Complete Guide to OPPE/FPPE Review Process Requirements

The Credentialing Process was created to ensure that patients receive the highest quality care from referred health care providers and institutions. Patients want a rating system that not only reviews the quality of health care received, but a measurement of the overall patient experience.

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Most healthcare providers have a system in place to review the quality of the healthcare that they provide. However, the credentialing process becomes complex because it does not clearly define who needs to be credentialed.

The Difference Between FPPE and OPPE

One of the major differences between OPPE and FPPE is in the way they treat the concentration of time observed. OPPE is expected to be performed more than twice a year and the information is accumulative overtime.

During corrective action, FPPE is concentrated over a period of time to observe where corrections can be made on a trigger. The amount of time an FPPE takes can vary, depending on whether the hospital has specific bylaws detailing the amount of time observed.

The Complexity of the Credentialing Process

The Complexity of the Credentialing Process

Although The Joint Commission (TJC) has clear rulings for medical staff, it defers the licensing of independent practitioners (LIP) to State Law. Centers for Medicare and Medicaid Services (CMS) requires both an initial and ongoing review of the credentials of “all practitioners who provide a medical level of care and/or conduct surgical procedures in the hospital.”

A common question for licensing is whether or not Advanced Nurse Practitioners (APN) and Physician Assistants (PA) are to be counted as medical staff. Under both, TJC and Medicare’s Condition of Participation, they are so long as it is allowed by State Law.

While APN and PA staff membership depends on State Law, all APNs and PAs must go through the credential and privileges process using standards set by TJC and CMS. The Credentialing Process uses 3 types of assessments – General Competency Assessment, OPPE, and FPPE.

General Competency Assessment

General Competency Assessment

The General Competency Assessment follows 6 general competencies as set by TJC and are endorsed by most medical and professional organizations:

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

Practitioners under TJC must be reviewed under these 6 general competencies. However, it does not specify on what the recommendations and requirements are. This is because there are many types of institutions, all of which provide different types of care, such as Critical Access Hospital, Academic Medical Center, and Government Medical Centers.

While the credential process may be different from hospital to hospital, the assessment requirements must have two core elements – the assessment of core competencies and a specialty or department-specific competency.

Ongoing Professional Practice Evaluation (OPPE)

Ongoing Professional Practice Evaluation

The Ongoing Professional Practice Evaluation (OPPE) is a continuous evaluation of a provider’s performance at a frequency greater than every 12 months. OPPE involves a peer review process, where practitioners are reviewed by other practitioners of the same discipline and have personal knowledge of the applicant. The assessment must have both quantitative performance data and a narrative assessment, preferably given by more than one fellow practitioner.

OPPE Challenges

One of the biggest challenges of OPPE is in keeping it simple and scalable. The type of data collected is normally determined by the individual departments as stated by TJC. No matter what data is collected, the key is to remain consistent in collecting this information.

For NPAs and PAs, the OPPE process can be challenging if their data is combined with a physician’s data. Certain metrics that are valuable for clinical pharmacists or psychologists may not necessarily apply to general practitioners.

Collection Methods

There are many methods you can utilize to collect information, such as direct observations, chart reviews, discussions with peers and staff, or test for competency in performing specific procedures. One effective method in collecting information for OPPE is the use of simulations. In this way, you can isolate variables and determine a practitioner’s competency under normal settings.

No matter the collection method, it is key that information collected remain relevant and meaningful to the service provided. Slimming it to the essentials allows the process to flow smoother and is scalable.

The use of Triggers

A key principle of OPPE is the use of Triggers – noticeable drops in performance. The trigger level is a predetermined baseline level of performance within an established criteria.

Staff members who are below the trigger level then move into Focused Professional Practice Evaluation (FPPE). FPPE is used to evaluate and act upon concerns regarding a privileged practitioner’s clinical practice and/or competence.

While FPPE may act as an extension of OPPE, FPPE has its own myriad of complications.

Creating a Successful OPPE Process for Your AHPs

There seems to be a void in the discussion of the OPPE (Ongoing Professional Practice Evaluation) process relating to AHPs (Allied Health Professionals). Like their sponsoring counterparts, an AHPs OPPE should contain a dynamic process of checks and balances serving to create a system of care that‘s current, data driven, evidence based and controlled. While the AHP OPPE shares many of the same elements as the Physician OPPE, the process of collecting and evaluating data is often captured differently.

From working in several hospitals and now supporting dozens of clients’ need to meet these requirements, I’ve created a list of steps and options you may wish to consider in creating a successful OPPE process for your AHPs.

