CPCS - Certified Provider Credentialing Specialist Medical Staff Governance Questions and Answers — Questions and Answers
Question 1: The Medical Executive Committee (MEC) has recommended denial of a physician's reappointment application due to peer review concerns. The hospital's Governing Body reviews the recommendation and all supporting documentation but ultimately disagrees with the MEC's conclusion. What is the final authority in this situation?
- The Chief of Staff, who can break the tie.
- The Governing Body, which has the ultimate authority for all appointments and reappointments. (Correct answer)
- The Medical Executive Committee, as it is responsible for the self-governance of the medical staff.
- The matter must be sent to an external, independent arbitrator for a binding decision.
Correct answer: The Governing Body, which has the ultimate authority for all appointments and reappointments.
While the Medical Executive Committee is responsible for making recommendations regarding medical staff membership and privileges, the ultimate legal and corporate authority rests with the hospital's Governing Body. The Governing Body must consider the MEC's recommendation but is not bound by it and makes the final decision.
Question 2: Which of the following represents the correct hierarchy of authority for medical staff governance documents, from most to least authoritative?
- Rules & Regulations, Medical Staff Bylaws, Departmental Policies
- Departmental Policies, Rules & Regulations, Medical Staff Bylaws
- Medical Staff Bylaws, Rules & Regulations, Departmental Policies (Correct answer)
- Rules & Regulations, Departmental Policies, Medical Staff Bylaws
Correct answer: Medical Staff Bylaws, Rules & Regulations, Departmental Policies
Medical Staff Bylaws are the foundational, highest-level governing document, approved by both the medical staff and the governing body. Rules and Regulations provide more detailed implementation of the principles in the bylaws. Departmental policies are the most specific and must not conflict with the higher-level documents.
Question 3: According to The Joint Commission (TJC) standards, which of the following is the one committee that is required for the medical staff to have?
- Credentials Committee
- Peer Review Committee
- Medical Executive Committee (Correct answer)
- Bylaws Committee
Correct answer: Medical Executive Committee
The Joint Commission standards mandate that the medical staff must have a Medical Executive Committee (MEC). While other committees like Credentials, Peer Review, and Bylaws are common and essential for carrying out the functions of the medical staff, the MEC is the only one explicitly required by TJC to act on behalf of the medical staff and provide leadership.
Question 4: A physician is facing a recommended adverse action that could lead to a report to the National Practitioner Data Bank (NPDB). Under the Health Care Quality Improvement Act (HCQIA), the physician is afforded due process, which includes a fair hearing. Which of the following is a guaranteed right for the physician during this hearing?
- The right to have the hearing open to the public.
- The right to be represented by legal counsel. (Correct answer)
- The right to a trial by a jury of their peers.
- The right to have the hospital pay for all legal fees.
Correct answer: The right to be represented by legal counsel.
The Health Care Quality Improvement Act (HCQIA) outlines specific procedural rights to ensure a fair hearing. Among these is the right for the practitioner to be represented by an attorney or another person of their choice. A public hearing, jury trial, and payment of legal fees are not rights guaranteed by HCQIA for a professional review action hearing.
Question 5: What is the primary purpose of a Fair Hearing and Appeal Plan as outlined within the medical staff bylaws?
- To provide a forum for resolving disputes between medical staff members and hospital administration over hospital policies.
- To offer an educational review of cases for quality improvement purposes without any punitive action.
- To establish the formal process for reviewing applications for initial medical staff appointment.
- To provide a mechanism of due process for practitioners facing an adverse recommendation affecting their membership or privileges. (Correct answer)
Correct answer: To provide a mechanism of due process for practitioners facing an adverse recommendation affecting their membership or privileges.
The Fair Hearing and Appeal Plan is a critical component of medical staff bylaws that ensures due process. Its primary function is to provide a formal, structured mechanism for a practitioner to challenge an adverse recommendation from a professional review body (like the MEC) that could negatively impact their staff membership or clinical privileges.
Question 6: A significant change to the medical staff bylaws is proposed by the Bylaws Committee. According to typical governance procedures and accrediting body standards, what are the final two steps required for the amendment to become effective?
- Approval by the Medical Executive Committee, followed by approval by the Chief of Staff.
- Approval by a majority vote of the active medical staff, followed by approval by the hospital's Governing Body. (Correct answer)
- Approval by the hospital's legal counsel, followed by approval by the Medical Executive Committee.
- Approval by a majority of department chairs, followed by approval by the hospital CEO.
Correct answer: Approval by a majority vote of the active medical staff, followed by approval by the hospital's Governing Body.
Amending medical staff bylaws is a formal process that reflects the shared governance structure. After development and committee review, the proposed amendment must typically be adopted by a vote of the organized medical staff. The final and essential step is approval by the hospital's Governing Body, which holds ultimate authority.
CPCS - Certified Provider Credentialing Specialist Medical Staff Governance Questions and Answers
The Medical Executive Committee (MEC) has recommended denial of a physician's reappointment application due to peer review concerns.
The hospital's Governing Body reviews the recommendation and all supporting documentation but ultimately disagrees with the MEC's conclusion.
What is the final authority in this situation?