Ongoing Professional Practice Evaluation

In my last column, we took an evidence-based look at the role of Morbidity & Mortality (M&M) conferences in quality improvement and here will briefly examine the potential contribution of Ongoing Professional Practice Evaluation (OPPE). To improve quality, your OPPE data would need to be used as part of a QI process. So the real question is whether you are doing that.

OPPE is a Joint Commission requirement that was intended to assure that provider performance is monitored during the 2 year interval from credentialing to re-credentialing. OPPE focuses on clinical competence. Most organizations have finessed it 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 easily meet the requirement and do nothing to improve quality.

In spirit, OPPE could also be viewed as encouragement for aggregation and analysis of clinical performance data. Data aggregation and analysis can be a valuable activity in support of quality improvement from two angles: feedback and issue identification.


Feedback can be very effective to facilitate self-correcting activity when the data are 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 goals, however, providers are likely to just say, “Interesting, but why are you wasting my time with this?”

Issue Identification

You can also 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 with the biggest payback potential are more likely to be at the group level than at the individual provider 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 QI process so that they can be effectively resourced and managed for implementation – and we know that implementation typically poses the greatest challenge to success.

Contribution of Clinical Peer Review

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

Coming Next: Clinical Peer Review Impact on Quality and Safety – Newest Findings

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Marc T. Edwards, MD, MBA

President & CEO

QA to QI

An AHRQ Listed Patient Safety Organization