Performance Management and Process Improvement PDF

PERFORMANCE MANAGEMENT AND PROCESS IMPROVEMENT Chapter 4-5 Mohamed Eldeeb CPHQ,CPHRM,LSSBB,TQM,SCRUM Master ,TOT , Team STEPPS master training TEAM: TEAMS & MEETING Multidi...

PERFORMANCE MANAGEMENT AND PROCESS IMPROVEMENT Chapter 4-5 Mohamed Eldeeb CPHQ,CPHRM,LSSBB,TQM,SCRUM Master ,TOT , Team STEPPS master training TEAM: TEAMS & MEETING Multidisciplinary groups in the same room, maybe focused on the same process, but each member focuses on the contributions his or her discipline can make, and not necessarily on the entire process. group of people who perform interdependent tasks to work toward a common mission. Limited life: team designed for developing a new product, or a process improvement team organized to solve a particular problem. Ongoing: department team that meets regularly to review goals, activities and performance. Teamwork and Group Process: Group: is a collection of individuals who affect the character of the group and who are in turn affected by the group. Group dynamics: are determined by the various combinations of individual interests, abilities, and personalities. group success is inevitably tied to : 1. The organization's culture. 2. Leadership's commitment. 3. The degree of empowerment. 4. Resources given to the group. There should be 6 to 8 members of the team, but no more than 10, whose membership is based on close work with the organizational function, processes, or topic (((( process owner , department supervisor , leaders )))) Elements determine group dynamic: Status and position of the leader in Individual background of each group member relation to the group members. Emotional involvement of each member Status and position of each group member with the subject. Leader-group relationship concerning the Relative amount and type of participation subject and outcome. of each group member. Relative amount of leader and group Effect of leadership methods and tools participation Effect of physical surroundings on the Interrelationships of the group members discussion The Role of Teams in Quality Management: The improvement of quality in healthcare organizations is dependent on teamwork, partly because providing care and service is complex, with many handoffs between practitioners/workers, and partly because healthcare workers like working with other people. Quality Improvement (QI) Teams : Must be comprised of appropriate clinical and non-clinical staff at various levels in the organization. Teams may be temporary as in a task-associated team, or permanent such as a team dealing with a specific topic such as medication management. Utilize scientific methods and tools Teamwork involves the team members working collaboratively, through generation of ideas, discussions, utilizing understanding that the team members bring different ideas and experiences to the team, and that only by working together will the team be successful. Teams play a large role when successful implementation of the problem solution or process design/ redesign depends on buy-in from persons across the organization. ❖Stages throughout the performance of the work: Forming stage Storming stage Norming phase Performing stage Member are getting to know Member start to push against Start to come together. 1-work toward the completion of the goal. each other boundaries Resolve the conflict 2-the team is working well together. (as a conflict between working Appreciate each other style) Respect leader authority Establish ground role Begin to realise their task (more moving to cooperation The leader at this time is able to delegate than their expectation) instead of competitiveness. work to the members and feel assured that it will get completed. Little progress toward meeting Resistance toward taking the 1- more likely to ask other goals tasks team members for help. 2- others for feedback or their opinion. Training and education for Challenge toward leaders become committed to the member about their roles authority team's goal. It will take a little bit long time start to progress in that direction. Does not move straight from Forming to Performing, and then remain there. If there is any change in the team or new task definitely team will go back to the forming stage. If any replacement n the team the new member will be in the forming stage and pulling all the team to this direction. Types of QI Teams: In quality/performance improvement, teams are frequently utilized to determine how to make improvements to processes that have been identified by the organization. The team is brought together to make the improvements and then disbanded once the improvements have been made. Functional teams: Cross-functional teams: 1- Permanent. 1- Temporary 2- Always include members of the same department with 2- made up of members from various departments. different responsibilities. 3- Leader rarely has formal authority 3- A manager is responsible for everything. 4- Information flow in all direction (Circular structure of the 4- Every one reported to the manager (Up and Down flow) information flow) 5- tackle specific tasks that require different inputs and 5- Organized to improve processes in a given important expertise. function, e.g., patient care / medication management, infection control / environment of care, safety /information management. 6-Resources is Owned. 6- Resources is borrowed (staff and funds)  Clinical teams: Operation teams: 1- Organized around a clinical condition (diagnosis-Procedure). 1- Organized to improve management and support (nonclinical) 2- To improve all associated processes of care and service. services. 