Study Session 2/4/2025

Question 1

An example of a Subsidiary Motion is:

a. Adjourning a meeting
b. Questioning a privilege
c. Postponing to a certain time

Answer 1

Postponing to a certain time

Question 2

_______________ motions 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

a. Subsidiary
b. Incidental
c. Main

Answer 2

Main

Question 3

During the Medical Executive meeting, you wish to Register a Complaint, you say:

a. I challenge the process
b. I rise to a question of privilege
c. I ask for postponement

Answer 3

I rise to a question of privilege

Question 4

What type of vote is needed to Close a Debate?

a. 2/3
b. Majority
c. the Chair determines when to close a debate

Answer 4

2/3

Question 5

ACHC recognizes _________ as a designated equivalent source.

a. FACIS
b. YMCA
c. A letter of recommendation

Answer 5

FACIS

Question 6

DNV standards do not use the language “designated equivalent sources”, but does recognize ______profiles and ________ as acceptable verification sources.

a. FACIS, AOA and ABMS
b. ABMS, AMA, ECFMG
c. AMA, AOA, ECFMG

Answer 6

AMA, AOA, ECFMG

Question 7

The temporary privilege process may include a provision for a designee to act in _______ the CEO or medical staff president when necessary.

a. the absence of
b. collaboration with
c. a silly manner with the doctor and

Answer 7

the absence of

Question 8

_________ states it is not necessary to obtain PSV of licensure if the volunteer LIP has:

a. NCQA; Only provided care to less than 10 patients
b. NCQA; Not provided care, treatment, or services or services under the disaster privileges
c. TJC; Not provided care, treatment, or services or services under the disaster privileges

Answer 8

TJC; Not provided care, treatment, or services or services under the disaster privileges

Question 9

Locum tenens or similar temporary staff may be used for a period not to exceed ________.

a. 2 months
b. 4 months
c. 6 months

Answer 9

6 months

Question 10

During an emergency/disaster, which accreditation body states that a documented phone call is acceptable for primary source ID from the volunteer’s hospital?

a. TJC
b. ACHC
c. AAAHC

Answer 10

ACHC

Question 11

_________ standards list 2 circumstances for which the granting of Temporary Privileges to a LIP would be acceptable (patient care need or a clean application).

a. TJC
b. DNV
c. ACHC

Answer 11

TJC

Question 12

TJC standards allow the ____ (or his or her authorized designee) to grant temporary privileges based on the recommendation of the medical staff president or authorized designee.

a. CMO
b. CEO
c. COO

Answer 12

CEO

Question 13

_____ standard allows the CEO to grant temporary privileges based on the recommendation of the president of the medical staff president or authorized designee.

a. TJC
b. URAC
c. DNV

Answer 13

TJC

Question 14

Which organizations current competence process states “data is collected on an ongoing basis and summarized at least (3) times during each three-year appointment cycle?

a. URAC
b. TJC
c. ACHC

Answer 14

ACHC

Question 15

_______ states medical staff bylaws must identify the individual(s) responsible for granting disaster privileges.

a. NCQA
b. TJC
c. URAC

Answer 15

TJC

Question 16

During a disaster, PSV of a license must begin as soonas the immediate situation is under control or within _________ hours from the time the volunteer LIP begins working at the hospital, whichever occurs first.

a. 24
b. 48
c. 72

Answer 16

72

Question 17

According to ______________, Primary source verification of license must begin as soon as the immediate situation is under control or within 72 hours from the time the volunteer LIP begins working at the hospital, whichever occurs first.

a. TJC
b. ACHC
c. DNV

Answer 17

TJC

Question 18

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

a. Main motions
b. Subsidiary motions
c. Privileged motions

Answer 18

Privileged motions

Question 19

During disasters, Disaster privileges may be granted to volunteer LIPs when the Emergency Operations Plan has been activated in response to a disaster and the hospital is unable to meet immediate patient needs for which accreditation?

a. TJC
b. DNV
c. AAAHC

Answer 19

TJC

Question 20

__________ states that primary source verification of license must begin as soon as the immediate situation is under control or within 72 hours from the time the volunteer physician and/or other licensed practitioner begins working at the hospital, whichever occurs first.

a. TJC
b. ACHC
c. DNV

Answer 20

TJC

Question 21

Which accreditation states that if temporary privileges are granted, any limits to the number of specific patients who may be cared for must be identified?

