Professional Documents
Culture Documents
Advanced Practice PDF
Advanced Practice PDF
ABSTRACT
The Ongoing Professional Performance Evaluation and the Focused Professional Practice Evaluation have
been required by The Joint Commission for providers, including advanced practice registered nurses, who
are credentialed and privileged in an accredited hospital. There are 6 required domains for these evaluations.
The objective of these evaluations is to monitor for competence in the credentialing and privileging process
for hospitals. The 6 domains come from medical education competencies. Nursing must develop a set of
competencies to measure the performance of advanced practice registered nurses or continue to be measured
by physician metrics.
Sharon L. Holley, DNP, CNM, is an assistant professor teaching midwifery at the Vanderbilt University School of Nursing in
Nashville, TN. She also currently serves as director for the Vanderbilt School of Nursing Faculty Nurse-Midwife Practice. She can be
reached at sharon.holley@vanderbilt.edu. In compliance with national ethical guidelines, the author reports no relationships with
business or industry that would pose a conflict of interest.
I n 2014, the American Association of Nurse setting, most see patients in the ambulatory setting
Practitioners estimated there were > 205,000 and are credentialed to see their patients who are
nurse practitioners (NPs) in the United States. hospitalized. NPs are 1 of the 4 types of advanced
Of that number, 44.8% hold hospital privileges.1 practice registered nurses (APRNs). The American
This CE learning activity is designed to augment the knowledge, skills, and attitudes of nurse practitioners and assist in understanding performance evaluations of APRNs.
At the conclusion of this activity, the participant will be able to:
A. Describe the purpose of the Ongoing Professional Performance Evaluation (OPPE)/Focused Professional Practice Evaluation (FPPE)
B. List 6 domains used for competency evaluation in OPPE/FPPE and medical education
C. Compare/contrast competency requirements for PAs with APNs
The authors, reviewers, editors, and nurse planners all report no financial relationships that would pose a conflict of interest.
The authors do not present any off-label or non-FDA-approved recommendations for treatment.
This activity has been awarded 1.0 Contact Hours of which 0 credits are in the area of Pharmacology. The activity is valid for CE credit until March 1, 2018.
Readers may receive the 1.0 CE credit for $5 by reading the article and answering each question online at www.npjournal.org, or they may mail the test answers and
evaluation, along with a processing fee check for $10 made out to Elsevier, to PO Box 1461, American Fork, UT 84003. Required minimum passing score is 70%.
NPAÔ is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
Accreditation does not imply endorsement by the provider, Elsevier, or ANCC of recommendations or any commercial products displayed or discussed in conjunction with
the educational activity.
68 The Journal for Nurse Practitioners - JNP Volume 12, Issue 2, February 2016
valid, and standardized.13 The OPPE and FPPE both applicants as well as all new privileges for existing
meet the goals set by these organizations by practitioners. There is no exemption for board certi-
standardizing the format in which data should be fication, documented experience, or reputation.14
collected and reported, as well as utilization of that There are 3 distinct reasons for the FPPE:
data to evaluate the provision of quality patient care. 1. Newly hired providers are evaluated using the
Prior to the last half of the 20th century, individual FPPE template after the first 6 months of
provider competency was evaluated through educa- employment so that their competence is
tion and board certification. Physicians functioned as assured after adequate time for orientation.
contractors to a hospital where they treated patients. 2. Currently credentialed providers who are
However, after a landmark case in 1965, a hospital requesting a new privilege, such as an advanced
could be held liable for the actions of a physician as an skill not typically covered with board certifi-
employee of that hospital. After this, hospitals began cation, yet still within the scope of practice of
to implement verification of individual competency. that specialty.
