Anesthesiology Department Review of FPPE/OPPE Indicators ...



Facility LogoMaster FPPE/OPPE Indicator TableDEPARTMENT/SpecialtyFPPEInitially Granted “Core” PrivilegesFPPE(Focused Review) TriggersOPPE IndicatorsData Source/Who gathers the dataDepartment/Medical Staff Approval DatesAllergy and ImmunologyReview the first five cases for adequacy of consultation, progress notes and operative reports, inclusive of OPPE Indicators.Readmission Same DXCritical/abnormal lab result unaddressedTimeliness of Consultations Consultations > 24 Hrs x 3Critical/abnormal lab result unaddressed X 3Readmission Same DXCritical/abnormal lab result unaddressedTimeliness of ConsultationsAnesthesiologyReview of 5 representative anesthesiology cases/charts, including adequacy of H&P, progress notes, consultation, operative reports, OPPE indicators:Unanticipated Dental InjuryUnplanned Re-intubation Failed IntubationUnexpected Transfer to ICU Due to Anesthesia ComplicationNarcotic Reversal Agent Required (across all discharges)Adverse effect of anesthesia (across all surgical discharges)Number of Anesthesia complications: Late effect of complications of surgical and medical careIatrogenic Pneumothorax (across all discharges)Cardiovascular DiseaseReview of 5 cases/charts for adequacy of progress notes, consultation, operative reports andEBM: HF Evaluation of LVS FunctionEBM: ACEI or ARB for LVSDHospital acquired DVT/PE (across all discharges)Trend of Unexpected MortalityExcessive complication rateEBM: HF Evaluation of LVS FunctionEBM: ACEI or ARB for LVSDHospital acquired DVT/PE (across all discharges)Heart Cath-related CVA (across all heart caths)Complication rateMortality rateCardiology-ElectrophysiologyReview of 5 cases/charts for adequacy of progress notes, consultation, operative reports andComplication of procedureAccidental puncture or lacerationHospital acquired DVT/PE Post operative hemorrhage or hematomaModerate Sedation:Reversal agent requiredTrend of Unexpected MortalityExcessive complication rateProcedure complication rateAccidental puncture or laceration rateHospital acquired DVT/PE (across all discharges)Post operative hemorrhage or hematoma rateModerate Sedation:Reversal agent requiredCardiovascular SurgeryReview 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 OrderedComplication of procedureAccidental puncture or lacerationHospital acquired DVT/PE Post operative hemorrhage or hematomaModerate Sedation:Reversal agent required Trend of accidental lacerations, or puncturesTrend of Unexpected Transfers to ICUEBM-SCIP: Antibiotic Discontinued within 24 Hours After Surgery EBM-SCIP: VTE Prophylaxis Ordered Procedure complication rateAccidental puncture or laceration rateHospital acquired DVT/PE (across all discharges)Post operative hemorrhage or hematoma rateModerate Sedation:Reversal agent requiredCertifiedNurse MidwifeReview 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 examsWrites appropriate orders in patients charts chart for appropriate laboratory, radiologic, diagnostic examination, or other studies based upon history and physical exam findingsElective Induction < 39 WeeksCircumcision repair during current hospitalization Prolapsed umbilical cord after elective rupture of membranes with the fetus at high stationTrend of high complication rate Performs appropriate history and physical examinations, including pelvic exam with pap smear, breast and rectal examsWrites appropriate orders in patients charts chart for appropriate laboratory, radiologic, diagnostic examination, or other studies based upon history and physical exam findingsCircumcision repair during current hospitalizationInduction < 39 WeeksColon & Rectal SurgeryReview of first 5 charts, for adequacy of consultation, H&P, progress notes and operative reports and the following:Post op infectionAccidental perforationProcedure complications Trend of accidental lacerations, or puncturesTrend of Unexpected Transfers to ICUPost-op Infections (across all surgical discharges)Procedure complication rateMortality rateDermatologyReview the first five cases for adequacy of consultation, progress notes and operative reports.Readmission Same DXCritical/abnormal lab result unaddressedTimeliness of Consultations Consultation > 24 Hrs x 3Critical/abnormal lab result unaddressed X 3Readmission Same DXCritical/abnormal lab result unaddressedTimeliness of ConsultationsEmergency MedicineReview of 3 representative charts/cases, for adequacy of documentation, progress notes, consents