Chapter 8: Medical Staff Privileges and Peer Review

Question 1

Which of the following statements about medical staff membership is MOST accurate?
Options:
A) Medical staff membership is limited to those with a doctor of medicine (MD) degree
B) Medical staff membership is not limited to those with a doctor of medicine (MD) degree; it may include other qualified professionals as defined by the Medicare statute
C) Medical staff membership is determined solely by the hospital CEO
D) Medical staff membership is limited to those with either MD or DO degrees

Answer 1

B) Medical staff membership is not limited to those with a doctor of medicine (MD) degree; it may include other qualified professionals as defined by the Medicare statute.

Question 2

The hospital board’s ultimate responsibility for the overall quality of care is:
Options:
A) Delegable to the medical staff organization
B) Nondelegable, though the board may delegate certain credentialing functions to the medical staff
C) Shared equally with the medical staff
D) Limited to financial matters only

Answer 2

B) Nondelegable, though the board may delegate certain credentialing functions to the medical staff.

Question 3

In the medical staff organization, which entity holds the ultimate decision-making authority regarding staff appointments?
Options:
A) The medical staff executive committee
B) The hospital governing board
C) The hospital CEO
D) The credentials committee

Answer 3

B) The hospital governing board.

Question 4

What is privileging in the context of medical staff?
Options:
A) The process of granting special financial benefits to certain physicians
B) The process whereby the specific scope and content of patient care services are authorized for a healthcare practitioner by a healthcare organization
C) The act of allowing physicians to use VIP parking spaces
D) The formal recognition of a physician’s board certification

Answer 4

B) The process whereby the specific scope and content of patient care services are authorized for a healthcare practitioner by a healthcare organization.

Question 5

Which of the following is NOT typically a function of the medical staff organization?
Options:
A) Serving as liaison between the board and the medical staff
B) Setting hospital-wide financial policies and budget allocations
C) Investigating applicants’ backgrounds for medical staff membership
D) Supervising quality of medical care through peer review

Answer 5

B) Setting hospital-wide financial policies and budget allocations.

Question 6

Under the Health Care Quality Improvement Act (HCQIA), which of the following statements is TRUE?
Options:
A) Participants in peer review are granted immunity from damages under certain conditions
B) Peer review is optional for hospitals
C) Peer review must be conducted by external consultants
D) Physicians cannot challenge peer review decisions

Answer 6

A) Participants in peer review are granted immunity from damages under certain conditions.

Question 7

In the case of Johnson v. Misericordia Community Hospital, what was the court’s primary finding?
Options:
A) Hospitals are never liable for the actions of independent physicians
B) A hospital has a duty to exercise due care in the selection of its medical staff
C) Physicians have complete autonomy in making clinical decisions
D) A hospital must have an open medical staff

Answer 7

B) A hospital has a duty to exercise due care in the selection of its medical staff.

Question 8

The doctrine of “corporate liability” in hospital-physician relationships means:
Options:
A) The hospital is liable only for actions of employed physicians
B) The hospital itself owes a direct duty to patients to ensure quality care, separate from respondeat superior
C) The corporation must pay for all physician malpractice cases
D) Corporate executives are personally liable for medical errors

Answer 8

B) The hospital itself owes a direct duty to patients to ensure quality care, separate from respondeat superior.

Question 9

Which of the following is NOT required for immunity protection under the Health Care Quality Improvement Act?
Options:
A) Reasonable belief that the action furthers quality healthcare
B) Reasonable effort to obtain the facts
C) Adequate notice and hearing procedures for the physician
D) Proof that the peer review was motivated by the physician’s inability to pay for medical malpractice insurance

Answer 9

D) Proof that the peer review was motivated by the physician’s inability to pay for medical malpractice insurance.

Question 10

What is credentialing in healthcare?
Options:
A) The process of determining physician compensation
B) A process for establishing the qualifications of medical staff applicants through review of their training, licensure, and practice history
C) The act of assigning hospital ID badges
D) The process of billing insurance companies

Answer 10

B) A process for establishing the qualifications of medical staff applicants through review of their training, licensure, and practice history.

Question 11

When a physician applies for medical staff privileges, the hospital board generally relies on recommendations from:
Options:
A) The medical staff credentialing committee
B) The hospital’s legal counsel
C) The state medical board
D) The Joint Commission

Answer 11

A) The medical staff credentialing committee.

Question 12

What is the primary purpose of the National Practitioner Data Bank (NPDB)?
Options:
A) To track physician productivity metrics
B) To prevent incompetent physicians from moving across state lines without disclosure of previous problems
C) To store patient health records
D) To track medical school rankings

Answer 12

B) To prevent incompetent physicians from moving across state lines without disclosure of previous problems.

