Example Test Flashcards
1
Q
the medical staff leaders are responsible for collaborating on the design of the credentialing process?
A
True
2
Q
The medical staff leaders establish standards for access to the credentialing process and medical staff membership?
A
True
3
Q
The medical staff leaders establish mechanisms to assure standards are uniformly and consistently applied to all practitioners who are eligible to be credentialed?
A
True
4
Q
The role of a credentials committee usually doesn’t include the following responsibility?
A
A) Assure the Medical Executive Committee that medical staff bylaws provisions that related to credentialing processes are being fulfilled.
B) That the credentialing committee only focuses on the files that have been determined to be problematic (as in gaps, claims and unfavorable references).******
C) Assure the credentials committee looks for completeness, thoroughness, and monitors compliance with all credentialing policies and procedures.
D) Evaluate recommendations made by department chairs.
E) Assure the Medical Executive Committee that department specific standards for clinical privileges are in compliance with medical staff bylaws and credentialing policies and procedures.
5
Q
LIP stands for
A
**A) Licensed Independent Practitioner - who operates within the scope of the individual’s license, consistent with individually granted clinical privileges.******
B) Limited Independent practitioner - who is limited by law and by the organization to provide care and services without direct or supervision.
C) Licensed Independent Practitioner - who is permitted by law to provide care and services under the direction or supervision.
6
Q
Competency is (as in current clinical competency)
A
A) ability of a criminal to stand trial
**B) a determination of an individual’s skills, knowledge, and capability to meet defined expectations.****
C) the ability to do something successfully
7
Q
Which are critical steps in the credentialing process
A
A) Analyze and Review the Data
B) Collect and Analyze the Data
**C) Verify and Evaluate the Data****
8
Q
Today’s MSP plays a vital role in which of the following healthcare delivery systems
A
A) Hospital and ambulatory care centers
B) Nursing Home centers and ambulatory care centers
**C) Credentialing Verification Organization and Managed Care settings******
9
Q
What accrediting agency is JC?
A
Joint Commission
10
Q
What accrediting agency is NCQA?
A
National Committee for Quality Assurance Review
11
Q
What accrediting agency is URAC?
A
Utilization Review Accreditation Commission
12
Q
What accrediting agency is CMS?
A
Centers for Medicare and Medicaid Services
13
Q
What accrediting agency is CARF?
A
Commission on Accreditation of Rehabilitation Facilities
14
Q
What accrediting agency is DNV?
A
Det Norske Veritas
15
Q
What agency is FDA?
A
Food and Drug Administration
16
Q
What does COP stand for?
A
Condition of Participation
17
Q
What accrediting agency is the only hospital accrediting organization guaranteed by statute to have Medicare “deeming” authority; that is, hospitals accredited by the __________are deemed by CMS to meet the Medicare COP
A
Joint Commission
18
Q
Medicare and Medicaid program were established in what year?
A
1960, 1965, 1969, 1970
Congress didn’t have much experience in health care and deferred to the expertise of the Joint Commission, a professional accreditation organization that had been in existence since 1951. Congress recognized that voluntary accreditation was one way that hospitals could demonstrate compliance with Medicare’s Hospital COP and mandated that accreditation by the JC was equivalent to meeting those conditions. The first Medicare COP was modeled after the JC standards as then written.
19
Q
In what year did CMS grant deeming authority to Det Norske Veritas (DNV) as a national hospital accrediting organization.
A
**September 2008***, September 2009, September 2010, September 2012
20
Q
In what year was DNV established?
A
DNV is an independent foundation whose purpose is to safeguard life, property, and the environment. 1860, **1864*** or 1865
21
Q
What does HFAP Stand for?
A
Health Facilities Accreditation Program; HFAP is a viable alternative to the joint commission. HFAP was created in what year to accredit osteopathic hospitals. Today it accredits acute care, ambulatory surgery centers, allopathic acute care, critical access hospitals and other health care organizations in the US.
22
Q
Title XVIII of the Social Security Act, Health Insurance for the Gaed, is commonly known as Medicare. This legislation was originally passed in _____ and went into effect a year later. The Dept. of Health and Human Services Centers for Medicare and Medicaid Services (CMS) operates the Medicare program.
A
1965
23
Q
What does NAMSS stand for?
A
National Association Medical Staff Services; Charlotte Cochrane and Joan Covell Carpenter of California established a medical staff association in 1971, which evolved into a national organization in 1976.
24
Q
NAMSS developed a certification program within the first five years of its existence as a national organization. The CMSC examination was established, and the first certification class was offered in 1981. What does CMSC stand for?
A
Certified Medical Staff Coordinator
25
The governing body of the hospital is the source of all legal authority and may not delegate the ultimate responsibility for the overall quality of care delivered in the hospital. The governing body does, however, delegate responsibility to the medical staff to perform credentialing and peer review activities. In carrying out these functions, the medical staff organization acts as an agent of the governing body and must be accountable for its performance. The Medical Staff organization reports directly to who?
***********A) The Governing Body through the president or chief of the medical staff***********
B) The Credentialing Committee
C) The Medical Executive Committee
26
The organized medical staff has a critical role in the process of providing oversight of quality of care, treatment and what?
SERVICES
27
Which statement is true?
A) Individual members of the medical staff care for patients within an organization
B) Individual members of the medical staff, as a group, interface with, and actively participate in important organization functions.
C) The hospital has an organized, self-governing medical staff that provides oversight of care, treatment and services provided by practitioners with privileges.
D) A and C
********E) All of the above**********
28
Which is not true about Active Staff Members?
A) Active members are the practitioners who actively admit or work in the hospital
B) The bylaws indicate if an active staff member has voting rights
**************C) Those who are Active Staff Members doesn't need to be identified in the bylaws************
D) Medical staff committees are generally composed of active members
E) There are sometimes meeting attendance requirement for active staff members
29
Do the bylaws need to identify staff categories of the medical staff organization?
*****Yes****** or No
30
Although there is variation from hospital to hospital, the usual officers of the medical staff are the president or chief of staff, the vice president or vice chief, and the secretary treasurer. Some medical staff organizations include the immediate past president/immediate past chief of staff as an officer. Is the president of the staff elected or selected to act as head of the medical staff and accountable to the governing body for all activities of the medical staff organization?
*****Yes***** or No
31
Is each clinical department represented by a chair or chief in a departmentalized medical staff organization?
*********Yes******* or No
32
The method of selection of each department chair doesn't need to be specified in the bylaws and may include selection by the department or appointment.
Yes or No - No it needs to be specified in the bylaws.
33
The president of the hospital is usually the chair of the Executive committee of the medical staff?
