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How to Maintain FPPE and OPPE Compliance

July 2, 2020

FPPE and OPPE are Joint Commission standards for physician privileging. These processes, where a hospital evaluates the physician’s performance within a specific time frame, ensure quality of care and patient safety. Although hospitals determine their own criteria for performance monitoring and evaluation, failure to perform these processes could lead to Joint Commission citation.

To help hospitals determine monitoring criteria, the Accreditation Council for Graduate Medical Education (ACGME) has established six core competencies for evaluation: patient care; medical knowledge; practice-based learning and improvement; interpersonal and communication skills; professionalism; and systems-based practice.

What Is FPPE?

After credentialing, Focused Professional Practice Evaluation (FPPE) ensures the competence of the physician to perform expected tasks. FPPE is required for all newly-privileged physicians.

FPPE performance monitoring must include:

  1. Criteria (set by the hospital) for conducting performance evaluations
  2. A method for conducting the monitoring plan for the privilege being requested
  3. A method for setting the time frame for the evaluation
  4. Specified circumstances requiring external monitoring

The Joint Commission recommends that hospitals use both qualitative and quantitative data to establish performance monitoring criteria.

6 Qualitative Data Measurements for FPPE

Non-numerical data can reveal aspects of a physician’s competence that quantitative data alone can’t capture.

Qualitative criteria can include:

  1. Chart reviews
  2. Patient complaints
  3. Peer recommendations
  4. Procedure descriptions
  5. Discussions with other medical staff
  6. Breaches of code of conduct

6 Quantitative Data Measurements for FPPE

Measurable data can help determine if a practitioner meets expected hospital benchmarks.

Quantitative data can include:

  1. Compliance with rules, regulations, and policies
  2. Length of stay
  3. Post-procedure infection rates
  4. History and physical (H&P) completion and documentation
  5. Chart reviews
  6. Compliance with core measures

What Is OPPE?

Ongoing Professional Practice Evaluation (OPPE) determines practitioner competence in order to maintain privileges. The process is intended to identify performance trends that could negatively impact patients and outcomes.

The Joint Commission expects OPPE to be undertaken frequently. Best practices are to complete the process every six months to allow practitioners time to address issues uncovered during monitoring. If any quality issues are identified during the OPPE process, it triggers the FPPE process.

OPPE monitoring should include:

  1. Medical staff responsibilities for data review
  2. Frequency of review
  3. The process for using data in making decisions
  4. The outcomes and process resulting from review decisions

As with the FPPE, the Joint Commission recommends using both qualitative and quantitative data in performance monitoring.

6 Qualitative Data Measurements for OPPE

Qualitative data can include:

  1. Chart reviews
  2. Patient complaints
  3. Peer recommendations
  4. Procedure descriptions
  5. Discussions with other medical staff
  6. Code of conduct breaches

6 Quantitative Data Measurements for OPPE

Quantitative data can include:

  1. Compliance with rules, regulations, and policies
  2. Length of stay
  3. Post-procedure infection rates
  4. History and physical (H&P) completion and documentation
  5. Chart reviews
  6. Compliance with core measures

FPPE and OPPE are important for hospitals to verify that their physicians are competent to provide safe, high-quality care to patients. Learn more from Verisys about how you can ensure your providers meet all government and regulatory standards.

Juliette Willard Written by Juliette Willard
Healthcare Communications Specialist
Being creative is my passion! Writer. Painter. Problem Solver. Optimist.
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