5 Sure-Fire Methods: Complying with MS.08.01.03 [REF: MDx, MD]
Source May 2011, Pg2, Vol 9, # 5
Accredited hospitals continue to have difficulty with OPPE and FPPE. Frequent citations include:
- Failure to define the data to be collected
- Failure to clearly define the OPPE process
- Failure to use collected data in privileging decisions
This article provides the following five Strategy steps to improve compliance:
- First identify data already being collected by your organization that could be used to address OPPE/FPPE.
- Determine the type of data to be collected for psychiatrists vs. non-psychiatrists
- Make sure your OPPE process is clearly defined
- Make sure there is a mechanism established to ensure the use of collected OPPE data in your FPPE and other privilege-related decisions
- Determine how OPPE/FPPE data will be incorporated into credentialing files. It need not be stored there permanently, but must be easily accessible for reviews.
MDX and JCSC should also review the recently developed FPPE/OPPE BoosterPak for more detailed implementation suggestions and tips. See also TJC-LPL resources to include: : FPPE OPPE Policy, Physician Performance Toolkit ,
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Tracer Methodology Evolves to Include Detailed Exploration of Several High-Risk Areas: Second Generation Tracers Now in Use for Some Hospital, Critical Access Hospital On-site Surveys [REF: JCSC]
Perspectives May 2011, Pg5, Vol 31, # 5
Second Generation Tracers (SGT) are deeper and broader systems explorations (drilling down) that are triggered when concerns are raised about what TJC calls high-risk issues (HRI). These are defined as including “processes or procedures that, if not planned or implemented correctly, have significant potential for affecting/impacting patient safety.” This article identifies the first 5 such issues as: 1) Cleaning, disinfection, and sterilization (CDS), 2) Patient flow across the care continuum, 3) Contracted services, 4) Diagnostic imaging, 5) OPPE and FPPE. HRIs 1, 2 and 4 may seem to have limited significance for psychiatric hospitals. While the CDS issue was generated largely in response to concerns about steam sterilization, its relevance to us includes the cleaning of small equipment and surfaces. Patient flow is relevant because of its applicability to any delay or lack of timeliness in patient services. Diagnostic imaging may affect few of our facilities. However, contracted services and OPPE/FPPE should be considered key HRI to pay attention to. The article also provides examples of possible triggers for SGT in Credentialing & Privileging session (OPPE FPPE) and Cleaning, disinfection, and sterilization. It should be noted that once an SGT is triggered, a specific patient may or may not be involved. See also: TJC-LPL: FPPE OPPE Policy Contributed by Teche Regional Medical Center Morgan City, LA (5/17/11)
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New Standards BoosterPak Available for Medical Staff Evaluations [REF: MDx, MD]
Perspectives April 2011, Pg8, Vol 31, # 4
TJC is now providing guidance on how to conduct focused professional practice evaluations (FPPEs – MS.08.01.01) and ongoing professional practice evaluations (OPPEs – MS.08.01.03) via its second BoosterPak. Its contents include the following:
- A description of both standards with implementation suggestions
- A description of what surveyors are likely to discuss and documents needed during an on-site survey credentialing and privileging session
- Key definitions and frequently asked questions related to FPPEs and OPPEs
- Definitions of key terms and supporting documentation, evidence, value, and historical information
- Links to relevant CMS Conditions of Participation and additional references