Revision Memo: Implementation of Enterprise-Wide Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) Specialty-Specific Clinical Indicators

Memorandum and attachments links below regarding “Implementation of Enterprise-Wide Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) Specialty-Specific Clinical Indicators.”

Memorandum – Implementation of Enterprise-Wide Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) Specialty-Specific Clinical Indicators

Master List for FPPE-OPPE_Specialty Clinical Indicators_v2.0_Dated 2021-05-12

Single Chart FPPE-OPPE Chart Review Form_Final Template_v2.0_Dated 2021-05-12

Five Chart FPPE-OPPE Chart Review Form_Final Template_v2.0_Dated 2021-05-12

Specialty Clinical Indicators – Program Office POCs_Dated 2021-04

 

1. This revision memo replaces the original memo published December 18, 2020. The purpose of FPPE and OPPE is to evaluate the clinical practice of licensed independent practitioners (LIPs) to ensure safe patient care. The FPPE/OPPE National Workgroup (NWG), in collaboration with the Veterans Health Administration Central Office’s (VHACO) Integrated Clinical Communities (ICC) and program offices, developed required standard clinical indicators and associated evaluation criteria for FPPE/OPPE. The suspense for the completion of implementation actions, as outlined below, has been extended to March 31, 2022.
2. Incorporating Required Clinical Indicators: All VHA medical facilities must incorporate the required clinical indicators (i.e., VHACO-level and specialty-specific) into current local FPPE and OPPE reviews under the Accreditation Council for Graduate Medical Education (ACGME)/Joint Commission “Patient Care” general competency (Attachment A). These required indicators apply to all LIPs (hereafter referred to as “practitioners”), to include those occupations on a scope of practice who are credentialed through the medical staff process.

The nationally developed FPPE and OPPE clinical indicators are the minimum number of required indicators that must be utilized. The Executive Committee of the Medical Staff (ECMS) at the facility may elect to include additional indicators for evaluations. Furthermore, all initial and revised service- and/or specialty-specific FPPE/OPPE forms must be reviewed and approved by the ECMS with the review documented in committee minutes.

Note 1: The required clinical indicators are only one component of a practitioner’s overall FPPE/OPPE and should be used in conjunction with other data/information (and corresponding documents) to comprehensively evaluate a practitioner’s privileges or scope of practice.

Note 2: This memo rescinds any previously approved national/VHACO-level clinical indicators to include those published in the December 18, 2020 memo as well as any others prior to that date (i.e., gastroenterology, pathology, nuclear medicine and radiation oncology). All specialties identified in the Master List (Attachment A) must implement the new clinical indicators as directed in this revision memo.

 

3. Standard Chart Review Forms: Two standardized chart review templates/forms were developed for use during the initial implementation of the clinical indicators by all specialties as part of initial FPPE and all OPPE. The two standardized chart review forms are:
   • The standard single-chart review form (Attachment B)

• • • Used for those instances when a reviewer evaluates only one chart during the review period. Also, if the same reviewer evaluates fewer than five (5) charts, then the single-chart review form should be used to individually document each of the charts that are reviewed for that practitioner.

• • • The standard five-chart review form (Attachment C)

• • • • Used when one reviewer will evaluate all five (5) charts during the review period.
  • Each of the standard forms includes the following data fields/sections:

1. 1. 1. Required VHACO-level clinical evaluation criteria (CEC) to be implemented for all practitioners
      2. Required ICC and program office specialty-specific CEC to be implemented across the designated specialties
      3. Required specialty-specific cases/medical diagnoses for high-risk patients or procedures that correspond to the associated clinical indicator(s)
      4. Additional VISN or facility-level case selections/medical diagnoses approved by local leadership
      5. Additional VISN- or facility-level approved CEC

• • A minimum of five (5) charts must be evaluated for the FPPE or OPPE review period if a required clinical indicator requires chart abstraction. Additional charts may need to be reviewed as required to adequately evaluate the LIP’s clinical competency.
  • Note 1: Chart reviews are only one method to collect data for FPPE/OPPE and should be used in conjunction with other data/information (and corresponding documents) to comprehensively evaluate a LIP’s privileges or scope of practice.
  • Note 2: Neither the single-chart nor five-chart review form is to be used as a FPPE/OPPE summary form. Summary forms are to be developed and approved at each facility.
  • Note 3: Facilities may elect to develop (e.g., automate) and improve chart review forms as long as the required fields from the standard chart review form are captured.

