CPE Medical Staff Governance 2 — Questions and Answers
Question 1: A hospital's medical staff bylaws conflict with a newly enacted state law on credentialing timelines. Which action should the physician executive take first?
- Ignore the conflict until the next bylaws review cycle
- Notify the medical executive committee and initiate a bylaws amendment (Correct answer)
- Ask individual department chairs to manage the conflict independently
- Defer to the CEO to resolve the matter without medical staff input
Correct answer: Notify the medical executive committee and initiate a bylaws amendment
When bylaws conflict with law, the medical executive committee must be notified promptly and a formal amendment process initiated to achieve compliance.
Question 2: A practitioner's clinical privileges lapse because renewal paperwork was not submitted on time. Under Joint Commission standards, what is the most appropriate immediate step?
- Allow the practitioner to continue working pending paperwork submission
- Suspend clinical privileges until the renewal process is completed (Correct answer)
- Grant a temporary extension without executive committee approval
- Transfer the practitioner's patients to another department
Correct answer: Suspend clinical privileges until the renewal process is completed
Lapsed privileges require suspension until the renewal is formally completed to maintain compliance with accreditation standards.
Question 3: Which committee is primarily responsible for recommending initial medical staff appointments to the governing board?
- Quality improvement committee
- Credentials committee (Correct answer)
- Peer review committee
- Finance committee
Correct answer: Credentials committee
The credentials committee evaluates practitioner qualifications and makes appointment recommendations to the governing board.
Question 4: A physician executive wants to implement focused professional practice evaluation (FPPE) for a newly appointed surgeon. Which trigger best justifies initiating FPPE?
- The surgeon has more than 10 years of practice experience
- The surgeon is new to the medical staff regardless of experience level (Correct answer)
- A patient complaint was filed about the surgeon's bedside manner
- The surgeon requested a change in scheduled operating days
Correct answer: The surgeon is new to the medical staff regardless of experience level
FPPE is required for all newly appointed practitioners and for any practitioner granted new privileges, regardless of prior experience.
Question 5: During a peer review case, a reviewer determines that a colleague's care was substandard. The reviewer and the colleague are close friends. What is the most appropriate action?
- Complete the review but note the friendship in the report
- Recuse from the review and assign an unbiased reviewer (Correct answer)
- Ask the colleague to recuse themselves from the case discussion
- Proceed normally since friendship does not affect professional judgment
Correct answer: Recuse from the review and assign an unbiased reviewer
The reviewer should recuse to avoid actual or perceived conflicts of interest that could undermine the integrity of the peer review process.
Question 6: A medical staff department chair refuses to participate in ongoing professional practice evaluation (OPPE) data collection. What is the most effective response from the physician executive?
- Excuse the chair from OPPE as an exception for leadership
- Escalate to the medical executive committee to enforce compliance (Correct answer)
- Remove the chair's privileges immediately without due process
- Allow the behavior and document it informally
Correct answer: Escalate to the medical executive committee to enforce compliance
The MEC has authority over medical staff compliance matters and should be engaged to enforce participation in required evaluation processes.
Question 7: A hospital is merging with another health system that has different medical staff bylaws. What governance principle should guide the integration process?
- The larger organization's bylaws automatically supersede the smaller one's
- Both medical staffs must vote to dissolve and reform a unified staff
- Bylaws should be harmonized through a joint task force with input from both medical staffs (Correct answer)
- The governing board should unilaterally impose a single set of bylaws
Correct answer: Bylaws should be harmonized through a joint task force with input from both medical staffs
A joint task force with representation from both medical staffs ensures legitimate, inclusive bylaws harmonization during a merger.
CPE Medical Staff Governance 2
A hospital's medical staff bylaws conflict with a newly enacted state law on credentialing timelines.
Which action should the physician executive take first?