Turn Mistakes into Opportunities for Performance Improvement: FPPE Action Plans

Turn Mistakes into Opportunities for Performance Improvement: FPPE Action Plans

Jan 21, 2019

Author: Angela Beardsley, CPMSM, CPCS, Manager, Client Success Services and Consulting


With every New Year also comes the idea of a clean slate, a chance for a fresh start. Inevitably, our clean slate will become tarnished at some point during the New Year, as the reality is, we are all human and therefore we all make mistakes. The good news is, we can learn and grow from our mistakes; we can look at these slip-ups as opportunities for improvement. We can set personal and/or professional goals and action plans that will guide us and hold us accountable to do better the next time. This applies to all of us, including providers in the health care industry.


Healthcare providers perform medical or professional activities and/or exercise surgical or technical skills on an ongoing basis, with the goal of maintaining or improving competency, in order that they may ultimately provide the highest level of quality of care and patient safety. Even with providers striving for this goal, unfortunately mistakes still do sometimes occur. When medical or professional errors do happen, it is important for the provider to be able to learn and grow from their mistake; that they are able to use the set-back as an opportunity to set goals and action plans for improvement. It is equally imperative that healthcare organizations support their providers in being able to accomplish this, by developing a culture where providers’ mistakes are not handled punitively, but rather as opportunities for learning and performance improvement.


Often times a medical or professional mistake may trigger the need for a focused evaluation in order to determine the underlying root cause and the best way to prevent the error from reoccurring; it may also determine that there is the need for an attributing provider to be monitored under an action plan based on the issue that occurred. When a providers’ slate does becomes tarnished by a medical or professional mistake which triggers a Focused Professional Practice Evaluation (FPPE), for cause, the following are best practice recommendations for creating an FPPE action plan that embodies a culture of learning and opportunity for improvement:


  • The physician leadership (Department Chair, Service Chief, Physician Quality Leader, etc.) should emphasize to the provider that the FPPE action plan is not meant to be punitive, is not considered a formal medical staff investigation and is not reportable.It is a learning opportunity for performance improvement with the goal of successfully preventing the mistake from reoccurring (it is important to keep in mind however, if the provider does not comply with/successfully complete the FPPE action plan and/or the mistake continues to occur, there is a possibility that at some point it could result in a formal medical staff investigation/become reportable).
  • The physician leadership should partner with the provider who has made the medical/professional mistake; they should collaboratively develop the FPPE action plan. By allowing the provider to participate in the development of their action plan, it allows the provider to take more accountability and ownership, increasing the probability of compliance and a successful outcome.
  • The physician leadership and the attributing provider should agree on the elements to be identified in the FPPE action plan. Below are some best practices recommendations for elements to be included:

What was the triggering issue (mistake) by the provider?


Did the triggering issue (mistake) result in any of the following?

  • Significant adverse variation(s) from internal and/or external benchmark(s) of performance.
  • Problematic pattern(s) or trend(s).
  • Quality of care concern(s) of a serious nature.
  • Behavior, health, and/or performance issue(s) that pose an immediate threat to the health and safety of the patient, public, or other members of the health care team.

What area(s) of competency/metrics is the triggering issue (mistake) related to?


Patient Care:

  • Department/Service/Privilege Specific Quality Indicator
  • Mortality Rate
  • Infection Rate
  • Return to OR
  • Readmits

Medical/Clinical Knowledge:

  • Continuing Medical/Professional Education (relevancy to scope of practice)
  • Core Measures

Practice-Based Learning and Improvement:

  • Peer Review Outcomes

System-Based Practice:

  • Legal Claims
  • Average Length of Stay
  • Blood Utilization
  • Medical Records Delinquency
  • Unusual Occurrences (Events/Incidents)

Interpersonal and Communication Skills/Professionalism:

  • Complaints

What are the requirements of the FPPE action plan?


What will the method of monitoring of the provider’s performance be under the FPPE action plan?

  • Chart Reviews
  • Direct Observations
  • Simulations
  • Mentoring
  • Counseling
  • Continuing Medical/Professional Education

What will be the review period for the FPPE action plan monitoring

  • Review at next OPPE
  • Review at other timeframe
  • Review after completion of a specific # of chart reviews, observations, simulations, etc.

Who are the accountable persons for the FPPE action plan?

  • Provider
  • Dept. Chair, Service Chief, Physician Quality Leader, etc.
  • Charge Nurse, OR Nurse, etc.
  • Reviewer (Quality Analyst), Observer (Medical/Professional Staff with similar privileges)

Who is required to review/approve the FPPE action plan?

  • Provider (should acknowledge that they have been informed of and agree with the FPPE/Action Plan)
  • Dept. Chair, Service Chief, Physician Quality Leader, etc.
  • Committees (Credentials, MEC, Board)

How will improvement under the FPPE action plan be measured and documented?


What expected improvement/learning should result from successful completion of the FPPE action plan?


  • The physician leadership should provide communication/feedback to the provider under monitoring and to the appropriate review bodies at the end of each review period in order to maintain a collaborative and transparent process. In addition, upon successful completion of the FPPE action plan, it is important to send a communication to the provider from the physician leaders thanking the provider for their support of the process, their willingness to participate, and for improving their performance.

Hopefully your organization already embodies a culture in which FPPE action plans enable learning opportunities and performance improvement. However, if this is something that your physician leaders and providers have struggled with over previous years, a New Year’s wish is that you will find this information helpful and can influence this type of culture and FPPE process within your organization.

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