The FPPE Toolbox: Field-Tested Documents for Credentialing, Competency, and Compliance, Second Edition

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The FPPE Toolbox, Second Edition

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The FPPE Toolbox: Field-Tested Documents for Credentialing, Competency, and Compliance, Second 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 Credentialing, 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.

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


Meet 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