Question 13

In the Poliner v. Texas Health Systems case, what was the court’s finding regarding HCQIA immunity?
Options:
A) The hospital and physicians were not entitled to immunity because they acted in bad faith
B) The hospital and physicians were entitled to immunity because they met the four standards specified in HCQIA
C) Only the hospital was entitled to immunity, not the physicians
D) Immunity was not available because the case involved antitrust claims

Answer 13

B) The hospital and physicians were entitled to immunity because they met the four standards specified in HCQIA.

Question 14

According to the text, what is “economic credentialing”?
Options:
A) The use of economic criteria unrelated to quality of care or professional competence in determining a physician’s qualifications for staff membership
B) The process of evaluating physicians based on their economic status
C) The requirement that physicians maintain certain levels of malpractice insurance
D) The method of determining physician compensation based on productivity

Answer 14

A) The use of economic criteria unrelated to quality of care or professional competence in determining a physician’s qualifications for staff membership.

Question 15

In Kadlec Medical Center v. Lakeview Anesthesia Associates, what was the primary issue?
Options:
A) Whether a hospital and medical group had a duty to disclose a physician’s drug problem when providing references
B) Whether hospitals must perform drug tests on all staff members
C) Whether the NPDB must be queried for all new hires
D) Whether hospitals are responsible for physician substance abuse

Answer 15

A) Whether a hospital and medical group had a duty to disclose a physician’s drug problem when providing references

Question 16

Which of the following is NOT one of the requirements for immunity under HCQIA?
Options:
A) The professional review action must be taken in the reasonable belief that it furthers quality healthcare
B) The professional review action must be taken after a reasonable effort to obtain the facts
C) The professional review action must be taken after adequate notice and hearing procedures
D) The professional review action must be taken by at least three physicians

Answer 16

D) The professional review action must be taken by at least three physicians.

Question 17

The Joint Commission’s accreditation standards for medical staff privileges are based on:
Options:
A) Financial metrics only
B) Areas of general competency including patient care, medical knowledge, practice-based learning, interpersonal skills, professionalism, and systems-based practice
C) The physician’s academic credentials only
D) The number of procedures performed annually

Answer 17

B) Areas of general competency including patient care, medical knowledge, practice-based learning, interpersonal skills, professionalism, and systems-based practice.

Question 18

Which of the following does NOT affect the confidentiality of peer review records?
Options:
A) State statutory protections
B) The hospital’s for-profit or non-profit status
C) Whether the records were created specifically for peer review
D) Court rulings on discoverability

Answer 18

B) The hospital’s for-profit or non-profit status.

Question 19

What was significant about the Greisman v. Newcomb Hospital case?
Options:
A) It established that hospitals cannot arbitrarily exclude whole classes of practitioners (in this case, DOs)
B) It established that hospitals could select physicians based solely on their medical school
C) It mandated that all hospitals must be accredited by the Joint Commission
D) It eliminated the corporate practice of medicine doctrine

Answer 19

A) It established that hospitals cannot arbitrarily exclude whole classes of practitioners (in this case, DOs).

Question 20

What is an Accountable Care Organization (ACO)?
Options:
A) A group of providers who work together to manage and coordinate care for Medicare fee-for-service beneficiaries
B) A federal agency that oversees hospital quality
C) A hospital department that handles financial accounting
D) A physician practice that guarantees patient outcomes

Answer 20

A) A group of providers who work together to manage and coordinate care for Medicare fee-for-service beneficiaries.

Question 21

Which statement best describes the standard for granting medical staff appointments according to Sosa v. Board of Managers of Val Verde Memorial Hospital?
Options:
A) Appointments may be refused if the refusal is based on a reasonable basis such as professional and ethical qualifications
B) Appointments may only be refused if the physician has been convicted of a felony
C) Appointments must be granted to all licensed physicians
D) Appointments may be refused solely on economic grounds

Answer 21

A) Appointments may be refused if the refusal is based on a reasonable basis such as professional and ethical qualifications.

Question 22

What does the Moore v. Board of Trustees of Carson-Tahoe Hospital case demonstrate?
Options:
A) The medical staff properly exercises its responsibility for quality-of-care issues, and a governing board should act on recommended corrective action
B) Hospitals have no duty to supervise physicians
C) Only state medical boards can discipline physicians
D) Physicians have an absolute right to practice in any hospital

Answer 22

A) The medical staff properly exercises its responsibility for quality-of-care issues, and a governing board should act on recommended corrective action.