*****Yes****** or No
34
Small hospitals that have non-departmentalized medical staff may have a medical executive committee, or the active members may act as a whole to perform the required functions?
*****True********** or False
35
Does the Joint Commission standards mention if the executive committee must be made up of fully license doctor of medicine or osteopathy who are actively practicing in the hospital?
****Yes***** or No
36
CMS doesn't require a medical executive committee, but does CMS Conditions of Participation (COP) state that the majority of members must be MD's or DO's?
*****Yes***** or No
37
Bylaws are a governance framework document that establishes the roles and responsibilities of a body and its members?
*****Yes***** or No
38
Bylaws are regulations and/or rules adopted by the organized medical staff and the governing body of an organization.
****True***** or False
39
What are not included in the bylaws?
A) Rules and Regulations
B) Fair hearing plan
C) Policies and Procedures
D) Roles and responsibilities for the medical staff
E) A and B
F) C and D
*********G) B and D********************
H) All of the above
40
What is peer review?
Ongoing peer review is required after appointment to the medical staff. Once medical staff privileges have been granted, hospitals have a legal duty to take reasonable steps to ensure ongoing patient safety. Hospitals can be held liable in a medical malpractice lawsuit if the plaintiff proves that a hospital knew or should have known that a physician engaged in a pattern of incompetent behavior and did nothing to safeguard hospitals' patients.
41
What is FPPE?
Focused Professional Practice Evaluation (FPPE) - is a review plan implemented at the time of initial appointment or granting of new privileges and continues for the first six months of medical staff membership.
42
What is OPPE?
Ongoing Professional Practice Evaluation, which continues as long as a physician has privileges. Each hospital develops the content method, and time period of peer review evaluation.
43
When can FPPE and OPPE be challenging?
If a physician does not admit a sufficient number of patients to the hospital to permit the collection and review of appropriate data.
44
What do poor FPPE or OPPE trigger?
additional chart reviews, discussions with medical staff officers or department chairpersons, or proctoring of cases corrective action under the medical staff bylaws generally is triggered or results that are found to be detrimental to patient safety or the delivery of quality patient care, below the standards and aims of the hospital, or disruptive to hospital operations.
45
What about immunity?
State and federal laws provide immunity for peer review activities conducted in good faith to reduce morbidity and mortality.
46
What is the NPDB?
Hospitals must report all denials of medical staff privileges for reasons of clinical or professional competence to the National Practitioner Data Bank (NPDB). Similarly, the NPDB must be queried by hospitals as part of the appointment process for every physician.
47
What is the correct order the JC uses to process applications?
1) Receive application
2) Verify completeness and that all requested materials are included
3) Process Application: conduct primary source verification and verify current competency for privileges requested
4) Chief of Service/Department Chair Review and recommendation (if departmentalized)
5) Executive Committee review and makes recommendations to the Board of Trustees
6) Board Approves
7) Notify applicant of final decision
48
What is the correct order NCQA uses to process applications?
1) Receive application
2) Verify completeness and that all requested materials are included
3) Process application: conduct primary source verification
4) Medical Director reviews and approves or makes recommendation to Credentials committee if required by procedure
5) Credentials Committee reviews for information only or to approve
6) Notify applicant of final decision
49
What is the correct order HFAP uses to process applications?
1) Receive application and then verify completeness and that all requested materials are included
2) Process application: conduct primary source verification and verify current competency for privileges requested
3) Chief of Service/Department Chair reviews and makes recommendation (if departmentalized)
4) Credentials Committee review and recommendation, if credentials committee exists.
50
Why was the NPDB Created?
The NPDB was established to prevent incompetent physicians from moving from hospital to hospital without disclosure of adverse credentialing history.
51
AMICUS
Friend of the court - a brief filed by an interested party giving an opinion/information on a case.
52
Antitrust
Unlawful restraints and monopolies or unfair business practices
53
Brief
Document an attorney prepares on appeal cases - gives history, facts, legal action, opinion about case presented to an appeals judge.
54
Consent
A voluntary act by which one person agrees to allow someone else to do something.
55
Contract
An agreement that identifies rights and obligations
56
Defendant
Party against whom legal action is brought "one who must complain"
57
Deposition
written sworn testimony made before a public officer for a court action, often as answers to questions posed by a lawyer, used for discovery of information or evidence for a trial.
58
Discovery
Pretrial activities to determine what evidence the opposing side will present if the case comes to trial, discovery may include depositions, written interrogatories, and the inspection and copying of documents.
59
According to NCQA, is the ABMS Certified Doctor Verification Program accessible through the ABMS web site, an acceptable source for verifying board certification for an MD?
No, this site is intended for consumer reference only and is not considered PSV.
60
The joint commission requires licensure to be verified with the primary source at what four times?
1) Initial granting
2) Renewal of privileges
3) Revision of privileges
4) At the time of license expiration
61
According to the Joint Commission, the hospital must query the National Practitioner Data Bank at what 3 times?
1) when the clinical privileges are initially granted
2) at the time of renewal of privileges
3) when a new privilege is requested
62
Can the hospital accept a NPDB self query performed by a physician to satisfy the Joint Commissions requirement for NPDB query?
No, the hospital or its designated agent must perform the query.
63
True or False: According to NCQA standards an organization must verify sanctions or limitations on licensure in each state where the practitioner holds or has ever held licensure
False: the organization must verify sanctions or limitations on licensure in each state where the practitioner provides care for its members.
64
Fraud and Abuse
A false misrepresentation of fact that is relied on by another to that person's detriment and is a departure from reasonable use.
65
Upcoding
submitting a bill for a higher reimbursement rate
66
Unbundling
submitting separate bills for each component of a procedure instead of using the proper procedural code for the entire procedure, resulting in a higher reimbursement rate to the health care provider.
67
Qui Tam Relator
another name for a whistleblower; On the simplest level, a whistleblower is someone who reports waste, fraud, abuse, corruption, or dangers to public health and safety.
68
Relators
Private Plaintiffs
69
Whistleblower
relator is a current or former employee of the health care provider or organization who has learned of the fraud and abuse and wishes to expose the activity.
70
Anti-kickback statute
prohibits the offer or solicitation of remunerations including kickbacks and rebates, in exchange for referrals of federally payable services, including Medicare services.
71
Physician self-referral prohibitions
laws that prohibit physicians from referring patients to services when the physician possesses a financial interest or will receive payment in return for the referral.
72
Are limitations of the clinical privileges of a psychiatrist for more than 30 days reportable to the NPDB?
Yes
73
According to TJC, who may amend the medical staff bylaws?
Governing body/board
74
Are limitations of the clinical privileges of a psychiatrist for more than 30 days reportable to the NPDB?
Yes
75
According to TJC, who may amend the medical staff bylaws?
