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    OPPE Indicator List by Depar

    Uploaded by

    Yandi
    This document lists ongoing professional practice evaluation indicators by department for 2011. It includes indicators for departments like Allied Health for Anesthesia, Anesthesia, and CRNA. For each department, it lists indicators for areas like patient care, interpersonal/communication skills, practice-based learning, system-based practice, medical knowledge, and professionalism. It provides definitions and identifies responsible resources for each indicator. Key departments and areas are monitored on a quarterly or yearly basis. The document was approved by the respective clinical departments, PI Committee, and Medical Executive Committee.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    OPPE Indicator List by Depar

    Uploaded by

    Yandi
    395 views11 pages
    This document lists ongoing professional practice evaluation indicators by department for 2011. It includes indicators for departments like Allied Health for Anesthesia, Anesthesia, and CRNA. For each department, it lists indicators for areas like patient care, interpersonal/communication skills, practice-based learning, system-based practice, medical knowledge, and professionalism. It provides definitions and identifies responsible resources for each indicator. Key departments and areas are monitored on a quarterly or yearly basis. The document was approved by the respective clinical departments, PI Committee, and Medical Executive Committee.

    Original Description:

    OPPE Idicator List

    Original Title

    OPPE_Indicator_List_by_Depar

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    This document lists ongoing professional practice evaluation indicators by department for 2011. It includes indicators for departments like Allied Health for Anesthesia, Anesthesia, and CRNA. For each department, it lists indicators for areas like patient care, interpersonal/communication skills, practice-based learning, system-based practice, medical knowledge, and professionalism. It provides definitions and identifies responsible resources for each indicator. Key departments and areas are monitored on a quarterly or yearly basis. The document was approved by the respective clinical departments, PI Committee, and Medical Executive Committee.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    395 views11 pages

    OPPE Indicator List by Depar

    Uploaded by

    Yandi
    This document lists ongoing professional practice evaluation indicators by department for 2011. It includes indicators for departments like Allied Health for Anesthesia, Anesthesia, and CRNA. For each department, it lists indicators for areas like patient care, interpersonal/communication skills, practice-based learning, system-based practice, medical knowledge, and professionalism. It provides definitions and identifies responsible resources for each indicator. Key departments and areas are monitored on a quarterly or yearly basis. The document was approved by the respective clinical departments, PI Committee, and Medical Executive Committee.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    2011 ONGOING PROFESSIONAL PRACTICE EVALUATION INDICATOR LIST BY DEPARTMENT

    CONFIDENTIAL

    Approved by Respective Clinical Department -


    Signature Date
    Approved by P.I. Committee -
    Signature Date
    Approved by Medical Executive Committee -
    Signature Date

    DEPARTMENT & INDICATORS TRIGGER DEFINITION RESOURCE


    ALLIED HEALTH FOR ANESTHESIA (ED Allied Health Follows ED OPPE)

    PATIENT CARE
    > 3 Cases Lacking PI Office Thru Random Sample of Cases in
    Required H&P Elements Documented Raw #
    Elements / Qtr SoftMed Chart Script
    INTERPERSONAL & COMMUNICATION SKILLS
    Risk Management - Complaints & Grievance
    Validated Complaints From Patient/Family/Staff >1 / Qtr. Raw #
    Report
    PRACTICE BASED LEARNING IMPROVEMENTS

    3 Unacceptable Abbrev / Pharmacy - Forwards Copied Orders with


    Adherence to NPSG for Abbreviations Raw #
    Qtr Unaccept. Abbrev.

