College of American Pathologists
Ongoing Professional Practice Evaluation And Focused Professional
Practice Evaluation

Introducing a new way to comply with OPPE/FPPE

Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) are processes required by The Joint Commission (TJC) for accreditation that assess competency of practitioners in performing the privileges they are approved to practice.

In 2008, TJC implemented a new standard mandating detailed evaluation of practitioners’ professional performance as part of the process of granting and maintaining practice privileges in a healthcare organization.

CAP produced a white paper with comprehensive details about the processes: Evalumetrics for Pathologists’ Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) (PDF, 188 KB).

Ongoing Professional Practice Evaluation

OPPE is intended as a means of evaluating professional performance on an ongoing basis for three reasons:

  1. as part of the effort to monitor professional competency;
  2. to identify areas for possible performance improvement by individual practitioners; and
  3. to use objective data in decisions regarding continuance of practice privileges.

Once a provider has achieved practice privileges in a health care organization, TJC requires that performance data be collected with evaluation of the provider conducted more frequently than annually. Evaluation done annually or less frequently is considered by TJC as “periodic” not “ongoing.” To comply with this requirement, Evalumetrics offers options for entry of providers’ OPPE performance data every month, every 3 months, or every 6 months.

Focused Professional Practice Evaluation

FPPE involves more specific and time-limited monitoring of a provider’s practice performance in 3 situations:

  1. when a provider is initially granted practice privileges;
  2. when new privileges are requested for an already privileged provider; and
  3. when performance non-conformance involving a privileged provider are identified (through the OPPE process or by any other means such as complaints or significant departure from accepted practice.)

TJC does not specify the length of time for FPPE. Therefore, each subscriber to Evalumetrics may choose the period of time for each FPPE episode.

However, the FPPE process should:

  1. be clearly defined and documented with specific criteria and a monitoring plan;
  2. be of fixed duration; and
  3. have predetermined measures or conditions for acceptable performance.

Most organizations set up FPPE monitoring sessions for periods of 3 to 6 months. For infrequently performed services, longer periods of monitoring, such as 12 months, may be appropriate. An alternative approach for infrequently performed services may be monitoring of a predetermined number of service events (eg, review of the diagnoses made on the first 10 or 20 cases of a specified type of surgical pathology specimen), rather than monitoring for a prescribed period.

The duration and scope of FPPE monitoring may also be adjusted for the level of documented training and experience of a practitioner, with shorter monitoring periods or fewer service events for more experienced practitioners. All practitioners must be subjected to FPPE for new privileges, even those with extensive prior experience at other health care organizations.