HCAD731-TEST #2 EXAM QUESTIONS AND ANSWERS WITH
COMPLETE SOLUTIONS VERIFIED
Code of Medical Ethics for physicians
•Emphasizes the importance of improving medical knowledge and skills, ultimately for the benefit of the
patient
Structure of Medical Staff organization accomplished thru
•Bylaws
•Rules and regulations
•Application
•Credentialing process
•Committee structure
Medical Staff Committees
• Executive Committee
• Bylaws committee
• Blood and transfusion committee
• Credentials committee
• Infection control committee
• Medical records committee
• Pharmacy and therapeutics committee
• Tissue committee
• Utilization review committee
Executive Committee
•Oversees the activities of the medical staff
•Responsible for recommending to the governing body such things as:
o Medical staff structure
o Process for reviewing credentials and appointing medical staff
o Process for delineating clinical Privileges
,o Process for peer review
o Mechanism by which medical staff can be terminated
o Mechanism for fair hearings and appeals
•Reviews and acts on the reports of the medical staff president, dept chair and designated medical staff
committees
Bylaws Committee
• Define bylaws which must be reviewed by the governing body
• Defines the various membership categories of the medical staff
• Defines processes thru bylaws for medical staff obtaining privileges
Bylaws
• Describe the various membership categories of the medical staff
Credentials Committee
• Oversees the application process for medical staff applicants, requests for clinical privileges and
reappointments to the medical staff
• Makes its recommendations to the medical committee
Infection Control Committee
•Responsible for the development of policies and procedures for the investigation and prevention of
infections
Medical Records Committee
•Develops policies and procedures as they pertain to management of medical records
•Makes recommendations for disciplinary action for incomplete medical records
Pharmacy and Therapeutics Committee
•Develops policies and procedures relating to the selection and safe use of medications and diagnostic
testing materials
•Oversees the development and maintenance of drug fomulary
•Tracks medication errors and adverse drug reactions
•Monitors areas such as drug-drug, drug-food and drug-disease interactions
,Tissue Committee
•Reviews all surgical procedures involving the removal of body tissue and the justification for doing so
Utilization Review Committee
•Monitors and evaluates utilization issues such as medical necessity of admissions and continued stay as
well as delay in the provision of diagnostic and supportive services
•Ensures that each patient is treated at an appropriate level of care.
•Objectives of the Committee include:
o Timely transfer of patients requiring alternate levels of care and treatment
o Efficient and effective use of the organizations resources
o Adherence to quality utilization standards of 3rd party payors
o Maintenance of high-quality, cost-effective care and identify improvement opportunities
Medical Director
• Serves as the liaison between the medical staff and the governing body
• Provides guidance and leadership to medical staff
• Plays major role in quality improvement activities
• Responsible for enforcing the bylaws, and monitoring the quality of medical care
Medical Staff Privileges
•Restricted to those professionals who fulfill the requirements as described in the organizations medical
staff bylaws
Credentialing Process
•Purpose is to evaluate the competency of the applicant to determine whether he or she is qualified for
appointment to the medical staff
Appointment Process of the medical staff
• Application
• Medical Staff bylaws
• Physical and mental status review
• Consent for release of information
• Certificate of insurance
, • State licensure
• National Practitioner Data Bank
• References
• Applicant Review process
• Delineation of clinical privileges
• Governing body responsibility
• Appeal process
• Reappointments
Application - Medical Staff
•Provides information about the applicant's medical school, internship residency, privileges requested,
availability to provide on call emergency dept coverage, etc
Bylaws - Medical staff application
• Sign a statement attesting to the fact that the bylaws have been read and that the applicant agrees to
follow the policies and procedures
National Practitioner Data Bank - medical staff application
• Created by congress as a national repository of information with the purpose of facilitating a
comprehensive review of physicians' and other HC practitioners professional credentials
• HC organizations must query this every 2 years on the renewal of clinical privileges of HC practitioners
Delineation of clinical privileges - medical staff application
• Process by which the medical staff determines precisely what procedures a physician is authorized to
perform
Governing Body responsibility - medical staff application
• Has ultimate responsibility for granting medical staff privileges
Ethical Values vs Legal Principals
• Both are usually closely related, however, ethical obligations typically exceed legal duties.
