Can our hospital use outside data to conduct FPPE on a new physician?

“The practitioner has a good track record of doing this procedure at our sister hospital. He now wants to do the procedure here. Do we have to do FPPE?”

“This is the first time the procedure has ever been done here. There is no one here who can evaluate whether the physician is competent performing this procedure. Can’t we rely on the proctoring data that the other facility gathered?”

These questions are both variants of the same theme: Does a hospital need to conduct focused professional practice evaluation (FPPE) on a physician if it has good data from another hospital, either within its own health system or outside? The answer is yes. Even though data can come from unaffiliated hospitals, the medical staff must review at least one internal case. The review can occur internally or through external peer review.
There are two reasons why medical staffs should conduct internal reviews on physicians who are new to the medical staff or existing medical staff members who are seeking new privileges:

1. The practitioner may do a procedure competently elsewhere, but your facility may have a different setup for the equipment, support personnel, and support services. You need to show that the physician is competent within your own facility.
2. Joint Commission standard MS.08.01.01 defines initial FPPE as “a process whereby the organization evaluates the privilege-specific competence of the practitioner who does not have documented evidence of competently performing the requested privilege in the organization.”
    

Everyone, even a world-renowned expert, must have initial FPPE, but that doesn’t mean you have to make things more complicated than they need to be. You do not have to treat all practitioners equally, but you do need to treat like practitioners alike. The world-renowned expert may need one case reviewed for FPPE to determine that he or she does well within the institution. A new graduate with minimal experience may require a more comprehensive FPPE process. In addition, The Joint Commission’s Standards BoosterPak™ for Focused Professional Practice Evaluation/Ongoing Professional Practice Evaluation (FPPE/OPPE) noted this tiered approach.

Also remember, that FPPE can be accomplished in three ways:

1. Prospectively, looking at the evaluation and indications before a procedure or other treatment is performed
2. Concurrently, observing a physician performing a procedure
3. Retrospectively, looking at the entirety of the medical care rendered.

Use the type of evaluation that most appropriately assesses a physician’s competency for the privilege he or she is requesting.

You can tailor the amount and the type of review that adequately assesses competency for a particular individual. This is usually a product of collaboration between the department/clinical service chair and the credentials committee. Usually, the credentials committee follows up to ensure that the FPPE is done in a timely manner.

Although FPPE must be done for all new privileges that the medical staff grants, use common sense in determining the amount and type of review that will adequately assess competency without overburdening the medical staff in performing extra review that does not add value.

Mary J. Hoppa, MD, MBA, CMSL, is a senior consultant with The Greeley Company, a division of HCPro, Inc., in Danvers, MA.