CONTINUING EDUCATION
Ongoing Professional Performance
Evaluation: Advanced Practice
Registered Nurse Practice
Competency Assessment
Sharon L. Holley, DNP, CNM
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.
Keywords: APRN, competency, evaluation, FPPE, OPPE
Ó 2016 Elsevier, Inc. All rights reserved.
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.
INTRODUCTION
I
n 2014, the American Association of Nurse
Practitioners estimated there were > 205,000
nurse practitioners (NPs) in the United States.
Of that number, 44.8% hold hospital privileges.1
Although many NPs work full time in the hospital
setting, most see patients in the ambulatory setting
and are credentialed to see their patients who are
hospitalized. NPs are 1 of the 4 types of advanced
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%.
This educational activity is provided by Nurse Practitioner AlternativesÔ.
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.
www.npjournal.org
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67
College of Nurse-Midwives found that, as of 2015,
there are 11,018 certified nurse-midwives (CNMs)
and 88 certified midwives (CMs). Although there are
no specific numbers for hospital-credentialed CNM/
CMs, 95% of births attended by CNM/CMs occur in
the hospital setting.2 Certified registered nurses
(CRNAs) number around 48,000, with approximately
37% of them employed by hospitals and another
34% employed by an anesthesia group, with most
credentialed to provide patient services in the hospital
setting.3,4 Although not all 50 states recognize the
clinical nurse specialist (CNS) as an APRN role, the
list is growing. It is difficult to find exact numbers for
how many hold hospital privileges, but this too is
known to be increasing. To simplify terminology,
for the remainder of this report, the term APRN
is used to represent NP, CNM/CM, CRNA, and
the CNS designations. Herein I focus on those
who hold credentialing and privileging in hospitals
that are accredited by The Joint Commission and
the requirement for the Ongoing Professional
Performance Evaluation (OPPE) and the Focused
Professional Practice Evaluation (FPPE).
APRNs, and other nonphysician providers, are
now required to be evaluated based on criteria that
come from physician competencies, rather than
nursing competencies, for credentialing and privileging
decisions. The OPPE and FPPE have been required
since 2008 for all medical staff and providers who are
granted privileges in hospitals accredited by The Joint
Commission.5,6 These providers include not only
physicians but also physician assistants (PAs), APRNs,
including CNM/CMs, and CRNAs.6 The OPPE is a
screening tool used on an ongoing basis to assess the
competency of medical staff and providers. The
OPPE/FPPE is used to evaluate the care provided to
determine whether it meets accepted standards for
provision of quality care.5 The OPPE is also used
identify those who may benefit by learning from
the results of the OPPE measures and implement
performance improvement. If there is a new provider
to the system, or an identified area that needs
evaluation focus, then the FPPE is implemented to
examine specific measures.
Collecting meaningful data in a consistent and
ongoing approach provides feedback opportunities
for each provider so they may implement changes
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immediately to their practice when needed.7 The
ongoing evaluation process also affords the opportunity
for analysis and can be used for faster response for
quality improvement at the level of the individual
provider as well as a given set of providers in a specific
practice. This is now part of the decision-making
process when providers are reviewed for a new
request for credentialing or privileging or for renewal
of credentialing. The OPPE/FPPE is meant to be
more objective and continuous in its approach as
compared with older methods that were more subjective, such as letters of reference. The Joint Commission
has left the specific methods for data collection up to
the individual hospitals and departments.8 This newer
type of evaluation process has created some unique
challenges for APRNs to have informative OPPE/
FPPE collection methods that can show competency
for their particular specialty and practice setting.
BACKGROUND
The Institute of Medicine defines quality health care
as, “The degree to which health services for individuals and populations increase the likelihood of
desired health outcomes and are consistent with
current professional knowledge.”9 Since 1996, the
Institute of Medicine has initiated a succession of
reports focused on improving the quality of health
care in the United States. All these reports have
demonstrated how wide the gap is in relation to what
is known to be quality care versus what is delivered in
practice.10,11 The most recent report identifies 15
core metrics that stipulate benchmarks that will be
used to improve health care in the nation as a whole
as well as health care system performance. Two of
these areas are patient safety and provision of
evidenced-based care. Patient safety is a culture in
which the priority is on prevention of errors and
adverse effects through system performance
throughout the organization. Evidenced-based care
stresses the importance of using scientific evidence
appropriately in the delivery of health care.12
The Agency for Healthcare Research and Quality, devoted to improving patient outcomes, has
noted that quality measurement is a type of evaluation used in many industries and is now used
increasingly in health care. When developing a
quality measure the collection tool must be reliable,
Volume 12, Issue 2, February 2016
valid, and standardized.13 The OPPE and FPPE both
meet the goals set by these organizations by
standardizing the format in which data should be
collected and reported, as well as utilization of that
data to evaluate the provision of quality patient care.
