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Ongoing Professional Practice Evaluation. Joel T. Patterson, MD University of Texas Medical Branch. Ongoing Professional Practice Evaluation (OPPE). Joint Commission requirement in place since 2008

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ongoing professional practice evaluation

Ongoing ProfessionalPractice Evaluation

Joel T. Patterson, MD

University of Texas Medical Branch

ongoing professional practice evaluation oppe
Ongoing Professional Practice Evaluation (OPPE)
  • Joint Commission requirement in place since 2008
  • Requires hospitals to document data collection on credentialed staff on an ongoing basis rather then at the two year reappointment process
  • Allows hospitals to take steps to improve performance on a more timely basis
  • History of the Joint Commission
  • Components of OPPE
  • UTMB system of data collection
  • Concerns about the future
ernest a codman m d
Ernest A. Codman, M.D.
  • “end results system”
  • Morbidity and mortality
  • Kicked off staff at MGH
  • End Result Hospital
joint commission
Joint Commission
  • 1913 American College of Surgeons
  • 1917 Minimum Standards for Hospitals
          • 89/692 passed
  • 1950 3,200 hospitals achieve approval
  • 1951 American College of Physicians, American Hospital Association, American Medical Association, and Canadian Medical Association join with the ACS to form the Joint Commission on Accreditation of Hospitals (JCAH)
joint commission6
Joint Commission
  • 1965 SSA Act of 1965: hospitals accredited by JCAH are “deemed” to be in compliance with conditions for participation
  • 1987 JCAHO formed, publishes “Agenda for Change”
  • 1990’s sentinel event, pain assessment, performance measures
joint commission7
Joint Commission
  • 2000’s National Patient Safety Goals, Universal Protocol, stroke center certification, certification programs for lung reduction surgery, LVAD, and COPD, etc.
  • 2006 Joint Commission – “helping health care organizations help patients”
joint commission8
Joint Commission
  • Hospitals
  • Hospices
  • Home care agencies
  • Health care delivery networks
  • Long term care facilities
  • Ambulatory health care organizations
  • Mental health services organizations

Clearly defined process that includes but is not limited to:

1. who is responsible for reviewing data

2. how often data are reviewed

3. process for using data to continue, limit, or revoke privileges

4. how data are to be incorporated into credentialing files


All practitioners, not just those with performance issues

1. chart review

2. direct observation

3. monitoring of diagnostic and treatment techniques

4. evaluation of practitioner by others involved in the care of the patient

  • Practitioner performing well, no further action warranted
  • Focused evaluation
  • Revoking the privilege because it is no longer required
  • Suspending the privilege
  • Zero performance should trigger a focused review whenever the practitioner performs the privilege
  • Privilege continues because the organization mission is to be able to provide the privilege to its patients
our process at utmb
Our Process at UTMB
  • Activity
    • Inpatient discharges
    • Outpatient visits
    • Procedures
  • Performance
    • Competencies
    • Not specifically mandated by Joint Commission
  • Patient Care core measures
  • Medical Knowledge CME
  • PBLI QI participation
  • Communication patient services
  • Professionalism documentation
  • SBP medical records
  • Future clarification regarding more specific expectations
  • How will data be used
  • Inappropriate use of peer review protections
  • Core credentialing
  • Economic credentialing
value proposition
Value Proposition