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Benefits of Ongoing or Periodic Professional Practice Evaluation Throughout a Healthcare Organization

Benefits of Ongoing or Periodic Professional Practice Evaluation Throughout a Healthcare Organization

January 10, 2023
January 10, 2023

One of the most effective ways for a healthcare organization to keep their patients safe is through ongoing periodic practice evaluation (OPPE) or periodic practice evaluation (PPE). PPE programs and processes are how healthcare organizations meet the regulatory and accreditation requirements for peer review. VerityStream shares industry-leading best practices to evaluate performance that can be implemented within your healthcare systems to leverage the PPE program as a valuable and strategic contributor to both individual provider performance and organizational quality.

Regulatory and Accreditation Requirements for PPE
PPE programs enable healthcare organizations to accurately meet the regulatory and accreditation requirements for peer review. As is the case with most processes in the medical field, PPE requirements vary depending on the agency. Here’s a quick summary of the details:

Centers for Medicare and Medicaid Services (CMS)

CMS has requirements that all healthcare organizations need to meet unless they have more stringent state requirements/accreditation body requirements. Those would need to be met as well while ensuring that the highest regulations and standards are met.

  • The medical staff must have oversight of providers through processes such as peer review.
    • That peer review must be taken into consideration when medical staff leaders are making recommendations regarding privileging of providers.
    • The medical staff must be accountable for the medical care provided to patients and for quality assessment and performance improvement.
  • The medical staff must periodically conduct appraisals of its members to determine whether an individual practitioner's membership or privileges should be continued, discontinued, revised, or otherwise changed.
    • The medical staff appraisal process must evaluate each practitioner's qualifications and demonstrated competencies to perform each task or activity within the applicable scope of practice or privileges that the provider has been granted.
    • Some components of this appraisal should include the quality of specific work and patient outcomes.
The Joint Commission (TJC)

TJC accreditation applies to hospitals, ambulatory surgery centers, and Federally Qualified Health Centers (FQHCs). Regardless of which Joint Commission program you are accredited under, there are PPE standards that apply.


  • TJC hospital accreditation requires ongoing professional practice evaluation, which cannot exceed every 12 months.
  • TJC hospital standards require a clearly defined OPPE process to evaluate each practitioner's professional performance.
    • The organized medical staff must approve the type of data to be collected as recommended by the individual departments.
    • It is required that the information resulting from the OPPE process be used to determine whether individual practitioners' privileges should be continued, limited, or revoked prior to or at the time of renewal.
  • The organization must evaluate the results of any peer review of the individual's clinical performance and review any clinical performance in the organization that is outside of acceptable standards.
  • TJC ambulatory standards require that before granting renewed or revised privileges to a licensed independent practitioner, the organization reviews information from any of its performance improvement activities pertaining to professional performance, judgment, and clinical or technical skills.
  • TJC ambulatory standards require the review of performance improvement data and peer review results before granting, renewing, or revising privileges which should be no later than every two years (or more frequently if required by state laws or organizational policies).

TJC will want to see both qualitative and quantitative criteria or data requirements which have been approved by the medical staff and designed into the OPPE process.
Healthcare Facilities Accreditation Program (HFAP)

The Healthcare Facilities Accreditation Program (HFAP) accreditation program applies to hospitals, ambulatory surgery centers, and physical rehab facilities.

  • OPPE data must be collected on an ongoing basis and must be summarized at least three times during each two-year reappointment cycle.
  • OPPE reports must be shared with the individual practitioners.
  • The OPPE plan must be clearly defined and approved by the medical staff and must address:
    • Reasons for OPPE
    • Performance indicators specific to each medical staff department
    • Methods for data collection
    • Those responsible for data collection
    • Sources of data
    • How frequently data will be collected
    • Methods for data evaluation and analysis
    • Data confidentiality and security
    • Who may access individual practitioner’s data
Det Norske Veritas, Inc. (DNV)

DNV accreditation applies to hospitals.

  • DNV requires that practitioner-specific performance data is evaluated and analyzed and that appropriate action is taken as necessary when variation is present and the standard of care has not been met as determined by the medical staff.
  • DNV requires performance data to be collected periodically within the reappointment period or as required as part of the period process. This may include comparative international data if available.
    • Examples include: blood usage, prescribing patterns, trends, surgical case reviews for high-risk procedures, readmissions, and unplanned returns to surgery.
    • Data variation from criteria reviewed by the medical staff can be used to determine if fracturing or additional training may be required.
Accreditation Association for Ambulatory Healthcare (AAAHC)

Accreditation applies to freestanding ambulatory centers such as surgery and pain management centers.

  • AAAHC states that privileged healthcare providers must participate in the development of peer review criteria.
    • Peer review criteria should not be limited to the review of clinical records but should include ongoing clinical care and incorporate other items such as infection, hospital transfers, adverse event rates, patient satisfaction, survey results, and compliance with medical staff rules and regulations as well as clinically-based outcomes criteria decided by the privileged health care providers.
  • AAAHC indicates that the peer review process should be an ongoing review of all providers and should not be limited to incident-based review. Peer review results must be part of the credentialing process communicated to the governing body.

Going Beyond Meeting Regulatory Requirements
Many healthcare systems throughout the country have failed to recognize the full potential of having a PPE program and the impact it can have on providers, patients, and the overall quality of care throughout an organization. PPE has been primarily viewed as an administrative function belonging to the medical staff services department, but it’s much more than that. PPE can be one of the most effective programs we have within the medical staff services department to make a significant impact on quality.

A PPE program is evidence that the medical staff has made a commitment to providing safe, kindly, efficient, effective, equitable, and patient-centered care in today's complex healthcare environment. It is through physician-supported and led programs and initiatives that performance expectations are established, and it provides assurance that the organization will exceed established standards of care for all patients. It is also one of the few mechanisms that allow the medical staff to proactively, concurrently, and retrospectively identify their combined and individual strengths, weaknesses, opportunities, and threats. In order to realize its full potential, we must make concerted efforts to move our PPE programs forward through standardization and optimization.

STANDARDIZATION OPTIMIZATION
Standardization ensures the PPE processes and procedures follow established industry best-practice recommendations that support results that are relevant, reliable, comparable, and consistent. Optimization ensures those processes and procedures function as efficiently and effectively as possible, and continuously evolve not only to maximize the value of the PPE program but contribute to the transformation of quality in healthcare.

There are many i’s to dot and t’s to cross to ensure PPE is done effectively, but that doesn’t mean it’s impossible. With a solution like CredentialStream, you have everything you need to request, gather, and validate information about a provider. Learn all about it and request a demo today!