Professional Performance Evaluation

FPPE & OPPE

Presented by John Pastrano, BBA, CPMSM, CPCS
Washington Association of Medical Staff Services
April 24, 2019
Privileging Historically…
Verification of training
• Residency / Fellowship
• CME

Credentialing Standards
• Numbers criteria
• Previous Chair/Faculty/Peer confirmation
Joint Commission 2007

Professional
Practice
Evaluation
JC Medical Staff Standards
MS.08.01.01 Focused Professional
Practice Evaluation

The organized medical staff defines the

circumstances requiring monitoring and
evaluation of a practitioner’s
professional performance.
…and JC Medical Staff
Standards
MS.08.01.03 Ongoing Professional Practice
Evaluation

Ongoing professional practice evaluation

information is factored into the decision to
maintain existing privilege(s), to revise
existing privilege(s), or to revoke an existing
privilege prior to or at the time of renewal.
Joint Commission 2007

Professional
Practice
Evaluation
What is FPPE?
Process whereby the organization
evaluates the privilege-specific
competence of the practitioner who does
not have documented evidence of
competently performing the requested
privilege at the organization
Concept
 External performance data cannot be
used for own privileging purposes

 Concept - CMS does not allow

privileging by proxy

 Sharing Compromises Peer Protection

What is OPPE?

Routine monitoring of current

competency for current Medical Staff
members
Isn’t this the same as Peer
Review?

The process by which a practitioner,

or committee of practitioners, examines the
work of a peer and determines whether the
practitioner under review has met accepted
standards of care in rendering medical
services.
Components of Peer
Review
• Focused Professional Practice Evaluation

• Ongoing Professional Practice Evaluation

• Individual Case Review

• Proctor / Consult
Individual Case Review

The process outlined for peer review of

a particular case identified with a potential
quality of care issue.
Peer Review

Peer - Any practitioner who possesses

the same or similar knowledge and training
in a medical specialty as the practitioner
whose care is the subject of review.
Peer Review
Examples of Peers:
• Emergency Medicine / Internal Med / Family Med
• Pediatrics / Family Practice
• General Surgery / Gynecology / Urology
• Orthopedics / Neurosurgery
• Pathology
• Radiology
Peer Review
More Examples of Peers:
• Anesthesiology
• Dentist / Oral Surgeon
• Cardiology / Internal Medicine
• Interventional Cardiology
• Nurse Practitioner / PA – same or physician
• CRNA – same or physician
Scope of FPPE & OPPE

Applies to all credentialed / privileged

members of the Medical Staff and Allied
Health Practitioners.
Scope of FPPE & OPPE
Exception:
No-volume providers with medical staff
membership and without clinical privileges per
Joint Commission clarification are exempt from
the Ongoing Professional Performance Evaluation
and Focused Professional Practice Evaluation
requirements contained within this document.
Purpose of FPPE & OPPE
• To assure that the hospital, through the activities
of its medical staff, assess the ongoing
professional practice and competence of its
medical staff, conducts professional practice
evaluations, and uses the results of such
assessments and evaluations to improve
professional competence, practice, and the quality
of patient care.
Purpose of FPPE & OPPE

• To define those circumstances in which an

external review or focused review may be
necessary.

• To address identified issues in an effective

and consistent manner.
Purpose of FPPE & OPPE

• “Professional Practice Evaluation” is

considered an element of the peer review
process and the records and proceedings
relating to this policy are confidential and
privileged to the fullest extent permitted by
applicable law.
FPPE….

Dept Chair
Gather data as reviews data
physician uses and makes an
privileges informed
decision re:
Analyze Data continuing or
concluding
FPPE
Initiation of FPPE
• Upon initial appointment
• When a new privilege is requested by an existing
practitioner
• When a question arises through the OPPE
process, individual case review, or other peer
review process regarding a currently privileged
practitioner’s ability to provide safe, high-quality
patient care
Initiation of FPPE

Example:
When a trigger is exceeded and preliminary
review indicates a need for further evaluation.
FPPE based on concern….

MS
Gather data leadership
related to makes an
questions or informed
concerns decision re:
Panel of peers reviews data continuing
to determine if variations in or removing
practice are privilege(s)
acceptable/appropriate
What is Initiated?
• FPPE is not considered an investigation as
defined in the Medical Staff Bylaws and is
not subject to the bylaws provisions
related to investigations.

• If FPPE results in an action plan to

perform an investigation, the process
identified in the Medical Staff Bylaws
would be followed.
Timeframe for Collection &
Reporting

Must be time-limited, defined by:

• A specific period of time, and/or

• A specific volume
(number of procedures/admissions)
Other FPPE considerations
May take into account previous experience in determining the approach, extent,
and time frame:

• Recent graduate from training program

affiliated with the facility (data available)

• Recent graduate from a training program

at another facility (data not available)
Other FPPE considerations
May take into account previous experience in determining the approach, extent,
and time frame:

• Practitioner with regular experience

exercising the requested privilege of fewer
than two years on another medical staff

• Regular experience exercising the

requested privilege of more than five years
at another medical staff
Other FPPE considerations
• Should begin with the first admission /
procedure

• Should (optimally) be completed with 3 months,

or a suitable period based upon volume

• Period may be extended as necessary but

may not extend beyond the first biennial
reappointment
 FPPE Methods
• Chart review - concurrent and/or retrospective
• Simulation
• Discussion with the practitioner and/or other
individuals involved in care
• Dependent AHPs – review or proctoring by the
sponsoring physician
• Internal or external peer review
 FPPE Methods
Communicate with the Practitioner
• Cause for the focused monitoring
• Anticipated duration
• Specific mechanism by which monitoring will
occur (i.e. chart review, proctoring, etc.)
Performance Monitoring
Criteria & Triggers
• Develop monitoring criteria
• Include specific performance elements
• Include thresholds or triggers

