Medical Staff Governance Flashcards
7 cards from real CPE practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Medical Staff Governance flashcards as text
A hospital's credentialing committee approves a surgeon's application, but the governing board denies the appointment. Which statement best describes this governance dynamic?
Answer: The governing board has ultimate authority over appointments and may deny credentialing committee recommendations
The governing board retains final authority over medical staff appointments and is not bound by the credentials committee's recommendation.
A physician executive is asked to define the scope of clinical privileges for a telemedicine radiologist who will read images remotely. Which credentialing model applies?
Answer: The distant site hospital may rely on the originating site's credentialing under a written agreement
CMS and Joint Commission allow the distant site to credential based on the originating site's credentialing under an approved written agreement.
During ongoing professional practice evaluation (OPPE), data shows a cardiologist's risk-adjusted mortality rate is a statistical outlier. What is the most appropriate next step?
Answer: Trigger focused professional practice evaluation (FPPE) to investigate the outlier
A statistical outlier in OPPE data is a trigger for FPPE, which allows structured investigation before any disciplinary action is taken.
Which of the following is a characteristic of an 'autonomous' medical staff model compared to an 'integrated' model?
Answer: The medical staff operates independently with its own bylaws, separate from hospital administration
An autonomous medical staff model maintains independent governance structure with its own bylaws, leadership, and decision-making processes.
A physician executive must respond to a report that a department chief has been altering peer review scores to protect a colleague. What is the most important governance response?
Answer: Conduct an internal investigation and consider removing the chief from the peer review role
Allegations of peer review manipulation require formal investigation and removal of the implicated individual from the review role to preserve process integrity.
Which body is responsible for investigating and acting on a complaint that a medical staff officer has violated the medical staff bylaws?
Answer: The medical executive committee
The medical executive committee has authority to investigate bylaw violations by medical staff officers and recommend appropriate action.
A hospital's medical staff bylaws have not been updated in six years. A physician executive identifies several provisions that conflict with current accreditation standards. What process must be followed to amend the bylaws?
Answer: Amendments must follow the process specified in the bylaws, typically requiring medical staff vote and governing board approval
Bylaws amendments must follow the amendment procedure within the bylaws themselves, usually requiring a medical staff vote and governing board approval.