Study 3/5/2025

Question 1

___________ requires that the process for application of privileges includes a statement regarding the physician’s physical and mental health in relation to privileges.

a. TJC
b. DNV
c. ACHC

Answer 1

ACHC

Question 2

According to _______, if there is doubt about an applicant’s ability to perform the privileges requested, an evaluation by an external and internal source may be required, if the medical staff wishes.

a. DNV
b. TJC
c. AAAHC

Answer 2

TJC

Question 3

As it relates to nondiscrimination, these three do not specifically address it?

a. DNV, ACHC, AAAHC
b. Medicare, URAC, DNV
c. AAAHC, Medicare, DNV

Answer 3

AAAHC, Medicare, DNV

Question 4

What accrediting body states, when renewing privileges if there are insufficient practitioner specific data available, the medical staff uses and evaluates peer recommendations?

a. TJC
b. NCQA
c. DNV

Answer 4

TJC

Question 5

_____ allows a statement that the organization will not discriminate against any providers.

a. ACHC
b. NCQA
c. URAC

Answer 5

URAC

Question 6

Which accreditation states “when renewing privileges, if there are insufficient practitioner-specific data available, the medical staff uses and evaluates peer recommendations.”

a. TJC
b. ACHC
c. NCQA

Answer 6

TJC

Question 7

What accreditation body states that the application include information concerning the applicant’s current physical, mental health, or chemical dependency problems that would interfere with the ability to provide high-quality patient are services?

a. DNV
b. ACHC
c. AAAHC

Answer 7

AAAHC

Question 8

Which organization states, application includes disclosure of any physical, mental, or substance abuse problems that could, without reasonable accommodation, impede the practitioner’s ability to provide care according to the accepted standards of professional performance or pose a thread to the health or safety of patients?

a. ACHC
b. URAC
c. TJC

Answer 8

URAC

Question 9

________ uses a peer-review process to make recommendations regarding credentialing decisions?

a. NCQA
b. AAAHC
c. URAC

Answer 9

NCQA

Question 10

Ability to perform privileges requested must be evaluated and this evaluation documented in the credentials file per _____.

a. DNV
b. ACHC
c. TJC

Answer 10

TJC

Question 11

What accreditation body does not have a specific requirement for peer recommendations. The organization must designate a Credentialing Committee that uses a peer-review process to make recommendations regarding credentialing decisions.

a. URAC
b. NCQA
c. AAAHC

Answer 11

NCQA

Question 12

_____ states, if there is not a peer with the same professional credential, then a practitioner in the same practice area who can speak to the applicant’s professional competence and ethical standards can provide the reference.

a. AAAHC
b. NCQA
c. ACHC

Answer 12

ACHC

Question 13

Which of the following are appropriate sources for peer recommendations?

a. Department Chair, CEO, and/or Peer in the same professional discipline
b. Performance Improvement Committee, Peer in the same professional discipline, Department Chair, and MEC
c. Chief of Staff, CEO, and/or Physician Assistant

Answer 13

Performance Improvement Committee, Peer in the same professional discipline, Department Chair, and MEC

Question 14

For initial applicants, where does ACHC suggest references come from?

a. Residency or Department Chair
b. MEC
c. Applicant’s previous employer

Answer 14

Residency or Department Chair