age 1 of 34
CPMSM (TJC) EXAM STUDY GUIDE 2025/2026
ACCURATE QUESTIONS WITH CORRECT DETAILED
ANSWERS || 100% GUARANTEED PASS <RECENT
VERSION>
The Joint Commission hospital standards require that clinical
privileges are hospital-specific and .......Answer.........Based on the
individual's demonstrated current competence and the
procedures the hospital can support.
According to The Joint Commission standards, medical staff
bylaws should define .......Answer.........The structure of the
medical staff
,age 2 of 34
Robert's Rule of order is an example of
.......Answer.........Parliamentary procedure
Robert's Rules of Order is a well-known guidebook for
conducting meetings and making decisions in a fair and orderly
manner. It provides a set of rules and procedures that are
commonly used in parliamentary settings, such as legislative
bodies or organizations with governing boards. Therefore, the
correct answer is "Parliamentary procedure."
According to The Joint Commission standards, medical staff
bylaws should define the structure of the medical staff. This
means that the bylaws should outline the organization and
hierarchy of the medical staff, including the roles and
responsibilities of different members. This helps to ensure clear
lines of authority and accountability within the medical staff,
,age 3 of 34
promoting effective and efficient functioning of the healthcare
organization.
Which of the following specialists is most likely to perform a
PTCA? .......Answer.........Interventional Cardiologist
According to The Joint Commission standards, which of the
following is considered a designated equivalent source for
verification of board certification? .......Answer.........The American
Board of Medical Specialties
Primary source verification is: .......Answer.........Receiving
information directly from the issuing source
According to NCQA standards, which of the following is an
approved source for verification of board certification?
.......Answer.........State licensing agency if state agency conducts
primary verification of board status
, age 4 of 34
What is the main reason for periodically assessing
appropriateness of clinical privileges for each specialty?
.......Answer.........To protect patient safety by ensuring current
competency, relevance to the facility, and accepted standards
of care.
When documenting a telephone conversation regarding primary
source verification what should be documented?
.......Answer.........Name of the person and organization contacted,
date of call, what was discussed and who conducted the
interview.
According to NCQA standards, an organization that discovers
sanction information, complaints, or adverse events regarding a
practitioner must take what action? .......Answer.........Determine if
there is evidence of poor quality that could affect the health
and safety of its members.
CPMSM (TJC) EXAM STUDY GUIDE 2025/2026
ACCURATE QUESTIONS WITH CORRECT DETAILED
ANSWERS || 100% GUARANTEED PASS <RECENT
VERSION>
The Joint Commission hospital standards require that clinical
privileges are hospital-specific and .......Answer.........Based on the
individual's demonstrated current competence and the
procedures the hospital can support.
According to The Joint Commission standards, medical staff
bylaws should define .......Answer.........The structure of the
medical staff
,age 2 of 34
Robert's Rule of order is an example of
.......Answer.........Parliamentary procedure
Robert's Rules of Order is a well-known guidebook for
conducting meetings and making decisions in a fair and orderly
manner. It provides a set of rules and procedures that are
commonly used in parliamentary settings, such as legislative
bodies or organizations with governing boards. Therefore, the
correct answer is "Parliamentary procedure."
According to The Joint Commission standards, medical staff
bylaws should define the structure of the medical staff. This
means that the bylaws should outline the organization and
hierarchy of the medical staff, including the roles and
responsibilities of different members. This helps to ensure clear
lines of authority and accountability within the medical staff,
,age 3 of 34
promoting effective and efficient functioning of the healthcare
organization.
Which of the following specialists is most likely to perform a
PTCA? .......Answer.........Interventional Cardiologist
According to The Joint Commission standards, which of the
following is considered a designated equivalent source for
verification of board certification? .......Answer.........The American
Board of Medical Specialties
Primary source verification is: .......Answer.........Receiving
information directly from the issuing source
According to NCQA standards, which of the following is an
approved source for verification of board certification?
.......Answer.........State licensing agency if state agency conducts
primary verification of board status
, age 4 of 34
What is the main reason for periodically assessing
appropriateness of clinical privileges for each specialty?
.......Answer.........To protect patient safety by ensuring current
competency, relevance to the facility, and accepted standards
of care.
When documenting a telephone conversation regarding primary
source verification what should be documented?
.......Answer.........Name of the person and organization contacted,
date of call, what was discussed and who conducted the
interview.
According to NCQA standards, an organization that discovers
sanction information, complaints, or adverse events regarding a
practitioner must take what action? .......Answer.........Determine if
there is evidence of poor quality that could affect the health
and safety of its members.
