Medical Staff Governance Flashcards
7 cards from real CPCS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Medical Staff Governance flashcards as text
A practitioner files a lawsuit claiming a hospital's peer review process violated the Health Care Quality Improvement Act (HCQIA). Under HCQIA, immunity from damages is available to peer reviewers if they meet which standard?
Answer: The review met the four HCQIA standards: reasonable belief, adequate notice, adequate hearing, and reasonable belief the action was warranted
HCQIA grants immunity when peer reviewers acted in the reasonable belief the action furthered quality care, provided adequate notice and hearing, and reasonably believed the action was warranted.
An allied health professional (AHP) such as a nurse practitioner applies for clinical privileges at a hospital. Who is typically responsible for overseeing the AHP's practice?
Answer: A supervising or collaborating physician as defined by the medical staff bylaws
Medical staff bylaws typically require AHPs to practice under the supervision or collaboration of a physician member of the medical staff, as specified in the bylaws or policies.
Which of the following situations would MOST likely require an immediate suspension of privileges without the standard fair hearing process?
Answer: A practitioner whose actions create an immediate threat to patient safety
Immediate suspension without prior hearing is justified only when a practitioner's continued practice poses an immediate threat to patient health or safety; due process follows the suspension.
The term 'primary source verification' means that credentials are confirmed directly with which entity?
Answer: The original issuing institution, board, or agency
Primary source verification requires obtaining confirmation of credentials directly from the original source (e.g., medical school, licensing board, certifying board) rather than from the practitioner.
Which of the following is an acceptable primary source for verifying a physician's medical school graduation?
Answer: Direct confirmation from the medical school's registrar
Only direct confirmation from the medical school's registrar qualifies as primary source verification of graduation; diplomas and third-party attestations are not acceptable.
When a hospital grants emergency privileges due to a declared disaster, which requirement is typically waived?
Answer: The standard credentialing and privileging process timelines
During a declared disaster, CMS and accreditation standards permit waiving standard credentialing process timelines so practitioners can be rapidly deployed, though licensure and basic identity verification still apply.
A credentials committee member has a financial relationship with a practitioner under review. According to best practices in medical staff governance, what should occur?
Answer: The member must recuse themselves from the review and vote on that practitioner
Conflict of interest policies require committee members with financial or personal relationships with an applicant to recuse themselves from all discussion and voting to protect the integrity of the process.