Treatment Protocols & Interventions Flashcards

Per Joint Commission, how often should Ongoing Professional Practice Evaluation (OPPE) data be reviewed?

Answer: More frequently than every 12 months

TJC expects OPPE to be truly ongoing, with data reviewed more frequently than annually.

An existing practitioner's OPPE data shows a rising complication rate for a procedure. What is the most appropriate next step?

Answer: Initiate a time-limited FPPE to evaluate the concern

FPPE is used when OPPE identifies a concern about a practitioner's ability to provide safe, quality care.

A low-volume practitioner has performed no cases of a privileged procedure at your hospital during the review period. What is the best way to assess competence?

Answer: Obtain performance data or peer references from another facility where cases were performed

For low or no volume, organizations should seek outside data or peer evaluations to confirm current competence.

Which is generally considered insufficient on its own for granting robotic-assisted surgery privileges?

Answer: Completion of a vendor-sponsored training course

Vendor training is a starting point, but organizations also require proctored cases and demonstrated competence.

An originating-site hospital may rely on a distant site's credentialing decisions for telemedicine practitioners when:

Answer: There is a written agreement and the distant site meets CMS/TJC requirements

Credentialing by proxy requires a written agreement with a distant site that complies with CMS conditions of participation.

Which federal regulation contains the Medicare Conditions of Participation for hospital medical staff?

Answer: 42 CFR 482.22

42 CFR 482.22 governs hospital medical staff, including privileging requirements.

Can a hospital grant procedure privileges based solely on board certification?

Answer: No, current competence must also be evaluated

Board certification is one factor, but privileges also require evidence of current clinical competence.