CPCS Medical Staff Governance 4 — Questions and Answers
Question 1: A credentials specialist discovers that a physician's board certification lapsed two years ago. The hospital's bylaws require current board certification for initial appointment. What is the MOST appropriate next step?
- Grant provisional privileges while the physician renews certification
- Notify the credentials committee and place the application on hold pending resolution (Correct answer)
- Deny the application immediately without further review
- Accept the application and flag it for the next reappointment cycle
Correct answer: Notify the credentials committee and place the application on hold pending resolution
The credentials specialist should escalate the finding to the credentials committee, which has authority to determine how the deficiency affects the application.
Question 2: What is the maximum time period typically allowed between the date an application is deemed complete and a credentialing decision under most bylaws and accreditation standards?
- 30 days
- 60 days
- 120 days (Correct answer)
- 180 days
Correct answer: 120 days
Most medical staff bylaws and accreditation frameworks set a 120-day maximum from complete application to credentialing decision to ensure timely processing.
Question 3: A practitioner holds privileges at two hospitals in the same health system. Under a 'unified' or 'systemwide' credentialing model, which of the following is TRUE?
- Each hospital must independently complete primary source verification
- One set of credentials is verified and shared across participating entities per agreement (Correct answer)
- Only the flagship hospital is responsible for credentialing system-wide
- CMS prohibits sharing credentialing information across a health system
Correct answer: One set of credentials is verified and shared across participating entities per agreement
Systemwide or unified credentialing models allow a single verification to be shared across multiple entities within a health system, provided governance agreements are in place.
Question 4: The 'focused professional practice evaluation' (FPPE) is typically triggered by which of the following circumstances?
- A routine reappointment with no concerns identified
- A new privilege request or a concern identified through OPPE (Correct answer)
- Completion of graduate medical education
- A practitioner's voluntary request for a performance review
Correct answer: A new privilege request or a concern identified through OPPE
FPPE is a time-limited, focused evaluation used when a new privilege is granted or when OPPE data raises concerns about a practitioner's performance.
Question 5: Which type of medical staff membership category typically permits physicians to admit patients and vote on medical staff matters?
- Courtesy staff
- Consulting staff
- Active staff (Correct answer)
- Honorary staff
Correct answer: Active staff
Active staff members have full admitting privileges and voting rights, representing the core category with the broadest participation in medical staff governance.
Question 6: A hospital is implementing a new robotic surgery program. Which process must be completed before surgeons may begin performing robotic procedures on patients?
- Surgeons must complete a new employment contract
- New specific privileges for robotic surgery must be requested, reviewed, and granted (Correct answer)
- Existing laparoscopic surgical privileges automatically extend to robotic procedures
- The hospital CEO must approve each surgeon individually
Correct answer: New specific privileges for robotic surgery must be requested, reviewed, and granted
New technology requires the development of specific privilege criteria and formal approval of those privileges before practitioners may use the technology on patients.
Question 7: Which accreditation standard most directly requires that a hospital's credentialing process include a query to the NPDB at initial appointment and at reappointment?
- The Joint Commission's HR standards
- The Joint Commission's MS (Medical Staff) standards
- CMS Conditions of Participation §482.22 (Correct answer)
- NCQA credentialing standards
Correct answer: CMS Conditions of Participation §482.22
CMS Conditions of Participation §482.22 explicitly requires hospitals to query the NPDB as part of the credentialing process at appointment and reappointment.
CPCS Medical Staff Governance 4
A credentials specialist discovers that a physician's board certification lapsed two years ago.
The hospital's bylaws require current board certification for initial appointment.
What is the MOST appropriate next step?