and reporting representative of Emergency Medicine privileges andReturns to ER within 72 Hrs3 day ED revisits resulting in admissionLumbar puncture complications Returns to the ER within 72 Hrs in a code situationReturns to ER within 72 HrsCritical/abnormal lab result unaddressed % Returns to ER within 72 Hrs% 3 day ED revisits resulting in admission% Lumbar puncture complicationsEndocrinologyReview the first 3 representative cases for adequacy of consultation, progress notes and operative reports, inclusive of OPPE Indicators as follows:Readmission same DXCritical/abnormal lab result unaddressedTimeliness of Consultations Consultations > 24 Hrs x 3Critical/abnormal lab result unaddressed X 3Readmission with Same DXCritical/abnormal lab result unaddressedTimeliness of ConsultationsFamily MedicineReview the first 3 representative cases for adequacy of consultation, progress notes and operative reports, inclusive of OPPE Indicators as follows:Readmission same DXAppropriate use of diagnostic testing Appropriate use of consultationsCritical/abnormal lab result unaddressed X 3Unexpected Transfer to ICU x 3Readmission same DXCritical/abnormal lab result unaddressedAppropriate use of diagnostic testing Appropriate use of consultationsGastroenterologyReview the first 3 representative cases for adequacy of consultation, progress notes, and operative reports, inclusive of OPPE Indicators and Cecum to rectum time>/= 6 MinUse of prophylactic antibiotics Moderate Sedation:Use of reversal agents Trend of increased complication rateTrend of unexpected transfers to higher level of careProcedure complications across all colonoscopiesProcedure complications across all upper endoscopiesCecum to rectum time>/= 6 MinUse of prophylactic antibioticsModerate Sedation:Use of reversal agentsGeneral SurgeryReview 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 OrderedPost op infectionAccidental PerforationHemorrhage due to a procedure Trend of accidental lacerations, or puncturesTrend of Unexpected Transfers to ICUEBM-SCIP: Antibiotic Discontinued within 24 Hours After Surgery EBM-SCIP: VTE Prophylaxis OrderedAccidental puncture and laceration rateProcedure complication ratePost op infection rateHemorrhage due to a procedure (across all surgical discharges)Gynecology OncologyReview of 3 representative charts for adequacy for adequacy of H & P, progress notes, consultation and operative reports in each of the following proceduresProcedure complicationMortality Unexpected Transfer to ICUUnplanned Injury or removal of organPost Procedure Infection rateProcedure Complication rateMortality rateHand Surgery(Ortho-Neuro Dept)Review of 3 representative charts, for adequacy of consultation, operative reports and the following indicators: Unplanned return to surgery Procedure ComplicationPost op Infection Peripheral/vascular complication Peri-operative arrest, deathunplanned return to surgery same admission/visit Procedure Complication RatePost-op infection ratePeripheral/vascular complication rate (across all surgical discharges)Peripheral nerve injuriesHematology-OncologyReview the first 3 representative cases for adequacy of consultation, progress notes and operative reports, inclusive of OPPE Indicators and, Bone Marrow Biopsy complicationsIndwelling venous access catheter complicationsCentral line infections Critical/Abnormal lab result unaddressed x 3Unexpected transfers to ICU x 3Critical/Abnormal lab result unaddressedUnexpected transfers to ICUBone Marrow Biopsy complication rateIndwelling venous access catheter complication rateCentral line infection rateInfectious DiseaseReview the first 3 representative cases for adequacy of consultation, progress notes and operative reports, inclusive of OPPE Indicators and Appropriate Management of investigational and/or anti-infective agentsCritical/abnormal lab result unaddressed Consultations > 24 HrsReadmission same DX Critical/abnormal lab result unaddressed X 3Consultations > 24 Hrs x 3Appropriate Management of investigational and/or anti-infective agentsCritical/abnormal lab result unaddressed Consultations > 24 HrsReadmission same DXInterventionalCardiologyReview the first 3 representative cases/charts for adequacy of progress notes, consultation, operative reports andComplications of procedure across all cardiac cathsHeart Cath related CVA across all cardiac cathsHospital acquired DVT/Pulmonary EmbolismModerate Sedation:Use of reversal agent required Critical/abnormal lab result unaddressed