Q&A: Clarifying MS.08.01.01 EP7 (Determination of FPPE indicators for new psychiatrist)

Q: During our recent survey, the surveyor cited lack of proactive determination of FPPE for a physician and lack of specific criteria identified to be evaluated. How can I clarify this?

A: Consider the following in this case for a clarification:

• If there is supporting evidence in the medical staff bylaws or rules and regulations regarding the FPPE process for new physicians, this can be used in the clarification as a process that has been previously determined and approved.
• Based on the timing of a new physician receiving privileges, can you demonstrate that the involved physician can still fall into this approved process?
• Is peer review or proctoring involved?
• Are basic triggers already identified?
• The surveyor cited length of time and specific criteria. Can you demonstrate 90% compliance evaluating previous providers’ oversight of the FPPE process, such as with any involved proctoring or oversight with the department chair?

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