Question of the Week

Question: A JC surveyor told us that it is inappropriate for our Chief of Surgery, who is an anesthesiologist, to perform the initial FPPE to confirm competence for a general surgeon.  The surveyor indicated that FPPE should be performed by a physician in the same specialty.  He also stated that initial FPPE must be performed at our hospital and cannot be accepted from another facility.   How are smaller hospitals addressing FPPE when they have a limited number of physicians in a specialty that can perform the evaluation?

Answer: Taking the latter issue first  –  the Joint Commission has been very clear from the inception of the OPPE and FPPE Standards in 2008 that the purpose of FPPE for initially-granted privileges (new applicants or existing members requesting new privileges) is to confirm the competence of the practitioner to exercise those privileges.  No matter how sophisticated a hospital’s initial credentialing and privileging may be, initial determinations to grant privileges are based on the applicant’s paper credentials.  The objective of initial FPPE is to confirm the competence suggested by those paper credentials.  Therefore, we agree with the surveyor that obtaining additional paper credentials from other facilities where the applicant practices does not meet that objective or the Joint Commission Standards.

But that is where our agreement with the surveyor ends.  The surveyor’s other statement – that FPPE must be performed by a physician in the same specialty – is surprising.  While proceeding in that manner is obviously optimal when it is possible to do so, we do not believe it is required.

We reviewed the FPPE Standard (MS.08.01.01) and the Elements of Performance under it, as well as FAQs about FPPE published by the Joint Commission on October 13, 2008.  None of those sources state that FPPE must be conducted by a physician in the same specialty as the physician whose competence is being evaluated.

In addition, both the glossary and the Elements of Performance under MS.07.01.03 (which pertain to peer recommendations that must be considered in the credentialing process) define a peer recommendation as “information submitted by a practitioner(s) in the same professional discipline as an applicant.”  Professional discipline is not defined in the glossary but is commonly understood to mean physician, dentist, advanced practice nurse, etc., not specialty.

Indeed, “peer” recommendations have traditionally been sought from department chairs at other hospitals where an applicant has practiced and department chairs play a primary role in the reappraisal of a physician’s competence to exercise clinical privileges at reappointment.   Department chairs may or may not practice the same specialty as the applicant for initial appointment or reappointment.  We are unaware of the Joint Commission ever taking the position that such peer recommendations are inadequate if the department chair does not practice in the same specialty as the applicant.

In fact, The Standards BoosterPak for Focused Professional Practice Evaluation/Ongoing Professional Practice Evaluation (FPPE/OPPE) published by the Joint Commission in 2011 states, in its implementation suggestions regarding FPPE, “Department chair (or whoever is evaluating the data) makes the determination to assign a period of focused evaluation.”  That certainly does not require (or even suggest) that the person who evaluates the data collected through FPPE must be in the same specialty as the person being reviewed.

So the bottom line is that there does not appear to be anything in the Standards or other materials published by the Joint Commission that supports the surveyor’s statement that FPPE must be performed by a physician in the same specialty as the physician being evaluated.

A detailed process for FPPE for initial privileges is just one of many topics presented at The Peer Review Clinic.  Join Paul Verardi and Phil Zarone for this intense, interactive program.