Focused and Ongoing Evaluations for Medical Staff
The Joint Commission Medical Staff standards have changed. Evaluation of physician performance must take place now on a continuous basis, not just at time of appointment and reappointment. Similarly, the intensity of the evaluation of physician competency has increased, especially during the Provisional period of being a new member of the staff and for established physicians performing new procedures whether or not adverse events have been identified.
The Joint Commission has dusted off an old descriptive term for this spotlight on new appointees and calls it “focused” evaluations. Of course, the term “focused” was coined by the Joint Commission many years ago to refer to select, in-depth review of physician performance at any time, especially if there is a pattern of adverse events.
The bottom line is that The Joint Commission requires a broad and continuous review of physician performance as well as an in-depth assessment at critical moments: at initial appointment, upon request for new privileges/adoption of new modalities, and as part of a closer inspection when concerns have been raised. Taken together, in Joint Commission lingo, these Medical Staff processes are called Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE).
Multiple data sources will be organized to assist in these evaluations. Your Department Chairs, Service Chiefs, the Credentials Committee, the President of the Medical Staff, Health Care Quality, Medical Staff Services, and my office have been, and will continue to be, involved in shepherding this process. As always, decisions related to credentialing and privileging report to the ECMS, chaired by the President of the Medical Staff.
From Leslie G. Selbovitz, MD
Chief Medical Officer
Senior Vice President for Medical Affairs
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Your Community Hospital 
