Cpmsm Practice Test Part II Of II

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Cpmsm Practice Test Quizzes & Trivia

Questions and Answers
  • 1. 

    According to HFAP standards, when confirming malpractice coverage the organization must:

    • A.

      Query the NPDB

    • B.

      Obtain the claim history with each carrier over the last five years

    • C.

      Have evidence of professional liability insurance, which includes certificate showing amounts of coverage

    • D.

      Require the applicant to attest that he/she has never been sued

    Correct Answer
    C. Have evidence of professional liability insurance, which includes certificate showing amounts of coverage
    Explanation
    According to HFAP standards, organizations must have evidence of professional liability insurance, which includes a certificate showing the amounts of coverage. This means that the organization must obtain proof that the applicant has sufficient liability insurance to cover any potential malpractice claims. This requirement ensures that the organization is protected in case of any legal actions or claims against the applicant. It also demonstrates that the applicant is responsible and has taken the necessary steps to mitigate any potential risks.

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  • 2. 

    Which of the following providers is considered a primary care physician (PCP)?

    • A.

      General Surgeon

    • B.

      Gastroenterologist

    • C.

      Family medicine practitioner

    • D.

      Orthopedic surgeon

    Correct Answer
    C. Family medicine practitioner
    Explanation
    A primary care physician (PCP) is a healthcare professional who provides general medical care and serves as the first point of contact for patients. They are trained to diagnose and treat a wide range of common illnesses and conditions. A family medicine practitioner is a type of PCP who specializes in providing comprehensive healthcare for individuals of all ages, from newborns to the elderly. They are responsible for managing and coordinating the overall healthcare needs of their patients, including preventive care, chronic disease management, and referrals to specialists when necessary.

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  • 3. 

    Which body has the obligation to the community to assure that only appropriately educated, trained and currently competent practitioners are granted medical staff membership and clinical privileges?

    • A.

      Medical Staff

    • B.

      Governing Body

    • C.

      The Joint Commission on Accreditation of Healthcare Organizations

    • D.

      State Licensing Board

    Correct Answer
    B. Governing Body
    Explanation
    The governing body has the obligation to the community to assure that only appropriately educated, trained and currently competent practitioners are granted medical staff membership and clinical privileges. They are responsible for overseeing the qualifications and credentials of medical staff members, ensuring that they meet the necessary standards to provide safe and effective care to patients. The governing body plays a crucial role in upholding the quality and integrity of the healthcare system by ensuring that only qualified professionals are granted privileges.

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  • 4. 

    When credentialing and privileging practitioners it is appropriate to:

    • A.

      Handle each applicant on a case-by-case basis

    • B.

      Follow a routine process for each applicant

    • C.

      Give preferential treatment to those providers whose specialty is primary care

    • D.

      Process all applications within one week of receipt

    Correct Answer
    B. Follow a routine process for each applicant
    Explanation
    When credentialing and privileging practitioners, it is appropriate to follow a routine process for each applicant. This ensures that all applicants are treated fairly and consistently, regardless of their specialty or background. Following a routine process helps maintain the integrity and standardization of the credentialing and privileging process. It also ensures that all necessary information and requirements are properly assessed for each applicant, reducing the risk of overlooking important factors. By following a routine process, healthcare organizations can ensure that they make informed decisions based on objective criteria and avoid any potential bias or preferential treatment.

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  • 5. 

    Medical liability insurance should be held in what limits?

    • A.

      $200,000 per occurrence and $500,000 annual aggregate

    • B.

      $500,000 per occurrence and $1,000,000 annual aggregate

    • C.

      $1,000,000 per occurrence and $3,000,000 annual aggregate

    • D.

      As specified by the medical staff and board directors

    Correct Answer
    D. As specified by the medical staff and board directors
  • 6. 

    Which of the following would be an appropriate question to ask an applicant for medical staff?

    • A.

      How many children do you have?

    • B.

      Are you married?

    • C.

      Do you have any medical conditions, treated or untreated, that would negatively affect your ability to provide the services or perform the privileges you are requesting?

    • D.

      Have you ever been diagnosed with AIDS or a sexually transmitted disease?

    Correct Answer
    C. Do you have any medical conditions, treated or untreated, that would negatively affect your ability to provide the services or perform the privileges you are requesting?
    Explanation
    The correct answer is "Do you have any medical conditions, treated or untreated, that would negatively affect your ability to provide the services or perform the privileges you are requesting?" This question is appropriate for an applicant for medical staff because it directly addresses their medical conditions and how it may impact their ability to perform their job responsibilities. It is important for medical staff to be able to provide services and perform their duties effectively, and this question helps to assess their ability to do so.