Prior to the last half of the 20th century, individual
provider competency was evaluated through education and board certification. Physicians functioned as
contractors to a hospital where they treated patients.
However, after a landmark case in 1965, a hospital
could be held liable for the actions of a physician as an
employee of that hospital. After this, hospitals began
to implement verification of individual competency.
This was accomplished by setting up processes that
utilized references, educational training, and certification.6 However, what was not included in this
process for competency assessment was a quality
and safety component. Realizing this need, The
Joint Commission began requiring the OPPE and
FPPE to help determine that the care provided by
credentialed and privileged providers meets acceptable
performance, quality, and safety standards.5,14
DEFINITIONS
OPPE
The OPPE is a document summary of ongoing data
collected for the purpose of assessing a practitioner’s
clinical competence and professional behavior. The
information collected during this process is factored
into decisions to maintain, revise, or revoke newly
requested or existing privilege(s) before or at the end
of the 2-year license and privilege-renewal cycle.
The intent for the OPPE is that the organization
examine data on performance for all practitioners
with privileges on an ongoing basis, rather than at the
2-year reappointment process. Performing the additional OPPE/FPPE verification of data allows a
hospital to take timely action, if needed, to improve
performance.15 The OPPE also allows verification
that a provider is delivering competent quality patient
care with professional behavior.
FPPE
The FPPE is a time-limited evaluation of practitioner
competence in performing newly requested specific
privileges. The intent is for the organization to have a
focused review for all new privileges of new
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applicants as well as all new privileges for existing
practitioners. There is no exemption for board certification, documented experience, or reputation.14
There are 3 distinct reasons for the FPPE:
1. Newly hired providers are evaluated using the
FPPE template after the first 6 months of
employment so that their competence is
assured after adequate time for orientation.
2. Currently credentialed providers who are
requesting a new privilege, such as an advanced
skill not typically covered with board certification, yet still within the scope of practice of
that specialty.
3. Whenever a question arises regarding a practitioner’s ability to provide safe, high-quality
patient care or identification of unprofessional
behavior.
Privileging
Privileging is the process whereby health care organizations, including hospitals, authorize providers to offer
specific services to their patients.16 The specific scope
and content of patient care services, or clinical privileges,
are authorized for a health care practitioner to perform
within a hospital. Privileging is based on evaluation of
the individual’s credentials and performance.15
Credentialing
Credentialing is the process of obtaining, verifying,
and assessing the qualifications of a provider performing patient care or services within, or for, a health
care organization. Credentials include documented
evidence of licensure, education, training, experience,
or other qualifications. Examples of credentials are a
certificate, letter, or experience that qualifies an individual to do something. A credential may be a letter,
badge, or other official identification that confirms a
person’s position or status. A hospital, or health care
organization, obtains primary source verification of the
licensed independent practitioner’s education, training,
certificates, and licensure from the primary source, and
maintains the file of information.17 Credentialing is
typically renewed every 2 years.
REQUIRED DOMAINS FOR EVALUATION
The Accreditation Council for Medical Education
(ACGME) is the accrediting body for graduate
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69
Table. Comparison of ACGME With The Joint Commission’s 6 Domainsa
Medical
Knowledge
Practice-based
Learning and
Improvement
Interpersonal and
Communication
Skills
Provide care
that is
compassionate,
appropriate,
and effective
treatment for
health
problems and
to promote
health
Demonstrate
knowledge
about
established and
evolving
biomedical,
clinical, and
cognate
sciences and
their
application in
patient care
Show an ability
to investigate
and evaluate
patient care
practices,
appraise and
assimilate
scientific
evidence, and
improve the
practice of
medicine
Demonstrate skills
that result in
effective information
exchange and
teaming with
patients, their
families and
professional
associates (eg,
fostering a
therapeutic
relationship that is
ethically sound and
uses effective
listening skills with
nonverbal and
verbal
communication;
work as both a team
member and, at
times, as a leader)
Demonstrate a
commitment to
carrying out
professional
responsibilities,
adherence to
ethical principles,
and sensitivity to
diverse patient
populations
Demonstrate
awareness of and
responsibility to
the larger context
and systems of
health care; be
able to call on
system resources
to provide optimal
care (eg,
coordinating care
across sites or
serving as the
primary case
manager when
care involves
multiple
specialties,
professions, or
sites)
Joint
Practitioners
Commission are expected to
provide patient
