Implementing an effective FPPE process

Dear credentialing colleague:

Effective January 1, 2008, The Joint Commission's (formerly JCAHO) new standards specific to focused professional practice evaluation (FPPE) go into effect, requiring that organizations implement a period of FPPE for all practitioners who are initially granted clinical privileges. As a result of the new 2007 standards and the upcoming changes for 2008, many organizations have been struggling to ensure that they clearly understand the circumstances for which The Joint Commission requires FPPE, and that they are prepared to implement an effective, compliant FPPE process.

First, let's discuss what FPPE entails. The Joint Commission defines FPPE as a process whereby the organization evaluates the privilege-specific competence of a practitioner who does not have documented evidence of competently performing the requested privilege at that organization. Healthcare organizations may also use this process when a question arises regarding a currently privileged practitioner's ability to provide safe, high-quality patient care. FPPE is a time-limited period during which an organization evaluates and determines the practitioner's professional performance, according to The Joint Commission.

FPPE would generally be performed under the following circumstances: 

• For all practitioners initially granted clinical privileges
• The practitioner has not yet performed the procedure for which he or she seeks privileges at your organization in the past
• There is a concern regarding the practitioner's current competency, either due to data from an ongoing professional practice evaluation or because the practitioner has not exercised the privilege in question for an extended period of time

Information gathered to support the FPPE may include chart review, monitoring clinical practice patterns, simulation, proctoring, external peer review, and discussions with other individuals involved in the care of each patient (e.g., consulting physicians, assistants at surgery, nursing staff, or administrative personnel). The method that your organization selects will depend on your organization's culture.

You need to ensure that your organization clearly defines its FPPE process, as well as the triggers that indicate a need for performance monitoring. Your organization's FPPE plan should also accomplish the following:

• Establish a monitoring plan that is specific to the requested privilege
• Determine the duration of performance monitoring
• Establish criteria for determining when it is necessary to extend the evaluation period
• Define the circumstances for which you require monitoring by an external source

Additionally, an effective FPPE process should outline how your organization will communicate the evaluation results, as well as recommendations based on those results, to the appropriate parties. Lastly, your organization should integrate information resulting from FPPEs into performance improvement activities.

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

That's all for this week.

All the best,

Anne Roberts, CPMSM, CPCS