This is used to fulfill an important patient care, treatment, and service need or when an initial
applicant with a complete clean application awaits review and approval of the medical
executive committee and the governing body - correct answer Temporary Privileges
Per TJC, the governing body may delegate the authority to render those decisions to a
committee of at least two voting members of the governing body. - correct answer Expedited
Privileges
A medical practitioner who temporarily takes the place of another - correct answer Locum
Tenens
Per TJC, these are only implemented when the hospital activates its emergency operations plan
- correct answer Disaster Privileges
For this consider what training/experience is required. Are there any other requirements? CME,
board certification, training course, peer recommendations - correct answer Addition of New
Privilege
Terminology used by national and state/provincial licensing boards for various professions that
defines the procedures, actions, and processes that are permitted for the licensed individual. -
correct answer Scope of Practice
This organization requires a process for obtaining, verifying, and assessing the qualifications of
a health care practitioner who seeks to provide patient care services in or for a hospital. -
correct answer The Joint Commission
This organization requires a process by which an organization reviews and evaluates
qualifications of licensed independent practitioners to provide services to its members. -
correct answer NCQA
An example of this would be "admit, evaluate, diagnose, treat, and provide consultation to
patients 15 years of age and older with common and complex illnesses". - correct answer Core
Privileges
This is sometimes referred to as privilege lists or privilege cards, are detailed checklists that
itemize the procedures/conditions that applicants can specifically request to perform/treat -
correct answer Laundry Lists
Use of medical information exchanged from one site to another via electronic communications
- correct answer Telemedicine
This organization stipulates that bylaws provide for the granting of temporary privileges during
review and consideration of application for care of specific patient(s) for locum tenens for times
of emergency/disaster - correct answer ACHC (HFAP)
,This can serve as a good resource for those who need additional training regarding what
procedures are specific to a particular specialty. - correct answer ACGME Residency
Requirements
Conformance with hospital's plan of care would be a good thing to consider when developing
these. - correct answer Developing New Privileging Criteria
Allows physicians to perform tasks outside of their existing privileges to save a patient's life,
limb, or organ - correct answer Emergency Privileges
The 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. - correct answer AAAHC
This organization requires an application include disclosure of any physical, mental, or
substance abuse problems that could, without reasonable accommodation, impede the
practitioner's ability to provide care according to accepted standards of professional
performance or pose a threat to the health or safety of patients. - correct answer URAC
In accordance with State law, including scope-of-practice laws, the medical staff may also
include other categories of non-physician practitioners (APPs) determined as eligible for
appointment by the governing body. - correct answer Medicare Conditions of Participation
These factors must be considered according to CMS CoPs: character, competence, judgment,
experience and training. - correct answer CCJET
For these, consider if the request for an activity is within the hospital's capability. - correct
answer New Procedure/Technology
An organization that gathers data and verifies the credentials of doctors and other health care
practitioners - correct answer Credentialing Verification
Organization (CVO)
Why is it important to check that the practitioner is not currently excluded, suspended,
debarred, or ineligible to participate in Federal health care programs?
a. A facility could lose its accreditation if it does not do so
b. It is required by Medicare Conditions of Participation
c. The facility won't get paid for treating patients unless service is provided by authorized
provider - correct answer c. The facility won't get paid for treating patients unless service is
provided by an authorized provider.
Which of the following credentials must be tracked on an ongoing basis?
a. Medical School completion
,b. Closed medical malpractice claims
c. Licensure - correct answer c. Licensure
According to NCQA standards, an organization that discovers sanction information, complaints,
or adverse events regarding a practitioner must take what action?
a. Determine if there is evidence of poor quality that could affect the health and safety of its
members
b. Immediately take action to remove the provider from its panel
c. Initiate Ongoing Professional Practice Evaluation - correct answer a. Determine if there is
evidence of poor quality that could affect the health and safety of its members
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? - correct answer The
National Practitioner Data Bank (NPDB)
When developing clinical privileging criteria, which of the following is important to evaluate?
a. How many providers are in that specialty
b. Established standards of practice such as, specialty board recommendations
c. Whether or not the quality department can support the FPPE process - correct answer b.
