FPPE for initial privileges

Focused professional practice evaluation (FPPE) is a Joint Commission requirement. But even if you are not accredited by The Joint Commission, you must conduct competency evaluations to be in compliance with CMS standards.  This initial assessment validates the competence of an individual when your organization only possesses anecdotal information that comes from other sources—peer references and other external material.

When Greeley consultants are out in the field, we see noncompliance and confusion over FPPE requirements, primarily regarding:

• FPPE not performed in a timely manner
• Organizations that created FPPE criteria that they cannot meet

First, let’s discuss timeliness.  We often see hospitals’ bylaws state: “FPPE will be evaluated at the end of the provisional period” (the provisional period usually being one year).  There are several things to note here. First, regulators do not require provision periods. They are a construct that medical staff organizations have in place for two reasons:

• To monitor the new practitioner
• To give the practitioner a period of accommodation to the organization before being allowed to vote

Organizations should complete FPPE within a shorter timeframe than the provisional period. Solve the voting issue by placing practitioners into an appropriate medical staff category. FPPE should be timely; The Joint Commission would like to see it completed within the first three to six months if possible, depending on volume.  When the practitioner has an adequate volume, organizations shouldn’t delay the evaluation of competence; they want to know this information as speedily as possible. Organizations should only extend the evaluation period when the practitioner has a low volume.

Second, many organizations cause themselves undue burden by creating FPPE evaluation requirements that they do not carry out. It doesn’t do any good to say that you want to evaluate 20 or 30 cases when you have trouble getting five or 10 accomplished. This puts you in violation of your policy. What you need to do is ask, “How many cases do we need to review to have a good feeling that the practitioner is doing okay?”  Remember, once FPPE is completed, OPPE will be in place.  Instead of looking at some random cases at the beginning of the initial appointment (FPPE), the medical staff organization will be looking at aggregate data to measure overall performance and identifying select cases to review based on meeting certain predefined indicators (OPPE). The FPPE period is a way to bridge the gap between competence determined outside the organization (prior to the practitioner’s arrival at this institution) and before the OPPE process has the chance to gather enough data to be meaningful to determine competence within the organization.

In summary, review enough cases for FPPE that you feel some level of comfort in the competence of the individual without reviewing so many that you are not getting value from the time spent reviewing (and being overly burdensome on the remainder of the medical staff), and do a timely review.