care that is
compassionate,
appropriate,
and effective for
the promotion
of health,
prevention of
illness,
treatment of
disease, and
care at the end
of life
Practitioners
are expected to
demonstrate
knowledge of
established and
evolving
biomedical,
clinical and
social sciences,
and the
application of
their knowledge
to patient care
and the
education of
others
Practitioners
are expected to
be able to use
scientific
evidence and
methods to
investigate,
evaluate and
improve patient
care practices
Practitioners are
expected to
demonstrate
interpersonal and
communication
skills that enable
them to establish
and maintain
professional
relationships with
patients, families,
and other members
of health care teams
Practitioners are
expected to
demonstrate
behaviors that
reflect a
commitment to
continuous
professional
development,
ethical practice,
an understanding
and sensitivity to
diversityb and a
responsible
attitude toward
their patients,
their profession
and society
Practitioners are
expected to
demonstrate both
an understanding
of the contexts
and systems in
which health care
is provided, and
the ability to apply
this knowledge to
improve and
optimize health
care
Patient Care
ACGME
Professionalism
Systems-based
Practice
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
standards for residency and fellowship training programs. The American Board of Medical Specialties
is an organization of approved medical specialties
responsible for board certification of physicians in
those specialties. ACGME first described 6 domains
for clinical competency for physicians and began
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using them in 1999.18 These domains are: (1) patient
care; (2) medical and clinical knowledge; (3) practicebased learning and improvement; (4) interpersonal
and communication skills; (5) professionalism; and
(6) systems-based practice.14 The American Board
of Medical Specialties then began using these same 6
domains as a framework for initial board certification
Volume 12, Issue 2, February 2016
and maintenance. The next step in this evolving
process is ongoing work by ACGME with the
newer Next Accreditation System that will begin
to link improved performance in clinical practice
by physicians, as well as practice outcomes over
their career in practice.19 In this effort, The Joint
Commission incorporated those same 6 domains for
evaluation of competency into the OPPE and FPPE
(see Table). Originally, the OPPE and FPPE were
interpreted for physicians, but in 2011 The Joint
Commission made it clear these evaluations are
required for all providers credentialed and privileged.
The OPPE/FPPE are now required for APRNs,
CNM/CMs, and PAs as well.5,7,8,15
ADVANCED PRACTICE PROVIDERS
Nonphysician Provider Competencies
PAs, CNMs/CMs, CRNAs, and other APRNs are
all required by The Joint Commission to be evaluated
more often than once per year using the OPPE
formula of 6 domains that were originally created as
an assessment for medical education of physicians.
Each of these nonphysician advanced practice specialties has their own certifying body and board
certification process, only one of which are based on
these 6 domains. This creates a challenge to try to
find methods that adequately assess individual performance and scope of practice competency of
nonphysician providers.
PAs. The Physician Assistant Education Association, National Commission on Certification of
Physician Assistants, Accreditation Review Commission on Education for Physician Assistant, and the
American Academy of Physician Assistants described
the importance of maintaining professional competence through continuous professional development.
These organizations define competence as application
of specialized knowledge. The PA profession adopted
the same 6 domains in 2005 for competency that was
originally developed by the ACGME.20,21 Although
position papers by the American Academy of
Physician Assistants indicate agreement with other
medical organizations on the terminology and
definitions of what these 6 domains are, they note the
caveat that PAs are not physicians and therefore this
model of competency assessment “should be carefully
applied to the PA profession.”20(p5) These same 4
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organizations worked together to answer this
dilemma by developing a self-assessment titled the
“Physician Assistant Competencies: A Self-evaluation
Tool.” This tool is focused on their own professional
competency within each of the 6 domains while also
used to self-identify areas they need to strengthen
through some type of continuing educational
opportunity. This self-evaluation is part of a larger
demonstration of continuing competency that
includes maintaining board certification, continuing
education, as well as quality improvement projects
meant to improve patient care.20
CNMs/CMs. CNM/CMs are certified by the
American Midwifery Certification Board (AMCB),
which is a national board that certifies graduates from
nurse-midwifery and midwifery programs accredited
by the Accreditation Commission for Midwifery
Education (ACME). The American College of
Nurse-Midwives (ACNM) is the professional
organization that represents CNM/CMs. The
AMCB, ACME, and ACNM utilize the Core
Competencies for Midwifery Practice as the basis for
what comprises competent midwifery practice. The
competencies include:
1. The Hallmarks of Midwifery.
2. Components of Midwifery Care: Professional
Responsibilities of CNMs and CMs.
