2016 Performance Enhancement Review Guidelines

Introducing the Federation of State Physician Health Programs’ 2016 Performance Enhancement Review Guidelines


Over the past ten years, state physician health programs have recognized the importance of accountability to regulators, the professionals we serve, and the public. The Federation of State Physician Health Programs (FSPHP) has also recognized the need for support to state members. In 2014, FSPHP established a taskforce to promote accountability, consistency, and excellence among physician health programs (PHPs). Recognizing the importance of this work, in 2015 the taskforce was renamed the Accountability, Consistency, and Excellence (ACE) Committee.

This work began with the 2011 recommendation of the Federation of State Medical Board’s (FSMB’s) Policy on Physician Impairment: "to gain the confidence of the regulatory boards, PHPs must develop audits of their programs that demonstrate an ongoing track record of ensuring safety to the public and reveal deficiencies if they occur."  For the past two years, the committee members have worked on producing this document whose purpose is to enable the FSPHP, individual PHPs, medical boards and other stakeholders to identify meaningful ways to enhance the quality of services being provided to physicians and other eligible healthcare providers by individual PHPs and ensure that public safety is met.

These 2016 Performance Enhancement Reviews (PER) Guidelines have been enthusiastically endorsed by the FSPHP Board of Directors and all FSPHP Members present at the 2016 Annual Membership Meeting voted unanimously in favor of these guidelines.

FSPHP believes that individual state physician health programs face many issues that will best be addressed by the collective voice of an organization of such programs. FSPHP is committed to collaborating with individual PHPs in an effort to create the best options for providing services to physicians and other licensed healthcare professionals, and in turn to the medical profession and to the public on a national level. 

This document is intended to be used as a guide for PHPs, their boards, licensing boards and other stakeholders in considering whether each individual program is meeting its own goals and expectations, as well as an instrument to support optimizing the efficacy of every PHP and to establish credibility with key stakeholders.  In addition, through its concrete examples, scenarios and appendices, this document provides a toolbox for PHPs to reach their optimal potential while allowing for the transparency and accountability necessary to maintain public trust. A well-constructed PER will provide a strong foundation for an ongoing commitment to maintaining quality of services, as well as strategic enhancement. 

The FSPHP encourages our members to engage in both internal and external PERs and to share their experiences with the FSPHP.  As such reviews become more common, it is hoped that the data may enable the development of deeper insight and awareness into the importance of allowing our professionals the dignity to be patients, as well as providers, thereby enhancing patient health and safety. Future strategic plans are in development for a FSPHP endorsed Performance Enhancement Review Program to offer to state programs in the future.

The guidelines can be found in the “resources” section of the FSPHP website. 

Special Acknowledgements

FSPHP would like to acknowledge the 2015-2016 Accountability, Consistency and Excellence Committee members. Special contributors include the committee co-chairs Maureen Dinnan, Esq. and Charles Meredith, M.D, along with Cae Allison and Doina Lupea, MD, MHSC. Their expertise and oversight greatly resulted in this completion of these guidelines.

FSPHP is also immensely grateful to all the members of the committee for their contributions. Terrance M. Bedient, FACHE; Laura Berg, LCSW-C; Chris Bundy, MD, MPH; Louis Cataldie, MD; Sarah Early, PsyD; Michael Gendel, MD; Logan Graddy MD; Debra Grossbaum, JD; Doris Gundersen, MD; P. Bradley Hall, MD; Gail Jara; Michael Kaufmann, MD; Warren Pendergast, MD; Michael Ramirez, MD; Robert Westcott, MD

For any questions related to these guidelines, please contact Linda Bresnahan, MS, Executive Director for the FSPHP, Phone: 978-347-0600 Fax: 978-347-0603 Email: lbresnahan [at] fsphp.org