3- Clinical path development is a common task performed by this team. Ongoing teams: Ad-hoc teams: 1- Can be functional, clinical, or operational. 1- formed to address one important issue or task.(RCA,FMEA) 2- Mostly cross-functional and multidisciplinary in (specific goal) composition. 2- are comprised of those with the most knowledge of, and 3- May replace committees, are permanent. information about the issue under study. 4- Self managed e.g. (Counsel) 3- once the project is complete and the process change or new design has been implemented and been proven to work, the team disbands. Self directed teams 1- teams have more autonomy with the organization and thus have more responsibility. 2- Given broad decision-making authority with access to all information needed. 3- Do their own planning, setting of priorities, organizing and managing the budget. 4- Measuring their performance, solving problems, taking corrective action, evaluating their effectiveness. 5- are trained cross functionally, share many management responsibilities  Team Roles and Basic Tasks Role Basic Tasks Sponsor Senior leader advisor, Guide, direct to the team Is a key leader or clinician who is passionate about the need for improvement Maintains the overall responsibility, authority, and accountability for the team effort. Continually monitors the decisions and planned changes of the team and assures that they are in alignment with strategic goals Implements changes the team is not authorized to make.  Facilitator Keep team on task Guides activities such as brainstorming, cause mapping, risk analysis Manage team dynamics Teach and support Help the team leader with assignments, needs between meetings, plan changes, team tool techniques, prep for presentations Seek opinions of all team members Caring Team Coordinate ideas and test for consensus dynamic about the Assist team in applying QI tools and techniques Process it Summarize key points Test for self Provide feedback to the team consensus Apply Q. serves as internal consultant or coach to the team. Tool does not care about the outcome of the team, but rather about the team process itself.  Prepare for meetings Conduct meetings Assign activities to team members and participate in carrying out assignments between meetings Provide direction Assess progress Interface with other teams and support resources Represent the team to management Follow up with team members as necessary. Communicate with team, facilitator , sponsor/champion, and the organization. Leader the person who "owns" the process examined and has the responsibility and authority to lead the improvement project. an active member of the team and is interested in the outcome of the team efforts. establishes the content for the meeting, runs the team meeting, and summarizes at the end of the meeting. If the team leader has never held that position, a strong facilitator should be appointed to the team. The facilitator will run the first several meetings as the leader learns the leadership role, and then the leader can gradually take on the role with the support of the facilitator. A team leader should have the following ten skills: communication, organization, confidence, respectful, fair, integrity, influential, delegation, facilitator, and negotiation  Participates as a member and sometimes subject matter expert Champion Encourages and supports team, particularly to the organization and leadership Keep the team within designated meeting time constraints for discussions, Time keeper brainstorming and other team tool sessions, and ending times Team member Attend regular meetings Participate willingly Is engaged in working to reach the goals of the charter Treats others the way he/she would want to be treated Realize that the work of the team is accomplished outside of the meetings Assist the team leader with documentation and meeting management Help critique and improve the meeting process Share experience and knowledge Listen to others and remain open to all views and ideas Complete assignments between meetings Communicate effectively with colleagues regarding team's work/progress and seek input/buy-in Participate in team QI/Pl process Understand role in implementation and monitoring  Responsible for working with the team leader to identify the opportunity for improvement, identify the issues, process flows, and root causes of the problem. They are responsible to collect and analyze the data and then to recommend corrective action /changes. Once approved by the team sponsor, the team members are responsible to implement the action plan and to assure that the monitoring is done and that Recorder a successful outcome can be achieved. Team members need the skills of listening , sacrificing , sharing , respecting others views, questioning , working hard, and persuading Keep minutes and other records to meet documentation requirements and facilitate team recall  Performance Improvement Team Establishment Problem Statement/Charter: Once it has been identified that there is a need for a performance improvement team, a problem or opportunity statement should be developed. The problem statement should indicate what the problem is, who has the problem, when the problem occurs, how often it occurs, what causes it and its overall impact. The problem statement should be concise, specific, and measurable and specify what is impacted The statement should not mention either causes or remedies. Obstacles (resources) Ground Rules: ❑ Are the code of conduct for the team. ❑ It is important to set and review the ground rules at