Governing body/board
76
Failure to meet the established qualifications and criteria for appointment should be reported to whom?
The applicant
77
NCQA requires the MCO to obtain a minimum of how many years of work history?
Five years
78
According to the NCQA what policy must an organization have in place to obtain approval to enter into a delegated agreement?
Credentialing policies
79
How often does the OIG report to the NPDB?
monthly
80
When must hospitals query the NPDB?
Initial appointment, granting of privileges and every two years.
81
NCQA requires verifications must be less than how many days old?
180 days
82
Are limitations of the clinical privileges of a psychiatrist for more than 30 days reportable to the NPDB?
Yes
83
According to TJC, who may amend the medical staff bylaws?
Governing body/board
84
Failure to meet the established qualifications and criteria for appointment should be reported to whom?
The applicant
85
NCQA requires the MCO to obtain a minimum of how many years of work history?
Five years
86
According to the NCQA what policy must an organization have in place to obtain approval to enter into a delegated agreement?
Credentialing policies
87
How often does the OIG report to the NPDB?
Monthly
88
When must hospitals query the NPDB?
Initial appointment, granting of privileges, every two years.
89
NCQA requires verifications must be less than how many days old?
180 days
90
What elements should a peer recommendation include according to TJC?
Patient care, medical clinical knowledge, practice based learning, interpersonal and communication skills, system based practice
91
Peer recommendations according to NCQA?
There is no specific requirement for peer recommendations. The organization must designate a credentialing committee that uses a peer-review process to make recommendations regarding credentialing decisions.
92
Peer recommendations according to HFAP?
Must obtain at least one peer with the same professional credential as the applicant that includes a statement regarding the physician's physical and mental health in relation to privileges requested.
93
Peer recommendations according to URAC?
There is no specific requirement for peer recommendations other than that a peer group makes the final credentialing determinations.
94
All individuals who are permitted by law and the hospital to provide patient care independently in the hospital are required to be credentialed and privileged under the medical staff standards.
Practitioners Credentialed and Privileged through the Medical Staff - TJC
95
Standards address credentialing not privileging
Practitioners Credentialed and Privileged through the Medical Staff - NCQA
96
Standards regarding medical staff composition are a direct quote of CMS. The governing body must ensure that any privileges granted to non-physician practitioners are in accordance with state law, regulations and scope of practice.
Practitioners credentialed and privileged through the medical staff - HFAP
97
The HCIIA was passed in what year?
1986 review - know patrick burget case (1988)
98
The HCA Protection data bank began accepting reports what year?
1999 - NPDB & HIPDB were made
99
Hospital that does not query NPDB as required by
liable legally
100
Peer reviews are protected except when information is from liablity
false & person knows its false
101
Payments made by physician
not reportable on NPDB - 30 days - tell them place, time date and/or witness's.
102
Only MD, DO and Dentists
Required for NPDB
103
information collected & disseminated through NPDB
all license types (2010)
104
query NPDB
any changes, every 2 years, temporary, expansion or revision to privileges - any change! (only hospitals)
105
What does HIPDB bank?
The Healthcare Integrity and Protection Data Bank (HIPDB) is a database that contains information about health care providers, suppliers, and practitioners. The HIPDB was created by the Health Insurance Portability and Accountability Act of 1996 to help prevent fraud and abuse in health care.
106
Not reportable to NPDB
denial of license application by state licensing board)
107
HIPAA - what does it stand for?
Health insurance portability and accountability act (180 days for complaints)
108
The Medical Staff leaders are responsible for collaborating on the design of the credentialing process?
**********True************ or False
109
The Medical Staff Leaders establish standards for access to the credentialing process and medical staff membership?
********True********** or False
110
The Medical Staff Leaders establish mechanisms to assure standards are uniformly and consistently applied to all practitioners who are eligible to be credentialed?
*********True********* or False
111
The role of a credentials committee usually doesn't include the following responsibility:
A) Assure the medical executive committee that medical staff bylaws provisions that related to credentialing processes are being fulfilled
********B) That the credentialing committee only focuses on the files that have been determined to be problematic (as in gaps, claims and unfavorable references)*********
C) Assure the credentials committee looks for completeness, thoroughness and monitors compliance with all credentialing policies and procedures
D) Evaluate recommendations made by department chairs
E) Assure the medical executive committee that department specific standards for clinical privileges are in compliance with medical staff bylaws and credentialing policies and procedures.
112
LIP stands for
A) licensed independent practitioner who operates within the scope of the individuals license, consistent with individually granted clinical privileges.
B) Limited Independent practitioner - who is limited by law and by the organization to provide care and services without direction or supervision.
*********C) Licensed independent practitioner who is permitted by law to provide care and services under direction or supervision*****
113
Competency is (as in current clinical competency)
A) ability of a criminal to stand trial
******B) a determination of an individual's skills, knowledge, and capability to meet defined expectations****
C) the ability to do something successfully
114
Which are critical steps in the credentialing process?
A) analyze and review the data
B) collect and analyze the data
****C) Verify and evaluate the data****
115
Today's MSP plays a vital role in which of the following healthcare delivery systems
A) Hospital and ambulatory care centers
B) Nursing Home centers and Ambulatory Care Centers
C) Credentialing Verification Organization and Managed Care Settings
***A & C**
116
What accrediting agency is JC?
The Joint Commission
117
What accrediting agency is NCQA?
National Certification Quality Assurance
118
What accrediting agency is URAC?
non-profit for patient safety; Utilization Review Accreditation Commission
119
What accrediting agency is CMS?
Medicare (centers for Medicare services)
120
What accrediting agency is CARF?
Commission on accreditation of Rehab Facilities
121
What accrediting agency is DNV?
Det Norske Veritas
122
What agency is FDA?
Food and Drug Administration
123
What does COP stand for?
Conditions of Participation
124
What accrediting agency is the only hospital accrediting organization guaranteed by statue to have Medicare deeming authority; that is hospitals accredited by the ______ are deemed by CMS to meet the Medicare COP
Joint Commission
125
Medicare and Medicaid program were established in what year?
1960
126
In what year did CMS grant deeming authority to Det Norske Veritas (DNV) as a national hospital accrediting organization?
Sept 2010
127
In what year was DNV established? (DNV is an independent foundation whose purpose is to safeguard life, property, and the environment
1864 Oslo Norway
128
What does HFAP stand for?
Healthcare Facilities Accreditation Program; HFAP is a viable alternative to the joint commission HFAP was created in what year to accredit osteopathic hospitals. Today it accredits acute care, ambulatory surgery centers, allopathic acute care, critical access hospitals and other health care organizations in the US. (1945)
129
Title XVIII of the Social Security Act, Health insurance for the aged, is commonly known as _____
Medicare; This legislation was originally passed 07/30/1965 and went into effect a year later. The Dept. of Health and Human Services Center for Medicare & Medicaid Services (CMS) operates the Medicare program.
