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Ongoing Professional Practice Evaluation and Focused Professional Practice

Evaluation: An Overview for Advanced Practice Clinicians

Article  in  Journal of midwifery & women's health · July 2014

DOI: 10.1111/jmwh.12190 · Source: PubMed

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Journal of Midwifery & Women’s Health
Resources for Clinicians
Ongoing Professional Practice Evaluation and Focused
Professional Practice Evaluation: An Overview for Advanced
Practice Clinicians
Sharon L. Holley, CNM, DNP, Christian Ketel, MSN, RN
BACKGROUND
Historically, hospitals have credentialed and privileged health
care providers using standards heavily weighted with personal
references and other subjective information. In 2008, the Joint
Commission added 2 new standards, the Ongoing Profes-
sional Practice Evaluation (OPPE) and the Focused Profes-
sional Practice Evaluation (FPPE), for all health care providers
credentialed and privileged within hospitals accredited by the
Joint Commission. These providers include physicians, ad-
vanced practice registered nurses (APRNs), certified nurse-
midwives/certified midwives (CNM/CMs), and physician as-
sistants (PAs).1 All hospitals are expected to have this process
in place, and the OPPEs must be available for Joint Commis-
sion review during inspections and audits. Inspectors may ad-
ditionally request the data and summaries used for collection
of the OPPE/FPPE evaluations and may interview providers
or department leadership regarding the process.
The OPPE is a summary of ongoing data collected for
the purpose of assessing a practitioner’s clinical competence
and professional behavior. It is completed more than once a
year in an ongoing cycle; however, it is left to the individual
hospital to decide the cycle length. For example, one hospital
may choose to perform an evaluation every 3 months, while
another hospital may choose to perform an evaluation every
6 months. The intent is for hospitals to use the OPPE to eval-
uate providers’ performance data on an ongoing basis. More
frequent evaluation allows for the timely correction of poor
performance.2
The FPPE, however, is a time-limited and focused eval-
uation of practitioner competence with a specific privilege.
There are several reasons for a focused evaluation. First, all
new providers must have the FPPE completed 6 months from
the date of hire. Providers also need a focused evaluation when
the OPPE reveals any problem. In addition, an FPPE is appro-
priate when a provider begins to perform a newly acquired
skill or when a particular skill has not been used for an ex-
tended period of time.
The OPPE and the FPPE are recurring processes that fit
into a cycle of credentialing that occurs regularly and drives
privileges at a hospital3 (Figure 1). The Joint Commission
requires these documents to be distinctly separate from an
annual review performed by an employer. Although the as-
sessment of competence should be a balance of subjective
Address correspondence to Sharon Holley, CNM, DNP, Vanderbilt
University School of Nursing, 461 21st Ave South, #354 Frist Hall,
Nashville, TN 37240. E-mail: Sharon.holley@vanderbilt.edu
452 1526-9523/09/$36.00 doi:10.1111/jmwh.12190
www.jmwh.org
and objective data, the overall intent of the OPPE and FPPE
is to use objective data to verify and monitor clinical com-
petence with less opportunity for personal bias. The pur-
pose of this article is to explain the OPPE and FPPE pro-
cess, as well as give examples of each general competency
and how it can be measured for hospital-based midwifery
practice.
PURPOSES OF THE ONGOING PROFESSIONAL
PRACTICE EVALUATION AND FOCUSED
PROFESSIONAL PRACTICE EVALUATION
The organizational credentialing process verifies a health care
provider’s training and competence for practice. Credential-
ing is typically completed when a provider is first accepted
onto hospital medical staff and then with each renewal cy-
cle. As part of credentialing, the provider and hospital de-
velop a list of skills and procedures within the provider’s
scope of practice, known as privileges. Organizations are re-
sponsible for ensuring that their providers give high-quality
care and are professional in their behavior. The institution
should use information collected during the OPPE process
to determine if the providers should maintain credentialing
or privileging or have any or all of their privileges revised
or revoked prior to or at the end of the 2-year reappoint-
ment cycle.4 The OPPE as an ongoing quality review can
take many forms, but hospitals accredited by the Joint Com-
mission must follow a process that involves the documented
summary of both subjective and objective data.2,3 Within the
OPPE, there are 6 required general competencies that must
be included: patient care, medical and clinical knowledge,
practice-based learning and improvements, interpersonal and
communication skills, professionalism, and systems-based
practice.
The FPPE is a distinct and separate type of evaluation
from the OPPE and is comprised of 3 evaluative categories.
The first category relates to newly hired providers and is
used to verify competence when orientation is completed at
the end of the first 6 months. The second category is used
when a health care provider requests privileges for new skills
or procedures. The FPPE closely monitors the health care
provider in the identified area(s) for a specified time to eval-
uate competence for the skill requested for privileging rather
than the overall competency for the entire scope of practice.5
The third category for an FPPE is used when there is a con-
cern about the provider’s competence for performance. The
OPPE is one way that a problem may be identified. The FPPE
can be implemented for providers with poor technical skills,

