What are the Dangers of FPPE's?

According to the Joint Commission, A "Focused Professional Practice Evaluation (FPPE) is a process whereby the medical staff evaluates the privilege-specific competence of the practitioner that lacks documented evidence of competently performing the requested privilege(s) at the organization. This process may also be used when a question arises of a currently-privileged practitioner's ability to provide safe, high quality patient care."

In the context of an already privileged physician, FPPE's come under the aegis of peer review, discipline or at best corrective assistance and risk reduction.  

But lurking within these essential processes is an acronym that can strike fear into the hearts of even the most seasoned practitioners: FPPE, or Focused Professional Practice Evaluation. While often seen as a routine part of maintaining hospital privileges, an FPPE, if not navigated carefully, can quickly escalate from a supportive quality improvement tool to a direct pipeline to severe disciplinary action, including license suspension or even revocation.

What is FPPE, Really?

At its core, FPPE is a structured, time-limited assessment of a physician's performance. It's typically triggered by a specific concern – perhaps an increase in complications, unusual prescribing patterns, or a handful of patient complaints. The goal is to identify areas where a physician might need additional support, education, or remediation to ensure they are practicing safely and effectively.

Read What the Joint Commission Says About FPPE's

Sounds benign, right? In many cases, it is. A well-executed FPPE can help a physician improve their practice and ultimately benefit patients. However, the process is far from foolproof, and missteps at any stage can have devastating consequences.

The Slippery Slope: When FPPE Turns Perilous

An FPPE can be imposed in good faith but it is often a step toward termination.  Behind many FPPE's are lawyers who are using the process to justify future discipline.  We find that this is the situation in more than half the cases that come to our office.  This many not be a representative sample obviously but it does give us a healthy skepticism about the process.  

Here's how an FPPE, intended to be a constructive process, can quickly morph into a disciplinary nightmare:

1. Poorly Defined Triggers and Scope: Sometimes, an FPPE is initiated with vague concerns or an overly broad scope. This makes it difficult for the physician to understand what specific areas need improvement and how to address them effectively. Without clear targets, the FPPE can feel like a fishing expedition, increasing frustration and the likelihood of a negative outcome.

2. Lack of Transparency and Due Process: The cornerstone of any fair evaluation is transparency. If a physician isn't fully informed about the specific concerns, the evaluation methodology, or the metrics being used, they are at a severe disadvantage. Furthermore, a lack of clear due process – such as the opportunity to respond to findings or appeal decisions – can leave a physician feeling railroaded and without recourse.

3. Biased or Inexperienced Evaluators: The individuals conducting the FPPE play a critical role. If evaluators have pre-existing biases, a personal agenda, or lack the necessary expertise in the physician's specialty, the evaluation can be skewed. This can lead to unfair assessments and recommendations that don't accurately reflect the physician's practice.

4. Inadequate Support or Resources for Remediation: An FPPE should ideally be coupled with resources and support for improvement. If a physician is identified as needing remediation but isn't provided with appropriate educational opportunities, mentorship, or time to implement changes, the FPPE becomes a punitive measure rather than a corrective one. Failure to improve under these circumstances can then be cited as a reason for further disciplinary action.

5. Failure to Meet "Acceptable" Improvement: The most direct path to severe discipline is the determination that the physician has failed to demonstrate sufficient improvement during or after the FPPE. This judgment can be subjective, and if the initial concerns were not clearly defined or the evaluation process flawed, a physician may be deemed to have failed even if they made good faith efforts to address the issues.

6. Automatic Reporting Requirements: Many hospitals and medical boards have strict reporting requirements. If an FPPE results in a suspension or restriction of privileges, even if temporary, it can trigger an automatic report to the National Practitioner Data Bank (NPDB) and/or the state medical board. Once reported, these actions become part of a physician's permanent record, making it challenging to secure future employment or maintain a clear license.

7. Escalation to Formal Disciplinary Hearings: A negative outcome from an FPPE often serves as the basis for a formal disciplinary hearing by the hospital's medical staff or an investigation by the state medical board. At this stage, the stakes are incredibly high, with the potential for:

   • Loss of Privileges: Permanent or long-term removal of the ability to practice at a specific facility.
   • License Restrictions: Limitations on the scope of practice, requiring supervision, or prohibiting certain procedures.
   • License Suspension: Temporary inability to practice medicine.
   • License Revocation: The complete and permanent loss of the right to practice medicine.

Protecting Yourself: Proactive Steps are Key

Given the potentially severe consequences, physicians must take an FPPE seriously from the outset.

• Understand the "Why": As soon as you are notified of an FPPE, demand a clear and specific understanding of the concerns that triggered it.
• Seek Legal Counsel Immediately: Do not underestimate the seriousness of an FPPE. Consulting with an attorney experienced in medical staff issues and licensing defense is crucial. They can help you understand your rights, navigate the process, and advocate on your behalf.
• Document Everything: Keep meticulous records of all communications, meetings, and actions taken during the FPPE process.
• Be Engaged and Proactive: Demonstrate a willingness to cooperate and address the concerns. If remediation is recommended, actively participate and seek out resources to improve.
• Address Underlying Issues: If there are systemic or personal factors contributing to the concerns, be honest and seek appropriate support (e.g., stress management, re-education).

An FPPE is not just a bureaucratic exercise; it's a critical juncture in a physician's career. While designed to enhance patient safety and physician performance, a poorly managed or unfairly conducted FPPE can quickly transform into a direct threat to a physician's livelihood and professional standing. By understanding the risks and taking proactive steps, physicians can better protect themselves and ensure that an FPPE remains a tool for improvement, not a path to severe discipline.

Daniel Horowitz and his medical lawyers defend physicians at all stages of discipline, peer review and board matters.  Call us early if you can.  We are most effective when we are not under time pressures.  However, in most cases we are contacted when "the sky is falling" and we are expert in assisting doctors on short notice.