Medical Staff Bylaws FAQs

1. Category 1 MS Bylaws

2. 100 points 100 points 100 points 100 points 100 points 100 points 200 points 200 points 200 points 200 points 200 points 200 points 300 points 300 points 300 points 300 points 300 points 300 points 400 points 400 points 400 points 400 points 400 points 400 points 500 points 500 points 500 points 500 points 500 points 500 points

3. QUESTION – 100 Points This is a medical record document that must be completed by a physician, an oral/maxillofacial surgeon, or qualified LIP in accordance with State law and hospital standards?

4. ANSWER H & P (Medical History & Physical Examination)

5. QUESTION – 300 Points Who acts on behalf of the organized medical staff between medical staff meetings?

6. ANSWER The Medical Executive Committee

7. QUESTION – 400 Points Who oversees the quality of [patient] care, treatment, and services provided by practitioners privileged through the medical staff process?

8. ANSWER The Organized Medical Staff

9. QUESTION – 500 Points Who manages and coordinates the patient’s care, treatment and services?

10. ANSWER LIP with appropriate privileges

11. Category 2 HOT Topics

12. QUESTION – 200 Points This is a process to fulfill an important patient care need and when a new applicant with a complete application raises no concerns awaiting approval of the MEC & the BOD?

13. ANSWER Temporary Privileges

14. QUESTION, 300 Points This process is consistently implemented for all initially requested privileges with criteria & requirements defined by the organized medical staff?

15. ANSWER Focused Professional Practice Evaluation (FPPE)

16. QUESTION – 400 Points What is March 30?

17. ANSWER Doctors’ Day

18. QUESTION – 500 Points This is a clearly defined process that facilitates the evaluation of each practitioner’s professional practice?

19. ANSWER Ongoing Professional Practice Evaluation (OPPE)

20. Category 3 wise words

21. QUESTION – 100 Points A formal process for defining and addressing unacceptable behavior for all healthcare professionals?

22. ANSWER Code of Conduct (LD.03.01.01)

23. QUESTION – 200 Points What are three types of FPPE proctoring?

24. ANSWER • Prospective • Concurrent • Retrospective

25. QUESTION – 300 Points This data is collected on all practitioners with privileges with privileges to decide to continue, limit or revoke privileges?

26. ANSWER Ongoing Professional Practice Evaluation (OPPE)

27. QUESTION – 400 Points This helps us locate standards and EPs that have been moved to other chapters?

28. ANSWER The TJC History Tracking Report

29. QUESTION – 500 Points This standard has been renumbered & addresses the credentialing & privileging of PAs and ARNPs?

30. ANSWER HR. 1.20 (NOW hr.01.02.05, EPs 10-14)

31. QUESTION – 100 Points This is the process historically called “peer review”?

32. ANSWER Focused Professional Practice Evaluation (FPPE)

33. QUESTION – 200 Points What are? • Interpersonal & Communication Skills • Medical Knowledge • Patient Care • Professionalism • Practice-Based Practice • Systems-Based Practice

34. ANSWER The six JC Core Competences

35. QUESTION – 300 Points These are mechanisms addressing adverse decisions regarding reappointment, denial, reduction, suspension, or revocation of privileges related to quality of care & treatment issues?

36. ANSWER The Fair Hearing & Appeal Process

37. QUESTION – 400 Points This group is responsible for determining competency?

38. ANSWER The medical staff (delegated responsibility through the BOD)

39. FINAL QUIZ QUESTION

40. QUESTION – 100 Points This process is also used when questions arise related to competency of practitioners granted privileges?

41. ANSWER Focused Professional Practice Evaluation (FPPE)