4. External Reviews: It is required that another LIP who has equivalent specialized training and holds similar privileges (or scope of practice) completes the FPPE or OPPE review. A LIP from another facility is required to complete the FPPE or OPPE review in the following circumstances:

1. 1. The practitioner is part of a “two-deep” service or specialty (i.e., only two individuals at the facility perform the privileges that have been granted), such that, without this outside review, they would be examining one another’s clinical performance, OR the practitioner is a “solo provider” (i.e., the only individual at the VHA medical facility who performs the privileges that have been granted); or
   2. The practitioner is the facility Chief of Staff (COS).

• Note: If the review is for the COS, results should be returned to a pre-designated/applicable clinical service chief at the respective facility.

5. Responsibilities: Responsibilities for implementing required requirements within this memo include, but are not limited to:
   • National ICC Committee:

• • • Oversee enterprise-wide specialty-specific indicator development and approval, going forward
    • Annually review VHACO-level clinical indicators and associated data for FPPE/OPPE reviews

• • VHACO Specialty Program Directors:

• • • Review specialty-specific FPPE/OPPE clinical indicators and all associated criteria for retrospective chart reviews annually and submit updates to ICC as needed

• • VISN Chief Medical Officer (CMO):
    • Lead and monitor implementation of specialty-specific clinical indicators outlined in this memo within their respective VISN
    • Attest to the implementation of the clinical indicators and guidelines as directed in this memo via the VISN annual Credentialing and Privileging (C&P) program oversight audit/review
    • Develop VISN-wide process for external reviews of FPPE/OPPE by practitioners with similar training and privileges as outlined in paragraph 4 above
  • VISN ICC Leads:

• • • Provide Subject Matter Experts to support implementation and coordinate communications with national ICC and program offices
    • Provide explicit guidance and interpretation of data/information collected on each of the required clinical indicators for the specific specialty
    • Guide COS in data aggregation and reporting of the clinical indicators.
    • Serve as the key point of contact for any procedural/operational questions related to the enterprise clinical indicators or procedures

• • Facility Medical Center Director:

• • • Ensure compliance with requirements outlined in this memo by March 31, 2022

• • Facility ECMS/Clinical Executive Committee:

• • • Ensure that required clinical indicators published are 1) incorporated into service-level FPPE and OPPE forms, and 2) reviewed for compliance
    • Document review of updated specialty specific FPPE/OPPE forms in ECMS committee minutes
    • Review and approve specialty-specific FPPE/OPPE forms annually and document review/approval in ECMS committee minutes
    • Stipulate the rules for not meeting an indicator benchmark and what to do if a trigger is met during a FPPE/OPPE review

• • Facility COS:

• • • Manage the facility-level implementation strategy/plan/timeline for integrating the required clinical indicators for the specific specialties
    • Manage and track the development, revision, review and approval of the modified FPPE/OPPE forms by the facility ECMS
    • Ensure that another practitioner at the facility with equivalent specialized training and similar privileges as the practitioner being evaluated completes the FPPE/OPPE review

• • Note 1: The COS may also assign a higher level peer at the facility to conduct the evaluation.
  • Note 2: If the practitioner does not meet a benchmark in one or more areas, the COS will ensure the service chief determines the need for further review or specific action based on the totality of clinical performance and unique aspects of a practitioner’s patient population.

6. If there are any questions related to the meaning, interpretation, or utilization of the approved specialty-specific clinical indicators, please contact the appropriate VHACO ICC lead listed on the ICC SharePoint site:  https://dvagov.sharepoint.com/sites/VACOVACOMPM/CSL/SitePages/CSLAbout.aspx or the respective program office point of contact (Appendix D).

This memo and its attachments as well as further references can be accessed on the Clinical Indicators page on the ICC SharePoint site:  https://dvagov.sharepoint.com/sites/VACOVACOMPM/CSL/Clinical%20Indicators/Forms/AllItems.aspx.

Please refer any questions regarding the implementation guidelines outlined in this memo to Dr. Ajay Dhawan, Acting Chief Officer, Specialty Care Services at Ajay.Dhawan@va.gov.

Please refer any questions regarding external reviews to VHACO Medical Staff Affairs program office at VHA17QM6MedStaffAffairsAction@va.gov.