[1870] Joint Commission Standards for Ongoing and Focused Performance Evaluation in Anatomic Pathology: Current Trends in Practice

JL Hunt, MT Smith, WS Black-Schaffer. Massachusetts General Hospital, Boston, MA; Medical University of South Carolina, Charlestown, SC

Background: In 2008, the Joint Commission (JC) began to require on-going and focused physician competency assessment. Ongoing professional practice evaluation (OPPE) must occur more than once a year, and focused professional practice evaluation (FPPE) must be used for new privileges or if performance issues arise. OPPE and FPPE must be clearly defined (metrics, duration/frequency of data collection, thresholds, and how data is used to affect privileging). In anatomic pathology (AP), very little information exists about applying such standards, or the metrics that are useful to assess physician competency.
Design: An on-line survey was designed to assess understanding of OPPE and FPPE, and to investigate metrics AP practices use to assess pathologist competency. The survey was sent to members of the Association of Directors of Anatomic and Surgical Pathology (ADASP).
Results: Of 44 respondents, 98% hold administrative positions in AP. When asked to rate their understanding of credentialing on a scale of 1 (worst) to 10 (best), the mean level was 8.4 for departmental/institutional policies, compared to 6.1 for these Joint Commission policies. 84% report a formal process for new physician credentialing. 98% report formal peer review, most commonly random (20%) and/or on focused subsets of cases (36%). Only 44% proctor signout and 38% proctor frozens for new hires. Frozen-final correlation, turnaround times, and conference case discrepancies are the most frequently collected physician performance metrics. Approximately 20% use group level data, and do not measure individual physician performance. 64% report tracking error rates for physicians, but fewer than half have established a threshold or formal process for acting on performance issues. Only 45% assess physician competency more than once a year; 10% never assess. The reported level of understanding of OPPE and FPPE is approximately the same in groups that meet JC standards as those that don't.
Conclusions: AP leaders report incomplete understanding of the standards set by the Joint Commission for OPPE and FPPE, and many identify policies that do not meet the JC standards for hospital physician competency and credentialing. Education around JC standards and sharing of best-practice policies among institutions would be of benefit to improve consistency, standardization, and implementation OPPE and FPPE in anatomic pathology.
Category: Quality Assurance

Monday, March 22, 2010 1:00 PM

Poster Session II # 202, Monday Afternoon


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