Incorporating Joint Commission OPPE into a Hospital-Wide Quality Improvement Program

Whether we particularly like it or not, physicians are accustomed to having our actions judged—by our patients and their loved ones, other members of the care team, and the organized medical staff of the hospital(s) where we have privileges. For many years, physician evaluation by the hospital and its medical staff came at periodic reappointment—every one or two years, was a somewhat basic, and was often a subjective validation of our perceived competence, technical skill and judgment.

More recently, The Joint Commission and other accrediting bodies and payers have established more stringent guidelines for the ongoing evaluation of the professional practice quality of each medical staff member, across all departments and services. Called Ongoing Professional Practice Evaluation (OPPE), the program features six core areas measuring a practitioner's clinical and behavioral competence. Evaluation is to be on a regular basis, such as every two, four or six months. This means more frequent scrutiny of physician practice patterns—and the outcomes of our practice of medicine—than ever before.

The Six Competencies in the Joint Commission Standards

• Patient Care.Practitioners are expected to provide patient care that is compassionate, appropriate and effective for the promotion of health, prevention of illness, treatment of disease and managing the end of life.
• Medical/Clinical Knowledge. Practitioners are expected to demonstrate knowledge of established and evolving biomedical, clinical and social sciences, as well as the application of their knowledge to patient care and the education of others.
• Practice-based Learning and Improvement. Practitioners are expected to be able to use scientific evidence and methods to investigate, evaluate and improve patient care practices.
• Interpersonal and Communication Skills. Practitioners are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families and other members of health care teams.
• Professionalism. Practitioners are expected to demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity, and a responsible attitude toward their patients, their profession and society.
• Systems-based Practice. Practitioners are expected to demonstrate both an understanding of the contexts and systems in which health care is provided and the ability to apply this knowledge to improve and optimize healthcare.

Some physicians may not view this change as major or as a reason for concern. Hospitals have already been delivering a variety of performance management data to them for some time. But as regulations and medical practice in general have become more complex—and data have become more plentiful—having a positive dialogue regarding the specifics of a physician's practice as part of the organization's quality improvement program has become more challenging.

After all, by our very nature and the job we're challenged to perform, physicians want to be perfect and don't generally like hearing when we're not. None of us enjoys criticism. Also, being told that our method of practice is less than perfect means we have to experience change, which is typically a challenge for every human being. This is especially true for something as ingrained as an individual physician's (or a department's) daily practice of medicine.

Moving through the stages
Those hospital executives tasked with sitting down with a physician to discuss practice variations as part of OPPE or any other performance-improvement initiative will need to be prepared for the reactions they'll likely encounter. Thinking through the process ahead of time will help move the conversation toward a positive dialogue and acceptance for implementing change—change designed to lead to broader implementation of best practices and achievement of improved outcomes.

An incredibly useful model for coping with all types of change—or any news people don't want to accept, for that matter—has proven to be one adapted from the Elizabeth Kübler-Ross model on the stages of grief ("On Death and Dying"), developed in 1969. These stages are fluid; during the process, a person can go from a bargaining stage to denial and back again. So while predicting human behavior is not an exact science, the Kübler-Ross model is a useful foundation.

Stage 1: Denial. "This is not right! The data are incorrect!" In this initial stage, the data is in effect summarily dismissed. The most common summary dismissal is "this is just 'administrative' data." In my mind, the term 'administrative' is outmoded and relates to a former, less complex time—when five or so discharge codes were applied only for the purposes of reimbursement. Today, a discharge abstract contains 36, 64 or even more ICD-9 codes so that all co-morbidities and complications can be effectively captured. Coders have long since learned that this data is being used for public reporting, quality improvement and many other purposes.

Stage 2: Anger. "How dare you? Who are you to tell me this?" Don't be scared off of by this response. Expect it as a move in the right direction to the next stages. Remember . . . there may be a need to visit this (and other) stages more than once before positive and consistent forward movement is achieved.

Stage 3: Bargaining. The "Yes, but . . ." stage. "If you just had better data . . . if it were more clinical and less administrative…my patients are sicker and this doesn't take that into account . . ."

Here's where executives can engage in a discussion of the validity of the data and the risk-adjustment model to help move the practitioner to the next stage. For example, Premier healthcare alliance member hospitals can point to the fact that they are using the largest clinical comparative database of its kind, used by more than 600 facilities in North America. It includes inpatient and outpatient data, from all payers, representing one in every five discharges in the U.S. Even that kind of evidence supporting the data presented may not be enough. But this is a critical juncture in the road toward acceptance-having a dialogue about the data instead of a total rejection of it.

Frame the discussion in terms of how "we" can use the data to improve patient care quality and safety, while maintaining the effective use of hospital resources and the practitioner's time.

Stage 4: Depression. Practitioners don't typically spend much time at this stage, once they've gone through bargaining. They will either move on into the acceptance phase, realizing that they need to get on with the tasks at hand, or they will circle back immediately to anger and then further bargaining. Framing the exercise as one of quality improvement for the sake of providing exceptional patient care—rather than as an attack on professional competence—will hasten progression to the acceptance phase.

Stage 5: Acceptance. Now's the chance to move this practitioner and the entire medical staff in a more transparent process to not only satisfy the OPPE requirements, but more fully ingrain an organization-wide, ongoing professional performance improvement culture that they will support willingly.

What can be achieved?
The need to have an operational OPPE program has become a given. It's a Joint Commission standard for recertification and thus important to virtually every hospital. Having an effective OPPE program is another matter. Making an OPPE program truly effective requires framing it within the context of using information for improvement rather than judgment, and using "actionable" information to improve the lives of patients and staff alike.

More importantly, having a process and tools to effectively gain practitioner buy-in can and should lead to an organizational culture where physician performance reporting is part of a larger, transparent quality improvement process-where the organization can focus on delivering the highest level of care possible, rather than engaging in non-productive "grief" sessions.

Recognizing the inherent challenges of coping with change, providing "actionable information" and correctly framing the exercise in the context of institutional improvement will allow hospital execs to be prepared to deal with roadblocks that will inevitably occur along the path towards improved performance and outcomes. It will also afford the opportunity to accelerate an organization's overall performance improvement initiatives and results.