Question 23

What standards apply when a physician challenges the termination of medical staff privileges?
Options:
A) The hospital must show that its decision was reasonable, based on evidence, and followed adequate procedures
B) The hospital must prove the physician committed malpractice
C) The physician must be given an opportunity to practice for at least one year
D) The case must be decided by the state medical board

Answer 23

A) The hospital must show that its decision was reasonable, based on evidence, and followed adequate procedures.

Question 24

How does the Healthcare Integrity and Protection Data Bank (HIPDB) relate to the National Practitioner Data Bank (NPDB)?
Options:
A) They are completely separate systems with different purposes
B) The two databases were somewhat redundant, and the Affordable Care Act required them to be merged
C) HIPDB is for physicians while NPDB is for nurses
D) HIPDB focuses on patient complaints while NPDB focuses on malpractice cases

Answer 24

B) The two databases were somewhat redundant, and the Affordable Care Act required them to be merged.

Question 25

What was distinctive about the approach to medical staff appointments in the Med. Staff of Avera Marshall Reg'l Med. Ctr. v. Avera Marshall case? Options: A) The medical staff filed suit against its own hospital after the board unilaterally rescinded and replaced the medical staff bylaws B) The hospital agreed to give physicians complete autonomy C) The medical staff agreed to all the hospital's demands D) The case established that medical staff bylaws are not binding contracts

Answer 25

A) The medical staff filed suit against its own hospital after the board unilaterally rescinded and replaced the medical staff bylaws.

Question 26

Which of the following criteria would NOT generally be considered valid grounds for denying or revoking medical staff privileges? Options: A) Poor clinical outcomes B) The physician's participation in a competing medical practice C) Failure to maintain accurate medical records D) Unprofessional conduct affecting patient care

Answer 26

B) The physician's participation in a competing medical practice.

Question 27

Under what circumstances can hospitals grant exclusive contracts to certain physician groups? Options: A) When they can demonstrate that the contract is aimed at improving the quality of patient care B) Only when all medical staff members agree C) Only when approved by the state medical board D) Only when the physicians are hospital employees

Answer 27

A) When they can demonstrate that the contract is aimed at improving the quality of patient care.

Question 28

What is the relationship between Complementary and Alternative Medicine (CAM) and hospital credentialing? Options: A) CAM practitioners cannot be credentialed by hospitals B) Hospitals must address credentialing questions for CAM providers independently as there is no standard system C) All CAM practitioners must be supervised by MDs D) Credentialing standards for CAM are set by federal law

Answer 28

B) Hospitals must address credentialing questions for CAM providers independently as there is no standard system.

Question 29

In the Baptist Health v. Murphy case, what was the court's finding regarding economic credentialing? Options: A) The hospital's policy of denying privileges to physicians with ownership interest in competing facilities constituted tortious interference B) Economic credentialing was deemed a legitimate hospital practice C) Hospitals can deny privileges based solely on financial considerations D) Economic credentialing is required by the Affordable Care Act

Answer 29

A) The hospital's policy of denying privileges to physicians with ownership interest in competing facilities constituted tortious interference.

Question 30

Which of the following is NOT a reason why the courts generally defer to hospitals' credentialing decisions? Options: A) Hospitals have expertise in evaluating physician competence B) The hospital's need to prevent economic competition from its medical staff C) Public welfare concerns about quality healthcare D) Medical staff committees have specialized knowledge

Answer 30

B) The hospital's need to prevent economic competition from its medical staff.

Question 31

What is the purpose of focused professional practice evaluation (FPPE)? Options: A) To evaluate specific questions about a practitioner's competency B) To review all physicians annually C) To conduct hospital-wide quality assessments D) To determine physician compensation

Answer 31

A) To evaluate specific questions about a practitioner's competency.

Question 32

What is NOT considered confidential under peer review protection laws? Options: A) Physician statements during peer review meetings B) Committee deliberations about physician competence C) Records created for purposes other than peer review, such as routine business records D) Committee recommendations about physician privileges

Answer 32

C) Records created for purposes other than peer review, such as routine business records.

Question 33

According to the text, what is a key principle of how courts view hospital governance and medical staff issues? Options: A) The hospital governing board has ultimate responsibility, but must balance this with appropriate medical staff autonomy B) Medical staff should have complete authority over clinical matters C) Hospital administration should control all aspects of medical practice D) State medical boards should have primary oversight of hospital medical staffs

Answer 33

A) The hospital governing board has ultimate responsibility, but must balance this with appropriate medical staff autonomy.

