CPCS Medical Staff Governance 3 — Questions and Answers
Question 1: Which federal law requires hospitals to report adverse credentialing actions of 30 days or more to the National Practitioner Data Bank (NPDB)?
- HIPAA
- The Health Care Quality Improvement Act (HCQIA) (Correct answer)
- The Affordable Care Act
- The Emergency Medical Treatment and Labor Act (EMTALA)
Correct answer: The Health Care Quality Improvement Act (HCQIA)
HCQIA of 1986 mandates hospitals to report professional review actions restricting or revoking clinical privileges for 30 days or more to the NPDB.
Question 2: A practitioner resigns from the medical staff while under investigation. How must the hospital respond regarding NPDB reporting?
- No report is required because no formal action was taken
- A report must be filed if the investigation would have resulted in a reportable adverse action (Correct answer)
- The report is optional at the hospital's discretion
- The report is filed only if the practitioner requests it
Correct answer: A report must be filed if the investigation would have resulted in a reportable adverse action
Under HCQIA, hospitals must file an NPDB report when a practitioner resigns or surrenders privileges while under investigation to prevent circumventing the reporting system.
Question 3: Under CMS Conditions of Participation, which of the following is required when a hospital grants a telemedicine practitioner privileges via a distant-site hospital agreement?
- The local hospital must independently verify all primary source documents
- The local hospital may rely on the distant site's credentialing if a written agreement exists (Correct answer)
- Telemedicine practitioners are exempt from credentialing requirements
- Only state licensure needs to be verified for telemedicine providers
Correct answer: The local hospital may rely on the distant site's credentialing if a written agreement exists
CMS allows a local hospital to rely on a distant-site hospital's credentialing decisions for telemedicine providers when a formal written agreement meeting specific criteria is in place.
Question 4: The 'ongoing professional practice evaluation' (OPPE) process is BEST described as which of the following?
- A one-time competency assessment conducted at initial appointment
- A continuous evaluation of a practitioner's performance used to inform privilege decisions (Correct answer)
- An annual peer review triggered only when a complaint is filed
- A credentialing verification performed by the credentials committee at reappointment
Correct answer: A continuous evaluation of a practitioner's performance used to inform privilege decisions
OPPE is a continuous, data-driven performance monitoring process used to make privilege-related decisions between formal reappointment cycles.
Question 5: A hospital's medical staff bylaws must be reviewed and approved by which two entities to be considered valid and enforceable?
- The credentials committee and the department chairs
- The medical staff and the governing board (Correct answer)
- The CEO and the chief medical officer
- The quality committee and the legal counsel
Correct answer: The medical staff and the governing board
Medical staff bylaws require approval by both the organized medical staff (through vote) and the governing board to be legally enforceable.
Question 6: Which document specifies the exact clinical activities a practitioner is authorized to perform at a specific hospital?
- The practitioner's curriculum vitae
- The delineation of privileges form (Correct answer)
- The medical staff bylaws
- The primary source verification report
Correct answer: The delineation of privileges form
The delineation of privileges (privilege form) lists the specific procedures and clinical activities a practitioner is granted permission to perform at that institution.
Question 7: Which of the following BEST defines 'proctoring' in the context of medical staff governance?
- A credential verification method used at initial appointment
- Supervised observation of a practitioner performing procedures to assess competency (Correct answer)
- The process of reviewing peer references before granting privileges
- An administrative audit of medical record documentation
Correct answer: Supervised observation of a practitioner performing procedures to assess competency
Proctoring involves a qualified observer watching a practitioner perform procedures to validate competency, often required for new privileges or when concerns arise.
CPCS Medical Staff Governance 3
Which federal law requires hospitals to report adverse credentialing actions of 30 days or more to the National Practitioner Data Bank (NPDB)?