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How to Meet Professional Practice Evaluation Requirements During a Pandemic


Robert Campbell, PharmD, director, Clinical Standards Interpretation for Hospital/Ambulatory Programs 

Editor’s Note: This blog post is part of The Joint Commission’s daily communication on issues relevant to organizations managing the COVID-19 pandemic. The full list of FAQs is available here. All examples are for illustrative purposes only.

What options do health care organizations have for meeting the Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) requirements when operating under their emergency operations plan?

Focused Professional Practice Evaluation 
FPPE is the process by which the medical staff evaluates privilege-specific competency.  Modifying or bypassing the FPPE process may create risk to the delivery of safe, quality care.  Therefore, the evaluation of Licensed Independent Practitioners (LIPs) currently under FPPE should continue per the defined medical staff process.

FPPE requirements(*) apply to:

  • practitioners new to the organization requesting initial privileges
  • currently privileged practitioners requesting additional privileges
  • practitioners who have been placed under an FPPE plan in response to performance concerns

* This does NOT apply to disaster privileges.

Ongoing Professional Practice Evaluation
To the extent possible, practitioner performance data collection for OPPE should continue based on the established process. 

If gaps in data occur as a result of a temporary reallocation of resources, the organization should document the contributing factors leading to such gaps.
If resources are unavailable to review the data within the defined time frames, the organization may temporarily modify the review process until such time resources can be re-allocated back to resume the process as designed. 

Any modifications to the review process should allow the medical staff to detect and address downward trending performance. Examples may include:

  • review of incident reports
  • staff/patient complaints
  • post-procedure complications
  • sentinel or other events resulting in negative patient outcomes

The organization should periodically reassess the availability of resources to determine when the OPPE data collection and review process can resume as designed.
Emergency management (EM) standard EM.02.02.13 at element of performance (EP) 4 requires the medical staff to oversee the performance of volunteer LIPs granted disaster privileges. 

The oversight process must be defined, in writing, and replace the 'traditional' FPPE/OPPE processes. Examples of ways such oversight may be accomplished may include, but are not limited to:

  • direct observation
  • mentoring
  • medical record review

The organization determines any documentation requirements associated with their defined oversight process.

Additional Resources
FAQ: Requirements for Granting Privileges During a Disaster
FAQ: Credentialing and Privileging - Temporary Privileges

Coronavirus (COVID-19) Guidance and Resources