CPMSM Study Guide (TJC) - CMH77 Questions with solutions 2024

CPMSM Study Guide (TJC) - CMH77 Questions with solutions 2024 Where must accreditors submit their standards for approval? CMS When is deemed status given? After approval by CMS Brainpower Read More Previous Play Next Rewind 10 seconds Move forward 10 seconds Unmute 0:07 / 0:15 Full screen What are requirements set by forces outside the organization? External criteria What factors are defined by the hospital's medical staff and governing body or the MCO's board? Internal criteria Name possible internal criteria? Board certification, an office within close proximity of facility, alternate coverage, need for a particular specialty, application fees, minimum amounts for malpractice insurance Is it an internal or external decision to allow practitioners to practice independently within the hospital? Internal According to TJC standards, can medical staff membership and privileges be based solely upon certification, fellowship, or membership in a specialty body? No What is the basis for criteria related to membership and privileging? Quality of healthcare, treatment, and services Does TJC's interpretation of privileges mean the duties and prerogatives of each category or the clinical privileges to provide patient care, treatment, and services related to each category? Duties and prerogatives of each category Does TJC require that an applicant submit a statement that no heath problems exist that could affect his/her ability to perform the privileges requested? Yes Before granting privileges, the medical staff must evaluate what? Challenges to any licensure; Voluntary & involuntary relinquishment of any license or registration, termination of medical staff membership, restrictions of clinical privileges Does TJC requires the medical staff to evaluate an evidence of an unusual pattern or an excessive amount of lawsuits prior to granting privileges? Yes According to TJC, organizations that use a CVO must have confidence in what 3 credentialing elements? Completeness Accuracy Timeliness According to TJC, what 9 principles should be outlined in order to evaluate a CVO? Disclosure of data Disclosure of information available Utilized processes Limitations of available information Identification of primary source information Overview of quality control measures related to data integrity, security & transmission accuracy What methods do TJC consider primary source? Secure electronic Secure communication Approved website Direct phone contact with a PSV According to TJC, a documented conversation can be used as primary source verification of what parts of an application? Education Licensure Experience Training Competence Peer references When does the primary source verification of relevant training or experience have to be completed? At the time of membership and initial granting of privileges According to TJC, are the AMA and AOA databases acceptable verifications of me medical school? Yes What primary source verification can be provided by the American Academy of Physician Assistants (AAPA)? Education According to the FAQ of TJC's website, would verifying affiliations meet their requirements related to issues with an applicant's privileges? No When would you contact a facility regarding a previous affiliation? When the applicants' responses to questions on the application conflict with the NPDB query What designated sources are equivalent to PSV when verifying board certification? ABMS or ABMS approved Display Agent American Osteopathic Association physician database When should licensure be verified per TJC? Time of appointment Before grant in privileges Revision of privileges Does TJC require verification of liability insurance? No What would require an organization to implement a method to verifying liability insurance coverage? If the medical staff bylaws/rules/regulations require liability insurance What 3 elements regarding an applicant's liability coverage would a facility be interested in? Involvement Final judgements Settlements According to TJC, who can confirm an applicant's health status? Director of a training program Chief of staff at another hospital where the applicant holds privileges Licensed physician approved by the medical staff When can an evaluation of an applicant's ability to perform privileges requested be obtained by an internal or external source? When there is doubt by the medical staff How is nondiscrimination defined by TJC? Consideration of gender, race, creed or national origin in making privileging decisions What two ways will TJC allow receipt of peer recommendations? Written documentation reflecting informed opinions or written peer evaluation of practitioner-specific data collected used to validate current competence What 6 elements must be used within a peer recommendation for a provider with insufficient volume during reappointment? Medical/clinical knowledge Technical& clinical skills Clinical judgement Interpersonal skills Communication skills Professionalism What does TJC allow for the purpose of validating current competence? Peer recommendations TJC remmonds or requires that hospitals base evaluation of experience, ability, and current competence? Recommend