Established standards of practice such as, specialty board recommendations
What is the main reason for periodically assessing appropriateness of clinical privileges for each
specialty?
a. It's required by accreditation standards
b. It is required by the Medicare Conditions of Participation
c. To protect patient safety by ensuring current competency, relevance to the facility, and
accepted standards of care - correct answer c. To protect patient safety by ensuring current
competency, relevance to the facility, and accepted standards of care
Which of the following specialists is most likely to perform a PTCA?
a. General Surgeon
b. OG/GYN
c. Interventional Cardiologist - correct answer c. Interventional Cardiologist
, The Joint Commission hospital standards required that clinical privileges are hospital specific
and
a. Based on the individual's demonstrated current competence and the procedures the hospital
can support
b. Based on board certification
c. Based on the privileges the individual is currently approved to perform at other hospitals. -
correct answer a. Based on the individual's demonstrated current competence and the
procedures the hospital can support
Which of the following would be routinely performed by a Cardiologist?
a. Hysterectomy
b. Transesophageal Echocardiography
c. Urethral dilation - correct answer b. Transesophageal Echocardiography
Which NCQA-required committee makes recommendations regarding credentialing decisions? -
correct answer Credentialing Committee
ACHC standards require two medical staff committees to be delineated in the medical staff
structure. One of them is the Medical Executive Committee. What is the other? - correct
answer Utilization Review Committee
If you needed to find out what the Federal Government requires in regards to anit-trust issues,
what law would you consult? - correct answer Sherman Anti-trust Act
Peer references should be obtained from:
a. Practitioners who have referred patients to the provider
b. Family, friends and neighbors
c. Practitioners in the same professional discipline as the applicant - correct answer c.
Practitioners in the same professional discipline as the applicant
Patrick vs. Burgett is an important case because it:
a. Showed that a hospital can assert that peer review is performed at the states request
b. Illustrates that the governing body is the ultimate authority
c. Illustrates the potential for antitrust liability arising out of peer review activities - correct
answer c. Illustrates the potential for antitrust liability arising out of peer review activities
If a medical staff member has privileges and/or medical staff appointment revoked, he/she
must be: - correct answer Provided due process
applicant with a complete clean application awaits review and approval of the medical
executive committee and the governing body - correct answer Temporary Privileges
Per TJC, the governing body may delegate the authority to render those decisions to a
committee of at least two voting members of the governing body. - correct answer Expedited
Privileges
A medical practitioner who temporarily takes the place of another - correct answer Locum
Tenens
Per TJC, these are only implemented when the hospital activates its emergency operations plan
- correct answer Disaster Privileges
For this consider what training/experience is required. Are there any other requirements? CME,
board certification, training course, peer recommendations - correct answer Addition of New
Privilege
Terminology used by national and state/provincial licensing boards for various professions that
defines the procedures, actions, and processes that are permitted for the licensed individual. -
correct answer Scope of Practice
This organization requires a process for obtaining, verifying, and assessing the qualifications of
a health care practitioner who seeks to provide patient care services in or for a hospital. -
correct answer The Joint Commission
This organization requires a process by which an organization reviews and evaluates
qualifications of licensed independent practitioners to provide services to its members. -
correct answer NCQA
An example of this would be "admit, evaluate, diagnose, treat, and provide consultation to
patients 15 years of age and older with common and complex illnesses". - correct answer Core
Privileges
This is sometimes referred to as privilege lists or privilege cards, are detailed checklists that
itemize the procedures/conditions that applicants can specifically request to perform/treat -
correct answer Laundry Lists
Use of medical information exchanged from one site to another via electronic communications
- correct answer Telemedicine
This organization stipulates that bylaws provide for the granting of temporary privileges during
review and consideration of application for care of specific patient(s) for locum tenens for times
of emergency/disaster - correct answer ACHC (HFAP)
,This can serve as a good resource for those who need additional training regarding what
procedures are specific to a particular specialty. - correct answer ACGME Residency
Requirements
Conformance with hospital's plan of care would be a good thing to consider when developing
these. - correct answer Developing New Privileging Criteria
Allows physicians to perform tasks outside of their existing privileges to save a patient's life,
limb, or organ - correct answer Emergency Privileges
The 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. - correct answer AAAHC
This organization requires an application include disclosure of any physical, mental, or
substance abuse problems that could, without reasonable accommodation, impede the
practitioner's ability to provide care according to accepted standards of professional
performance or pose a threat to the health or safety of patients. - correct answer URAC
In accordance with State law, including scope-of-practice laws, the medical staff may also
include other categories of non-physician practitioners (APPs) determined as eligible for
appointment by the governing body. - correct answer Medicare Conditions of Participation
These factors must be considered according to CMS CoPs: character, competence, judgment,
experience and training. - correct answer CCJET
For these, consider if the request for an activity is within the hospital's capability. - correct
answer New Procedure/Technology
An organization that gathers data and verifies the credentials of doctors and other health care
practitioners - correct answer Credentialing Verification
Organization (CVO)
Why is it important to check that the practitioner is not currently excluded, suspended,
debarred, or ineligible to participate in Federal health care programs?
