anesthesiology department review of fppe/oppe · web viewcircumcision revision during current...

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Master FPPE/OPPE Indicator Table

DEPARTMENT/Specialty

FPPEInitially 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






Unplanned Re-intubation

complications of surgical and medical care

Iatrogenic Pneumothorax (across all discharges)

Cardiovascular DiseaseReview 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


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 hematoma

Moderate Sedation: Reversal agent

required

Trend of

accidental lacerations, or punctures

Trend of Unexpected Transfers to ICU




Accidental puncture or laceration rate


Post operative hemorrhage or hematoma rate

Moderate Sedation:Reversal agent required

Certified Review of 5 Cases for

Prolapsed umbilical Performs appropriate






Nurse Midwife 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 < 39 Weeks

Circumcision repair during current hospitalization

cord after elective rupture of membranes with the fetus at high station

Trend of high complication rate

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

Colon & Rectal Surgery Review of first 5 charts, for adequacy of consultation, H&P, progress notes and operative reports and the following:

Trend of


Trend of

Post-op Infections (across all surgical discharges)







Post op infection Accidental

perforation Procedure

complications

Unexpected Transfers to ICU

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


Consultation > 24

Hrs x 3

Critical/abnormal lab result unaddressed X 3

Readmission Same DX

Critical/abnormal lab result unaddressed


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 the ER

within 72 Hrs in a code situation

Returns to ER within 72 Hrs


% Returns to ER within 72 Hrs

% 3 day ED revisits resulting in admission

% Lumbar puncture complications






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



Family MedicineReview 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: VTE

Trend of





Accidental puncture and laceration rate


Post op infection






Prophylaxis Ordered

Post op infection Accidental

Perforation Hemorrhage due

to a procedure

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

Peri-operative

arrest, death unplanned return

to surgery same admission/visit

Procedure Complication Rate

Post-op infection rate

Peripheral/vascular complication rate






Peripheral/vascular complication

(across all surgical discharges)

Peripheral nerve injuries

Hematology-OncologyReview 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

Infectious Disease 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 X 3

Consultations > 24 Hrs x 3

Appropriate Management of investigational and/or anti-infective agents

Critical/abnormal lab result






Appropriate Management of investigational and/or anti-infective agents


Consultations > 24 Hrs

Readmission same DX

unaddressed Consultations >

24 Hrs Readmission

same DX

InterventionalCardiology

Review the first 3 representative cases/charts for adequacy of progress notes, consultation, operative reports and

Complications of procedure across all cardiac caths

Heart Cath related CVA across all cardiac caths

Hospital acquired DVT/Pulmonary Embolism

Moderate Sedation:Use of reversal agent

Critical/abnormal lab

result unaddressed Consultations > 24

Hrs

Complications of procedure across all cardiac caths

Heart Cath related CVA across all cardiac caths

Hospital acquired DVT/Pulmonary Embolism


Mortality rate

Moderate Sedation:Use of reversal agent required






required

Maternal/FetalMedicine

Review of 2 Charts for adequacy for adequacy of H & P, progress notes, consultation and operative reports, in addition to the following indicators


Unexpected Transfer to ICU

*2 cases within 12 months

Maternal

Mortality



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


Consultation > 24 hrs x 3



Readmission same DX Vascular/Catheter

associated infection across all discharges

ALOS Average consults

used

NeurologicalSurgery

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

Wrong Site EBM-SCIP: VTE

Prophylaxis Ordered



Mortality rate






Discontinued within 24 Hours After Surgery

Cervical or Lumbar Fusion:

Antibiotic selection for surgical procedures

Post Op Post – op

infections

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 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


Appropriately maintains sterile field







Nurse Practitioner

Medicine

Review of 3 representative charts, for adequacy of H&P, progress notes, consultation, operative reports and discharge summaries and review of the following::

Performs and documents initial and ongoing assessment of patients’ medical, physical, and psychosocial status, including H&P and changes in health status

Orders and interprets diagnostic testing appropriately

Validated patient


Performs and documents initial and ongoing assessment of patients’ medical, physical, and psychosocial status, including H&P and changes in health status

Orders and interprets diagnostic testing appropriately

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:

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






Induction < 39 Weeks Circumcision revision

during current hospitalization

Ruptured uterus during delivery

Gynecology: EBM: SCIP:

Appropriate Antibiotic Selection


Post op infection* Completed within first 3 months

Gynecology: EBM: SCIP:

Appropriate Antibiotic Selection

EBM: SCIP: Antibiotic Discontinued within 24 Hrs after Surgery


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

Consults < 24 Hrs

Consult > 24 Hrs

x 3 % of OP

Procedures with ED visit within 30 days

Consults < 24 Hrs

Orthopedic Surgery Review of 3 representative cases, for adequacy of progress notes, consultation and

Wrong Site EBM-SCIP: VTE

Prophylaxis Ordered

EBM-SCIP:






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.

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:


Surgical site infection rate

Trend of


Consult > 24 hrs x 3








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

orOther 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

orOther 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

DiscrepanciesCase TAT < 2.0 (days)

Frozen Section:Average TAT < 20 (min)






PediatricsReview of first 3 representative cases charts, for adequacy H&P, Progress notes, consultation and operative reports and the following:

Mortality Procedure

complications 30 Day

readmission

Circumcision

revision required Unplanned

transfers to ICU Average length of

stay Mortality rate 30 day

readmission rate

Plastic Surgery Review of first 3 representative cases charts, for adequacy of consultation, H&P, progress notes, operative reports, and the following:



Trend of


Consult > 24 Hrs x 3








Podiatric Surgery Review of first 3 representative charts, for adequacy of consultation, H&P, progress notes, and operative reports, and

Appropriate use of consultants


Consult > 24 Hrs x 3



Psychiatry Review of first 3 representative cases for adequacy of consultation and operative reports, inclusive of OPPE Indicators.

Readmission with Same Dx



Consultation notes not documented

Readmission with Same Dx







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

ReproductiveEndocrinology

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:



*2 cases within 12 months

Post-procedure

hemorrhage



Rheumatology Review of first 3 representative cases for adequacy of

critical/abnormal

lab result unaddressed x 3

Critical/Abnormal lab result unaddressed






consultation, progress notes and operative, inclusive of OPPE Indicators and, Critical/Abnormal

lab result unaddressed


Unplanned transfer to ICU x 3


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:


Appropriately maintains sterile technique


Validated patient


Validated incidents of inappropriate behavior


Appropriately maintains sterile field


Urology Review of first 3 Trend of Surgical Site






representative charts, for adequacy of consultation, H&P, progress notes, and operative reports, and

Surgical Site Infection Rate



Trend of unexpected transfers to ICU

Infection Rate


Urogynecology Review of first 3 representative charts for adequacy for adequacy of H & P, progress notes, consultation and operative reports in each of the following procedures

Surgeries of the genitourinary system

or Consultations

or Other procedures

representative of Urogynecology

Unplanned injury

or removal of organ

Retained foreign body



Post Op Infection Rate

Vascular Surgery Review of first 3 representative charts, for adequacy of consultation,

Retained foreign

body EBM-SCIP:

Antibiotic Discontinued






H&P, progress notes and operative reports in each of the following procedures




within 24 Hours After Surgery


Wound Care Review of first 3 representative cases for adequacy of consultation, progress notes and operative reports, inclusive of OPPE Indicators, and


Daily progress notes not documented

Consultation > 24 Hrs x 3

Consultation > 24 Hrs

anesthesiology department review of fppe/oppe · web viewcircumcision revision during current...

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