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Best Practices for Professional Practice Evaluation - Measure and Monitor Provider Performance

Best Practices for Professional Practice Evaluation: Measure and Monitor Provider Performance

April 11th, 2023
April 11th, 2023

Patient safety is always a priority, and one of the most effective ways for a healthcare organization to ensure safety is through Ongoing or Periodic Professional Practice Evaluation. These programs and processes help organizations meet the many regulatory and accreditation requirements needed. Read on for some industry-leading best practices healthcare systems can leverage to ensure individual provider performance and organizational quality. Let’s start with the basics.

Periodic vs. Ongoing

Ongoing Professional Practice Evaluation (OPPE) Periodic Professional Practice Evaluation (PPPE)
OPPE is a term coined by The Joint Commission (TJC). It is the ongoing monitoring and evaluation (not to exceed every 12 months) of current competency and professional behavior in providers with granted privileges. OPPE is accomplished through peer review activities and the resulting information factors into decisions to maintain, revise, or revoke existing privileges. OPPE relies on qualitative and quantitative criteria to assess how a provider is performing in key areas. A well-designed OPPE process should be able to help identify performance issues that could negatively impact patient care. Other regulatory and/or accreditation organizations require periodic professional practice evaluation, instead of ongoing.

Organizations that require OPPE: The Joint Commission (TJC), the Accreditation Association for Ambulatory Health Care (AAAHC), and the Accreditation Commission for Health Care (ACHC).

Organizations that might require PPE:

Centers for Medicare and Medicaid Services (CMS) and the Det Norske Veritas (DNV).

OPPE or PPPE = Decisions must be made

Regardless of your organization's size or type, there are certain decisions that need to be made, as a whole, to ensure requirements are met.


  • Identify the performance/competency metrics (quantitative and qualitative) for each specialty and/or provider type to be tracked and obtain approval from the Medical Staff. Additionally, organizations must ensure that the patient data to support the metrics is available.
  • Set thresholds/organizational targets (as applicable) for each of the metrics selected.
  • Determine who will be responsible for obtaining and managing both the data and the evaluation processes.
  • Determine evaluation timeframes.

With these decisions made, your organization will have the information necessary to create a repeatable, reliable, and actionable process to enable OPPE or PPPE. Of course, there are a number of ways to set up these processes within your organization, which is why HealthStream has a few tried and true best practices we recommend to all organizations.


Best Practices

OPPE and PPPE can offer the most effective programs within the medical staff services department to make a significant impact on quality. To realize their full potential, we must make concerted efforts to move our evaluation programs forward through standardization and optimization, and that starts with the following best practices:


  • Metrics should correlate with the clinical privileges granted to the providers.
  • Use General Competencies (Patient Care, Medical/Clinical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and Systems-Based Practice) as a framework for the PPE process.
  • Perform evaluation of providers’ data according to the timeframe determined and required by the applicable accreditation organization(s).
  • For health systems with multiple facilities, standardize the performance metrics and evaluation timeframes across all facilities within the organization, as much as possible. The standardization should be aligned with how privileges are being standardized.
  • Establish the process for end-user(s) in the Medical Staff Office (MSO) and/or Quality Department to audit the performance metrics reports and identify red flags, prior to sending reports to the clinical reviewer(s) for review and recommendation.
  • Establish the process for incorporating the performance metrics/reviews into the providers’ evaluation for renewal of privileges at reappointment.

There are many i’s to dot and t’s to cross to ensure OPPE and PPPE are 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.


How CredentialStream can help

CredentialStream’s Evaluate is designed to support OPPE and PPPE by helping organizations track and trend performance data using configurable content templates and metrics. Using Evaluate’s Performance Metrics, organizations establish and monitor the data that is collected on either an ongoing or periodic basis, for the purpose of assessing the provider’s clinical competence and professional behavior and incorporating these factors into privileging decisions.

In very broad terms, CredentialStream enables users to:


  • Adopt performance metrics reports and templates
  • Establish a review process
  • Automate schedules
  • Audit reports
  • Complete provider reviews
  • Incorporate performance metrics reports and reviews into the provider’s reappointment process

Ongoing or Periodic Professional Practice Evaluation programs provide evidence that the medical staff has made a commitment to providing safe, efficient, effective, equitable, and patient-centered care in today's complex healthcare environment. It is through provider-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. With Evaluate, you get the process, content, and data needed to support peer review and Ongoing or Periodic Professional Practice Evaluation and the insight required to improve patient care while in compliance with regulations. Learn all about Evaluate here.

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