CPCS Clinical Privileging 3 — Questions and Answers
Question 1: A hospital wants to grant temporary privileges to a locum tenens physician immediately. Which condition MUST be met before temporary privileges can be granted?
- The physician must hold board certification in the specialty
- Verification of licensure, relevant training or experience, and a query of the NPDB must be completed (Correct answer)
- The physician must have malpractice coverage from an approved carrier
- A peer reference from the previous employer must be on file
Correct answer: Verification of licensure, relevant training or experience, and a query of the NPDB must be completed
Before granting temporary privileges, Joint Commission and CMS standards require at minimum verification of current licensure, relevant training/experience, and an NPDB query.
Question 2: Which body has final authority to approve or deny clinical privileges at a hospital?
- The credentials committee
- The department chair
- The governing board (Correct answer)
- The chief medical officer
Correct answer: The governing board
While department chairs and credentials committees make recommendations, the governing board holds ultimate legal authority for credentialing and privileging decisions.
Question 3: Under Joint Commission standards, Ongoing Professional Practice Evaluation (OPPE) data must be reviewed at what minimum frequency?
- Monthly
- Quarterly
- At least every 12 months (Correct answer)
- Only at the time of reappointment
Correct answer: At least every 12 months
The Joint Commission requires that OPPE data be reviewed at least every 12 months, though more frequent review is permitted and often practiced.
Question 4: A podiatrist applies for ankle surgery privileges at a facility that has historically only considered foot procedures within podiatry scope. What process should guide the privileging decision?
- Automatic denial because ankle surgery is outside the traditional podiatry scope
- Review of applicable state law, specialty-specific training, and the facility's defined criteria (Correct answer)
- Referral to the orthopedic department for competitive review
- Granting the privileges only if a podiatric surgeon joins the medical staff
Correct answer: Review of applicable state law, specialty-specific training, and the facility's defined criteria
Privileging decisions for emerging or scope-of-practice questions must be guided by state law, documented training and competency, and the facility's established criteria.
Question 5: What is the maximum period for which temporary privileges may be granted under standard hospital policy aligned with Joint Commission standards?
- 30 days, with the possibility of one renewal
- 90 days, with the possibility of one renewal (Correct answer)
- 120 days total
- 180 days without restriction
Correct answer: 90 days, with the possibility of one renewal
Joint Commission standards allow temporary privileges for a period not to exceed 120 days total, often implemented as an initial 90-day grant with one 30-day renewal.
Question 6: A physician in good standing at Hospital A applies to Hospital B using the same health system's centralized credentialing. Which privileging model does this describe?
- Reciprocal privileging
- System-wide or enterprise privileging (Correct answer)
- Expedited credentialing
- Telemedicine privileging
Correct answer: System-wide or enterprise privileging
Enterprise or system-wide privileging allows health systems to share credentialing information and apply uniform privilege criteria across multiple facilities.
Question 7: Which six general competencies defined by ACGME/ABMS are commonly used as the framework for evaluating provider performance in OPPE?
- Education, Training, Experience, Certification, References, Licensure
- Patient Care, Medical Knowledge, Practice-Based Learning, Interpersonal Skills, Professionalism, Systems-Based Practice (Correct answer)
- Outcomes, Efficiency, Safety, Communication, Leadership, Research
- Quality, Compliance, Risk Management, Ethics, Documentation, Teamwork
Correct answer: Patient Care, Medical Knowledge, Practice-Based Learning, Interpersonal Skills, Professionalism, Systems-Based Practice
The six ACGME/ABMS core competencies—Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and Systems-Based Practice—form the standard OPPE framework.
CPCS Clinical Privileging 3
A hospital wants to grant temporary privileges to a locum tenens physician immediately.
Which condition MUST be met before temporary privileges can be granted?