Lyndon Box, MD, FSCAI and Faisal Latif, MD, FSCAI

Introduction

The Joint Commission requires that an FPPE be part of the credentialing process for all practitioners.¹ It also recommends that an FPPE should be conducted when there are performance concerns. It is the latter situation that is the most challenging and will be the focus of this Tip of the Month. 

In its statement on Privileging and Credentialing for Interventional Cardiology Procedures, SCAI recommends that an FPPE process should be part of institutional credentialing for percutaneous coronary intervention (PCI); however, the details of how an FPPE should be structured are not defined.² The Joint Commission provides general guidance but does not give additional detail regarding FPPE for specific procedures. In this Tip of the Month, we will expand on the general outline of an FPPE with recommendations specific to PCI.

Conducting an FPPE

Defined criteria should be in place regarding when to initiate a “for cause” FPPE. Though objective criteria are more easily implemented, they may be overly limiting. For example, if staff repeatedly raise concerns regarding an operator’s performance, an FPPE should not be delayed until there is a bad outcome. To limit the likelihood of an unwarranted FPPE, a key group of decision-makers, such as the Hospital Review Committee, should approve the FPPE initiation.

The Committee should then notify the physician that an FPPE has been initiated and the specific reasons why. Following notification, the physician should request an individual outcomes report from the National Cardiology Data Registry (NCDR).³ This report can help establish baseline clinical performance, and if there are any identified deficits, these could be added to the FPPE as objective endpoints for monitoring improvement. 

An FPPE typically takes three months, but this time frame may be adjusted depending on the volume of FPPE cases. Instead, a consecutive number of FPPE cases may be reviewed, in which 25 would be a reasonable number of cases.

The recommendation for reviewing FPPE cases is having multiple reviewers for each case—ideally, three experienced interventional cardiologists per case. Particular sensitivity should be taken regarding potential biases—if there is any question of objectivity, an outside reviewer should be contracted. 

During the FPPE, key aspects of the interventional cardiology practice should be reviewed, including the following:

• Appropriateness of case selection
• Quality of diagnostic angiography
• Technical execution of intervention
• Clinical outcome
• Documentation

In addition, communication is crucial throughout the FPPE process, including providing feedback to allow for corrections to be made in a timely manner. This will ultimately lead to the primary goal of the FPPE, which is to complete it successfully with a positive result.

To ensure the successful completion of an FPPE, clearly defined criteria should be in place. For example, having 95% of cases reviewed as acceptable care would be a reasonable expectation. Additionally, improvement criteria in the deficits identified in the NCDR report may be included.

Lastly, the FPPE policy must state what actions may be taken in the event of failure to reach the performance standard. Some leeway is necessary depending on the findings of the FPPE, but potential options include extended monitoring under direct supervision, additional training, restriction of privileges to certain types of cases, or revoking privileges.

Conclusion

It is essential that every cardiac catheterization laboratory have a clearly defined FPPE policy in order to ensure patient safety. It is also necessary that the policy be fair and balanced, as a poorly executed FPPE may cause irreparable damage to a physician’s career and emotional health. A transparent, objective, and thoughtful approach to this difficult situation is necessary.

References

1. The Joint Commission. “What are the key elements organizations need to understand regarding the Focused Professional Practice Evaluation requirements ?” Last updated September 7, 2022. https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/medical-staff-ms/000001485/.
2. Blankenship JC, Rosenfield K, Jennings HS. Privileging and credentialing for interventional cardiology procedures. Catheter Cardiovasc Interv. 2015 Oct;86(4):655–663.
3. Quality Improvement for Institutions, American College of Cardiology. “Professional Level Dashboard.” https://cvquality.acc.org/NCDR-Home/reports/professional-level-dashboard.