CPCS Medical Staff Committee Support and Management 3 — Questions and Answers
Question 1: Under CMS Conditions of Participation, which body must ultimately approve medical staff bylaws?
- The medical staff executive committee
- The credentials committee
- The governing board (Correct answer)
- The state health department
Correct answer: The governing board
CMS requires that the hospital's governing board approve the medical staff bylaws, ensuring accountability to the organization's leadership.
Question 2: A physician's privileges are being summarily suspended. Which committee is typically convened first to review the action?
- The credentials committee
- The medical executive committee (Correct answer)
- The quality improvement committee
- The patient safety committee
Correct answer: The medical executive committee
Summary suspensions are typically reviewed by the medical executive committee, which has authority to act on urgent patient safety matters.
Question 3: What does 'focused professional practice evaluation' (FPPE) require from a committee support standpoint?
- Annual reviews of all medical staff members
- A structured time-limited monitoring period with defined criteria and a conclusion report (Correct answer)
- Monthly reporting to the board of directors
- Peer review by physicians from outside the hospital
Correct answer: A structured time-limited monitoring period with defined criteria and a conclusion report
FPPE is a time-limited focused review with defined evaluation criteria that must be documented and concluded with a formal committee determination.
Question 4: Which of the following is a key difference between a hearing committee and an appeals committee in the fair hearing process?
- Only the hearing committee can include non-physicians
- The hearing committee reviews the initial adverse action, while the appeals committee reviews the hearing outcome (Correct answer)
- The appeals committee has more authority to grant privileges than the hearing committee
- There is no functional difference; they serve the same role
Correct answer: The hearing committee reviews the initial adverse action, while the appeals committee reviews the hearing outcome
The hearing committee conducts the initial review of an adverse recommendation, while the appeals committee reviews whether the hearing was conducted properly and the decision was supported by evidence.
Question 5: What is the credentialing specialist's responsibility regarding committee confidentiality under Health Care Quality Improvement Act (HCQIA) protections?
- To ensure all committee deliberations are publicly disclosed within 30 days
- To maintain confidentiality of peer review proceedings to preserve statutory protections (Correct answer)
- To share committee findings with the applicant's previous employers
- To report all peer review findings to the state medical board
Correct answer: To maintain confidentiality of peer review proceedings to preserve statutory protections
HCQIA protections depend on maintaining confidentiality of peer review deliberations, and the credentialing specialist must safeguard these records accordingly.
Question 6: When preparing for a credentials committee meeting, what should a credentialing specialist verify about the meeting notice?
- That the notice was sent only to voting members
- That adequate advance notice was given per bylaws and the agenda was distributed (Correct answer)
- That the hospital CEO approved the agenda
- That all agenda items were pre-approved by legal counsel
Correct answer: That adequate advance notice was given per bylaws and the agenda was distributed
Bylaws specify required notice periods and agenda distribution requirements, and the specialist must ensure these procedural standards are met.
Question 7: A medical staff committee wishes to table a motion. What does this procedural action accomplish?
- It permanently removes the motion from consideration
- It postpones consideration of the motion to a later time (Correct answer)
- It refers the motion to a subcommittee for review
- It requires a two-thirds vote to defeat the motion
Correct answer: It postpones consideration of the motion to a later time
Tabling a motion temporarily postpones its consideration, allowing the committee to address it at a subsequent meeting.
CPCS Medical Staff Committee Support and Management 3
Under CMS Conditions of Participation, which body must ultimately approve medical staff bylaws?