This was accomplished by setting up processes that 3. Whenever a question arises regarding a practi-
utilized references, educational training, and certifi- tioner’s ability to provide safe, high-quality
cation.6 However, what was not included in this patient care or identification of unprofessional
process for competency assessment was a quality behavior.
and safety component. Realizing this need, The
Joint Commission began requiring the OPPE and Privileging
FPPE to help determine that the care provided by Privileging is the process whereby health care organi-
credentialed and privileged providers meets acceptable zations, including hospitals, authorize providers to offer
performance, quality, and safety standards.5,14 specific services to their patients.16 The specific scope
and content of patient care services, or clinical privileges,
DEFINITIONS are authorized for a health care practitioner to perform
OPPE within a hospital. Privileging is based on evaluation of
The OPPE is a document summary of ongoing data the individual’s credentials and performance.15
collected for the purpose of assessing a practitioner’s
clinical competence and professional behavior. The Credentialing
information collected during this process is factored Credentialing is the process of obtaining, verifying,
into decisions to maintain, revise, or revoke newly and assessing the qualifications of a provider per-
requested or existing privilege(s) before or at the end forming patient care or services within, or for, a health
of the 2-year license and privilege-renewal cycle. care organization. Credentials include documented
The intent for the OPPE is that the organization evidence of licensure, education, training, experience,
examine data on performance for all practitioners or other qualifications. Examples of credentials are a
with privileges on an ongoing basis, rather than at the certificate, letter, or experience that qualifies an indi-
2-year reappointment process. Performing the addi- vidual to do something. A credential may be a letter,
tional OPPE/FPPE verification of data allows a badge, or other official identification that confirms a
hospital to take timely action, if needed, to improve person’s position or status. A hospital, or health care
performance.15 The OPPE also allows verification organization, obtains primary source verification of the
that a provider is delivering competent quality patient licensed independent practitioner’s education, training,
care with professional behavior. certificates, and licensure from the primary source, and
maintains the file of information.17 Credentialing is
FPPE typically renewed every 2 years.
The FPPE is a time-limited evaluation of practitioner
competence in performing newly requested specific REQUIRED DOMAINS FOR EVALUATION
privileges. The intent is for the organization to have a The Accreditation Council for Medical Education
focused review for all new privileges of new (ACGME) is the accrediting body for graduate
Joint Practitioners Practitioners Practitioners Practitioners are Practitioners are Practitioners are
Commission are expected to are expected to are expected to expected to expected to expected to
provide patient demonstrate be able to use demonstrate demonstrate demonstrate both
care that is knowledge of scientific interpersonal and behaviors that an understanding
compassionate, established and evidence and communication reflect a of the contexts
appropriate, evolving methods to skills that enable commitment to and systems in
and effective for biomedical, investigate, them to establish continuous which health care
the promotion clinical and evaluate and and maintain professional is provided, and
of health, social sciences, improve patient professional development, the ability to apply
prevention of and the care practices relationships with ethical practice, this knowledge to
illness, application of patients, families, an understanding improve and
treatment of their knowledge and other members and sensitivity to optimize health
disease, and to patient care of health care teams diversityb and a care
care at the end and the responsible
of life education of attitude toward
others their patients,
their profession
and society
ABMS ¼ American Board of Medical Specialties; ACGME ¼ Accreditation Council for Medical Education; FPPE ¼ Focused Professional Practice Evaluation; OPPE ¼ Ongoing
Professional Performance Evaluation.
