CHCS CHCS Healthcare Organization & Governance 2

Question 1

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

Accepted Answer

The Joint Commission (TJC)

Answer

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?

Accepted Answer

2 years

Answer

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?

Accepted Answer

Clinical specialty or type of service provided

Answer

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?

Accepted Answer

Fair hearing plan

Answer

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?

Accepted Answer

Health Care Quality Improvement Act (HCQIA)

Answer

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

CHCS - Certified Healthcare Credentialing Specialist Practice Test

CHCS - Certified Healthcare Credentialing Specialist Practice Test

CHCS CHCS Healthcare Organization & Governance 2