POLICY AND GUIDELINE
TOMAH MEMORIAL HOSPITAL
Tomah, Wisconsin 54660
DIVISION: Leadership
P&G #: 100-MSF-002-0113
ORIGINATION DATE: 7/01/97
TITLE: Focused Professional Practice
Evaluation
PAGE: 1 of 5
DATE:
Author
Approved By:
DATE:
Administrative Team Leader
DATE:
Medical Staff President
01. INVOLVES
Medical Staff
Administration
Quality
Medical Records
02. PURPOSE
To establish a systematic process to ensure that there is sufficient information available to confirm the current
competency of practitioners granted privileges at Tomah Memorial Hospital. This process, termed Focused
Professional Practice Evaluation (FPPE) will provide the basis for obtaining organization-specific information
of current competence for those practitioners.
FPPE defined: A specifically defined method of determining competency of an individual practitioner when
the organization either has no first-hand data or the data it does have suggests a potential issue. FPPE includes
the following criteria:
 Criteria for conducting performance monitoring
 Method for establishing a monitoring plan specific to the requested privilege
 Method for determining the duration of performance monitoring
 Circumstances under which monitoring by an external source is required
Information for focused professional practice evaluation may include chart review, monitoring clinical practice
patterns, simulation, proctoring, external peer review, and discussion with other individuals involved in the
care of each patient (e.g., consulting physicians, assistants at surgery, nursing or administrative personnel).
Relevant information resulting from the focused evaluation process is integrated into performance
improvement activities, consistent with the organization’s policies and guidelines that are intended to preserve
confidentiality and privilege of information.
P&G #: 100-MSF-002-0113
TITLE: Focused Professional Practice Evaluation
PAGE: 2 of 5
03. POLICY
It is the policy of Tomah Memorial Hospital Medical Staff to define the circumstances requiring monitoring
and evaluation of a practitioner’s professional performance.
MEDICAL STAFF OVERSIGHT
The Credentials Committee shall be responsible for maintaining this policy and the Focused Professional
Practice Evaluation process. FPPE shall be administered by the medical staff office or the quality department
as applicable. The Medical Staff is ultimately held responsible for FPPE.
The Credentials Committee accomplishes oversight be receiving regular status reports related to the progress of
all practitioners required to be proctored as well as any issues or problems involved in implementing this
policy.
The medical staff committees involved with OPPE (Ongoing Professional Practice Evaluation) will provide the
Credentials Committee with data that are systematically collected for OPPE for practitioners, as appropriate, at
reappointment. OPPE data is provided on a six-month basis to the Medical Executive Committee.
The focused professional practice review time period shall be for up to one year and re-evaluate assignment
after one year. Those with low/no volume activity in the FPPE process shall be asked of their intentions for
future activity at this facility.
04. GUIDELINES
A. WHO IS PROCTORED
All providers granted privileges will be proctored under Focused Professional Practice Evaluation,
including:
1.
2.
3.
Initially granted clinical privileges.
Privileges for which the practitioner seeks, but has not yet performed the procedure at this
organization in the past.
There is a concern regarding the practitioner’s current competency, either due to data from an
ongoing professional practice evaluation or because the practitioner has not exercised the privilege
in question for an extended period of time.
B. METHODS
Proctoring may be performed using prospective, concurrent or retrospective approaches. Providers who
most often provide cognitive care, as opposed to procedural care, are usually evaluated prospectively or
retrospectively. Prospective proctoring and concurrent proctoring are the preferred methods of evaluating
practitioners who request privileges to perform various procedures. The appropriate proctoring methods for
an individual practitioner will be determined by the Credentials Committee or the MSEC as applicable.
P&G #: 100-MSF-002-0113
TITLE: Focused Professional Practice Evaluation
PAGE: 3 of 5
C. DURATION
Proctoring shall begin with the first admissions or performance of a newly requested privilege. Newly
granted privileges shall be considered under FPPE either for a specific period of time or for a specific
number of cases based on the recommendation of the Credentials Committee. The Credentials Committee
may alter this as needed. The proctoring period may be extended for a period to be determined if initial
concerns are raised that require further evaluation or if there is insufficient activity during the initial period.
In the event that the Peer Review Committee recommends FPPE due to a quality concern discovered in
OPPE, the Peer Review Committee will determine the extent and duration of the FPPE on an individual
case basis and be responsible for the on-going monitoring.
