CPCS Medical Staff Committee Support and Management 3

Question 1

Under CMS Conditions of Participation, which body must ultimately approve medical staff bylaws?

Accepted Answer

The governing board

Answer

The medical staff executive committee

Answer

The credentials committee

Answer

The state health department

Question 2

A physician's privileges are being summarily suspended. Which committee is typically convened first to review the action?

Accepted Answer

The medical executive committee

Answer

The credentials committee

Answer

The quality improvement committee

Answer

The patient safety committee

Question 3

What does 'focused professional practice evaluation' (FPPE) require from a committee support standpoint?

Accepted Answer

A structured time-limited monitoring period with defined criteria and a conclusion report

Answer

Annual reviews of all medical staff members

Answer

Monthly reporting to the board of directors

Answer

Peer review by physicians from outside the hospital

Question 4

Which of the following is a key difference between a hearing committee and an appeals committee in the fair hearing process?

Accepted Answer

The hearing committee reviews the initial adverse action, while the appeals committee reviews the hearing outcome

Answer

Only the hearing committee can include non-physicians

Answer

The appeals committee has more authority to grant privileges than the hearing committee

Answer

There is no functional difference; they serve the same role

Question 5

What is the credentialing specialist's responsibility regarding committee confidentiality under Health Care Quality Improvement Act (HCQIA) protections?

Accepted Answer

To maintain confidentiality of peer review proceedings to preserve statutory protections

Answer

To ensure all committee deliberations are publicly disclosed within 30 days

Answer

To share committee findings with the applicant's previous employers

Answer

To report all peer review findings to the state medical board

Question 6

When preparing for a credentials committee meeting, what should a credentialing specialist verify about the meeting notice?

Accepted Answer

That adequate advance notice was given per bylaws and the agenda was distributed

Answer

That the notice was sent only to voting members

Answer

That the hospital CEO approved the agenda

Answer

That all agenda items were pre-approved by legal counsel

Question 7

A medical staff committee wishes to table a motion. What does this procedural action accomplish?

Accepted Answer

It postpones consideration of the motion to a later time

Answer

It permanently removes the motion from consideration

Answer

It refers the motion to a subcommittee for review

Answer

It requires a two-thirds vote to defeat the motion