  • Be sure to describe the process in your by-laws as well as policies and procedures. Surveyors want to ensure processes are well documented and established plans are adhered to.
  • Choose meaningful measures that accurately reflect AHP performance. Taking the time to determine important measures related to your providers may be time consuming on the front end, but once complete the results are worth it.
  • Don’t rely solely on data driven measures. Sponsoring Physicians account for much of the performance of the AHP’s OPPE and the use of narrative in the report is appropriate. The chart review required for maintaining privileges can serve to provide much of the information needed by the Sponsor to complete the OPPE.
  • Include the six core competencies in a way that’s easy to address.
    1. Patient Care: Has the AHP been referenced in the patient satisfaction surveys? Are there any complements or complaints?
    2. Medical/Clinical Knowledge: Has the AHP been reviewed in the Peer Review committee? What does a review of the chosen patient assessment and treatments say about the competency of the AHP?
    3. Practice Based Learning and Improvements: Does a chart review indicate a working knowledge of current scientifically based treatment choices? Is the AHP involved in on-going educational opportunities?
    4. Interpersonal and Communication Skills: This is another area you can address through complements and complaints from staff and patients. How does the AHP function in a team setting? Do they take feedback and direction well?
    5. Systems-Based Practice: This can be ascertained from a chart review and study of the treatment choices and care plans created for patients treated. Is the practitioner able to see past an individual episode of care and evaluate the family, the community the other bodily systems and their contribution to the current state of the patient?
    6. Professionalism: This area can be assessed by evaluating the overall impression made by this practitioner in all other competency areas. It’s the sum of all other parts reviewed.
  • While all OPPE’s should contain the 6 core competencies, an evaluation should also include a minimum of two “hospital specific” and two “department specific” monitors. These can be the same for AHP’s as well as Physicians to simplify the processes.
  • Although the main review for AHPs will likely be manual and narrative, it doesn’t have to be cumbersome. When documenting answers to competency questions, simply have the Sponsor check “MET” or “NOT MET” with a column to check whether a PIP (Performance Improvement Plan) was or should be initiated. This type of format allows the medical staff to satisfy two standards, Sponsor Review of Charts and OPPE Report Submission, that often cause issues during surveys.

In today’s healthcare delivery model, the eyes of our patients see a thinning line between Doctor and Allied Health Professional. That same line is thinning in the eyes of those writing and enforcing the quality requirements healthcare organizations are judged and reimbursed by. Although the work required to create and manage effective OPPE programs for AHPs can be challenging, the results of improved patient care and helping every practitioner be the best they can be are worth it, even without the requirements.


OPPE for Low Volume, High Risk Procedures

Lately we've received questions regarding monitoring low volume/high risk procedures (LV/HR) related to privileging and OPPE (Ongoing Professional Practice Evaluation). Specifically, “How should we manage procedures performed so infrequently that required productivity numbers aren’t met?” thus, creating the dilemma of whether to approve/renew privileges for two more years.

Considerations when presented with a LV/HR procedure privileging request:

  • Is this privilege/procedure required by enough patients in the community to warrant your facility offering the service
  • How many local facilities offer the same procedure
  • How many times has the procedure been required/performed in the last two years

Low Volume, High Risk OPPE alternatives:

  • Perform an FPPE for the high risk procedure, include a plan for monitoring, so the Medical Executive Committee (MEC) can confidently approve re-privilege
  • Consider Peer Referencing from other facilities
  • Allow Department Chair proctoring for those procedures less likely to be performed often

Keep an open mind in relation to outcomes and observations and collegial interactions. Giving your medical staff flexibility will increase adoption and improve compliance with the program.

Address LV/HR issues in policies or bylaws:

  • Define LV/HR procedures for your institution
  • Keep an open mind in defining reliable confirmation of competency; don’t just use “the provider must perform ‘X’ number of procedures to maintain this privilege”
  • Consider peer referencing, proctoring or direct observation to validate competency of known LV/HR procedures

As with any unexpected situation, always keep your standards and regulations handy for reference. Don’t forget to utilize the resources of your surveying authority; there are few questions they haven’t already confronted and conquered so don’t be shy about taking advantage of their knowledge and experience.

Lastly, keep the intent of the standard in mind when answering questions and developing your plan. If you develop your processes from that perspective you will usually find yourself in good standing come survey time. (Medical Staff Handbook: A Guide to Joint Commission Standards, 2011)     

Focused Professional Practice Evaluation (FPPE)

Focused Professional Practice Evaluation

Focused Professional Practice Evaluations (FPPE) involve more specific, time-limited monitoring of a provider’s practice performance for a couple of different situations.

