CPCS Clinical Privileging and Competency Evaluation (FPPE/OPPE) 3 — Questions and Answers
Question 1: Which situation requires a hospital to obtain information from the National Practitioner Data Bank (NPDB) during privileging?
- Annual reappointment for all practitioners
- Initial appointment and every two-year reappointment (Correct answer)
- Only when a practitioner has a malpractice claim pending
- Only for practitioners applying for surgical privileges
Correct answer: Initial appointment and every two-year reappointment
NPDB regulations mandate querying at initial appointment and at least every two years at reappointment.
Question 2: A proctor observing a surgeon during FPPE determines the surgeon lacks sufficient skill for one of the requested privileges. Who has authority to DENY that specific privilege?
- The proctor
- The department chair acting unilaterally
- The governing body, upon recommendation from the medical staff (Correct answer)
- The CEO based on risk management input
Correct answer: The governing body, upon recommendation from the medical staff
Only the governing body has authority to grant, modify, or deny privileges, acting on the medical staff's recommendation.
Question 3: What is the purpose of 'threshold' or 'trigger' criteria in an OPPE program?
- To set minimum CME requirements for reappointment
- To define performance levels that prompt additional review or action (Correct answer)
- To establish the minimum case volume for privilege maintenance
- To determine billing compliance benchmarks
Correct answer: To define performance levels that prompt additional review or action
Thresholds define the point at which OPPE data triggers escalation to focused review or other action.
Question 4: A telemedicine physician provides services at a hospital without being physically present. Under TJC standards, how must this practitioner be credentialed?
- Credentialed only at the distant site hospital
- Credentialed at the originating site or through a TJC-approved credentialing-by-proxy agreement (Correct answer)
- Not required to be credentialed if licensed in the state
- Credentialed only through the telemedicine vendor
Correct answer: Credentialed at the originating site or through a TJC-approved credentialing-by-proxy agreement
TJC allows credentialing by proxy for telemedicine practitioners under specific conditions, or they must be fully credentialed at the originating site.
Question 5: Which of the following BEST illustrates a 'low volume' challenge in OPPE?
- A practitioner with 500 cases per year who has one complication
- A practitioner who performs only 3 procedures per year, making statistical comparison unreliable (Correct answer)
- A practitioner who works part-time and submits fewer CME hours
- A practitioner in a rural hospital with fewer than 100 beds
Correct answer: A practitioner who performs only 3 procedures per year, making statistical comparison unreliable
Low case volume makes it statistically difficult to draw meaningful conclusions from performance data in OPPE.
Question 6: During an FPPE, a practitioner refuses to cooperate with the assigned proctor. What should the credentials committee consider?
- Waiving the proctoring requirement as an accommodation
- Treating non-cooperation as a potential basis for adverse privilege action (Correct answer)
- Extending the FPPE period indefinitely until cooperation occurs
- Reporting the practitioner directly to the state board
Correct answer: Treating non-cooperation as a potential basis for adverse privilege action
Failure to cooperate with an FPPE is itself a performance concern that can support adverse privilege action.
Question 7: Which term describes the process of a hospital accepting another hospital's credentialing work product to avoid duplication?
- Temporary privileging
- Credentialing by proxy (Correct answer)
- Reciprocal privileging
- Expedited review
Correct answer: Credentialing by proxy
Credentialing by proxy (or privileging by proxy) allows one hospital to rely on another's credentialing under defined conditions, most commonly for telemedicine.
CPCS Clinical Privileging and Competency Evaluation (FPPE/OPPE) 3
Which situation requires a hospital to obtain information from the National Practitioner Data Bank (NPDB) during privileging?