a. DNV
b. ACHC
c. AAAHC

Answer 21

ACHC

Question 22

_____ accrediting body states bylaws must include a process for approving practitioners for care of patients in the event of an emergency or disaster.

a. DNV
b. ACHC
c. TJC

Answer 22

DNV

Question 23

Some Medical Staff Committees will allow a meeting to be called to order without a _______________ but will not take action on any issue until the _________ is present.

a. Chair
b. Medical staff professional (MSP)
c. Quorum

Answer 23

Quorum

Question 24

What motion is defined as pending business but have to do with special matters of immediate importance that should be allowed to interrupt the consideration of anything else.

a. Main Motion
b. Privileged Motion
c. Incidental Motion

Answer 24

Privileged Motion

Question 25

According to ___________, bylaws must include a process for approving practitioners for care of patients in the event of an emergency or disaster. a. AAAHC b. ACHC c. DNV

Answer 25

DNV

Question 26

Name the precedence of motions from the highest ranking to the lowest ranking. a. Main, Privileged, Subsidiary b. Privileged, Subsidiary, Main c. Main, Subsidiary, Incidental

Answer 26

Privileged, Subsidiary, Main

Question 27

What are the designated sources for ACHC? a. FSMB, FACIS, AMA, ECFMG, NPDB, ABMS , AOA b. AMA , AOA c. NPDB, ECFMG

Answer 27

FSMB, FACIS, AMA, ECFMG, NPDB, ABMS , AOA

Question 28

When obtaining a primary source ID during a disaster, which accreditation states that a documented phone call from the volunteer’s hospital is acceptable? a. ACHC b. DNV c. AAAHC

Answer 28

ACHC

Question 29

Per TJC, __________ is information used in the decision to maintain, revise, or revoke existing privileges prior to, or at the time of renewal. a. QAPI b. OPPE c. CAMH

Answer 29

OPPE

Question 30

______ is the number or proportion of the members that must be present in order to transact business. a. Majority b. Quorum c. Whole

Answer 30

Quorum

Question 31

During emergency/disaster, which standard accepts a documented phone call as a primary source ID from volunteer’s hospital? a. TJC b. NCQA c. ACHC

Answer 31

ACHC

Question 32

For AAAHC, documentation of current competence is obtained from? a. Peers b. Attestation on application c. Verification of primary source

Answer 32

Peers

Question 33

Name the privileged Motions: a. Adjourn, recess & question of privilege. b. Lay on the table, previous question (end debate) & limit or extend debate. c. Postpone to a certain time (or “postpone” definitely), commit or refer (to committee), amend.

Answer 33

Adjourn, recess & question of privilege

Question 34

What regulation states that governing body must ensure that the competence criteria for selection of medical staff are individual character, competence, training, experience and judgement? a. Medicare b. DNV c. AAAHC

Answer 34

Medicare

Question 35

TJC standards list two circumstances for which granting of temporary privileges to a LIP is acceptable. Which of the following is not one of the circumstances? a. An applicant with a clean file waiting MEC and Board Approval b. Locum Tenens c. Important patient care need

Answer 35

Locum Tenens

Question 36

____________ motions assist the body in considering or disposing of a main motion? a. Subsidiary b. Incidental c. Privileged

Answer 36

Subsidiary

Question 37

Temporary privileges can be used in time of emergency and/or disaster. The hospital has a plan for dealing with clinical volunteers during emergency / disaster. This plan should provide for primary source ID from the volunteer’s hospital (a documented phone call is acceptable). a. ACHC b. DNV c. TJC

Answer 37

ACHC

Question 38

For current competence, the TJC states that the organized medical staff defines the frequency for OPPE data collection. However, the timeframe for review of data cannot exceed every ____ ______? a. 180 days b. 2 years c. 12 months

Answer 38

12 months

Question 39

Who states locum tenens or similar temporary staff may be used for a period not to exceed (6) months? a. ACHC b. AAAHC c. DNV

Answer 39

DNV

Question 40

What accrediting organization does not use the language “DES”, but does recognize the AMA, AOA profiles and the ECFMG as acceptable verification sources? a. ACHC b. URAC c. DNV

Answer 40

DNV

Question 41

Which 2 recognize FSMB as a designated equivalent source? a. DNV and AAAHC b. NCQA and ACHC c. TJC and ACHC

Answer 41

TJC and ACHC

Question 42

For ____ the Bylaws must include a process for approving practitioners for care of patients in the event of an emergency or disaster. a. TJC b. DNV c. ACHC

