Current Competency

Current Competency

What does Current Competency mean?

Current competency refers to evidence that a provider can perform clinical privileges based on whether they are properly educated, trained, and are proficient in a particular skill. The term “current” is extremely important since organizations must confirm that a provider is currently competent. For example, just because a provider completed a fellowship, holds a license to practice, and has performed a set of procedures in the past doesn’t necessarily equate to current competence to exercise those privileges today. Organizations must confirm providers have the proper education, training, and credentials but must also inquire as to their level of current performance when exercising clinical privileges. You certainly wouldn’t want a surgeon to give you a knee replacement if that surgeon hadn’t performed a knee replacement in 3 years, or if the majority of the knee replacements performed in the last year had a bad outcome. When determining the criteria for competency in a given clinical privilege or bundle of core privileges the following items are typically considered:

  • Minimum Education/Training required: this can be assessed based on the provider’s degree earned, plus whether they’ve completed additional training, such as a fellowship or Continuing Medical Education (CME) in a specialty field.
  • Board Certification: this can be used as a factor in determining eligibility criteria for granting privileges, but The Joint Commission (TJC) does not allow for Board Certification to be considered the only criteria.
  • Minimum case thresholds: these numbers are determined based on the size and structure of the organization and its medical staff. Case thresholds should be able to be realistically obtained within the review period.
  • Provisional Proctoring / Initial Focused Professional Practice Evaluation (FPPE): for a new applicant to the medical staff this would be equivalent to an employee’s probationary period. Initial FPPE/Proctoring must be evaluated within a pre-defined period (per MS Bylaws), must be objective and standardized, and is typically either based on a percentage of cases completed during that period or pre-defined minimums of cases proctored by specialty or privilege.
  • Providers with low/no case volume: Peer recommendations can be used to assess competency, as can Ongoing Professional Practice Evaluation (OPPE) data or procedure/case logs from other hospitals.
  • Age-Related Competency: Providers will be asked to document their ability to perform clinical privileges requested with or without reasonable accommodation, and this will be verified, typically through a Peer Recommendation. Many medical staffs will create an aging provider policy in which additional information, such as a health screening or letter from the provider’s physician is obtained to ensure they are physically and cognitively capable of performing their privileges.


Why is Current Competency important? 

Failing to appropriately track and monitor current competency can endanger patient safety and leave the Medical Staff, and Hospital or Organization open to liability.

Roles and Responsibilities
* Information provided by NAMSS


How to track and maintain evidence of current competency in ASM products?

It starts with MD-App!

  • Provider NPI and personal identifiers
  • Education & Training
  • Hospital Affiliations
  • Peer References
  • License Data
  • Board Certifications
  • Case Log Files
  • Requesting Privileges that the provider is qualified for and intends to perform that the facility
  • Aiva Aware will automatically notify users if there are gaps in a provider’s timeline over 180 days.

Credentialing / Verifications using Checklists and Web Services

  • Verify all the applicant’s information, ensure that the information they provided is true and accurate and that there are no unexplained gaps in training or employment as they could potentially be flags against continued competency.

Reference Evaluations using Pronto with MD-Staff

  • Collect references from peers, supervisors, and collaborating physicians as a means of confirming their current competence and ability to practice the privileges requested at their facility. These reference evaluations ask specific questions and require that the evaluator review the privileges the applicant has requested and comment on their knowledge of the provider’s ability to practice the requested privileges. It is critical that a reference is obtained from someone who has knowledge of the provider’s current clinical performance.

OPPE – Ongoing Professional Practice Evaluation in MD-Stat

  • Process of collecting and comparing provider volume and core competencies to ensure that all providers are operating within acceptable ranges. If a provider falls out of the acceptable range or has other flags like excessive suspensions, excessive patient complaints, a higher-than-average negative outcome on peer/case review, it will trigger an FPPE for Quality Concerns.
  • The Joint Commission (TJC) requires each organization to only have 1 specialty specific OPPE indicator per specialty, in addition to those that are all-specialty such as total volume.
  • OPPE indicators must be measurable and actually measured at the organization where patient care is provided.

FPPE – Focused Professional Practice Evaluation in MD-Staff and/or MD-Stat

  • Initial or Provisional FPPE must be done within a limited time and have pre-defined requirements for proctoring requested privileges. Some organizations will measure a percentage of cases completed during the defined timeframe while others will have defined proctoring requirements per privilege, or per procedure that must be completed satisfactorily for the provider to be advanced to full unrestricted privileges.
  • New Privilege FPPE may be required if a provider requests additional privileges on top of the privileges they’ve already been granted. Multiple data points will be taken into consideration before the privilege can be granted, including – education (i.e. additional fellowship)/training (Continuing Medical Education (CME) courses), case logs from another hospital, and proctored cases completed at the organization where new privileges are being requested.
  • Quality Concern FPPE could be triggered based on some kind of flag in the provider’s behavior or from adverse results on their OPPE. Physician leadership will decide the length of time and/or measurements to be collected during a Quality Concern FPPE. If a provider is under FE and decides to resign from the medical staff this must be reported to the NPDB.

Peer Review in MD-Stat

  • Peer/Case Review cases are flagged/triggered by fallouts in patient care, by patient complaints, or risk events, by random sampling, or might be brought before a committee as a learning opportunity.
  • Peer Review cases are almost always anonymized so that there can be no excuse for unfair treatment by the reviewing provider.
  • It is recommended that outcomes be standard and measurable, as they will be used to measure performance against other providers during OPPE.
  • Cases flagged for peer review that do not meet requirements for Peer Review may be documented as a Track and Trend case. If enough track and trend cases are accumulated or minor deviations of the standard of care or minor complaints this could also be used as a determinator to trigger an FPPE. For example – one peer review with an outcome equivalent to Major Deviation of Standard of care could trigger the same FPPE as a provider with three or more Minor Deviations of Standard of care.

Founded in 1982 and headquartered in Temecula, CA, Applied Statistics & Management, Inc. (ASM) is dedicated to the development and support of software solutions that leverage the latest technologies and methodologies for the healthcare industry. ASM’s flagship product, MD-Staff, is the most advanced credentialing, privileging and provider information management platform available. Used by over 2,000 facilities worldwide, MD-Staff Credentialing Software is a proven system that helps healthcare organizations of any size streamline their credentialing process while reducing overall costs. Winner of the KLAS Research for Credentialing Software!

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