An organized medical staff requires governance in order to function. This sounds straightforward enough, but what does it have to do with credentialing? Medical staff membership, staff categories, privileging, credentialing, suspensions, fair hearing rights, medical executive committee composition and function, department chairs, oversight of peer review—all these things, and more, are part of medical staff governance. Effective governance requires a solid structure, organization, and strong processes.
Medical staff bylaws, rules and regulations, and policies and procedures are the governing documents of your medical staff. Without this structure there would be chaos in the OR, the doctors'lounge, the ER, the Cath Lab, the parking lot, etc.Needless to say, these documents are important to the medical staff and the hospital.
Well written documents not only give structure to themedical staff, they are the definitive guidelines for all of the medical staff processes—including credentialing—thatmedical staff leaders and MSPs encounter.
Medical staff governance touches a huge area, as noted earlier. The first things to consider are regulatory requirements. There are certain elements that are required to be in your bylaws and rules and regulations. You must keep abreast of changes in state and federal regulations as well as standards requirements so your medical staff bylaws and rules and regulations are always in compliance.
FAQs
Medical Staff Governance. A medical staff organization has two major purposes. It establishes mechanisms for controlling the quality of care rendered by medical staff members and other practitioners granted clinical privileges.
What are the main topics addressed in a medical staff bylaws What is the importance of addressing those topics? ›
In general, bylaws should outline the administrative structure of the medical staff, how high-level decisions will be made in the organization, core due process rights of members, and the mechanism for adoption and amendment of governing documents.
What are medical staff privileges and how are they determined? ›
Hospital privileges authorize medical practitioners for a specific practice of patient care in a specified healthcare facility. Privileges are granted to physicians based on their current medical credentials and previous performance.
What is staff governance? ›
Staff Governance is defined as: “a system of corporate accountability for the fair and effective management of all staff.”
What is the governance structure of healthcare? ›
Hospital governance can be defined as the set of structures and processes that define the strategic direction for the hospital and the means by which resources are assembled and allocated to achieve them [4].
What are bylaws in simple terms? ›
Bylaws are a system of rules adopted by a corporation, organization or community to govern and regulate its members. Your business may have corporate bylaws for its internal affairs but must also follow government laws regarding taxes, permits and licenses.
What are the three most important aspects of professional responsibility a healthcare worker has toward their colleagues? ›
Health care is delivered by teams of professionals who need to communicate well, respecting the principles of honesty, respect for others, confidentiality and responsibility for their actions.
What is the purpose of the medical staff? ›
They're responsible for administering medicine, assessing a patient's overall health, and supporting their immediate needs.
What dictates how the medical staff operates? ›
Medical Staff Bylaws as a governing document are required by the Medicare Conditions of Participation for Hospitals, applicable accreditation organization standards (e.g., The Joint Commission, HFAP, DNV, etc.)
Who has ultimate responsibility for decisions about medical staff membership and why? ›
A healthcare provider's membership at a hospital is governed by the hospital's bylaws, which are approved by the hospital's governing body.
Privileging, however, involves authorizing a healthcare practitioner to perform specific clinical activities or procedures within their scope of practice. Unlike credentialing, which focuses on qualifications, privileging determines the specific patient care services a practitioner can deliver.
What is IT governance in healthcare? ›
IT governance in healthcare is the amalgamation of strategies, policies, and processes that ensure the effective and efficient use of IT to enable an organization to achieve its goals.
What is professional governance in healthcare? ›
Professional governance provides the structural framework for partnership across the clinical continuum, with organizational leadership, and with the clinical teams that collaborate to advance the health of individuals and communities.
What is information governance and why is it important in healthcare? ›
AHIMA defines IG as “an organizationwide framework for managing information throughout its life cycle and for supporting the organization's strategy, operations, regulatory, legal, risk and environmental requirements.” IG for Health Care Includes: All departments, areas of the organization. All types of organizatoins.
What is clinical governance for nurses? ›
Clinical governance is a shared responsibility to ensure that all patients receive the best care. Nurses, midwives and managers therefore share the common goal of optimising patient care.
