Applies To: All HSC Hospitals
Responsible Department: Office of Clinical Affairs; Quality
Management
Title: Professional
Patient Age Group:
Practice Evaluations, Medical Staff
Procedure
N/A
DESCRIPTION/OVERVIEW
This document details the process for medical staff Focused Professional Practice Evaluations
(FPPE) and Ongoing Professional Practice Evaluations (OPPE). The goals of this procedure are
to help assure patient safety; to support quality improvement; and to assist the members of the
Medical Staff in self-assessment.
REFERENCES
UNMHSC Medical Staff Bylaws
Joint Commission Standards MS 4.30 and 4.40
AREAS OF RESPONSIBILITY
This procedure is maintained by the Office of Clinical Affairs. Oversight and coordination of the
FPPE and OPPE are the responsibility of the Office of Clinical Affairs and the Quality
Management Department. Performance of the FPPE Pre-Appointment Assessments is the
responsibility of the Office of Clinical Affairs. Performance of the FPPE Initial PostAppointment Assessment, and the OPPE, are the responsibility of the medical staff member’s
Clinical Department or UNMH program.
PROCEDURE
A. Areas of Core Competency
a. The areas of competence evaluated in FPPE’s and OPPE’s will include the six core
competencies of Patient Care, Medical/Clinical Knowledge, Practice-based Learning &
Improvement, Interpersonal & Communication Skills, Professionalism, and Systemsbased Practice. Please refer to Appendix A for examples of measures in each of these
areas.
B. Department Patient Safety Officer
a. Each Clinical Department will appoint one of its members, who is also a member
in good standing of the Active Medical Staff, to be the Department’s Patient
Safety Officer (PSO). In addition to other duties which may be specified
elsewhere, the Department PSO is responsible for assuring the timely FPPE and
OPPE of each member of the Medical Staff assigned to that Department, as
specified below.
b. The Department PSO is also responsible for reporting the results of those
evaluations to the Medical Staff Credentials Committee and/or the Associate
Dean for Clinical Affairs, as specified below.
c. The Department PSO may personally conduct the designated reviews and reports,
or may develop and direct an appropriate Departmental structure for so doing.
_________________________________________________________________________________________________________________
Title: Professional Practice Evaluations, Medical Staff
Owners: Associate Dean for Clinical Affairs, Executive Director for Quality Management; Executive Medical Director for Patient Safety &
Quality Management
Effective Date: TBA
Doc. #
Page 1 of 9
C. Focused Professional Practice Evaluation (FPPE)
1) Pre-Appointment Assessment
a. The pre-appointment assessment will be completed as part of an applicant’s
initial application for membership in the UNMHSC Medical Staff, and will be
the responsibility of the applicant’s Department PSO and the Office of
Clinical Affairs.
b. If the applicant is a new graduate, or a recent graduate not previously
employed, the applicant’s training director will be asked to attest to the
applicant’s competency. If the applicant has been previously employed, an
appropriate official at the applicant’s immediately preceding place of
employment will be asked to attest to the applicant’s competency. If neither of
these assessments is possible, the Chair of the Medical Staff Credentials
Committee and/or the Associate Dean for Clinical Affairs will determine an
appropriate alternative.
c. Peer references (selected by the applicant) will be asked to evaluate the
applicant’s competency.
d. The results of the pre-appointment assessment will be reported to the
applicant’s Department PSO; will be included in the applicant’s medical staff
file; and will be reviewed and acted upon as part of the initial appointment
process specified in the Medical Staff Bylaws.
2) Initial Post-Appointment Assessment
a. Within 1 month of the medical staff member’s initial 6 months of
employment, the information enumerated below will be acquired and
reviewed by the member’s Department, under the direction of the Department
PSO:
i. Three instances of clinical care will be evaluated in writing by a peer
who is a medical staff member in good standing. These peer reviews
will be organized by the medical staff member’s Department PSO.
These reviews may consist of a combination of the following:
1. at least one direct observation of a substantive and
representative episode of care provided by the member (e.g., a
surgery, endoscopy, course of anesthesia, outpatient visit,
consultation, ER visit, interventional radiologic procedure,
psychotherapy session, or equivalent);
2. medical record reviews of patients cared for by the member;
3. other appropriate data approved by the Chair of the Credentials
Committee and/or the Associate Dean for Clinical Affairs.
ii. The Office of Clinical Affairs will query the National Practitioner Data
Bank.
iii. Relevant individual information obtained during ongoing quality and
safety review of clinical and professional indicators by the
Department, Quality Management, Risk Management, the Office of
Clinical Affairs, or other components of the UNMHSC may also be
forwarded to the Department for consideration during the initial postappointment assessment.
3) Events Triggering an Additional FPPE
_________________________________________________________________________________________________________________
Title: Professional Practice Evaluations, Medical Staff
Owners: Associate Dean for Clinical Affairs, Executive Director for Quality Management; Executive Medical Director for Patient Safety &
Quality Management
Effective Date: TBA
Doc. #
Page 2 of 9
a. At any point during a member’s membership in the Medical Staff a serious
event, or a pattern of events, that raises significant concern about the
member’s professionalism, clinical competence, or ability to safely exercise
clinical privileges may trigger an FPPE to determine whether additional
monitoring or other action is needed. Examples of such events include:
i. any adverse action taken against a member’s clinical privileges at
UNMHSC or elsewhere;
ii. any adverse action taken against a member’s professional licensure or
certification;
iii. any surrender of a member’s professional licensure or certification;
iv. a National Practitioner Data Bank case report;
v. any suspension or restriction of clinical privileges related to the
member’s clinical competence, unprofessionalism, or unsafe exercise
of clinical privileges;
vi. any of the following legal occurrences:
1. a felony conviction;
2. a conviction involving alcohol or a substance of abuse;
3. a conviction involving assault, battery, or other violent
behavior;
vii. identification of an atypical pattern or unexpectedly high number of
patient deaths, legal claims or lawsuits, or negative or adverse quality
indicators;
viii. a complaint or series of complaints from a patient, patient’s family
member, UNM employee, UNM student, professional organization, or
other medical professional, alleging serious unprofessionalism,
