CPCS Medical Staff Bylaws, Rules, and Policies Development 3 — Questions and Answers
Question 1: Which body is typically responsible for recommending amendments to medical staff bylaws before they go to the governing board?
- The department of medicine
- The credentialing committee
- The medical executive committee (Correct answer)
- The quality improvement committee
Correct answer: The medical executive committee
The medical executive committee typically reviews and recommends bylaw amendments before they are forwarded to the governing board for final approval.
Question 2: A medical staff policy grants temporary privileges to a locum tenens physician for up to 120 days. Which accreditation standard most directly governs this limit?
- The Joint Commission standards on medical staff (Correct answer)
- CMS anti-kickback statute requirements
- HIPAA privacy rule provisions
- State medical board licensing rules
Correct answer: The Joint Commission standards on medical staff
The Joint Commission medical staff standards govern the granting of temporary privileges, including duration limits for locum tenens practitioners.
Question 3: What is a 'fair hearing' in the context of medical staff bylaws?
- A routine credentialing interview for new applicants
- A formal process giving practitioners the right to contest adverse actions (Correct answer)
- An annual performance review conducted by department chairs
- A public meeting where community members review medical staff decisions
Correct answer: A formal process giving practitioners the right to contest adverse actions
A fair hearing is a formal due process mechanism allowing practitioners to contest adverse credentialing or privileging decisions.
Question 4: Hospital bylaws require a two-thirds majority of the medical staff to ratify amendments. This is an example of which type of bylaw provision?
- Quorum requirement
- Amendment procedure (Correct answer)
- Conflict of interest disclosure
- Membership eligibility criteria
Correct answer: Amendment procedure
Amendment procedures specify the voting threshold and process required to change the bylaws.
Question 5: Which element distinguishes a 'policy' from 'rules and regulations' in the medical staff governance hierarchy?
- Policies require governing board approval; rules and regulations do not
- Policies address specific operational procedures; rules and regulations address broader clinical standards (Correct answer)
- Rules and regulations are department-specific; policies apply hospital-wide
- Policies are voluntary guidelines; rules and regulations are mandatory
Correct answer: Policies address specific operational procedures; rules and regulations address broader clinical standards
Policies typically address specific operational procedures, while rules and regulations set broader clinical practice standards applicable to all medical staff.
Question 6: A credentialing specialist notes that the bylaws do not address the process for granting disaster privileges. What should be the next step?
- Create a separate disaster privilege form and use it without bylaw authority
- Recommend a bylaw or policy amendment to address disaster privileges (Correct answer)
- Defer to the state emergency management plan exclusively
- Deny disaster privileges until the bylaws are amended
Correct answer: Recommend a bylaw or policy amendment to address disaster privileges
Gaps in bylaws coverage should prompt a recommendation to amend bylaws or create a supporting policy to address the missing process.
Question 7: Under HCQIA, reporting to the National Practitioner Data Bank is required when a peer review action results in which outcome?
- A verbal warning documented in the practitioner's file
- A mandatory leave of absence of less than 30 days
- A professional review action adversely affecting clinical privileges for more than 30 days (Correct answer)
- A request for additional training without privilege restriction
Correct answer: A professional review action adversely affecting clinical privileges for more than 30 days
HCQIA requires NPDB reporting when a professional review action adversely affects clinical privileges for more than 30 days.
CPCS Medical Staff Bylaws, Rules, and Policies Development 3
Which body is typically responsible for recommending amendments to medical staff bylaws before they go to the governing board?