The Complete Guide to OPPE and FPPE

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The Complete Guide to OPPE and FPPE

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The Complete Guide to OPPE and FPPE

Juli Maxworthy, DNP, MSN, MBA, RN, CNL, CPHQ, CPPS, CHSE 
Evalynn Buczkowski, RN, BSN, MS

OPPE and FPPE are mainstays in the privileging process, but they’re anything but cut and dry. In today’s evolving healthcare industry, medical staff leaders and MSPs often encounter scenarios that don’t fit squarely into evaluation frameworks, such as telehealth providers, low-volume practitioners, and the growing ranks of advanced practice professionals. With a myriad of factors at play, it can be difficult to take the proper steps to ensure effective peer review.

The Complete Guide to OPPE and FPPE is your comprehensive guide to navigating today’s OPPE and FPPE landscape, and a handy companion to The OPPE Toolbox and The FPPE Toolbox. Authors Juli Maxworthy, DNP, MSN, MBA, RN, CNL, CPHQ, CPPS, CHSE, and Evalynn Buczkowski, RN, BSN, MS, shed light on the industry’s most pressing questions about hard-to-evaluate practitioners, data aggregation, effective reporting strategies, and more. Plus, customizable forms make for a seamless transition from education to application.

With a healthy blend of practical guidance on core OPPE and FPPE concepts and targeted strategy on specific pain points, The Complete Guide is a must-have for medical staff veterans and newcomers alike.

This book will help you: 

  • Evaluate and strengthen existing OPPE/FPPE approaches 
  • Integrate, evaluate, and share meaningful performance data 
  • Understand confusing OPPE/FPPE scenarios 
  • Prepare for the future of OPPE/FPPE 


Table of Contents 

  • Introduction: Why Are OPPE and FPPE Still Such Challenges? 
    • Emerging Issues: New Types of Practitioners (and Practices) on the Medical Staff 
  • Section 1: Revisiting Your Strategies for OPPE and FPPE 
    • Processes and Policies for Ensuring Successful OPPE and FPPE Programs 
    • The Critical Role of Strong Communication 
    • OPPE, FPPE, and Emerging Legal Concerns 
  • Section 2: Selecting Data 
    • Performance Indicators for OPPE and FPPE 
      • Perception data as a source for OPPE evaluations 
    • Establishing Performance Thresholds and Benchmarks 
      • Solving the attribution problem 
      • Developing protocols for low-volume practitioners and advanced practice practitioners 
      • Using retrospective reviews to evaluate FPPE performance 
      • Proctoring: Definitions, expectations, and responsibilities 
    • Use of Databases for Sharing Information 
      • PPE and NPDB reporting 
  • Section 3: Evaluating OPPE and FPPE Results 
    • Designing Practitioner-Friendly Reports 
    • Delivering Reports to Practitioners 
      • Evaluating performance and engaging practitioners in performance improvement 
      • Engaging practitioners through collaborative peer-to-peer performance conversations and coaching 
      • Clinical simulation training and procedural education courses 
      • Conversations when OPPE leads to FPPE 
      • Conversations when FPPE reveals nonclinical issues 
  • Section 4: Specific Challenge Areas 
    • Low-Volume/No-Volume Practitioners 
    • Locum Tenens and “Temporary” Privileges 
    • Advanced Practice Professionals 
    • Telemedicine Providers 
    • Behavioral Health 
  • Section 5: The Future of OPPE/FPPE 
    • Simulation and Other Tools 
    • Evolution and Expansion of Standards 
    • New Environments 
    • Unified, Integrated Medical Staffs 


About the Authors: 

Juli Maxworthy, DNP, MSN, MBA, RN, CNL, CPHQ, CPPS, CHSE, brings nearly 30 years of nursing experience to her roles. Her last clinical position was vice president of quality and risk, where she had oversight of many of the activities of the medical staff. She has implemented OPPE and FPPE at the institutions in which she had oversight of the process. Through her work, she has learned how challenging and rewarding this implementation can be, both for organizations mandated to execute OPPE and FPPE to maintain their accreditation as well as the medical staffs working to understand and comply with the associated mandates.

Evalynn Buczkowski, RN, BSN, MS, has over 30 years of healthcare experience in consulting and in leadership roles in the delivery of healthcare services. Her background and experience provides strong knowledge and proven leadership skills for accreditation and regulatory compliance, clinical quality, case management, and medical staff affairs. Prior to joining MedAssets/Vizient, Buczkowski was a regional leader in a large multi-hospital system. In that role, she provided leadership for the clinical and operational aspects of clinical quality; clinical informatics; accreditation; medical staff administration, including credentialing and peer review; case management, utilization review, and social work; and infection prevention. Core competencies include innovative healthcare delivery models, case management/care coordination, value-based care strategies, clinical quality processes and structures, physician-hospital alignment, accreditation/regulatory compliance, medical staff affairs, and physician performance (OPPE/FPPE). Buczkowski was an active member of the Michigan Health and Hospital Association's Quality and Accountability Committee. In addition, she has recently published two books on the topics of OPPE and FPPE and has had national speaking engagements as a result of the publications.

Published: July 2016