Clinical Services FPPE-OPPE Clinical Indications Memo

1. 1. The purpose of FPPE and OPPE is to evaluate the clinical practice of licensed independent practitioners 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 mandatory standard clinical indicators and associated evaluation criteria for FPPE/OPPE to be utilized at all VHA medical facilities for over 35 specialty services (Attachment A). The suspense for the completion of implementation actions is twelve (12) months from publication of this memo.
   2. Incorporating Mandatory Clinical Indicators:  FPPE and OPPE reviews must apply specialty-specific clinical indicators consistently and objectively to all privileged practitioners within the same clinical specialty, regardless of appointment. These nationally developed FPPE and OPPE indicators (Attachment B) are the minimum number of mandatory indicators that must be incorporated into the FPPE/OPPE forms (under the “Patient Care” section) utilized to evaluate privileged practitioners in the designated specialties.
      • The Executive Committee of the Medical Staff (ECMS) at the facility may elect to add additional indicators for evaluations. Any FPPE/OPPE revised forms approved by local leadership must be reviewed at a meeting of the ECMS and the review documented in committee minutes.
      • Note:  This memo rescinds any previously approved VHACO-level clinical indicators that were implemented in the past (i.e., gastroenterology, pathology, nuclear medicine and radiation oncology). These specialties must implement the new clinical indicators as directed in this memo and attachments.
   3. Mandatory Retrospective Chart Review Form:  A standard template/form was developed to be utilized for FPPE/OPPE retrospective chart reviews (Attachment C). The form includes the following fields (Note:  These forms may be automated and utilized as long as the following fields are captured):
      1. The specialty-specific cases/medical diagnoses for high-risk patients or procedures that correspond to the associated clinical indicator(s);
      2. Mandatory VHACO-level clinical evaluation criteria (CEC) to be implemented for all privileged practitioners;
      3. Mandatory ICC and program office specialty-specific CEC to be implemented across the designated specialties;
      4. Optional additional VISN- or facility-level CEC and/or medical diagnosis approved by local leadership.
         • Note:  For retrospective chart reviews, each mandatory indicator must be evaluated using a minimum of five (5) charts for the FPPE or OPPE review period. Additional charts may need to be reviewed as required to adequately evaluate the practitioner’s professional competency.
   4. External Reviews:  The facility Chief of Staff must ensure that another practitioner at the facility with equivalent specialized training and similar privileges as the practitioner being evaluated completes the FPPE/OPPE review. It is required that a practitioner from another VHA medical facility with the same specialized training and similar privileges shall complete the FPPE or OPPE in the following circumstances:
      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);
      2. The practitioner is a supervisor of the service or section of specialty; or
      3. The practitioner is the facility Chief of Staff.
         • Note: If the review is for a clinical service chief, the results of the review shall be returned directly to the Chief of Staff. Furthermore, if the review is for the Chief of Staff, results should be returned to a pre-designated/applicable clinical service chief at the respective facility.
   5. Responsibilities:  Responsibilities for implementing mandatory requirements within this memo include, but are not limited to:
      1. National ICC Committee:
         1. Oversee enterprise-wide specialty-specific indicator development and approval, going forward
      2. VHACO Specialty Program Directors:
         1. Review specialty-specific FPPE/OPPE clinical indicators and all associated criteria for retrospective chart reviews annually and submit updates to ICC as needed
      3. VISN Chief Medical Officer (CMO):
         1. Lead and monitor implementation of specialty-specific clinical indicators outlined in this memo within their respective VISN
         2. Develop VISN-wide process for external reviews of FPPE/OPPE by practitioners with similar training and privileges as outlined in paragraph 4 above
      4. VISN ICC Leads:
         1. Provide Subject Matter Experts to support implementation and coordinate communications with national ICC and program offices
      5. Facility Medical Center Director:
         1. Ensure compliance with requirements outlined in this memo within twelve (12) months of memo publication
      6. Facility ECMS/Clinical Executive Committee:
         1. Ensure that mandatory clinical indicators published are 1) incorporated into service-level FPPE and OPPE forms, and 2) reviewed for compliance
         2. Document review of updated specialty specific FPPE/OPPE forms in ECMS committee minutes
         3. Review and approve specialty-specific FPPE/OPPE forms annually and document review/approval in ECMS committee minutes
   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 program office lead. This memo and its attachments as well as further references will be provided 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, Executive Director of Medicine, Specialty Care at Ajay.Dhawan@va.gov.

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

Attachments: (3)

FPPE-OPPE Chart Review Form_Final Template_ v1.0_Dated 2020-12-14

Master List for FPPE-OPPE_Specialty Clinical Indicators_v1.0_Dated 2020-12-14

Memo on FPPE-OPPE Clinical Indicators_121820