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  • 7. 

    The governing body delegates the responsibility of credentialing, recredentialing, and privileging to

    • A.

      The hospital administrator

    • B.

      The medical staff office

    • C.

      The medical staff

    • D.

      The credentials committee

    Correct Answer
    C. The medical staff
    Explanation
    The medical staff is responsible for credentialing, recredentialing, and privileging. They are the group of healthcare professionals who have been granted privileges to practice in a specific healthcare facility. They have the expertise and knowledge to assess the qualifications and competence of other healthcare providers and make decisions regarding their privileges. The medical staff office may assist in the administrative tasks related to credentialing, but the ultimate responsibility lies with the medical staff themselves. The hospital administrator may have oversight and provide support, but they do not directly handle the credentialing process. The credentials committee, which is typically comprised of members of the medical staff, may review and make recommendations on credentialing matters, but the final decision-making authority rests with the medical staff.

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  • 8. 

    Who should have access to medical staff meeting minutes?

    • A.

      Medical Staff President

    • B.

      Governing Body members

    • C.

      Personnel as documented in a records access policy and procedure

    • D.

      Hospital President

    Correct Answer
    C. Personnel as documented in a records access policy and procedure
    Explanation
    The correct answer is personnel as documented in a records access policy and procedure. Access to medical staff meeting minutes should be limited to individuals who have been specified in a records access policy and procedure. This ensures that only authorized personnel, such as relevant staff members or individuals with a legitimate need to know, can access the minutes. The policy and procedure would outline the specific criteria and process for granting access to the meeting minutes, ensuring confidentiality and privacy of sensitive information.

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  • 9. 

    In addition to conclusions, recommendations made, and actions taken, which of the following should always be documented in meeting minutes:

    • A.

      Names and professional titles of all in attendance

    • B.

      Date and location of next scheduled meeting

    • C.

      Any required follow-up to occur

    • D.

      Complete transcription of all discussion that occurred

    Correct Answer
    C. Any required follow-up to occur
    Explanation
    In addition to conclusions, recommendations, and actions, documenting any required follow-up to occur in meeting minutes is important. This ensures that all tasks and responsibilities discussed during the meeting are properly recorded and assigned to the relevant individuals. By documenting follow-up actions, it becomes easier to track progress, hold people accountable, and ensure that all necessary tasks are completed in a timely manner.

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  • 10. 

    Active, Associate, Courtesy, Honorary, Consulting are all examples of:

    • A.

      Committees

    • B.

      Medical Staff officers

    • C.

      Membership categories

    • D.

      Privileges

    Correct Answer
    C. Membership categories
    Explanation
    The given words - Active, Associate, Courtesy, Honorary, Consulting - all refer to different types or categories of membership. Each word represents a specific status or level within a particular group or organization. Therefore, the correct answer is "Membership categories."

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  • 11. 

    Changes in medical staff bylaws are not final until formally approved by the:

    • A.

      Medical staff

    • B.

      Medical staff president

    • C.

      Governing body

    • D.

      Hospital CEO

    Correct Answer
    C. Governing body
    Explanation
    Changes in medical staff bylaws are not final until formally approved by the governing body. This means that the ultimate authority to approve or reject the changes lies with the governing body of the organization, which may include board members or other high-ranking officials. While the medical staff and medical staff president may have input or recommendations, the final decision rests with the governing body. Similarly, the hospital CEO may have influence, but the governing body has the final say in approving the changes to the medical staff bylaws.

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  • 12. 

    What is the only hospital medical staff committee required by The Joint Commission hospital standards?

    • A.

      Credentials committee

    • B.

      Medical executive committee

    • C.

      Pharmacy and therapeutics committee

    • D.

      Utilization review committee

    Correct Answer
    B. Medical executive committee
    Explanation
    The only hospital medical staff committee required by The Joint Commission hospital standards is the Medical Executive Committee. This committee is responsible for overseeing and managing the medical staff and ensuring that the hospital meets quality and safety standards. They play a crucial role in decision-making, policy development, and coordination of medical staff activities within the hospital.

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  • 13. 

    The Healthcare Quality Improvement Act:

    • A.

      Provides immunity for health care entities that do not report information to the National Practitioner Data Bank

    • B.

      Keeps hospitals and physicians who perform peer review from being sued

    • C.

      Provides qualifies immunity from antitrust liability arising out of peer review activities that are conducted in good faith

    • D.