    SYSTEM BASED PRACTICE


    HIM Forwards # to PI Office - PI Office
    # Completed / # of Admissions
    Rate of H&Ps Within 24 Hours of Admission < 90% Obtains Physician Report and Does
    = % Compliance
    Compliance
    MEDICAL KNOWLEDGE
    Number of Times Placed on Focused Review due to PI Office - Count of OPPE Findings for
    > 1 / Yr Raw #
    Performance Issues Focused Reviews
    PROFESSIONALISM
    NRC Picker Comments Thru PI Office &
    Pt/Fam/Staff Written Positive Feedback NA Raw #
    Letters Received from H.R. or Admin
    2011 ONGOING PROFESSIONAL PRACTICE EVALUATION INDICATOR LIST BY DEPARTMENT
    CONFIDENTIAL

    Approved by Respective Clinical Department -


    Signature Date
    Approved by P.I. Committee -
    Signature Date
    Approved by Medical Executive Committee -
    Signature Date

    DEPARTMENT & INDICATORS TRIGGER DEFINITION RESOURCE


    ANESTHESIA
    PATIENT CARE
    Death Within 24 Hrs Post Anesthesia > 1 / Qtr Raw # Anesthesia - Clinical Indicator List
    # of Cases Peer Reviewed with Outcome Classification of PI Office - Count of Peer Review Sheets with
    > 1 / Qtr Raw #
    2 or 3 Classification of 2 or 3
    Cardiac Arrest Within 24 Hrs Post Anesthesia > 1 / Qtr Raw # Anesthesia - Clinical Indicator List
    INTERPERSONAL & COMMUNICATION SKILLS
    3 Notes Not Immediate / PI Office - Random Sample of O.R. / Endo
    Immediate Post Op Note Raw #
    Qtr Cases Thru Chart View
    Risk Management - Complaints & Grievance
    Validated Complaints from Patients/Family/Staff > 1 / Qtr Raw #
    Report
    PRACTICE BASED LEARNING IMPROVEMENTS
    3 Unacceptable Abbrev / Pharmacy - Forwards Copied Orders with
    Adherence to NPSG for Abbreviations Raw #
    Qtr Unaccept. Abbrev. To PI Office
    SYSTEM BASED PRACTICE
    # Met Criteria / # Units Laboratory - Forwards Raw Numbers & PI
    Packed Cell Transfusion Appropriateness > 90%
    Transfused = % Compliance Office Reviews with Screening Criteria
    # Crossmatches / # Transfused Laboratory - Forwards Raw Numbers to PI
    CT Ratio > 2.0
    = Rate Office
    MEDICAL KNOWLEDGE
    Number of Times Placed on Focused Review due to PI Office - Count of OPPE Findings for
    > 1 / Yr Raw #
    Performance Issues Focused Reviews
    New Procedure Training Obtained NA Raw # Medical Staff Office
    PROFESSIONALISM
    OR Delay Due to Surgeon Being Late > 3 / Qtr Raw # Operating Room Report
    NRC Picker Comments Thru PI Office &
    Pt/Family/Staff Written Positive Feedback NA Raw #
    Letters Received from H.R. or Admin
    2011 ONGOING PROFESSIONAL PRACTICE EVALUATION INDICATOR LIST BY DEPARTMENT
    CONFIDENTIAL

    Approved by Respective Clinical Department -


    Signature Date
    Approved by P.I. Committee -
    Signature Date
    Approved by Medical Executive Committee -
    Signature Date

    DEPARTMENT & INDICATORS TRIGGER DEFINITION RESOURCE


    CRNA
    PATIENT CARE
    Re-intubation in OR or PACU > 3 / Qtr. Raw # Anesthesia - Clinical Indicator List
    Post Dural Headache > 3 / Qtr. Raw # Anesthesia - Clinical Indicator List
    INTERPERSONAL & COMMUNICATION SKILLS
    Risk Management - Complaints & Grievance
    Validated Complaints from Patients/Family/Staff > 1 / Qtr. Raw #
    Report
    PRACTICE BASED LEARNING IMPROVEMENTS
    PI Office - SCIP and Outpt Surgery Reports
    Documentation Compliance for Antibiotic Timeliness > 2 Non-Compliance / Qtr. Raw #
    Thru Premier
    SYSTEM BASED PRACTICE
    Volumes NA Raw # I. T. Dept - Report from Invision
    MEDICAL KNOWLEDGE
    CEU's NA Yes or No Answer Anesthesia Secretary
    PROFESSIONALISM
    NRC Picker Comments Thru PI Office &
    Pt/Family/Staff Written Positive Feedback NA Raw #
    Letters Received from H.R. or Admin
    2011 ONGOING PROFESSIONAL PRACTICE EVALUATION INDICATOR LIST BY DEPARTMENT
    CONFIDENTIAL

