Question:  We do Ongoing Professional Practice Evaluation. How is this process important to Quality Improvement?

Short Answer:  As important as you are willing to make it.


To improve Quality, your Ongoing Professional Practice Evaluation (OPPE) data would need to be used as part of a QI process. OPPE is a Joint Commission requirement. The requirement is intended to assure that provider performance is monitored during the 2 year interval from credentialing to re-credentialing. In essence, it is all about assuring clinical competence. Most organizations are managing this requirement by developing provider profiles based on administrative data sets (case volume, complications, core measures, resource use, etc.). If that’s all that your organization does, you can meet the requirement and accomplish nothing for quality improvement.

In spirit, however, OPPE can be viewed as a requirement that encourages the aggregation and analysis of clinical performance data. Data aggregation and analysis can be a valuable activity in support of quality improvement from 2 major angles: Feedback and Issue Identification.


Feedback can be very effective to facilitate self-correcting activity. The data need to be understandable and the performance goals clear. For example, if your OPPE provider profile includes performance benchmarks, it could be used to give performance feedback to clinicians. No self-respecting clinician likes to be below average. Without comparative benchmarks or norms, however, providers are likely to just say, “Interesting, but why are you wasting my time with this?”

Issue Identification

The other angle to improve quality is to analyze your OPPE data to identify improvement opportunities. Your success with this approach is somewhat dependent on the nature of your data and the sophistication of those who analyze it. The opportunities may be either at the group level or the individual provider level. Those with the biggest payback potential for correction are likely to be at the group level. Finding improvement opportunities is not of itself sufficient to improve quality. The findings and related recommendations from any such aggregate data analysis need to be connected to your organization’s Quality Improvement process so that they can be effectively resourced and managed for implementation. FYI: implementation is almost always the hardest part in generating improvement.

Contribution of Clinical Peer Review

Clinical peer review can contribute substantial performance data to the OPPE profile, but only if it is captured in the review process. Most programs fall short in this regard. My whitepaper Measuring Clinical Performance offers a general method for how to accomplish this.