The OPPE Toolbox: Field-tested Documents for Credentialing, Competency, and Compliance

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The OPPE Toolbox: Field-tested Documents for Credentialing, Competency, and Compliance

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The OPPE Toolbox: Field-tested Documents for Credentialing, Competency, and Compliance

Author: Juli Maxworthy, DNP, MSN, MBA, RN, CNL, CPHQ, CPPS

Not sure how to organize and present all your OPPE data? Just open your toolbox

Get the tools you need to carry out OPPE. The OPPE Toolbox: Field-Tested Documents for Credentialing, Competency, and Compliance contains forms and policies that hospitals of various scope and size are currently using to conduct OPPE that complies with accreditors’ standards.

Streamline your processes, eliminate the background work, and implement a comprehensive and compliant OPPE process with these expertly reviewed tools and forms. Author Juli Maxworthy, DNP, MSN, MBA, RN, CNL, CPHQ, CPPS, provides medical staff leaders, medical staff professionals, and the quality team with best practices and highlights how to tailor the tools to your organization’s needs.

This book will help you:

  • Save the time and hassle involved in developing OPPE forms from scratch
  • See what your peers are using to conduct OPPE at their organizations and compare your process
  • Implement new indicators for various specialties
  • Pick up new tips for getting your medical staff on board with OPPE
  • Download and customize each form

Table of Contents

Chapter 1: Beebe Healthcare

Figure 1.1: OPPE and FPPE Policy

Figure 1.2: Reappointment OPPE Scorecard

Figure 1.3: Peer Evaluation Form—Low- and No-Volume Providers

Figure 1.4: OPPE Data Analysis and Discussion Form

Figure 1.5: Behavior Incident Classification Form

Figure 1.6: FPPE Plan

Figure 1.7: OPPE Indicator Proposal Sheet

Figure 1.8: Sample Indicators

Chapter 2: MaineGeneral Medical Center

Figure 2.1: OPPE and FPPE Policy

Figure 2.2: OPPE—Hospitalist

Figure 2.3: OPPE—Emergency Department

Figure 2.4: OPPE—Anesthesia

Figure 2.5: OPPE—Orthopedic Surgery

Figure 2.6: OPPE—Pathology

Figure 2.7: 360° Peer Rating for Provider Performance

Figure 2.8: Low- and No-Volume Competency Attestation

Figure 2.9: Quality Data Inquiry Letter

Chapter 3: Methodist Medical Center

Figure 3.1: OPPE Process Flow Chart

Figure 3.2: FPPE for Cause Process Flow Chart

Figure 3.3: OPPE Evaluation—Hospitalist

Figure 3.4: OPPE for Physician Assistant—Surgical

Figure 3.5: OPPE for Physician Assistant or Nurse Practitioner—Non-Surgical

Chapter 4: Teche Regional Medical Center

Figure 4.1: OPPE Policy

Figure 4.2: Data Inventory for OPPE and FPPE

Figure 4.3: Peer Review Form

Figure 4.4: OPPE Review for Nurse Practitioner—Emergency Department

Figure 4.5: Report From Department Chair

Figure 4.6: Reappointment Confirmation Letter for Low-or No-Volume Practitioners

Chapter 5: Tuomey Regional Medical Center

Figure 5.1: OPPE—Internal Medicine

Figure 5.2: OPPE—Surgery

Figure 5.3: OPPE—Family Medicine

Figure 5.4: OPPE—Pain Management

Figure 5.5: Comment Page

Chapter 6: USMD Hospitals at Arlington & Fort Worth

Figure 6.1: OPPE and FPPE Policy and Procedures

Figure 6.2: OPPE Summary and Action Form

Figure 6.3: Medical Staff Clinical Indicator Green Sheet

Figure 6.4: OPPE Summary for Credentials Committee Meeting

Figure 6.5: OPPE—Emergency Medicine

Figure 6.6: OPPE—Gynecology

Figure 6.7: OPPE—Allied Health Practitioner

Chapter 7: Wabash County Hospital

Figure 7.1: OPPE Policy

Figure 7.2: Chart Review—Emergency Medicine

Figure 7.3: Evidence-Based Data: Anesthesiology

Figure 7.4: Evidence-Based Data: Emergency Medicine

Figure 7.5: Evidence-Based Data: General or Specialty Surgery

Figure 7.6: Evidence-Based Data: Specialty/Consulting Associate Staff (Non-Admitting)

Figure 7.7: Evidence-Based Data: Community-Based Practice

About the Author

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

Publish Date: October 1, 2014