Addressing Consistency Among Clinical Department Rules and Regulations

Departmental rules and regulations can vary significantly in content and are often not reviewed on a regular basis; in some instances, they are also not regularly approved by the governing body.

This is an excerpt from an article that appeared on Credentialing Resource Center on July 10, 2017. 

Beyond the medical staff rules and regulations, many clinical departments choose to develop and implement department-specific rules and regulations. However, there is not much guidance from accreditors or consistancy among hospitals when it comes to department rules and regulations. Departmental rules and regulations can vary significantly in content and are often not reviewed on a regular basis; in some instances, they are also not regularly approved by the governing body.

In researching this column, it was found that department of surgery rules and regulations, range in content volume from three to 17 pages. This sheer variation in volume again reflects the varying content of similar documents from different facilities. 

For hospitals who are looking for some consistency among their departments' governing documents, or for departments looking to create or revise their documents, it is suggested that the following sections be included:

• Purpose: State the department's role in the care of patients 
• Leadership: Identify the chain of command; identify which positions are appointed or elected.
• Membership: The various types of professionals who function within the department and level of medical staff membership 
• Structure: Detail any divisions or subsections within the department and the responsibilities of those subsections.