Module 10: Medical Staff Services

Welcome to Medical Staff Services!

Note: This journal entry should address the department that is responsible for credentialing the medical staff and any associated activities.

Accrediting bodies such as the Joint Commission and state licensure laws require that every hospital must have an organized medical staff. The medical staff (MS) has the overall responsibility for the quality of professional patient care services and is accountable to the governing board (GB) for the facility. All medical staff members must have delineated privileges that allow them to provide patient care services respective of each physician's professional qualifications. All members of the medical staff must comply with bylaws, rules and regulations. Medical Staff bylaws outline the organization and guiding principles of the MS. Rules and regulations outline the mechanisms used to implement the principles contained in the bylaws. The bylaws, rules and regulations have legal standing.

Physicians must apply for medical staff membership and/or clinical privileges from the GB. Their applications are evaluated on the basis of education, experience, ethics, competence, physical health status, and proof of current licensure. Appointment to the MS cannot exceed 2 years without having a mechanism for reappointment in which there is a reevaluation of the physician's professional performance (performance appraisal) that includes reviewing reasonable indicators of continuing qualifications. Initial appointment and reappointment to the MS also requires an inquiry to the National Practitioner Data Bank (NPDB) to evaluate if any adverse actions have been taken and recorded against the physician such as malpractice.

Medical staff bylaws must provide a mechanism to elect officers to medical staff committees. Medical staff committees serve as a peer review mechanism (i.e.- physician-to-physician) of medical cases. This is most often done by reviewing the patients' medical records, to determine the appropriateness and quality of care. Examples of MS committees include: Surgical Case Review Committee, Infection Control Committee, Blood Utilization Review Committee, Pharmacy and Therapeutics Committee, etc. This is often under the oversight of the chief of staff who is responsible for presiding at staff meetings, appointing MS committees, and communicating the views of the medical staff to the hospital administrator and the GB., At minimum, there must be an Executive Committee which acts for the medical staff between meetings.