Sample bylaws language for FPPE

In the past, medical staffs appointed new members for a provisional period, typically for six to 12 months, during which time they monitored the practitioner’s performance. This provisional status/period need no longer exist because The Joint Commission’s FPPE and OPPE regulations have replaced the old provisional period with a more rigorous process. Medical staffs must include some language in their bylaws regarding FPPE and OPPE if they are Joint Commission-accredited.

The following sample bylaws language reflects a simplified approach to FPPE: 

Sample bylaws language: Focused professional practice evaluation 

All initially requested privileges shall be subject to a period of FPPE. The credentials committee, after receiving a recommendation from the department chair or input from the clinical service chair, and with the approval of the MEC, will define circumstances that require the clinical performance of each practitioner to be monitored and evaluated after he or she is initially granted privileges at the hospital.

Such monitoring may use prospective, concurrent, or retrospective proctoring, including but not limited to the following:

• Chart review
• Tracking performance monitors/indicators
• External peer review
• Simulations
• Morbidity and mortality reviews
• Discussion with other healthcare workers involved in the care of patients

The credentials committee will also establish the duration for such FPPE, as well as triggers that indicate the need for performance monitoring.