      Creates an exemption to the Doctrine of Ostensible Agency

    Correct Answer
    C. Provides qualifies immunity from antitrust liability arising out of peer review activities that are conducted in good faith
    Explanation
    The Healthcare Quality Improvement Act provides qualified immunity from antitrust liability for peer review activities conducted in good faith. This means that hospitals and physicians who engage in peer review are protected from being sued for antitrust violations as long as their activities are done in good faith. This immunity encourages healthcare entities to engage in peer review, which is important for improving the quality of healthcare services.

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  • 14. 

    If you have a question regarding whether or not information regarding a practitioner should be released to a third party, which of the following would be the best person to ask?

    • A.

      Director of Medical Records

    • B.

      Chief of Staff

    • C.

      Approval from the organization's attorney

    • D.

      Organization's attorney

    Correct Answer
    D. Organization's attorney
    Explanation
    When it comes to releasing information regarding a practitioner to a third party, the best person to ask would be the organization's attorney. This is because the attorney is knowledgeable about the legal aspects and regulations surrounding the release of such information. They can provide guidance on whether or not it is appropriate to disclose the practitioner's information and ensure that the organization is in compliance with the law. The Director of Medical Records may have knowledge about the process, but the attorney is the most suitable person to consult in this situation.

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  • 15. 

    Prior to releasing information to a third party regarding a practitioner, the organization should acquire

    • A.

      A picture ID of the provider

    • B.

      A signed consent and release form

    • C.

      Approval from the organization's attorney

    • D.

      Informed consent

    Correct Answer
    B. A signed consent and release form
    Explanation
    Before releasing information about a practitioner to a third party, the organization should acquire a signed consent and release form. This form ensures that the practitioner has given their permission for their information to be shared with the third party. It is important for the organization to have this documented consent in order to protect the privacy and confidentiality of the practitioner's information and to comply with legal and ethical requirements. A picture ID of the provider, approval from the organization's attorney, and informed consent may also be important in certain situations, but the signed consent and release form is the most essential requirement in this case.

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  • 16. 

    You are working at an AAAHC accredited facility and you want to introduce the concept of utilizing a credentials verification organization.  If the CVO is not accredited by a nationally recognized organization you must:

    • A.

      Perform an initial on-site visit of the CVO to assess their capabilities and quality of work

    • B.

      Perform an assessment of the capability and quality of the CVO's work

    • C.

      Perform an assessment of their turn-around times

    • D.

      Perform an assessment of all CVO policies and procedures

    Correct Answer
    C. Perform an assessment of their turn-around times
  • 17. 

    What are three major sources of authority in the traditional structure of the hospital organization?

    • A.

      Chief executive officer, governing body, and medical staff

    • B.

      Chief executive officer, hospital vice-president, medical director

    • C.

      Medical staff president, vice-president, and secretary-treasurer

    • D.

      Chief executive officer, nursing director, medical staff president

    Correct Answer
    A. Chief executive officer, governing body, and medical staff
    Explanation
    The three major sources of authority in the traditional structure of the hospital organization are the chief executive officer, governing body, and medical staff. The chief executive officer is responsible for the overall management and decision-making in the hospital. The governing body, which is usually a board of directors or trustees, provides oversight and sets policies for the hospital. The medical staff, consisting of doctors and other healthcare professionals, plays a crucial role in providing medical care and expertise within the organization.

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  • 18. 

    How does the governing body of a hospital set the organization policy that supports quality patient care?

    • A.

      By assigning these responsibilities to the chief executive officer

    • B.

      By seeking medical staff input in the hiring if key personnel

    • C.

      By examining the finances of the hospital

    • D.

      By developing the mission, vision, policies, and bylaws that govern the hospital's operations

    Correct Answer
    D. By developing the mission, vision, policies, and bylaws that govern the hospital's operations
    Explanation
    The governing body of a hospital sets the organization policy that supports quality patient care by developing the mission, vision, policies, and bylaws that govern the hospital's operations. This means that they establish the overall goals and objectives of the hospital, define the policies and procedures that guide the delivery of patient care, and establish the rules and regulations that govern the hospital's operations. By doing so, they ensure that the hospital operates in a manner that supports and promotes quality patient care.

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  • 19. 

    Governing boards may be generally classed into which two types?

    • A.

      For-profit or not-for-profit

    • B.

      Philanthropic or corporate

    • C.

      General or specialty

    • D.

