Managing Your Medical Staff’s OPPE and FPPE

In 2008, The Joint Commission (TJC) implemented a new standard, MS.08.01.03, requiring detailed evaluation of practitioners’ professional performance as part of the process of granting and maintaining practice privileges in a healthcare organization. Although the standard took effect in 2008, many organizations continue to struggle to establish meaningful indicators and ensure these processes are consistently implemented. Let’s start at the beginning….

These processes are known as the Ongoing Professional Practice Evaluation (OPPE) and the Focused Professional Practice Evaluation (FPPE). One process for maintaining one’s privileges and the other for initial evaluation, when requesting additional privileges or when issues arise with the practitioner’s performance. This process allows for trends in one’s practice to be identified and evaluated to see how it may impact the quality and safety of care given to patients along with creating opportunities for growth and development of the practitioner. Failure to satisfactorily meet the established measures may result in medical staff intervention, inclusive of education, training, mentoring but also escalation to termination of privileges as warranted.

Different performance measures are set depending on which specialty or area of the organization the practitioner is practicing. For example, surgeons, internal medicine physicians and radiologists may have different criteria due to their specialty field of practice. Measures are set by the organization with input from the organized medical staff. Some common OPPE criteria are as follows:

o Review of operative and other clinical procedure(s) performed and their outcomes

o Pattern of blood and pharmaceutical usage

o Requests for tests and procedures

o Length of stay patterns

o Morbidity and mortality data

o Practitioner’s use of consultants

o Other relevant criteria as determined by the organized medical staff

The assessment of the individual’s performance can be completed through periodic chart review, direct observation, monitoring of diagnostic and treatment techniques, and/or discussion with other individuals involved in the care of each patient including consulting physicians, assistants at surgery, and nursing and administrative personnel. While this data is designed to measure individual performance, the information collected could also be included into the organizations performance improvement program and identified trends in the data may be used for medical staff education and/or revisions/updates to the organizations policies and procedures.

When performing a Focused Professional Practice Evaluation (FPPE), whether for initial assessment of skills or in response to a for-cause type of situation, your process should set forth the following:

o Defined criteria for conducting performance evaluations – this is especially important when in response to a “for-cause” situation.

o Develop a method for establishing the monitoring plan specific to the requested privilege – determine who the key-stakeholders are and ensure their engagement in the process.

o Develop a method to determining the duration of performance monitoring – your method must be consistently applied across the process in order to remain objective.

o Define the circumstances under which monitoring by an external source is required – use of external sources is imperative when a practitioner holds a unique skill not held by others within the organization.

Time frames vary for a FPPE. Joint Commission does not require a specific time frame. Typically, three to six months is sufficient time to evaluate a new practitioner, however, depending on the specialty and frequency of services performed it can vary in time or number of cases. Because of this, many organizations will define the minimum number of cases to be reviewed as opposed to establishing a time period for the evaluation. It is important to note that regardless of the years of practice or education of the practitioner, all initial appointments are required to have an FPPE evaluation completed.

In addition to the above-mentioned criteria for OPPE and FPPE, the Accreditation Council for Graduate Medical Education has the following core competency categories that can be used when performing these evaluations.

o Patient Care: patient care is compassionate, appropriate, and effective for the promotion of health, prevention of illness, treatment of disease and care at the end of life.

o Medical and Clinical Knowledge: knowledge of established and evolving biomedical, clinical, and social sciences, and the application of their knowledge to patient care and education of others.

o Practice-based Learning and Improvement: use of scientific evidence and methods to investigate, evaluate, and improve patient care practices.

o Interpersonal and Communication Skills: interpersonal and communication skills that support the establishment and maintenance of professional relationships with patients, families, and other health-care team members.

o Professionalism: behaviors that reflect a commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity and a responsible attitude toward patients, profession, and society.

o System-Based Practice: understanding contexts and systems in which health care is provided and applying this knowledge to improve and optimize health care.

In summary, all practitioners are to have a FPPE when initially credentialed, upon granting of a new privilege(s) or if there are performance issues otherwise referred to as “for -cause”. OPPE, which must be performed more frequently than every 12 months, is to be performed for all practitioners and integrated into the recredentialing process as well as the organizations performance improvement program. The key to a successful OPPE-FPPE program is to ensure that it includes the collection of data that is meaningful to the Medical Staff and Organization.


Joint Commission Manual for Accreditation, 2020
Accreditation Council for Graduate Medical Education, Core Measures
What is OPPE vs FPPE

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