CHCS Healthcare Organization & Governance Flashcards

Which accrediting body's standards most directly govern hospital credentialing and privileging processes in the United States?

Answer: The Joint Commission (TJC)

The Joint Commission's Medical Staff chapter sets the foundational credentialing and privileging standards for accredited hospitals.

Under TJC standards, what is the maximum appointment/reappointment period for medical staff membership?

Answer: 2 years

TJC limits medical staff appointments and reappointments to no more than two years.

A 'service line' or 'department' in a hospital medical staff structure is primarily organized around which concept?

Answer: Clinical specialty or type of service provided

Hospital medical staff departments are organized by clinical specialty (e.g., surgery, internal medicine) to facilitate peer review and competency oversight.

What is the term for a formal written policy that outlines the procedures a hospital follows when making adverse credentialing decisions?

Answer: Fair hearing plan

A fair hearing plan details the due process rights and procedures afforded to practitioners when an adverse credentialing action is being considered.

Which federal law provides practitioners limited appeal rights and governs reporting of adverse credentialing actions to the NPDB?

Answer: Health Care Quality Improvement Act (HCQIA)

HCQIA established the NPDB reporting requirement and provides immunity to peer reviewers acting in good faith.

When a hospital grants 'temporary privileges' to a physician, which situation most commonly justifies this action?

Answer: There is an urgent patient care need or a locum tenens situation pending full credentialing

Temporary privileges are granted for an urgent patient care need or to accommodate a locum tenens practitioner while full credentialing is completed.