malpractice, negligence, or criminal behavior; that are atypically
frequent or numerous; or that suggest a concerning pattern of behavior;
ix. a documented pattern of recurrent noncompliance with clinical
standards of care, medical records requirements, regulatory
requirements, patient safety programs, or UNMHSC policies and
procedures;
x. exercise of clinical privileges at UNMHSC while suspected to be
under the influence of alcohol or a substance of abuse;
xi. report or discovery of a physical or mental condition that raises
concern about the member’s clinical competence, ability to safely
exercise his/her clinical privileges, or ability to sustain
professionalism.
4) Any identified need for additional monitoring will result in the development of an
individualized action plan by the member’s Department (in consultation with the
Office of Clinical Affairs, if desired), and will include provisions for appropriate reevaluation of competence.
5) The Department PSO will develop a written report for each FPPE. The report will
include any individualized action plan that has been developed, and a
recommendation from the Department regarding continued appointment to the
Medical Staff. The PSO will provide the FPPE report to the Department Chair for
consideration during the member’s Departmental annual review. The PSO will also
_________________________________________________________________________________________________________________
Title: Professional Practice Evaluations, Medical Staff
Owners: Associate Dean for Clinical Affairs, Executive Director for Quality Management; Executive Medical Director for Patient Safety &
Quality Management
Effective Date: TBA
Doc. #
Page 3 of 9
provide a copy of the FPPE report to the Office of Clinical Affairs for inclusion in the
member’s credentialing file. This latter copy will be reviewed by the Medical Staff
Credentials Committee at reappointment, and otherwise as appropriate. The
Credentials Committee may, at its sole discretion, forward the FPPE report to the
Medical Executive Committee for additional review and action.
D. Ongoing Professional Practice Evaluation (OPPE)
1) Ongoing professional practice evaluations (OPPEs) will be conducted on a twiceyearly basis for each medical staff member by the member’s Department (with certain
measures also being monitored on an ongoing basis). The PSO will develop a written
report for each OPPE, including recommendations for action.
2) Each Department will establish an array of measures for its members, sufficient to
assess the member’s competence under the six core clinical competencies, as the
basis for the OPPEs. Individual data on these measures will be collated and reported
to the Department. (See Appendix A for examples of measures for each core
competency.)
a. The Quality Management Department and the Office of Clinical Affairs are
available to consult with each Department in the development and
maintenance of the array of measures.
b. In addition to the array of measures developed by each Department, relevant
individual information obtained during ongoing quality and safety review of
clinical and professional indicators by the Department, Quality Management,
Risk Management, the Office of Clinical Affairs, or other components of the
UNMHSC may also be forwarded to the Department for consideration during
the OPPE.
3) The Department PSO will develop a written report for each OPPE. The report will
include any individualized action plan that has been developed, and a
recommendation from the Department regarding continued appointment to the
Medical Staff. The PSO will provide the twice-yearly OPPE report to the Department
Chair for consideration during the member’s Departmental annual review. The PSO
will also provide a copy of the twice-yearly OPPE report to the Office of Clinical
Affairs for inclusion in the member’s credentialing file. This latter copy will be
reviewed by the Medical Staff Credentials Committee at reappointment, and
otherwise as appropriate. The Credentials Committee may, at its sole discretion,
forward the OPPE report to the Medical Executive Committee for additional review
and action.
4) For medical staff members who have been recently appointed to the medical staff, the
initial FPPE may substitute for the first annual OPPE.
E. Additional Actions
1) As well as the above-specified actions, any identified issue(s) may, independently or
concurrently, result in professional review actions as specified in the Medical Staff
Bylaws, or in other actions in accordance with the UNM Faculty Handbook or UNM
policies and procedures.
DEFINITIONS
_________________________________________________________________________________________________________________
Title: Professional Practice Evaluations, Medical Staff
Owners: Associate Dean for Clinical Affairs, Executive Director for Quality Management; Executive Medical Director for Patient Safety &
Quality Management
Effective Date: TBA
Doc. #
Page 4 of 9
1) Focused Professional Practice Evaluation (FPPE) – An FPPE is a process whereby the
Medical Staff evaluates the competence of the practitioner who does not have
documented evidence of competently performing the requested privilege at the
UNMHSC. This process may also be used when a question arises regarding a currentlyprivileged medical staff member’s ability to act professionally or to provide safe, highquality patient care.
2) Ongoing Professional Practice Evaluation (OPPE) – An OPPE is a process whereby the
Medical Staff continues to evaluate the competence of its members, including the
member’s ability to act professionally or to provide safe, high-quality patient care. This
process also allows the UNMHSC to identify professional practice trends that are
relevant to quality of care and patient safety.
SUMMARY OF CHANGES
This is a new procedure.
RESOURCES/TRAINING/CONSULTATION
Resource/Dept
Telephone
Office of Clinical Affairs
Quality Management Department
272-2525
ATTACHMENTS
1. Ongoing Professional Practice Evaluation Sample Measures List
2. Professional Practice Evaluation peer review form template
DOCUMENT APPROVAL & TRACKING
Item
Owner
Contact
Date
Approval
Associate Dean for Clinical Affairs; Executive Director, Quality Management
Department
Committee(s)
[Committee Name(s)]
Official Approver
[Name, Title, Area]
[Y or N/A]
Y
Official Signature
[Day/Mo/Year]
Effective Date
Origination Date
Issue Date
[Day/Mo/Year]
[Month/Year]
Clinical Operations Policy Coordinator
APPENDIX A: Ongoing Professional Practice Evaluation Sample Measures List
(related to the six Clinical Competencies)
Abbreviations for Data Source
 Dept – medical staff member’s academic Department or clinical program
 FAD – Faculty Activity Database
 HIM – Health Information Management
_________________________________________________________________________________________________________________
Title: Professional Practice Evaluations, Medical Staff
Owners: Associate Dean for Clinical Affairs, Executive Director for Quality Management; Executive Medical Director for Patient Safety &
Quality Management
Effective Date: TBA
Doc. #
Page 5 of 9