    Approved by Respective Clinical Department -


    Signature Date
    Approved by P.I. Committee -
    Signature Date
    Approved by Medical Executive Committee -
    Signature Date

    DEPARTMENT & INDICATORS TRIGGER DEFINITION RESOURCE


    FAMILY PRACTICE
    PATIENT CARE
    PI Office - Pnuemonia Core Measure Report
    Appropriate Antibiotic Selection for PN Direct Inpts > 1 Non Compliance / Qtr Raw #
    Thru Premier
    INTERPERSONAL & COMMUNICATION SKILLS
    HIM Forwards # to PI Office - PI Office
    # Completed / # of Admissions
    Rate of H&Ps Within 24 Hours of Admission < 90% Obtains Physician Report and Does
    = % Compliance
    Compliance
    PRACTICE BASED LEARNING IMPROVEMENTS
    3 Unacceptable Abbrev / Pharmacy - Forwards Copied Orders with
    Adherence to NPSG for Abbreviations Raw #
    Qtr Unaccept. Abbrev.
    SYSTEM BASED PRACTICE
    Index = ALOS / Expected
    Average Length of Stay (Severity Adjusted) Phy Index > 1.25 / Qtr PI Office Runs Report Thru Premier
    ALOS
    MEDICAL KNOWLEDGE
    Number of Times Placed on Focused Review due to PI Office - Count of OPPE Findings for
    > 1 / Yr Raw #
    Performance Issues Focused Reviews
    PROFESSIONALISM
    NRC Picker Comments Thru PI Office &
    Pt/Family/Staff Written Positive Feedback NA Raw #
    Letters Received from H.R. or Admin
    2011 ONGOING PROFESSIONAL PRACTICE EVALUATION INDICATOR LIST BY DEPARTMENT
    CONFIDENTIAL

    Approved by Respective Clinical Department -


    Signature Date
    Approved by P.I. Committee -
    Signature Date
    Approved by Medical Executive Committee -
    Signature Date

    DEPARTMENT & INDICATORS TRIGGER DEFINITION RESOURCE


    MEDICINE
    PATIENT CARE
    > Hosp. Specialty Peer/2 PI Office - Readmission (for Any Reason)
    Readmission Rate Severity Adjusted Rate
    Qtrs Report Thru Premier
    # of Cases Peer Reviewed with Outcome Classification of PI Office - Count of Peer Review Sheets with
    > 1 / Qtr Raw #
    2 or 3 Classification of 2 or 3
    INTERPERSONAL & COMMUNICATION SKILLS
    HIM Forwards # to PI Office - PI Office
    # Completed / # of Admissions
    Rate of H&Ps Within 24 Hours of Admission < 90% Obtains Physician Report and Does
    = % Compliance
    Compliance
    Risk Management - Complaints & Grievance
    Validated Complaints from Patients/Family/Staff > 1 / Qtr Raw #
    Report
    PRACTICE BASED LEARNING IMPROVEMENTS
    3 Unacceptable Abbrev / Pharmacy - Forwards Copied Orders with
    Adherence to NPSG for Abbreviations Raw #
    Qtr Unaccept. Abbrev.
    SYSTEM BASED PRACTICE
    # Met Criteria / # Units Laboratory - Forwards Raw Numbers & PI
    Packed Cell Transfusion Appropriateness > 90%
    Transfused = % Compliance Office Reviews with Screening Criteria
    # Crossmatches / # Transfused Laboratory - Forwards Raw Numbers to PI
    CT Ratio > 2.0
    = Rate Office
    Index = ALOS / Expected
    Average Length of Stay (Severity Adjusted) Phy Index > 1.25 / Qtr PI Office Runs Report Thru Premier
    ALOS
    MEDICAL KNOWLEDGE
    Number of Times Placed on Focused Review due to PI Office - Count of OPPE Findings for
    > 1 / Yr Raw #
    Performance Issues Focused Reviews
    PROFESSIONALISM
    NRC Picker Comments Thru PI Office &
    Pt/Family/Staff Written Positive Feedback NA Raw #
    Letters Received from H.R. or Admin
    2011 ONGOING PROFESSIONAL PRACTICE EVALUATION INDICATOR LIST BY DEPARTMENT
    CONFIDENTIAL

