CMSP flashcards

33 cards. Read the term and the definition here. The deck at the top of this page is optional.

Medical Executive Committee

The executive body of the organized medical staff that acts between staff meetings, makes recommendations on appointments and privileges, and reports to the governing body.

Governing Body Authority

Ultimate authority for medical staff appointment, reappointment, and privilege granting rests with the governing body, which delegates credentialing work to the organized medical staff.

Fair Hearing Rights

Due process rights triggered by adverse actions affecting appointment, reappointment, or clinical privileges; bylaws define notice, hearing, and appeal procedures.

Bylaws Amendment Threshold

Bylaws typically require a supermajority (often two-thirds) of voting medical staff plus governing body approval; rules and policies require lower approval thresholds.

Emergency Privileges

Temporary privileges granted by the CEO or designee in a disaster or emergency without prior verification, with a defined window (commonly 72 hours) to complete verification.

Primary Source Verification

Direct confirmation of licensure, DEA, board certification, and education from the issuing source or an approved credentialing verification organization, not from the applicant.

Focused Professional Practice Evaluation

Time-limited monitoring (proctoring or chart review) required for new practitioners, new privileges, or concerns, with documented results and a defined endpoint.

Ongoing Professional Practice Evaluation

Continuous monitoring of practitioner performance using objective data such as infection rates, readmissions, and complaints, reviewed at least every 6-12 months.

Telemedicine Credentialing

Credentialing by proxy may rely on the distant site's privileging if that site is accredited and the practitioner is privileged there, per CMS requirements.

Temporary Privileges

Time-limited privileges (often 120 days aggregate) granted while a complete application is processed; require current license and NPDB query before care.

Reappointment Cycle

Routine reappointment typically occurs every 2 years and requires evidence of current competence, licensure, malpractice history, and health status.

NPDB Reporting Threshold

Adverse clinical privilege actions lasting more than 30 days, malpractice payments, and adverse licensure actions must be reported to the National Practitioner Data Bank.

HCQIA Immunity Test

Peer review immunity requires reasonable belief in quality furtherance, reasonable fact-finding effort, adequate notice and hearing, and reasonable belief warranted by facts.

Peer Review Privilege

State law protection for peer review deliberations and records; it can be waived by sharing outside the committee and does not protect underlying facts.

Focused Review Trigger

Events such as sentinel events, high-risk procedures, complaints, or adverse outcomes that prompt a targeted peer review, often within 30 days.

Conflict of Interest Recusal

A practitioner involved in reviewing or voting on his or her own case, or a case with a financial or personal conflict, must recuse from the decision.

CMS Conditions of Participation

Federal requirements (42 CFR 482) for governing body, organized medical staff, and credentialing; Joint Commission accreditation is deemed to meet them.

OIG Exclusion Screening

Monthly screening of employees and practitioners against the OIG and SAM exclusion lists; billing for excluded providers creates repayment and penalty liability.

HIPAA Minimum Necessary

Credentialing and peer review access must be limited to the minimum necessary information for the purpose, with audit trails and breach notification for unauthorized disclosure.

Deemed Status

Accreditation by a CMS-approved accreditor (such as Joint Commission) is deemed to meet Medicare Conditions of Participation, subject to CMS validation surveys.

Root Cause Analysis

A structured retrospective analysis required for sentinel events that identifies system failures and produces an action plan with measurable outcomes.

FMEA

A proactive risk assessment that scores severity, occurrence, and detection to prioritize failure modes before harm occurs.

Just Culture

A framework distinguishing human error, at-risk behavior, and reckless behavior so that the response matches the behavior rather than the outcome.

Patient Safety Organization

An entity recognized under the PSQIA that provides federal privilege protection for patient safety work product submitted to it.

PDSA Cycle

Plan-Do-Study-Act, an iterative improvement framework used to test small changes before broad implementation.

Informed Consent Elements

Disclosure of risks, benefits, alternatives, and the right to refuse, measured by what a reasonable patient would want to know.

Malpractice Elements

Duty, breach, causation, and damages; the plaintiff must prove all four by a preponderance of the evidence.

Peer Review Antitrust Risk

Medical staff decisions must rest on objective, documented criteria; anticompetitive motives can expose the organization to antitrust liability.

Statute of Limitations

State-defined time limit for filing malpractice claims (commonly 2-3 years from injury or discovery), with tolling rules for minors or concealment.

Expirables Management

A tickler system tracking licenses, DEA, board certification, and malpractice expiration with advance notice (often 90-120 days) to prevent lapses.

Credentialing File Indexing

Organizing the credentialing file by category (application, verification, privileging, peer review) for rapid retrieval during surveys or litigation.

Meeting Minutes Retention

Minutes are legal documents that must record quorum, actions, and votes, and be retained per state and accreditation retention schedules.

MSO Performance Dashboard

Metrics such as turnaround time, incomplete applications, and expirables that help identify bottlenecks in the medical staff services process.