Q. What is the intent of the Focused Professional Practice Evaluation requirement?
A. There are essentially two components:
- Element of Performance 1 which requires "A period of focused professional practice evaluation is implemented for all initially requested privileges." This would mean all privileges for new practitioners and all new privileges for existing practitioners. The EP was published in January 2007 with an effective date of January 1/2008.
- Elements of Performance 2 - 9 which were relocated from the 2006 standard MS.4.90. These elements address what had previously been termed "Peer Review".
Focused Professional Practice Evaluation for New Privileges
Q. What is the requirement for new privileges?
A. A period of focused review is required for all new privileges meaning all privileges for new applicants and all new privileges for existing practitioners. There will be no exemption for board certification, documented experience, or reputation. All applicants for new privileges must have a period of focused review.
Q. Must the process be pre-defined or can it be determined for each specific applicant for the new privilege?
A. The components for design are listed in EP 3 and would include, but not be limited to :
- criteria for conducting performance evaluations
- method for establishing the monitoring plan specific to the requested privilege
- method to determining the duration of performance monitoring
- circumstances under which monitoring by an external source is required
The organization may choose to use the methodologies for collecting information such as those outlined at MS.4.40 for ongoing professional practice evaluation:
- periodic chart review
- direct observation
- monitoring of diagnostic and treatment techniques
- discussion with other individuals involved in the care of each patient including consulting physicians, assistants at surgery, nursing, and administrative personnel.
There is nothing in EP 3 that would prevent the design of a multi tiered/level approach. The type of review can certainly be different, especially for different privileges, e.g. for some direct observation is appropriate but for other chart audits are more appropriate.
Q. Must the process be defined in writing or defined in the medical staff bylaws?
A. The process would need to be pre-defined as EP 4 requires that focused professional practice evaluation be consistently implemented in accordance with the criteria and requirements defined by the organized medical staff. Since the process must be consistently implemented (EP 4), the organization may wish to put it in writing. There is no requirement that it be in the medical staff bylaws.
Q. What is the duration of the monitoring, e.g. can it be a twelve month provisional period?
A. With regard to establishing the monitoring plan specific to the requested privilege, and the possibility of using a twelve month provisional period, it is important to remember that there is no required provisional period. The provisional period when it was required related to appointment to the medical staff and not to privileges. Using a 12 month provisional period for focused review might be burdensome when the volume of activity is very large.
It may be more appropriate to consider a different approach for high volume vs. low volume privileges or high risk vs. low risk privileges for example performing a focused review for a defined number of admissions such as the first 5, 10, 20, etc, or a defined number of procedures, such as 5, 10, 20, etc, or for a short period of time such as 1 month or 3 months. For an infrequently performed privilege numbers might work better than a time period especially if the privilege isn't performed in that time period.
While the EP would require an evaluation of each new privilege it could be possible to group very similar activities together and then evaluate a set number of any mix of the privileges for example, any ten from the group will be evaluated to determine competence for the whole group, but you cannot just look at one privilege from the group.
The duration could also be different for different levels of documented training and experience, e.g.
- practitioners coming directly from an outside residency program
- practitioners coming directly from the organization’s residency program
- practitioners coming with a documented record of performance of the privilege and its associated outcomes
- practitioners coming with no record of performance of the privilege and its associated outcomes
Q. Can the focused review for new privileges be only for performance issues or when triggers occur?
A. A focused review/peer review process for new privileges, which is triggered by practice indicators which only relate to untoward outcomes, would not meet EP 1 for a focused practice review for all privileges for new applicants and new privileges for existing practitioners.
The bottom line principles are:
- The process must be defined
- The process must be consistently implemented as defined
- All new privileges (new applicants and new privileges for existing applicants) must be reviewed in accordance with the defined process
Focused Professional Practice Evaluation for Performance issues
Q. What is the distinction between performance issues and triggers and are there any examples?
A. The standard requires that organized medical staff develops criteria to be used for evaluating the performance of practitioners when issues affecting the provision of safe, high quality patient care are identified (EP 2).
In addition, the triggers that indicate the need for performance monitoring are clearly defined (EP 5). Triggers can be single incidents or evidence of a clinical practice trend.
There is a somewhat fine line between criteria and triggers but triggers are the very obvious issues, e.g., infection rates, sentinel events, perhaps complaints, other events that aren't sentinel like sponges left in during surgery, etc.
Criteria for performance issues might include but not be limited to:
- small number of admissions or procedures over an extended period of time that raise the concern of continued competence
- a growing number of longer lengths of stay than other practitioners
- returns to surgery
- frequent or repeat readmission suggesting possibly poor or inadequate initial management/treatment
- patterns of unnecessary diagnostic testing/treatments
- failure to follow approved clinical practice guidelines--may or may not indicate care problems but why the variance
- frequent or repeat readmission suggesting possibly poor or inadequate initial management/treatment
- patterns of unnecessary diagnostic testing/treatments
- failure to follow approved clinical practice guidelines--may or may not indicate care problems but why the variance
Issues affecting the provision of safe, high quality patient care and indicate the need for performance monitoring may be identified as part of the ongoing practitioner performance evaluation at MS.4.40.
They may also be that the negative or outlier data on a practitioner that will be used to identify the trigger that indicate the need for performance monitoring.
Q. Are there any required components for design of the focused evaluation process?
A. The four required components for design of the process are outlined in EP 3:
- criteria for conducting performance evaluations
- method for establishing the monitoring plan specific to the requested privilege
- method to determining the duration of performance monitoring
- circumstances under which monitoring by an external source is required
Since the process must be consistently implemented (EP 9), the organization may wish to put it in writing. There is no standard requiring that it be in the medical staff bylaws.
With regard to establishing the monitoring plan specific to the requested privilege it could either be pre-defined for different type of performance issues or triggers or it could be appropriate to allow the reviewers to recommend to the organized medical staff the type of monitoring and duration based on the issue under review.
Q. Are there any guidelines for how to collect information for evaluation?
A. The organization may choose to use the methodologies for collecting information outlined at MS.4.40 for ongoing professional practice evaluation:
- periodic chart review
- direct observation
- monitoring of diagnostic and treatment techniques
- discussion with other individuals involved in the care of each patient including consulting physicians, assistants at surgery, nursing, and administrative personnel.
Q. Is this really just the process that was historically called “Peer Review”?
A. The Joint Commission renamed “peer review” to be termed “Focused Review of Practitioner Performance” in 2004. The current term is now Focused Professional Practice Evaluation. If an organization's current "peer review" process includes the criteria to be used for identified performance issue (EP 2), defined triggers that indicate the need for performance monitoring (EP 5),the four required components outlined in EP 3, and the remaining requirements at EP's 4 and 6 - 9, it would meet the intent for the existing focused professional practitioner evaluation covered by EP's 2 - 9.