    Approved by Respective Clinical Department -


    Signature Date
    Approved by P.I. Committee -
    Signature Date
    Approved by Medical Executive Committee -
    Signature Date

    DEPARTMENT & INDICATORS TRIGGER DEFINITION RESOURCE


    OBGYN
    PATIENT CARE
    Unscheduled Returns to O.R. > 1 / Qtr Raw # Operating Room Report
    Number of Elective Inductions/Scheduled C-Sections Prior
    > 1 / Qtr Raw # Obstetrics Department Report
    to 39 Weeks Without Medical Indication
    INTERPERSONAL & COMMUNICATION SKILLS
    1 Exceeding Immediate / PI Office - Random Sample of O.R. / Endo
    Immediate Post Op Note Raw #
    Qtr Cases Thru Chart View
    PRACTICE BASED LEARNING IMPROVEMENTS
    3 Unacceptable Abbrev / Pharmacy - Forwards Copied Orders with
    Adherence to NPSG for Abbreviations Raw #
    Qtr Unaccept. Abbrev.
    SYSTEM BASED PRACTICE
    # Met Criteria / # Units Laboratory - Forwards Raw Numbers & PI
    Packed Cell Transfusion Appropriateness > 90%
    Transfused = % Compliance Office Reviews with Screening Criteria
    MEDICAL KNOWLEDGE
    Number of Times Placed on Focused Review due to PI Office - Count of OPPE Findings for
    > 1 / Yr Raw #
    Performance Issues Focused Reviews
    PROFESSIONALISM
    OR Delay Due to Surgeon Being Late > 3 / Qtr Raw # Operating Room Report
    2011 ONGOING PROFESSIONAL PRACTICE EVALUATION INDICATOR LIST BY DEPARTMENT
    CONFIDENTIAL

    Approved by Respective Clinical Department -


    Signature Date
    Approved by P.I. Committee -
    Signature Date
    Approved by Medical Executive Committee -
    Signature Date

    DEPARTMENT & INDICATORS TRIGGER DEFINITION RESOURCE


    PATHOLOGY
    PATIENT CARE
    Discrepancies with External Consults > 1 / Qtr Raw # Pathology Forwards to PI Office
    INTERPERSONAL & COMMUNICATION SKILLS
    > 1 Should Be
    Phoned Results to Physicians - Documented Raw # Pathology Forwards to PI Office
    Documented / Qtr
    PRACTICE BASED LEARNING IMPROVEMENTS
    Completeness of Reports (Staging) > 2 Lacking / Qtr Raw # Pathology Forwards to PI Office
    Turnaround Time on Non-Gyn 90% in 48 Hr Rate Pathology Forwards to PI Office
    SYSTEM BASED PRACTICE
    # of Amended Reports > 3 / Qtr Raw # Pathology Forwards to PI Office
    MEDICAL KNOWLEDGE
    Number of Times Placed on Focused Review due to PI Office - Count of OPPE Findings for
    > 1 / Yr Raw #
    Performance Issues Focused Reviews
    PROFESSIONALISM
    NRC Picker Comments Thru PI Office &
    Pt/Family/Staff Written Positive Feedback NA Raw #
    Letters Received from H.R. or Admin
    2011 ONGOING PROFESSIONAL PRACTICE EVALUATION INDICATOR LIST BY DEPARTMENT
    CONFIDENTIAL

