Focused and Ongoing Professional Practice Evaluation (F/OPPE) for Medical Staff &

1. Your Facility Name Focused and Ongoing Professional Practice Evaluation (F/OPPE) for Medical Staff & Allied Health Professionals Facility Name Last Update: _________

2. What is the Goal of Professional Practice Evaluation? Professional Practice Evaluation is a Medical Staff-led initiative to establish performance expectations and ensure that patient care meets appropriate standards Facility Name Last Update: _________

3. Why F/OPPE? For the Safety of our Patients The Medical Staff Leadership and the Governing Board have approved this process to ensure physician competency and high quality care for our patients, and to ensure (your facility name) providers are the best they can be. Facility Name Last Update: _________

4. FPPE is the acronym for Focused Professional Practice Evaluation and it is to validate competency at (your facility name) using the hospital’s resources, equipment, environment, staff, etc. FPPE occurs at initial appointment, a new privileges request, or if a question arises regarding current privileges. What is FPPE? Facility Name Last Update: _________ 4

5. OPPE is the acronym for Ongoing Professional Practice Evaluation. It is the ongoing review of your performance here at (your facility name), to validate your competency, and to identify professional practice trends. Again, using the hospital’s resources, equipment, environment, staff, etc. OPPE review is conducted in 8 month cycles, and in order to maintain privileges at (your facility name) the Medical Staff requires providers to complete 3 patient encounters every 8 months What is OPPE? Facility Name Last Update: _________ 5

6. Newly appointed physician / AHP or new privilege request Focused and Ongoing Professional Practice Evaluation Physician & AHP Ongoing Evaluation OPPE Cycle 3/ 3rd 8 month review OPPE Cycle 2/ 2nd 8 month review OPPE Cycle1/1st 8 month review FPPE first 3 months or # of cases specified, but not to exceed 6 months. Issue of Competency: When questions of competency arise regarding a provider’s current privileges. Peer Evaluation/Chart Review Credentials Committee Once the specified number of cases has been reviewed, Medical Executive Committee Reappointed/ Privileges Granted/Maintained – Physician/ AHP Notified NOT Reappointed/ Privileges NOT Granted / Maintained – Physician/AHP Notified Governing Board

7. Specialty Specific Indicators Facility Name Last Update: _________ 7

8. Department Specific Indicator Samples Facility Name Last Update: _________ 8

9. Analytics Application • Source for severity adjusted analytics for OPPE • Provides drill down access to case detail • Self evaluation of patient care performance • Resource for benchmarks and best practice data • Care cost analysis to review utilization trends Facility Name Last Update: _________ 9

10. FPPE Documentation • Complete the form provided to help us document your first 3 cases ______________________________________ Your Name (Please Print) Facility Name Last Update: _________ 10

11. 5 patient encounters in the first 3 months If you are a part of a group practice, please notify your scheduler to rotate you to (your facility name) until you acquire 3 patient encounters within the first 3 months. Remember... Facility Name Last Update: _________ 11

12. FPPE/OPPE Q & A • Questions about FPPE or OPPE? • Is there anyone who will have a problem with meeting 3 cases in the first 3 months for FPPE? Facility Name Last Update: _________ 12