Professional Practice Evaluations

NewYork-Presbyterian Hospital Sites: All Centers Hospital Policy and Procedure Manual Number: P132

To ensure safe and high-quality clinical care for all patients, Professional Practice Evaluations (PPE) are performed at the direction of the Medical Board and represent a non-biased, fair, and comprehensive physician led activity to measure, assess and, where necessary, improve performance and clinical care throughout the organization. The goals of PPEs are to improve the quality of care provided and monitor the ongoing practice of all healthcare practitioners (members of the medical, professional associate, nurse practitioner, midwifery and graduate medical staff) with clinical privileges at the Hospital.

• Ongoing Professional Practice Evaluation (OPPE)

A process through which all practitioners are evaluated annually for identifying professional practice patterns or trends that may impact quality of care and patient safety.  Review of the information obtained through OPPEs by the Medical Staff Office (MSO) occurs no less frequently than every 12 months.  The MSO may accept peer reference evaluations in lieu of an OPPE for physicians with consulting privileges.

• Focused Professional Practice Evaluation (FPPE)

FPPEs are a time-limited period during which the Hospital evaluates and determines a practitioner’s competence to perform specific clinical privileges. FPPEs are conducted when:

                  a) Requests are made for a new privilege from a currently privileged practitioner

                  b) Requests are made  for privileges from an applicant for initial appointment to the medical staff.

The time period for conducting a FPPE under the above two (2) circumstances shall be a minimum of three (3) months, or, at the discretion of the Clinical Service Chief, a certain number or percentage of procedures performed during a time-limited period. After the designated time period for the FPPE has been met, the department may either extend or discontinue the evaluation period.

• “For Cause” or “Triggered” Focused Professional Practice Evaluation (FPPE)
• For cause or triggered FPPEs are initiated by the clinical department for reasons that include but are not limited to:
  • Concerns regarding clinical activity and performance quality that include but are not limited to
    • A significant event directly or indirectly attributed to the practitioner.
    • Failure to follow standard of care based on evidence-based practice.
  • Specific questions of clinical competence, patient care and treatment, case management.
  • A substantiated number of patient, family, staff, or peer complaints.
  • Inappropriate or disruptive behavior as referenced in Policy C155 DISRUPTIVE BEHAVIOR/ BEHAVIORS THAT UNDERMINE A CULTURE OF QUALITY, SAFETY AND COMPASSIONATE CARE
  • Violations of
    • applicable ethical standards
    • the Medical Staff Bylaws, Policies and Rules & Regulations
    • NYP and/or departmental Policies & Procedures
    • the Corporate Bylaws
    • the Code of Ethical Conduct.
  • Any other circumstance where the Vice President and Chief Medical Officer for Medical and Professional Affairs, Chief Medical Officer, or Clinical Service Chief is concerned about the practitioner’s current competency to perform his/her specially delineated clinical privileges.

Click here to access the Weill Department of Medicine’s process for FPPEs.

Click here to access the FPPE form.

Questions?

Please contact the respective division QIPS representative or email Zohra Habib at the Medical Staff Office (zoh9005@nyp.org) for additional information and guidance.