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When extending FPPE becomes reportable

Credentialing Resource Center Connection, May 4, 2010

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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:

All new members of the medical staff who are granted clinical privileges are required to undergo an initial focused professional practice evaluation (FPPE). FPPE is also assigned when practitioners request new privileges or when a question arises regarding a practitioner’s current clinical competence. For the most part, FPPEs are completed without any significant cause for concerns; however, MSPs need to be aware of how to address FPPEs that trigger concerns.

For example, if a proctor completes the initial FPPE and expresses concerns regarding the practitioner’s documentation and cites that improvement is needed, the department chief has the option to recommend further documentation review until such time that they feel confident that the practitioner’s documentation meets the organization’s criteria and the FPPE can be concluded successfully. The organization should also take into consideration whether or not the poor documentation affected patient care and take appropriate action according to their policies.

Whenever a proctor completes a review and identifies concerns regarding a practitioner’s clinical practice, competency, judgment, etc., it is the department chief and the credentials committee’s responsibility to protect patient safety by determining under what level of monitoring this practitioner can continue to practice or whether his or her clinical privileges need to be modified, restricted or revoked. Organizations should clearly outline in their due process policy when an extension of FPPE for clinical competency concerns would trigger a practitioner’s right to due process.

Organizations should also keep in mind that any professional review action that adversely affects a practitioner’s privileges for a period of more than 30 days is reportable to the National Practitioner Data Bank, such as:

• Based on assessment of professional competence (not the standard FPPE process), a proctor is assigned to a physician or dentist for a period of more than 30 days. The practitioner must be granted approval before certain medical care is administered.
• A physician or dentists voluntarily resigns their privileges after a recommendation for additional proctoring based on an assessment of professional competence.
• Based on significant clinical competency concerns identified through the FPPE process, the organization determines to terminate the practitioner’s clinical privileges

Organizations also have the responsibility for reporting information to the appropriate State Medical Board.

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

All the best,

Anne Roberts, CPMSM, CPCS

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