Answer 42

DNV

Question 43

Which accreditation standards do not use the language "designated equivalent sources" but does recognize AMA / AOA profiles and ECFMG as acceptable verification sources? a. ACHC b. DNV c. URAC

Answer 43

DNV

Question 44

Under the Facilities and Environment standards, a comprehensive written emergency and disaster preparedness plan to address internal and external emergencies is presented with _________? a. DNV b. NCQA c) AAAHC

Answer 44

AAAHC

Question 45

What 2 accrediting organization do not specifically address an emergency management plan for privileges? a. ACHC and URAC b. TJC and DNV c. NCQA and URAC

Answer 45

NCQA and URAC

Question 46

When granting temporary privileges which standard states “any limits to the number of specific patients who may be cared for must be identified.” a. ACHC b. DNV c. NCQA

Answer 46

ACHC

Question 47

This accrediting body is required to assess the practitioner’s ability to deliver care based on the credentialing information collected and verified prior to making a credentialing decision. a. URAC b. TJC c. NCQA

Answer 47

NCQA

Question 48

ACHC says the ________________ provide for the granting of temporary privileges. a. Medicare b. Bylaws c. Policies & Procedures

Answer 48

Bylaws

Question 49

Which one of the following is not a privileged motion? a. Question of privilege b. Lay on the table c. Adjourn

Answer 49

Lay on the table

Question 50

For ______, documentation of current competence is obtained from Peers.  a. ACHC b. AAAHC c. TJC

Answer 50

AAAHC

Question 51

Standards do not use designated equivalent sources language, but it does recognize AMA/AOA and ECFMG as acceptable verification sources. a. NCQA b. TJC c. DNV

Answer 51

DNV

Question 52

Which accreditation collects ongoing professional practice evaluation data on an ongoing basis and summarized at least three (3) times during each three-year appointment cycle? a. TJC b. ACHC c. DNV

Answer 52

ACHC

Question 53

_____ states that an organization can rely on the verification activities of state licensing boards and if this is done, it should be noted in the Credentials file. a. NCQA b. AAAHC c. URAC

Answer 53

URAC

Question 54

The Medical Staff Bylaws provide for a Medical Staff Chief and/or the CEO to grant emergency privileges to practitioners to accomplish lifesaving procedures, within the scope of his/her license, if a credentialed practitioner with appropriate privileges is not available. a. DNV b. TJC c. ACHC

Answer 54

ACHC

Question 55

This accrediting body requires the medical staff to have a documented mechanism for oversight of the professional performance of volunteer physicians and other licensed practitioners who receive disaster privileges. a. DNV b. TJC c. ACHC

Answer 55

TJC

Question 56

Under the facilities and environment standards, a comprehensive written emergency and disaster preparedness plan to address internal and external emergencies is present for which accreditation? a. DNV b. URAC c. AAAHC

Answer 56

AAAHC

Question 57

Name the three accreditors that do not use the language “designated equivalent sources.” a. TJC, NCQA, ACHC b. DNV, URAC, AAAHC c. NCQA, DNV, URAC

Answer 57

NCQA, DNV, URAC

Question 58

Which accrediting body standard allows the CEO or his/her authorized designee to grant temporary privileges based on the recommendation of the president of the medical staff or authorized designee? a. TJC b. ACHC c. DNV

Answer 58

TJC

Question 59

Temporary privileges can be used in time of emergency and/or disaster under which accreditation? a. TJC b. ACHC c. Medicare

Answer 59

ACHC

Question 60

DNV states that locum tenens or similar temporary staff may be used for a what length of time? a. not to exceed 6 months b. not to exceed 120 days c. not to exceed 3 years

Answer 60

not to exceed six months

Question 61

Thoracentesis: a medical procedure that involves inserting a needle into the chest wall to remove fluid or air from the pleural space. It's also known as a pleural tap, needle thoracostomy, or needle decompression

Answer 61

Physician or Physician Assistant Advanced Practice Nurse Radiologist Surgeon

Question 62

Osteosarcoma: a rare cancer of the bone.

Answer 62

Oncology Pathology Orthopedic Surgeons

Question 63

Metatarsal Surgery

Answer 63

Podiatry

Question 64

Nephrolithiasis: hard solid masses mineral deposits that form in kidneys or urinary tract

Answer 64

Urologist Nephrologist