Facility Logo Master FPPE/OPPE Indicator Table DEPARTMENT/ Specialty FPPE Initially Granted “Core” Privileges FPPE (Focused Review) Triggers OPPE Indicators Data Source/ Who gathers the data Department/Medical Staff Approval Dates Allergy and Immunology Review the first five cases for adequacy of consultation, progress notes and operative reports, inclusive of OPPE Indicators. Readmission Same DX Critical/abnormal lab result unaddressed Timeliness of Consultations Consultations > 24 Hrs x 3 Critical/abnormal lab result unaddressed X 3 Readmission Same DX Critical/abnormal lab result unaddressed Timeliness of Consultations Anesthesiology Review of 5 representative anesthesiology cases/charts, including adequacy of H&P, progress notes, consultation, operative reports, OPPE indicators: Unanticipated Dental Injury Failed Intubation Unexpected Transfer to ICU Due to Anesthesia Complication Narcotic Reversal Agent Required (across all discharges) Adverse effect of anesthesia (across all surgical discharges) Number of Anesthesia complications: Late effect of complications
Unplanned of surgical and medical care Iatrogenic Pneumothorax (across all discharges) Cardiovascular Disease Review of 5 cases/charts for adequacy of progress notes, consultation, operative reports and EBM: HF Evaluation of LVS Function EBM: ACEI or ARB for LVSD Hospital acquired DVT/PE (across all discharges) Trend of Unexpected Mortality Excessive complication rate EBM: HF Evaluation of LVS Function EBM: ACEI or ARB for LVSD Hospital acquired DVT/PE (across all discharges) Heart Cath-related CVA (across all heart caths) Complication rate Mortality rate Cardiology- Electrophysiology Review of 5 cases/charts for adequacy of progress notes, consultation, operative reports and Complication of procedure Accidental puncture or laceration Hospital acquired DVT/PE Post operative hemorrhage or hematoma Trend of Unexpected Mortality Excessive complication rate Procedure complication rate Accidental puncture or laceration rate Hospital acquired DVT/PE (across all discharges) Post operative hemorrhage or hematoma rate Moderate Sedation:
Moderate Sedation: Reversal agent required Reversal agent required Cardiovascular Surgery Review of first 5 charts, for adequacy of consultation, H&P, progress notes and operative reports and the following: EBM-SCIP: Antibiotic Discontinued within 24 Hours After Surgery EBM-SCIP: VTE Prophylaxis Ordered Complication of procedure Accidental puncture or laceration Hospital acquired DVT/PE Post operative hemorrhage or Trend of accidental lacerations, or punctures Trend of Unexpected Transfers to ICU EBM-SCIP: Antibiotic Discontinued within 24 Hours After Surgery EBM-SCIP: VTE Prophylaxis Ordered Procedure complication rate Accidental puncture or laceration rate Hospital acquired DVT/PE (across all discharges) Post operative hemorrhage or hematoma rate Moderate Sedation: Reversal agent required
hematoma Moderate Sedation: Reversal agent required Certified Nurse Midwife Review of 5 Cases for adequacy for adequacy of H & P, consultation and operative report documentation in addition to the following: Performs appropriate history and physical examinations, including pelvic exam with pap smear, breast and rectal exams Writes appropriate orders in patients charts chart for appropriate laboratory, radiologic, diagnostic examination, or other studies based upon history and physical exam findings Elective Induction < Prolapsed umbilical cord after elective rupture of membranes with the fetus at high station Trend of high complication rate Performs appropriate history and physical examinations, including pelvic exam with pap smear, breast and rectal exams Writes appropriate orders in patients charts chart for appropriate laboratory, radiologic, diagnostic examination, or other studies based upon history and physical exam findings Circumcision repair during current hospitalization Induction < 39 Weeks
