What is a Focused Professional Practice Evaluation (FPPE)?

A  Focused Professional Practice Evaluation (FPPE)  is a thorough inquiry conducted by medical staff into a physician's qualifications and/or performance.  An FPPE is routine and required by the Joint Commission when new privileges are granted.  This can last from the day privileges are granted until the governing board meets and grants formal approval.

 A second type of FPPE is based upon concerns relating to performance or overall competence.  This second type of FPPE arises in light of a sentinel event, performance complaint or other competence based criticism.   The performance based FPPE can result in medical board or NPDB reporting and requires legal advice at the earliest opportunity.

What is the History of FPPE's?

In 2008, the Joint Commission created two evaluation categories:

1. Ongoing Professional Practice Evaluation (OPPE)
2. Focused Professional Practice Evaluation (FPPE).

Credentialing and privileging will be based upon many factors and OPPE and FPPE’s are part of that assessment. In fact in a recent matter, John Muir Health in Walnut Creek, California was cited for failure to seriously review OPPE’s as part of its credentialing process.

Vanderbilt's FPPE policy addresses this as follows:

"Use of Clinician Professional Performance Evaluation to Guide Privileging Decisions:

A. At the time of recredentialing, the service chief or the service chief’s designee reviews compiled data from OPPE and/or FPPE to support privileging decisions

B. At the time of recredentialing, the service chief or the service chief’s designee reviews compiled data from OPPE and/or FPPE to support privileging decisions. Failure to successfully complete an FPPE or to participate faithfully in OPPE, may result in corrective action as outlined in Article XIII of VUMC Medical Staff Bylaws."

This corrective FPPE is different from the standard, required FPPE requirement for new privileges or it can be in response to a peer review complaint or peer review investigation.  Some FPPE's follow a seemingly benign OPPE or PIP (Performance Improvement Plan).   This is why our medical lawyers recommend treating all OPPE or PIP referrals as a precursor to a more serious FPPE.

How Does the Joint Commission Define an FPPE?

Here is what the Joint Commission says about the intent behind FPPE's.

"Intent

The Focused Professional Practice Evaluation (FPPE) is a process whereby the medical staff evaluates the privilege-specific competence of the practitioner that lacks documented evidence of competently performing the requested privilege(s) at the organization. This process may also be used when a question arises of a currently-privileged practitioner's ability to provide safe, high quality patient care. 

A period of FPPE is required for all new privileges. This includes privileges requested by new applicants and all newly-requested privileges for existing practitioners. There is no exemption based on board certification, documented experience, or reputation."

How are the FPPE Rules Implemented?

UCSF has published their FPPE rules and procedures.  You can read the UCSF FPPE rules here.  Each institution has variations in their FPPE rules but they are always similar as they track Joint Commission rules and Joint Commission requirements.   The key factors are consistency in application.  New privilege FPPE's are highly standardized.  Intrusive FPPE's that focus on potential failings trigger peer review protections requiring notice, right to contest and provide input and fair hearing rights as well.

Are FPPEs Reportable?

Standard FPPE supervision is mandatory when new privileges are granted. This is not reportable and applies even to experienced and respected practitioners, including medical professors, board-certified individuals, and even those who invented a technique but are using it for the first time at a specific hospital.

How Custom Are FPPEs in Their Design?

A new privilege FPPE must be fair and consistent, with a standard design that applies equally in all cases (at least on paper). Every privilege-based FPPE includes the following factors:

• Criteria for conducting performance evaluations

• Method for establishing the monitoring plan specific to the requested privilege

• Method for determining the duration of performance monitoring

• Circumstances under which monitoring by an external source is required

Practical Implementation of FPPEs

Temporary, expedited, guest, and full privileges have different time frames, but the FPPE starts immediately when the privilege is granted. The Joint Commission suggests, but does not require, that FPPE evaluations include quantitative data, not just positive feedback from supervisors. Comparing data raises interesting issues, such as whether to use national, local, rural vs. city, or internal hospital standards. For example, surgical site infections can highlight pre-op assessment, post-op management, and nursing training and care. Surgeons seeking privileges might benefit from inquiring about hospital NSQIP numbers for the surgeries they specialize in.

Institutional FPPE Policies

Most institutions have a written FPPE policy that should be reviewed. For instance, UCSF states that an "FPPE for new applicants should be completed within 12 months; if indicated, the time may be extended at the discretion of the Department Chair." It's important to know how many FPPEs are extended at the institution you are applying to and whether you are entitled to a "fair hearing" if you object to an extension. Under UCSF rules, no such hearing is provided.

To avoid reporting requirements, UCSF generally deems an FPPE as non-disciplinary. However, if there are restrictions on privileges (rather than a delay in granting or an extension of proctoring), mandatory reporting may be required.

UCSF FPPE Policy

Stanford FPPE Policy

We like Vanderbilt's policy because it is easier to read and less dense!  (See Vanderbilt's FPPE Policy)  

 When is an FPPE Reportable?

The following (modified) is from the Stanford policy on FPPE's.

Indications for Focused Professional Practice Evaluation (FPPE)

• Single egregious or sentinel event:

  • Judged by relevant PPEC, CIC, Service Chief, APP Administrator, MEC, or Chief of Staff

  • May be referred to the CIC for consideration of an FPPE

• When indicator thresholds are exceeded within the agreed-upon time:

  • Cases rated “care inappropriate” or “improvement opportunity”:

    • Exceeds a threshold for concern as determined by relevant PPEC or in consultation with CIC

  • Other indicators:

    • Exceeds a threshold as determined by PPEC

    • Exceeding indicators does not automatically result in referral to CIC

    • PPEC will consider individual circumstances for referral

These are certainly peer review actions and do not fall under the training or non-reportable category.  There may be grey areas but in general this type of accelerated FPPE is a type of disciplinary action and may well be reportable.  

Is Resignation During an FPPE a Resignation While Under Investigation?

Resignations while under investigation are reportable to both the State of California (medical board) and the National Practitioner Data Bank (NPDB).  Each case is different and the matter can be discussed or potentially negotiated.

FPPE Lawyers

For any non-privilege based FPPE, contact the Horowitz Physician Group. Our distinguished team includes:

• Dr. Mark Ravis (MD/JD): A renowned physician lawyer with unparalleled expertise.

• Daniel Horowitz: A legal powerhouse known for safeguarding the licenses of countless medical professionals.

Trust the Horowitz Physician Group to protect your career and reputation with unmatched dedication and excellence.