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

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

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

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 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


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
ISBN: 978-1-61569-388-7

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