Study Session 1/28/2025 Flashcards by Alicia Arterbury

Paracentesis: procedure to aspirate fluid from the abdomen through a long needle. Usually performed for ascites due to liver damage.

Radiologist

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Pyelonephritis: kidney infection

Primary Care Physician
Nephrologist
Urologist

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Hematopoiesis: blood cell production

Hematology

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Electrocardiogram (ECG or EKG): a test that measures your heart’s electrical activity to detect heart health and is written by a cardiogram

Internal Medicine
Cardiologists
Cardiac Surgeons

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Salpingo-Oophorectomy: a surgical procedure where both fallopian tubes and ovaries are removed, often done as a preventative measure for women at high risk for ovarian cancer

Obstetrician-Gynecologist
Gynecologic Oncologist
General Surgeons

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Bring an item of business to the body for consideration. It can only be made when no other motion is pending and ranks lowest in the order of precedence of motions

Main motions

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Assist the body in considering or disposing of main motion

Subsidiary motions

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Do not relate to pending business but have to do with special matters of immediate importance that should be allowed to interrupt the consideration of anything else

Privileged motions

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Deal with questions of procedure arising out of other motions or business

Incidental motions

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According to AAAHC, a CVO is allowed. Accreditation or certification of the CVO by a nationally recognized organization can meet this requirement. Which of the following is a nationally recognized organization?

a. DNV
b. TJC
c. NCQA

NCQA

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All these situations would lead to ineligibility for expedited credentialing except.

a. Current or previously successful challenge to licensure or registration
b. Involuntary termination of Medical Staff Membership
c. Complete application with no unexplained gaps

Complete application with no unexplained gaps

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Fast-track credentialing can be used for applications that pose no problems, including new graduates or physicians fully credentialed at a sister hospital with ______?

a. DNV
b. ACHC
c. AAAHC

ACHC

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When the medical staff processes a file for expedited or fast-tracking approvals, bylaws should define this process including a definition of ___________________

a. A complete application
b. Competency
c. Primary and secondary sources

A complete application

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What accrediting agency states organizations must ensure that provisional credentialing does not extend for more than 60 calendar days?

a. TJC
b. URAC
c. NCQA

NCQA

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To meet NCQA standards, provisional credentialing files must contain what information within the specified time frames?

a. Complete application with all required attachments; no unexplained gaps; all primary source verifications received; no discrepancies identified; and documentation of current competency and ability to perform privileges.
b. PSV of current, valid license to practice; PSV of five years of malpractice history; Complete application and signed attestation.
c. Current or previously successful challenge to licensure or registration; Involuntary termination of medical staff membership; Involuntary limitation, reduction, denial, or loss of clinical privileges; Unusual pattern of, or an excessive number of, professional liability actions resulting in a final judgment

PSV of current, valid license to practice; PSV of five years of malpractice history; Complete application and signed attestation

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__________ conducts a one-time provisional credentialing.

a. ACHC
b. NCQA
c. AAAHC

NCQA

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According to Medicare CoPs, surgical privileges should be reviewed and updated at least every ____.

a. 2 years
b. 3 years
b. 180 days

2 years

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Criteria for expedited appointments or “fast tracking” appointments for applications should be defined by the ___________________.

a. Medical Executive Committee
b. Governing body
c. Medical / Dental staff bylaws

Medical / Dental staff bylaws

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There are various methods for delineating clinical privileges. One example is/a __________ _______, this is an exhaustive list of individual procedures or conditions.

a. Laundry list
b. Core privileges
c. Categories or levels

Laundry list

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________ is a time-limited period during which the organization evaluates and determines the practitioner’s professional performance?

a. Probation
b. OPPE
c. FPPE

FPPE

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To meet NCQA standards, provisional credentialing files must contain three pieces of information within the specified time frames. What are they?

a. PSV of five years of malpractice history; Complete application & signed attestation; The recommendation of a Senior Clinical Staff Person
b. PSV of five years of malpractice history; Complete application & signed attestation; PSV of current valid license to practice
c. PSV of five years of malpractice history; Complete application & signed attestation; Verification of training

PSV of five years of malpractice history; Complete application & signed attestation; PSV of current valid license to practice

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Who requires that the governing body must ensure the criteria for selection are individual character, competence, training, experience, and judgement?

a. TJC
b. URAC
c. Medicare

Medicare

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Medicare CoP regarding privileges state that the governing body must ensure the criteria for selection are individual what?

a. current licensure, relevant training or experience, current competence, and ability to perform privileges
b. PSV for current licensure or certification; PSV of relevant training; Evidence of physical ability to perform the requested privilege; Data from professional practice review from other organizations where the applicant currently has privileges (if available);Recommendations from peers/faculty; and On renewal, review of the practitioner’s performance within the hospital.
c. character, competence, training, experience, and judgment

character, competence, training, experience, and judgment

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Which standards require that Medical Staff Bylaws must describe the qualifications to be met by a candidate in order for the medical staff to be able to recommend appointment by the governing body?

a. NCQA and URAC
b. DNV and TJC
c. AAAHC and Medicare

AAAHC and Medicare

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The application will be processed as follows: if the file is clean (per policy) with no problems, it will be forwarded to the ________ _________ or his designee for approval. a. Credential Committee b. Medical Director c. Credential Coordinator

Medical Director

Which accreditation specifically states that "while hospitals may use third-party CVOs to compile and verify the credentials of practitioners applying for privileges, the hospital’s governing body is still legally responsible for all privileging decisions." a. DNV b. NCQA c. AAAHC

