Study Session 3/5/2025

Question 1

Although not specifically addressed in the standards, instructs surveyors to validate the hospitals method for reviewing practitioner’s surgical privileges to determine if the process includes require verification of training, experience, health status and performance.

a. DNV
b. AAAHC
c. ACHC

Answer 1

DNV

Question 2

The application includes information concerning the applicant’s current physical, mental health, or chemical dependency problems that would interfere with the ability to provide high-quality patient care

a. ACHC
b. TJC
c. AAAHC

Answer 2

AAAHC

Question 3

Current signed attestation statement from the applicant regarding the reasons for any inability to perform the essential functions of the position, with or without accommodation and the lack of present illegal drug use.

a. ACHC
b. NCQA
c. TJC

Answer 3

NCQA

Question 4

Application includes disclosure of any physical mental or substance abuse problems that could without reasonable accommodation impede the practitioner’s ability to provide care

a. URAC
b. DNV
c. AAAHC

Answer 4

URAC

Question 5

Although not specifically addressed in the regulations, the interpretative guidelines instruct surveyors to review the hospital’s method for reviewing the surgical privileges of practitioners

a. DNV
b. Medicare
c. URAC

Answer 5

Medicare

Question 6

The applicant must submit a statement that no health problems exist that could affect the exercise of clinical privileges

a. TJC
b. ACHC
c. NCQA

Answer 6

TJC

Question 7

Information regarding ability to perform privileges requested (health status is considered for each applicant and reapplicant during the review and approval process

a. AAAHC
b. TJC
c. ACHC

Answer 7

ACHC

Question 8

What must applicants provide under The Joint Commission (TJC) to confirm their ability to perform clinical privileges?

a. A personal letter explaining their skills
b. A statement from a director, chief of service, or approved physician
c. A signed document from a colleague

Answer 8

A statement from a director, chief of service, or approved physician

Question 9

___________ 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 9

ACHC

Question 10

Applicants are asked to document the ability to safely exercise the privileges requested with or without reasonable accommodation. What is the name of the federal civil rights law that prohibits discrimination against a qualified individual due to a disability?

a. Civil Rights Act
b. American with Disabilities Act (ADA)
c. Social Security Act

Answer 10

American with Disabilities Act (ADA)

Question 11

This organization requires and reviews pertinent information concerning the applicant’s current physical, mental health, or chemical dependency problems that would interfere with the ability to provide high quality patient care or services.

a. TJC
b. AAAHC
c. ACHC

Answer 11

AAAHC

Question 12

In reference to health status, which three accreditations include “mental” health?

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

Answer 12

ACHC, URAC, AAAHC

Question 13

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 13

TJC

Question 14

According to NCQA, what must an applicant’s attestation include regarding their ability to perform?

a. A statement about any inability to perform essential functions, with or without accommodation
b. A health report from their primary care doctor
c. A record of past surgeries performed

Answer 14

A statement about any inability to perform essential functions, with or without accommodation

Question 15

Which accreditation body state that consideration of gender, race, creed, or national origin cannot be used in making privileging decisions?

a. TJC
b. AAAHC
c. DNV

Answer 15

TJC

Question 16

Which organization states medical staff membership criteria cannot include sex, race, creed, national origin or handicap or other considerations not impacting the applicant’s ability to discharge the privileges for which he or she has applied?

a. TJC
b. ACHC
c. URAC

Answer 16

ACHC

Question 17

The Civil Rights Act of 1871 prohibits unlawful discrimination of what?

a. Discrimination based on a disability
b. Discrimination to treat indigent patients due to the inability to pay for services
c. Discrimination based on race, color, religion, gender, & national origin

Answer 17

Discrimination based on race, color, religion, gender, & national origin

Question 18

The Civil Rights Act of ______ prohibits unlawful employment discrimination by public and private employers, labor organizations, training programs and employment agencies based on race or color, religion, gender, and national origin.

a. 1971
b. 1871
c. 1981

Answer 18

1871

Question 19

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 19

AAAHC, Medicare, DNV

Question 20

Under ACHC standards, when is health status considered?

a. Only during the initial appointment
b. During initial and reappointment reviews
c. Only when concerns are raised by peers

Answer 20

During initial and reappointment reviews

Question 21

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

a. Medicare
b. DNV
c. NCQA

Answer 21

Medicare

Question 22

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 22

TJC

Question 23

Per DNV for ability to perform although not specifically addressed in the standard the surveyor is instructed to validate the hospitals method for reviewing practitioner’s what?

a. Board Certification
b. Ongoing monitoring
c. Surgical privileges

Answer 23

Surgical privileges

Question 24

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

a. ACHC
b. NCQA
c. URAC

Answer 24

URAC

Question 25

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 25

TJC

Question 26

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 26

AAAHC

Question 27

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 27

URAC

Question 28

How does URAC address physical and mental health issues in credentialing? a. Applicants must disclose any issues that could affect patient care b. No disclosure is required c. Only substance abuse issues need to be reported

Answer 28

Applicants must disclose any issues that could affect patient care

Question 29

________ uses a peer-review process to make recommendations regarding credentialing decisions? a. NCQA b. AAAHC c. URAC

Answer 29

NCQA

Question 30

What is required on a practitioner’s application under AAAHC regarding health status? a. Disclosure of any physical, mental, or substance abuse problems that may affect care b. A yearly physical exam report c. A recommendation from a licensed therapist