c 2014 by the American College of Nurse-Midwives
 Health Care Provider Evaluation
The OPPE/FPPE Process 1. New Advanced
Practice Provider
within Organization
2. New Privileges: skill (CNM/CM, APRN,
or procedure) PA, etc.)
3. Clinical Issue(s)
Identϔied: Competency
NOT MET

FPPE
1. Initial Appointment
- Completed by 6 months
from time of hire
OPPE - All Competency
- Occurs MORE THAN measures are evaluated
Once A Year. OR
2. New Skill or Procedure
- All Competency - Speciϔic Competency Focused
Criteria/Measures - Time limit determined
Are Evaluated FPPE Policy)
OR
3. OPPE Competency Not Met
- Speciϔic Competency Focused
- Time limit determined by
FPPE Policy/Procedures

1. All new provider

Competencies MET
2. Speci ic Skill or
Procedure
Competency MET
Reappointment With
3. Clinical competency One or More
Full Privileges
Issue RESOLVED Privileges
-Occurs Every Two
Years Removed

Figure 1. OPPE or FPPE Decision Making Algorithm

Abbreviations: APRN, advanced practice registered nurse; CNM/CM, certified nurse-midwife/certified midwife; FPPE, Focused Professional Practice Evaluation; OPPE, On-
going Professional Practice Evaluation; PA, physician assistant.

disabilities, poor judgment, unethical or illegal behavior,
age-related limitations, actions contrary to the organization
bylaws, or other impairments that affect patient safety. In this
case, the intent of this type of review is to assist a struggling
provider to improve.5 It should be emphasized that the FPPE
is not meant to be a punitive process; rather, it is used to
closely monitor or provide mentorship when necessary to help
improve outcomes. Table 1 compares the OPPE and FPPE
requirements.
The Joint Commission does not require that the OPPE
or FPPE be shared with the individual provider being evalu-
ated. However, offering individual feedback to facilitate trans-
parency and quality improvement is considered beneficial
for facilitating overall improvement of competence. Allowing
providers to see comparative data about their practice in re-
lation to their peers within and outside of the organization
demonstrates a need for improvement.1,5
DEVELOPMENT OF ONGOING PROFESSIONAL
PRACTICE EVALUATION AND FOCUSED
PROFESSIONAL PRACTICE EVALUATION POLICIES
Responsibility for policy development for the OPPE and FPPE
can be organized in various ways; the Joint Commission does
not give specific direction. For example, a credentialing com-
mittee could be created; a committee of the organized med-
ical staff could be formed; or a department chair or desig-
nated senior leader could be placed in charge of this pol-
icy development.3 Thus, each institution decides how to best
meet this challenge. Whoever is designated to oversee the
collection and analysis of the OPPE and FPPE should be
well respected and have the credibility to do this challenging
job. Having specialties review their own individual providers
would ensure that they know the full scope and requirements
of the job being evaluated. However, if there is only a sin-
gle provider of any specialty, then it must be determined
who would be best to develop, monitor, and review the out-
comes of the OPPE and/or FPPE. In a smaller hospital, the
head of the department might evaluate everyone within the
department, whereas in a larger hospital each department
might appoint individual managers to review specific groups
of providers. The designated person or committee members
must be able to have difficult conversations about professional
competency with peers in a constructive and improvement-
focused manner that facilitates practice improvement when
problems are identified. Clearly this would not be an appro-
priate administrative duty for junior or novice members of
the team.1
A method to gather and maintain data collection should
be developed. There should be tracking systems in place and