DNV

Documentation of attendance can be done by obtaining copies of program certificates a. ACHC b. TJC c. NCQA

TJC

Every 2 years evidence of continuing medical education needs to be presented by this standard a. ACHC b. TJC c. DNV

ACHC

MS.15 Interpretive guidelines read that while hospitals may use third-party credentialing verification organizations to compile and verify the credentials of practitioners applying for privileges, the hospital’s governing body is still legally responsible for all privileging decisions a. TJC b. URAC c. DNV

DNV

___________ states that evidence of continuing educational activities every two years may be requested? a. TJC b. ACHC c. DNV

ACHC

For all facilities, evidence of ______________ requested is required of all applicants for renewal of privileges a. Verified CME within the past 24 months matching the b. Board Certification is the specialty area c. Current ability to perform privileges

Current ability to perform privileges

What accrediting body does not address CMEs for medical staff members? a. AAAHC b. DNV c. ACHC

AAAHC

Which accreditation takes action until CME information is available and verified? a. TJC b. ACHC c. DNV

DNV

_______ defines privileging as the process whereby the specific scope and content of patient care services (that is, clinical privileges) are authorized for a healthcare practitioner by a healthcare organization, based on evaluation of the individual's credentials and performance a. TJC b. ACHC c. URAC

TJC

The organization’s credentialing process describes the building security that adequately limits physical access to credentials information. a. NCQA b. URAC c. ACHC

NCQA

What is CAMH and what aspect references the CAMH with CVOs and Delegation a. Center for Addiction and Mental Health - DNV b. Comprehensive Accreditation Manual for Hospitals - TJC c. Commission Accreditation Manual for Hospitals - ACHC

Comprehensive Accreditation Manual for Hospitals - TJC

___________ requires organization to perform an assessment of the capability and quality of the CVO’s work? a. TJC b. AAAHC c. NCQA

AAAHC

This standard defines privileging as process whereby the specific scope and content of patient care services (that is, clinical privileges) are authorized for a healthcare practitioner by a healthcare organization, based on evaluation of the individual’s credentials and performance. a. ACHC b. DNV c. TJC

TJC

What entity does not specifically address CVOs / Delegations? a. URAC b. Medicare c. DNV

Medicare

Which accreditation states “If the CVO achieves _____ certification for all delegated credentialing elements, the oversight responsibility is waived? a. TJC b. NCQA c. AAAHC

NCQA

Temporary privileges cannot exceed ____ days a. 60 b. 90 c. 120

120

An NCQA accredited organization’s credentialing process describes the monitoring of compliance with policies and procedures at least how often? a. Annually b. Every 3 years c. Every 36 months

Annually

How the organization monitors its compliance with the policies and procedures at least annually and takes appropriate action when applicable is included in this organization’s credentialing process? a. TJC b. AAAHC c. NCQA

NCQA

ACHC says evidence of continuing educational activities every _________ may be requested. a. 2 years b. 3 years c. Time privileges are requested

2 years

What is the only accrediting organization that has standards regarding Credentialing System Controls? a. TJC b. AAAHC c. NCQA

NCQA

How often an organization monitors its compliance with the policies and procedures? a. at least every two years b. at least annually c. at least every six months

at least annually

Maintenance of continuing education every 2 years may be requested. a. TJC b. NCQA c, ACHC

ACHC

With this accreditation a criminal background is conducted on initial application and must request any criminal history for what length of time? a. NCQA; annually b. ACHC; every 7-10 years c. TJC; every 3 years

ACHC; every 7-10 years

Criminal background checks but must be performed if required by State law for which of the following? a. Medicare b. URAC c. TJC

Medicare

Which accreditors address CME? a. ACHC, DNV, AAAHC b. TJC, ACHC, DNV c. TJC, DNV, AAAHC

TJC, ACHC, DNV

What entity requires a Criminal Background Check if it is “required by State Law”? a. Medicare b. AAAHC c. NCQA

Medicare

Which accreditation obtains a criminal background check to hospital employees? a. TJC b. ACHC c. Medicare

TJC

Name 3 organizations that do not specifically address criminal background checks. a. Medicare, DNV, NCQA b. URAC, Medicare, TJC c. NCQA, URAC, AAAHC

NCQA, URAC, AAAHC

A professional credentialing organization, such as a CVO, can be used to perform PSV but the process for credentialing by the organization must reflect the requirements as stated in the standards. a. TJC b. NCQA c. ACHC

ACHC

Under TJC the __________ states that organizations that use information from a CVO should have confidence in the completeness, accuracy, and timeliness of that information and outlines ten principles to evaluate such an agency.? a. CIHQ b. CAMH c. CAHP

CAMH

The organization's credentialing process describes how primary source verification is received, dated, and stored. a. TJC b. NCQA c. ACHC

NCQA

This accreditor is the only one with requirements for Credentialing System Controls. a. NCQA b. URAC c. AAAHC

NCQA

The initial application must request information regarding any criminal history for 7-10 years a. TJC b. NCQA c. ACHC

ACHC

ACHC requires criminal history for what time frame? a. 10–15 years b. 5–10 years c. 7–10 years

7–10 years

The organization maintains the right to approve, suspend or terminate practitioners and has responsibility for oversight of the delegated agency. a. TJC b. NCQA c. ACHC

NCQA