130
Charlotte Cochrane and Joan Covell Carpenter of California established a medical staff association in 1971, which evolved into a national organization in 1976. What does NAMSS stand for?
National Association of Medical Staff Services
131
NAMSS developed a certification program within the first five years of its existence as a national organization. The CMSC examination was established, and the first certification class was offered in 1981.
What does CMSC stand for?
Certified Medical Staff Credentialist/Coordinator
132
The governing body of the hospital is the source of all legal authority and may not delegate the ultimate responsibility for the overall quality of care delivered in the hospital. The governing body does, however, delegate responsibility to the medical staff to perform credentialing and peer review activities. In carrying out these functions, the medical staff organization acts as an agent of the governing body and must be accountable for its performance. The medical staff organization reports directly to who?
****A) The governing body through the president or chief of the medical staff******
B) The Credentialing Committee
C) The Medical Executive Committee
133
The Organized medical staff has a critical role in the process of providing oversight of quality of care treatment and what?
Standard of Care/Services
134
Which statement is true?
A) Individual members of the medical staff care for patients within an organization
B) Individual members of the medical staff, as a group, interface with, and actively participate in, important organization functions.
C) The Hospital has an organized, self-governing medical staff that provides oversight of care, treatment and services.****
135
Does each clinical department is represented by a chair of chief in a departmentalized medical staff organization?
*****Yes***** or No
136
The method of selection of each department chair doesn't need to be specified in the bylaws and may include election by the department or appointment.
******Yes******* or No
137
The method of selection of each department chair doesn't need to be specified in the bylaws and may include election by the department or appointment.
**********Yes********* or No
138
The president of the hospital is usually the chair of the executive committee of the medical staff?
******Yes**** or No
139
Small hospitals that have non-departmentalized medical staff may have a medical executive committee, or the active members may act as a whole to perform the required functions?
*****True******* or False
140
Does the joint commission standards mention if the executive committee must be made up of fully license doctor of medicine or osteopathy who are actively practicing in the hospital?
*******Yes**** or No
141
CMS doesn't require a medical executive committee, but does CMS conditions of participation (COP) state that the majority of members must be MDs or DO's?
******Yes****** or No
142
Bylaws are a governance framework document that establishes the roles and responsibilities of a body and its members?
******Yes******* or No
143
Which is not true about active staff members
********A) active members are the practitioners who actively admit or work in the hospital*********
B) The bylaws indicate if an active staff member ahs voting rights
C) Those who are active staff members doesn't need to be identified in the bylaws
D) Medical staff committees are generally composed of active members
E) there are sometimes meeting attendance requirement for active staff members
144
Do the bylaws need to identify staff categories of the medical staff organization?
*****Yes**** or No
145
Although there is variation from hospital to hospital, the usual officers of the medical staff are the president or chief of staff, the , the vice president or vice chief, and the secretary treasurer. Some medical staff organizations include the immediate past president, immediate past chief of staff as an officer. Is the president of the staff elected or selected to act as head of the medical staff and accountable to the governing body for all activities of the medical staff organization?
******Yes******* or No
146
Bylaws are regulations and/or rules adopted by the organized medical staff and the governing body of an organization.
*****True***** or False
147
What are not included in the bylaws?
A) Rules and Regulations
********B) Fair Hearing Plan*******
C) Policies and Procedures
D) Roles and responsibilities for the medical staff
E) A & B
F) C & D
G) B & D
H) All of the above
148
Physician
Medical Doctor/Doctor of Osteopathic Medicine licensed and privileged to practice without supervision also know as Licensed Independent Practitioner
149
LIP
Other licensed independent practitioner who is licensed and privileged to practice without supervision (podiatrist, dentist, and in some setting may be advanced practice nurse, psychologist)
150
APP
Advanced Practice Professional; provides direct patient care services under a defined degree of supervision (advanced practice nurse, psychologist, and physician assistant)
151
Peer
professionals of similar types and degrees of expertise (e.g DPM, MD/DO, PA, APRN, MD/DO - can be a peer for PA and APRN)
152
Why do we do what we do?
Patient Safety!
153
Peer review
objective case review by a peer to determine appropriateness of care (usually triggered by medical staff approved criteria).
154
Focused Professional Practice Evaluation (FPPE)
A process where by the organization evaluates the privilege specific competence of a practitioner.
155
Ongoing Professional Practice Evaluation (OPPE)
A screening tool to evaluate all practitioners who have been granted privileges and to identify these clinicians who might be delivering an unacceptable quality of care.
156
What is Credentialing?
Credentialing is a process of assessing and validating the qualifications of an individual to provide services. The Objective of credentialing is to establish that the applicant has the specialized professional background that he or she claims and that the position requires. Credentialing is used to determine whether individuals who apply for medical staff appointments meet the minimum threshold criteria approved by the medical staff and board of directors.
157
An organization should:
review/validate/verify an individual's qualifications, including education, training, experience, certification, licensure, and any other competence.
158
What is privileging?
Privileging is the process to determine the specific procedures and treatments that a physician/LIP/APP may perform.
159
An organization should # 2:
determine the qualifications related to training and experience that are required to authorize an applicant to obtain each privileges, and establish a process for evaluating the applicant's qualifications using appropriate criteria and approving, modifying, or denying any or all of the requested privileges in a non-arbitrary manner.
160
Who must be credentialed?
to meet joint commission standards, hospitals must at a minimum, credential all licensed independent practitioners who are permitted by law to provide healthcare services without direction or supervision. All other individual's providing services in your organization provide specified patient care services outlined by his or her privileges, job description or contract.
161
Types of Information in or part of a credentialing application
- application
- other names used
- email addresses
- office manager name and number
- privilege form (specific to the specialty)
- certificate of insurance
- life support certificates (ACLS, BLS, PALS, etc.)