the beginning of the first team meeting and then briefly at each subsequent meeting. The ground rules may include: 1. Turn off cell phones or put on vibrate 2. No side bar conversations 3. Everyone's input is equally important 4. Start on time; end on time (or sooner) 5. Answer calls/pages outside of the meeting room 6. All members should participate 7. Respect everyone's ideas and opinions Orient/Educate the Team: Work together The team needs to be able to work together successfully in order to address the problem statement. Address The team members must be willing to listen to others and elicit their problem ideas. statement Trust and self-disclosure are critical for the team. Utilise PI Every team member is willing to self-disclose and be honest and tools Listen to respectful with other members. other Group members must be willing to support one another as they work toward an action plan. Elicit for The team members will require Just-In-Time training regarding the idea performance improvement tools that they will be utilizing within the team process. There should be an ongoing analysis of the effectiveness of this training Self with additional training provided as needed. disclosure Just in time training Team Process: Utilizing improvement process methodology (PDCA & SSBB…..). Develop project time line & SMART goals & responsibility of each member (Gantt chart). Time line should be reviewed every meeting to check the progression. Make sure that data collected (base line) to know the real situation. Once the data analyzed , the team can identify the needs to be done for improvement. Choosing the proper approach to fix the situation and address the specific barrier. Concerned group will receive the identified intervention which should be tailored for that group Multidisciplinary team will be helpful to set an action suitable for the multi disciplinary service. Getting team to come to consensus.  It is possible that the entire group may not be in full agreement on every single aspect of the issue at hand, but at least they are willing to be flexible enough to allow forward momentum and progress with the initiative. (consensus): moving toward at least some level of agreement) team leader should be communicating with the team Sponsor to assure that the team is processing in a manner acceptable to the organization. Once the action plan is formulated and approved for implementation, the team members must determine how to implement it. Sometimes it is best to implement it on a pilot basis and then make improvements before it is rolled out to the entire organization. If the desired outcome has not been achieved, the team must an order to sustain the measures, monitors must be put repeat the process and implement the revised action plan, then in place to measure if the process/outcomes are measure again. Once the desired results have been obtained, performing as desired. It has to be determined who will the teams work is not over. They must determine a way to conduct the ongoing monitoring and analysis. sustain the results. Evaluation of Team Performance: The simplest way to determine if the performance improvement team was effective is to ask these three basic questions: 1. Did the team reach the goal(s) that were stated in the charter? (Task completion) 2. Did the team working together and follow the performance improvement model? ( Team dynamic) 3. Were individuals responsible in completing their assigned tasks? (Individual performance) Productivity: the extent to which goal achieved. Satisfaction: Ability to work together. Individual growth: Member develop professionally by serving the team 1-Who is responsible for creating and monitoring the implementation of improvement project work plan and 4-One of the team members that keep members on track time line & focus on the process is: a. Sponsor b. Team leader A- Leader c. Team facilitator B- Facilitator d. Quality council C- Time keeper 2-A hospital process improvement team aims to reduce the severity and numbers of adverse drug events. Who in 5-Which of the following team members is responsible for the team should be considered subject matter keeping meetings focused? expert/experts A. time keeper.a. Team leader B. facilitator b. Team facilitator C. recorder c. sponsor d. Team members D. leader 6-the team member that keep team on track & clarify 3-Overall responsibility for the improvement project lies with the issues : a. Facilitator A- Leader b. Sponsor B- Facilitator c. Team leader C- Time keeper d. Team members D- Recorder  9-A facilitator`s best start with a team is to: 7-Team members are divided about the next course of A. Agree on meetings golden rules. action in an important project. It appears that the conflict B. Forming homogeneous team members is severe enough to warrant intervention. Who is C. Support team leader decisions. responsible for managing the conflict? D. Set meeting agenda and priorities A. Sponsor or Team Leader B. Team Leader or Coach 10-By forming a team After 1 month team attendance is C. Coach or Sponsor declined , which stage of team development: D. Team Leader only A. Storming B. Norming 8-The CPHQ evaluates the Performance Improvement C. Performing team to ensure it is effective and efficient. Three D. Forming areas to evaluate are completion of assigned tasks, the ability of the team to cooperate and reach a 11-What is the main purpose of the team charter? consensus, and the A. Help team members understand the purpose and A. effectiveness of the team as a whole. function of the team. B. effectiveness of the individual team members. B. Help others in the organization to understand the C. efficiency of the team’s leader. purpose and function of the team. D. efficiency of the team’s facilitator C. Facilitate accountability among team members. D. Inform leaders about the resources required. 