November 2013

Professional Practice Evaluation FAQs

The following frequently asked questions focus on medical staff professional practice evaluations.

Q: Why are we doing Professional Practice Evaluations?
A: The Joint Commission requires that the Medical Staff review physician competency on a regular basis. These reviews are then used for reappointment to the Medical Staff.

Q: What kind of evaluations are there?
A: The Focused Professional Practice Evaluation (FPPE) is performed for new members to the medical staff, if a new privilege is requested or if specific concerns are noted. Initial FPPE is a brief period looking at the basic safety and competence in exercising all privileges for new medical staff members. The Ongoing Professional Practice Evaluation (OPPE) is performed every 6 to 12 months to review current performance. OPPE is an ongoing period looking at just a few indicators of quality for each practitioner.

Q: What is being reviewed?
A: Each department or section chooses their own indicators for review. Chart review or direct observation may be used to complete the review. For specialties that do procedures, the indications, technique and complications may be reviewed. Clinical management may be used for medical specialties.

Q: What happens if practitioner quality issues are found?
A: Quality issues may trigger a Focused Professional Practice Evaluation based on the concerns found. For example, if a practitioner was found to have a high complication rate for a particular procedure, an FPPE may be developed to monitor or proctor these cases.

Q: Who gathers the data and evaluates the performance?
A: The data will be collected and monitored by the Quality Department. It will be made available to the practitioner for review and verification. The department chief, or their designee, will review and sign the performance review.
For questions about the professional practice evaluation process, contact Lucy Hammerberg, MD, Chief Quality Officer at NCH, at 847.618.4384 or