- drivers license
- photo of the provider - usually certified
- other facility specific forms
- visa status/#
- medical license (mass and others)
- federal & state DEA
- Education
- Institutions' name, address, phone
- Work history from mm/yyyy to mm/yyyy
- training/certification & institution's name
- institution's name/address/phone
(from mm/yyyy to mm/yyyy)
type of program
- training program director with name/address, phone, email address
- ECFMG (foreign medical education)
- CV - with any gaps explained
- peer references - contact, names, email or fax
- board certification - app certification
- signed authorization release (required to start any verifications)
162
Types of information queried or obtained as part of the credentialing process
- malpractice claim history (query all previous malpractice insurance company's for the last 10 years)
- verification of medical licensure (PSV online, state medical licensing board)
- verification of state and federal DEA (PSV online NTIS)
- mass address must be on the federal DEA
- verification other state medical licenses - state website or AMA
- checked the OIG website
- ran NDPB through website
- verifying education and training (institution or AMA profile)
- verify foreign medical education (ECFMG)
- verify canadian education (psv)
- gaps explained - five years
- verify board certification
- check for any disciplinary actions, sanctions, challenges (current/past - online state medical licensing board)
- healthcare affilaitions
-facility name (from mm/yyyy to mm/yyyy)
- category status
- peer references
- dept/service chief name
- must be someone with direct/recent knowledge of current clinical competence
- same or related specialty
- peer reference forms should be formatted within six general competencies.
163
What should be sent to the applicant?
- application form
- bylaws
- other policies (code of conduct, health and wellness)
164
BURDEN of a complete application is always on the applicant!
After making an appropriate and reasonable effort to obtain the information, and you have exhausted all efforts, place the burden firmly on the applicant. It is acceptable to reach out the applicant and ask for assistance in obtaining the missing information.
165
What is PSV/Primary Source Verification?
to reach out to the primary school, hospital, business location, or accepted websites approved by the joint commission. The joint commission states that the hospital verifies in writing and from the primary source whenever feasible. The applicant's current licensure must be verified by the PSV at initial and reappointment, renewal, and revision of privileges, and at the time of license expiration.
- your hospital should verify all of the statements on an applicant's application and closely question the applicant about any blank entries. The hospital may be liable if it fails to verify information that would have resulted in clinical privilege restrictions or a decision not to grant affiliation had the information been available for consideration. By contacting the primary source of the credentials, your hospital can ensure that the credentials information it received from the applicant is accurate.
166
AMA
American Medical Association - verifying medical school, american board of medical specialties (abms) - certifacts; for verification of a physician's board certification
167
ECFMG
Education Commission for Foreign Medical Graduate; for verification of a physician's graduation from a foreign medical school.
168
AOA
American Osteopathic Associate physician database for predoctoral education accredited by the AOA bureau of professional education, postdoctoral education approved by the AOA council on postdoctoral training and osteopathic specialty board certification.
169
FSMB
Federation of State Medical Boards for all actions against a physician's medical license
170
NPDB
National Practitioners Data Base/Bank: the joint commission requires that hospitals query the NPDB when clinical privileges are initially granted, at the time of renewal of privileges, and when an applicant requests new privileges. Hospitals may query at other times, as they deem necessary.
171
What is a complete application?
All malpractice, education, training, work experience have been verified.
All items on the check list are present.
Most importantly, there are no concerns.
172
Temporary Privileges
The use of temporary privileges (done in accordance with applicable standards) is allowed by the joint commission (TJC). The TJC describe two situations in which temporary privileges may be granted:
- When a new applicant is fully processed but awaiting review and approval of the organized medical staff. Timeframe: no more than 120 calendar days.
- When the services of the practitioner are needed in order to meet an immediate patient care need (eg the patient's care needs are unique and there is no other practitioner on staff with the requisite education, training, skills, and current competencies who is immediately available to meet those needs. These should be very rare situations. Timeframe: no more than 30 calendar days.
- Allowed only if the file is considered "Clean".
173
What is a clean file?
Clear of any current or previous issues to licensure or registration
No subjection to involuntary termination of medical staff membership at another organization
No subjection to involuntary limitation, reduction, denial or loss of clinical privileges
No malpractice claims or board complaints
174
What is required to process Temporary Privileges?
CV, verification of current licensure, signed authorization and release, NPDB, current competence is obtained through relevant training, peer recommendation, approval: medical staff president or authorized designee - CEO or authorized designee
175
APPLICANT
The applicant's primary responsibility is to ensure that the hospital receives, in a timely manner, all of the information necessary to evaluate his or her application for medical staff membership. The applicant must answer all of the hospital's questions truthfully and completely.
176
Credentialing Specialist
Prescreen the information in the application to make sure that he/she meets the minimum criteria necessary to apply for membership.
Sending and receiving the application
Ensuring that the applicant completes his or her application within the specified time period.
Submits all required documentation
Conducting primary source verification and gathering all necessary documents to complete the credentialing process.
177
CCO Centralized Credentialing Office
- Received and distributes application
- Conducting primary source verification
- Collecting letters of reference
- Querying the National Practitioner Data Bank
- Verify Clinical Experience
- Reviews and evaluates the data collected
178
Attestation
acknowledges that the applicant allowed the credentialing specialist to query information in his/her application. A credentialing specialist cannot process any queries until the attestation is in place.
179
Checklist
to help the credentialing specialist a check list is available as a tool to make sure all documents are gathered, processed or evaluated.
180
Documents
all documents must be scanned or uploaded into the credentialing software.
181
GAPS
time gaps, such as periods that are unaccounted for or a timeline reported by the applicant that does not match the timeline reported by the organizations with which the applicant is or was affiliated.
182
POSSIBLE RED FLAGS
inability to produce requested information
change of insurance companies several times in recent years
documentation from coworkers or staff members related to professional conduct or possible impairment
inability to provide reference that can attest to his or her currently clinical competence
information obtained indicates that the individual holds a license in another state which was not listed on his or her application, however documentation provided by the applicant does not show that he or she has ever practiced, trained, or otherwise had a need for a license in that state.
inability to verify information reported on the application
the applicant is constantly requesting you rush the process
vague answers from reference that refuse to complete a detailed evaluation
time gaps
183
Licensure
The credentialing software should list when a licensure is issued and when it is due to expire
The software should have a tracking mechanism
reminder notices should be emailed to the providers prior to the licensure expires.
expiring licensure: medical license, malpractice insurance, state and federal dea, board certifications, acls, pals, bls and ASHA
All licensure shoudl be verified at initial appointments and reappointment
If a license is expired, the provider should not be allowed to practice - period. No Exceptions.
184
Why is it important to check that the practitioner is not currently excluded, suspended, debarred or ineligible to participate in federal health care programs?
the facility wont get paid for treating patients unless service is provided by authorized provider.
185
Which of the following credentials must be tracked on an ongoing basis?
licensure
186
According to NCQA standards, an organization that discovers sanction information, complaints or adverse events regarding a practitioner must take what action?
determine if there is evidence of poor quality that could affect the health and safety of its members.
187
What is the name of the entity that was established through the health care quality improvement act of 1986 to restrict the ability of incompetent physicians, dentists and other health care practitioners to move from state to state without disclosure or discovery of previous medical malpractice payment and adverse action history?
The National Practitioner Data Bank
188
When developing clinical privileging criteria, which of the following is important to evaluate?
established standards of practice such as specialty board recommendations.