12-Team charted in mental & psychiatry health to improve level of care,the facilitator should be knowledgeable about A. Mental& psychiatry health B. Level of care 15-Which of the following action should a facilitator C. Moderate group teamwork make the highest priority during the customer focus D. Assign tasks to team members group 13-At one of its meetings, the team has digressed from its A. Select homogenous group original discussion. Who is responsible for bringing the B. Establish rapport with the group conversation back to the meeting agenda? C. Provide written ground rules A. Team sponsor D generalizing the findings to the population B. Team leader C. Team facilitator 16-Which of the following make a successful focus D. Team members group? 14-During patient focus group, the facilitator should do 1- small group first: 2- include patient A. Choose homogenous group. 3- short duration B. Make ground rules. 4- good moderator C. Make rapport to the group. D. Instruct orders. Meeting Management: Meeting : "a coming together of two or more people, by chance or arrangement“ Meetings that are productive and well organized are well accepted by staff, where as meetings that are disorganized and not productive are determined unnecessary. There are only three reasons to hold a meeting. 1. Provide information that cannot be easily or effectively conferred by other means. 2. Create an opportunity for decisions to be made. 3. Allow feedback and discussion, such as a focus group, or as a post implementation meeting to determine what worked and what did not  It can be helpful to classify meetings or agenda items in a meeting by the type of communications involved. This allows participants to have realistic expectations of their role and to be prepared. Effective Meetings: ❑ Meetings are more than just showing up at a certain time and sitting in a room until it is completed. ❑ The leader's job is to be certain of the need for the meeting, conveying the need to the participants and conducting the meeting in an organized and productive manner. ❑ No matter how well the meeting planning is done, if the members in the meeting are not willing to participate, the meeting will not be successful. Therefore, the meeting leader must have a set of skills that can be effective in keeping participants engaged and also keeps the meeting moving through the agenda in a timely manner.  seven steps to an effective meeting: 1. Clear objective for the meeting. 2. Consider who is invited to the meeting. It should be determined who really needs to be at the meeting. 3. Rule is to stick to the agenda. The agenda should include the amount of time allotted to each specific item. All participants should have a copy of the agenda. 4. keep the meeting moving. Do not allow one individual to monopolize the conversation. 5. Start on time and end on time. Do not conduct the meeting for longer than 60 minutes 6. Ban technology'. Do not allow attendees to use their phone 7. The leader must follow-up. It is important to send out the minutes or the highlights of the meeting to all who attended and others that need to have the information, including any team members who were not present, within 24 hours of the meeting. Document the responsibilities and tasks assigned, as well as the deadlines.  If this is the first meeting of the Before the meeting During the meeting End of meeting group, ground rules should be established. Four ground rules should always be followed, with the addition of others deemed as appropriate. Everyone know the Start the meeting on Time for feedback ( 5 m-10 m ) The four ground rules are a must and time and place time apply to all attendees. Any one will not Attendees have copy Participate End on time attend inform us of the agenda Focus ahead of time maintain momentum Quorum (start with Review the action reach closure. Send reminder + taken and assignment The ground rules should be posted at Agenda the approval of previous meeting) all times during the meeting. Any one will present Set a time for next should be ready NO quorum (start with meeting If the conversation is wandering off the Old business should items need discussion) topic, bring it back by announcing to be mentioned the group that they need to get back Remind all the on topic. Put the important Share the goal& attendees with their item in the beginning purpose responsibilities Clarify the agenda If there are sidebar conversations, ask of the agenda those in the conversation if they would Time limit for each If the planned time on the agenda is not sufficient to like to share what they were discussing item in agenda close a topic, ask the group what they wish to do. with the group.  Meeting Minutes & Documentation: Following the meeting, the best practice is to send the attending members, and others as appropriate, a summary of the meeting or the meeting's minutes within 24 hours. Whenever someone asks you for a copy of the minutes, they are given only the minutes and not all the attachments. The minutes should not be vague, the reader cannot tell what really happened. The golden rule to follow when writing minutes is to "close the loop". At the time the minutes are completed, items that need follow up should be added to the agenda for the next meeting. THE PRACTITIONER APPRAISAL PROCESS: ❑ The medical staff bylaws: rules, and regulations establish a framework for medical/professional staff activities and accountability and are subject to governing body approval. ❑ They relate to all licensed independent practitioners with clinical privileges in the care of inpatients, emergency care patients, and patients in home care, ambulatory care, and long-term care. ❑ Membership on the medical staff requires an application process, including: credentialing, privileging, and appointment. ❑ The credentialing and privileging processes are extremely important in that there are legally required processes that protect the patient, physician and the organization.  