Journal of Midwifery & Women’s Health r www.jmwh.org 453

454
Table 1. Comparison of Requirements for Ongoing and Focused Professional Practice Evaluations
Description OPPE FPPE
Who must complete All currently credentialed and privileged providers New providers
Providers who initiate new procedures
Provider is requesting privileges for a certain procedure, but has had
no previous experience performing it within the hospital.
Provider is privileged for a certain procedure, but has limited volume
of performing it during the credentialing or OPPE cycle.
Providers with an identified concern triggered by OPPE
Providers with any trigger that raises question of competency or
professional behavior
Who is exempt New hires under their initial FPPE Those with no identified need for FPPE
A provider not credentialed or privileged in the hospital A provider not credentialed or privileged in the hospital
When is it required More than once a year; time frame to be determined by each institution Time-limited; can be renewed if indicated and time frame specified
If a new hire, 6 months from hire date
What is affected Required for continued credentialing and privileging New providers: Affects maintaining credentialing after the initial FPPE
is completed
Currently credentialed providers: Affects only the privilege in question
Links back to decision for credentialing and privileging decision
How the information is utilized Currently credentialed provider: Monitoring determines if FPPE Currently credentialed provider: Utilized for performance
indicated improvement activities
Credentialing and privileging Direct further education
Process monitoring Modify an existing privilege
New provider: Used to determine if provider can maintain initial
credentialing and privileging following the first 6 months
What is needed to evaluate Subjective data can be utilized because it pertains to the 6 Identified monitoring plan specific to requested privilege(s) or triggers
OPPE-defined competencies. related to provider privileges
Objective data to be collected and evaluated using the 6 OPPE-defined Specified duration of performance monitoring
competencies. Establish criteria for any extension of evaluation period
Both the subjective and objective data can be prospective, concurrent, Define any monitoring by an external source if required
or retrospective.

Continued

Volume 59, No. 4, July/August 2014

 Table 1. Comparison of Requirements for Ongoing and Focused Professional Practice Evaluations
Description OPPE FPPE
What resources are utilized Quality data Quality data
Chart review Chart review
Monitoring clinical practice patterns Monitoring clinical practice patterns

Journal of Midwifery & Women’s Health r www.jmwh.org

Who can receive the results
Simulation Simulation
Proctoring Proctoring
Patient satisfaction reports Patient satisfaction reports
Discussions with peers, consulting physician, nursing staff, Discussions with peers, consulting physician, nursing staff,
administrative personnel administrative personnel
Specialty-specific performance criteria Specialty-specific performance criteria
Core measures Core measures
Clinical practice guidelines Clinical practice guidelines
FPPE-triggered items
Organization credentialing body Organization credentialing body
Office of risk management Office of risk management
Chief medical or quality officer Chief medical or quality officer
Auditor for the Joint Commission Auditor for the Joint Commission
Any department or authorized manager as indicated Any department or authorized manager as indicated
Health care provider being evaluateda Health care provider being evaluateda

Abbreviations: FPPE, Focused Professional Practice Evaluation; OPPE, Ongoing Professional Practice Evaluation.
a
Not required, but recommended for quality improvement.

455
 Table 2. Examples of How Ongoing Professional Practice Evaluation Might Trigger a Focused Professional Practice Evaluation
Triggers Noted in the OPPE Examples of Actions that Could be Taken in the FPPE
Elevated infection rates Procedure-specific education
Quality assurance monitoring for 6 months
Chart review of infection reduction measures taken
Sentinel events Recommendation for personal counseling related to personal distress
Mentoring with an experienced colleague for coaching to improve work performance
Department quality assurance review
A monitored simulation experience for a similar type of event to practice a procedure and verify
competence
Suspension of privileges
Too small a number of admissions Suspension or revocation of specific privileges
or procedures over an extended Demonstration of skills to prove competence
period of time A monitored simulation experience for a similar type of event to practice a procedure and verify
competence

