 2, four month reporting period for FPPE Reduced the number of Nursing / Clinical Staff Feedbacks 7 Challenges and Progress OPPE / FPPE Process Identified quickly Excel wasnt the solution Statistical reporting was very difficult due to the provider being in OPPE and FPPE (stored in different spreadsheets) Reappointment timeline Push Pull relationship Dimension Data EMR did not resolve Delinquency days Timeliness of signing records EMR did resolve : STD (Sign, Date and Time) itemsEcho OPPE Module Echo OPPE Module since 2010 have processed over 27,000 OPPE/FPPE reports 8 Making healthcare remarkable Data Applies to both OPPE and FPPE 10/31/2012 Novant Health: Enter Presentation Title in Footer Menu 10 Sample Size Sample Size project H&P, Unsigned Consents, STD, TO/VO Monthly reports by facility Peer Review Peer Review Policy Activity Data Imports ran by the BSAs for Dimensions (HL7) Others have to enter manually Data Sources Fingers in all things data OPPE / FPPE Process Nursing / Clinical Staff Feedbacks Collected in OPPE once every 24 months Collected during the 2 nd period of FPPE unless improvement needed has been identified HIM Medical record delinquencies Suspensions EPIC / Dimension Data will still occur for the data indicators Always looking for other data sources Always looking to improve the process through automation 11 Making healthcare remarkable OPPE Basics OPPE OPPE / FPPE Process Who is in OPPE A Practitioner Who holds at least one or more clinical privileges On staff longer than 8 months Not currently in a FPPE Reports are generated for each Medical Staff Office Based 5 Primary Specialty cycles 13 OPPE / FPPE Process 14 Making healthcare remarkable FPPE Basics OPPE / FPPE Process Who is in FPPE Any practitioner that would meet any one of the following requirements: New Practitioner with one or more clinical privileges Existing practitioner who has requested an additional privilege Improvement needed threshold(s) met during OPPE process Referral from Credentials Committee, Med Exec or BOT Reports are generated based the month placed into FPPE FPPE reporting is performed on 2, four month cycles 8 months is a complete FPPE process unless one additional 4 month period is necessary to sync with the OPPE cycle Possibility of an adjustment cycle to synchronize with the OPPE cycle Could be placed into an extended FPPE if improvement has not been demonstrated or addition of privilege Extended FPPE cycle can not go beyond 24 months 5 OPPE / FPPE Process 17 New provider New privilege Result of OPPE Committee Referral Placed into FPPE Committee Review Chair Review Data FPPE 1 Data Chair Review Committee Review FPPE 2 Place into OPPE Extended FPPE Limit, Deny, Revoke or Remove privilege(s) Decision Placed back into the FPPE cycle (FPPE 3) Can not exceed 24 months total (6 total FPPEs) Extended FPPE Sync with OPPE cycle Possible FPPE 3 to sync OPPE Privilege: Limited Denied Revoked Removed Privilege Affected See Larry and Robin Run!!! 18 OPPE / FPPE Process Making healthcare remarkable Echo OPPE Module Applies to both OPPE and FPPE Wish Came True OPPE / FPPE Process THE OPPE Module 20 Data Storage OPPE / FPPE Process Parts of ECHO involved Checklists OPPE / FPPE cycle checklist MSO (Who, What and When) Tracks OPPE or FPPE with a Reporting Mechanism Checklist When placed into OPPE or FPPE What OPPE cycle the practitioner is in When the Nursing / Clinical Staff Feedback is due Who is the Primary Reviewer (Dept Chair or Section Chief) Who is the Chief of Staff or Credentials Chair When the last data audit was performed on the individual provider Nursing / Clinical Staff Feedback moving to an automated Survey Module Peer Review Medical Record Status (delinquencies and suspensions) QA Review (all other provider indicators) Population (activity and procedural data) 21 We, as a team have processed over 27,000 OPPE and FPPE since January 2010! OPPE / FPPE Process 22 Making healthcare remarkable Forms and Committee Reports Applies to both OPPE and FPPE OPPE / FPPE Process 24 OPPE / FPPE Process 25 OPPE / FPPE Process 26 OPPE / FPPE Process 27 Making healthcare remarkable What the Future Holds Automation Nursing / Clinical Staff Feedbacks SURVEY MODULE Providers able to log in and view OPPE / FPPE forms Provider Navigator Online Chair Review Provider Assessment Portal Peer Review Portal HL7 Module live population data Online Application Future Goals OPPE / FPPE Process Additional Indicators Changes to the process Updated FPPE policy 2015 Notification of any new data source Uniform Additional Privilege Checklist Customized privilege line Uniform By-Laws Uniform staff status 29 Making healthcare remarkable Questions 31 OPPE / FPPE Process 32 Larry Thacker, CPMSM