Approved by the medical staff department/committee, MEC

Triggers
• Single egregious case
• Evidence of a practice trend
• Exceeding a threshold established for OPPE
• Patient / staff complaints
• Non-compliance with Bylaws, R&R
• Elevated infection, mortality
• Elevated complication rates
• Failure to follow approved clinical practice guidelines
• Unprofessional behavior or disruptive conduct
Conclusion of FPPE
 Findings reviewed by MEC or Department/Chair

 Decision and recommendation

• Move forward with OPPE
• Extend period and/or scope of FPPE
• Develop performance improvement plan
• Limit or suspend privilege(s)
Conclusion of FPPE
 Practitioner should be notified of performance
outcome in writing
• Findings & outcome of FPPE
• Specific actions that need to be taken by
Practitioner to address any quality concerns,
including follow-up
• If FPPE is complete or will continue (w/period)
• If complete – move to OPPE
Conclusion of FPPE
Activity/volume insufficient to meet FPPE,
Practitioner may:
• Voluntarily resign privilege(s)
• Submit request for extending FPPE period
• Submit evidence of sufficient volume from
another local facility w/ external peer reference
• Chair/Department/Committee may discretionarily
extend FPPE
NOTE: Practitioner is not entitled to a hearing/procedural rights for
voluntary relinquishment
Performance Improvement
Plan
 Plan drafted by Department/Chair/Committee
• Presented to MEC for approval
• Practitioner offered opportunity to address
Committee and respond to findings
 Methods to resolve issues clearly defined
• Education / CME
• Proctoring and/or mentoring
• Counseling
• Practitioner assistance program
• Suspension or revocation of privilege(s)
Performance Improvement
Plan

 MEC approved PI Plan

• Dept Chair and/or COS meet w/ Practitioner
• Agree – sign written document
• Does not agree – forward to MEC for resolution
OPPE ….

Medical/Clinical
Knowledge

Patient Care
Departments
define data for Interpersonal Skills
areas of Data collected
Practice-Based Learning regularly and
competency
collated by
Professionalism individual
physician to
Systems-Based Practice identify
opportunities
for improving
performance
OPPE

 Timeline for collection and reporting

• All practitioners with clinical privileges

• Every 3 to 6 months (discretion)
• No less than every 9 months
 OPPE Indicators for Review
 Type of data to be collected and related thresholds
or triggers is determined by medical staff
committees/departments & approved by MEC
 Indicators may changes as appropriate
 Reviewed annually
 Do not limit data collection to negative/outlier
trending data – consider good performance data
 OPPE Indicators for Review
 Department selects 3 to 5 specialty-specific indicators
 MEC selects general indicators applicable to all practitioners
 Consider using ACGME “General Competencies”
• Patient care
• Medical/clinical knowledge
• Practice-based learning and improvement
• Interpersonal and communication skills
• Professionalism
• Systems-based practice
OPPE Indicators for Review

 Threshold/triggers for performance must be

defined for select indicators

 Triggers define unacceptable levels of

performance
– may trigger FPPE
 OPPE Indicators for Review
 Triggers to consider
• Defined number of events occurring
• Defined number of adverse outcomes
• Elevated infection, mortality, complication rates
• Sentinel events
• Low admissions/procedures over extended time
• Increased LOS compared to peers
• Increased returns to surgery
• Frequent unanticipated readmits for same issue
• Patterns of unnecessary diagnostic testing
• Failure to follow approved practice guidelines
“Examples of Performance Measures & Triggers”
 OPPE Results & Reporting
Data
 Data are analyzed and reported to determine
whether to continue, limit, or revoke any
privilege(s)

 Outcome of evaluation must be documented and

maintained in the Practitioners quality file

 At Completion of review period, OPPE results

(practitioner profile report) is communicated to
Practitioner & filed in quality file
Practice Data …..
Patient Care
Mortality
Medical/Clinical
Resource use Knowledge
Readmissions
Practice-Based Learning
Avg LOS
Process Measures Interpersonal
Communication & Skill
Medical Records
Board Certification
Professionalism
CME / Certification
Peer Discussion System-Based Practice
Challenges to Implementation
• Identifying meaningful FPPE / OPPE

• Education & compliance of Medical Staff

• Most data collection is manual (FTE)

• Software / IT support

• Restructure & training of support staff

• Urgency of implementation
Steps toward change and
conformance…
Dept Chairs define FPPE / OPPE indicators

Obtain MEC & Board approval

Identify data collection methodology

Create data inventory / statistical analysis / reporting tool

Establish reporting chain of command

Write practice evaluation policy / plans

 External Review
 MEC/COS/Dept Chair/Board may request external
peer review
 External Reviewer – Board Certified same specialty
 Circumstances
• Eligible reviewers unable to serve
• No qualified Practitioner on Staff to review
• Litigation risk

NOTE: Practitioner may not require Hospital to obtain external review

 Review Form
 Type of data to be collected and related thresholds
or triggers is determined by medical staff
committees/departments & approved by MEC
 Indicators may changes as appropriate
 Reviewed annually
 Do not limit data collection to negative/outlier
trending data – consider good performance data
What about temporary privileges?
Temporary – Applicant
• Application must be complete
• May grant temporary privileges up to 120 days
• FPPE applicable

Temporary – Non-applicant / Locums

• Fits under urgent patient care needs
• Verification of license, competence, NPDB, insurance
• Temporary privileges to care for patient (non-applicant)
or up to 15 days (Locums)
Professional Performance Evaluation

FPPE and OPPE

 THANK YOU!
Contact Information:
John Pastrano, BBA, CPMSM, CPCS
Southern Belles and Beau Speaker Bureau
Email: John.Pastrano@tenethealth.com