Question 34

Which of the following is TRUE about hospital-owned ambulatory surgery centers and medical staff privileges? Options: A) Physicians with staff privileges at the main hospital automatically have privileges at affiliated ambulatory centers B) Physicians with staff privileges at the main hospital do not automatically have privileges at affiliated ambulatory centers C) Only hospital-employed physicians can practice at ambulatory surgery centers D) Ambulatory surgery centers cannot grant independent privileges

Answer 34

B) Physicians with staff privileges at the main hospital do not automatically have privileges at affiliated ambulatory centers.

Question 35

What legal principle underlies the confidentiality of peer review records? Options: A) The public interest in creating a candid environment for quality improvement outweighs discovery interests B) Physician privacy rights supersede all other considerations C) Hospital corporate secrecy is guaranteed by law D) Federal law prohibits disclosure of any peer review information

Answer 35

A) The public interest in creating a candid environment for quality improvement outweighs discovery interests.

Question 36

In what way did the Affordable Care Act affect physician-hospital relationships? Options: A) It encouraged greater integration through mechanisms like Accountable Care Organizations B) It prohibited hospital employment of physicians C) It mandated completely independent medical staffs D) It eliminated hospital credentialing requirements

Answer 36

A) It encouraged greater integration through mechanisms like Accountable Care Organizations.

Question 37

What is the main difference between an employed physician and an independent contractor physician regarding hospital liability? Options: A) The hospital is generally responsible for negligence of employed physicians under respondeat superior but not for independent contractors B) The hospital has no liability for either employed or independent physicians C) The hospital has equal liability for both employed and independent physicians D) Only employed physicians can be granted medical staff privileges

Answer 37

A) The hospital is generally responsible for negligence of employed physicians under respondeat superior but not for independent contractors.

Question 38

What does the "Triple Aim" in healthcare refer to? Options: A) Improving population health, enhancing patient experience, and reducing per capita costs B) Increasing hospital profits, physician satisfaction, and patient volume C) Expanding insurance coverage, technology, and facilities D) Focusing on prevention, treatment, and rehabilitation

Answer 38

A) Improving population health, enhancing patient experience, and reducing per capita costs.

Question 39

A hospital denies privileges to a physician based on documented evidence of poor surgical outcomes and inadequate technical skills. The physician sues, claiming improper denial. Apply the IRAC method to analyze this situation.

Answer 39

* Issue: Whether the hospital properly denied the physician's application for privileges * Rule: Hospitals have a duty to exercise reasonable care in granting privileges and may deny privileges based on professional qualifications * Analysis: Hospital based decision on objective evidence related to competence; courts generally defer to hospitals when decisions are evidence-based and related to patient safety * Conclusion: Hospital's denial likely upheld if proper procedures were followed and decision was based on documented evidence rather than personal or economic factors

Question 40

Explain how the Joint Commission's standards interact with legal standards in the context of medical staff privileging decisions.

Answer 40

* Joint Commission standards establish professional norms for credentialing and privileging * Courts often consider these standards as evidence of expected care standards (Darling case) * Not legally binding themselves, but inform what courts consider reasonable conduct * Hospitals failing to follow these standards may face difficulty defending credentialing decisions * Serve as benchmark for developing hospital policies and procedures * Can be introduced as evidence in litigation concerning negligent credentialing

Question 41

Describe the four requirements that must be met under the Health Care Quality Improvement Act for immunity protection during peer review.

Answer 41

* Reasonable belief that the action furthers quality healthcare * Reasonable effort to obtain the relevant facts * Adequate notice and hearing procedures (or other fair process) provided to the physician * Reasonable belief that the action was warranted based on known facts after meeting procedural requirements * These create an objective test with presumption of compliance unless rebutted by preponderance of evidence

Question 42

Compare and contrast corporate liability and respondeat superior in the context of hospital liability for physician actions.

Answer 42

* Respondeat superior: Based on employment relationship; applies only to employees; requires action within scope of employment * Corporate liability: Direct duty owed to patients; applies regardless of employment status; covers selection/retention of competent staff * Respondeat superior requires employer-employee relationship; corporate liability does not * Hospital can be liable under corporate liability even when physician is independent contractor * Corporate liability focuses on hospital's independent obligations to patients * Both theories have expanded hospital liability beyond traditional "doctor's workshop" concept

Question 43

Discuss how the concept of economic credentialing has evolved and the legal challenges it presents.

