Premier Health’s Focused Professional Practice Evaluation Process

By Shirley Bowling, quality innovation specialist, Miami Valley Hospital

Focused Professional Practice Evaluation (FPPE) is a process mandated by the Joint Commission whereby the medical staff evaluates the privilege-specific competence of the practitioner who lacks documented evidence of competently performing the requested privilege(s) at the organization. This process is also used when a question arises about a currently privileged practitioner’s ability to provide safe, high-quality patient care.

All new privileges require a period of FPPE. This includes privileges requested by new applicants and all newly requested privileges for practitioners. There is no exemption based on board certification, documented experience, or reputation.

At Premier Health, the FPPE process is pre-defined by the organized medical staff. FPPE is consistently implemented for all newly requested privileges. From start to finish, this process involves the collaboration of the Central Credentialing Office (CVO), Quality Innovation Staff (QIS), Department Chairs, Credentials Committee, and Medical Executive Committee (MEC).

The quality innovation specialist is responsible for initiating an FPPE for all initial appointments and requests for new privileges. This involves using qualitative and quantitative criteria (data) during the chart review process.

Qualitative Data Examples

• Description of procedures performed
• Chart review
  • quality/accuracy of documentation
  • appropriateness of tests/ procedures
  • patient outcomes
• Types of patient complaints
• Code of conduct breaches
• Peer review
• FPPE for Cause may include discussion with other individuals involved in patient(s) care, i.e.: consultants, surgical assistants, nursing, administration, etc.

Quantitative Data Examples

• Length of stay trends
• Post-procedure infection rates
• Chart review
  • Dating/timing/signing entries
  • Presence/absence of required information (H & P elements, etc.)
• Number of H & P / updates completed within 24 hours after inpatient admission/registration
• Compliance with medical staff rules, regulations, policies, etc.
• Documenting the minimum required elements of an H & P / update.
• Compliance with core measures

The Quality Innovation staff conducts chart reviews to find three appropriate cases. If the practitioner has insufficient numbers at ninety days (FPPE time limit) and each one hundred twenty days after that, the practitioner(s)' Department Chair completes an FPPE summary form. 

Once a provider has completed three chart reviews, QIS sends the information to the Department Chair. Upon review, the Department Chair completes an FPPE summary form, including his/her recommendation. The CVO compiles and presents a list of the Department Chair's recommendations to the credentials committee monthly.

After receiving a recommendation from the Department Chair and with the approval of the MEC, the credentials committee makes the final determination on whether to extend the FPPE, advance to OPPE, or request case evaluation from an external source. The committee will also define the circumstances that require monitoring and evaluation of each practitioner's clinical performance after their initial grant of clinical privileges at the hospital.

FPPE improves patient safety and helps to prevent negative patient outcomes while maintaining high-quality care. FPPE is a systematic process that assesses a health care practitioner's competence. For initial appointments and new privileges, FPPE improves patient safety by identifying and addressing potential issues early on or when concerns arise (FPPE for Cause) regarding a practitioner(s) ability to provide safe, high-quality patient care. FPPE allows for targeted evaluation and potential corrective action to be taken if necessary, essentially acting as a quality control mechanism to ensure patient safety. 

Back to the September 2024 issue of Premier Pulse