CPCS Clinical Privileging and Competency Evaluation (FPPE/OPPE) 2

Question 1

Which trigger MOST commonly initiates a focused review under FPPE for an existing practitioner (as opposed to a new appointee)?

Accepted Answer

A specific concern about clinical performance or conduct

Answer

FPPE for existing practitioners is triggered by a specific concern, such as a sentinel event, complaint, or pattern of adverse outcomes.

Question 2

A hospital's OPPE program shows a surgeon's complication rate is consistently twice the peer benchmark over 12 months. What is the MOST appropriate next step?

Accepted Answer

Refer the findings to the FPPE process for focused evaluation

Answer

Consistent outlier performance in OPPE should trigger an FPPE to investigate the specific concern before any privilege action.

Question 3

Under The Joint Commission standards, who is ultimately responsible for recommending privileges to the governing body?

Accepted Answer

The medical staff through peer review

Answer

TJC standards require the organized medical staff to evaluate and recommend privileges, which the governing body then acts upon.

Question 4

A privilege request for a new minimally invasive procedure is submitted. The hospital has no established criteria. What should the credentials committee do FIRST?

Accepted Answer

Develop criteria using available evidence, specialty society guidelines, and peer input before acting

Answer

Criteria must be established using evidence-based resources before granting privileges for a new procedure or technology.

Question 5

Which metric is considered a CORE measure category for OPPE under TJC standards?

Accepted Answer

Operative and procedure utilization

Answer

TJC identifies operative and other procedure utilization as one of the core data categories for OPPE.

(CPCS) Certified Professional Credentialing Specialist Practice Test

(CPCS) Certified Professional Credentialing Specialist Practice Test

CPCS Clinical Privileging and Competency Evaluation (FPPE/OPPE) 2