Improve Healthcare Provider Performance With OPPE

MSPs might not entirely own ongoing professional practice evaluation (OPPE), but it’s a critical process that links provider competency assessment to privileges. In addition, advanced practice professionals (APPs) who are credentialed and privileged through the hospital medical staff process require OPPE. Tap into your unique role in practitioner data management to improve provider performance.

One innovative way to include the medical staff services department in OPPE is pairing MSPs with quality improvement or peer review professionals to support ongoing practitioner improvement programs. Such dyads require coordination of data and resources but foster collaboration. This strategy is successful for organizations that don’t plan to merge the medical staff services and quality improvement departments.

Using clinical staff to help medical staff services professionals evaluate practitioner competence and privilege requests is another optional pairing for OPPE improvement. The most common example is teaming nurses with medical staff services to facilitate performance reviews and engender buy-in from providers.

The differences between OPPE, FPPE & practitioner quality measures

Practitioner involvement in optimizing OPPE at your organization is crucial, but understanding precedes buy-in. Don’t assume that physicians and APPs know what distinguishes OPPE from other types of performance evaluation. Educate your medical staff about OPPE’s precise goals and what their role is in it. Perhaps you fully understand the OPPE process, but if you have trouble articulating the differences between OPPE, FPPE, and performance improvement/quality measurements to others, use this guide to help convey the big three distinguishing characteristics guiding each method:

OPPE is a method of evaluating professional performance on an ongoing basis to:

  1. Monitor professional competency
  2. Identify areas for improvement by individual practitioners
  3. Use objective data in decisions regarding practitioner privileging 


FPPE entails specific and time-limited monitoring of professional performance when:

  1. A practitioner is initially granted practice privileges
  2. An already privileged practitioner requests privileges new to them
  3. Performance issues involving a privileged practitioner are identified (either through OPPE or other means) 


Peer review includes FPPE and OPPE and all manner of reviews (e.g., cases; charts; KPIs like rule, rate, and review indicators) used to:

  1. Evaluate individual practitioner professional performance
  2. Identify opportunities to improve practitioner care
  3. Help practitioners achieve those improvements    


Aside from ensuring that the medical staff is well educated about OPPE’s goals, organizations with successful ongoing evaluation programs check the box on some other common habits that contribute to ongoing improvements of provider performance. 

1. Continue to refine OPPE by specialty

First, their OPPE processes measure what they are designed to measure, and they take into account that some data are better than none. They collect information knowing that aspects of the process will improve over time, whether adjustments are made to:

  • The design or collection method: As organizations grow and change, data collection may require adjustments based on role/responsibility of department chairs and committees, the process used for decision-making, or other global changes to the process.
  • The data targets and indicators themselves: The Joint Commission describes myriad ways to collect quantitative and qualitative data.The collected data might even represent both qualitative and quantitative information for a target or indicator. But it’s up to organizations to determine, usually by specialty, what to collect.
  • The timeline of collecting it: OPPE data for an emergency medicine physician might take just days or weeks as this practitioner handles high volumes of cases that range in severity. On the other hand, data for an obstetrician will require a more extended timeline.

2. Contribute to a successful OPPE environment

Second, they’re adept at delivering performance data in a manner that feels collegial and not punitive. Practitioners have been invited to participate in identifying the measures they’ll be evaluated on and are able to discern what is done with their data throughout the process. They understand that the basic question being asked when outlier data is found through the OPPE process is, “Why are you different?” rather than, “Why is your performance poor?”

Integrity not only speaks to trust with patients as they ask, “Where did my provider's data come from and how can we know we’re safe?” Likewise, providers deserve to understand what is being done with their data and how they can trust it will be used appropriately.  

Successful OPPE programs make commendations where appropriate, almost as frequently as they address potential problem areas. If we make it a priority to address areas of concern, why ignore exceptional performance? Most provider data management software programs with quality measuring capability have commendation letter templates that make this an easy task.

Debunk the common misconception that OPPE is an adverse action reportable to the NPDB. This is false. The truth is that OPPE is a part of the peer review process and generally provides the majority of the data needed to make reappointment decisions, for most practitioners. The most recent NPDB Guidebook (April 2015) states that “a routine, formal peer review process under which a healthcare entity evaluates, against clearly defined measures, the privilege-specific competence of all practitioners is not considered an investigation for the purposes of reporting to the NPDB.” 

Educate providers and other staff that OPPE is not subjective. This misconception may stem from the fact that some dimensions of practitioner performance require providers to accept and use data that relies on the perceptions of patients and other healthcare clinicians and staff. 

3. Broadly use the 6 general competencies for OPPE

The Joint Commission states that OPPE criteria may include:

  • Review of operative and other clinical procedure(s) performed and their outcomes
  • Patterns of blood and pharmaceutical usage
  • Requests for tests and procedures
  • Length of stay patterns
  • Morbidity and mortality data
  • Practitioner’s use of consultants
  • Other relevant criteria as determined by medical staff

OPPE targets are specialty specific, but the process can broadly use the Six General Competencies established by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties:

  1. Patient Care examples: Core measures, results of cases referred to Peer Review Committee, report of diagnoses treated and procedures performed, mortality rates
  2. Medical/Clinical Knowledge examples: Continuing medical education (CME) activities attended, board certification and maintenance, appropriateness of antibiotic usage
  3. Interpersonal Communication Skills examples: Specialty-related CME hours earned, education related to best practices, patient satisfaction survey results, handwriting legibility, timeliness of H&P completion
  4. Professionalism examples: Written complaints/compliments from peers and associates, timeliness of H&P and operative reports, medical staff meeting attendance, responsiveness to on-call obligations, compliance with bylaws and R&R
  5. Systems-Based Practice examples: Average LOS, resource utilization, on-time OR case starts or turnover times in OR
  6. Practice-based Learning and Improvement examples: Dating/timing/signing of orders, compliance with established evidence-based practice guidelines, appropriate drug use—VTE prophylaxis, statins at discharge for all AMI patients.

Collecting and working with OPPE data is a high-profile medical staff function that contributes to MSPs’ career advancement. However, MSPs are still only on the periphery when it comes to helping to verify competency and foster practitioner improvement. The National Association Medical Staff Services (NAMSS) showed that OPPE tasks rank just 16th out of 23-specified MSP duties on a 2017 NAMSS survey. While it’s the Peer Review Committee’s responsibility to oversee measurement system management and practitioner performance evaluation that lead to improvements, medical staff services must play an important role. 

Learn more about automating your OPPE process.


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