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September 22, 2020

The Joint Commission (TJC) is a not-for-profit, independent standards organization that accredits and certifies health care organizations based on quality in patient safety and process improvement.

Focused Professional Practice Evaluations (FPPE) and Ongoing Professional Practice Evaluations (OPPE) are systematic evaluation processes created in 2008 by TJC to gauge a health care provider’s competence and ongoing performance.

FPPE applies to providers new to an organization, currently privileged providers who desire additional privileges, and those providers who have been flagged for performance concerns.

OPPE is designed to identify trends in performance and through data-driven qualitative and quantitative documentation, early detection and rapid response measures will reduce negative impact to patients. Should an issue arise on a provider’s performance, an FPPE review will be implemented to further assess the issue.

In this blog, Hugh Greeley outlines the process of implementing a successful FPPE and OPPE program in a health system.

The following is contributed by Hugh Greeley, author of Hugh’s Credentialing Digest

During my consultant visits, I have received a significant number of questions about Focused and Ongoing Professional Performance Evaluation (FPPE and OPPE.) Consequently, this blog will address these topics. FPPE and OPPE functions are both understandable and often remarkably easy for physician leaders who have the assistance of competent support staff.

Above all, the organization must recognize that the process of evaluation is not simply to meet requirements. Without this recognition, there is no beneficial purpose to the activity.


  1. A leader must accept responsibility for supervising new and existing practitioners. This person could be a department chair or designee (chief medical officer, vice president of medical affairs, committee, etc.)
  2. This person must receive training in the rationale for and the process used to perform the evaluations, including what to do if there is no or insignificant volume.
  3. The chair, if there is one—if there is not, then the medical executive committee (MEC) must design or approve the system to be used to perform and document the initial and ongoing evaluations.
  4. Data must be gathered by support staff members for review by the designated physician leader. It is not generally their job to gather such data.
  5. Collected data must be arrayed on a designated form for review.
  6. A designated leader must review the data and (if necessary) discuss the practitioner’s work with others.
  7. The designated leader must document his or her review and evaluation on a structured worksheet and develop a conclusion about initial and ongoing performance.
  8. Ideally, the results of the review should be discussed with the new practitioner and presented to existing ones.
  9. Confirmation of completion of the reviews should be presented to the MEC, the designated committee, or the designated person to assure that the function is performed as necessary and to permit general oversight. It is not necessary that each FPPE or OPPE be individually presented for approval. However, those with recommendations needing further attention should be submitted. A well-organized summary of the activity might be presented annually to the MEC showing that all required reviews were completed, how many required action, how many could not be completed due to lack of data, and perhaps a comparison of results broken down by “evaluator.”
  10. The results must be filed for posterity.


Designing and adhering to a process saves reinventing the wheel when medical services and leadership staff shift. Consistent documentation of process and final results helps with compliance audits and adjustments to bylaws and regulations.

Download the FPPE and OPPE Process Checklist here.

Hugh Greeley Written by Hugh Greeley
Credentialing and Healthcare Industry Expert
HG Healthcare Consultant
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