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Focused Professional Practice Evaluations - Update

Credentialing Resource Center Connection, October 9, 2008

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Anne Roberts, CPMSM, CPCS, is the director of medical affairs at Children's Medical Center of Dallas, where she oversees the medical administration, graduate medical education, and medical staff services departments.

Dear credentialing colleague:

In January 2008, The Joint Commission implemented the standard for focused professional practice evaluations (FPPE). At that time, hospitals struggled to implement FPPE for all initial applicants granted privileges. The first steps toward implementation were determining the appropriate level of FPPE, how the FPPE would be conducted, and who would monitor the FPPE process.

At Children’s Medical Center in Dallas, we incorporated our FPPE requirements into each privilege delineation. Our department chiefs designed FPPEs specific to each category of privileges (i.e, core privileges, special procedures, outpatient clinic privileges, etc.). We tested the system with a few of the smaller departments in late 2007 and then rolled out FPPEs to the rest of the staff in January 2008. In addition to adding FPPE to the initial privileging process, we incorporated it into requests for additional privileges and into the peer review processes.

After nearly a year of working with FPPE, the following is a list of some lessons we learned and clarifications we have obtained from The Joint Commission regarding our process:

1. The medical records department is an essential team player in this initiative! They assist with pulling charts for retrospective chart reviews, reminding the proctors when charts are ready, and sending the completed forms to the medical staff office.
2. An FPPE policy should include the following details which must be consistently implemented:
     a. The criteria for conducting FPPE.
     b. Method for establishing the monitoring plan specific to the requested privilege.
     c. Method to determine the duration of performance monitoring.
     d. Circumstances in which monitoring by an external source would be required.
3. The Joint Commission has indicated the intent of FPPE is to measure and document a practitioner’s performance in your organization. Therefore, regardless of how much data the practitioner can give you to show their performance elsewhere, the internal FPPE is not optional.
4. There can be different levels of FPPE for different circumstances, such as:
     a. Different duration or other requirements for practitioners who are coming directly from the organization’s residency program versus an outside residency program.
     b. Different requirements for those who have documented experience and outcomes versus those who do not have this documentation.
     c. Different approaches may be considered for high volume vs. low volume privileges or high risk vs. low risk procedures (for example, if a procedure is performed infrequently it may make more sense to require FPPE for a specific number of cases rather than for a set time period).
     d. The triggers that indicate the need for performance monitoring are clearly defined. The triggers can be single incidents, (e.g. sentinel events), or evidence of a clinical practice trend.

In summary, the FPPE process has changed the way we monitor new practitioners, just as the ongoing professional practice evaluation (OPPE) process changes the way we provide continuous monitoring. Ensuring that your processes and procedures are well defined and consistently implemented is key to implementing a successful FPPE process.

Remember, clear, effective communication is the key to success!

That's all for this week.

All the best,

Anne Roberts, CPMSM, CPCS

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