process , including focused and ongoing professional practice evaluations ( FPPE and OPPE , respectively ) and case reviews . The goal is to partner with physicians and APPs to accomplish the following : a . deliver reliable , safe , high quality care ; b . ensure competency and professionalism ; c . support a fair “ Just Culture ”; d . strive for zero preventable harm by adopting the principles of High Reliability Organizations ; and e . promote performance improvement with transparency , timely data , and recognition of excellence as well as opportunities for improvement .
3 . Professional Practice Evaluation activities , including all communications , data , information and records , are privileged and confidential pursuant to Nevada Peer Review Statutes and the Medical Staff bylaws pertaining to confidentiality and non-discoverability . These privileged and confidential protections are specifically extended to other medical staff department , section , committee , director , and physician / APP reviews that have been delegated by or on the behalf of the QPRC .
4 . All Physicians and APPs are obligated to participate in the Professional Practice Evaluation processes .
PROCEDURE : 1 . FOCUSED PROFESSIONAL PRACTICE EVALUATION ( FPPE ): FPPE will be a time-limited process for the
Medical Staff to evaluate a Physician ’ s / APP ’ s general competence or for specific privileges . a . Initial FPPE : when a Physician / APP has not yet demonstrated competence for performing the requested privileges at the Renown hospitals , i . e . initial appointment , request for additional privileges , or privileges that have not been exercised for an extended period . i . Initial FPPE is the purview and responsibility of the Medical Staff Credentials Committee . ii . Initial FPPE plans will include the type and number of reviews as well as the specific time period in which the reviews will be completed . iii . Medical Staff department chairs , section chiefs and individual Physicians / APPs will assist in establishing and monitoring the review requirements , as requested . iv . Reviews may include , but not be limited to , any or all the following : a ) Retrospective case review ; b ) Direct observation ; c ) Proctoring ; or d ) Specific training requirements , e . g . course , continuing medical education ( CME ) v . Initial FPPE reviews will include at least three ( 3 ) reviews of the core privileges and one ( 1 ) review for each special privilege , unless the Credentials Committee deems a review for a specific special privilege not necessary given the other demonstrated competencies . vi . Medical Staff Services ( MSS ) will track the completion of the required reviews . The initial FPPE period may be extended , at the discretion of the Credentials Committee Chair , if there has been insufficient volume of activity for review . b . For Cause FPPE : when questions arise about a privileged Physician ’ s / APP ’ s ability to provide optimal , safe , high quality patient care . Examples include individual or trend of case review ( s ) with potentially preventable harm or negative outcomes , rate indicator or rule violation concerns , and OPPE concerns . i . For Cause FPPE is the purview and responsibility of the QPRC . ii . Medical Staff department chairs , section chiefs and individual Physicians / APPs will assist in developing and monitoring FPPE plans , as requested on behalf of the QPRC . iii . For Cause FPPE may include , but not be limited to , any or all the following : a ) Retrospective case review ; b ) Direct observation ; c ) Voluntary education ;