CPCS Clinical Privileging 4 — Questions and Answers
Question 1: A hospital receives a request to credential a provider who trained at a foreign medical school. Which verification is MOST critical to complete that differs from domestic graduate verification?
- Verification through the Educational Commission for Foreign Medical Graduates (ECFMG) (Correct answer)
- Direct verification with the foreign country's ministry of health
- A notarized translation of the diploma only
- Verification through the AMA Physician Masterfile
Correct answer: Verification through the Educational Commission for Foreign Medical Graduates (ECFMG)
ECFMG certification verifies the authenticity of medical education and postgraduate training for graduates of foreign medical schools practicing in the US.
Question 2: During reappointment, peer references are reviewed and one reference raises significant concerns about a physician's clinical judgment. What should the credentials committee do?
- Disregard the reference if the other references are positive
- Request additional information or references and potentially trigger FPPE (Correct answer)
- Automatically deny reappointment based on one negative reference
- Forward the reference to the state medical board immediately
Correct answer: Request additional information or references and potentially trigger FPPE
A concerning peer reference warrants further inquiry, which may include requesting additional references, convening a peer review, or initiating FPPE before making a final recommendation.
Question 3: What distinguishes 'core privileges' from 'special privileges' in a privilege delineation system?
- Core privileges are granted automatically; special privileges require additional documentation
- Core privileges define the standard scope of a specialty; special privileges cover procedures requiring demonstrated additional competency (Correct answer)
- Core privileges are permanent; special privileges expire annually
- Core privileges apply hospital-wide; special privileges are department-specific
Correct answer: Core privileges define the standard scope of a specialty; special privileges cover procedures requiring demonstrated additional competency
Core privileges represent the baseline clinical activities expected of all practitioners in a specialty, while special privileges require demonstration of specific additional training or competency.
Question 4: A hospitalist requests privileges to perform bedside thoracentesis. The credentials committee has no established criteria for this procedure. What is the appropriate first step?
- Deny the request until criteria are formally established
- Grant the privileges provisionally without criteria
- Develop criteria based on specialty society guidelines before granting privileges (Correct answer)
- Refer the physician to interventional radiology for supervision
Correct answer: Develop criteria based on specialty society guidelines before granting privileges
When criteria for a requested privilege do not exist, the committee must first develop evidence-based criteria—typically referencing specialty society guidelines—before acting on the request.
Question 5: Which term describes the process by which a provider's privileges are immediately suspended pending investigation of a patient safety concern?
- Summary suspension (Correct answer)
- Administrative leave
- Focused Professional Practice Evaluation
- Emergency credentialing
Correct answer: Summary suspension
Summary suspension is an immediate, precautionary restriction of privileges imposed when patient safety is at risk, pending a formal investigation.
Question 6: A nurse practitioner applies for privileges at a hospital in a state with collaborative practice requirements. Which additional element is MOST important to verify before granting privileges?
- DEA registration number
- Existence and validity of a collaborative practice agreement with a supervising physician (Correct answer)
- Membership in a professional nursing organization
- Completion of a hospital-specific orientation program
Correct answer: Existence and validity of a collaborative practice agreement with a supervising physician
In states requiring collaborative practice agreements for NPs, the existence and validity of such an agreement is a prerequisite to practicing and must be verified before privileges are granted.
Question 7: Which accreditation standard specifically requires hospitals to have a process for evaluating new procedures or technology before privileges are granted?
- Joint Commission MS.06.01.05 (Correct answer)
- CMS CoP §482.22
- NCQA Credentialing Standard CR 7
- URAC Health Utilization Management Standard UM 1
Correct answer: Joint Commission MS.06.01.05
Joint Commission Medical Staff Standard MS.06.01.05 requires a process to evaluate new procedures, including gathering information from external authoritative sources, before granting privileges.
CPCS Clinical Privileging 4
A hospital receives a request to credential a provider who trained at a foreign medical school.
Which verification is MOST critical to complete that differs from domestic graduate verification?