Radiology Peer Review

In 2008, The Joint Commission (TJC) implemented a new standard mandating detailed evaluation of practitioners’ professional performance as part of the process of granting and maintaining practice privileges within healthcare organizations.

Ongoing Professional Practice Evaluation (OPPE) is intended as a means of evaluating professional performance on an ongoing basis for three reasons:

  • as part of the effort to monitor professional competency;
  • to identify areas for possible performance improvement by individual practitioners; and
  • to use objective data in decisions regarding continuance of practice privileges.

Once a provider has achieved practice privileges in a health care organization, TJC requires that performance data be collected with evaluation of the provider conducted more than once per year. Evaluations that are conducted annually (or less frequently) are considered by TJC as periodic not ongoing.

To comply with this requirement Argus Radiology utilizes provider evaluation metrics, which provides options for entry of providers’ OPPE performance data every month, three months or six months.

Focused Professional Practice Evaluation (FPPE) involves more specific and time-limited monitoring of a provider’s practice performance in three situations when:

  • a provider is initially granted practice privileges;
  • new privileges are requested for an already privileged provider; and
  • performance non-conformance involving a privileged provider is identified (through the OPPE process or by any other means such as complaints or significant departure from accepted practice.)

TJC does not specify the length for a time period of FPPE. Therefore, each facility may choose the period of time for each FPPE episode. However, the FPPE process should be:

  • clearly defined and documented with specific criteria and a monitoring plan;
  • of fixed duration; and
  • predetermined measures or conditions for acceptable performance.