Standards FAQ Details | Joint Commission
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Sunday 4:18 CST, February 7, 2016

Standards FAQ Details


Medical Staff (MS) (Critical Access Hospitals / Critical Access Hospitals)

Using Data from Outside Organizations to Accomplish the Ongoing Professional Practice Evaluation/Low Volume Practitioners
Current | March 23, 2010
Q. Can organizations use data from outside organizations in lieu of collecting their own data to accomplish the Ongoing Professional Practice Evaluation (OPPE)?  Can outside data be used for low volume practitioners?

A.  For practitioners who have been granted clinical privileges at an organization,  every organization must collect data for the ongoing professional practice evaluation (OPPE) related to performance within its own organization.  OPPE would not apply if the practitioner has membership only with no clinical privileges.  

Any information received from another organization can only be used as supplemental information and not in lieu of collecting organization specific data or evaluating performance within the organization.  

Prior to sharing such information between organizations, even with the practitioner’s consent, organizations should obtain legal advice on whether such sharing would affect the protections provided by any applicable State peer review statute.  

The OPPE standard will not fully address the issue of the low or no volume practitioner.  Organizations must collect data, even data showing zero performance.  At each review point, e.g. quarterly or every six months, the medical staff and governing body would use the data, however, limited, to determine whether to continue, limit, or revoke any existing privileges. 

At the two year reappointment if the organization determines it has insufficient practitioner specific data, then per standard MS.07.01.02 EP 2 "Upon renewal of privileges, when insufficient practitioner-specific data are available, the medical staff obtains and evaluates peer recommendations."