The field of medicine is continuously evolving. Hospital medicine is in the forefront of transforming care delivery. To continuously improve practice, hospitalists need to participate in accredited continuing medical education (CME). Accredited CME is required for maintenance of licensure, credentialing, and other professional privileges. The Ongoing Professional Practice Evaluation (OPPE) is a regulatory requirement for many health care providers. The OPPE is utilized by Joint Commission–accredited hospitals to maintain licensure and oversee the practice of their credentialed staff. Combining the CME with the OPPE allows hospitalists to transform their practice while obtaining CME credit and meeting regulatory requirements.


To improve hospitalist delivery of care while meeting regulatory requirements, obtaining CME, and transforming the culture of an academic hospitalist group.


We implemented a weekly peer review process for hospitalists. Each hospitalist on clinical service reviewed and discussed a current case with the hospitalist of record and completed an OPPE/PI‐CME form. Time was set aside for this process every Friday at noon for 30 minutes. The discussion was designed to utilize nonconfrontational feedback regarding the case reviewed. The form had 3 sections based on the 2012 Core Measures and Project BOOST: heart failure, pneumonia, and transitions of care. The purpose of reviewing the core measures and transitions of care was to create a peer pressure effect to improve knowledge and documentation of processes of care. The transitions‐of‐care section required hospitalists to review their risk‐specific interventions for Project BOOST's “8‐Ps” readmission risks: problem medicines, polypharmacy, principal diagnosis, poor health literacy, psychological, patient support, prior hospitalization, palliative care. At least 1 section needed to be addressed by the peer reviewer on the OPPE/PI‐CME form. Nearly 1000 OPPE/PI‐CME forms have been completed over a 3‐stage, 1‐year CME program combined with an educational component. Thus far, 385 AMA category 1 CME credits have been issued to 44 hospitalists, and all providers met the Joint Commission OPPE requirements. We were able to improve our core measure performance and quickly disseminate the knowledge and process to our new hires. The repetitive weekly process helped to ingrain specific practice habits for core measures and transitions of care. The next step is to sustain our improvements in heart failure and pneumonia while continuing our practice transformation in care transitions and adding new quality issues: adequate glycemic control, adverse drug events, and patient satisfaction assessment.


By implementing a newly designed, accredited CME program, we were able to address 3 needs for our hospital medicine group in one step: CME, improved quality of patient care, and regulatory requirement compliance through the OPPEs.