CPCS Reappointment and Recredentialing 3 — Questions and Answers
Question 1: Under The Joint Commission (TJC) standards, how frequently must an organization conduct reappointment of medical staff members at a minimum?
- Annually
- Every two years (Correct answer)
- Every three years
- Every five years
Correct answer: Every two years
TJC MS.06.01.03 requires that reappointment occur at least every two years.
Question 2: A provider's reappointment application is complete, but the credentials committee cannot reach quorum for three consecutive scheduled meetings. The provider's privileges will lapse next week. What is the best course of action?
- Allow privileges to lapse until quorum is reached
- Grant automatic renewal until committee review
- Convene an emergency session or invoke a provisional reappointment process per bylaws (Correct answer)
- Refer the matter to the governing body for direct action
Correct answer: Convene an emergency session or invoke a provisional reappointment process per bylaws
Organizations should have bylaw provisions for emergency or provisional reappointment to prevent lapses when quorum cannot be achieved in time.
Question 3: When recredentialing a CRNA, which additional verification is essential beyond standard physician recredentialing requirements?
- DEA registration verification
- Confirmation of collaborating physician agreement if required by state law (Correct answer)
- Board certification maintenance
- Malpractice coverage limits
Correct answer: Confirmation of collaborating physician agreement if required by state law
Some states require CRNAs to have a supervising or collaborating physician agreement, making verification of that relationship essential during recredentialing.
Question 4: A physician's reappointment is approved with a condition requiring completion of CME in a specific area within 90 days. The physician does not complete the CME within the timeframe. What should happen?
- The condition is automatically waived after 90 days
- Privileges related to that area are automatically suspended per the conditional approval terms (Correct answer)
- The credentials committee must hold a new hearing before any action
- The CME requirement converts to a voluntary recommendation
Correct answer: Privileges related to that area are automatically suspended per the conditional approval terms
Conditional reappointment terms are enforceable; failure to meet the condition typically triggers the stated consequence, such as suspension of related privileges.
Question 5: During recredentialing, a provider discloses a DUI arrest that did not result in conviction. How should the credentials committee handle this disclosure?
- Disregard it since no conviction occurred
- Request additional information and evaluate whether it raises patient safety concerns (Correct answer)
- Automatically deny reappointment
- Report it to the NPDB immediately
Correct answer: Request additional information and evaluate whether it raises patient safety concerns
The committee should gather full context and assess whether the disclosure raises patient safety concerns, even without a conviction.
Question 6: What is the primary purpose of the Focused Professional Practice Evaluation (FPPE) that may be triggered during reappointment?
- To replace the standard reappointment process for low-risk providers
- To evaluate a specific competency concern identified during OPPE review (Correct answer)
- To satisfy NPDB reporting requirements
- To confirm board certification maintenance
Correct answer: To evaluate a specific competency concern identified during OPPE review
FPPE is initiated to evaluate a specific concern about a provider's competency that has been identified, often through OPPE data review.
Question 7: A provider requests expansion of privileges during her reappointment cycle. How should this request be handled?
- Defer the privilege expansion to the next reappointment cycle
- Process the privilege expansion separately from reappointment using the organization's privilege delineation process (Correct answer)
- Automatically approve if the core reappointment is approved
- Require a new initial appointment application
Correct answer: Process the privilege expansion separately from reappointment using the organization's privilege delineation process
Privilege expansion requests follow the privilege delineation process with required competency evidence and are processed independently from the routine reappointment.
CPCS Reappointment and Recredentialing 3
Under The Joint Commission (TJC) standards, how frequently must an organization conduct reappointment of medical staff members at a minimum?