CPCS Medical Staff Governance 5 — Questions and Answers
Question 1: A practitioner files a lawsuit claiming a hospital's peer review process violated the Health Care Quality Improvement Act (HCQIA). Under HCQIA, immunity from damages is available to peer reviewers if they meet which standard?
- The review was conducted by at least three physicians
- The review met the four HCQIA standards: reasonable belief, adequate notice, adequate hearing, and reasonable belief the action was warranted (Correct answer)
- The hospital had Joint Commission accreditation at the time of the review
- The practitioner was given 90 days' notice before the adverse action
Correct answer: The review met the four HCQIA standards: reasonable belief, adequate notice, adequate hearing, and reasonable belief the action was warranted
HCQIA grants immunity when peer reviewers acted in the reasonable belief the action furthered quality care, provided adequate notice and hearing, and reasonably believed the action was warranted.
Question 2: An allied health professional (AHP) such as a nurse practitioner applies for clinical privileges at a hospital. Who is typically responsible for overseeing the AHP's practice?
- The state licensing board exclusively
- A supervising or collaborating physician as defined by the medical staff bylaws (Correct answer)
- The nursing administration department without physician involvement
- The CEO of the hospital
Correct answer: A supervising or collaborating physician as defined by the medical staff bylaws
Medical staff bylaws typically require AHPs to practice under the supervision or collaboration of a physician member of the medical staff, as specified in the bylaws or policies.
Question 3: Which of the following situations would MOST likely require an immediate suspension of privileges without the standard fair hearing process?
- A practitioner who fails to complete medical records on time
- A practitioner whose actions create an immediate threat to patient safety (Correct answer)
- A practitioner who misses two consecutive department meetings
- A practitioner whose malpractice insurance renewal is 10 days late
Correct answer: A practitioner whose actions create an immediate threat to patient safety
Immediate suspension without prior hearing is justified only when a practitioner's continued practice poses an immediate threat to patient health or safety; due process follows the suspension.
Question 4: The term 'primary source verification' means that credentials are confirmed directly with which entity?
- The practitioner who submitted the application
- The original issuing institution, board, or agency (Correct answer)
- The National Practitioner Data Bank
- A third-party credentialing verification organization (CVO)
Correct answer: The original issuing institution, board, or agency
Primary source verification requires obtaining confirmation of credentials directly from the original source (e.g., medical school, licensing board, certifying board) rather than from the practitioner.
Question 5: Which of the following is an acceptable primary source for verifying a physician's medical school graduation?
- A copy of the diploma provided by the physician
- Direct confirmation from the medical school's registrar (Correct answer)
- Confirmation from the state medical board that a license was issued
- A letter from a department chief attesting to the physician's education
Correct answer: Direct confirmation from the medical school's registrar
Only direct confirmation from the medical school's registrar qualifies as primary source verification of graduation; diplomas and third-party attestations are not acceptable.
Question 6: When a hospital grants emergency privileges due to a declared disaster, which requirement is typically waived?
- State licensure verification
- The standard credentialing and privileging process timelines (Correct answer)
- NPDB query requirements for the preceding two years
- The requirement for malpractice insurance coverage
Correct answer: The standard credentialing and privileging process timelines
During a declared disaster, CMS and accreditation standards permit waiving standard credentialing process timelines so practitioners can be rapidly deployed, though licensure and basic identity verification still apply.
Question 7: A credentials committee member has a financial relationship with a practitioner under review. According to best practices in medical staff governance, what should occur?
- The member may participate if they disclose the relationship at the start of the meeting
- The member must recuse themselves from the review and vote on that practitioner (Correct answer)
- The member may vote but must abstain from discussion
- No action is required if the relationship is not a direct employment arrangement
Correct answer: The member must recuse themselves from the review and vote on that practitioner
Conflict of interest policies require committee members with financial or personal relationships with an applicant to recuse themselves from all discussion and voting to protect the integrity of the process.
CPCS Medical Staff Governance 5
A practitioner files a lawsuit claiming a hospital's peer review process violated the Health Care Quality Improvement Act (HCQIA).
Under HCQIA, immunity from damages is available to peer reviewers if they meet which standard?