CPCS - Certified Provider Credentialing Specialist Medical Staff Governance 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?

Accepted Answer

The Governing Body, which has the ultimate authority for all appointments and reappointments.

Answer

The Chief of Staff, who can break the tie.

Answer

The Medical Executive Committee, as it is responsible for the self-governance of the medical staff.

Answer

The matter must be sent to an external, independent arbitrator for a binding decision.

Question 2

Which of the following represents the correct hierarchy of authority for medical staff governance documents, from most to least authoritative?

Accepted Answer

Medical Staff Bylaws, Rules & Regulations, Departmental Policies

Answer

Rules & Regulations, Medical Staff Bylaws, Departmental Policies

Answer

Departmental Policies, Rules & Regulations, Medical Staff Bylaws

Answer

Rules & Regulations, Departmental Policies, Medical Staff Bylaws

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?

Accepted Answer

Medical Executive Committee

Answer

Credentials Committee

Answer

Peer Review Committee

Answer

Bylaws Committee

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?

Accepted Answer

The right to be represented by legal counsel.

Answer

The right to have the hearing open to the public.

Answer

The right to a trial by a jury of their peers.

Answer

The right to have the hospital pay for all legal fees.

Question 5

What is the primary purpose of a Fair Hearing and Appeal Plan as outlined within the medical staff bylaws?

Accepted Answer

To provide a mechanism of due process for practitioners facing an adverse recommendation affecting their membership or privileges.

Answer

To provide a forum for resolving disputes between medical staff members and hospital administration over hospital policies.

Answer

To offer an educational review of cases for quality improvement purposes without any punitive action.

Answer

To establish the formal process for reviewing applications for initial medical staff appointment.

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?

Accepted Answer

Approval by a majority vote of the active medical staff, followed by approval by the hospital's Governing Body.

Answer

Approval by the Medical Executive Committee, followed by approval by the Chief of Staff.

Answer

Approval by the hospital's legal counsel, followed by approval by the Medical Executive Committee.

Answer

Approval by a majority of department chairs, followed by approval by the hospital CEO.