Consultations > 24 HrsComplications of procedure across all cardiac cathsHeart Cath related CVA across all cardiac cathsHospital acquired DVT/Pulmonary EmbolismProcedure complication rateMortality rateModerate Sedation:Use of reversal agent requiredMaternal/FetalMedicineReview of 2 Charts for adequacy for adequacy of H & P, progress notes, consultation and operative reports, in addition to the following indicatorsConsultations > 24 HrsUnexpected Transfer to ICU*2 cases within 12 months Maternal Mortality Consultations > 24 HrsUnexpected Transfer to ICU Neonatal-Perinatal MedicineReview 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 careMortality RateBirth trauma – injury to neonate (post delivery)Transfers to higher level of careComplication ratePacked cell transfusion rateNephrology Review the first 3 representative cases for adequacy of consultation, progress notes and operative reports, inclusive of OPPE Indicators and, Critical/abnormal lab result unaddressedDaily progress/consultation notes not documentedUnplanned transfers to ICUConsultations > 24 Hrs Consultation > 24 hrs x 3Critical/abnormal lab result unaddressedCritical/abnormal lab result unaddressedReadmission same DXVascular/Catheter associated infection across all dischargesALOSAverage consults usedNeurologicalSurgeryReview of 3 representative charts, for adequacy of consultation and operative reports in the following:Peri-operative:EBM-SCIP: VTE Prophylaxis OrderedEBM-SCIP: Antibiotic Discontinued within 24 Hours After SurgeryCervical or Lumbar Fusion:Antibiotic selection for surgical proceduresPost OpPost – op infections Wrong SiteEBM-SCIP: VTE Prophylaxis OrderedEBM-SCIP: Antibiotic Discontinued within 24 Hours After SurgeryProcedure complication rateMortality ratePost-op surgical infectionsNurse PractitionerSurgeryReview 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 appropriatelyAppropriately maintains sterile techniqueCompetently sutures to close surgical incision as appropriate Validated patient complaints regarding quality of careValidated incidents of inappropriate behavior Positions and preps patients appropriatelyAppropriately maintains sterile fieldCompetently sutures to close surgical incision as appropriateNurse PractitionerMedicineReview 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 statusOrders and interprets diagnostic testing appropriately Validated patient complaints regarding quality of carePerforms and documents initial and ongoing assessment of patients’ medical, physical, and psychosocial status, including H&P and changes in health statusOrders and interprets diagnostic testing appropriatelyObstetrics &GynecologyReview of 3 representative cases* for adequacy for adequacy of H & P, consultation and operative reports, in addition to the following indicators:Obstetrics: Induction < 39 WeeksCircumcision revision during current hospitalizationRuptured uterus during deliveryGynecology:EBM: SCIP: Appropriate Antibiotic SelectionProcedure complicationPost op infection* Completed within first 3 months Prolapsed umbilical cord after elective rupture of membranes with the fetus at high stationObstetrics:Induction < 39 WeeksCircumcision revision during current hospitalizationRuptured uterus during delivery3rd & 4th degree lacerationsAnal sphincter tearGynecology:EBM: SCIP: Appropriate Antibiotic SelectionEBM: SCIP: Antibiotic Discontinued within 24 Hrs after SurgeryProcedure complicationPost op infectionOphthalmologyReview of 3 representative cases, for adequacy of consultation, H&P, progress notes, and operative reports, and% of OP Procedures with ED visit within 30 daysConsults < 24 Hrs Consult > 24 Hrs x 3% of OP Procedures with ED visit within 30 daysConsults < 24 Hrs Orthopedic SurgeryReview of 3 representative cases, for adequacy of progress notes, consultation and operative reports in the following procedure(s)Peri-operative:EBM-SCIP: VTE Prophylaxis OrderedEBM-SCIP: Antibiotic Discontinued within 24 Hours After SurgeryTotal Knee or Hip Replacement: Antibiotic selection for surgical proceduresPost op infectionModerate Sedation:Use of reversal agent required. Wrong SiteEBM-SCIP: VTE Prophylaxis OrderedEBM-SCIP: Antibiotic Discontinued within 24 Hours After SurgeryProcedure Complication rateHospital acquired DVT/PEPost – op infection ratePeripheral vascular complicationsHospital acquired pheripheral nerve injuryModerate Sedation:Use of reversal agent required.OtolaryngologyReview of first 3 representative charts, for adequacy