Increased length of stay compared Monitoring and review of outcomes

to other providers in the same
specialty
Failure to follow approved clinical Proctoring one-on-one to reinforce correct performance of specific procedure with a
practice guidelines verification of skills by a more experienced colleague
Suspension or revocation of specific privileges until competence can be demonstrated
Patterns of unnecessary diagnostic Quality assurance review
testing or treatments Review of individual outcomes and compare to other providers in the same department or
national benchmarking standards
Start FPPE process for 3 months and review
Unprofessional behavior Assistance programs for coping with identified behaviors
Monitor patient satisfaction reports
Requirement to attend anger management course

Abbreviations: FPPE, Focused Professional Practice Evaluation; OPPE, Ongoing Professional Practice Evaluation.

people in charge of identified data elements that are collected.
Unfortunately, at present there are no standardized quality
measurement tools to collect health care provider outcomes
for use in OPPE and FPPE; this increases challenges in de-
ciding what should trigger an FPPE. Because these processes
are further developed, more complete databases with specialty
specific measures will likely be created, and more meaningful
data will eventually be available on a local and national level
to help improve the OPPE/FPPE process.5 Until that time,
institutions will have to decide individually what measures
they want to use to assess competency. Table 2 provides some
examples of OPPE triggers for FPPE and possible resulting
actions.
Until specific values, indicators, or standards for evalu-
ation are developed, it is considered best practice to have
several measures that compare with the 6 general OPPE
competencies (patient care, medical and clinical knowledge,
practice-based learning and improvements, interpersonal and
communication skills, professionalism, and systems-based
practice). Table 3 provides examples for evaluating these 6
general competencies.
A variety of measures will also better summarize the over-
all picture of competency for the OPPE. In addition, the 6 gen-
eral competencies in the OPPE can be revised or updated as
situations indicate. Consider an example such as a maternal
death related to a uterine rupture following a trial of labor af-
ter cesarean birth. In addition to the expected investigation
into the reasons the death occurred, there could also be an
addition to the current OPPE process focused on documenta-
tion. Was there proper documentation in the antepartum pe-
riod of the predicted chance of success for a vaginal birth after
cesarean? Was there properly documented informed consent?
Were clinical practice guidelines adhered to with regard to the
notification and documentation of the collaborating physician
when the patient presented in labor to the hospital? These
could become part of the OPPE evaluation for every obstet-
ric provider for the next year or onward.
Triggering a Focused Professional Practice Evaluation
When setting up the tracking measures to be used for the
OPPE, a threshold for initiating a focused evaluation should

456 Volume 59, No. 4, July/August 2014

 Table 3. Six General Ongoing Professional Practice Evaluation Competencies and Examples of Data Collected to Monitor Practice
General Competencies
Patient care
Medical/clinical knowledge
Practice-based learning
and improvements
Interpersonal and
communication skills
Professionalism
Systems-based practice
Examples of Data Collected
to Monitor Practice
Episiotomy rates for
individual providers
Incidence shoulder dystocia
Review of electronic
medical record for
documentation of
counseling and informed
consent for attempted
trial of labor after
cesarean
Peer review
Staff reports, patient
complaints, self-report
Infrequent number of births
at the hospital
Examples of Triggers that
Might Initiate a Focused
Professional Practice
Evaluation
None documented on
hospital admissions (3
out of 10) reviewed charts
Individual rate is 20%
higher than other similar
providers.
Higher-than-average rate of
shoulder dystocia with
individual provider as
compared with the other
providers
Fails to consistently counsel
and document informed
consent or risk vs benefit
in the electronic medical
record for patients who
report a desire to attempt
a trial of labor after a
cesarean
If an area is ⬍ or ⬎ others
in a given practice, a
percentage can be used to
identify poor
performance outliers.
Poor professional behavior
such as yelling at staff or
throwing items across
room when upset
Less than 6 births a year
Examples of a Plan for a Focused
Professional Practice Evaluation
Inform provider of national and
practice benchmarks to compare
with the provider’s rates.
Review specific area again in 3 months.
Provider education on shoulder
dystocia diagnosis and management
Reinforce use of clinical practice
guidelines and evidenced-based
guidelines
Simulation for shoulder dystocia to
verify competence with maneuvers
to resolve shoulder dystocia
Provider’s cases of shoulder dystocia
within the next 6 months are
reviewed for proper procedure and
documentation of the event
Place on FPPE for 6 months and
monitor for improvement over that
time
Review of department policy with the
provider
Review of clinical practice guideline
requirements with the provider
Identify specific areas that need
improvement and review with
provider.
Reevaluate in a specified amount of
time.
Employee assistance programs
identified and possibly required
Possible suspension
Simulation can be used to verify
competence.
If they are competent, the FPPE may
not need to be triggered any further
and the provider can remain on the
routine OPPE.

