Does OPPE/FPPE need to be reported to the board?
There is no requirement to report any physician specific OPPE or FPPE data to the board. There is, however, a requirement to design a uniform process with criteria and triggers, describe it in the bylaws, and consistently implement it as designed. The standards are MS.08.01.01 FPPE, MS.08.03.01 OPPE, and MS.09.01.01 evaluate and act upon the board approved process.
To show the board that the process is functional, the hospital might produce a high-level management report for board review. For example, General Surgery chair reviewed 120 OPPE files in May as scheduled. One general surgeon met criteria for a focused FPPE, and the chair met with one additional surgeon consultatively. Then Medicine, etc.
The TJC Surveyor Activity Guide continues to focus surveyors on questioning the sensitivity of the measures. If the OPPE process takes place every six (6) months but there has never been any outlier performance identified, the measures are likely not sensitive enough. Having a management report that allows the medical staff and board to see what is being identified in the aggregate might be useful.
Having a clearly designed and uniformly implemented process is also helpful to the hospital in the event that the hospital ever wants to curtail or restrict some privilege. Such actions are reportable to the National Provider Data Bank (NPDB) and always raise concerns about law suits from the practitioner. We have seen hospitals taken to task by attorneys for those physicians asking about counseling, warnings and focused FPPE processes questioning why the physician was never forewarned by the bylaws approved processes prior to deciding to take NPDB reportable action.
Also, the board actually needs to approve the clearly designed and uniformly implemented process for credentialing and privileging decisions at a high level as described in bylaws. The basic TJC approach to bylaws is the “basic requirements” are in bylaws. Details and step by step processes may be in other medical staff documents.
Finally, the board also approves credentialing and privileging recommendations made by the MEC. The MEC recommendations are forwarded up to the board by the MEC. This is normally in the form of a high-level review of MEC recommendations however the board could ask to review specifics of an individual provider. OPPE/FPPE are part of the data reviewed by MEC before making credentialing and privileging decisions.