The FPPE Toolbox: Field-tested Documents for Competency and Compliance, 2nd Edition

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The FPPE Toolbox: Field-tested Documents for Competency and Compliance, 2nd Edition

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The FPPE Toolbox: Field-tested Documents for Competency and Compliance, 2nd Edition

Juli Maxworthy, DNP, MSN, MBA, RN, CNL, CPHQ, CPPS, CHSE

In order to be compliant with The Joint Commission’s requirements of establishing and tracking practitioner competency using measurable data, MSOs must apply and adopt a standard framework defining the dimensions of privileged practitioners’ performance.

But just like all healthcare regulations, the focused professional practice evaluation (FPPE) of providers is a process that is constantly changing and being refined. With an evolving provider landscape and commensurate legal findings, knowing how to collect, organize, and document FPPE data is critical for all facilities. Failing to gather and organize sufficient FPPE data in a standardized way presents risks including redundancy, inconsistency across specialties, and inadequate articulations for practitioners regarding their role in FPPE.

The second edition of The FPPE Toolbox: Field-tested Documents for Competency and Compliance, provides an up-to-date, comprehensive resource with the forms and tools MSOs need to conduct and manage FPPE. This book provides compliant and customizable forms, policies, letters, scorecards, and reports that can be utilized in facilities of all types and sizes. Author Juli Maxworthy, DNP, MSN, MBA, RN, CNL, CPHQ, CPPS, CHSE, shares her expert knowledge so MSPs can create a cohesive competency documentation process at their organization. 

This toolbox offers sample tools you can adapt for use in your own facility without making you wade through lengthy background information, including:

  • Case studies describing how your peers implemented FPPE
  • FPPE policy documents
  • FPPE language excerpted from peers’ bylaws documents or policies and procedures
  • Department-specific proctoring forms
  • Inpatient and outpatient proctoring forms
  • FPPE documents for HFAP-accredited facilities
  • Forms that work for initial appointment and for-cause FPPE, and documents that illustrate the OPPE-FPPE connection 
  • Notification to a practitioner—successful conclusion of provisional staff status and advancement of staff category
  • A letter to a physician requesting his or her service as proctor
  • Physician competency data scorecards
  • Retrospective, concurrent, and prospective proctoring guidelines


This book:

  • Saves time—medical staff offices don’t need to develop an FPPE system from scratch or spend hours researching and updating their organizations’ outdated forms
  • Eliminates the hassle of having to research FPPE forms and policies from multiple sources
  • Enables MSPs to download, adapt, and use the most up-to-date FPPE forms at their organization
  • Provides tips on implementing the forms and applying FPPE data to credentialing and privileging decisions in the future
  • Includes field-tested FPPE policies and forms in use now at medical staff services departments nationwide


Five organizations have FPPE down to a science, and they’ve shared their policies and forms in this book. These all-new, downloadable forms cover all aspects of FPPE for new applicants and for cause, from proctoring and other practitioner evaluation methods to quality indicators to compliance with The Joint Commission and HFAP standards.


About the Author:

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 the implementation of these processes 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 those mandates.


Published: May 2015

Page count: 116
Dimensions: 8.5x11
ISBN: 978-1-55645-340-3

Table of Contents

  • Chapter 1: Acadiana Management Group
    • Figure 1.1: FPPE Protocol
    • Figure 1.2: FPPE/OPPE Quality Proctor Review Form
    • Figure 1.3: FPPE/OPPE Quality Proctor Review Form—On-Call/Alternate
    • Figure 1.4: FPPE Generic Peer Review Tool
    • Figure 1.5: Peer Review Profile Chart
    • Figure 1.6: Comparison of Joint Commission and HFAP FPPE/OPPE Standards
  • Chapter 2: Beebe Healthcare
    • Figure 2.1: Initial Focused Professional Practice Evaluation Policy
    • Figure 2.2: FPPE Plan
    • Figure 2.3: Sample Evaluator Letter
    • Figure 2.4: Summary Report to Credentials Committee
    • Figure 2.5: FPPE Procedure Proctoring
    • Figure 2.6: FPPE Procedure Proctoring
    • Figure 2.7: FPPE Evaluation for Department of Anesthesia
    • Figure 2.8: Department of Medicine FPPE Retrospective Chart Review 
  • Chapter 3: Care New England Health System 
    • Figure 3.1: FPPE Policy
    • Figure 3.2: FPPE Protocol Form
    • Figure 3.3: Kent Hospital Credentials Committee Procedural FPPE
    • Figure 3.4: Kent Hospital Credentials Committee Nonprocedural FPPE
    • Figure 3.5: Kent Hospital FPPE Proctoring Assessment and Recommendation—Single Procedure
    • Figure 3.6: Department of OB/GYN Supplemental Privilege Criteria Robotic Surgery
    • Figure 3.7: Department of OB/GYN Supplemental Privilege Criteria Robotic Single Site Surgery
  • Chapter 4: Doctors Hospital of Manteca
    • Figure 4.1: FPPE Policy and Procedure
    • Figure 4.2: Doctors Hospital of Manteca FPPE/Proctorship Status Report
    • Figure 4.3: FPPE Evaluation/Proctorship Report for Invasive Procedures
    • Figure 4.4: FPPE Evaluation/Proctorship Report for Admitting Practitioners
    • Figure 4.5: FPPE Evaluation/Proctorship Report for Anesthesiologists
    • Figure 4.6: FPPE for Surgical Practitioner
    • Figure 4.7: FPPE/Proctorship Report for Emergency Medicine Practitioners
    • Figure 4.8: FPPE/Proctorship Report for Pediatrics
    • Figure 4.9: FPPE/Proctorship Report for Consulting Practitioners 
  • Chapter 5: Portneuf Medical Center
    • Figure 5.1: Professional Evaluation Policy
    • Figure 5.2: Specialty-Specific FPPE Plans
    • Figure 5.3: FPPE Table
    • Figure 5.4: Sample FPPE Contract
    • Figure 5.5: Documentation of OPPE Results
    • Figure 5.6: FPPE Report
    • Figure 5.7: Monitoring Evaluation Form
    • Figure 5.8: Surgical Monitoring Report Form
    • Figure 5.9: Radiology Monitoring Evaluation Form
    • Figure 5.10: Monitoring Evaluation Form for Allied Health Providers