39 Weeks Circumcision repair during current hospitalization Colon & Rectal Surgery Review of first 5 charts, for adequacy of consultation, H&P, progress notes and operative reports and the following: Post op infection Accidental perforation Procedure complications Trend of accidental lacerations, or punctures Trend of Unexpected Transfers to ICU Post-op Infections (across all surgical discharges) Procedure complication rate Mortality rate Dermatology Review the first five cases for adequacy of consultation, progress notes and operative reports. Readmission Same DX Critical/abnormal lab result unaddressed Timeliness of Consultations Consultation > 24 Hrs x 3 Critical/abnormal lab result unaddressed X 3 Readmission Same DX Critical/abnormal lab result unaddressed Timeliness of Consultations
Emergency Medicine Review of 3 representative charts/cases, for adequacy of documentation, progress notes, consents and reporting representative of Emergency Medicine privileges and Returns to ER within 72 Hrs 3 day ED revisits resulting in admission Lumbar puncture complications Returns to the ER within 72 Hrs in a code situation Returns to ER within 72 Hrs Critical/abnormal lab result unaddressed % Returns to ER within 72 Hrs % 3 day ED revisits resulting in admission % Lumbar puncture complications Endocrinology Review the first 3 representative cases for adequacy of consultation, progress notes and operative reports, inclusive of OPPE Indicators as follows: Readmission same DX Critical/abnormal lab result unaddressed Timeliness of Consultations Consultations > 24 Hrs x 3 Critical/abnormal lab result unaddressed X 3 Readmission with Same DX Critical/abnormal lab result unaddressed Timeliness of Consultations
Family Medicine Review the first 3 representative cases for adequacy of consultation, progress notes and operative reports, inclusive of OPPE Indicators as follows: Readmission same DX Appropriate use of diagnostic testing Appropriate use of consultations Critical/abnormal lab result unaddressed X 3 Unexpected Transfer to ICU x 3 Readmission same DX Critical/abnormal lab result unaddressed Appropriate use of diagnostic testing Appropriate use of consultations Gastroenterology Review the first 3 representative cases for adequacy of consultation, progress notes, and operative reports, inclusive of OPPE Indicators and Cecum to rectum time >/= 6 Min Use of prophylactic antibiotics Moderate Sedation: Use of reversal agents Trend of increased complication rate Trend of unexpected transfers to higher level of care Procedure complications across all colonoscopies Procedure complications across all upper endoscopies Cecum to rectum time >/= 6 Min Use of prophylactic antibiotics Moderate Sedation: Use of reversal agents
General Surgery Review of first 3 representative charts, for adequacy of consultation, H&P, progress notes and operative reports, and inclusive of OPPE Indicators: EBM-SCIP: Antibiotic Discontinued within 24 Hours After Surgery EBM-SCIP: VTE Prophylaxis Ordered Post op infection Accidental Perforation Hemorrhage due to a procedure Trend of accidental lacerations, or punctures Trend of Unexpected Transfers to ICU EBM-SCIP: Antibiotic Discontinued within 24 Hours After Surgery EBM-SCIP: VTE Prophylaxis Ordered Accidental puncture and laceration rate Procedure complication rate Post op infection rate Hemorrhage due to a procedure (across all surgical discharges) Gynecology Oncology Review of 3 representative charts for adequacy for adequacy of H & P, progress notes, consultation and operative reports in each of the following procedures Procedure complication Mortality Unexpected Transfer to ICU Unplanned Injury or removal of organ Post Procedure Infection rate Procedure Complication rate Mortality rate