a
Six Core Competencies for medical education identified by ACGME and American Board of Medical Specialties (AMBS).14
b
Six Core Competencies for The Joint Commission.15
medical education. ACGME determines and enforces using them in 1999.18 These domains are: (1) patient
standards for residency and fellowship training pro- care; (2) medical and clinical knowledge; (3) practice-
grams. The American Board of Medical Specialties based learning and improvement; (4) interpersonal
is an organization of approved medical specialties and communication skills; (5) professionalism; and
responsible for board certification of physicians in (6) systems-based practice.14 The American Board
those specialties. ACGME first described 6 domains of Medical Specialties then began using these same 6
for clinical competency for physicians and began domains as a framework for initial board certification
70 The Journal for Nurse Practitioners - JNP Volume 12, Issue 2, February 2016
and maintenance. The next step in this evolving organizations worked together to answer this
process is ongoing work by ACGME with the dilemma by developing a self-assessment titled the
newer Next Accreditation System that will begin “Physician Assistant Competencies: A Self-evaluation
to link improved performance in clinical practice Tool.” This tool is focused on their own professional
by physicians, as well as practice outcomes over competency within each of the 6 domains while also
their career in practice.19 In this effort, The Joint used to self-identify areas they need to strengthen
Commission incorporated those same 6 domains for through some type of continuing educational
evaluation of competency into the OPPE and FPPE opportunity. This self-evaluation is part of a larger
(see Table). Originally, the OPPE and FPPE were demonstration of continuing competency that
interpreted for physicians, but in 2011 The Joint includes maintaining board certification, continuing
Commission made it clear these evaluations are education, as well as quality improvement projects
required for all providers credentialed and privileged. meant to improve patient care.20
The OPPE/FPPE are now required for APRNs, CNMs/CMs. CNM/CMs are certified by the
CNM/CMs, and PAs as well.5,7,8,15 American Midwifery Certification Board (AMCB),
which is a national board that certifies graduates from
ADVANCED PRACTICE PROVIDERS nurse-midwifery and midwifery programs accredited
Nonphysician Provider Competencies by the Accreditation Commission for Midwifery
PAs, CNMs/CMs, CRNAs, and other APRNs are Education (ACME). The American College of
all required by The Joint Commission to be evaluated Nurse-Midwives (ACNM) is the professional
more often than once per year using the OPPE organization that represents CNM/CMs. The
formula of 6 domains that were originally created as AMCB, ACME, and ACNM utilize the Core
an assessment for medical education of physicians. Competencies for Midwifery Practice as the basis for
Each of these nonphysician advanced practice spe- what comprises competent midwifery practice. The
cialties has their own certifying body and board competencies include:
certification process, only one of which are based on 1. The Hallmarks of Midwifery.
these 6 domains. This creates a challenge to try to 2. Components of Midwifery Care: Professional
find methods that adequately assess individual per- Responsibilities of CNMs and CMs.
formance and scope of practice competency of 3. Components of Midwifery Care: Midwifery
nonphysician providers. Management Process.
PAs. The Physician Assistant Education Associ- 4. Components of Midwifery Care:
ation, National Commission on Certification of Fundamentals.
Physician Assistants, Accreditation Review Com- 5. Components of Midwifery Care of Women.
mission on Education for Physician Assistant, and the 6. Components of Midwifery Care of the
American Academy of Physician Assistants described Newborn.22
the importance of maintaining professional compe- These competencies can be expanded to advanced
tence through continuous professional development. skills, but the core competencies are seen as the basic
These organizations define competence as application knowledge, skills, and behaviors expected for any
of specialized knowledge. The PA profession adopted new CNM/CM. The core competencies were
the same 6 domains in 2005 for competency that was initially adopted by the ACNM in 2002.23
originally developed by the ACGME.20,21 Although In 1986, the ACNM developed the Continuing
position papers by the American Academy of Competency Assessment program as a voluntary
Physician Assistants indicate agreement with other way to demonstrate continuing competency. The
medical organizations on the terminology and Continuing Competency Assessment program was
definitions of what these 6 domains are, they note the discontinued in 2010 and continuing competence is
caveat that PAs are not physicians and therefore this now maintained through the AMCB’s Certification
model of competency assessment “should be carefully Maintenance Program.20 Competency is now
applied to the PA profession.”20(p5) These same 4 determined by maintenance of board certification,
72 The Journal for Nurse Practitioners - JNP Volume 12, Issue 2, February 2016
