was successfully added to your cart.


It Could Happen to You: Medical Staff – Conclusion

It Could Happen to You: Medical Staff – Conclusion

OR-Team-Joint Commission Medical Staff Consulting Consultant TeamLast month we reviewed a scenario that involved a hospital receiving a for-cause visit from The Joint Commission (TJC) related to a physician complaint. The physicians alleged that the organization had inconsistent re-appointment practices. At the end of the for cause survey, Dr. Jacobs, the Physician Surveyor indicated that he did have concerns and cited the following RFIs:

  • There was no clearly defined process for implementing the Focused Professional Practice Evaluation (FPPE) nor any process for how the monitoring would be performed.
  • Peer reviews were not consistently obtained for all medical staff members, as required. These members were still re-appointed.
  • Two physician (Anesthesia and Pediatrician) files reviewed did not have defined department-specific data and both physicians had been re-appointed.

The scenario questions, poll responses and correct answers are listed below.

  • The surveyor cited the organization incorrectly on FPPE according to the standard, as specific criteria is not required.

The correct answer is false and 83% of poll respondents also answered false. In the TJC standard, MS.08.01.01, EP 2 the following is stated, “The organized medical staff develops criteria to be used for evaluating the performance of practitioners when issues affecting the provision of safe, high quality patient care are identified”. The surveyor’s RFI was appropriate.

  • Joint Commission standard, MS.07.01.03, requires organizations to obtain peer reviews on all medical staff members for re-appointment.

The correct answer is false and 65% of the poll respondents answered incorrectly. The standard, MS.07.01.03, EP2 states, “Upon renewal of privileges, when insufficient practitioner-specific data is available, the medical staff obtains and evaluates peer recommendations”.

  • According to the OPPE standards, the organization was incorrectly cited for their OPPE process.

The correct answer is false and 71% of poll respondents answered correctly. Dr. Jacobs, the surveyor, cited the organization for not having defined data specific for each department. The standard, MS.08.01.03, EP1 states the organization should have a “clearly defined process”. That same standard EP2 states, “The process for ongoing professional practice evaluation includes the type of data to be collected as determined by individual departments and approved by the organized medical staff”.

Stay tuned for another It Could Happen to You scenario.

Sharon Dills

Author Sharon Dills

More posts by Sharon Dills