  1. During an initiation: New hires who are given initial privileges and credentialing, regardless of past performance. Current staff members who are applying for an expansion or new privileges and credentials are also given an FPPE. This is done for all privileges to be granted, as well as any privilege they may ask for.
  2. As needed basis: After the initial FPPE, the assessment isn’t imposed again unless used as a corrective measure. When a trigger or serious complaint is identified during an OPPE, the trigger is inspected further with a FPPE assessment for corrective action to TJC standards.

The Joint Commission defines triggers as “unacceptable levels of performance within the established defined criteria.” FPPE, as well as other assessments, are only effective if they provide the medical staff with opportunities for improvement. According to a report made by the TJC in 2013, if triggers are never activated during the OPPE, then the triggers are not sensitive enough.

It is important that the process remain consistent for all practitioners, including APNs and PAs.

Clear Guidelines and Benchmarks

Many of the guiding principles of OPPE also apply to FPPE, such as measurements taken using quantitative data, a narrative assessment, and collection methods. Just like OPPE, best practice is to keep the assessment consistent, simple and scalable with clear guidelines and benchmarks.

Effective FPPE processes answer the criteria needed for the evaluation, the specific method for establishing a monitoring plan, a method of determining the monitoring duration, and an outline of circumstances by which monitoring will occur from an external source.

Since different roles have their own unique responsibilities and the FPPE is meant to be a method of enacting service quality improvements, TJC allows institutions to design their own FPPE process.However, they offer guidelines by which to shape the FPPE process:

  • The processes used for FPPE do not need to apply to all staff members, they only need to be applied consistently.
  • Training courses and board certification do not equal competency.
  • Sampling of group privileges does not mean someone is competent in every privilege in that group. Individual assessments must be made, regardless of what the group standard is.


One of the major differences between OPPE and FPPE is in the way they treat the concentration of time observed. OPPE is expected to be performed more than twice a year and the information is accumulative overtime.

During corrective action, FPPE is concentrated over a period of time to observe where corrections can be made on a trigger. The amount of time an FPPE takes can vary, depending on whether the hospital has specific bylaws detailing the amount of time observed.

10 details your policies and procedures should address to meet minimum requirements:

  1. The frequency of performing evaluations should be standardized
  2. Reviews should be handled consistently for all providers
  3. Standard workflows should be established
  4. Clinical performance benchmarks should be defined
  5. Document event types that trigger automatic evaluation
  6. Establish guidelines of how FPPE/OPPE is used for re-credentialing
  7. Determine whether internal or external staff will perform the evaluations
  8. Define the methods utilized for collecting information (chart review, direct observation, etc.)
  9. List all possible outcome actions and next steps
  10. Feedback to providers should be consistent regardless of the outcome


Indicators of an Ineffective OPPE/FPPE Process

10 signs of an ineffective FPPE and OPPE program:

  1. Redundant processes across various review functions
  2. Applying FPPE and OPPE inconsistently across providers
  3. Reporting capabilities are inefficient and time-consuming
  4. Not recognizing or identifying potential peer review conflicts
  5. Inability to compensate for a lack of physicians in a given specialty
  6. Delay in review of incident reporting or performance metrics
  7. Paper-based processes and charts are utilized
  8. Providers only receiving feedback when outcomes are negative
  9. Oversight committee doesn't communicate with re-credentialing committee
  10. Lack of provider buy-in for processes

Creating and maintaining a FPPE/OPPE program that allows your organization to prosper is the pinnacle for healthcare executives. Structuring your program to be intuitive and nimble will allow your processes to grow and change with your organization. Consider investing in software that maintains the structure needed; yet allows for the flexibility required.

After all, if your organization’s professional practice evaluations are cumbersome or only used for surveys, you and your patients aren’t receiving the benefits intended by the requirements - increasing the quality of the healthcare we deliver and receive.

Learn More about OPPE/FPPE and the Credentialing Process

The credentialing process is a valuable tool for not only verifying the qualifications of a practitioner, but a powerful holistic assessment of the quality of care given in an institution. For more detailed information about the TJC’s policies on the FPPE assessment, listen to our webinar by Zachary Hartsell, MHA, PA-C.

For more information on the credentialing process and how symplr can help your institution streamline its process with simple and effective solutions, Schedule a Demo today!

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