Challenges appropriate. This is why, ideally, some of the data
Although the OPPE/FPPE process was required by should have measureable objectives that can be
The Joint Commission starting in 2008, before 2011 also compared with other providers doing similar
only physicians on medical staff were required to work. For example, are the outcomes with a certain
complete the OPPE/FPPE process, whereas non- procedure within the accepted norms for local, or
physician providers were allowed to have alternative national benchmarking results? Are readmission
methods for credentialing and privileging. However, rates or infection rates at acceptable levels when
after the 2011 release of the OPPE/FPPE Boos- compared with guidelines? If they are not, this may
terPak, all APRNs and PAs who provide “medical be because the results are stellar, or it may indicate
level of care” must use the same medical staff process they are suboptimal. In the latter case, a closer look
for credentialing and privileging as physicians.15 Only may reveal a trigger for an FPPE for a particular
those APRNs and PAs who are not providing medical provider who needs re-education on technique or
level of care are allowed to use an alternative pathway instruction on when to offer or not offer a proce-
for these processes. This means all APRNs and PAs dure. The OPPE is required to be completed more
who seek to provide patient care in these hospitals often than once a year to quickly identify triggers,
undergo a credentialing process similar to that of or concerns, that can be addressed and corrected in
physicians and are granted privileges through the a timelier manner than once every 2 years, as with
authority granted to the medical staff through the previous credentialing methods. If concerns are
board of directors.30 Therefore, most hospitals have serious, an FPPE may be indicated on the individual
opted to use the same method of OPPE and FPPE trigger while maintaining the rest of the OPPE
for physicians as well as APRNs and PAs. This cycle. Analysis of the data gives meaning to what is
necessitates an understanding of what both OPPE being accumulated and reported. Ideally, the indi-
and FPPE measure and how it is applicable to vidual provider will be able to see the results of this
nonphysicians, including ARPNs. analysis and have an opportunity to respond with
Often data that could be collected to inform the more positive results.
OPPE/FPPE, such as the specific number of times The field of APN must continue to develop
certain procedures are performed or documented core competencies that APRN competency can be
patient encounters performed, are billed and measured against. Nursing lags behind medicine, and
accounted for under the physician the APRN or PA PA’s, on identifying competency domains to measure
is working for. This can make it hard to separate out against. Therefore advanced practice nurses find
the work each individual has done and the quality of themselves being evaluated with six domains origi-
work performed. The creation of metrics that are nally constructed to measure physician education
identifiable down to the individual provider are and clinical performance. As noted earlier, there is
needed. Some data may be able to be identified for an ongoing global nursing initiative to develop
units that track statistics, or some may find they have standardized general nursing competencies, but this
to track their own data for documentation that sup- has yet to be adopted either nationally or interna-
ports the competency being maintained. For tionally. APRNs may have the same or differing
example, if a specific skill is performed, the individual needs for identified competencies as general nursing,
may need to create a method to track these en- but this also needs to be identified. If nursing does
counters and outcomes that may otherwise show up not continue to move this work forward, the 6
under the data for the physician they work with. domains will remain in place and the unique qualities
Objectively demonstrating ongoing competency of what makes APN unique from physician practice
requires access and analysis to data that is mean- will not be evaluated for the purposes of quality
ingful. Noting only numbers of times something improvement, competency assessment, or decisions
is done is not the same as measuring the quality made in relation to credentialing and privileging.
of care performed or following through on out- To this point, nursing organizations have remained
comes to see that the care delivered was indeed silent on this issue.
education and certification, allows for flexibility with WorkArea/DownloadAsset.aspx?id¼3104. Accessed July 16, 2015.
22. American College of Nurse Midwives. Core competencies for basic midwifery
regard to what data to include in the monitoring practice. Washington DC. 2012. http://www.midwife.org/ACNM/files/
ccLibraryFiles/Filename/000000002730/Core%20Competencies%20June
process. APRN educational, certifying, and profes- %202012.pdf. Accessed July 17, 2015.
23. American College of Nurse-Midwives. Continuing competency assessment.
sional organizations must work toward fully devel- Silver Spring, MD. [n.d]. http://www.midwife.org/Continuing-Competency-
oping a robust set of competencies. Otherwise, Assessment. Accessed July 17, 2015.