    Approved by Respective Clinical Department -


    Signature Date
    Approved by P.I. Committee -
    Signature Date
    Approved by Medical Executive Committee -
    Signature Date

    DEPARTMENT & INDICATORS TRIGGER DEFINITION RESOURCE


    PEDIATRICS
    PATIENT CARE
    HIM Forwards # to PI Office - PI Office
    # Completed / # of Admissions
    Rate of H&Ps Within 24 Hours of Admission < 90% Obtains Physician Report and Does
    = % Compliance
    Compliance
    INTERPERSONAL & COMMUNICATION SKILLS
    Risk Management - Complaints & Grievance
    Validated Complaints from Patients/Family/Staff > 1 / Qtr Raw #
    Report
    PRACTICE BASED LEARNING IMPROVEMENTS
    3 Unacceptable Abbrev / Pharmacy - Forwards Copied Orders with
    Adherence to NPSG for Abbreviations Raw #
    Qtr Unaccept. Abbrev.
    SYSTEM BASED PRACTICE
    Index = ALOS / Expected
    Average Length of Stay (Severity Adjusted) Phy Index > 1.25 PI Office Runs Report Thru Premier
    ALOS
    MEDICAL KNOWLEDGE
    Number of Times Placed on Focused Review due to PI Office - Count of OPPE Findings for
    > 1 / Yr Raw #
    Performance Issues Focused Reviews
    PROFESSIONALISM
    NRC Picker Comments Thru PI Office &
    Pt/Family/Staff Written Positive Feedback NA Raw #
    Letters Received from H.R. or Admin
    2011 ONGOING PROFESSIONAL PRACTICE EVALUATION INDICATOR LIST BY DEPARTMENT
    CONFIDENTIAL

    Approved by Respective Clinical Department -


    Signature Date
    Approved by P.I. Committee -
    Signature Date
    Approved by Medical Executive Committee -
    Signature Date

    DEPARTMENT & INDICATORS TRIGGER DEFINITION RESOURCE


    PSYCHIATRY
    PATIENT CARE
    Operating Room Sends Qtrly Surgery List -
    Appropriateness of ECT > 1 Not Appropriate / Qtr Raw #
    PI Office Reviews with Screening Criteria
    INTERPERSONAL & COMMUNICATION SKILLS
    Risk Management - Complaints & Grievance
    Validated Complaints from Patients/Family/Staff > 1 / Qtr Raw #
    Report
    PRACTICE BASED LEARNING IMPROVEMENTS
    3 Unacceptable Abbrev / Pharmacy - Forwards Copied Orders with
    Adherence to NPSG for Abbreviations Raw #
    Qtr Unaccept. Abbrev.
    SYSTEM BASED PRACTICE
    # of Cases Peer Reviewed with Outcome Classification of PI Office - Count of Peer Review Sheets with
    > 1 / Qtr Raw #
    2 or 3 Classification of 2 or 3
    MEDICAL KNOWLEDGE
    Number of Times Placed on Focused Review due to PI Office - Count of OPPE Findings for
    > 1 / Yr Raw #
    Performance Issues Focused Reviews
    PROFESSIONALISM
    NRC Picker Comments Thru PI Office &
    Pt/Family/Staff Written Positive Feedback NA Raw #
    Letters Received from H.R. or Admin
    2011 ONGOING PROFESSIONAL PRACTICE EVALUATION INDICATOR LIST BY DEPARTMENT
    CONFIDENTIAL

    Approved by Respective Clinical Department -


    Signature Date
    Approved by P.I. Committee -
    Signature Date
    Approved by Medical Executive Committee -
    Signature Date