Medical Record
COMPLETE SOLUTIONS VERIFIED
Code of Medical Ethics for physicians
•Emphasizes the importance of improving medical knowledge and skills, ultimately for the benefit of the
patient
Structure of Medical Staff organization accomplished thru
•Bylaws
•Rules and regulations
•Application
•Credentialing process
•Committee structure
Medical Staff Committees
• Executive Committee
• Bylaws committee
• Blood and transfusion committee
• Credentials committee
• Infection control committee
• Medical records committee
• Pharmacy and therapeutics committee
• Tissue committee
• Utilization review committee
Executive Committee
•Oversees the activities of the medical staff
•Responsible for recommending to the governing body such things as:
o Medical staff structure
o Process for reviewing credentials and appointing medical staff
o Process for delineating clinical Privileges
,o Process for peer review
o Mechanism by which medical staff can be terminated
o Mechanism for fair hearings and appeals
•Reviews and acts on the reports of the medical staff president, dept chair and designated medical staff
committees
Bylaws Committee
• Define bylaws which must be reviewed by the governing body
• Defines the various membership categories of the medical staff
• Defines processes thru bylaws for medical staff obtaining privileges
Bylaws
• Describe the various membership categories of the medical staff
Credentials Committee
• Oversees the application process for medical staff applicants, requests for clinical privileges and
reappointments to the medical staff
• Makes its recommendations to the medical committee
Infection Control Committee
•Responsible for the development of policies and procedures for the investigation and prevention of
infections
Medical Records Committee
•Develops policies and procedures as they pertain to management of medical records
•Makes recommendations for disciplinary action for incomplete medical records
Pharmacy and Therapeutics Committee
•Develops policies and procedures relating to the selection and safe use of medications and diagnostic
testing materials
•Oversees the development and maintenance of drug fomulary
•Tracks medication errors and adverse drug reactions
•Monitors areas such as drug-drug, drug-food and drug-disease interactions
,Tissue Committee
•Reviews all surgical procedures involving the removal of body tissue and the justification for doing so
Utilization Review Committee
•Monitors and evaluates utilization issues such as medical necessity of admissions and continued stay as
well as delay in the provision of diagnostic and supportive services
•Ensures that each patient is treated at an appropriate level of care.
•Objectives of the Committee include:
o Timely transfer of patients requiring alternate levels of care and treatment
o Efficient and effective use of the organizations resources
o Adherence to quality utilization standards of 3rd party payors
o Maintenance of high-quality, cost-effective care and identify improvement opportunities
Medical Director
• Serves as the liaison between the medical staff and the governing body
• Provides guidance and leadership to medical staff
• Plays major role in quality improvement activities
• Responsible for enforcing the bylaws, and monitoring the quality of medical care
Medical Staff Privileges
•Restricted to those professionals who fulfill the requirements as described in the organizations medical
staff bylaws
Credentialing Process
•Purpose is to evaluate the competency of the applicant to determine whether he or she is qualified for
appointment to the medical staff
Appointment Process of the medical staff
• Application
• Medical Staff bylaws
• Physical and mental status review
• Consent for release of information
• Certificate of insurance
, • State licensure
• National Practitioner Data Bank
• References
• Applicant Review process
• Delineation of clinical privileges
• Governing body responsibility
• Appeal process
• Reappointments
Application - Medical Staff
•Provides information about the applicant's medical school, internship residency, privileges requested,
availability to provide on call emergency dept coverage, etc
Bylaws - Medical staff application
• Sign a statement attesting to the fact that the bylaws have been read and that the applicant agrees to
follow the policies and procedures
National Practitioner Data Bank - medical staff application
• Created by congress as a national repository of information with the purpose of facilitating a
comprehensive review of physicians' and other HC practitioners professional credentials
• HC organizations must query this every 2 years on the renewal of clinical privileges of HC practitioners
Delineation of clinical privileges - medical staff application
• Process by which the medical staff determines precisely what procedures a physician is authorized to
perform
Governing Body responsibility - medical staff application
• Has ultimate responsibility for granting medical staff privileges
Ethical Values vs Legal Principals
• Both are usually closely related, however, ethical obligations typically exceed legal duties.
Medical Record
