FPPEs

1. What Is a For Cause FPPE?

A For Cause FPPE (Focused Professional Practice Evaluation) is a tool for departments and leadership to help medical staff members and privilege-holders address a range of professional or clinical issues specific to that individual. FPPEs are structured evaluation processes used to assess clinical competence and professional behavior in specific areas of concern. They involve systematic monitoring through proctoring, coaching, and other interventions tailored to the individual's needs. The goal is to support improvement and ensure quality patient care through focused observation and feedback. For Cause FPPEs differ in scope from the standard initial proctoring FPPE:

Note: Standard initial FPPEs are those administered for all new applicants. These are routine credentialing evaluations required of all privilege-holders.

In contrast, For Cause FPPEs described in this FAQ are specifically triggered by unique identified professional or clinical concerns.

2. FPPEs Are Not Disciplinary Actions

At UCSF, FPPE is not considered a disciplinary or punitive process. As such, any cost of conducting the FPPE must be borne by the clinical department.

FPPEs differ from Behavior Agreements in that Behavior Agreements typically address conduct and professionalism issues through a formal agreement with specific behavioral expectations, while FPPEs are evaluative processes focused on clinical competence and professional practice.

This FAQ applies to UCSF Medical Staff; individual sites (including Stanyan, Hyde, and Oakland) may have variations in their implementation and should be consulted for site-specific policies.

3. Why Are FPPEs Established?

FPPEs can be initiated for a broad number of reasons, related to issues with:

  • Professionalism and Communications (i.e. Incident Reports or peer reference responses regarding trainees, colleague, nursing, staff, and/or learner interactions)
  • Patient Complaints (i.e. excessive number or singular instances of patient concern)
  • Medical Record Documentation (i.e. deficiencies in content, or delinquency in completing medical records)
  • Clinical Performance (i.e. M&Ms, quality metrics, OPPE review, poor outcomes, prescribing patterns, direct observation)
  • Privacy/Compliance Issues
  • FPPEs may be recommended by the department, the Professionalism Committee or the Credentials Committee

4. What is Specifically In an FPPE

An FPPE's components must be tailored to the issues identified by leadership for an individual, and typically include some subset of the following:

  • Proctoring (Direct, or done by chart review/tracking clinic visits)
  • Coaching (can be intradepartmental, conducted through Learning and Organization Development at UCSF (LDO), or an outside coach)
  • Coursework (either online or in-person, and specific to the matter at hand). Resources for FPPE plans may include UCSD PACE (Professional Assessment and Continuing Education), UCI PBI (Physician Behavior Institute), and other institutional programs that have been utilized for structured development and remediation.
  • Interviews (anonymous interviews of trainees, colleague, nursing, staff, and/or learner interactions)
  • 360 Evaluation (conducted by LDO); note that external coaches may utilize their own proprietary 360 evaluation tools in addition to or instead of LDO's evaluation
  • APEX Peak Training
  • Changes to clinical load and work patterns

5. What Performance Metrics Should Be Evaluated?

Key Considerations for Metrics:

  • Set metrics/expectations specific to the proctoree's situation
  • Metrics should have clear timeline and check-in points
  • Create a clear list of explicit outcome measures and a corresponding checklist

For Cause FPPE Workflow

 

 

 

Credentials Committee / OMAG Responsibility

 
Department Responsibility
Share FPPE Templates
  1. Credentials Committee/OMAG provides FPPE templates to department
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Department Initiates FPPE Draft
  1. Identify and assign proctor
  2. Notify proctor and OMAG of FPPE Draft
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Review FPPE Draft
  1. Department meets with Credentials Committee Chair (15 minute Zoom)
  2. Revise draft as needed
↓
Review and Provide Feedback
  1. Credentials Committee reviews FPPE draft and provides feedback
↓
Present to Credentials Committee
  1. Department presents FPPE to Credentials Committee for approval
↓
Final Approval
  1. Credentials Committee approves FPPE plan
  2. Forward to President of Medical Staff/Chancellor for final approval
↓
Inform Subject and Begin FPPE
  1. Department informs and meets with the FPPE subject regarding their FPPE
  2. Notify OMAG that meeting has occurred
  3. THE FPPE OFFICIALLY BEGINS AFTER THIS MEETING
↓
Send Formal Letter
  1. Credentials Committee Chair sends formal letter to subject and proctor
  2. Letter with FPPE attached goes in internal credentials file
  3. Sent AFTER confirmation that FPPE has begun
↓

Ongoing FPPE Implementation

Department Actions

  • Send email updates to OMAG/Credentials Committee as needed
  • Present formal updates at monthly Credentials Committee meetings
  • Meeting time: 3:30-5:00 PM, Third Tuesday of each month

Committee Actions

  • Check for updates as indicated in the plan
  • Monitor FPPE progress
  • Provide ongoing oversight
↓
FPPE Completion
  • When FPPE is deemed complete, Credentials Committee/OMAG sends completion letter to the doctor
  • Completion letter is filed in internal credentials file

Note: This diagram represents the chronological workflow. The process involves collaboration between the Credentials Committee/OMAG and the Department throughout all stages, with handoffs occurring at each major milestone.