Answer 43

* Economic credentialing: Using economic criteria unrelated to clinical competence in privileging decisions * Evolved as hospitals sought to protect financial interests against competing facilities * Courts divided: Cobb County case upheld hospital policy requiring patients to receive services within hospital * Baptist Health v. Murphy found denying privileges based on competing interests constituted tortious interference * Raises antitrust concerns and conflicts with hospital's duty to ensure quality care * ACA restrictions on physician-owned hospitals altered landscape * Tension between hospital financial interests and physician autonomy continues * Legal challenges driven by questions of whether economic factors should influence clinical privileges

Question 44

What are the major legal and ethical considerations for hospitals when credentialing complementary and alternative medicine (CAM) practitioners?

Answer 44

* Varying state licensing requirements for different CAM disciplines * Scope of practice issues to prevent unauthorized practice of medicine * Professional liability insurance coverage limitations * Balancing patient demand against evidence-based practice standards * Evaluating training and competency when educational standards vary significantly * Integrating CAM services with conventional care * Establishing clear clinical governance structures and accountability * Managing through limited practice privileges and physician collaboration agreements * Defining appropriate documentation and informed consent requirements

Question 45

Explain the concept of "apparent agency" and how it affects hospital liability for the actions of non-employed physicians.

Answer 45

* Occurs when hospital creates impression that physician is its agent or employee * Has eroded the independent contractor defense for hospitals * Courts consider: hospital "holding out" physicians as employees; patients looking to hospital for care; patient reliance on apparent relationship * Especially applies in emergency departments, anesthesiology, radiology, and pathology * Hospital can be held liable despite lack of actual employment relationship * Reflects recognition that patients cannot distinguish between employed and contracted physicians * Has expanded hospital liability beyond traditional respondeat superior boundaries

Question 46

Discuss the tension between medical staff autonomy and hospital administrative authority in the context of the "three-legged stool" metaphor mentioned in the text.

Answer 46

* "Three-legged stool": governing board, medical staff, and executive management * Physicians value clinical autonomy while board has ultimate legal responsibility * Medical staff often independent practitioners yet subject to hospital policies * Administration balances operational efficiency with physician preferences * Tension evident in credentialing, peer review, and strategic planning * Successful hospitals develop collaborative governance with clear roles * Joint Commission emphasizes leaders must work together constructively * Failure leads to costly litigation (Med. Staff of Avera Marshall case) * Physician employment and ACOs reshaping relationship but need for balance remains

Question 47

How does the National Practitioner Data Bank function in the credentialing process, and what are its limitations?

Answer 47

* Repository for adverse actions: malpractice payments, licensure actions, privilege restrictions * Hospitals must query when physicians apply and every two years thereafter * Entities must report significant adverse actions to NPDB * Helps prevent practitioners from moving across state lines to escape disciplinary history * Limitations: underreporting remains problem; information may be outdated or inaccurate * Wrongly reported physicians face difficulties clearing names * Depends on voluntary compliance with limited enforcement mechanisms * Primary enforcement is potential loss of immunity protection * These limitations compromise effectiveness as patient safety tool

Question 48

What are the legal implications of the Kadlec case for hospitals providing references for former medical staff members?

Answer 48

* Providing references is voluntary, but once given, must not include affirmative misrepresentations * Physician group liable for falsely praising doctor fired for drug use * Hospital not liable because it provided only factual information without misleading statements * No general affirmative duty to volunteer negative information * Creates challenging balance between defamation concerns and misrepresentation liability * Organizations should either provide complete, truthful information or limit to factual verification * Highlights tension between protecting future patients and avoiding litigation from former staff * Emphasizes importance of thoughtful reference policies

Question 49

Analyze how the role of hospital medical staff has evolved with the implementation of Accountable Care Organizations under the Affordable Care Act.

Answer 49

* Traditional model: independent practitioners with privileges * ACOs promote integration and shared accountability for quality and costs * More employment relationships, clinical co-management, joint governance structures * Evolution from focusing on credentialing to population health management * Raises questions about operational control, quality assessment, revenue distribution * Medical staff bylaws and contracts adapted to address changing relationships * Physician autonomy giving way to collaborative decision-making * Emphasis on standardized protocols and evidence-based practices * Fundamental shift from separate entity to integrated component of healthcare system

Question 50

What standards should hospitals follow when making decisions to grant, limit, or revoke medical staff privileges to ensure they will be upheld if challenged in court?

Answer 50

* Establish clear, objective criteria related to patient care quality and safety * Document criteria in medical staff bylaws and apply consistently * Thoroughly verify training, licensure, experience, and current competence * Provide procedural due process: notice, hearing opportunity, evidence presentation * Base decisions on documented evidence related to clinical competence or professional conduct * Maintain detailed records of the credentialing process * Ensure compliance with applicable laws, accreditation standards, and bylaws * Avoid decisions based primarily on economic factors * Focus on patient safety as primary consideration * Follow proper appeals process when decisions are challenged