CPCS Peer Review & Performance Improvement 2 — Questions and Answers
Question 1: Which federal law provides immunity protections to peer review participants in healthcare organizations?
- HIPAA
- The Health Care Quality Improvement Act (HCQIA) (Correct answer)
- The Stark Law
- The False Claims Act
Correct answer: The Health Care Quality Improvement Act (HCQIA)
HCQIA provides qualified immunity to peer review participants who act in good faith when reviewing physician performance.
Question 2: A credentialing specialist discovers that a physician's peer review files contain patient-identifiable information. What is the most appropriate action?
- File the information with the physician's credentials
- Remove patient identifiers to protect confidentiality per HIPAA (Correct answer)
- Report the finding to the medical staff office only
- Discard the documents immediately
Correct answer: Remove patient identifiers to protect confidentiality per HIPAA
Patient-identifiable information in peer review files must be de-identified to comply with HIPAA privacy requirements.
Question 3: In a focused professional practice evaluation (FPPE), what triggers the review process?
- Routine annual credentialing renewal
- A new privilege request or a specific concern about a practitioner (Correct answer)
- A patient complaint filed with HR
- A malpractice settlement over $50,000
Correct answer: A new privilege request or a specific concern about a practitioner
FPPE is initiated for new privileges or when a specific concern arises about a practitioner's competence or conduct.
Question 4: What is the primary purpose of the National Practitioner Data Bank (NPDB) in the peer review process?
- To store peer review minutes for accreditation surveys
- To flag practitioners with adverse actions for credentialing bodies (Correct answer)
- To rank physicians by clinical outcomes nationally
- To issue malpractice insurance certificates
Correct answer: To flag practitioners with adverse actions for credentialing bodies
The NPDB collects and reports adverse actions and malpractice payments, helping organizations identify practitioners with a history of performance issues.
Question 5: Which performance improvement model uses Define, Measure, Analyze, Improve, and Control phases?
- PDCA
- Six Sigma DMAIC (Correct answer)
- Root Cause Analysis
- Lean 5S
Correct answer: Six Sigma DMAIC
Six Sigma's DMAIC framework is a data-driven methodology for eliminating defects and improving processes.
Question 6: When a peer review committee recommends suspension of privileges, what due process right must the practitioner be afforded?
- Immediate reinstatement pending appeal
- The right to a hearing before the medical staff (Correct answer)
- Access to other practitioners' peer review files
- Transfer to an affiliated facility
Correct answer: The right to a hearing before the medical staff
HCQIA and medical staff bylaws require that practitioners facing adverse privilege actions receive a fair hearing opportunity.
Question 7: A hospital's quality dashboard shows a surgeon's complication rate is two standard deviations above the mean. What is the most appropriate next step?
- Immediately revoke surgical privileges
- Initiate a focused professional practice evaluation (FPPE) (Correct answer)
- Report the surgeon to the state licensing board
- Notify the malpractice carrier and suspend billing
Correct answer: Initiate a focused professional practice evaluation (FPPE)
An outlier statistical finding warrants a structured FPPE to determine whether the deviation reflects a true performance concern.
CPCS Peer Review & Performance Improvement 2
Which federal law provides immunity protections to peer review participants in healthcare organizations?