Department of Veterans Affairs
Medical Center
Wilkes-Barre, Pennsylvania 18711
POLICY 11C-11-37
February 23, 2011
ONGOING PROFESSIONAL PRACTICE EVALUATION AND FOCUSED
PROFESSIONAL PRACTICE EVALUATION
1. SCOPE/EFFECT: This new Medical Center Policy (MCP) applies to all Licensed
Independent Providers (LIP) and Advanced Practice Providers (APP). Services
affected are, Geriatrics and Extended Care Service, Medical Service, Mental Health and
Behavioral Service, Primary Care Service including community outpatient clinics, Dental
Service, Imaging Service, Pathology and Laboratory Medicine Service and Surgical
Service.
2. PURPOSE: To provide guidance regarding the ongoing professional evaluation and
focused professional evaluation for Licensed Independent Providers.
3. POLICY:
a. The professional practice of licensed independent practitioners with clinical
privileges will be evaluated according to criteria approved by the medical staff. This
evaluation will be applicable to all physicians, dentists, podiatrists, optometrists and
psychologists. This policy also applies to the following practitioners with scopes of
practice: nurse practitioners, clinical nurse specialists, nurse anesthetists, and physician
assistants.
Exception: The following providers are exempt from Ongoing Professional Practice
Evaluations:
(1) Providers who are credentialed with no clinical privileges and no patient care
activity. (e.g. Researchers)
(2) Providers who have the privileges to read patient medical records but do not
participate in patient care. (e.g. Researchers)
(3) Providers who conduct limited patient interviews but do not prescribe patient
care treatment.
b. An “ongoing” professional practice evaluation will be conducted on an annual
basis for all providers to assess their competency related to an existing privilege(s) or
scope(s) of practice, or to revise or revoke an existing privilege(s) or scope(s) of
practice prior to or at the time of renewal.
c. A “focused” professional practice evaluation will be conducted on all new
providers who are starting employment at the VAMC Wilkes-Barre, when a provider
requests new clinical privileges or scopes of practice, and when issues affecting the
provision of safe, high quality patient care are identified.
4. DEFINITIONS:
a. Professional Practice Evaluation is a process that requires monitoring and
evaluation of a provider’s professional performance to ensure that the provider is
delivering safe and high quality patient care. The evaluation is comprised of six areas
of general competencies as established by the joint initiative of the Accreditation
Council for Graduate Medical Education (ACGME) and the American Board of Medical
Specialties that include:
(1) Patient Care: provides patient care that is compassionate, appropriate and
effective for the promotion of health, prevention of illness, treatment of disease, and
care at the end of life.
(2) Medical/Clinical Knowledge: demonstrates knowledge of established and
evolving biomedical, clinical and social sciences, and applies knowledge to patient care
and the education of others.
(3) Practice-Based Learning and Improvement: uses scientific evidence and
methods to investigate, evaluate, and improve patient care practices.
(4) Interpersonal and Communication Skills: demonstrates interpersonal and
communication skills to establish and maintain professional relationships with patients,
families, and other members of the health care team.
(5) Professionalism: demonstrates behaviors that reflect a commitment to
continuous professional development, ethical practice, an understanding and sensitivity
to diversity, and a responsible attitude toward patients, the medical profession, and
society.
(6) Systems-Based Practice: demonstrates an understanding of the contexts and
systems in which health care is provided, and the ability to apply this knowledge to
improve and optimize health care.
b. “Ongoing” Professional Practice Evaluation is a process that continuously
evaluates a practitioner’s professional performance to identify practice issues that may
impact quality of care and patient safety. Ongoing professional practice evaluation is an
evidence-based privilege renewal process and is part of a decision-making process that
will be used on an annual basis to continue a provider’s existing privilege(s) or scope(s)
of practice, or to limit or revoke existing privilege(s) or scope(s) of practice prior to or at
the time of renewal. Electronic databases may be accessed to assess professional
practice related to:




Operative and other clinical procedures performed and their
outcomes
Blood and pharmaceutical usage
Requests for tests and procedures
Length of stay patterns
2





Morbidity and mortality data
Use of consultants
Performance measures
Student supervision
Medical record management, etc.
Other information that may be added by the service to an ongoing professional
practice evaluation may include:






Periodic chart review
Direct observation
Monitoring of diagnostic and treatment techniques
Discussion with other individuals involved in the care of each
patient including consulting physicians, surgical assistants, and
nursing and administrative personnel.
Compliance with hospital policies.
Compliance with mandatory training.
c. “Focused” Professional Practice Evaluation will be conducted on all new
providers who are starting employment at the VAMC Wilkes-Barre that focuses on
specific aspects of a practitioner’s performance. This is a time-limited process (90 days
for new hires), that will be used when a practitioner has the credentials to suggest
competence, but additional information or a period of evaluation is needed to confirm
competence in the organization’s setting. A focused professional practice evaluation
will also be used when a provider requests new clinical privileges or scopes of practice
or if questions arise regarding a practitioner’s professional practice that affect the safety
or quality of patient care. The decision to assign a period of performance monitoring to
further assess current competence is based on the evaluation of a practitioner’s current
clinical competence, practice behavior, and ability to perform requested privileges or
scope of practice. The focused professional practice evaluation is to be discussed with
the provider, the form is to be signed by the provider, and a copy of the signed focused
professional practice evaluation is to be given to the provider. The time period for
review may be extended if performance issues have not been fully resolved.
Information for a focused professional practice evaluation may include:






Chart review
Monitoring clinical practice patterns
Simulation
Proctoring
External peer review
Discussion with other individuals involved in the care of each patient
(e.g. consulting physicians, surgical assistants, nursing or
administrative personnel).
3
d. Triggers are single incidents or evidence of a clinical practice pattern that
generate a need for performance monitoring. Triggers for a “focused” professional
practice evaluation will be initiated when:
(1) A new employee with clinical privileges or a scope of practice has the
credentials to suggest competence, but additional information or a period of evaluation
is needed to confirm the new employee’s competence in the organization’s setting.
(2) An employee has requested a new clinical privilege or scope of practice.
(3) A practitioner requires supervision for a new procedure or modality to be
performed at the VAMC Wilkes-Barre.
(4) The service has questioned a practitioner’s competency in relation to a sentinel
event, a provider-specific tort settlement, a substantiated practitioner-specific complaint,
a significant safety violation, or repeated or egregious unprofessional behavior.
(5) Concerns have been raised by the Ethics Committee or Medical Executive
Committee regarding the performance of one or more practitioners.
5. PROCEDURE:
a. Professional practice evaluations will be conducted to assess a provider’s
performance in the following six areas: patient care, medical/clinical knowledge,
practice-based learning and improvement, interpersonal and communication skills,
professionalism, and systems-based practice.
b. An electronic professional practice evaluation form will be generated by the
Service for every provider who is due for an ongoing or focused professional practice
evaluation (please see example Attachments A and B).
c, Data from electronic databases (if available for the provider) will be entered on
the professional practice evaluation form by the Service.
d. Each provider’s performance will be rated by the Service Chief as:


Fully Satisfactory (meets performance expectations); or,
Unsatisfactory (fails to meet a few or several performance expectations).
e. Ongoing and focused professional practice evaluations will be addressed with
the provider and the provider will receive a copy of the evaluation; the focused
professional practice evaluation is to be signed by the provider. Issues that have been
identified by the Service along with recommendations for performance improvement will
be referred to the Credentialing & Privileging Committee reports to the Medical
Executive Committee. When a provider’s performance does not meet expectations, the
Credentialing & Privileging Committee as appropriate will review the action(s) for
performance improvement as recommended by the Service, and any additional actions
recommended by the Committee will be documented in the Committee meeting minutes
4
for follow up by the Service. Unresolved clinical practice problems may result in a
reduction or loss of clinical privileges or scope of practice. Practitioners have access to
a fair hearing and appeal process as defined in the medical staff bylaws.
f. When appropriate clinical expertise for oversight of a provider’s practice is not
available in-house, the Credentialing and Privileging Committee may recommend
assistance by an external source (e.g. another VAMC).
g. The length of time for a focused professional practice evaluation will be
determined by the Credentialing & Privileging Committee as appropriate. When the
Credentialing & Privileging Committee determines that the provider is clinically
competent to safely provide the patient care services, the provider may be converted
from the focused professional practice evaluation to the ongoing professional practice
evaluation process.
h. Ongoing professional practice evaluation forms performed at the time of
recredentialing and focused professional practice evaluation forms with patient
identification sanitized will be submitted by the Service to the Credentialing & Privileging
Office for review by the Credentialing & Privileging Committee. The original evaluation
form will be kept in the Credentialing & Privileging file. The supporting documentation
including patient identification will be kept at the Service in the provider profile.
i. Ongoing professional practice evaluations will be conducted annually during the
month of the provider’s credentialing date; however, the Service or the provider can
request a provider-specific report at any time.
j. Annual ongoing professional practice evaluation forms and supporting
documentation will be kept at the Service in the provider profile. Any type of trigger
found will be reported appropriately to the Credentialing & Privileging Committee.
6. RESPONSIBILITIES:
a. The Chief of Staff and Service Chiefs are responsible for ensuring that ongoing
and focused professional practice evaluations are conducted for all providers.
b. The Medical Executive Committee and Credentialing & Privileging Committee
are responsible for evaluating the professional practice of all providers and determining
actions for performance improvement of providers to ensure patient safety. When a
particular concern has been raised by the Medical Executive Committee or
Credentialing & Privileging Committee about the performance of one or more providers,
a focused review can be conducted to monitor and improve performance.
c. Service Chiefs/Section Chiefs/Supervisors are responsible for conducting
professional practice evaluations with providers to assess their performance, identify
when performance does not meet expectations, and initiate appropriate action to
improve performance.
5
d. Providers are responsible for meeting performance expectations. When their
performance does not meet expectations, providers are responsible for improving their
performance. Providers are also responsible for performing peer review evaluations on
other providers for ongoing professional practice evaluations and focused professional
practice evaluations when assigned by Chief of Staff, Service Chiefs/Section
Chiefs/Supervisors.
7. CUSTOMER SATISFACTION: No impact on patient/family satisfaction.
8. REFERENCES: Joint Commission Hospital Accreditation Standards and Updates
9. RESCISSION: Medical Center Policy 11-08-37 dated November 5, 2008, same
subject.
10. DISTRIBUTION: Electronic Access to All Employees
11. ATTACHMENT: A
OPPE template
EXAMPLE A-.doc
ATTACHMENT: B
FPPE EXAMPLE B.doc
ATTACHMENT: C
6
7