To determine the appropriate action for the provider based on the Ongoing Professional Practice Evaluation (OPPE) profile shown, we first assess how many measures meet the thresholds set by the organization and categorize the provider's performance according to the provided criteria:
Timely Medical Record Documentation: Current performance is 95%, which meets the threshold of 90%.
Readmission Rate: Current performance is 13%, which does not meet the threshold of 10%.
Surgical Site Infection Rate: Current performance is 9%, which does not meet the threshold of 5%.
Use of Pre-procedure Timeouts: Current performance is 100%, which meets the threshold of 100%.
Patient Experience Score (Top Box): Current performance is 94%, which meets the threshold of 80%.
Clinical Pathway Adherence: Current performance is 81%, which meets the threshold of 70%.
Out of these six measures, four measures meet or exceed the threshold:
Timely Medical Record Documentation
Use of Pre-procedure Timeouts
Patient Experience Score (Top Box)
Clinical Pathway Adherence
This constitutes meeting the threshold in approximately 67% of the measures (4 out of 6).
According to the OPPE criteria:
Fully Meets: >80% of measures at threshold
Meets: 65% to 80% of measures at threshold
Partially Meets: 40% to 64% of measures threshold
Does Not Meet: <40% of measures at threshold
Given that 67% of measures meet the thresholds, the provider's performance falls within the "Meets" category.