Medical Staff Governance Flashcards
7 cards from real CPCS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Medical Staff Governance flashcards as text
Which federal law requires hospitals to report adverse credentialing actions of 30 days or more to the National Practitioner Data Bank (NPDB)?
Answer: The Health Care Quality Improvement Act (HCQIA)
HCQIA of 1986 mandates hospitals to report professional review actions restricting or revoking clinical privileges for 30 days or more to the NPDB.
A practitioner resigns from the medical staff while under investigation. How must the hospital respond regarding NPDB reporting?
Answer: A report must be filed if the investigation would have resulted in a reportable adverse action
Under HCQIA, hospitals must file an NPDB report when a practitioner resigns or surrenders privileges while under investigation to prevent circumventing the reporting system.
Under CMS Conditions of Participation, which of the following is required when a hospital grants a telemedicine practitioner privileges via a distant-site hospital agreement?
Answer: The local hospital may rely on the distant site's credentialing if a written agreement exists
CMS allows a local hospital to rely on a distant-site hospital's credentialing decisions for telemedicine providers when a formal written agreement meeting specific criteria is in place.
The 'ongoing professional practice evaluation' (OPPE) process is BEST described as which of the following?
Answer: A continuous evaluation of a practitioner's performance used to inform privilege decisions
OPPE is a continuous, data-driven performance monitoring process used to make privilege-related decisions between formal reappointment cycles.
A hospital's medical staff bylaws must be reviewed and approved by which two entities to be considered valid and enforceable?
Answer: The medical staff and the governing board
Medical staff bylaws require approval by both the organized medical staff (through vote) and the governing board to be legally enforceable.
Which document specifies the exact clinical activities a practitioner is authorized to perform at a specific hospital?
Answer: The delineation of privileges form
The delineation of privileges (privilege form) lists the specific procedures and clinical activities a practitioner is granted permission to perform at that institution.
Which of the following BEST defines 'proctoring' in the context of medical staff governance?
Answer: Supervised observation of a practitioner performing procedures to assess competency
Proctoring involves a qualified observer watching a practitioner perform procedures to validate competency, often required for new privileges or when concerns arise.