Answer 30

Disclosure of any physical, mental, or substance abuse problems that may affect care

Question 31

Requirement of a written assessment of the practitioner’s training, experience, health status, and performance is mentioned under which entity?” a. NCQA b. DNV c. Medicare

Answer 31

Medicare

Question 32

Ability to perform privileges requested must be evaluated and this evaluation documented in the credentials file per _____. a. DNV b. ACHC c. TJC

Answer 32

TJC

Question 33

According to Medicare CoPs, what must be part of surgical privilege reviews? a. The method should require a written assessment of health status, training, and performance b. A letter of recommendation from another hospital c. A self-assessment form

Answer 33

The method should require a written assessment of health status, training, and performance

Question 34

What accreditation organization(s) do(es) not specifically address the Applicant Identity? a. TJC b. TJC, DNV, ACHC, AAAHC c. NCQA, ACHC, DNV, URAC, AAAHC, Medicare

Answer 34

NCQA, ACHC, DNV, URAC, AAAHC, Medicare

Question 35

When must an applicant’s identity verification be performed? a. Prior to the practitioner performing patient care services b. Within 6 months of the practitioners hire date c. When requested by the patient

Answer 35

Prior to the practitioner performing patient care services

Question 36

If there’s doubt about an applicant’s ability to perform privileges, what can TJC require? a. An evaluation by an internal or external source b. A voluntary resignation of privileges c. A performance review after six months

Answer 36

An evaluation by an internal or external source

Question 37

Under which accreditation does a “peer group makes the final credentialing determination.” a. ACHC b. DNV c. URAC

Answer 37

URAC

Question 38

The following, with the exception of _____ may be used for applicant ID? a. Passport b. Written acknowledgement of applicant’s ID by COS c. Hospital ID

Answer 38

Written acknowledgement of applicant’s ID by COS

Question 39

What must The Joint Commission (TJC) verify to confirm an applicant's identity? a. A birth certificate b. A valid picture ID issued by a state or federal agency c. A signed letter from a previous employer

Answer 39

A valid picture ID issued by a state or federal agency

Question 40

What documents are needed to verify/determine an applicant is the individual identified in the credentialing documents? a. Birth certificate and Driver License b. Passport and Driver License c. Social Security Card and Birth Certificate

Answer 40

Passport and Driver License

Question 41

Which organization references - MS 7 SR4 (c) and MS 8 SR1(b) bylaws describe the qualifications to be met by a candidate in order for the medical staff to recommend that the governing body appoint the candidate. Those qualifications shall include two peer recommendations on initial appointment. a. URAC b. AAAHC c. DNV

Answer 41

DNV

Question 42

Which form of ID is acceptable under TJC standards? a. Driver’s license or passport b. Social Security card c. Employee ID badge from a previous hospital

Answer 42

Driver’s license or passport

Question 43

Peer references should be obtained from: a. Prior chairs of training programs, department chairs, chiefs of staff, or colleagues b. Practitioners in the same professional discipline as the applicant c. Both a & b

Answer 43

Both a & b

Question 44

When must identity verification occur under TJC standards? a. After the practitioner starts seeing patients b. Before the practitioner provides patient care services c. During the first performance review

Answer 44

Before the practitioner provides patient care services

Question 45

What accreditation body does not have a specific requirement for peer recommendations a. URAC b. NCQA c. AAAHC

Answer 45

NCQA

Question 46

Per TJC, how can identity verification be conducted if not done in person? a. Through email confirmation b. Via a telecommunication link with audio and video capabilities c. Using a notarized letter from the applicant

Answer 46

Via a telecommunication link with audio and video capabilities

Question 47

_____ 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 47

ACHC

Question 48

What is the main purpose of verifying applicant identity? a. To comply with tax regulations b. To ensure the applicant is the individual in the credentialing documents c. To track employment history

Answer 48

To ensure the applicant is the individual in the credentialing documents

Question 49

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 your Physician Assistant

Answer 49

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

Question 50

Which document is NOT typically acceptable for identity verification? a. A state ID card b. A professional license without a photo c. A military ID

Answer 50

A professional license without a photo

Question 51

Which elements should peer recommendations include under TJC standards? a. Medical knowledge, clinical skills, judgment, communication, and professionalism b. Only clinical skills and malpractice history c. Communication skills and training history

Answer 51

Medical knowledge, clinical skills, judgment, communication, and professionalism

Question 52

How many peer recommendations are preferred for initial appointment under ACHC? a. At least one, but preferably three b. Only one c. A minimum of five

Answer 52

At least one, but preferably three

Question 53

Does NCQA require individual peer recommendations? a. Yes, at least two written recommendations b. Only for high-risk specialties c. No, but they require a peer-review process through a Credentialing Committee

Answer 53

No, but they require a peer-review process through a Credentialing Committee

Question 54

For initial applicants, where does ACHC suggest references come from? a. Residency or Department Chair b. The MEC c. The applicant’s previous employer

Answer 54

Residency or Department Chair

Question 55

How are peer recommendations handled for reappointment under ACHC? a. Routine review functions like peer review and medical records review b. Two fresh peer recommendations every cycle c. No peer input is needed for reappointment

Answer 55

Routine review functions like peer review and medical records review

Question 56

What is an acceptable format for a peer recommendation? a. Written documentation or phone conversations documented in writing b. Verbal statements during committee meetings c. A signed checklist without written comments

Answer 56

Written documentation or phone conversations documented in writing