Question:

A surveyor from The Joint Commission is at our hospital and has stated that Ongoing Professional Practice Evaluation (“OPPE”) must be completed every six months.  Our policies specify that OPPE must be completed every nine months.  Is the surveyor right?  Help!

Answer:

The Joint Commission requires OPPE to be conducted on an ongoing basis.  Although the written standards and elements of performance do not specify an exact time frame for gathering and evaluating OPPE data, a 2008 “FAQ” on The Joint Commission website states that it is expected that OPPE reviews will occur more frequently than annually, preferably at least once every six months.

This FAQ was updated in March 2010 and states in part as follows:

Q.  What is the intent of the requirement for Ongoing Professional Practice Evaluation?

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2.  A clearly defined process would include but not be limited to:

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• how often the data will be reviewed. The frequency of such evaluation can be defined by the organized medical staff, e.g., three months, six months, nine months, etc.  However, as noted in the teleconferences during 2007, twelve months would be periodic rather than ongoing.

So clearly, six months is not a hard and fast rule, and the FAQ even stretches out to nine months.