      Full-time or part time

    Correct Answer
    A. For-profit or not-for-profit
    Explanation
    Governing boards can be classified into two types based on the nature of the organizations they govern. For-profit boards are responsible for overseeing the operations and financial performance of companies that aim to generate profits for their shareholders. On the other hand, not-for-profit boards govern organizations that are focused on providing a service or benefit to the community without the goal of making profits. These organizations may include charities, foundations, or educational institutions.

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  • 20. 

    Which of the following is a major responsibility of the CEO?

    • A.

      Directly observing nursing care to assure that patients receive proper care and treatment

    • B.

      Keeping the medical staff informed about the hospital's plans, organizational changes, board policies, and decisions affecting providers and their patients

    • C.

      Overseeing the patient accounts department to assure accurate billing practices

    • D.

      Orientation of all new employees

    Correct Answer
    B. Keeping the medical staff informed about the hospital's plans, organizational changes, board policies, and decisions affecting providers and their patients
    Explanation
    The CEO's major responsibility is to keep the medical staff informed about the hospital's plans, organizational changes, board policies, and decisions affecting providers and their patients. This involves ensuring that the medical staff is aware of any updates or changes that may impact their work and the care they provide to patients. By keeping the medical staff informed, the CEO promotes transparency, effective communication, and collaboration within the organization, which ultimately contributes to the overall success and quality of patient care.

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  • 21. 

    To whom is the medical staff organization accountable for the quality of the professional services provided by individuals with clinical privileges?

    • A.

      The Joint Commission

    • B.

      Hospital chief executive officer

    • C.

      Governing body

    • D.

      American Medical Society

    Correct Answer
    C. Governing body
    Explanation
    The governing body is responsible for holding the medical staff organization accountable for the quality of professional services provided by individuals with clinical privileges. The governing body is typically composed of individuals who oversee the operations and policies of the organization, ensuring that it meets regulatory requirements and maintains high standards of care. They have the authority to implement and enforce quality improvement measures and make decisions regarding the medical staff organization's performance.

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  • 22. 

    Which term describes a physician employed or contracted by the hospital as a top-level management employee to act as a liaison between the medical staff and hospital administration?

    • A.

      Medical director

    • B.

      Chief financial officer

    • C.

      Medical staff president

    • D.

      Patient care coordinator

    Correct Answer
    A. Medical director
    Explanation
    A medical director is a physician who is employed or contracted by the hospital to serve as a liaison between the medical staff and hospital administration. They are responsible for overseeing the medical operations of the hospital, ensuring quality patient care, and collaborating with the administrative team to make strategic decisions. The medical director plays a crucial role in bridging the gap between the clinical and administrative aspects of the hospital, making them an essential top-level management employee.

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  • 23. 

    Which of the following are included in the function of the medical staff?

    • A.

      Contracting for Medicare assignment

    • B.

      Training of nursing staff

    • C.

      Providing and evaluating patient care

    • D.

      Participating in the design of operating rooms

    Correct Answer
    C. Providing and evaluating patient care
    Explanation
    The function of the medical staff includes providing and evaluating patient care. This means that they are responsible for ensuring that patients receive appropriate medical treatment and monitoring their progress. This can involve conducting examinations, ordering tests, prescribing medications, and making treatment recommendations. Evaluating patient care involves assessing the effectiveness of the treatment provided and making any necessary adjustments. This is a crucial role in ensuring the well-being and recovery of patients.

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  • 24. 

    Which of the following describes a committee that is assembled or appointed to perform a specific task or duty, works independently and reports back to larger committee and typically disbands after the assigned task or duty is performed or completed?

    • A.

      Standing committee

    • B.

      Ad hoc committee

    • C.

      Task force

    • D.

      Continuous quality improvement team

    Correct Answer
    B. Ad hoc committee
    Explanation
    An ad hoc committee is formed for a specific purpose or task, and it operates independently. It is appointed or assembled to address a particular issue or complete a specific duty. After the task or duty is fulfilled, the committee disbands. This type of committee is temporary and not meant to be a permanent part of the larger committee or organization.

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  • 25. 

    When developing bylaws language for a committee, consideration should be given to which of the following?

    • A.

      The mission statement of the hospital

    • B.

      Medical staff restructuring

    • C.

      Room set up and audiovisual requirements

    • D.

      Composition, duties, and frequency of meetings

    Correct Answer
    D. Composition, duties, and frequency of meetings
    Explanation
    When developing bylaws language for a committee, consideration should be given to the composition, duties, and frequency of meetings. This is because the bylaws outline the structure and operations of the committee, including who will be part of it, what their responsibilities are, and how often they will meet. By addressing these aspects in the bylaws, it ensures that the committee is properly organized and functions effectively. Considering the mission statement of the hospital, medical staff restructuring, and room set up and audiovisual requirements may also be important, but they are not directly related to the composition, duties, and frequency of meetings.