3. Components of Midwifery Care: Midwifery
Management Process.
4. Components of Midwifery Care:
Fundamentals.
5. Components of Midwifery Care of Women.
6. Components of Midwifery Care of the
Newborn.22
These competencies can be expanded to advanced
skills, but the core competencies are seen as the basic
knowledge, skills, and behaviors expected for any
new CNM/CM. The core competencies were
initially adopted by the ACNM in 2002.23
In 1986, the ACNM developed the Continuing
Competency Assessment program as a voluntary
way to demonstrate continuing competency. The
Continuing Competency Assessment program was
discontinued in 2010 and continuing competence is
now maintained through the AMCB’s Certification
Maintenance Program.20 Competency is now
determined by maintenance of board certification,
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71
20 hours of continuing education, and the option
to complete 3 modules or take a reexamination of
the certification exam within a 5-year cycle.24
CRNAs. CRNAs are initially certified by the
National Board of Certification and Recertification
for Nurse Anesthetists. In 1978, a recertification
process was established for verification of continued
competency. In 2011, the Board began work with
the American Association of Nurse Anesthetists to
redevelop the Continuing Professional Certification
program. This work has been ongoing with the
anticipated start date for the new changes taking
affect August 1, 2016. The Continuing Professional
Certification is an 8-year program made up of two
4-year cycles. Currently, the requirements include
maintaining board certification by recertifying, every
8 years, completion of 60 Class A (assessed) continuing
education units and 40 Class B (professional
development) continuing education units all in a
4-year cycle. There is also a voluntary set of core
modules that are based in 4 core areas and 1 module
should be completed in each core area within each
both of the 4-year cycles.25
APRNs. There has been some work to move
toward creating competencies for general nursing
practice as well as nursing education. An example is
the Quality and Safety Education for Nurses project,
a global nursing initiative that developed recommendations for nursing competencies in the
areas of: (1) patient-centered care; (2) teamwork
and collaboration; (3) evidenced-based practice;
(4) quality improvement; (5) safety; and (6) informatics.23
The National League for Nurses has created
competencies for nursing education for development
of nursing curriculum and continuing education.26
The Commission on Collegiate Nursing Education,
an accreditor for nursing education programs, the
American Association of Colleges of Nursing and the
American Nursing Association have recommended, in
a white paper on APRN practice, that clinical
education and assessment should be competencybased, although no specific competencies were
identified. The recommendation in the white paper
states the need to standardize core competencies and
assessment tools in nursing education programs for
educators to utilize similar evaluative approaches for
assessing competency with advanced practice nursing
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students.27,28 Ostensibly these competencies in
nursing education could also be used with board
certification and clinical evaluation in the working
environment. Some advanced practice nursing
specialties have already begun work on specialtyspecific competencies.
The Consensus Model for APRN Regulation:
Licensure, Accreditation, Certification and Education has defined an APRN as someone with national certification; preparation in health promotion
and assessment, diagnosis, and management of
patient problems, which includes prescribing of
nonpharmacologic and pharmacologic interventions,
providing direct patient care; and graduate-level
education in 1 of 4 recognized roles. These roles
include:
1. CRNA.
2. CNM.
3. CNS.
4. Certified Nurse Practitioner.29
Although the Consensus Model just described
does not define competencies, it does state that
educational programs must prepare graduates with
the nationally recognized ARPN core courses, role,
and population-focused competencies. The 3 core
courses are: (1) health assessment; (2) advanced
physiology/pathophysiology; and (3) advanced
pharmacology.
The National Organization of Nurse Practitioner
Faculties promotes NP education at the national and
international levels. The organization has developed
curriculum guidelines for NP educational programs
and competencies for entry-level NP as well as domains and core competencies for NP practice with
specific educational levels and specific population
focus. Their work has created a way to standardize
what the expectations are, but does not address how
to measure individual practice competency in the
same way the OPPE is designed to do.
Overall, all APRN organizations recommend
ongoing maintenance of competency in some form
or fashion using board certification, continuing education, completion of various assigned modules for
learning, or other requirements, such as a specified
number of clinical hours in the specialty. However,
each APRN specialty has its own requirements that
must be met and kept updated.