Abbreviations: FPPE, Focused Professional Practice Evaluation; OPPE, Ongoing Professional Practice Evaluation.

Journal of Midwifery & Women’s Health r www.jmwh.org 457

be decided upon beforehand. The FPPE thresholds should be
sensitive enough to identify appropriate competency issues
and concerns without being so sensitive that they trigger un-
necessary evaluations.1 Most important, there must be con-
sensus on who will review the data and analyze it. Data col-
lected must be placed in context by people who understand its
implications as well as what the practice entails. Peer reviews
may be used as part of the professional behavior monitoring,
but these should remain confidential. Finally, data must be
stored in a secure manner but accessible for review by Joint
Commission audits.1
A challenge to creating standard measures and templates
for evaluation is the problem of using rigid outcomes to com-
pare providers from dissimilar practice and acuity settings.
This has the potential to trigger an FPPE in a higher acuity
environment if the measurements were designed for a lower
risk population. Conversely, if the OPPE trigger is designed
only for the higher acuity setting, then an appropriate FPPE
may never be triggered in the low acuity setting. For exam-
ple, rates of preterm births from a perinatology practice would
not reasonably be compared to rates from a midwifery prac-
tice. Perinatologists are far more likely to care for women who
are at higher risk for preterm birth. Although individual prac-
tices should tailor their OPPE and FPPEs to reflect their prac-
tice setting, some measures inclusive of higher risk clientele
still should be considered. Otherwise, there is the potential
for avoiding the care of higher risk populations in favor of pa-
tients whose low-risk status would specifically improve per-
formance data in avoidance of triggering an FPPE.6
Considerations Specific for Advanced Practice
Clinicians
Developing methods to track data collection for providers
other than physicians, such as CNMs/CMs, nurse practi-
tioners, certified registered nurse anesthetists, clinical nurse
specialists, and PAs, can be challenging. Their data are often
linked to their collaborating or supervising physician and
therefore are harder to access. These providers may bill for
services or admit under the name of a physician, but they are
not tracked by traditional methods such as billing codes or
admission rates.3 One way to easily avoid this problem is to
find and use measures already being captured by the depart-
ment or practice for that individual provider. Some examples
of these data sources might include the Joint Commission
perinatal core measures for elective induction of labor rates
and episiotomy rates, or for meaningful use core measures
such as updating the medication list or problem list. Other
items that might be found or tracked in electronic medical
records, the electronic billing clearinghouse, or existing
benchmarking data sources could be utilized but must be
able to identify individual provider data. Chart reviews are
common ways to collect OPPE and FPPE data, but they
are more labor intensive than what is already being tracked
within electronic data systems.
USING ONGOING PROFESSIONAL PRACTICE
EVALUATION AND FOCUSED PROFESSIONAL
PRACTICE EVALUATION DATA
Once data on provider performance are collected, they should
be compared with other providers in the specific hospital
department or compared with regional or national norms.
458
An individual provider’s outcome for an example indicator
is more informative when placed in the context of practice
norms. For example, does one midwife have a much higher
rate of episiotomies when compared to the rest of the practice
or national benchmarks? Unfavorable outcomes data should
prompt a more thorough assessment of the provider’s prac-
tice and skill level. For instance, is the midwife with high lac-
eration rates doing something differently from the rest of the
practice? This might be an acceptable reason to initiate an
FPPE for that metric, stipulating a time frame for improve-
ment. At the end of the specified time frame, the following de-
cision must be made: 1) stop the FPPE and resume the normal
OPPE cycle with no additional specific evaluation of this out-
come; 2) continue the FPPE for another specified amount of
time; or 3) have some other defined action taken, such as con-
tinuing education units, structured mentoring, or dismissal.
The following scenario illustrates the process. A midwife’s
high episiotomy rate was noted by the service director while