189
What is the main reason for periodically assessing appropriateness of clinical privileges for each specialty?
To protect patient safety by ensuring competency, relevance to the facility, and accepted standards of care.
190
Which of the following specialists is most likely to perform a PTCA?
Interventional cardiologist (percutaneous transluminal coronary angioplasty)
191
The Joint Commission hospital standards require that clinical privileges are hospital specific and
based on the individual's demonstrated current competence and the procedures the hospital can support.
192
Which of the following would be routinely performed by a cardiologist?
Transesophageal Echocardiography
193
Which NCQA required committee makes recommendations regarding credentialing decisions?
Credentialing Committee
194
HFAP standards require two medical staff committees to be determined in the medical staff structure. One of them is the medical executive committee what is the other required medical staff committee?
Utilization Review Committee
195
If you needed to find out about what the federal government requires in regards to anti-trust issues, what law would you consult?
Sherman Anti-trust act
196
Peer references should be obtained from
Practitioners in the same professional discipline as the applicant
197
Patrick V Burget
is an important case because it: illustrates the potential for antitrust liability arising out of peer review activities.
198
If a medical staff member has privileges and/or medical staff appointment revoked, he/she must be
provided due process
199
Access to credentials files should be
described fully in an access policy
200
Which of the following bodies approves clinical privileges?
Governing Body or Board
201
What primary source verification is required by NCQA prior to provisional credentialing?
Licensure and 5 year malpractice history or NPDB
202
According to the Joint Commission standards, initial appointments to the medical staff are made for a period of
Not to exceed two years (now 3)
203
According to the Joint Commission standards, temporary privileges may be granted by
The CEO on the recommendation of the medical staff president or authorized designee
204
According to the Joint Commission standards, which of the following items must be verified with a primary source?
Licensure, training, experience and competence
205
According to NCQA standards, a copy of which of the following is acceptable verification of the document?
DEA certificate
206
According to NCQ standards, which is a acceptable source for primary source verification of Medicare and Medicaid sanction activity against physicians?
Federation of State Medical Boards
207
According to the Joint Commission standards, which of following is considered a designated equivalent source for verification of board certification?
The American Board of Medical Specialties (ABMS)
208
Which of the following organizations have been recognized by the Joint Commission and NCQA to provide primary source verification of medical school graduation and residency training for US graduates?
American Medical Association Masterfile
209
According to NCQA standards, the application attestation statement must affirm that the application
is correct and complete
210
According to the Joint Commission standards, medical staff bylaws should define
the structure of the medical staff
211
According to the Joint Commission hospital standards, professional criteria for the granting of clinical privileges must include at least
relevant training or experience, ability to perform privileges requested, current licensure, and competence.
212
The Joint Commission hospital standards require medical staff bylaws to include:
a mechanism for selection and removal of officers.
213
According to NCQA standards, which of the following is an approved source for verification of board certification?
State licensing agency if state agency conducts primary verification of board status
214
According to the Joint Commission hospital standards, which of the following is a required component of the reappointment process?
documentation of the applicant's health status (health attestation)
215
According to URAC's health network standards, each applicant within the scope of credentialing program submits an application that includes at least which of the following:
State licensure information, including current license(s) and history of licensure in all jurisdictions.
216
According to AAAHC, which must be monitored on an ongoing basis?
Current licensure
217
According to the Joint Commission, a nurse practitioner functioning independently and providing a medical level of care must
Be granted delineated clinical privileges.
218
According to the Joint Commission, which of the following is an acceptable source for verification for medical education of an international graduate?
education commission for foreign medical graduates
219
When evaluating compliance with the required time frame for re-credentialing, NCQA counts the re-credentialing period to the
month
220
NCQA standards require the organization to verify board certification at recredentialing
in all cases
221
To whom does the AAAHC give the responsibility for approving and ensuring compliance with policies and procedures related to credentialing, quality improvement, and risk management?
Governing Body
222
In order for a healthcare facility to participate in the Medicare and Medicaid programs it must comply with the
Medicare conditions of participation
223
According to the Joint Commission hospital standards, which of the following is an element of a self-governing medical staff?
The medical staff determines the mechanism for establishing and enforcing criteria for assigning oversight responsibilities to practitioners with independent privileges.
224
Robert's Rules of order is an example of
parliamentary procedure
225
The medical staff application should provide a chronological history of
the applicant's education, training and work history
226
In order to participate in a managed care plan, a provider must be accepted to the plan's
provider panel
227
In order for a physician to practice medicine in any state in the united states, he/she must posess
current state licensure
228
Which of the following is considered post graduate education?
residency training
229
Which of the following elements may not be used to evaluate credentials of applicants?
Gender
230
The release of liability statement signed by the applicant for medical staff appointment should include
A statement providing immunity to those who respond in good faith to requests for information
231
Primary source verification is
receiving information directly from the issuing source.
232
Unexplained delays between graduation and medical school, incomplete training, and unexplained lapses in professional practice are examples of
Red Flags
233
When documenting a telephone conversation regarding primary source verification what should be documented?
Name of person and organization contacted, date of call, what was discussed and who conducted the interview.
234
According to HFAP standards, when confirming malpractice coverage the organization must:
Have evidence of professional liability insurance, which includes certificate showing amounts of coverage.
235
Which of the following providers is considered a primary care physician (PCP)?
family medicine practitioner
236
Which body has the obligation to the community to assure that only appropriately educated, trained, and currently competent practitioners are granted medical staff membership and clinical privileges?
Governing Body
237
When credentialing and privileging practitioners it is appropriate to
follow a routine process for each applicant.
238
Medical liability insurance should be held in what limits?
as specified by the medical staff and board of directors
239
Which of the following would be an appropriate question to ask an applicant for medical staff?
Do you have any medical conditions, treated or untreated, that would negatively affect your ability to provide the services or perform the privileges you are requesting?
240
The governing body delegates the task of credentialing, re-credentialing and privileging to
The medical staff
241
Who should have access to medical staff meeting minutes?
personnel as documented in a records access policy and procedure
242
In addition to conclusions, recommendations made, and actions taken, which of the following should always be documented in meeting minutes:
any required follow up to occur
243
Active, Associate, Courtesy, Honorary, consulting are all examples of
Membership categories
244
Changes in medical staff bylaws are not final until formally approved by the
governing body
245
What is the only hospital medical staff committee required by the Joint Commission hospital standards?
Medical executive committee
246
The Healthcare Quality Improvement Act
provides qualified immunity from antitrust liability arising out of peer review activities that are conducted in good faith.
247
If you have a question regarding whether or not information regarding a practitioner should be released to a third party, which of the following would be the best person to ask?