The credentialing and privileging processes are utilized in healthcare to assure that licensed professional practitioners have the credentials required for the position and the ability to perform the tasks or privileges required. Licensed Independent Practitioners: Active member in organization Provide independent patient care service Appointment/Reappointment: 1. Application 1 2 3 2. Credentialing and privileges Process Leading to Appointment: 3. Medical executive committee 4. Governing body > appointment Credentialing Raise it for Application complete & approval from GB (submitted by specific clinical Or the designated applicant) privellidge committee granted  Credentialing: Is the verification of the practitioner's right and competency to provide patient care in the appropriate setting. The credentialing and re-credentialing process involves verification of compliance with predetermined standards and criteria concerning 1. Current, valid (state in U.S.) license to practice 2. Relevant training and education 3. Current competence 4. Board certification, if so stated 5. Work history 6. History of loss of license and felony conviction 7. Professional liability claims history resulting in settlements or judgments paid 8. Current malpractice insurance coverage 9. Evidence of physical ability to perform the requested privilege (or) inability to perform essential functions of the position Primary source verification: ❑ Is required at the time of initial credentialing and re- credentialing for all elements required by the state or the applicable accreditation organization. This means that direct contacts must be made with licensing states, certifying agencies, educational institutions, insurance carriers , state medical boards, and perhaps other institutions where the practitioner has privileges. Copies of these documents are not allowed to be accepted as verification since these copies could be digitally altered. ✓ Centralized credentialing: is another attempt to refine this verification process to streamline the demands on practitioners to complete multiple applications, credentialing and privileging processes, and perhaps medical staff appointments.  A centralized credentialing process, healthcare organizations have one center that completes all the credentialing verification for a given practitioner at one time for all facilities within the system. The practitioner has one reappointment date, which is the same throughout the organization. The essence of the system is one credentialing application and one-time primary source verification for all providers, and then one reapplication and information collection process, including profiling for current competency for re- credentialing and perhaps reappointment. Instead of organizations performing this centralized credentialing themselves, many organizations delegate the credentialing/re-credentialing function to credentials verification organizations (CVOs). CVOs are accredited themselves by accreditation organizations, so they musts meet identified standards. Privileging of Licensed Independent Practitioners: Once the applicant's credentialing process is completed, it is time to move into the privileging process. Once the centralized credentialing office or CVO has completed the credentialing, the application and file are returned to the specific facility where the applicant wants to practice. Privileging ✓ Is granting permission to provide specific medical or other patient care services in the organization, within well-defined limits, based on the individual's professional license and his or her experience, scope of practice, competence, ability, and judgment and on the organization's ability to provide and support the service. ✓ Granted for the time period specified in the bylaws or policies and procedures, but for no more than three or two years as defined by the accrediting organization.  Upon initial application, the information concerning the competency of the practitioner is obtained through the credentialing process 1. Review of education 2. Malpractice findings 3. Reference checks During the periodic reappraisal process set by the organization, the privileges must be re-requested and be renewed, revised, added, or deleted, based on information from the practitioner's practice patterns and review for the reappointment period. A practitioner may also apply for a new privilege at any time during the reappointment cycle. However, when this occurs, the practitioner must demonstrate the competencies required for that privilege.  Delineation of Privileges ✓ Clinical privileges are granted individually, based on criteria established by the organization 1. usually using privilege lists or groupings that are specific to each department, section, service, or specialty. 