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Peer Review Monthly: FPPE: How many prunes are enough?

Medical Staff Leader Connection, June 11, 2008

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Remember that old laxative commercial in which the actor ponders how many prunes will do the job? Are three enough? Are five too many? When working with clients on their internal peer review programs, Greeley consultants often are asked the “prune” question relating to focused professional practice evaluation (FPPE).

When The Joint Commission created the term focused profession practice evaluation in 2007, it did not provide clear guidance in the elements of performance.

Given the complicated nature of FPPE, medical staffs should be flexible when determining how to approach it, but too much flexibility may also lead to an inadequate evaluation or unnecessary time and expense.

Before you begin selecting records for review, the first step is to ask yourself the following four questions:

• What am I measuring?
• What are my goals?
• How will I interpret the data?
• What is the impact of cost?

While most organizations want to start by determining sample method and size, these questions should determine which records you choose to review. Let’s discuss each question a bit further.

What am I measuring? Unless you define what you are measuring, you may not get the right answer. For example, some reviews are concerned about a particular outcome. Others focus on the use of particular practice or compliance with a policy. Then there is the more complex issue of whether a physician used good judgment.

What are my goals? Different goals require different approaches. For example, are you trying to determine whether something is occurring or why it is occurring? The answer would affect the level of detail and expertise needed to conduct a focused review. Are you seeking to understand current competency or improved performance? The answer would affect how far into the past or future you need to go.

How will I interpret the data? Unless you decide how you will interpret data upfront, you may introduce bias into the focused review process. For example, are you trying to establish statistical significance or a reasonable understanding? The former is more expensive and may not be achievable. Yet if you don’t decide that in advance, physicians will often refute the findings. The other factor is the comparison group. Are you comparing the physician to others, to a best practice, or to previous performance?

What are my resources? A reasonable FPPE design that you can afford is better than an ideal design that you can’t. Considering the impact of cost on your goals may not sound very scientific, but it is very appropriate because it allows you to revisit your goals to see if there is an alternative approach that gets you to the answer you need.

Just like eating prunes, performing FPPE usually isn’t a pleasant task. I hope these tips will help you get the job done—but not overdo it.

Regards,

Robert Marder, MD
Vice president
The Greeley Company

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