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  • 26. 

    The credentials committee needs guidance regarding which physicians will be allowed to perform a new procedure in the hospital.  It is recommended that a committee be appointed to evaluate this issue and report back to the credential's committee.  What kind of committee would be appointed?

    • A.

      Standing committee

    • B.

      Ad hoc committee

    • C.

      Utilization committee

    • D.

      Continuous quality improvement team

    Correct Answer
    B. Ad hoc committee
    Explanation
    An ad hoc committee would be appointed in this scenario. An ad hoc committee is a temporary committee formed for a specific purpose or issue. In this case, the committee would be formed to evaluate and provide guidance on which physicians should be allowed to perform the new procedure in the hospital. Once their task is completed, the committee would be dissolved.

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  • 27. 

    Which term describes a physician who provides the general medical care of hospitalized patients only and turns over the care of the patient to the primary care physician after discharge?

    • A.

      Hospitalist

    • B.

      Internist 

    • C.

      Primary care provider

    • D.

      Specialist

    Correct Answer
    A. Hospitalist
    Explanation
    A physician who provides general medical care to hospitalized patients and transfers the patient's care to the primary care physician after discharge is referred to as a hospitalist. Hospitalists specialize in caring for patients during their hospital stay, focusing on acute medical conditions and coordinating with other specialists as needed. They do not typically provide long-term primary care but instead work in collaboration with the patient's primary care provider.

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  • 28. 

    Which term describes a category of medical staff appointment that provides a basic framework within which physicians and other health care providers carry out their duties and responsibilities?

    • A.

      Staff duties

    • B.

      Privileges

    • C.

      Committee appointment

    • D.

      Department

    Correct Answer
    B. Privileges
    Explanation
    Privileges refers to a category of medical staff appointment that outlines the rights and responsibilities of physicians and other healthcare providers. It provides them with the authority to perform specific medical procedures or treatments within a healthcare facility. Privileges ensure that healthcare professionals are qualified and competent to carry out their duties and responsibilities, while also maintaining patient safety and quality of care.

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  • 29. 

    Which term describes interns and residents in medical education programs of a teaching hospital? 

    • A.

      Affiliate staff

    • B.

      Allied health professionals

    • C.

      House staff

    • D.

      Students

    Correct Answer
    C. House staff
    Explanation
    House staff refers to interns and residents in medical education programs of a teaching hospital. They are medical professionals who are undergoing training and gaining practical experience in a hospital setting. The term "house staff" is commonly used to describe these individuals, as they typically reside within the hospital while completing their training.

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  • 30. 

    Which term describes a special classification used to reflect honor and respect for selected distinguished members of the community?

    • A.

      Consulting staff

    • B.

      Active staff

    • C.

      House staff

    • D.

      Honorary or emeritus staff

    Correct Answer
    D. Honorary or emeritus staff
    Explanation
    Honorary or emeritus staff is the term used to describe a special classification that reflects honor and respect for selected distinguished members of the community. This term is typically used to recognize individuals who have made significant contributions to the community or organization and are granted a special status as a result. The honorary or emeritus staff designation is a way to acknowledge and show appreciation for their achievements and service.

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  • 31. 

    Which term describes privileges granted for a specific period of time to a practitioner while hospital board approval is pending?

    • A.

      Temporary privileges

    • B.

      Provisional staff

    • C.

      Interim appointment

    • D.

      Medial staff appointment

    Correct Answer
    A. Temporary privileges
    Explanation
    Temporary privileges are granted to a practitioner while their hospital board approval is pending. These privileges allow the practitioner to practice within the hospital for a specific period of time until their full staff appointment is finalized. This temporary arrangement ensures that the practitioner can provide necessary medical services while their application is being reviewed.

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  • 32. 

    Which document describes the organizational structure of the medical staff and defines the framework within which medical staff appointees act and interact in hospital related activities?

    • A.

      Fair hearing plan

    • B.

      Medicare Conditions of Participation

    • C.

      Joint Commission Comprehensive Accreditation Manual

    • D.

