What is an FPPE (Focused Professional Practice Evaluation)?
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.
Ultimately any level of FPPE including initial credentialing has a level of danger to a physician and can either be part of the peer review process or lead to peer review.
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. So even though an OPPE is technically not part of peer review once a physician is in the peer review headlights everything is fair game.
On paper an OPPE and even a successfully completed FPPE are non-punitive. The Joint Commission's view is that an FPPE complements an OPPE process. The OPPE is non-remedial or only mildly remedial and it monitors performance over time for all privileged practitioners. Successful completion of FPPE typically transitions a practitioner to OPPE monitoring. But in practice any special attention however labeled is ammunition to be used against the doctor in the future.
We have seen cases where a hospital genuinely wanted to retain a new physician and used the OPPE/FPPE process to protect itself against claims of failure to supervise but genuinely worked to keep the doctor on staff. This was a smaller hospital in an underserved area. Its options for hiring were limited and the doctor was truly intelligent and willing to learn.
This instance was consistent with the non-punitive approach is outlined in TJC standards (e.g., MS.08.01.01). It ensures patient safety by verifying current competence before full independent practice or when questions arise. As of late 2025, these requirements remain consistent with prior years, emphasizing evidence-based, non-punitive evaluation where possible.
However!
Even the successful completion of a Performance Improvement Plan (as part of an FPPE) is no guarantee of safety in the future. We have seen many cases where a doctor was highly successful in the FPPE process and years later new charges were brought with the headline "He did it once and he's doing it again." Or there is the alternate attack which is, "We gave him one chance and it didn't stick". Even successful completions can be a justification for a claim of imminent safety concerns leading to a summary suspension.
"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.
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. Remember that once an FPPE is initiated a resignation is likely reportable as a resignation while under investigation. It can be reported to a state medical board and to the National Practitioner Data Bank (NPDB).
Review the NPDB Guidebook
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.
When is an FPPE Reportable?
The following (modified) is from the Stanford policy on FPPE's.
Indications for Focused Professional Practice Evaluation (FPPE)
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. Summary Suspensions are the great landmine for physicians and reporting. Once that is in place a resignation is automatically reported.
FPPE Lawyers
For any non-privilege based FPPE, contact the Horowitz Physician Group. Our distinguished team includes:
Trust the Horowitz Physician Group to protect your career and reputation with unmatched dedication and excellence. If you are the subject of an FPPE or if an FPPE is being considered in your case you need legal help. Call us at (925) 283-1863 to schedule a consultation.
