Tip: Tie initial FPPE approaches to privilege type

Once an applicant has been granted clinical privileges, the organization should monitor the practitioner’s competence through an initial assessment. For organizations accredited by The Joint Commission or HFAP, focused professional practice evaluation (FPPE) is required to gauge the individual’s ability to proficiently exercise clinical privileges using staff, equipment, and resources. For organizations accredited by other entities, initial competence assessment is a best practice that promotes safe, quality patient care. The approach to initial review should align with the type of privileges requested. Consider the following assessment routes:  

• Core privileges: The credentials committee could indicate that all department chairs must assign a minimum number of retrospective chart reviews for core privileges. The department chair would have the option to increase the number of chart reviews, but the number could not fall below the minimum set by the credentials committee. Involved parties would ensure studied cases reflect the scope of privileges included in the core.
• Special procedures: For more invasive or specialized procedures or more acute patients, the department chair should carefully consider what type of initial competence assessment is appropriate. This often involves direct observation for a specified number of procedures to demonstrate competence prior to allowing the practitioner to practice independently.
• Privileges unrepresentative of the applicant’s recent practice: If an applicant does not have recent experience relevant to the privileges he or she has requested, the department chair has the option of adding requirements to the FPPE to better evaluate the practitioner’s current clinical competence. For example, if the minimum criteria for core privileges in a department is 10 retrospective reviews for most applicants and the applicant does not have recent experience, the department chair could increase the FPPE requirement either in volume or by adding provisions, such as direct observation, precepting, or remedial courses.

Source: The Medical Staff’s Guide to Overcoming Competence Assessment Challenges