2. The criteria is established by the medical staff to determine the level of competency appropriate for each privilege, e.g. the number of procedures that must be performed every reappointment cycle for the practitioner to be considered currently competent and to retain the privileges. ✓ A practitioner may also apply for a new privilege at any time during the reappointment cycle. However, when this occurs, the practitioner must demonstrate the competencies required for that privilege. ✓ Advanced practice practitioners may be awarded clinical privileges as defined by the medical staff bylaws, yet they are not members of the medical staff. Special Privilege Statuses: The majority of the time privileges are awarded for the three or two year period, or until the next reappointment time. However, there are two exceptions to this rule, and these are based on the clinical needs of the facility. 1-Temporary Privileges: Temporary privileges are awarded to practitioners in only two circumstances. Both types of temporary privileges may only be awarded for a period of up to a total of 120 days. If the practitioner is needed for a longer period of time, the practitioner must apply for membership in the medical staff of the facility. The length of time that a practitioner can provide patient care under temporary privileges should be closely monitored ❑ The first type of temporary privileges are those given to a locum practitioner. Locum privileges are given to a practitioner who will be working at the facility to either meet an identified clinical need or to replace a practitioner who will be absent from the facility for a period of time. ❑ The second type of temporary privileges are awarded to applicants to the medical staff during probation period who have been through the credentialing and privileging processes and who are needed or wish to practice in that facility prior to the completion of the approval process. The application must have no red flags. ❖ Red flags could include: gaps on a physician's resume resignations from healthcare facilities insurance reduction in coverage over a period of time 2-Emergency & Disaster Privileges: Emergency privileges are awarded during an emergency to existing members of the medical staff that allow them to perform tasks outside of their delineated privileges to save a patient's life, limb or organ. When a practitioner with the appropriate privileges arrives, the emergency privileges are relinquished by the first practitioner.  In a disaster, any volunteer independent licensed practitioner who has a picture identification badge demonstrating membership in a hospital medical staff, and/or membership on one or more disaster management teams, or other specific organizations, may be allowed to practice at a healthcare facility during the disaster. Any volunteer practitioner is permitted to do everything possible to save a life or protect a patient from further or serious harm within the scope of his/her license, regardless of membership status, credentialing status, or approval of specific privileges. Once the disaster has been declared as being over, or if a practitioner on the medical staff of the facility arrives to take over, then the volunteer practitioner must relinquish those privileges. Initial Appointment: ❑ Is often provisional, with a time period consistent for all applicants, generally 6 months to 1 year, as determined by the medical staff bylaws. ❑ The full appointment period is also determined by the bylaws, but cannot exceed three years in managed care organizations or two years in other organizations such as those accredited by The Joint Commission. ❑ At the time of appointment, or once the provisional time period has elapsed and required proctoring (under supervision) is completed, the practitioner is awarded a specific category of membership depending on the categories listed in the medical staff bylaws. Reappointment: ✓ Reappointment includes reappraisal of the activity of the practitioner over the time period from last appointment, including both credentialing and privileging. ✓ Reappointment is granted for the time period specified in the bylaws or policies/procedures, but never for longer than three years or two years depending on whether it is a managed care organization or not. Recredentialing: ✓ Consists of submission of an application as previously occurred during the initial credentialing, and updating the information concerning current activity, licensure and certifications/registrations. ✓ All information that was reviewed at the time of appointment, except information that does not expire, such as education achieved. ✓ If any new credentials, education, or other information has been obtained since the last appointment, it must also be verified at this time. Re-privileging: Consists of a review of the current competency , quality management activities , and peer review activities of the practitioner. It also includes: Review of other reasonable indicators of continuing qualifications, peer and departmental recommendations. Review and renewal of specific clinical privileges, and compliance with continuing medical education requirements. Following the re-credentialing and re privileging processes, the information is sent from the appropriate department who recommends reappointment to the Medical Executive Committee, which then sends their recommendation to the governing body.  Credentialing of Licensed Independent Practitioners: ❑ Credentialing and privileging are two distinctly different processes. The credentialing process occurs before the privileging process is begun. Licensed Independent Practitioner (LIP): is any individual who is professionally licensed by the state (U.S.) and permitted by the organization to provide patient care services without direction or supervision, within the scope of that license.  