CHCS CHCS Healthcare Organization & Governance

Question 1

What document governs the medical staff's self-governance structure, including credentialing requirements, within a hospital?

Accepted Answer

Medical staff bylaws

Answer

The Joint Commission manual

Answer

State licensing statute

Answer

CMS Conditions of Participation

Question 2

Which body is typically responsible for making the final credentialing and privileging decisions for a hospital's medical staff?

Accepted Answer

Governing board

Answer

Department chief

Answer

Credentials committee

Answer

Chief Medical Officer

Question 3

What is the primary role of the credentials committee in the medical staff governance structure?

Accepted Answer

Review and recommend credentialing and privileging actions to the medical executive committee

Answer

Investigate malpractice claims

Answer

Set hospital financial policy

Answer

Manage HR disciplinary actions

Question 4

Which of the following best describes 'focused professional practice evaluation' (FPPE)?

Accepted Answer

A time-limited review triggered by a new privilege or concern about a provider's performance

Answer

Annual peer review of all providers

Answer

A credentialing renewal process

Answer

An internal audit of billing practices

Question 5

Ongoing Professional Practice Evaluation (OPPE) must be conducted at minimum how often according to The Joint Commission standards?

Accepted Answer

Every 12 months

Answer

Monthly

Answer

Quarterly

Answer

Every 24 months

Question 6

What is the purpose of the medical executive committee (MEC) in hospital governance?

Accepted Answer

Serve as the liaison between the medical staff and the governing board on credentialing and clinical matters

Answer

Manage hospital budgets

Answer

Conduct malpractice litigation

Answer

Oversee nursing staff credentials