Hand Surgery (Ortho-Neuro Dept) Review of 3 representative charts, for adequacy of consultation, operative reports and the following indicators: Unplanned return to surgery Procedure Complication Post op Infection complication Peri-operative arrest, death unplanned return to surgery same admission/visit Procedure Complication Rate Post-op infection rate complication rate (across all surgical discharges) Peripheral nerve injuries Hematology-Oncology Review the first 3 representative cases for adequacy of consultation, progress notes and operative reports, inclusive of OPPE Indicators and, Bone Marrow Biopsy complications Indwelling venous access catheter complications Central line infections Critical/Abnormal lab result unaddressed x 3 Unexpected transfers to ICU x 3 Critical/Abnormal lab result unaddressed Unexpected transfers to ICU Bone Marrow Biopsy complication rate Indwelling venous access catheter complication rate Central line infection rate
Neonatal-Perinatal Medicine Review the first 3 representative charts, for adequacy of H&P, progress notes, consultation and operative reports in each of the following procedures Birth trauma – injury to neonate (post delivery) Transfers to higher level of care Mortality Rate Birth trauma – injury to neonate (post delivery) Transfers to higher level of care Complication rate Packed cell transfusion rate Nephrology Review the first 3 representative cases for adequacy of consultation, progress notes and operative reports, inclusive of OPPE Indicators and, Critical/abnormal lab result unaddressed Daily progress/consultation notes not documented Unplanned transfers to ICU Consultations > 24 Hrs Consultation > 24 hrs x 3 Critical/abnormal lab result unaddressed Critical/abnormal lab result unaddressed Readmission same DX Vascular/Catheter associated infection across all discharges ALOS Average consults used
Neurological Surgery Review of 3 representative charts, for adequacy of consultation and operative reports in the following: Peri-operative: EBM-SCIP: VTE Prophylaxis Ordered EBM-SCIP: Antibiotic Discontinued within 24 Hours After Surgery Cervical or Lumbar Fusion: Antibiotic selection for surgical procedures Post Op Post – op infections Wrong Site EBM-SCIP: VTE Prophylaxis Ordered EBM-SCIP: Antibiotic Discontinued within 24 Hours After Surgery Procedure complication rate Mortality rate Post-op surgical infections Nurse Practitioner Surgery Review of 3 representative charts, for adequacy of H&P, progress notes, consultation, operative reports and discharge summaries and review of the following: Positions and preps Validated patient complaints regarding quality of care Validated incidents of inappropriate behavior Positions and preps patients appropriately Appropriately maintains sterile field Competently sutures to close surgical incision as appropriate
Obstetrics & Gynecology Review of 3 representative cases* for adequacy for adequacy of H & P, consultation and operative reports, in addition to the following indicators: Obstetrics: Induction < 39 Weeks Circumcision revision during current hospitalization Ruptured uterus during delivery Gynecology: EBM: SCIP: Appropriate Antibiotic Selection Procedure complication Post op infection * Completed within first 3 months Prolapsed umbilical cord after elective rupture of membranes with the fetus at high station Obstetrics: Induction < 39 Weeks Circumcision revision during current hospitalization Ruptured uterus during delivery 3rd & 4th degree lacerations Anal sphincter tear Gynecology: EBM: SCIP: Appropriate Antibiotic Selection EBM: SCIP: Antibiotic Discontinued within 24 Hrs after Surgery Procedure complication Post op infection Ophthalmology Review of 3 representative cases, for adequacy of consultation, H&P, progress notes, and operative reports, and % of OP Procedures with ED visit within 30 days Consult > 24 Hrs x 3 % of OP Procedures with ED visit within 30 days Consults < 24 Hrs
Consults < 24 Hrs Orthopedic Surgery Review of 3 representative cases, for adequacy of progress notes, consultation and operative reports in the following procedure(s) Peri-operative: EBM-SCIP: VTE Prophylaxis Ordered EBM-SCIP: Antibiotic Discontinued within 24 Hours After Surgery Total Knee or Hip Replacement: Antibiotic selection for surgical procedures Post op infection Moderate Sedation: Use of reversal agent required. Wrong Site EBM-SCIP: VTE Prophylaxis Ordered EBM-SCIP: Antibiotic Discontinued within 24 Hours After Surgery Procedure Complication rate Hospital acquired DVT/PE Post – op infection rate Peripheral vascular complications Hospital acquired pheripheral nerve injury Moderate Sedation: Use of reversal agent
