In 2008, The Joint Commission issued new standards related to focused and ongoing practitioner performance evaluations. These evaluations became part of the medical staff process for granting and maintaining practice privileges in a healthcare organization. Despite these standards being issued over 15 years ago, healthcare organizations still struggle today in establishing meaningful performance measurement indicators as well as ensuring that these processes are consistently implemented.
Review of Definitions
Focused Professional Practice Evaluation (FPPE) involves more specific and time-limited monitoring of a provider’s practice performance in three situations:
- When a provider is initially granted practice privileges
- When new privileges are requested for an already privileged provider
- When performance non-compliance involving a privileged provider is identified (through the OPPE process or by any other means such as complaints or significant departure from accepted practice). This may also be termed, “for-cause.”
Ongoing Professional Practice Evaluation (OPPE) is intended as a means of evaluating professional performance on an ongoing basis for three reasons:
- As part of the effort to monitor professional competency
- To identify areas for possible performance improvement by individual practitioners
- To use objective data in decisions regarding the continuance of practice privileges
Both FPPE and OPPE performance measurement indicators should be specific to the area of specialty that the practitioner is practicing. For FPPE, the organization sets either the timeframe for evaluation or a set number of monitoring events depending on the specific area of practice and the performance measurement indicators chosen. On the other hand, OPPE is ongoing throughout the year and that review process timeframe is set by the organization. Most organizations around the country collect data for OPPE evaluations quarterly, others every six months.
Lessons Learned – 15 Years Later
Although the requirement has existed for 15 years, some organizations still do not have meaningful FPPE and OPPE data. In some cases, areas coming under an organization’s license do not have a program to collect this data for evaluation at the time of practitioner re-privileging. The areas lacking in these organizations include one or more of the following:
- Defined outpatient performance measurement indicators
- Lack of qualitative data
- Lack of quantitative data
- Lack of data on low volume practitioners
FPPE and OPPE do not only apply to hospitals.
Non-inpatient areas are required to have performance evaluations if that setting is included within the scope of the hospital survey ( Bills for services under the hospital CMS CCN) as privileges need to be granted to anyone providing a medical level of care, i.e., making medical diagnoses or medical treatment decisions. Examples of these settings include:
- Inpatient
- On-campus outpatient
- Off-campus outpatient
- Hospital-owned physician office practices, etc.
The privileges granted in outpatient locations must be limited to those services that can be performed in the outpatient care setting. If the non-inpatient settings do not have the same clinical record system or information technology, collecting data may be more difficult, but if the privileges are the same, the data collected should be the same.
Where should the data come from?
The data source used for the OPPE process must include practitioner activities performed at the organization where privileges have been granted. This may include activities performed at any location that falls under the organization's single CMS Certification Number (CCN). For example, if an organization operates two hospitals that fall under the same CCN number, data from both hospital locations should be used. In multi-hospital systems where each hospital operates independently under separate CMS Certification Numbers (CCN), data from those entities may be used to supplement local data but cannot replace local data.
A well-designed OPPE process includes qualitative and quantitative data that support re-privileging decisions based upon the hospital’s defined re-appointment schedule. Keep in mind, The Joint Commission just recently modified the timeframe within their recredentialing requirements.
Examples of qualitative data include, but are not limited to:
- Inclusion of a description of procedure performed as a component of the post-operative/procedure note
- Patient complaints
- Code of conduct infractions
- Review of charting with consideration to quality, appropriateness, and accuracy of documentation
- Medical appropriateness of tests ordered, and procedures performed
- Patient outcomes
Examples of Quantitative data may include, but are not limited to:
- Trends in length of stay
- Rates of post-procedure infection
- Frequency of missing information in charts
- Dating, timing, and signing of entries
- Number of T.O./V.O. not authenticated within the defined timeframe
- Presence or absence of required information (H & P elements, etc.)
- Number of H & P updates completed within 24 hours after inpatient admission
- Compliance with medical staff rules, regulations, policies, etc.
- Number of illegible medical record entries
- Number of incomplete medication reconciliations
- Documenting the minimum required elements of an H & P / update
- Compliance with core measures
What about those low-volume practitioners?
Supplemental data may be used from another CMS-certified organization where the practitioner holds the same privileges. This data may not be used in lieu of a process to capture local data. If supplemental data is used it needs to be accurate, relevant, and timely. The medical staff must develop policies and procedures which ensure oversight of local data and the use of supplemental data.
Two examples of when low-volume data may be expected include:
- When practitioner activity is limited to periodic on-call coverage for other physicians or groups
- When practitioner practice is limited to occasional consultations in a clinical specialty
Lacking Analysis of the Data
Frequently on surveys, we see lots of data, however, there is no analysis of the data. In order for the data to be meaningful during the re-privileging process the information needs to be analyzed, reviewed, and action taken. From this data, the department chair and credentialing committee can determine what action(s) to take. Examples of actions that can be taken by the committee may be one of the following:
- Determining that the practitioner is performing well or within desired expectations and that no further action is warranted
- Determining that a performance issue exists and requires intervention and/or a focused evaluation
- Revoking the privilege because it is no longer required
- Suspending the privilege, which suspends the data collection, and notifying the practitioner that if they wish to reactivate it, they must request a reactivation
Remember, that any revocation or suspension of privilege is reportable to the National Practitioner Data Bank.
In summary, FPPE and OPPE are important components of the re-credentialing process. More importantly, it allows organizations to see what practitioners are practicing safely and providing quality patient care. Failure to have a robust FPPE-OPPE program places the organization in a situation where there is a possibility for adverse events and errors to occur.
References
- What is Ongoing Professional Practice Evaluation (OPPE)?, Hugh Greeley, Verisys.
- Ongoing Professional Practice Evaluation (OPPE) - Understanding the Requirements - What are the key elements needed to meet the Ongoing Professional Practice Evaluation (OPPE) requirements? TJC FAQ, February 2022.
- 2023 The Joint Commission Hospital Accreditation Program Manual
To learn more about FPPE and OPPE contact the Courtemanche and Associates Team at 704-573-4535 or email us at info@courtmanche-assocs.com.
C&A and MRN are divisions of SAYAS Alliance. Through MRN, 
(Medical Resources Network) we also offer a range of legal nurse consulting services, including medical record review and analysis, medical chronologies, peer review, retention of medical experts, and adverse event and call center management.