      Medical Staff Bylaws

    Correct Answer
    D. Medical Staff Bylaws
    Explanation
    The correct answer is Medical Staff Bylaws. Medical Staff Bylaws are a document that outlines the organizational structure of the medical staff and provides guidelines for how members of the medical staff should act and interact in hospital-related activities. It defines the roles and responsibilities of medical staff appointees and helps ensure that the medical staff operates in accordance with established policies and procedures. The Fair hearing plan, Medicare Conditions of Participation, and Joint Commission Comprehensive Accreditation Manual may be relevant documents in a healthcare setting, but they do not specifically describe the organizational structure of the medical staff.

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  • 33. 

    Bylaws changes are not effective until final approval by which body?

    • A.

      Medical staff executive committee

    • B.

      Bylaws committee

    • C.

      Governing body

    • D.

      Medical Staff

    Correct Answer
    C. Governing body
    Explanation
    The governing body is responsible for giving final approval to any changes in the bylaws. This means that the changes made by the bylaws committee or the medical staff executive committee are not considered effective until they are approved by the governing body. The governing body holds the ultimate authority and decision-making power in this matter.

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  • 34. 

    Which term describes  the mechanism by which an aggrieved practitioner, one who has been the recipient of disciplinary action, is entitled to be heard and to appeal an adverse decision?

    • A.

      Medical staff executive committee

    • B.

      Procedure rights of fair hearing

    • C.

      Corrective action

    • D.

      Rules and regulations

    Correct Answer
    B. Procedure rights of fair hearing
    Explanation
    Procedure rights of fair hearing refers to the mechanism by which an aggrieved practitioner, who has been subjected to disciplinary action, is granted the right to present their case and appeal against an unfavorable decision. This ensures that the practitioner is given a fair opportunity to be heard and provides a platform for addressing any grievances or concerns regarding the disciplinary action taken against them. It is an essential aspect of due process and upholding justice in disciplinary proceedings.

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  • 35. 

    What the landmark case set aside the Charitable Immunity Doctrine and established the corporate negligence doctrine, also known as negligent credentialing?

    • A.

      Patrick vs. Burgett

    • B.

      Miller vs. Eisenhower General Hospital

    • C.

      Darling vs. Charleston Memorial Community Hospital

    • D.

      Harrell vs. Total Healthcare, Inc.

    Correct Answer
    C. Darling vs. Charleston Memorial Community Hospital
    Explanation
    Darling vs. Charleston Memorial Community Hospital is the correct answer because this landmark case set aside the Charitable Immunity Doctrine and established the corporate negligence doctrine, also known as negligent credentialing.

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  • 36. 

    What is the name of the act, known as the Federal " anti-dumping" law, which was enacted to stop hospitals transferring, discharging, or refusing to treat indigent patients coming to the emergency department because of cost factors?

    • A.

      Emergency Medical Treatment and Active Labor Act (EMTALA)

    • B.

      Transfer of Indigent Patients Act

    • C.

      Sherman Act

    • D.

      Hospital Licensing Act

    Correct Answer
    A. Emergency Medical Treatment and Active Labor Act (EMTALA)
    Explanation
    The correct answer is Emergency Medical Treatment and Active Labor Act (EMTALA). This act was enacted to prevent hospitals from denying treatment to indigent patients who come to the emergency department due to financial reasons. It ensures that all patients, regardless of their ability to pay, receive appropriate medical care in emergency situations.

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  • 37. 

    In a hospital setting, the need for informed consent, explaining the risks and benefits of a particular course of treatment, allowing the patient to participate in decisions regarding treatment options, and confidentiality are all examples of what?

    • A.

      Peer Review

    • B.

      Ethical issues

    • C.

      Credentialing

    • D.

      Quality assurance

    Correct Answer
    B. Ethical issues
    Explanation
    In a hospital setting, the need for informed consent, explaining the risks and benefits of a particular course of treatment, allowing the patient to participate in decisions regarding treatment options, and confidentiality all pertain to ethical issues. These issues involve ensuring that patients have the necessary information to make informed decisions about their treatment, respecting their autonomy and right to participate in their own healthcare decisions, and maintaining their privacy and confidentiality. These ethical considerations are crucial in providing patient-centered care and upholding the principles of medical ethics.

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  • 38. 

    Which act mandates regulations that prohibit disclosure of health information except as authorized by the patient or specifically permitted by the regulation?

    • A.

      Hospital Licensing Act (HLA)

    • B.

      Health Insurance Portability and Accountability Act of 1996 (HIPPA)

    • C.

      Emergency Medical Treatment and Active Labor Act (EMTALA)

    • D.

