CPMSM STUDY GUIDE (TJC) - CMH77 CORRECT 100%
Where must accreditors submit their standards for approval? - (ANSWERS)CMS 很高兴见到你
When is deemed status given? - (ANSWERS)After approval by CMS
What are requirements set by forces outside the organization? - (ANSWERS)External criteria
What factors are defined by the hospital's medical staff and governing body or the MCO's
board? - (ANSWERS)Internal criteria
Name possible internal criteria? - (ANSWERS)Board certification, an office within close
proximity of facility, alternate coverage, need for a particular specialty, application fees,
minimum amounts for malpractice insurance
Is it an internal or external decision to allow practitioners to practice independently within the
hospital? - (ANSWERS)Internal
According to TJC standards, can medical staff membership and privileges be based solely upon
certification, fellowship, or membership in a specialty body? - (ANSWERS)No
What is the basis for criteria related to membership and privileging? - (ANSWERS)Quality of
healthcare, treatment, and services
Does TJC's interpretation of privileges mean the duties and prerogatives of each category or the
clinical privileges to provide patient care, treatment, and services related to each category? -
(ANSWERS)Duties and prerogatives of each category
Does TJC require that an applicant submit a statement that no heath problems exist that could
affect his/her ability to perform the privileges requested? - (ANSWERS)Yes
Before granting privileges, the medical staff must evaluate what? - (ANSWERS)Challenges to
any licensure;
Voluntary & involuntary relinquishment of any license or registration, termination of medical
staff membership, restrictions of clinical privileges
Does TJC requires the medical staff to evaluate an evidence of an unusual pattern or an
excessive amount of lawsuits prior to granting privileges? - (ANSWERS)Yes
According to TJC, organizations that use a CVO must have confidence in what 3 credentialing
elements? - (ANSWERS)Completeness
Accuracy
Timeliness
According to TJC, what 9 principles should be outlined in order to evaluate a CVO? -
(ANSWERS)Disclosure of data
, CPMSM STUDY GUIDE (TJC) - CMH77 CORRECT 100%
Disclosure of information available 很高兴见到你
Utilized processes
Limitations of available information
Identification of primary source information
Overview of quality control measures related to data integrity, security & transmission accuracy
What methods do TJC consider primary source? - (ANSWERS)Secure electronic
Secure communication
Approved website
Direct phone contact with a PSV
According to TJC, a documented conversation can be used as primary source verification of
what parts of an application? - (ANSWERS)Education
Licensure
Experience
Training
Competence
Peer references
When does the primary source verification of relevant training or experience have to be
completed? - (ANSWERS)At the time of membership and initial granting of privileges
According to TJC, are the AMA and AOA databases acceptable verifications of me medical
school? - (ANSWERS)Yes
What primary source verification can be provided by the American Academy of Physician
Assistants (AAPA)? - (ANSWERS)Education
According to the FAQ of TJC's website, would verifying affiliations meet their requirements
related to issues with an applicant's privileges? - (ANSWERS)No
When would you contact a facility regarding a previous affiliation? - (ANSWERS)When the
applicants' responses to questions on the application conflict with the NPDB query
What designated sources are equivalent to PSV when verifying board certification? -
(ANSWERS)ABMS or ABMS approved Display Agent
American Osteopathic Association physician database
When should licensure be verified per TJC? - (ANSWERS)Time of appointment
Before grant in privileges
Revision of privileges
Does TJC require verification of liability insurance? - (ANSWERS)No
Where must accreditors submit their standards for approval? - (ANSWERS)CMS 很高兴见到你
When is deemed status given? - (ANSWERS)After approval by CMS
What are requirements set by forces outside the organization? - (ANSWERS)External criteria
What factors are defined by the hospital's medical staff and governing body or the MCO's
board? - (ANSWERS)Internal criteria
Name possible internal criteria? - (ANSWERS)Board certification, an office within close
proximity of facility, alternate coverage, need for a particular specialty, application fees,
minimum amounts for malpractice insurance
Is it an internal or external decision to allow practitioners to practice independently within the
hospital? - (ANSWERS)Internal
According to TJC standards, can medical staff membership and privileges be based solely upon
certification, fellowship, or membership in a specialty body? - (ANSWERS)No
What is the basis for criteria related to membership and privileging? - (ANSWERS)Quality of
healthcare, treatment, and services
Does TJC's interpretation of privileges mean the duties and prerogatives of each category or the
clinical privileges to provide patient care, treatment, and services related to each category? -
(ANSWERS)Duties and prerogatives of each category
Does TJC require that an applicant submit a statement that no heath problems exist that could
affect his/her ability to perform the privileges requested? - (ANSWERS)Yes
Before granting privileges, the medical staff must evaluate what? - (ANSWERS)Challenges to
any licensure;
Voluntary & involuntary relinquishment of any license or registration, termination of medical
staff membership, restrictions of clinical privileges
Does TJC requires the medical staff to evaluate an evidence of an unusual pattern or an
excessive amount of lawsuits prior to granting privileges? - (ANSWERS)Yes
According to TJC, organizations that use a CVO must have confidence in what 3 credentialing
elements? - (ANSWERS)Completeness
Accuracy
Timeliness
According to TJC, what 9 principles should be outlined in order to evaluate a CVO? -
(ANSWERS)Disclosure of data
, CPMSM STUDY GUIDE (TJC) - CMH77 CORRECT 100%
Disclosure of information available 很高兴见到你
Utilized processes
Limitations of available information
Identification of primary source information
Overview of quality control measures related to data integrity, security & transmission accuracy
What methods do TJC consider primary source? - (ANSWERS)Secure electronic
Secure communication
Approved website
Direct phone contact with a PSV
According to TJC, a documented conversation can be used as primary source verification of
what parts of an application? - (ANSWERS)Education
Licensure
Experience
Training
Competence
Peer references
When does the primary source verification of relevant training or experience have to be
completed? - (ANSWERS)At the time of membership and initial granting of privileges
According to TJC, are the AMA and AOA databases acceptable verifications of me medical
school? - (ANSWERS)Yes
What primary source verification can be provided by the American Academy of Physician
Assistants (AAPA)? - (ANSWERS)Education
According to the FAQ of TJC's website, would verifying affiliations meet their requirements
related to issues with an applicant's privileges? - (ANSWERS)No
When would you contact a facility regarding a previous affiliation? - (ANSWERS)When the
applicants' responses to questions on the application conflict with the NPDB query
What designated sources are equivalent to PSV when verifying board certification? -
(ANSWERS)ABMS or ABMS approved Display Agent
American Osteopathic Association physician database
When should licensure be verified per TJC? - (ANSWERS)Time of appointment
Before grant in privileges
Revision of privileges
Does TJC require verification of liability insurance? - (ANSWERS)No