Evaluation of the Practice of Licensed Independent Practitioners: An ongoing process that begins when the first privileges are delineated and continues until the individual no longer practices at the facility. Is any individual who is professionally licensed by the state (U.S) and permitted by the organisation to provide patient care services without direction or supervision with in the scope of this license. Only LIP who are appointed has the authority to approve admission of patient. Proctoring: FOCUS review: Observation and evaluation of new LIP or with newly request of privellidge. Patient Care Clinical Practice-based Interpersonal and Professionalism Systems- Knowledge Learning and Communication Skills based Improvement Practice ▪ Appropriate ▪ Demonstrate ▪ Utilize ▪ Establish and ▪ Behaviors ▪ Understandi and Effective knowledge scientific maintain professional reflect ng of to patient evidence relationships with commitment, systems care patients and health development, care teams ethical practice & responsibility  Practitioner Profiling Profiles are practitioner-specific data and information summaries are used in the reappraisal process, usually in conjunction with re-credentialing and re- privileging activities. Closing of the loop for performance monitoring and analysis, helping to effectively communicate appropriate findings to those leaders who need to know. Provide information (ongoing measurement) to assist Department chairs, section chairs, must review the profile data for both positive findings and any areas of concern then the Medical Executive Committee in the determination of the privileges to be renewed, discontinued, and so forth with each practitioner.  This profile should be constructed utilizing the information from. 1. the Ongoing Professional Practice Evaluation (OPPE) 2. the Focused Professional Practice Evaluation (FPPE) 3. the peer review that has been completed 4. other indicators Ideally profiling should be as concurrent as possible, with review, analysis, and reporting at least quarterly Practitioner profiles must be maintained in a strictly confidential environment, electronic or hard copy and should NOT be kept in the Credentials file.  Ongoing Professional Practice Evaluation (OPPE) The ongoing measurement (evaluation) and analysis of each (all) practitioner's performance relative to existing privileges, including licensed independent practitioners and others with clinical privileges granted by the organization. The purpose of OPPE is to provide an ongoing practitioner's performance evaluation to assist the practitioner in making improvements in his/her practice and patient safety. designed for the practitioner to identify his/her weak spots and then undertake efforts to improve those areas of care and performance. This intervention could include additional focused review, proctoring for a period of time, up to limiting or revoking existing privileges for that practitioner. The purpose of OPPE is making ongoing improvements, must be completed at least three reports every two years.  Focused Professional Practice Evaluation (FPPE) A privilege-specific, time-limited process to validate practitioner competency when: 1. there is no current performance documentation for the requested privilege(s) at the organization(new applicants and to existing practitioners). 2. when concerns arise about a practitioner's ability to provide safe, high quality patient care (Peer Review) based on criteria determined by healthcare providers (triggers).  Peer review process It is the review of an individual practitioner by a “like” practitioner who has the same training and expertise. It is used for in-depth analysis for licensed independent practitioner performance. It is a main component in practitioner appraisal. Peer review documents are considered to be “Confidential”. It is the responsibility of the appropriate department or specialty, but is usually delegated to a committee “Peer review Committee”. JCI focuses on the design and function of peer review process which must be consistent ,useful ,timely , balanced and ongoing. Professional practice evaluation (PPE) types : 1. Focused 2. Ongoing The indications of peer review: 1. ongoing performance measure data collection and initial analysis 2. utilization review 3. infection surveillance activities 4. occurrence or event reporting, a sentinel event 5. team QI/Pl activities, and/or data aggregation with internal or external comparisons (averages or benchmarks) The purpose of peer review: 1. identify patterns outside recognized standards, behavior problems, or other circumstances, which endanger the safety or care of patients 2. upgrading the practitioner's clinical knowledge, enhancing his/her medical practice, reducing medical errors and improving patient safety and care 3. protect patients, assure due process to the practitioner under investigation and preserve the immunity of the medical facility and medical staff. The analysis of cases should be reviewed for the following factors: 1. clinical management 2. timeliness of medical interventions 3. adherence to a facility's clinical pathways and/or established guidelines for medically appropriate care 4. medical record documentation 5. professional conduct, and other reasons as requested by the facility Confidentiality Peer review committee / QM committee Ranking score: 1 = Peers would have managed care in the same manner 2 = Patient outcome unaffected by the variance 3 = Peers would have managed care differently 4 = Negative outcome resulted from the variance