      Healthcare Quality Improvement Act (HCQIA)

    Correct Answer
    B. Health Insurance Portability and Accountability Act of 1996 (HIPPA)
    Explanation
    The correct answer is the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA mandates regulations that prohibit the disclosure of health information except as authorized by the patient or specifically permitted by the regulation. This act was implemented to ensure the privacy and security of individuals' health information and to establish standards for electronic health transactions. It also provides individuals with rights regarding their health information, including the right to access and control the use and disclosure of their information.

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  • 39. 

    Which act defines the elements of due process that must be followed in order for an organization to have peer review protection?

    • A.

      Patient Self-Determination Act

    • B.

      Health Insurance Portability and Accountability Act of 1996 (HIPAA)

    • C.

      Emergency Medical Treatment and Active Labor Act (EMTALA)

    • D.

      Healthcare Quality Improvement Act (HCQIA)

    Correct Answer
    D. Healthcare Quality Improvement Act (HCQIA)
    Explanation
    The Healthcare Quality Improvement Act (HCQIA) defines the elements of due process that must be followed for an organization to have peer review protection. This act establishes a framework for healthcare organizations to conduct peer review activities, such as evaluating the competence and professional conduct of healthcare providers. It ensures that fair procedures are in place, including notice, opportunity to respond, and a hearing, before any adverse actions are taken against a healthcare provider. The HCQIA aims to promote quality improvement in healthcare while protecting the rights of healthcare professionals.

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  • 40. 

    The Code of Ethics for which organization includes the language, " shall share knowledge, foster educational opportunities, and encourage personal and professional growth through continued self-improvement and applications of current advancements in the profession"? 

    • A.

      American Medical Association

    • B.

      American Hospital Association

    • C.

      NAMSS Certification Commission

    • D.

      Centers for Medicare and Medicaid Services

    Correct Answer
    D. Centers for Medicare and Medicaid Services
    Explanation
    The correct answer is Centers for Medicare and Medicaid Services. The language mentioned in the question aligns with the principles of knowledge sharing, educational opportunities, and personal and professional growth, which are important aspects of the Code of Ethics for this organization.

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  • 41. 

    What term is used to describe the evaluation or review of the performance of colleagues by professionals with similar types and degrees of clinical expertise?

    • A.

      Reappointment

    • B.

      Conditional period of appointment

    • C.

      Peer Review

    • D.

      Immunity

    Correct Answer
    C. Peer Review
    Explanation
    Peer review is the term used to describe the evaluation or review of the performance of colleagues by professionals with similar types and degrees of clinical expertise. This process involves the assessment of an individual's work by their peers in order to ensure quality and maintain professional standards. It is a valuable tool in various fields, including medicine, research, and academia, as it allows for constructive feedback, identification of areas for improvement, and the promotion of best practices.

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  • 42. 

    Which medical staff officer is responsible for enforcing the medical staff bylaws, rules, and regulations, and procedural guidelines of the medical staff including imposing sanctions for noncompliance?

    • A.

      Credentials committee chairman

    • B.

      Medical Staff president or chief of staff

    • C.

      Utilization Review Committee chairman

    • D.

      Medical staff secretary-treasurer

    Correct Answer
    B. Medical Staff president or chief of staff
    Explanation
    The Medical Staff president or chief of staff is responsible for enforcing the medical staff bylaws, rules, and regulations, and procedural guidelines of the medical staff including imposing sanctions for noncompliance. They hold a leadership position within the medical staff and have the authority to ensure that all members adhere to the established standards and guidelines. As the head of the medical staff, they have the responsibility to maintain the integrity and quality of medical care provided by the staff.

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  • 43. 

    Which term defines a functional unit of the hospital, so designated because of the clinical service it performs?

    • A.

      Department

    • B.

      Credentials Committee

    • C.

      Peer Review Committee

    • D.

      Service

    Correct Answer
    A. Department
    Explanation
    A department is a functional unit of a hospital that is designated based on the clinical service it provides. It is a distinct division within the hospital that focuses on a specific area of healthcare. Departments can include areas such as cardiology, radiology, or surgery, and each department is responsible for providing specialized care and services related to their specific clinical service.

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  • 44. 

    Which of the following is a responsibility of the department chairman?

    • A.

      Recommending criteria for clinical privileges of the department

    • B.

      Recommending amount of dues to be paid annually

    • C.

      Recommending to the medical executive committee the number of applicants to be allowed in the department

    • D.

