Q&A: Focused professional practice evaluation (FPPE)

Q: What are the processes required related to meet the standards for FPPE?

A: The Joint Commission requires a period of FPPE to be determined by the hospital for providers initially seeking privileges or for current practitioners seeking the addition of new privileges. Many books have been published on this issue since inception of the standard in 2007. Although it does not have to be completed, a process must be in place using established criteria. Specifically, surveyors will look for information related to your plan based on the provider’s and the organization’s responsibilities. Do new providers understand what data will be collected to evaluate them? Some organizations include this information in the privilege award letter. Others include it up front with the application. This way, a physician knows early on what is important related to his or her performance in the organization. Have you established what triggers the FPPE process?

Important note: Surveyors have been issuing RFIs due to lack of a specified duration for the FPPE process for new providers and lack of specific criteria for this evaluation. One organization was cited for failure to monitor the quality of H&Ps based on the requirements set forth in medical staff bylaws. This is why it is important to determine your methodology for monitoring performance, such as medical record review, direct observation or proctoring, peer and staff feedback, and notation of practice patterns. If you are not reviewing any records, can you articulate the process and provide examples for the surveyor on how this works for your organization?