NPQR Provides a Value-Add and Efficient Platform to Share Pathologists’ Practice and Quality Data with Credentialing Domains of Health System

Credentialing and professional practice evaluations are essential to assure high reliability for patient-focused health care. ASCP’s National Pathology Quality Registry (NPQR) is helping healthcare organizations gather data in a real time, digital format to evaluate the performance of privilege holders and to ensure the highest quality of patient care provided by the laboratory.¹

High reliability organizations (a term coined with the advent of professional practice evaluations) operate in complex, high-hazard domains for extended periods without serious accidents or catastrophic failures. Sometimes people interpret high reliability as meaning effective standardization of healthcare processes. High reliability is an integral part of the medical laboratory where quality is defined through accuracy, reliability, and timeliness of the reported test results and diagnoses to benefit patient care, treatment, and safety.

The dialogue around high reliability organizations began in 2007, when The Joint Commission (JC) introduced its Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) standards to help determine if the care delivered by a practitioner meets or falls below an acceptable level of performance. The JC has required hospitals to assure data for FPPEs and OPPEs since 2008, yet hospital administrators and medical staff in all specialties, including the laboratory, continue to struggle with these requirements. Each contributing area of the hospital is expected to develop criteria-based measures that are consistent with OPPE and FPPE. The criteria must be focused on patient safety and quality, while outcome-driven and based on an individual practitioner’s (including pathologist’s) performance.

OPPE is an assessment tool to evaluate all practitioners who have been granted privileges.  OPPE indicators and benchmarks may identify those clinicians who might be delivering an unacceptable quality of care.

FPPE is the follow-up process to determine the validity of any outliers in data points, findings, or the credentialing process (whether true or false) which may have been identified through OPPE. The FPPE process is applied only to the small number of clinicians who were identified by OPPE for closer review. FPPE may also be a valuable process for new clinicians or pathologists to evaluate their competencies as a baseline as compared to the data within a similar cohort.

Unfortunately, at present there are no standardized quality measurement tools to collect health care provider outcomes for use in OPPE and FPPE; this increases challenges in deciding what should trigger an FPPE.

Information gathered during the professional practice evaluation processes is used for decision-making as to whether an individual maintains their privileges after assessment in a renewal cycle. Performance data are not readily extractable from many hospital computer systems or laboratory information systems, making data collection an arduous manual process. Laboratories must find a way to share the practitioner-specific data with the credentialing, regulatory and quality domains of the healthcare system. This is where the NPQR proves of high value to the laboratory team.  NPQR is compatible with any laboratory information system and removes administrative burden from registry participants, benefiting the performance evaluation and credentialing experience.

Another challenge is that there are no standardized measures from the JC for identifying or collecting professional practice data (whether OPPE or FPPE) for the laboratory. At present, it is considered best practice to have measures that harmonize with six general OPPE competencies—patient care, medical and clinical knowledge, practice-based learning and improvements, interpersonal and communication skills, professionalism, and systems-based practice.

NPQR has established, relevant measures that can provide registry participants with meaningful credentialing experiences and individualized reports.  Additionally, interactive dashboards allow laboratories to analyze their performance across tests, indications, responsible staff and other dimensions to include benchmarking with other lab systems and pathologists.

Ultimately, the Registry can reveal best practices as well as variations in practices, processes, and outcomes, and identify targets for improvement to benefit the patients we serve. This Registry is one more opportunity that NPQR participants can utilize to ease the level of administrative burden routinely experienced with any type of practice evaluation while utilizing benchmarking to advance patient safety and continuous quality improvement.

“Now is the time for individual laboratories to collaborate and become more involved in driving excellence in patient care on a national level. NPQR is the value-add tool to initiate and sustain this journey toward elevating patient outcomes,” said Amy J. Wendel Spiczka, MS, HTL(ASCP)^CM, SCT, MB^CM, ASCP Senior Director, Quality Pathology and Laboratory Medicine Practice.  

To learn more about ASCP’s NPQR click here.

Reference:

1. Given the unique contributions to patient care provided from the laboratory (i.e., laboratory medicine and pathology), references to clinicians and practitioners are inclusive of pathologists in this publication.