Define FPPE/OPPE.
Determine the scope of the professional
practice evaluations.
Understand the requirements as expected by
the Joint Commission surveyors.
Review evaluation presentation tools.
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DEFINITION
What is FPPE/OPPE?
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TJC Medical Staff Standards
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When should FPPE occur?
Initial privileging
New privileging
Triggers
Unhappy trend
Incident undetermined
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And
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SCOPE
Who must be privileged?
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What about advanced practice?
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Who grants privileges?
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Temporary privileges – 2 types
Temporary
“I am an applicant and I want to work.”
Application must be complete
May then grant privileges for 120 days
Locums
Fits under urgent patient care needs
Verification of license, competence, NPDB, insurance
Not limited to 120 days
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Core Privileging
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What about accepting external
performance evaluations?
External performance data can not be used
for your privileging for credentialing
purposes
The Joint Commission is surveying CMS
standards deemed. CMS does not allow
privileging by proxy.
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REQUIREMENTS
FPPE may include…
Chart review
Monitoring clinical practice patterns
Simulation
Proctoring/direct observation
External peer review
Discussion with other individuals involved in the
care of each patient.
Direct observation
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OPPE may include…
1. Define indicators
2. Obtain department/leadership approval
3. Institute data inventory and method for data
collection
4. Establish reporting chain of command
5. Write the plan
6. Define focused evaluation
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Steps continued
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The organized Medical Staff
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Determines practitioner is within desired
expectations – no further action
Determine that issue exists requiring focused
review
Revoke the privilege because it is not longer
required
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Suspend the privilege which requires notifying the
practitioner that he/she will need to request
reactivation if he/she desires to reactivate
Determine if zero performance triggers a focused
review
Determine if the privilege should be continued
because the organization’s mission is to be able to
provide the privilege to its patients.
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Challenges
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RESOURCES
Questions…
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