Organization's attorney
248
Prior to releasing information to a third party regarding a practitioner, the organization should acquire
a signed consent and release form
249
You are working at an AAAHC accredited facility and you want to introduce the concept of utilizing a credentials verification organization. If the CVO is not accredited by a nationally recognized organization you must:
perform an assessment of the capability and quality of the CVO's work
250
What are the three major sources of authority in the traditional structure of the hospital organization?
Chief executive officer, governing body, and medical staff
251
How does the governing body of a hospital set the organization policy that supports quality patient care?
By developing the mission, vision, policies, and bylaws that govern the hospital's operations.
252
Governing bodies may be generally classed into which two types?
Philanthropic or corporate
253
Which of the following is a major responsibility of the CEO?
Keeping the medical staff informed about the hospital's plans, organizational changes, board policies, and decisions affecting providers and their patients.
254
To whom is the medical staff organization accountable for the quality of the professional services provided by individuals with clinical privileges?
Governing body
255
Which term describes a physician employed or contracted by the hospital as a top-level management employee to act as a liaison between the medical staff and hospital administration?
Medical director
256
Which of the following are included in the functions of the medical staff?
providing and evaluating patient care
257
Which of the following describes a committee that is assembled or appointed to perform a specific task or duty, works independently and reports back to larger committee and typically disbands after the assigned task or duty is performed or completed?
Ad hoc committee
258
When developing bylaws language for a committee, consideration should be given to which of the following?
composition, duties, and frequency of meetings.
259
The credentials committee needs guidance regarding which physicians will be allowed to perform a new procedure in the hospital. It has recommended that a committee be appointed to evaluate this issue and report back to the credentials committee. What kind of committee would be appointed?
Ad hoc committee
260
Which term describes a physician who provides the general medical care of hospitalized patients only and turns over the care of the patient to the primary care physician after discharge?
Hospitalist
261
Which term describes a category of medical staff appointment that provides a basic framework within which physicians and other health care providers carry out their duties and responsibilities?
Staff status
262
Which term describes interns and residents in medical education programs of a teaching hospital?
House staff
263
Which term describes a special classification used to reflect honor and respect for selected distinguished members of the medical community?
Honorary or emeritus staff
264
Which term describes privileges granted for a specific period of time to a practitioner while hospital board approval is pending?
Temporary privileges
265
Which document describes the organizational structure of the medical staff and defines the framework within which medical staff appointees act and interact in hospital related activities?
medical staff bylaws
266
Bylaw changes are not effective until final approval by which body?
Governing body
267
Which term describes the mechanism by which an aggrieved practitioner, one who has been the recipient of disciplinary action, is entitled to be heard and to appeal an adverse decision?
procedural rights or fair hearing
268
What landmark case set aside the charitable immunity doctrine and established the corporate negligence doctrine, also known as negligent credentialing?
Darling vs. Charleston Memorial Community Hospital
269
What is the name of the act, known as the Federal "anti-dumping" law which was enacted to stop hospitals transferring, discharging or refusing to treat indigent patients coming to the emergency department because of cost factors?
Emergency Medical Treatment and Active Labor Act (EMTALA)
270
In a hospital setting, the need for informed consent, explaining the risks and benefits of a particular course of treatment, allowing the patient to participate in decisions regarding treatment options, and confidentiality are all examples of what?
ethical issues
271
Which act mandates regulations that prohibit disclosure of health information except as authorized by the patient or specifically permitted by the regulation?
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
272
Which act defines the elements of due process that must be followed in order for an organization to have peer review protection?
Healthcare Quality Improvement Act (HCQIA)
273
The Code of Ethics for which organization includes the language "shall share knowledge, foster educational opportunities, and encourage personal and professional growth through continued self-improvement and applications of current advancements in the profession"?
NAMSS Certification Commission
274
What term is used to describe the evaluation or review of the performance of colleagues by professionals with similar types and degrees of clinical expertise?
Peer review
275
Which medical staff officer is responsible for enforcing the medical staff bylaws, rules and regulations, and procedural guidelines of the medical staff including imposing sanctions for noncompliance?
Medical Staff president or chief of staff
276
Which term defines a functional unit of the hospital so designated because of the clinical service it performs?
Department
277
Which of the following is a responsibility of the department chairman?
recommending criteria for clinical privileges in the department
278
Which of the following is a joint commission requirement element for the process for managing LIP health?
Education of LIP and organization staff regarding recognizing illness and impairment issues specific to LIPs.
279
In the case of Frigo vs Silver Cross Hospital, the podiatrist who performed surgery on Ms. Frigo did not meet initial criteria or revised criteria for Level II surgical privileges but was granted privileges regardless. What was the legal concept under which the jury found silver cross hospital to be negligent?
Breach of Duty/Corporate Negligence
280
Which term below describes the achievement of the organization's objectives through and with people and other resources?
Management
281
Which continuing medical education system has become the CME standard for licensing boards and specialty organizations nationwide and is recognized by vs jurisdictions?
The AMAs PRA category 1 credit system
282
If you needed to find out about what the federal government requires in regards to anti-trust issues, what law would you consult?
Sherman Anti-trust act
283
Average Length of Stay (ALOS) figures are used for which of the following purposes?
One measure of hospital utilization review
284
Expenses that may vary directly with the quantity of work being performed are ______ costs.
Variable
285
In a joint commission accredited hospital, applications for initial appointment to the medical staff must be acted on:
as specified in the medical staff bylaws
286
Joint Commission standards require hospital-sponsored educational activities to be prioritized and that when developing these programs, they relate to:
the type and nature of care, treatment and services offered by the hospital
287
According to CMS's COPs for hospitals, when utilizing telemedicine, the hospital must have evidence of an internal review of the distant-site physician's or practitioner's of these privileges and must send the distant-site hospital such performance information for use in the periodic appraisal of the distant-site physician or practitioner. At a minimum, this information must include
all adverse events that result from the telemedicine services provided by the distant-site physician or practitioner. At a minimum, this information must include:
all adverse events that result from the telemedicine services provided by the distant-site physician or practitioner to the hospital's patients and all complaints the hospital has received about the distant site physician or practitioner.
288
According to Joint Commission standards who must inform the patient about unanticipated outcomes of care, treatment and services related to sentinel events?
Responsible licensed independent practitioner or his or her designee
289
Which of the following is a responsibility of the department chairman?
Recommending criteria for clinical privileges in the department
290
Which of the following is a Joint Commission requirement element for the process for managing LIP Health?
Education of LIP and organization staff regarding recognizing illness and impairment issues specific to LIP's.
291
Which of the following is a responsibility of the department chairman?
Recommending criteria for clinical privileges in the department.
