Common questions regarding FPPE for low- and no-volume practitioners

During a recent credentialing education program I provided for a hospital, we spent considerable time wrestling with how best to handle the problem of low- and no-volume providers. I thought everyone understood how to move forward, but a month later, their leaders called to ask some questions about FPPE for low- and no-volume providers. I realized from their questions that this topic still creates lots of confusion, so here are the questions they raised and the answers that I hope you’ll find helpful.

Our FPPE policy says we review a provider’s performance for a year. What do we do with providers who haven’t done any work at our hospital during that year?

This question must be answered in three parts. First, defining FPPE as reviewing a provider’s performance for one year misses a key intent of the FPPE standard. In the past, many hospitals appointed physicians to a “provisional” category for the first year of their membership. At the end of that year, the physician would be “promoted” to the active staff. The problem with this approach has been that one year is too long a time to allow a physician to practice in your hospital without assessing their performance. The goals of FPPE are “timely measurement, timely evaluation, and timely follow through,” in the words of Bob Marder, MD, CMSL, vice president for The Greeley Company, a division of HCPro, Inc., in Danvers, MA. Waiting a full year before measuring and evaluating a physician’s performance is too long. Use the first few times a physician provides care in your organization to make timely measurements that lead to timely evaluation of the practitioner’s performance. Observe the physician’s first few deliveries or surgical procedures or reviewing medical records on his or her first half-dozen inpatients. For most physicians, these evaluations can be completed in a matter of weeks to a few months. This is the appropriate time frame for completing FPPE.

Second, recognize that this hospital appears to have attempted to meet the FPPE standard by repackaging its old provisional process as FPPE without substantively changing how it monitored the performance of new medical staff members. The one-year timeframe was a tipoff. So was the fact that the hospital still seems to be applying the outdated, “no news is good news” approach to physician performance. One of Greeley’s principles for effective credentialing and privileging states, “Base credentialing and privileging decisions on the affirmation of competence and conduct, not the absence of negative information.”

Third, a provider who hasn’t done any work in your hospital during the first year after being granted privileges produces no data regarding his or her competence. Under such circumstances, the provider’s FPPE remains incomplete. It is unacceptable to simply declare his or her FPPE finished after any designated period of time. Competence is not measured through the passage of time but through evaluation of patient care given. If no patient care is given, no competence has been demonstrated. 

My response led to a follow up question:

Since we don’t have data on what they’ve done in our hospital, can we use references from places where they did provide patient care to complete the FPPE?

The answer is a clear no. Any initial decision to grant privileges to new members or new privileges to existing members is always based on references about care they’ve provided outside of your institution. The function of FPPE is to determine if you made a good decision based on those references. In other words, FPPE is an evaluation of how effectively your credentialing process assessed their competence before they gave care to patients in your hospital. Thus, the only way to assess your credentialing process is by evaluating the care the practitioner gives to patients in your hospital. References about care given outside your organization do not provide any meaningful data for FPPE.

So what should we do with these no-volume providers when it comes to FPPE?

You have two choices. The first is to grant no-volume providers continuity-of-care privileges (otherwise known as refer-and-follow privileges) only. If you do this, there is no need to assess their competence because they are not authorized to do anything in your organization that could adversely affect patient care. The second is to keep their FPPE incomplete until they provide care to enough patients in your institution to allow you to meaningfully measure their competence.

What happens when this provider comes up for reappointment and still has an incomplete FPPE?

Now you have another choice to make. If a physician is not providing inpatient care anywhere, he or she is not likely currently competent in inpatient care, and by policy, you could make him or her only eligible for refer-and-follow privileges. You could also make a no-volume provider eligible for comanagement privileges so he or she would not be authorized to practice independently in your organization. This latter option will still require that you complete an FPPE for this practitioner if and when he or she provides inpatient care in your hospital. If the provider is actively practicing at one or more other hospitals, you can depend on references from those other facilities for reappointment decisions, but you will still need to complete an FPPE for the care he or she provides in your hospital, however long that may take.

No wonder the hospital’s medical staff office was confused. Hope this clears up any confusion you’ve had about FPPE for low- and no-volume providers.

All the best,

Richard A. Sheff, MD, CMSL
Chairman and Executive Director, the Greeley Company, a division of HCPro, Inc., in Danvers, MA.