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Gaining control of the OPPE process: A Q&A with OSF HealthCare

September 8, 2017

    OSF HealthCare—an 11-hospital system based in Peoria, Illinois—started out like many other health care organizations when it came to meeting the Joint Commission's Ongoing Professional Practice Evaluation (OPPE) mandate. It was difficult for each of its facilities to come together as a system, since they had different OPPE labor-intensive processes in place—most of which focused on "checking the box," rather than the real intent of OPPE: engaging physicians in their performance. 

    But two years ago, with a Joint Commission review coming up, OSF HealthCare's leadership knew they had to make changes to their process, and fast. We recently sat down with two members of OSF HealthCare's staff that were essential to the system's success—Dr. Ralph Velazquez, Ministry Chief Medical Officer, and Diana Webb, Provider Performance Reporting Program Manager—to ask them about their process, the impact it's had on physicians, and how they were able to slash 500 hours of reporting time in just one year.

    Question: Take us back in time a little bit—could you explain how OPPE reporting processes originally looked at OSF HealthCare?

    Dr. Ralph Velazquez: One of our biggest challenges was that we couldn't compare apples to apples, because everything was different at each of our facilities. They were using different data sets, definitions, and reporting timelines—and each even involved different types of stakeholders in the review process.

    But we also noticed that many of the facilities weren't focusing on measures that were important. Instead, they were focusing on rare events, like foreign bodies from surgery and operating room buyers, or measures that were primarily system-focused rather than physician-focused.

    Q: We understand the Joint Commission's scheduled review was a big impetus for the OPPE reporting changes at OSF HealthCare. How were you able to make quick decisions?

    Dr. Ralph Velazquez: The Joint Commission had already identified some areas for a few of our facilities to improve on OPPE, so everyone in the system was motivated to quickly get on the same page and move away from managing multiple databases. The very first thing we did was create an OPPE Governance Committee that consisted of the CMOs at each facility. This committee met every two weeks and was responsible for making all the big decisions throughout the process, as well as garnering buy-in at the clinician level.

    Before we really got started, we decided to use Crimson Continuum of Care to automate our reporting process. We had actually already been using the tool to help us with cost and quality improvements, so we just had to pull in the OPPE reporting module that would help us build a report template to automatically generate every eight months.

    Q: Could you explain what the actual process looked like, once you had all the right people and tools in place?

    Diana Webb: Once we had the committee together, the first thing we had to do was select the right measures that would be applicable for all facilities across the system to track among their physicians. Gradually, the list of measures we should track kept getting smaller and smaller, until it was manageable and easy to make clear decisions.

    Next, we had to create a new process for review sign-off. When reports generate in Crimson, physicians can quickly see their performance at a glance to see if it's in the green, or has moved into yellow or red—and if it's the latter two, they can quickly click through and dive a layer deeper to see what's going on. It sounds simple, but we found this to be incredibly helpful in communicating performance to physicians.

    Occasionally when a measure goes into the yellow or red, it may not be a result of poor performance—it could instead be the documentation, or another physician on the same case. For instance, if you’re looking at a physician’s surgical performance, you may see they were flagged for accidental laceration or puncture, but you may have to dive a little deeper because that flag goes to everyone on the case. You may find the surgeon you’re reviewing was the one to repair the punctured bowel that was a result of another physician’s complication of care. This can happen from time to time, and is something we can finally look into at a global level now that we are all on Crimson. In fact, we’ve identified a clinical or quality-focused person at each facility that can now look into yellow and red performance indicators to properly flag areas that need attention.


    Your OPPE questions, answered

    Use this FAQ to understand the OPPE process and interpret your report

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    Q: What kind of impact have these reporting changes made to OSF HealthCare?

    Diana Webb: For me, one of the best things has been watching physicians have that "aha" moment when I'm training them. One time I was training a department chair on the workflow for signing and completing OPPE eReviews, and when I walked in he was already sitting at his computer biting his nails—I could tell he just wanted to get this over with, maybe due to his past experiences. But as I trained him to review a physician in his department that appeared to have performance issues and how to dive deeper into the tool, he was able to see that performance wasn't actually the issue, the physician's documentation just wasn't as robust as it could've been. By the end of it, he was digging into measures, looking at his own documentation, and was actually excited about electronic OPPE.

    Dr. Ralph Velazquez: Before, some physicians were signing off on hundreds of paper reports they barely even looked at, let alone engaged in. Now, we're actually seeing them really looking into the tool and hearing them say things like "oh yeah, I could actually make that small change." It's really been an important part in our success as we progress towards our goal of becoming "one" OSF HealthCare.

    Your OPPE questions, answered

    Download this resource to get answers to frequently asked questions about your Ongoing Professional Practice Evaluation (OPPE) reports.

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