OCA/CO – Office of Clinical Affairs - Credentialing Office
OCA/RM – Office of Clinical Affairs – Risk Management
OUC – Office of University Counsel
QM – Quality Management Department
UHC – our UHC data
1. All Competencies
a. medical staff appointment/reappointment process – OCA/CO
b. annual reviews - Dept
c. academic promotion process - Dept
d. peer reviews – Dept
e. outlier information from ongoing quality management reviews - QM
f. publications – FAD
g. NBPD reports – OCA/CO
2. Patient Care
a. number and type of clinical activities – Billing
b. average length of stay (ALOS) – QM/UHC
c. readmissions within 30 days – QM/UHC
d. patient compliments/complaints
i. patient satisfaction surveys
ii. Patient Assistance Coordinator contacts
iii. patient communications
e. core measures performance – QM/UHC
f. mortality index – QM/UHC
g. infection rates – QM/UHC
h. adverse clinical outcomes – QM/UHC, OCA/RM
i. RCA participation – OCA/RM
j. claims/lawsuits – OUC
k. Mortality Review Committee
3. Medical Knowledge
a. medication utilization b. blood/blood product utilization c. adverse clinical outcomes – OCA/RM, OUC
d. CME - member
e. Board certification/recertification - member
f. teaching - member
g. research - member
h. RCA participation – OCA/RM
i. claims/lawsuits – OUC
j. Mortality Review Committee
4. Interpersonal and Communication Skills
a. patient compliments/complaints
i. patient satisfaction surveys
ii. Patient Assistance Coordinator contacts
iii. patient communications
_________________________________________________________________________________________________________________
Title: Professional Practice Evaluations, Medical Staff
Owners: Associate Dean for Clinical Affairs, Executive Director for Quality Management; Executive Medical Director for Patient Safety &
Quality Management
Effective Date: TBA
Doc. #
Page 6 of 9
b. staff/peer compliments/complaints - OCA
c. medical records performance - HIM
5. Professionalism
a. committee and work group service - FAD
b. leadership positions - FAD
c. attendance at medical staff meetings - OCA
d. staff/peer compliments/complaints - OCA
e. RCA participation – OCA/RM
f. medical records performance (including admin suspension) – HIM, OCA
6. Practice Based Learning
a. Board certification/recertification – FAD?
b. CME - member
c. RCA participation – OCA/RM
d. research - member
7. Systems Based Practice
a. medical records performance - HIM
b. appointment cancellations <30 days –
c. external educational activities - member
NB: Only presence at an RCA is noted; further information from the RCA is not utilized, to preserve the
necessary openness of the RCA process.
_________________________________________________________________________________________________________________
Title: Professional Practice Evaluations, Medical Staff
Owners: Associate Dean for Clinical Affairs, Executive Director for Quality Management; Executive Medical Director for Patient Safety &
Quality Management
Effective Date: TBA
Doc. #
Page 7 of 9
APPENDIX B: Professional Practice Evaluation Peer Review Sample Template
Professional Practice Evaluation
Medical Staff Member: _______________________________________
Type:
Evaluation Date: _______________
Inpatient record review
Outpatient record review
Other record review (specify) ___________________________________________________
Direct observation of episode of care (specify) ____________________________________________
Other (specify) _____________________________________________________________________
1) Based on the evaluated episode of care, please rate the medical staff member’s competency in the following
areas:
Competency
Satisfactory
Marginal
Unsatisfactory
Patient Care