      Recommending medications for inclusion on formulary

    Correct Answer
    A. Recommending criteria for clinical privileges of the department
    Explanation
    The responsibility of the department chairman is to recommend the criteria for clinical privileges of the department. This means that the chairman is responsible for determining the qualifications and requirements that must be met by individuals in order to be granted clinical privileges within the department. This ensures that only qualified individuals are allowed to practice within the department and maintain the quality of care provided.

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  • 45. 

    Which of the following is a Joint Commission requirement element for the process for managing LIP health?

    • A.

      Participation in AAA meetings

    • B.

      Notification of patients regarding practitioner's participation on program

    • C.

      Education of LIP and organization staff regarding recognizing illness and impairment issues specific to LIPs

    • D.

      Mandatory monitoring by a state or federal physician wellness program

    Correct Answer
    B. Notification of patients regarding practitioner's participation on program
    Explanation
    The correct answer is "Notification of patients regarding practitioner's participation on program." This requirement element ensures that patients are informed about their practitioner's involvement in a program related to managing LIP health. This notification promotes transparency and allows patients to make informed decisions about their healthcare. It also helps to establish trust between the practitioner and the patient.

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  • 46. 

    In the case of Frigo vs. Silver Cross Hospital, the podiatrist who performed surgery on Ms. Frigo did not meet initial criteria or revised criteria for Level II surgical privileges, but was granted privileges regardless.  What was the legal concept under which the jury found Silver Cross Hospital to be negligent?

    • A.

      Breach of duty/Corporate Negligence

    • B.

      Respondeat superior

    • C.

      Antitrust

    • D.

      Res Ipsa Loquitur

    Correct Answer
    A. Breach of duty/Corporate Negligence
    Explanation
    The jury found Silver Cross Hospital to be negligent under the legal concept of breach of duty/corporate negligence. This means that the hospital failed to fulfill its duty of care towards the patient by granting surgical privileges to a podiatrist who did not meet the necessary criteria. This breach of duty resulted in harm to the patient, making the hospital liable for negligence.

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  • 47. 

    Which term below describes the achievement of the organization's objectives through and with people and other resources?

    • A.

      Planning

    • B.

      Staffing

    • C.

      Controlling

    • D.

      Management

    Correct Answer
    D. Management
    Explanation
    Management is the correct answer because it refers to the process of achieving organizational goals and objectives by coordinating and utilizing resources effectively and efficiently. It involves planning, organizing, leading, and controlling the activities of individuals and teams within the organization. Through management, organizations can optimize their resources and ensure that they are aligned with the overall objectives of the organization.

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  • 48. 

    Which continuing medical education system has become the CME standard for licensing boards and specialty organizations nationwide and is recognized by U.S. jurisdictions?

    • A.

      The AMA's PRA Category 1 Credit system

    • B.

      The ACGME's CME program

    • C.

      FSMB's Profile report

    • D.

      Joint Commission's CME processing system

    Correct Answer
    A. The AMA's PRA Category 1 Credit system
    Explanation
    The correct answer is the AMA's PRA Category 1 Credit system. This system has become the CME standard for licensing boards and specialty organizations nationwide and is recognized by U.S. jurisdictions. It is a widely accepted and respected system for continuing medical education, providing physicians with credits that demonstrate their ongoing commitment to professional development and knowledge enhancement.

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  • 49. 

    What is the document that surveyors for the Centers of Medicare and Medicaid Services reference when surveying a hospital?

    • A.

      Joint Commission Standards and Scoring

    • B.

      Healthcare Quality Improvement Act of 1986

    • C.

      Federal Register

    • D.

      State Operations Manual - Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals

    Correct Answer
    D. State Operations Manual - Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals
    Explanation
    The document that surveyors for the Centers of Medicare and Medicaid Services reference when surveying a hospital is the State Operations Manual - Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. This manual provides surveyors with the necessary guidelines and regulations to assess the compliance of hospitals with the required standards and protocols. It serves as a reference for surveyors to ensure that hospitals are meeting the necessary requirements for quality and safety in healthcare.

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  • 50. 

    Average Length of Stay (ALOS) figures are used for which of the following purposes?

    • A.

      One measure of hospital utilization review

    • B.

      To calculate drug doses

    • C.

      Part of the calculation to determine reimbursement

    • D.

      To determine the amount of charitable care to be given

    Correct Answer
    A. One measure of hospital utilization review
    Explanation
    ALOS figures are used as one measure of hospital utilization review. This means that it is a metric used to assess how efficiently hospitals are being used by measuring the average length of time patients stay in the hospital. By analyzing ALOS, hospitals can evaluate their resources, patient flow, and overall efficiency. This information can help hospitals make improvements to better manage patient care and optimize their operations.

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