CHCS CHCS Healthcare Organization & Governance 2 — Questions and Answers
Question 1: Which accrediting body's standards most directly govern hospital credentialing and privileging processes in the United States?
- URAC
- NCQA
- The Joint Commission (TJC) (Correct answer)
- AAAHC
Correct answer: The Joint Commission (TJC)
The Joint Commission's Medical Staff chapter sets the foundational credentialing and privileging standards for accredited hospitals.
Question 2: Under TJC standards, what is the maximum appointment/reappointment period for medical staff membership?
- 1 year
- 2 years (Correct answer)
- 3 years
- 5 years
Correct answer: 2 years
TJC limits medical staff appointments and reappointments to no more than two years.
Question 3: A 'service line' or 'department' in a hospital medical staff structure is primarily organized around which concept?
- Physician seniority
- Clinical specialty or type of service provided (Correct answer)
- Alphabetical physician names
- Insurance payer type
Correct 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.
Question 4: What is the term for a formal written policy that outlines the procedures a hospital follows when making adverse credentialing decisions?
- Fair hearing plan (Correct answer)
- Credentialing manual
- Medical staff rules and regulations
- Peer review policy
Correct 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.
Question 5: Which federal law provides practitioners limited appeal rights and governs reporting of adverse credentialing actions to the NPDB?
- HIPAA
- Health Care Quality Improvement Act (HCQIA) (Correct answer)
- Emergency Medical Treatment and Labor Act (EMTALA)
- Stark Law
Correct answer: Health Care Quality Improvement Act (HCQIA)
HCQIA established the NPDB reporting requirement and provides immunity to peer reviewers acting in good faith.
Question 6: When a hospital grants 'temporary privileges' to a physician, which situation most commonly justifies this action?
- The physician's reappointment application is under routine review
- There is an urgent patient care need or a locum tenens situation pending full credentialing (Correct answer)
- The physician requests expedited processing
- The credentials committee is behind schedule
Correct 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.
CHCS CHCS Healthcare Organization & Governance 2
Which accrediting body's standards most directly govern hospital credentialing and privileging processes in the United States?