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Medical Staff Pulse is
a Publication of the Chief of Staff
Joint Commission Medical Staff Standards

Preparing for the Joint Commission Survey

We expect to be surveyed in the upcoming weeks. The information below outlines what you should know when asked about new Joint Commission Medical Staff Standards. (Please click here to print a PDF version of this article.)

Ongoing Professional Practice Evaluation or OPPE
this is a screening evaluation

  • I get evaluated every 8 months so the Medical Staff can assure I am competent to provide care for the privileges I have been granted.

Focused Professional Practice Evaluation or FPPE
this is a diagnostic evaluation

  • New members or current members of the staff who ask for new privileges have to complete proctoring for each group of new privileges granted so the Medical Staff can confirm their competence.
  • This evaluation is also initiated if there is any concern about the care provided by a member of the staff or if the ongoing review reveals the need for further evaluation.
The Courtesy category of Medical Staff membership has been eliminated and is being phased out.

New category of Medical Staff membership for low/no volume providers:

Refer and Follow Category

  • Members with low or no volume at CSMC would not ordinarily qualify for ongoing membership on the Medical Staff because volume is required to assess competence of privileges granted.
  • In this new category members do not have clinical or admitting privileges and cannot write orders or progress notes.
  • However, the new category allows practitioners to remain members of the Medical Staff, refer and visit patients, view Web/VS, access CME and remain a member of the CSMC Medical Staff community.