a. A facility could lose its accreditation if it does not do so
b. It is required by Medicare Conditions of Participation
c. The facility won't get paid for treating patients unless service is provided by authorized
provider - correct answer c. The facility won't get paid for treating patients unless service is
provided by an authorized provider.
Which of the following credentials must be tracked on an ongoing basis?
a. Medical School completion
,b. Closed medical malpractice claims
c. Licensure - correct answer c. Licensure
According to NCQA standards, an organization that discovers sanction information, complaints,
or adverse events regarding a practitioner must take what action?
a. Determine if there is evidence of poor quality that could affect the health and safety of its
members
b. Immediately take action to remove the provider from its panel
c. Initiate Ongoing Professional Practice Evaluation - correct answer a. Determine if there is
evidence of poor quality that could affect the health and safety of its members
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? - correct answer The
National Practitioner Data Bank (NPDB)
When developing clinical privileging criteria, which of the following is important to evaluate?
a. How many providers are in that specialty
b. Established standards of practice such as, specialty board recommendations
c. Whether or not the quality department can support the FPPE process - correct answer b.
Established standards of practice such as, specialty board recommendations
What is the main reason for periodically assessing appropriateness of clinical privileges for each
specialty?
a. It's required by accreditation standards
b. It is required by the Medicare Conditions of Participation
c. To protect patient safety by ensuring current competency, relevance to the facility, and
accepted standards of care - correct answer c. To protect patient safety by ensuring current
competency, relevance to the facility, and accepted standards of care
Which of the following specialists is most likely to perform a PTCA?
a. General Surgeon
b. OG/GYN
c. Interventional Cardiologist - correct answer c. Interventional Cardiologist
, The Joint Commission hospital standards required that clinical privileges are hospital specific
and
a. Based on the individual's demonstrated current competence and the procedures the hospital
can support
b. Based on board certification
c. Based on the privileges the individual is currently approved to perform at other hospitals. -
correct answer a. Based on the individual's demonstrated current competence and the
procedures the hospital can support
Which of the following would be routinely performed by a Cardiologist?
a. Hysterectomy
b. Transesophageal Echocardiography
c. Urethral dilation - correct answer b. Transesophageal Echocardiography
Which NCQA-required committee makes recommendations regarding credentialing decisions? -
correct answer Credentialing Committee
ACHC standards require two medical staff committees to be delineated in the medical staff
structure. One of them is the Medical Executive Committee. What is the other? - correct
answer Utilization Review Committee
If you needed to find out what the Federal Government requires in regards to anit-trust issues,
what law would you consult? - correct answer Sherman Anti-trust Act
Peer references should be obtained from:
a. Practitioners who have referred patients to the provider
b. Family, friends and neighbors
c. Practitioners in the same professional discipline as the applicant - correct answer c.
Practitioners in the same professional discipline as the applicant
Patrick vs. Burgett is an important case because it:
a. Showed that a hospital can assert that peer review is performed at the states request
b. Illustrates that the governing body is the ultimate authority
c. Illustrates the potential for antitrust liability arising out of peer review activities - correct
answer c. Illustrates the potential for antitrust liability arising out of peer review activities
If a medical staff member has privileges and/or medical staff appointment revoked, he/she
must be: - correct answer Provided due process