reviewing the OPPE data. The service director met with the
midwife privately to discuss the discrepancy between her epi-
siotomy outcomes compared to those of her peers. Upon re-
flection, the midwife shared that she often performs an epi-
siotomy when the head is crowning because this is how she
was taught in her previous practice setting. After review-
ing the recommended best practices and the current practice
guidelines, the midwife agreed to stop performing routine epi-
siotomies. An FPPE was started to monitor her episiotomy
rates, and at the end of 3 months her rates were comparable to
practice-level averages. At this point, the FPPE ended. Mean-
while, during the FPPE to monitor the midwife’s episiotomy
rate, the OPPE process continued per the hospital protocol.
Monitoring the objective data helped trigger closer scrutiny
for this particular area of concern and was used to improve
outcomes.
Another example might be a provider who becomes ver-
bally abusive to staff or patients. This could immediately trig-
ger an FPPE for performance behavior concerns related to
unprofessional behaviors. It could also result in recommenda-
tions to the provider’s supervisor for counseling or evaluation
for substance abuse. The FPPE would have specific require-
ments that must be met and a time frame to accomplish the
identified actions. At the end of the FPPE time frame, if the
requirements were not met, further action such as continuing
another FPPE or removing the provider from staff would be
decided.
CONCLUSION
The OPPE/FPPE is a mandatory process for all credentialed
and privileged providers in hospitals accredited by the Joint
Commission. Accredited hospitals are required to have an
OPPE/FPPE process that monitors and evaluates competence
for the providers. The OPPE and FPPE process uses objec-
tive data (in combination with subjective) to assess compe-
tence and performance on a regular and ongoing basis. The
process is meant to quickly identify the need for performance
improvement. However, the Joint Commission has left the
process and methods for data collection up to individual hos-
pitals. While this allows for creativity in structuring these
evaluations to meet local needs, it provides little guidance
on best practice when initiating the process. In the future,
Volume 59, No. 4, July/August 2014
development of more standardized evidence-based, high-
quality OPPE/FPPE collection tools may be developed, but for
now, the OPPE and FPPE process should be started using the
6 general competencies to identify individual data points for
collection in individual institutions.
AUTHORS
Sharon L. Holley, CNM, DNP, is Assistant Professor of mid-
wifery at Vanderbilt University School of Nursing in Nashville,
TN. She also currently serves as a Co-Director for the Vander-
bilt School of Nursing Nurse-Midwife Faculty Practice, and
serves on the American College of Nurse-Midwives Division
of Education and Quality committees.
Christian Ketel, MSN, RN, is Instructor of Nursing at Vander-
bilt School of Nursing. He currently serves as the Clinical Di-
rector for a nurse-managed indigent care clinic in Nashville,
TN, and consults on nursing and biomedical informatics op-
portunities.
CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose.
Journal of Midwifery & Women’s Health r www.jmwh.org
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REFERENCES
1.Hunt JL. Assessing physician competency: An update on the
joint commission requirement for ongoing and focused pro-
fessional practice evaluation. Adv Anat Pathol. 2012;19:388-
400.
2.Rauch DA. Committee on hospital and section on hospital. Medical staff
appointment and delineation of pediatric privileges in hospitals. Pedi-
atrics. 2012;129:784-767.
3.The Joint Commission. Standards FAQ details: Medical staff
(CAMH/hospitals): Ongoing professional practice evaluation (OPPE).
http://www.jointcommission.org/mobile/standards information/
jcfaqdetails.aspx?StandardsFAQId=213&StandardsFAQChapterId=74.
Accessed June 2014.
4.The Joint Commission. Standards boosterpak for focused profes-
sional practice evaluation/ongoing professional practice evaluation
(FPPE/OPPE). www.jointcommissionconnect.org/NR/rdonlyres/
A846669C-D456-44D5-A1AF-DC47975CEE8C/0/BP FPPEOPPE.pdf.
Accessed June 2014.
5.Makary MA, Wick E, Freischlag JA. PPE, OPPE, and FPPE: com-
plying with the new alphabet soup of credentialing. Arch Surg.
2011;146(6):642-644.
6.Bass BL, Polk HC, Jones RS, et al. Surgical privileging and cre-
dentialing: A report of a discussion and study group of the
American Surgical Association. J Am Coll Surg. 2009;209:396-
404.
459