Overcome lingering FPPE and OPPE challenges

Although The Joint Commission has required hospitals to conduct focused professional practice evaluation (FPPE) and ongoing professional practice evaluation (OPPE) since 2007, MSPs and medical staff leaders alike continue to struggle to carry out the details.  In this column, I address some of the questions that I’ve received from readers during the past few months.

Does our organization need to conduct OPPE on courtesy staff members?
A hospital does not need to conduct OPPE on courtesy staff members as long as the organization’s definition of courtesy staff does not allow physicians in that category to have delineated clinical privileges. Typically, courtesy staff members have refer-and-follow privileges, which allow them to perform preadmission history and physicals, refer patients to the hospital, order outpatient diagnostic tests, and follow patients’ progress. However, physicians with refer-and-follow privileges are not allowed to write in the chart, either notes or orders, because doing so could be construed as directing patient care.

How should our organization conduct FPPE and OPPE for low-volume and no-volume physicians? 
If a physician never exercises his or her privileges, your organization should first ask itself whether that individual should be a member of the active staff or courtesy staff. If the individual is a courtesy staff member, the hospital does not need to conduct FPPE or OPPE because the practitioner does not have privileges.  If the physician is a member of the active staff, your medical staff should request OPPE profiles from any other organizations that the practitioner actively exercises privileges. However, such a practice is somewhat controversial; it is unclear whether The Joint Commission will accept OPPE data from another facility as the sole basis for OPPE. If your organization has no data regarding the practitioner’s competence, the typical approach is to obtain qualitative references from those other facilities to ensure current competency.
 
How often should we distribute our OPPE results to physicians? 
Organizations commonly aggregate and distribute OPPE data every six months. This time frame provides physicians with four reports within the two-year reappointment cycle. Organizations may aggregate and distribute OPPE data every eight months, but this timing only allows for three reports during each reappointment cycle, thus not providing as timely feedback to physicians. It also does not coordinate as well with electronic data source time periods.
 
Is denying medical staff membership and privileges to a physician who does not turn in FPPE and OPPE paperwork on time an acceptable practice?
Withholding a physician’s medical staff membership and privileges if he or she does not fulfill his or her medical staff obligation is acceptable as long as that practice is delineated in the medical staff bylaws. However, it is a somewhat dangerous practice to impose on volunteer medical staff members, unless the medical staff agrees that it wants to maintain a culture of mutual accountability and use this mechanism to enforce that culture. Rather than withholding medical staff membership and privileges, your organization may choose to impose fines on physicians who do not complete their proctoring requirements within the specified timeframe or reward them for turning in their FPPE and OPPE paperwork on time. 
 
Do we need to credential an external proctor, and can he or she intervene if the physician runs into trouble?
This all depends on your organization’s FPPE policy regarding interventions. The traditional definition of proctoring did not allow intervention, but most organizations today believe that intervention should be allowed. If the proctor from an outside company is a physician, and your policy permits physician proctors to intervene, your organization should credential the proctor and grant him or her emergency privileges or privileges for the limited procedures that he or she will observe. If your policy does not allow proctors to intervene, then your organization does not have to credential him or her or grant him or her privileges. Always inform patients if the proctor cannot intervene.  Representatives and trainers from external drug and device manufacturing companies are not really proctors and should not be treated as such. 
  
Robert Marder, MD, CMSL, is vice president of The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.