CPE Medical Staff Governance 2

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?

Accepted Answer

Notify the medical executive committee and initiate a bylaws amendment

Answer

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?

Accepted Answer

Suspend clinical privileges until the renewal process is completed

Answer

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?

Accepted Answer

Credentials committee

Answer

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?

Accepted Answer

The surgeon is new to the medical staff regardless of experience level

Answer

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?

Accepted Answer

Recuse from the review and assign an unbiased reviewer

Answer

The reviewer should recuse to avoid actual or perceived conflicts of interest that could undermine the integrity of the peer review process.

(CPE) Certified Physician Executive Practice Test

(CPE) Certified Physician Executive Practice Test

CPE Medical Staff Governance 2