Volume 12, Issue 2, February 2016
Challenges
Although the OPPE/FPPE process was required by
The Joint Commission starting in 2008, before 2011
only physicians on medical staff were required to
complete the OPPE/FPPE process, whereas nonphysician providers were allowed to have alternative
methods for credentialing and privileging. However,
after the 2011 release of the OPPE/FPPE BoosterPak, all APRNs and PAs who provide “medical
level of care” must use the same medical staff process
for credentialing and privileging as physicians.15 Only
those APRNs and PAs who are not providing medical
level of care are allowed to use an alternative pathway
for these processes. This means all APRNs and PAs
who seek to provide patient care in these hospitals
undergo a credentialing process similar to that of
physicians and are granted privileges through the
authority granted to the medical staff through the
board of directors.30 Therefore, most hospitals have
opted to use the same method of OPPE and FPPE
for physicians as well as APRNs and PAs. This
necessitates an understanding of what both OPPE
and FPPE measure and how it is applicable to
nonphysicians, including ARPNs.
Often data that could be collected to inform the
OPPE/FPPE, such as the specific number of times
certain procedures are performed or documented
patient encounters performed, are billed and
accounted for under the physician the APRN or PA
is working for. This can make it hard to separate out
the work each individual has done and the quality of
work performed. The creation of metrics that are
identifiable down to the individual provider are
needed. Some data may be able to be identified for
units that track statistics, or some may find they have
to track their own data for documentation that supports the competency being maintained. For
example, if a specific skill is performed, the individual
may need to create a method to track these encounters and outcomes that may otherwise show up
under the data for the physician they work with.
Objectively demonstrating ongoing competency
requires access and analysis to data that is meaningful. Noting only numbers of times something
is done is not the same as measuring the quality
of care performed or following through on outcomes to see that the care delivered was indeed
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appropriate. This is why, ideally, some of the data
should have measureable objectives that can be
also compared with other providers doing similar
work. For example, are the outcomes with a certain
procedure within the accepted norms for local, or
national benchmarking results? Are readmission
rates or infection rates at acceptable levels when
compared with guidelines? If they are not, this may
be because the results are stellar, or it may indicate
they are suboptimal. In the latter case, a closer look
may reveal a trigger for an FPPE for a particular
provider who needs re-education on technique or
instruction on when to offer or not offer a procedure. The OPPE is required to be completed more
often than once a year to quickly identify triggers,
or concerns, that can be addressed and corrected in
a timelier manner than once every 2 years, as with
previous credentialing methods. If concerns are
serious, an FPPE may be indicated on the individual
trigger while maintaining the rest of the OPPE
cycle. Analysis of the data gives meaning to what is
being accumulated and reported. Ideally, the individual provider will be able to see the results of this
analysis and have an opportunity to respond with
more positive results.
The field of APN must continue to develop
core competencies that APRN competency can be
measured against. Nursing lags behind medicine, and
PA’s, on identifying competency domains to measure
against. Therefore advanced practice nurses find
themselves being evaluated with six domains originally constructed to measure physician education
and clinical performance. As noted earlier, there is
an ongoing global nursing initiative to develop
standardized general nursing competencies, but this
has yet to be adopted either nationally or internationally. APRNs may have the same or differing
needs for identified competencies as general nursing,
but this also needs to be identified. If nursing does
not continue to move this work forward, the 6
domains will remain in place and the unique qualities
of what makes APN unique from physician practice
will not be evaluated for the purposes of quality
improvement, competency assessment, or decisions
made in relation to credentialing and privileging.
To this point, nursing organizations have remained
silent on this issue.
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73
Obtaining Data for the OPPE/FPPE
Demonstrating competency through the OPPE/
FPPE process requires a mechanism for collection of
data that drills down to the individual provider as
well as having comparative data when appropriate.
Data collected and analyzed can be used to fit within
the required 6 domains identified by The Joint
Commission.
CONCLUSION
The Joint Commission has required the OPPE and
FPPE processes for all credentialed and privileged
providers in hospitals they accredit. This process is
mandatory for any physician, PA, APRN, CNM/
CM, or CRNA who provides medical-level patient
care. The OPPE is an ongoing evaluation process that
monitors for continuing competence by using both
objective and subjective data. It is used to immediately identify any specific provider in need of performance improvement monitoring through the
FPPE process. Ideally, the responsiveness to concerns
will help improve overall health care quality by
monitoring individual provider competence. The use
of the 6 domains, with origins based in physician
education and certification, allows for flexibility with
regard to what data to include in the monitoring
process. APRN educational, certifying, and professional organizations must work toward fully developing a robust set of competencies. Otherwise,
APRNs will continue to be evaluated using a metric
originally designed for evaluating physicians.
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1555-4155/15/$ see front matter
© 2016 Elsevier, Inc. All rights reserved.
http://dx.doi.org/10.1016/j.nurpra.2015.08.037
Volume 12, Issue 2, February 2016