d ) Rate or rule compliance tracking ; e ) External peer review ; or f ) Referral for voluntary psychological or professional competency review iv . For Cause FPPE reviews will be approved by the QPRC and will specify the review details as well as the specific time period in which the review will be completed . For Cause FPPE that are voluntary will be summarized and shared with the MEC . Involuntary For Cause FPPE will require approval by the MEC . v . For Cause FPPE may be utilized , when appropriate , to assess a privileged Physician ’ s / APP ’ s quality of care or conduct when a determination has not been made whether corrective action and / or an investigation is warranted . However , the “ For Cause FPPE ” would still be considered synonymous with an “ investigation ” and any resignation while under this type of “ For Cause FPPE ” should result in a report to the National Practitioner Databank ( NPDB ). vi . The Peer Review Coordinator ( PRC ), in collaboration with the Quality Department , will track the completion of the required reviews . c . Failure of a Physician / APP to cooperate with these provisions may result in corrective action as delineated in the Medical Staff Credentials Policy .
2 . ONGOING PROFESSIONAL PRACTICE EVALUATION ( OPPE ) a . OPPE will provide a process for evaluating a Physician ’ s / APP ’ s professional practice every six ( 6 ) to eight ( 8 ) months , but no less than three ( 3 ) times during any twenty-four ( 24 ) month period . The process is intended to monitor quality of care , identify exemplary performance , and recognize opportunities for improvement . b . OPPE Reports : i . The OPPE content will incorporate general competencies modeled after those outlined by the Accreditation Council for Graduate Medical Education ( ACGME ) and the American Board of Medical Specialties ( ABMS ): a ) Patient Care ; b ) Systems-Based Practice ; c ) Medical Knowledge ; d ) Interpersonal and Communication Skills ; e ) Professionalism ; and f ) Practice-Based Learning and Improvement . ii . Data used to compile the OPPE reports may include , but will not be limited to , the following : a ) Patient care volume ; b ) Patient satisfaction ; c ) Clinical quality indicators defined by the Department ; d ) Individual case review results ; e ) Rule indicators ; f ) Rate indicators ; and g ) Significant citizenship events ( positive and negative ), i . e ., appreciation from patients and staff , citizenship / behavior report determinations . iii . The OPPE reports will be maintained by Medical Staff Services for at least two ( 2 ) years . c . OPPE Review : Individual and section OPPE reports will be reviewed and approved by the QPRC , with assistance from department chairs and section chiefs , as requested . Approval may be documented in the QPRC minutes . d . Informing the reappointment process : The QPRC will share significant concerns with the Credentials Committee to help inform the reappointment process . The QPRC may collaborate