SU-F-P-38: Professional Practice Evaluation and Quality Improvement




In 2008, The Joint Commission (JC) implemented a standard mandating clearly defined quality improvement metrics to be factored into the evaluation of medical practitioners’ professional performance as part of the process of granting and maintaining medical staff privileges in a hospital. Specifically, there are two processes for a credentialed medical staff member to go through: Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE). This is an unfamiliar area to many of our medical physicists. The process of implementing Professional Practice Evaluation (PPE) into clinical practice is rather complex. It requires a considerable amount of work and collaboration. The quality metrics are typically different for physicists than physicians, and are specialty specific (therapy physicists vs. imaging physicists). However, in the future, some clinical medical physicists will likely be involved in this process for quality improvement. This presentation will provide an update to clinical medical physicists regarding OPPE and FPPE as well as discuss how to implement PPE in medical physics practice.


Provide an overall of JC requirements and OPPE/FPPE.Discuss quality improvement metrics for clinical medical physicists.Evaluate methods/tools for meaningful data collection.Demonstrate the process of implementing PPE into clinical practice.


By understanding the concepts of OPPE and FPPE and the JC requirements, the clinical medical physicists will be better prepared for going through the credentialing process and achieving quality improvement.


Sooner or later the clinical medical physicists will likely be involved in the process of PPE. It is challenging but also an opportunity for the medical physicists to become members of medical staffs of their institutions. AAPM as a group should start preparing for and/or implementing PPE in their clinical practices for achieving quality improvement.