of consultation, H&P, progress notes, operative reports, and the following:Procedure complication rateSurgical site infection rate Trend of accidental lacerations, or puncturesConsult > 24 hrs x 3Procedure complication rateSurgical site infection ratePain ManagementReview of first 3 representative cases cases/charts, including adequacy of H&P, progress notes, consultation and operative reports in the following: Lumbar or cervical EpiduralorFacet Blocks orRhizotomyorOther Representative Pain Management Cases/Charts Emergency IntubationPost Procedure ParalysisReview of 5 cases/charts, including adequacy of H&P, progress notes, consultation and operative reports in the following: Lumbar/Cervical EpiduralsorFacet BlocksorRhizotomyorOther Representative Pain Management Cases/ChartsPathologyRandom 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: MortalityProcedure complications30 Day readmission Circumcision revision required Unplanned transfers to ICUAverage length of stayMortality rate30 day readmission ratePlastic SurgeryReview of first 3 representative cases charts, for adequacy of consultation, H&P, progress notes, operative reports, and the following:Procedure complication rateSurgical site infection rate Trend of accidental lacerations, or puncturesConsult > 24 Hrs x 3Procedure complication rateSurgical site infection ratePodiatric SurgeryReview of first 3 representative charts, for adequacy of consultation, H&P, progress notes, and operative reports, andAppropriate use of consultantsProcedure complication rate Consult > 24 Hrs x 3Procedure complication rateSurgical site infection ratePsychiatryReview of first 3 representative cases for adequacy of consultation and operative reports, inclusive of OPPE Indicators.Readmission with Same DxTimeliness of ConsultationsCritical/abnormal lab result unaddressedConsultation notes not documentedReadmission with Same DxTimeliness of ConsultationsRadiology, DiagnosticOver reads of the first 3 cases by the Department Vice ChairPeer Congruence on Radiology FindingsCompliance with stroke protocol for head CT Two (2) Level 3 or 4 Discrepancies in InterpretationPeer Congruence on Radiology FindingsCompliance with stroke protocol for head CTReproductiveEndocrinologyReview 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 HrsUnexpected Transfer to ICU*2 cases within 12 months Post-procedure hemorrhage Consultations > 24 HrsUnexpected Transfer to ICURheumatology Review of first 3 representative cases for adequacy of consultation, progress notes and operative, inclusive of OPPE Indicators and, Critical/Abnormal lab result unaddressedUnplanned transfers to ICU critical/abnormal lab result unaddressed x 3Unplanned transfer to ICU x 3Critical/Abnormal lab result unaddressedUnplanned transfers to ICURN First AssistantReview 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 appropriatelyAppropriately maintains sterile techniqueCompetently sutures to close surgical incision as appropriate Validated patient complaints regarding quality of careValidated incidents of inappropriate behavior Positions and preps patients appropriatelyAppropriately maintains sterile fieldCompetently sutures to close surgical incision as appropriateUrologyReview of first 3 representative charts, for adequacy of consultation, H&P, progress notes, and operative reports, andSurgical Site Infection RateProcedure Complication Rate Trend of accidental lacerations, or puncturesTrend of unexpected transfers to ICUSurgical Site Infection RateProcedure Complication RateUrogynecologyReview of first 3 representative charts for adequacy for adequacy of H & P, progress notes, consultation and operative reports in each of the following proceduresSurgeries of the genitourinary systemorConsultationsorOther procedures representative of Urogynecology Unplanned injury or removal of organRetained foreign body Unexpected Transfer to ICUConsultations > 24 HrsPost Op Infection RateVascular SurgeryReview 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 bodyTrend of Unexpected Transfers to ICUEBM-SCIP: Antibiotic Discontinued within 24 Hours After Surgery EBM-SCIP: VTE Prophylaxis Ordered Wound CareReview of first 3 representative cases for adequacy of consultation, progress notes and operative reports, inclusive of OPPE Indicators, andCritical/abnormal lab result unaddressedDaily progress notes not documented Consultation > 24 Hrs x 3 Consultation > 24 Hrs ................
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