Evaluating performance and determining privileges can be a challenge for medical staff services departments. According to a study by The Joint Commission (TJC), MS.4.15 was one of the most frequent standards identified as noncompliant in surveys. When compliance gets tied up in performance and engagement, things can get messy.

Ongoing Professional Practice Evaluations (OPPE) programs use data to determine whether physicians are clinically competent in their privileges. They incorporate self-reviews and peer evaluations, as well as supervisor input, to provide a total picture of competency. If there are issues with competencies, a follow-up Focused Professional Practice Evaluation (FPPE) may be necessary, although it’s important to keep in mind false positives are possible. While it can take time to put together and implement an OPPE program, medical staff members know it’s a key part of providing quality care at an organization.

Keeping physicians engaged and compliant is an important step in the process of providing quality care, says Lori Brostrom, Vice President of Marketing at Physician Wellness Services, which surveys physicians’ engagement levels. “Quality and cost accountabilities mandated through the Affordable Care Act are driving healthcare organizations to develop new models and systems of delivery that are increasingly physician-dependent.”

What Makes for an Effective OPPE Program?

The Physician Performance Toolkit contributed by LifePoint Hospitals of Brentwood, Tennessee, and adopted in The Joint Commission’s Leading Practices Library, says there are six important factors that make an OPPE program successful:

1. Consistent. If the OPPE standards vary by practitioner, the review process may be less effective. TJC recommends collecting data on every practitioner, not just those with performance problems. 
2. Timely. If the review is a routine OPPE evaluation, it should follow an established schedule. If the FPPE is following up on a trigger or benchmark uncovered during the OPPE, it may need to move more quickly.
3. Defensible. The organization should avoid conflicts in peer evaluations and establish standards that clearly reflect the organization’s culture and experience. Procedures for collecting the data and who reviews it (the department chair, credentials committee or medical executive committee) should be clearly defined.
4. Balanced. It’s important that practitioners being reviewed have a chance to have their say, and for minority opinions to be included in the process.
5. Useful. The data analysis should be included in the practitioner’s file and referred to as necessary. TJC also says organizations should use data they already collect, such as medical record delinquency, infection control and core measures.
6. Ongoing. Following the data over time can help medical staff members track the effectiveness of quality improvement efforts. TJC says data evaluations must be performed more than once a year; every six to eight months is ideal.

As with any evaluating tool, buy-in is crucial. “By achieving greater physician buy-in and active participation in new initiatives around quality, efficiency, patient satisfaction and related strategies, healthcare organizations have a greater likelihood of success in a competitive environment based on increasingly objective measures,” Brostrom says.

If OPPEs find low engagement is driving poor performance, Brostrom recommends including physicians in more decisions and leading lead key initiatives and activities when possible.