CPCS CPCS - Certified Provider Credentialing Specialist Clinical Privileging Questions and Answers 2 — Questions and Answers
Question 1: What is the primary purpose of a 'proctoring' requirement for a newly privileged physician?
- To reduce malpractice insurance premiums
- To verify the physician's ability to perform specific procedures in the facility's environment (Correct answer)
- To satisfy HIPAA requirements for new staff
- To replace the need for primary source verification
Correct answer: To verify the physician's ability to perform specific procedures in the facility's environment
Proctoring allows a qualified peer to observe a newly privileged physician performing specific procedures to verify competence in the specific facility's environment and with its resources.
Proctoring (also called focused professional practice evaluation or FPPE) requires newly privileged practitioners to have their clinical performance observed by a qualified peer during an initial evaluation period. The purpose is to verify that the practitioner can perform the requested privileges competently within the specific hospital's environment, with its staff, equipment, and patient population. Proctoring is facility-specific and goes beyond training and credentials verification.
Question 2: A hospital's clinical privileging form asks physicians to request privileges for 'laparoscopic cholecystectomy.' Which type of privilege is this an example of?
- Core privilege
- Threshold privilege
- Specific or special privilege (Correct answer)
- Provisional privilege
Correct answer: Specific or special privilege
Laparoscopic cholecystectomy is a specific or special privilege because it requires demonstrated training and competency beyond general surgery, typically requiring documentation of a minimum case volume.
Clinical privileges are often categorized as core/base privileges (procedures common to all practitioners in a specialty) and specific/special privileges (procedures requiring additional training, credentialing, or competency documentation). Laparoscopic procedures, robotic surgery, and other advanced techniques typically fall into the specific/special category, requiring practitioners to document training, case volume, and competency through a proctor or other means before privileges are granted.
Question 3: Under The Joint Commission standards, which of the following is required before granting temporary privileges to a practitioner with a complete credentials file?
- Full medical executive committee approval
- Governing board approval
- A favorable recommendation from the department chief or designee (Correct answer)
- Completion of FPPE for at least 10 cases
Correct answer: A favorable recommendation from the department chief or designee
TJC standards allow temporary privileges to be granted by the CEO or designee based on a favorable recommendation from the department chief or designee when there is a completed credentials file and no adverse information.
The Joint Commission MS.06.01.07 allows temporary privileges to be granted for (1) an important patient care need or (2) while a complete application is being processed. For a practitioner with a complete credentials file pending full approval, temporary privileges may be granted by the CEO (or designee) upon the recommendation of the appropriate clinical department chief or designee. This process bypasses the full committee approval timeline while maintaining oversight.
Question 4: The 'Ongoing Professional Practice Evaluation' (OPPE) program requires hospitals to review practitioner performance data at regular intervals. What is the TJC-required maximum interval between OPPE reviews?
- Monthly
- Quarterly
- Every 6 months (Correct answer)
- Annually
Correct answer: Every 6 months
The Joint Commission requires that OPPE data be used to assess whether each practitioner's privileges should be continued, revised, or revoked at intervals not to exceed every 6 months.
Under TJC MS.08.01.03, the organized medical staff must define the criteria used to evaluate practitioner performance through OPPE and use the data to determine whether to continue, modify, or revoke existing privileges. The standard requires that this evaluation occur at intervals defined by the organization, but the interval cannot exceed every 6 months (twice per year). This ensures ongoing monitoring rather than waiting until recredentialing.
Question 5: Which of the following situations would trigger a Focused Professional Practice Evaluation (FPPE) for an already-credentialed practitioner?
- Completion of a new CME course
- Routine annual performance review
- A sentinel event involving the practitioner (Correct answer)
- Expiration of board certification
Correct answer: A sentinel event involving the practitioner
FPPE is triggered by concerns about a practitioner's ability to provide safe, quality care, such as following a sentinel event, complaint, or identified performance concern, not just for routine monitoring.
While FPPE is always required for new practitioners or new privileges, it is also triggered for existing practitioners when a performance concern arises. Triggers include: sentinel events involving the practitioner, patterns of unexpected outcomes, concerns raised by peer review, complaints from patients or staff, or any situation raising questions about the practitioner's competence. FPPE for cause involves a defined period of focused monitoring with specific evaluation criteria.
Question 6: A physician requests privileges for a procedure not currently on the hospital's privilege delineation form. What is the most appropriate first step?
- Automatically deny the request since it is not on the approved list
- Grant the privilege if the physician has documented training
- Convene the credentials committee to evaluate whether to add the procedure to the privilege form (Correct answer)
- Refer the physician to another facility for this procedure
Correct answer: Convene the credentials committee to evaluate whether to add the procedure to the privilege form
When a physician requests a privilege for a procedure not on the current delineation form, the appropriate process is to evaluate whether the procedure should be added to the approved privilege list before granting it.
Privilege delineation forms should evolve as medical technology and procedures advance. When a practitioner requests a privilege for a procedure not yet on the form, the medical staff office should work with the appropriate department chief and credentials committee to evaluate the procedure, determine if the hospital has the necessary resources and support services, establish criteria for granting the privilege, and then add it to the form. The privilege should not be granted ad hoc without this process.
CPCS CPCS - Certified Provider Credentialing Specialist Clinical Privileging Questions and Answers 2
What is the primary purpose of a 'proctoring' requirement for a newly privileged physician?