292
Which document contains a listing of drugs and pharmaceuticals maintained for use in the hospital?
formulary
293
According to Joint Commission standards, the qualifications and competence of a non-employee individual, other than a PA or APRN who is brought into the hospital by an LIP to provide care, treatment and must be assessed by
the hospital
294
According to NCQA, the health plan must notify an initial applicant of the credentialing committee's decision within
60 days
295
NCQA requires that an organizations policies and procedures describe specific credentialing system controls, including which of the following?
unique user IDs and passwords
296
NCQA requires that re-credentialing of practitioners and providers occur
at least every three years
297
Under NCQA standards, when credentialing activities are delegated by a health plan, the right to approve, terminate or suspend individual practitioners or providers is retained by
the health plan
298
You are working at a AAHC accredited facility and are credentialing a new applicant. In addition to verifying licensure, DEA, education, training and malpractice insurance, what other credentials are required to be primary or secondary source verified according to AAAHC standards?
Peer references and NPDB
299
According to URAC's health network standards, each applicant within the scope of the credentialing program submits an application that includes at least which of the following?
State licensure information, including current license (s) and history of licensure in all jurisdictions
300
Before granting of initial privileges Joint Commission standards require the organization to verify current licensure, certification, or registration and training with the primary source. Which of the following is an additional Joint Commission requirement for new applicants?
The applicant must attest that he or she has no health problems that could affect his or her ability to perform the requested privileges
301
You are working at a Joint Commission accredited hospital. You are processing a reappointment for medical staff membership and you find that the practitioner has not performed any procedures at your facility since her last reappointment. The appointment is due to expire in one month. What should you do?
Ask the applicant to provide the names of other facilities where she is practicing, then write to those facilities to obtain documentation of procedures performed and outcome data, if available.
302
According to HFAP standards, in addition to direct contact with program, which of the following is/are approved designated source(s) for verification of residency training?
AMA Physicians Profile for MDs and AOA official osteopathic physician profile for DOs
303
AAAHC standards require appointments to be for no longer than
3 years
304
Substantive and procedural are two distinct elements of
due process
305
Which of the following is a requirement of the Joint Commission for the medical staff?
Define circumstances requiring focused review of a practitioner's performance.
306
Which federal agency has been delegated the responsibility for conducting the Medicare Program?
Centers for Medicare and Medicaid Services
307
What term best describes the examination and evaluation of the appropriateness of use of an organization's resources to determine medical necessity and cost effectiveness of services provided?
Utilization review or utilization management
308
Which is the term applied to initial appointment to the medical staff to permit observation for monitoring and evaluation of physician performance?
provisional appointment
309
Which term applies to a practitioner filling in or working in place of another practitioner?
Locum tenens
310
Which term is used to describe the use of criteria unrelated to quality of care or professional competency in determining an individual's qualifications for initial or continuing hospital medical staff appointment or privileges or continued participation in a provider panel of a managed care plan?
Economic credentialing
311
New amendments to the Medicare conditions of participation are officially published in the
Federal Register
312
Which type of hospital board consists of non-paid individuals who contribute their time and expertise in the interest of service to the facility or to the community?
Philanthropic
313
Mind-body interventions, biologically-based treatments, manipulative and body-based methods, and energy therapies and all examples of:
alternative or complimentary medicine
314
Which term describes an organization which reviews services provided under the Medicare program to determine whether a hospital has misrepresented admission or discharge information or has taken an action that results in the unnecessary admission of an individual entitled to benefits under Medicare Part A?
Peer review organization
315
Which term describes programs providing palliative care and emotional and physical support to terminally ill patients and their families, generally during the last six months of the patient's life in the patient's home?
Hospice
316
Which body acts for the medical staff as a whole, and makes recommendations to the governing body with regard to medical staff issues?
Medical executive committee
317
You go to the file cabinet and pick out 20 files for audit. This type of sample is called
a simple random sample
318
What is the name of the data collection developed by the centers for Medicare and Medicaid services to improve outcomes of patient care and to ensure that they receive the best health care available?
Core Measures
319
When a proctor visits a hospital nursing station to review inpatient health records, this is called
concurrent review
320
In any computerized data collection system
computerized information processing requires quality control checks to be performed
321
Which graphical presentation type always depicts percentages?
Pie chart
322
A person against whom an action is brought in a lawsuit is the
defendant
323
What a reasonably prudent person would have done under similar circumstances is termed the
standard of care
324
The party who commences a lawsuit is the
plaintiff
325
In order to verify HIPAA security provisions are met, an organization should have a
Information Access Control Plan
326
According to the Medicare Conditions of Participation for Hospitals, criteria for selection to the medical staff must include individual competence, training, experience, judgement and
CHARACTER
327
Which statement is a characteristic of a group practice?
It consists of a single specialty or multi-specialty and provides comprehensive care
328
Which is an example of what would be include in a medical staff rule and regulation?
description of how members are appointed to the emergency room call schedule
329
Compliance by a hospital with which of the following would be considered voluntary?
HFAP standards
330
According to the DNV, a history and physical completed within 30 days prior to admission or registration shall include an entry in the medical record which documents an examination for any change in the patient's current medical condition and placed in the patient's medical record within what time frame?
Within 24 hours after admission or registration, and prior to surgery, or procedures requiring anesthesia services
331
A departmentalized medical staff is organized according to service. What is the title of the medical staff leader who is responsible for directing the functions of each service?
chairperson
332
Automatic Suspension of Clinical privileges may be considered at a DNV accredited hospital for the following instances:
Revocation/Restriction of provisional license, non-compliance with completing medical records.
333
In selecting a new information system, the primary consideration should be the
available technology
334
According to the DNV, if the medical staff has an executive committee, who must attend the meetings?
Medical staff members, CEO and CNO (or designee) on an ex-officio basis
335
Information is
less complex than data
336
In addition to the chief executive officer, what medical staff authority is required for granting temporary privileges
Member of the executive committee, president of the medical staff or Medical Director.
337
A system that shows who has accessed what information in a computer system, such as a patient registration database, is called an
audit trail
338
Which term most accurately defines programs designed to control liability for human errors and equipment failures?
risk management programs
339
According to Joint Commission standard, relevant finding from quality management activities must be considered as part of the
reappointment of clinical privileges of medical staff members.
340
Per NCQA is the ABMS "is my doctor board certified" - which is accessible through the ABMS website an acceptable source for verifying board certification for an MD?
No
341
The Joint Commission requires licensure to be verified with the primary source at what four times?
Initial, Reappointment, Privilege revision/temp privileges, and at time of license expiration
342
Query NPDB per TJC when?
when clinical privileges are granted, new privileges requested and at renewal of privileges
