Accreditation overview

FPPE, proctoring & temporary privileges

Focused professional practice evaluation (FPPE)

FPPE is a time-limited review of a practitioner's performance when they get new privileges. The Joint Commission's FAQs say:

• FPPE is required for all newly requested privileges. Board certification or years of experience don't exempt anyone.
• The medical staff defines the process ahead of time: the criteria for monitoring, the monitoring method, how long it lasts, and when outside monitoring is needed.
• FPPE starts when privileges are granted, including temporary privileges.

Proctoring is one way to do FPPE: an assigned practitioner observes or reviews cases. Your medical staff picks the methods, such as chart review, direct observation or proctoring (general practice). Our Privileging Request Form Outline has a focused evaluation and proctoring section.

Temporary privileges

TJC's FAQ allows temporary privileges in only two situations, and your bylaws must describe both:

1. An important patient care, treatment or service need. Document the need in the file when you grant the privileges, usually as a recommendation from the medical staff president to the CEO. A late reappointment isn't a patient care need by itself.
2. A new applicant whose application is complete and raises no concerns, while it waits for medical executive committee and governing body approval. These privileges can last no more than 120 consecutive days.

Example from TJC: privileges granted July 1 with a governing body meeting on Sept 15 means FPPE starts July 1.

OPPE & expedited credentialing

Ongoing professional practice evaluation (OPPE)

Under 42 CFR 482.22(a)(1), the medical staff must periodically appraise its members. TJC handles ongoing evaluation in OPPE (MS.18.02.03 in 2026). The concept: collect practitioner-specific performance data on an ongoing basis, and use it to decide whether to keep, limit or revoke privileges. FPPE (MS.18.02.01) covers new privileges and concerns raised by triggers.

How often to review OPPE data, which indicators to use, and the thresholds are set by your medical staff (general practice; check your manual for exact requirements).

Expedited credentialing

TJC lists expedited approval as its own standard (MS.17.03.01 in 2026). In general practice, it lets a governing-body committee approve clean applications that meet criteria set in the bylaws. Confirm the exact conditions in your licensed manual (EP-level detail is not confirmed here).

To audit a provider file for credentialing, OPPE and FPPE elements, use our Joint Commission Provider Checklist (fillable PDF and Word).

Peer review & bylaws

Bylaws (CMS)

Under 42 CFR 482.22(c), medical staff bylaws must:

• be approved by the governing body;
• state the duties and privileges of each staff category;
• describe the medical staff's organization;
• describe the qualifications for appointment;
• include history and physical requirements;
• include criteria for granting privileges and a procedure for applying them.

TJC's 2026 bylaws standards are MS.14.01.01 and MS.14.02.01.

Peer review

TJC's 2026 chapter covers peer recommendations (MS.18.01.01), investigating clinical practice concerns (MS.18.03.01), and fair hearing and appeal (MS.18.04.01). How your organization structures peer review, such as committees, referral triggers and outside review, is set by your bylaws and policies (general practice).