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Volume 8, Issue 4 | April 2010

Conducting Ongoing Professional Practice Evaluations (OPPE): How to Improve Compliance with MS.08.01.03
Does your hospital or critical access hospital have a clear process to review and evaluate licensed independent practitioners with privileges? Are you collecting the right kind of data to properly decide whether to continue, limit, or revoke any existing privileges? Or are you collecting too much data? Many hospitals and critical access hospitals find it a challenge to comply with Standard MS.08.01.03, which requires that OPPE information be factored into the decision to maintain an existing privilege(s), to revise an existing privilege(s), or to revoke an existing privilege(s) prior to or at the time of renewal. This article provides recommendations on how to conduct the OPPE process and the elements needed for an organization to begin to clearly define its process.

5 Sure-Fire Methods: Granting Privileges to Individuals Practicing Independently
For an ambulatory care organization and an office-based surgery practice one of the most important responsibilities is determining that its licensed independent practitioners are competent to provide quality, safe patient care. Credentialing and privileging enable your organization to know exactly who is on your staff and define what care they can provide to your patients. However, this important process isn’t getting done as thoroughly as it should. Standard HR.02.01.03 requires that organizations grant initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently. This article provides five practical how-to strategies to help your organization better comply with this standard.

New Hospital Standards to Improve Patient-Provider Communication: Free guide offers “how-to”s and other resources before standards go into effect
The Joint Commission, with funding from The Commonwealth Fund, has developed new and revised requirements for hospitals to advance effective communication, cultural competence, and patient- and family-centered care. The January 2010 issue of Joint Commission Perspectives published these new and revised hospital requirements that are expected to go into effect sometime in 2011. Before these standards are implemented, The Joint Commission will provide a free implementation guide in April 2010 that offers recommendations on how hospitals can advance effective communication, cultural competence, and patient- and family-centered care. This article provides some general information about the content in the guide and how to obtain it.

Tracer Methodology 101: The Laboratory Integration Tracer
Hospitals and critical access hospitals rely on information from laboratory tests to determine patient diagnosis and status. Without this important information, there can be delays in treatment planning, which can cause unnecessary stresses on staff and put patients at risk of harm. The laboratory integration tracer focuses on how well a hospital's laboratory is included in the wider functioning of the facility. This inclusion is traced by following laboratory processes within the hospital, such as a test from its order for a patient to the reporting of results, or by evaluating related laboratory data collected by the hospital. This tracer scenario, sample questions, and tips checklist shows you how to conduct your own tracer to self-assess laboratory integration at your organization.

Spoltlight on Success: Achieving Staff and Physician Buy-In for Accreditation
Whether an organization is seeking accreditation for the first time or renewing their accreditation for the tenth time, the key to sustaining a culture of safety is getting staff and physicians invested in accreditation. Without their support, providing high quality patient care would not be possible. Leaders at Crystal Run Healthcare, an accredited ambulatory care/office-based surgery, physician-owned multispecialty group practice in New York, share how they developed an “in-the-trenches” training program to achieve and sustain staff and physician buy-in for accreditation. This article includes information on how to access a copy of Crystal Run’s infection control tracer audit form and tracer rounds questions list that are posted on The Source’s Web site.

Click here to view Figure 1. Priority Focus Audit Form: Infection Control Tracer, from Crystal Run Healthcare.

Click here to view a list of sample questions for tracer rounds with answers.