D. APPLICANT EXPERIENCE
The practitioner’s previous experience should be taken into account in determining the approach and extent
of proctoring needed to confirm current competence.
E. TOMAH MEMORIAL HOSPITAL-SPECIFIC CRITERIA
1. When the organization cannot reasonably conduct on-site proctoring, evidence of credential status from
a hospital with which the provider is affiliated is used.
2. If formal proctoring reports are not available from the hospital with which the provider is affiliated for
reciprocal proctoring, a Tomah Memorial Hospital Proctor Inquiry From Affiliated Hospital Form will
be requested from the provider's department chairman or colleague at 6 months and 12 months after
privileges granted.
3. Evidence of proctorship from a hospital with which the provider is affiliated may be used to
supplement actual in-house observation.
o The proctor shall be a member in good standing on the Medical Staff/Allied
Health Professional Staff, as appropriate, and must have unrestricted privileges to
perform any procedure/s to be concurrently observed.
o The Medical Staff President will assign the appropriate proctor to the provider.
The provider will be informed of the proctoring process at the time of the
provider's orientation, at the time of granting of any subsequent privileges, or at
the time of a focused review for questionable performance or no
/low volume activity. The provider will be asked to sign a proctoring liability
release form.
P&G #: 100-MSF-002-0113
TITLE: Focused Professional Practice Evaluation
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F. PROCTOR RESPONSIBILITIES
1. Commitment.
2. Prospective, concurrent review with direct observation, which may include direct clinical observation,
or retrospective review.
3. Selection of Proctor will be based on specialty and privileges granted.
4. The name of the proctor shall be kept confidential except for those directly involved in the proctor
process and proctor records.
5. A Proctoring Waiver from Release of Liability form will be signed by the provider.
6. Proctor Report forms will be sent to the Proctor directly for completion, non-surgical and surgical, as
applicable. Forms are to be completed in their entirety.
G. PROCTORING CRITERIA FOR GRANTING OF INITIAL PRIVILEGES
1. For the time period defined, a review of charts for a total minimum of 10 charts, including same day
surgery and observation, with a majority being inpatient admission charts, from a representative sample
of patient care types and criticality levels. Proctoring reports shall include a review of core and
supplemental privileges.
2. For ED/UC physicians or ED/UC allied health professional staff, a review of a total minimum of 20
charts with a representative sample of patient care types and criticality levels including pediatrics,
major traumas, cardiorespiratory and other.
3. For locum tenens physicians, a Proctorship Program – Summary Report shall be completed if there is
not sufficient time or cases for the normal proctoring process evaluation.
4. If the required number of charts for proctor review is not available, then a summary report from the
Proctor shall be completed.
5. If a quality problem is determined in the proctoring process, this information is sent to the Credentials
Committee. The information is then forwarded to the Medical Staff Executive Committee.
If at any time during the FPPE process the Medical Staff Executive Committee determines that the
provider is not competent to perform specific clinical privileges and his/her continued exercise of
those privileges jeopardizes patient safety, the Medical Executive Committee shall make a
recommendation regarding the provider's continued appointment and clinical privileges. If
necessary, the clinical privileges of the provider may be summarily suspended as outlined in the
Medical Staff By-Laws.
P&G #: 100-MSF-002-0113
TITLE: Focused Professional Practice Evaluation
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6. At the end of the FPPE process, the proctor shall provide a summary report to the Credentials
Committee that shall include the following:
a. Whether a sufficient number of cases have been presented according to established criteria.
b. Whether in the proctor's opinion, the FPPE process should be extended for an additional
period.
c. If sufficient treatment of patients has occurred to properly evaluate the clinical privileges
requested, the proctor shall make his/her recommendation regarding the provider
qualifications and competence.
H. PROCTORING CRITERIA FOR ADDITIONAL PRIVILEGES REQUESTED
1. To be determined on individual case basis.
I. PROCTORING CRITERIA FOR QUESTION OF COMPETENCY DUE TO DATA RECEIVED OR
HAS NOT EXERCISED PRIVILEGE FOR AN EXTENDED PERIOD OF TIME.
1. To be determined on individual basis
05 FORMS
Forms are available in the Credentialing office