Medical Staff Organization and Governance — Credentialing Resource Center Forums

Policy Approvals

uabmdso — Fri, 23 Jun 2017 14:52:31 +0000

What policies do you take through your Medical Executive Committee?

Closed Medical Staff Policy

darla.mcclead@wvumedicine.org — Thu, 06 Jun 2024 14:11:54 +0000

Hi! Does anyone have a policy on a closed medical staff that they can share?

Medical Staff Officer Duties and Responsibilities

kerra.ball@wvumedicine.org — Thu, 11 Jan 2024 17:28:24 +0000

We are looking to enhance the duties and responsibilities for our President, Vice President, Chair of Surgery, and Chair of Medicine Departments. I would appreciate seeing what your facility has listed for each of these important member roles.

Locum Tenen Category

darla.mcclead@wvumedicine.org — Tue, 24 Oct 2023 14:37:55 +0000

I need to update our current bylaws to reflect a category of Locum tenens. Does anyone have this category in their bylaws that they're willing to share?

New Medical Staff Officers Welcome and Orientation

trisha.monis@phci.org — Tue, 13 Sep 2022 20:35:00 +0000

We will be having new chairs/vice chairs as well as changes in our medical staff leadership. Does anyone have an orientation or welcome email they would be willing toshare? Trying to cover the components of their responsibilities in credentialing, chart/peer review and FPPE/OPPE. Thanks in advance!

Trish Monis

Manager – Medical Staff Services

ProHealth Care

Office: (262) 928.2261

Mobile: (414) 791.2187

Trisha.Monis@phci.org

Are the Medical Staff Rules and Regs Necessary?

vanhove — Fri, 18 Mar 2022 19:43:35 +0000

We are revising our Rules and Regs and much of the content is already contained in policy. I can find no regulatory requirement for a document entitled "Rules and Regs" although the CoPs say that the medical staff must "approve medical staff bylaws and other medical staff rules and regulations."

Has anyone eliminated this document? If so, what consequences have you experienced?

Beth Van Hove, CPMSM, CPCS

Manager, Medical Staff Affairs and GME

University of Missouri Health Care

O: 573/882-4913 | E: vanhovee@missouri.edu

Back-Up Coverage for Established Patients

kanderso@communitymedical.org — Thu, 06 Jan 2022 18:36:27 +0000

We have the following medical staff policy:

III. POLICY

Established patients
It is the policy of the medical staff for its members to provide care to their established patients if these patients present (or are inpatients) at a facility at which they hold privileges and the physician’s specialty is required
If a physician is unable to provide care for his or her patients, then the physician must provide coverage through another appropriately credentialed physician. The covering physician must be available and qualified to assume responsibility for the patients during the entirety of the attending physician's absence and must be aware of the status and condition of any hospital inpatient which he or she is to cover.

So at Initial and Reappointment, the provider must name who their back-up is for such coverage and we make sure that their back-up has similar enough privileges to be able to back that provider up.

For any other hospitals that require their medical staff members to have back-up coverage:
What do you do when you have a physician who is either the only one in the organization with certain privileges?

And, what do you do if a provider is in solo practice and no other provider on your medical staff is willing to provide back-up coverage? Does that provider lose his/her privileges?

Legal Representation at Committees?

DBEMENT — Fri, 13 Sep 2019 16:17:05 +0000

Do other hospitals routinely have legal council represented at their Credentials Committee, Medical Executive Committee and Peer Review Committees?

Members who attend at MEC during disciplinary action

de12 — Tue, 18 Jun 2019 07:16:55 +0000

Which members are allowed to attend MEC when it convenes as a disciplinary committee.

Department of Hosptial Medicine? Hospitalists Department? Hospitalists Category?

easesq@snelsonlaw.com — Tue, 10 Oct 2017 14:46:26 +0000

How do you categorize/organize hospitalists in your medical staff? Does anyone have a hospitalist department with a seat on the Medical Executive Committee? If so, how are the privileges it delineates different from those in the internal medicine department?

Physician Dyads

easesq@snelsonlaw.com — Sun, 19 Mar 2017 16:09:06 +0000

Is your hospital medical staff using physician dyads as part of governance, represented on the MEC, replacing departments? What is the role of physician dyads in your organization?

Advanced Practice Providers

Trussell@hughchatham.org — Wed, 01 Mar 2017 20:43:19 +0000

We are currently changing our definition of PA/NP to Advanced Practice Providers (from Allied Health). They are currently governed by the bylaws however they are not currently classified under a category of the medical staff. They are classified as Allied Health. We are looking to move them under the Active medical staff category, either Active APP which would be hospital based and Community Based APP which would be medical offices and clinic based.

Questions that have come up are below - so I am asking for your assistance with these questions as they pertain to your facility.

Are APPs an Active member of your medical staff?

Are they able to vote? Hold office?

Do they serve on committees?

Participate in QI and Peer review?

I thank you for your time.

Tracey H Russell, CPCS

Hugh Chatham Memorial Hospital

Elkin, NC

Trussell@hughchatham.org

Clinical Psychologists

meffingham — Wed, 06 Sep 2017 17:41:15 +0000

If you credential Clinical Psychologists...are they members of your Allied Health Staff, or are they full members of your Medical & Dental Staff?

TEXTING / MESSAGING ORDERS

maryod — Thu, 21 Dec 2017 16:19:18 +0000

I am wondering if anyone has any language about not accepting texted or messaged orders in their MS policies / documents. Would you share? Thanks in advance.

Mary

Unified Medical Staffs - facility privileges

scrawford36 — Wed, 24 May 2017 17:41:02 +0000

Anyone out there have a Unified Medical Staff with several hospitals and one board of trustees? How do you address privileges in your unified medical staff?

Health Systems with an Integrated Medical Staff

pgilcher3404 — Fri, 20 Jan 2017 23:43:33 +0000

I'm hoping to get some guidance regarding a CMS/TJC standard that reads, "For hospitals that use Joint Commission accreditation for deemed status purposes: When a multihospital system has a unified and integrated medical staff, the bylaws describe the process by which medical staff members at each separately accredited hospital (that is, all medical staff members who hold privileges to practice at that specific hospital) are advised of their right to opt out of the unified and integrated medical staff structure after a majority vote by the members to maintain a separate and distinct medical staff for their respective hospital."

We have two hospitals with a single medical staff and board of directors since 2000. There is nothing in our Bylaws that addresses this standard (MS.01.01.01, EP 37). If you have any suggested language that I can use to help me address this in our Bylaws, I would appreciate receiving a copy.

Thanks, as always, and have a wonderful weekend!