7 Tips for Making Sure Your OPPE Program Passes a Joint Commission Survey

What surveyors are actually looking for — and what zero-deficiency programs do differently. Essential reading for hospital executives, MECs, and the Medical Staff Services and Quality Management professionals who own OPPE.

The Ongoing Professional Practice Evaluation (OPPE) requirement isn't new — but it remains one of the areas where hospitals get tripped up during Joint Commission surveys. Not because organizations aren't doing OPPE, but because they can't demonstrate it the way surveyors need to see it.

After years working in credentialing and privileging at the federal level, including overseeing OPPE for over 1,700 physicians and nearly 3,000 clinicians across 39 clinical service lines at VA Puget Sound — with zero findings across seven Joint Commission surveys — I've seen what works and what gets flagged. Here's what you need to know.

Tip 1: Treat Your MEC Minutes as Evidence

The Medical Executive Committee (MEC) is where OPPE oversight needs to be formally documented. Surveyors will pull those minutes. They are looking for two things: that OPPE data is being routinely reviewed, and that the organization is making decisions about outliers based on that data.

Vague language like "OPPE was discussed" won't cut it. Minutes should reflect which service lines presented, what the data showed, and what action — if any — was taken regarding practitioners who fell outside expected thresholds. If no outliers exist in a given cycle, document that too.

Tip 2: Build a Rotation That Proves Continuous Review

One of the most common OPPE survey deficiencies is the inability to demonstrate continuous performance monitoring. TJC doesn't want a snapshot. They want an ongoing process.

At VA Puget Sound, we solved this with a structured rotation across all 39 clinical service lines. Service lines were grouped into cohorts and rotated quarterly — Cardiology and General Surgery presenting in January, April, July, and October; Dental, Urology, and Mental Health in February, May, August, and November; and so on. Every quarter, multiple departments were reporting out.

This model gives you something critical: a paper trail proving that every service line's OPPE data is being reviewed at least three to four times per year on a predictable schedule. Surveyors can see the rotation. They can see it has been maintained. That is what "continuous review" looks like in practice.

Tip 3: Privileging and OPPE Must Feed Each Other

OPPE indicators don't exist in a vacuum. They should be directly tied to the privileges a practitioner holds — and when those privileges change, OPPE must change with them.

This is especially important for procedure-specific privileges. If a surgeon is granted privileges for a new minimally invasive technique, your OPPE indicators need to reflect that. Volume, outcomes, and complication rates for that specific procedure should appear in their ongoing monitoring. Surveyors will ask.

Make it a standard workflow: every time a new privilege is approved, someone in Medical Staff Services should be asking, "Do we have an OPPE indicator for this?" If not, one needs to be built before that privilege is activated.

Tip 4: Allied Health Professionals Require a Different Lens

OPPE for Allied Health Professionals follows the same conceptual framework as physicians, but the implementation is different. The scope of privileges for AHPs is typically more defined and limited, and evaluation criteria need to reflect that scope. Supervision requirements, collaborative practice agreements, and scope-of-practice documentation all intersect with OPPE for this population.

Don't apply a physician-focused OPPE template directly to AHPs without adjustment. Surveyors know the difference.

Tip 5: Know Which Other TJC Standards Feed Into OPPE

This is where many Medical Staff offices leave points on the table: OPPE doesn't operate in a silo. Several other TJC standards feed directly into — and will be evaluated alongside — OPPE during a survey.

Quality department data, patient safety indicators, peer review outcomes, and department-level quality improvement initiatives can all be relevant to a surveyor assessing OPPE. The closer your working relationship with your Quality department and your Chief of Staff's office, the better positioned you are when a surveyor starts connecting dots across standards.

Take the time to understand which other standards overlap with your OPPE program. You don't need to be an expert in all of them, but you need to know where they intersect with what you're responsible for.

Tip 6: New Services Mean New OPPE Obligations — From Day One

If your hospital has opened a new ICU, launched a new procedural service, or begun providing any new clinical service involving credentialed practitioners, expect surveyors to ask how you are monitoring quality and performance in that new context.

OPPE is often the first place they look when Medical Staff is involved. "We just opened this unit six months ago" is not a sufficient answer. If practitioners are exercising privileges there, OPPE indicators should already be developed and in use. The data set may still be maturing, but the framework, the indicators, and the documentation should be operational from day one.

Tip 7: Track, Monitor, and Document Everything — Continuously

If there is one principle that runs through every TJC standard, it is this: demonstrate continuous performance improvement. Surveyors are looking for evidence that your organization has the systems to find problems, respond to them, and continuously improve. Your OPPE program is one of the clearest windows into whether that culture exists at the practitioner level.

Keep the documentation tight. Keep the rotation consistent. Keep privileging and indicators synchronized. And make sure the people who will be in the room with a surveyor — department chairs, the CMO, Medical Staff leadership — can speak fluently about how the program works.

The Bottom Line

OPPE done well is not a compliance exercise. It is a real-time picture of practitioner performance across your organization. The hospitals that perform best under survey have built systems that make the data visible, the review consistent, and the documentation unassailable — not just for surveyors, but because it makes patient care better.

If you have questions about structuring your OPPE program, preparing for a TJC survey, or building the documentation infrastructure to support both, this is exactly the kind of work I do.

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Claudia M. Rausch

15 years of federal and institutional healthcare policy experience — available to hospitals, medical executive committees, medical staff services offices, and legal counsel navigating credentialing, privileging, and NPDB compliance. Engagements are strictly confidential.

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