OPPE & FPPE Joint

Commission Standards

Jennifer L. Hunt, M.D., M.Ed.

Associate Chief of Pathology
Director of Quality and Safety
Massachusetts General Hospital
Harvard Medical School
jhunt5@partners.org

Agenda

Definitions
Joint Commission guidelines and
requirements

Survey results
Conclusions

HARVARD MEDICAL SCHOOL

MASSACHUSETTS GENERAL HOSPITAL

ADASP | Hunt | 2010 | 2

What is the Joint Commission Standard for OPPE?

Ongoing Professional Practice Evaluation (OPPE)
Measurement of physician performance data to
assess competency and approve privileges on an
on-going, non-periodic basis to allow them to take
steps to improve performance on a timelier basis.

Patient care
Medical/Clinical knowledge
Practice-based learning and improvement
Interpersonal and communication skills
Professionalism
Systems-based practice

HARVARD MEDICAL SCHOOL

MASSACHUSETTS GENERAL HOSPITAL

ADASP | Hunt | 2010 | 3

What is the Joint Commission Standard for FPPE?

Focused Professional Practice Evaluation (FPPE)
Focused assessment of physician competency in
two very specific scenarios:
The period of review for initially
requested privileges (whether for
a new practitioner or a practitioner
requesting new privileges).
The period of review directed at a
practitioner who has exceeded a
threshold in the OPPE analysis

HARVARD MEDICAL SCHOOL

MASSACHUSETTS GENERAL HOSPITAL

ADASP | Hunt | 2010 | 4

Joint Commission OPPE and FPPE Standard

guidelines and requirements are specific.
OPPE
FPPE
Defined frequency* Defined duration

Timing
Metrics

Measures are clearly defined

Who reviews is clearly defined
Values are clearly defined
Process is clearly defined

Thresholds

Outcome
Policies

Used to begin, continue, revoke, or

limit privileges
Applies to all practitioners
Policies are approved by med staff
*Once a year is not considered to be ongoing

HARVARD MEDICAL SCHOOL

MASSACHUSETTS GENERAL HOSPITAL

ADASP | Hunt | 2010 | 5

This survey assessed understanding of JC

OPPE/FPPE standard and compliance with
guidelines & recommendations

ADASP Respondents were senior

members in leadership positions
44 respondents
98% AP and SP leadership

88% >15 years experience

98% in academic practice

HARVARD MEDICAL SCHOOL

MASSACHUSETTS GENERAL HOSPITAL

ADASP | Hunt | 2010 | 6

Respondents rated their understanding of policies

about credentialing at JC, hospital, and departmental
levels
Mean = 6.1

Mean = 8.4

8 to 10 Good

100%

5 to 7
1 to 4

80%
60%
40%
20%
0%
JC OPPE

JC FPPE

Hospital
policies

Department
policies

Poor

Respondents described the process for credentialing

new physicians in their practice: Type of experience
and during of experience
JC: Clearly defined process, frequency and duration
Observes Signout
Co-Signing

25%
25
20%
20
15%
15
10%
10
5%5
0
No
formal
N/A
process

Designated
time

Designated # Until competent

cases

Approximately 30% describe policies that meet the standard

Respondents described the process when a

physician meets a designated threshold for errors
JC: Clearly defined threshold values & process for when threshold is met
60%
50%
40%
30%
20%
10%
0%

Meeting with
supervisor

An observation A period where

period
the pathologist is
co-signed

Remedial
training

We don't have a
formal process

Other (please
specify)

Less than 20% describe policies that meet the standard

How well are academic practices meeting

guidelines for OPPE and FPPE?
FPPE OPPE
Timing
Metrics

Defined duration & frequency

Measures clearly defined

84%*

~30% <70%

Thresholds Values clearly defined

Outcome
Policies

<20%
<20%
<20%

Process clearly defined

Continue, Revoke, Limit privileges
Applies to all practitioners
Policies approved by med staff

92%+

95%

42%

*Less than use tests, observation, co-signing, proctoring

+ Less than 1/3 comply with more than once a year
^ More than 30% do not track data by physician
HARVARD MEDICAL SCHOOL
MASSACHUSETTS GENERAL HOSPITAL

ADASP | Hunt | 2010 | 10

Summary
The level of understanding JC OPPE and
FPPE standards is low

Many report practices that are not in

compliance with the JC standards
Policies that meet JC standard guidelines &
requirements could be shared between institutions
Metrics and procedures
Suggested ranges for acceptable values
Established procedures for when thresholds are met
HARVARD MEDICAL SCHOOL
MASSACHUSETTS GENERAL HOSPITAL

ADASP | Hunt | 2010 | 11