Joint Commission Rules for FPPE's
What is the Joint Commission?
Before we define an Joint Commission, FPPE let's first describe and define the Joint Commission as an entity. What is it and what powers does it have?
If you are impatient and want to jump to the specific Joint Commission FPPE rules, you can jump here to the Joint Commission's own statement on the topic. In general the Joint Commission states that Focused Professional Practice Evaluation (FPPE) is a mandatory Joint Commission process designed to evaluate a practitioner's privilege-specific competence when evidence is lacking, such as with new hires, new privilege requests, or for-cause concerns. Key rules require a defined, consistently applied process (not necessarily identical for all) focusing on data-driven monitoring methods, such as chart reviews or Proctoring, to ensure quality care,
But this definition is of limited use in the real world where FPPE's are used differently by different institutions and can vary hospital by hospital even if both hospitals are accredited by the commission.
So this brings us back to the initial question - What exactly is the "Joint Commission"?
The Joint Commission is known throughout the medical field as the most important organization for ensuring the quality and safety of our healthcare system. It was established in 1951. Despite its government type influence, the Joint Commission has been and still is an independent, not-for-profit organization dedicated to setting high standards for healthcare excellence. It oversees the accreditation of more than 22,000 healthcare organizations across the United States, including hospitals, clinics, and other medical facilities.
To the patient the Joint Commission is largely invisible but it has daily influence through a rigorous quality control system that requires healthcare organizations to meet strict criteria for patient safety, treatment effectiveness, and operational excellence.
The weakness is enforcement because hospitals will hire professionals to meet the standards on the surface regardless of whether this technical compliance is truly carried out on a day to day basis. As television host Nancy Grace says, “You can’t put perfume on a pig” but unfortunately some facilities do this and get away with it.
When there are patient care failures or when a doctor is targeted by a hospital, the Horowitz office will look at Joint Commission rules governing the procedure or situation. If the hospital or medical facility is out of compliance or just putting perfume on a pig, we can use that to put responsibility where it belongs which his on the facility and its administration.
Among the most important rules of the Joint Commission are risk avoidance requirements.
The Joint Commission sets strict guidelines to minimize risks requiring basic things like infection control and protection against SSI’s which are Surgical Site Infections. Physician supervision including privilege rules, Focused Professional Practice Evaluation and review, reporting of major adverse events called “Never Events” or “Sentinel Events” are all part of the Joint Commission rules.
A healthcare facility cannot be accredited by the Joint Commission if it fails to substantially comply with the rules.
Federal funding for healthcare organizations can depend on Joint Commission compliance. To receive federal payments from Medicare or Medicaid, a healthcare organization must meet the government's health and safety requirements, known as Conditions of Participation (CoPs) or Conditions for Coverage (CfCs).
Is the Joint Commission FPPE Definition Controlling in All Circumstances?
Here is the key. The Joint Commission is not a governmental agency. It's definitions of an FPPE are tremendously persuasive but not law.
Organizations can achieve certification through a survey conducted by a state agency or by a national accrediting body like the Joint Commission, which has been recognized by the Centers for Medicare & Medicaid Services (CMS) as meeting or exceeding Medicare’s requirements. This process, known as deemed status, allows accredited organizations to qualify for federal reimbursement. There are other accreditation organizations including DNV (Det Norske Veritas), which offers annual on-site surveys, or the Center for Improvement in Healthcare Quality (CIHQ). Other options include HFAP (Healthcare Facilities Accreditation Program) for osteopathic hospitals and ACHC (Accreditation Commission for Health Care) for specialized services. In that instance the Joint Commission rules might be followed but would not be mandatory for accreditation.
Here is an outline of FPPE standards.
Joint Commission FPPE: This is a strictly defined, mandatory process required for all new practitioners or those requesting new privileges. It is also triggered when issues regarding a practitioner's ability to provide safe, high-quality patient care are identified. It is a formal, time-limited period of evaluation.
Normal (General) FPPE: Often referred to in hospitals as "proctoring" or "onboarding oversight," this might be less structured depending on the facility’s bylaws. Without TJC's specific mandates, it might simply be an informal period of supervision by a department head without the rigorous data-tracking requirements.
MS.08.01.01
Under Joint Commission standards MS.08.01.01, there are two specific instances where an FPPE must be implemented:
Initial Granting of Privileges: Every single practitioner new to an organization (or an existing practitioner requesting a new specialty privilege) must undergo an FPPE. This is a standard practice and there is absolutely nothing negative about this being imposed. It is not a "cause" FPPE which is where discipline and negative implications can arise.
"For Cause": If a peer review or internal monitoring identifies a performance trend or a single "sentinel event" that raises concerns about a practitioner’s clinical performance, a focused evaluation is triggered. By-laws among Joint Commission governed hospitals can and usually do define when an FPPE is a reportable event; discipline or simply a type of training or internal process that does not have immediate license implications. (However any for cause FPPE can be a prelude to discipline.
In a non-accredited or more loosely governed environment, an evaluation might only happen if there is a glaring problem, rather than as a universal requirement for all new staff.
Peer Review Integration
In a Joint Commission environment, the FPPE is a core component of the peer review process. The results must be used to make a data-driven decision:
Grant the privileges fully.
Extend the evaluation period.
Limit or revoke the privileges.
Again this starts in a complete benign manner. Everyone goes through the initial FPPE process. However the same term can also apply when someone is already credentialed and that status is called into question. This is the punitive FPPE.
UCSF By-Laws define what we call a punitive FPPE as follows:
"FPPE processes are used to evaluate, for a time-limited period, a Practitioner's professional performance or professionalism to include quality of care, patient safety and unprofessional behavior."
UCSF indicates that this type of cause (we say punitive) FPPE "is not normally imposed as a form of discipline but rather to assess competency/professionalism". So on a case by case basis, a UCSF FPPE may be disciplinary - or not.
Again relying on UCSF whose rules are very well expressed and are representative of how most institution function - what are the sources of information upon which an FPPE can be based? UCSF says it includes, discussion with other individuals involved in the care of each patient (e.g. consulting physician, assistants in surgery, nursing, or administrative personnel); Chart review, review of Ongoing Professional Practice Evaluation (OPPE) and review of malpractice claims. Monitoring clinical practice patterns Direct observation of practitioner; Simulation ; External peer review.
For comparison you can read the Stanford FPPE rules. These rules define two committees from medical staff that conduct these reviews:
Professional Practice Evaluation Committee (PPEC) is a peer review committee authorized to conduct peer review for providers within a designated clinical service or services.
Care Improvement Committee (CIC) is designated as the parent PPEC and is ultimately accountable to the Medical Executive Committee and the SHC Board of Directors for oversight of the peer review processes of all clinical services (i.e. all of the PPECs). Services, divisions and/or interdisciplinary groups may form PPECs when approved by the CIC.
Daniel Horowitz is the leading peer review, FPPE and medical license attorney for doctors in California. His leadership in championing physician independence is legendary. If you need help call Daniel for help. You worked years to earn your license let Daniel Horowitz protect what you have earned.