required. Otolaryngology Review of first 3 representative charts, for adequacy of consultation, H&P, progress notes, operative reports, and the following: Procedure complication rate Surgical site infection rate Trend of accidental lacerations, or punctures Consult > 24 hrs x 3 Procedure complication rate Surgical site infection rate
Pain Management Review of first 3 representative cases cases/charts, including adequacy of H&P, progress notes, consultation and operative reports in the following: Lumbar or cervical Epidural or Facet Blocks or Rhizotomy or Other Representative Pain Management Cases/Charts Emergency Intubation Post Procedure Paralysis Review of 5 cases/charts, including adequacy of H&P, progress notes, consultation and operative reports in the following: Lumbar/Cervical Epidurals or Facet Blocks or Rhizotomy or Other Representative Pain Management Cases/Charts Pathology Random review of first 10 cases for adequacy of consultation and operative reports. Case TAT < 2.0 (days) Frozen Section: Average TAT < 20 (min) Major Diagnostic Discrepancies Case TAT < 2.0 (days) Frozen Section: Average TAT < 20 (min)
Podiatric Surgery Review of first 3 representative charts, for adequacy of consultation, H&P, progress notes, and operative reports, and Appropriate use of consultants Procedure complication rate Consult > 24 Hrs x 3 Procedure complication rate Surgical site infection rate Psychiatry Review of first 3 representative cases for adequacy of consultation and operative reports, inclusive of OPPE Indicators. Readmission with Same Dx Timeliness of Consultations Critical/abnormal lab result unaddressed Consultation notes not documented Readmission with Same Dx Timeliness of Consultations
Radiology, Diagnostic Over reads of the first 3 cases by the Department Vice Chair Peer Congruence on Radiology Findings Compliance with stroke protocol for head CT Two (2) Level 3 or 4 Discrepancies in Interpretation Peer Congruence on Radiology Findings Compliance with stroke protocol for head CT Reproductive Endocrinology Review of first 2* representative cases for adequacy for adequacy of H & P, progress notes, consultation and operative reports, in addition to the following indicators: Consultations > 24 Hrs Unexpected Transfer to ICU *2 cases within 12 months Post-procedure hemorrhage Consultations > 24 Hrs Unexpected Transfer to ICU
Rheumatology Review of first 3 representative cases for adequacy of consultation, progress notes and operative, inclusive of OPPE Indicators and, Critical/Abnormal lab result unaddressed Unplanned transfers to ICU critical/abnormal lab result unaddressed x 3 Unplanned transfer to ICU x 3 Critical/Abnormal lab result unaddressed Unplanned transfers to ICU RN First Assistant Review of first 3 representative cases, for adequacy of H&P, progress notes, consultation, operative reports and discharge summaries and review of the following: Positions and preps patients appropriately Appropriately maintains sterile technique Competently sutures to close surgical incision as appropriate Validated patient complaints regarding quality of care Validated incidents of inappropriate behavior Positions and preps patients appropriately Appropriately maintains sterile field Competently sutures to close surgical incision as appropriate
Vascular Surgery Review of first 3 representative charts, for adequacy of consultation, H&P, progress notes and operative reports in each of the following procedures EBM-SCIP: Antibiotic Discontinued within 24 Hours After Surgery EBM-SCIP: VTE Prophylaxis Ordered Retained foreign body Trend of Unexpected Transfers to ICU EBM-SCIP: Antibiotic Discontinued within 24 Hours After Surgery EBM-SCIP: VTE Prophylaxis Ordered Wound Care Review of first 3 representative cases for adequacy of consultation, progress notes and operative reports, inclusive of OPPE Indicators, and Critical/abnormal lab result unaddressed Daily progress notes not documented Consultation > 24 Hrs x 3 Consultation > 24 Hrs