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
A credentials specialist discovers that a physician's board certification lapsed two years ago. The hospital's bylaws require current board certification for initial appointment. What is the MOST appropriate next step?
Answer: Notify the credentials committee and place the application on hold pending resolution
The credentials specialist should escalate the finding to the credentials committee, which has authority to determine how the deficiency affects the application.
What is the maximum time period typically allowed between the date an application is deemed complete and a credentialing decision under most bylaws and accreditation standards?
Answer: 120 days
Most medical staff bylaws and accreditation frameworks set a 120-day maximum from complete application to credentialing decision to ensure timely processing.
A practitioner holds privileges at two hospitals in the same health system. Under a 'unified' or 'systemwide' credentialing model, which of the following is TRUE?
Answer: One set of credentials is verified and shared across participating entities per agreement
Systemwide or unified credentialing models allow a single verification to be shared across multiple entities within a health system, provided governance agreements are in place.
The 'focused professional practice evaluation' (FPPE) is typically triggered by which of the following circumstances?
Answer: A new privilege request or a concern identified through OPPE
FPPE is a time-limited, focused evaluation used when a new privilege is granted or when OPPE data raises concerns about a practitioner's performance.
Which type of medical staff membership category typically permits physicians to admit patients and vote on medical staff matters?
Answer: Active staff
Active staff members have full admitting privileges and voting rights, representing the core category with the broadest participation in medical staff governance.
A hospital is implementing a new robotic surgery program. Which process must be completed before surgeons may begin performing robotic procedures on patients?
Answer: New specific privileges for robotic surgery must be requested, reviewed, and granted
New technology requires the development of specific privilege criteria and formal approval of those privileges before practitioners may use the technology on patients.
Which accreditation standard most directly requires that a hospital's credentialing process include a query to the NPDB at initial appointment and at reappointment?
Answer: CMS Conditions of Participation §482.22
CMS Conditions of Participation §482.22 explicitly requires hospitals to query the NPDB as part of the credentialing process at appointment and reappointment.