24. American Midwifery Certification Board. Certificate maintenance program.
APRNs will continue to be evaluated using a metric Linthicum, MD. 2013. http://www.amcbmidwife.org/certificate-maintenance
-program/objectives. Accessed July 17, 2015.
originally designed for evaluating physicians. 25. National Board of Certification & Recertification for Nurse Anesthetists.
Background and history of the CPC program. Chicago, IL. 2015. http://www.
References nbcrna.com/cpc/Pages/Background-and-History.aspx. Accessed July 17, 2015.
26. Melnyk BM, Gallagher-Ford L, Long LE, Fineout-Overholt E. The
1. American Association of Nurse Practitioners. NP fact sheet. 2015. http:// establishment of evidenced-based practice competencies for practicing
www.aanp.org/all-about-nps/np-fact-sheet. Accessed July 30, 2015. registered nurses and advanced practice nurses in real-world clinical settings:
2. American College of Nurse-Midwives. Essential facts about midwives. 2015. Proficiencies to improve healthcare quality, reliability, patient outcomes, and
http://www.midwife.org/Essential-Facts-about-Midwives. Accessed August cost. Worldviews Evid Based Nur. 2014;11(1):5-15.
16, 2015. 27. APRN Clinical Task Force. Current state of APRN clinical education [White
3. American Association of Nurse Anesthetists. Who are we. 2015. http:// Paper]. 2013. http://www.aacn.nche.edu/APRN-White-Paper.pdf. Accessed
www.aana.com/aboutus/Pages/Who-We-Are.aspx. Accessed August 16, 2015. July 12, 2015.
4. Brassard A, Smolenski, M. Removing barriers to Advanced Practice Registered 28. Summers, L. Interprofessional task force tackles barriers to clinical training.
Nurse Care: Hospital Privileges. Insight on the Issues, 55. 2011. http:// Am Nurse. 2015. http://www.theamericannurse.org/index.php/2015/03/01/
campaignforaction.org/sites/default/files/RemovingBarriers-HospitalPrivileges interprofessional-task-force-tackles-barriers-to-clinical-training/. Accessed
.pdf. Accessed August 16, 2015. July 12, 2015.
5. Wise RA. OPPE and FPPE: Tools to help make privileging decisions. [Web log 29. APRN Consensus Work Group, & National Council of State Boards of Nursing
comment]. 2013. http://www.jointcommission.org/jc_physician_blog/oppe_ APRN Advisory Committee. Consensus model for APRN regulation: licensure,
fppe_tools_privileging_decisions/. Accessed August 21, 2013. accreditation, certification & education. 2008. http://www.aacn.nche.edu/
6. Hunt JL. Assessing physician competency: An update on The Joint education-resources/APRNReport.pdf. Accessed July 17, 2015.
Commission requirement for ongoing and focused professional practice 30. Kleinpell RM, Hudspeth R, Scordo KA, Magdic K. Defining NP scope of
evaluation. Adv Anat Pathol. 2012;19:388-400. practice and associated regulations: Focus on acute care. J Am Acad Nurse
7. Ziaya, P. Using OPPE as a performance improvement tool. [Web log Pract. 2012;24(1):11-18.
comment]. 2014. http://www.jointcommission.org/jc_physician_blog/using
_oppe_as_a_performance_improvement_tool/. Accessed February 5, 2014.
8. Holley SL, Ketel C. Ongoing Professional Practice Evaluation (OPPE) &
Focused Professional Practice Evaluation (FPPE): understanding the process 1555-4155/15/$ see front matter
from an advanced practice viewpoint. J Midwifery Women’s Health. © 2016 Elsevier, Inc. All rights reserved.
2014;59(4):453-459. http://dx.doi.org/10.1016/j.nurpra.2015.08.037
74 The Journal for Nurse Practitioners - JNP Volume 12, Issue 2, February 2016