    DEPARTMENT & INDICATORS TRIGGER DEFINITION RESOURCE


    RADIOLOGY
    PATIENT CARE
    Wheeling Radiology Office Emails Monthly
    Discrepancies in X-Ray Interpretations Raw#
    > 3 / Yr Report to PI Office
    INTERPERSONAL & COMMUNICATION SKILLS
    Risk Management - Complaints & Grievance
    Validated Complaints from Patients/Family/Staff > 1 / Qtr Raw #
    Report
    PRACTICE BASED LEARNING IMPROVEMENTS
    Appropriateness of Thyroid Exams ???????? ??????? ?????? ??????
    SYSTEM BASED PRACTICE
    Mammogram Call Back Rate ???????? ??????? ?????? ??????
    MEDICAL KNOWLEDGE
    Number of Times Placed on Focused Review due to PI Office - Count of OPPE Findings for
    > 1 / Yr Raw #
    Performance Issues Focused Reviews
    PROFESSIONALISM
    NRC Picker Comments Thru PI Office &
    Pt/Family/Staff Written Positive Feedback NA Raw #
    Letters Received from H.R. or Admin
    2011 ONGOING PROFESSIONAL PRACTICE EVALUATION INDICATOR LIST BY DEPARTMENT
    CONFIDENTIAL

    Approved by Respective Clinical Department -


    Signature Date
    Approved by P.I. Committee -
    Signature Date
    Approved by Medical Executive Committee -
    Signature Date

    DEPARTMENT & INDICATORS TRIGGER DEFINITION RESOURCE


    SURGERY
    PATIENT CARE
    # of Cases Peer Reviewed with Outcome Classification of PI Office - Count of Peer Review Sheets with
    > 1 / Qtr Raw #
    2 or 3 Classification of 2 or 3
    Discontinuation of Antibiotic Within 24 Hrs. of Inpatient PI Office - SCIP Core Measure Report Thru
    > 0 Exceeding 24 Hrs / Qtr Raw #
    Surgery Premier
    Surgical Site Infections > 1 / Qtr Raw # Infection Prevention Office
    Unscheduled Returns to O.R. > 1 / Qtr Raw # Operating Room Report
    INTERPERSONAL & COMMUNICATION SKILLS
    HIM Forwards # to PI Office - PI Office
    # Completed / # of Admissions
    Rate of H&Ps Within 24 Hours of Admission < 90% Obtains Physician Report and Does
    = % Compliance
    Compliance
    3 Exceeding Immediate / PI Office - Random Sample of O.R. / Endo
    Immediate Post Op Note Raw #
    Qtr Cases Thru Chart View
    Risk Management - Complaints & Grievance
    Validated Complaints from Patients/Family/Staff > 2 / Qtr Raw #
    Report
    PRACTICE BASED LEARNING IMPROVEMENTS
    3 Unacceptable Abbrev / Pharmacy - Forwards Copied Orders with
    Adherence to NPSG for Abbreviations Raw #
    Qtr Unaccept. Abbrev.
    SYSTEM BASED PRACTICE
    # Met Criteria / # Units Laboratory - Forwards Raw Numbers & PI
    Packed Cell Transfusion Appropriateness > 90%
    Transfused = % Compliance Office Reviews with Screening Criteria
    # Crossmatches / # Transfused Laboratory - Forwards Raw Numbers to PI
    CT Ratio > 2.0
    = Rate Office
    Index = ALOS / Expected
    Average Length of Stay (Severity Adjusted) Phy Index > 1.25 PI Office Runs Report Thru Premier
    ALOS
    MEDICAL KNOWLEDGE
    Number of Times Placed on Focused Review due to PI Office - Count of OPPE Findings for
    > 1 / Yr Raw #
    Performance Issues Focused Reviews
    PROFESSIONALISM
    OR Delay Due to Surgeon Being Late > 3 / Qtr Raw # Operating Room Report
    NRC Picker Comments Thru PI Office &
    Pt/Family/Staff Written Positive Feedback NA Raw #
    Letters Received from H.R. or Admin

    This sample quality program tool is intended to be reviewed and revised by a hospital to meet that hospital’s unique circumstances. Neither this nor any quality
    program tool should be used until it has been adopted by a hospital’s medical staff and governing board. Nothing herein is a substitute for the independent medical or
    clinical decision-making of any person.

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