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Why is OPPE Required by The Joint Commission?

November 9, 2020

In the case where a physician no longer practices at a location where he or she is granted full privileges, OPPE adds an important layer of transparency that protects the organization and patients.

In this blog, Hugh Greeley outlines six options to offer a fully privileged provider with sparse activity that could be observed and contributed to OPPEs.

What is Ongoing Professional Practice Evaluation (OPPE)?

The Joint Commission (TJC) mandates both Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) in order for a provider to receive privileges with a healthcare organization that is accredited by The TJC.

OPPE is required for the purpose of performance improvement and identifying trends and issues that could adversely affect patient outcomes. A well-designed OPPE process includes both qualitative and quantitative data that support re-privileging decisions every two years. An average cadence is every eight months so at a minimum three sets of data are collected over a two-year period.

An annual evaluation is considered periodic, and not ongoing.

Qualitative data may include a description of procedures performed, types of patient complaints, code of conduct infractions, review of charting with consideration to quality and accuracy of documentation, relevance of tests ordered and procedures performed, and patient outcomes.

Quantitative data reflects some type of unit of measure. Possible content within the quantitative category might include trends in length of stay, rates of post-procedure infection, frequency of missing information in charts, noncompliance to rules, regulations, policies, or core measures.

If a provider has not kept charts, ordered tests, or performed procedures, an effective OPPE is impossible, so re-privileging presents challenges.

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

What are the options when OPPE (ongoing professional practice evaluation) as required by The Joint Commission (TJC) identifies a practitioner who no longer practices to any significant degree at the hospital or within its affiliated outpatient units (no admissions, surgeries, consults, etc.)? Let’s consider this scenario:

Dr. Joe Smith has not practiced at the hospital for years, but is very active at another hospital in town or in his office-based practice and refers patients only to the other hospital. He has internal medicine privileges, including a few special procedures. He is generally known to be an excellent physician. He is a member of the associate staff, but this is not relevant to the issue.

Analysis:  His OPPE report discloses no clinical performance at all. Therefore, there is no data demonstrating his clinical competence in his areas of clinical privilege.

Options for a Privileging Review for an Inactive Provider:

  1. Decline to offer him/her an opportunity to reapply, but leave the door open for him/her to apply as a new applicant at some point in the future.
  2. Offer him/her appointment without privileges (thus eliminating the need for OPPE in the future).
  3. Offer him/her collaborative privileges requiring him/her to work only in conjunction with another physician on all patient care matters
  4. Offer him/her “refer and follow privileges,” which also does not require any OPPE, as they do not permit independent direction or treatment ability.
  5. Continue to monitor his/her “non-work” through your FPPE (focused professional practice evaluation) process and point out this fact to the surveyor during your next survey.
  6. Switch your accreditor to Det Norske Veritas (DNV), which does not require OPPE in the manner specified in TJC standards.

Note: depending upon how you approach B, C, or D your medical staff may end up having to offer a hearing because some might consider these actions an involuntary reduction in clinical privileges. Staff leaders can avoid this outcome by offering B, C, or D as options at the time of reappointment with the addition of perhaps a fourth option, full independent privileges.

This fourth option would require that the practitioner supply significant data and recommendations from his/her primary hospital or other practice location demonstrating his/her competence for full independent privileges. If this option were selected and data were furnished, the practitioner might then be granted the privileges in question, subject to FPPE for any cases admitted or otherwise treated in the hospital.

OPPE Provides the Template for Ongoing Monitoring of License Status

Medical license verification that includes national medical license searches at the time of granting initial privileges provides critical information about the status of all medical licenses and shows if there are any additional licenses that may have been surrendered, suspended, expired, or are in good standing.

Verisys’ Verified License Search and Status (VLSS) service monitors licenses across all U.S. jurisdictions against every specialty licensing board. The most important aspect to this process is identity verification using scientific algorithms that match records to aliases and other instances of a name change or variation. Notifications are sent regarding license expiration, restrictions, impending CEU requirements, and adverse findings.

Ongoing monitoring against FACIS® is different than OPPE in that it provides data on provider exclusions, sanctions, debarments, and disciplinary actions, among other critical actionable data insights. The two in combination show the full picture of a provider—competence in practice, and compliance to licensure and state and federal entitlement program requirements.

Verisys integrates provider license verification and FACIS exclusion search results into a streamlined, real-time data delivery platform for health systems.

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