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Develop the Right Medical Staff Structure

Analysis  |  By Credentialing Resource Center  
   September 14, 2020

While many medical staffs remain organized by clinical departments, there is no requirement to do so.

A version of this article was first published September 14, 2020, by HCPro's Credentialing Resource Center, a sibling publication to HealthLeaders.

Does your organized medical staff structure help or hinder the strategic development and mutual success of physicians and the hospital? 

A comprehensive medical staff development plan is incomplete without an analysis of the effectiveness of your medical staff structure and processes. The following best practices will help you conduct such an analysis:

  • Clear bylaws: Most medical staff bylaws resemble archaeological documents that are occasionally dusted off and modified to accommodate a new accreditation requirement or to address a current controversy. Well-written bylaws clearly define the purpose of the medical staff, promote good citizenship by clearly outlining the rights and responsibilities of members, foster excellent credentialing/privileging and peer review/performance improvement processes, and set unequivocal expectations for appropriate behavior.
  • Clinical services: While many medical staffs remain organized by clinical departments, there is no requirement to do so. Many medical staffs have moved to a clinical section or clinical service line model to achieve greater flexibility and higher quality patient care.
  • Committees: The only committee required by The Joint Commission is the medical executive committee. Effective medical staffs often have a credentials committee and a centralized, multi-specialty medical staff quality committee. Other committees are determined by strategic direction (e.g., a cancer committee for ACS certification or a trauma committee, if required). Other areas can be addressed as functions without the bureaucracy of ongoing committees, such as pharmacy and therapeutics, medical records, and infection control.
  • Policies and procedures: The effective medical staff develops clearly understood policies addressing key issues, such as code of conduct, medical record documentation, national patient safety goal compliance, conflicts of interest, and other areas of importance.
  • Credentialing and privileging: Credentialing and privileging processes need to be vigorous and rigorous without being onerous or unfair. Best practices include determining criteria-based privileges, developing new-technology privileges, creating a cross-specialty privilege dispute policy, and developing experienced medical staff credentials committee members. The seamless incorporation of focused professional practice evaluation for new privileges and ongoing performance practice evaluation for renewal of privileges are hallmarks of effective medical staffs.
  • Peer review and performance improvement: Peer review is the assessment and management of individual physician performance. The effective medical staff improves individual physician performance by setting and communicating clear expectations of performance, measuring performance, providing physicians with performance feedback on an ongoing basis, and designing processes to increase compliance and manage non-compliance. Performance improvement involves continuous changes to systems and processes to achieve ever-improving outcomes. An effective medical staff addresses the performance of individual physicians and actively participates in the hospital’s system and process improvement efforts.

The Credentialing Resource Center (CRC) is the premier destination for credentialing, privileging, and peer review expertise. Membership provides MSPs, quality professionals, and medical staff leaders with a collection of continuously updated tools, best practice strategies, and compliance tips developed by industry experts. With three membership tiers, you can customize your access level depending on your education and training needs. Learn more

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