Creating Effective OPPE Performance Measurement Indicators

It’s time to look at OPPE again!  

In 2008, The Joint Commission issued new standards related to ongoing professional 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.  There are some organizations that still are not doing ongoing professional performance evaluations on their credentialed licensed independent professionals, including credentialed physician assistants, nurse practitioners, etc.  Others are using generalized performance measurement indicators instead of those that are specialty specific.  When designing your OPPE program keep in mind the six core competencies that you should be evaluating.  These include:

  1. Patient Care
  2. Medical Knowledge
  3. Practice-Based Learning and Improvement
  4. Interpersonal Communication
  5. Professionalism
  6. Systems-Based Practice

It is my goal to provide you with meaningful general and specialty-specific performance measurement indicators that can be used in your organization.  First, I will provide you with generalized indicators to be used on most if not all practitioners and then some specialty-specific indicators in the areas of surgery, medicine, behavioral health, emergency, and obstetric departments.

General Performance Measurement Indicators

  • A description of procedures performed
  • Relevance of tests ordered and procedures performed
  • Patient outcomes
  • Trends in length of stay
  • Rate of procedure infections
  • Frequency of missing information in charts
    • Dating, timing, and signing/authenticating of entries
  • Telephone/verbal orders 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/registration
  • Documenting the minimum required elements of a H & P / update.
  • Medical record delinquency rate exceeds  ___ %
  • Discharge summary delinquency rate exceeds ___%
  • Review of charting with consideration to quality, appropriateness, and accuracy of documentation
  • Legibility of medical record entries
  • Types of patient complaints
  • Compliance with medical staff rules, regulations, policies, etc.
  • Compliance with core measures
  • Peer recommendations
  • Staff complaints
  • Patient complaints
  • Code of conduct infractions
  • EMTALA concerns

Surgical Performance Measurement Indicators

  • Surgical site infections
  • Returns to the Operating Room within 24 hours
  • Returns to the Operating Room within 72 hours
  • Burns
  • OR fires
  • Hemorrhage/blood loss requiring intervention
  • Hematoma/Seroma at surgical site
  • Nerve injury at surgical site
  • Retained foreign body
  • Pain location, type, and intensity greater than anticipated post-operatively
  • Mortality
  • Transfer to another hospital
  • Wrong site, procedure, patient, implant
  • Pre-operative diagnosis/pathology discrepancy
  • Post-operative complications
  • Non-participation in surgical time-out
  • ED call response greater than 30 minutes
  • Consult delays

Medical Performance Measurement Indicators

  • Mortality
  • Unexpected death
  • Abnormal test results not addressed
  • Discharge summary not timely
  • Medication reconciliation not performed
  • Hospital-acquired infection
  • Inappropriate use of antibiotics
  • Opioid use
  • Use of blood outside of criteria
  • ED call response greater than 30 minutes
  • Consult delays
  • Delays in treatment

Behavioral Health Performance Measurement Indicators

  • Restraint/seclusion/1:1 orders – appropriateness, complete, follow-up
  • Participates in interdisciplinary team meetings
  • Appropriateness of medications ordered
  • Treatment effectiveness
  • Treatment complications (adverse effects of medications)
  • Communication with family/significant other, if applicable
  • Delay responding to initial consult
  • Appropriate consults called
  • Readmission within ___ days

Emergency Department Performance Measurement Indicators

  • Delays in treatment
  • Mortality
  • Returns to ED within 24 hours
  • Missed diagnosis
  • AMA’s rate
  • Appropriate prescribing of antibiotics
  • Opioid prescriptions given
  • CPR outcome review issues
  • Appropriateness/completeness of restraint/1:1 orders
  • Beta blocker on admission of an MI patient
  • Aspirin on admission of an MI patient
  • EMTALA concerns

Obstetrics Department Performance Measurement Indicators

  • Laceration/tear/puncture of body part
  • Primary c-section rate
  • Childbirth complications
  • Procedure or post-procedure complications
  • Unplanned/unscheduled return to the OR within 30 days
  • Surgical site infection
  • Length of stay
  • Primary obstetrician – missed delivery
  • Non-participation in surgical time-out
  • ED call response greater than 30 minutes

Now that you have examples of what to include in your OPPE process it is important to do something with the data you have collected.  Remember, “data rich, information poor” has no place in performance evaluations.  It is important to analyze what the data is telling you and act on it.  Once analyzed, act on your findings and document those actions in the practitioner's file.  Follow up as needed.  This will assist you in deciding whether to re-credential this individual or not.

In summary, ongoing professional performance evaluations are important components of the re-credentialing process.  More importantly, it allows organizations to see that practitioners are practicing safely and providing quality patient care.  Failure to take this process seriously only places the organization in a situation where there is a possibility for adverse events and errors to occur.

To learn more about OPPE Performance Measurement Indicators contact the Courtemanche and Associates Team at 704-573-4535 or email us at


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