Medical/Clinical Knowledge


Practice-based Learning & Improvement


Interpersonal & Communication Skills


Professionalism


Systems-based Practice


N/A
2) Was the associated documentation clinically adequate and timely?
 Yes  No. If ‘no’, please specify:
3) Was the diagnosis (or differential diagnosis) accurate, complete, and consistent with the findings?
If ‘no’, please specify:
_________________________________________________________________________________________________________________
Title: Professional Practice Evaluations, Medical Staff
Owners: Associate Dean for Clinical Affairs, Executive Director for Quality Management; Executive Medical Director for Patient Safety &
Quality Management
Effective Date: TBA
Doc. #
Page 8 of 9
Professional Practice Evaluation, Page 2
Medical Staff Member: _______________________________________
Evaluation Date: _______________
4) Was the treatment (or treatment plan) adequate and appropriate for the patient’s diagnosis?  Yes  No
If ‘no’, please specify:
5) Was the medical staff member’s care within the standard of care?  Yes  No. If ‘no’, please specify:
6) Please add any additional comments (include additional pages if desired):
Evaluator: ________________________________
Printed Name
_________________________________
Signature
___________
Date
_________________________________________________________________________________________________________________
Title: Professional Practice Evaluations, Medical Staff
Owners: Associate Dean for Clinical Affairs, Executive Director for Quality Management; Executive Medical Director for Patient Safety &
Quality Management
Effective Date: TBA
Doc. #
Page 9 of 9