CPCS Peer Review & Performance Improvement 5 — Questions and Answers
Question 1: A physician requests to review peer review documents about another physician during a malpractice lawsuit. What is the correct response?
- Provide the documents as they are hospital records
- Deny access because peer review records are protected from discovery in most states (Correct answer)
- Refer the request to the billing department
- Release only the adverse action summary
Correct answer: Deny access because peer review records are protected from discovery in most states
Most states have peer review protection laws that shield peer review records from discovery in civil litigation to encourage candid quality review.
Question 2: Which CPCS competency domain addresses the credentialing specialist's role in ensuring that performance data collection methods are valid and reliable?
- Legal and Regulatory Compliance
- Credentialing Verification
- Ongoing Monitoring and Evaluation (Correct answer)
- Privileging
Correct answer: Ongoing Monitoring and Evaluation
Ongoing Monitoring and Evaluation encompasses the design and integrity of OPPE/FPPE data collection systems used in performance improvement.
Question 3: A quality improvement team applies the Lean concept of 'waste elimination.' Which of the following is an example of waste in a credentialing process?
- Conducting primary source verification
- Re-entering data already collected in a prior credentialing cycle without a defined review purpose (Correct answer)
- Querying the NPDB at reappointment
- Obtaining a signed attestation from the applicant
Correct answer: Re-entering data already collected in a prior credentialing cycle without a defined review purpose
Rework and redundant data entry without added value are classic examples of Lean 'waste' (specifically, the waste of motion or overprocessing).
Question 4: What is the purpose of a 'proctoring' arrangement in the context of FPPE?
- To allow a senior physician to bill under a trainee's NPI
- To observe and evaluate a practitioner's clinical performance directly before granting full privileges (Correct answer)
- To provide continuing medical education credits during peer review
- To assign a mentor for new administrative staff
Correct answer: To observe and evaluate a practitioner's clinical performance directly before granting full privileges
Proctoring involves direct observation of a practitioner's clinical work by a qualified colleague to assess competence as part of FPPE.
Question 5: An organization's peer review process consistently results in no adverse findings despite high complication rates. This pattern most likely suggests:
- The organization has an exceptionally high standard of care
- The peer review process may be biased or lacking objectivity (Correct answer)
- OPPE data is being reviewed too frequently
- The NPDB query process is functioning correctly
Correct answer: The peer review process may be biased or lacking objectivity
A disconnect between objective outcome data and peer review findings may indicate a culture of collegial protection or a flawed review methodology.
Question 6: Which metric is most appropriate for measuring the effectiveness of a credentialing department's performance improvement initiative targeting application processing time?
- Number of NPDB queries performed per month
- Average days from application receipt to appointment decision (Correct answer)
- Total number of peer review cases reviewed annually
- Percentage of physicians with board certification
Correct answer: Average days from application receipt to appointment decision
Average processing time directly measures the efficiency improvement being targeted and can be tracked before and after the intervention.
Question 7: Under The Joint Commission's MS.08.01.01 standard, who holds ultimate accountability for the peer review process?
- The Chief Credentialing Officer
- The Medical Staff
- The Hospital CEO
- The Board of Directors / Governing Body (Correct answer)
Correct answer: The Board of Directors / Governing Body
TJC standard MS.08.01.01 places ultimate accountability for the peer review and performance improvement process with the governing body of the organization.
CPCS Peer Review & Performance Improvement 5
A physician requests to review peer review documents about another physician during a malpractice lawsuit.
What is the correct response?