NAHQ CPHQ Practice Exam

A critically ill patient is admitted and requires a specialized procedure; however, the surgeon does not have privileges at the facility. Which of the following documents will be most helpful in identifying the course of action the hospital should take?

1. Medical staff bylaws

2. Patient safety manual

3. Risk management plan

4. Surgical policies and procedures

The correct answer is: Medical staff bylaws

The correct answer is A. Medical staff bylaws. Medical staff bylaws are essential in determining the appropriate steps to take in situations where a surgeon does not have privileges at a facility. These bylaws outline the rules and regulations governing the medical staff, including the process for granting privileges, handling new procedures, and addressing situations where certain specialists may not have privileges but are needed for a specific case. By referring to the medical staff bylaws, the hospital can establish the proper protocol to ensure the critically ill patient receives the necessary care while maintaining compliance with regulations and standards. The other options are not as relevant in this scenario: B. The patient safety manual focuses on protocols and procedures to ensure patient safety but may not address the specific issue of surgeon privileges. C. The risk management plan is designed to identify and mitigate risks in healthcare operations, but it may not provide guidance on handling situations related to surgeon privileges. D. Surgical policies and procedures typically outline protocols for surgical care within the facility but may not specifically address the scenario where a surgeon lacks privileges.