Medical staff committee

1. Medical staff
committee

2. Purpose
• Medical staff committee acts as the organizational body
which oversees the functions of medical staff.
• It is empowered to act for the staff and to coordinate all
activities and policies of the staff, review its credentials
and its departments and committees.
• An important area of responsibility for the Board is that of
medical affairs. Trustees are responsible for all activities
of the hospital, including ensuring the quality of the
medical care

3. • This does not mean that the Board tells physicians how
to treat their patients. Just as there is a way to delegate
the administrative activities of the hospital, there is a way
to delegate and yet control the quality of health care.
• The Governing Board grants to the medical staff the
privilege of establishing its own bylaws, rules and
regulations. These must have the approval of the Board
to become effective. The medical staff holds individual
members accountable for the quality of care they provide
to their patients

4. The role of Governing Board
• The Governing Board is responsible for the quality of patient care.
In exercising that responsibility, the Board has final approval of
the selection of a qualified medical staff. In reviewing the
recommendations made to the Board by the medical staff, the
Governing Board should be sure that it:
• Reviews and approves the medical staff bylaws.
• Reviews and approves the criteria and procedures used for the
credentialing and privileging of the medical staff.
• Ensures that data regarding clinical competence is acquired and
considered prior to making a recommendation.
• Ensures that the procedures and polices are followed.
• Considers the overall mission and needs of the hospital.
• Communicates with the medical staff when there are questions or
areas of disagreement.

5. Medical Staff Committee Structure
• This committee may be composed of the elected physicians plus
the department chairs. In a small hospital, the medical staff
serves as a committee of the whole.
• Committees are usually established to carry out the medical
staff’s functions and activities. For example, many medical staffs
perform the primary activities of credentialing and privileging
through a credentials committee. It is important to remember that
required quality assurance functions are often handled by
committee(s):
• Surgical case monitoring
• Drug usage
• Pharmacy and therapeutics
• Medical records
• Mortality and morbidity
• Medical care review/peer review

6. Duties
• Represent the medical staff and act on its behalf, as
needed under the limitations imposed by bylaws.
• Be regularly involved in medical staff management,
including the enforcements of rules and regulations, and
oversight of committee and departmental affairs.
• Coordinate the activities and general policies of various
departments and services as required.
• Receive and act on committee reports and make
required recommendations to the governing bodies
pursuant to these bylaws.
• Implement the policies of medical staff not otherwise the
responsibility of clinical personnel

7. • Take all reasonable steps to insure professionally ethical
conduct on the part of all members of the medical staff
and to initiate and/ or participate in medical staff
corrective action as required by the bylaws.
• provide liaison between medical staff and the chief
executive officer and the governing bodies.
• Recommend action to the chief executive officer on
matters of a medico administrative nature.
• Make recommendations on hospital management
matters including, but not limited to, long-range planning
to the governing bodies through the CEO

8. • Fulfill the medical staffs accountability to the governing
bodies for the medical care rendered to patients in the
hospitals by making recommendations directly to the
governing bodies concerning, but not limited to the
following: the structure of the medical staff, mechanism
used to review credentials and delineate individual
clinical privileges, recommendations for delineated
clinical privileges for each eligible individual, the
organization of quality assessment activities of the
medical staff as well as the mechanism used to conduct,
evaluate and revise such activities.

9. Medical Staff Bylaws
The medical staff has its own set of bylaws which are the guidelines for its
operation. The medical staff bylaws provide for a group of officers and a
committee structure designed to carry out the functions and duties of the
medical staff. The medical staff bylaws must be approved by the Governing
Board and should spell out:
• How individuals are to be recommended for staff appointments and hospital
privileges. This includes the qualifications and performance standards to be
met by candidates for initial appointment and the criteria and procedures for
recommending privileges.
• Mechanisms for monitoring the performance of the medical staff.
• The organizational structure of the medical staff, including the function, size
and composition of committees and the method for selecting members
• Procedures for automatic and summary suspension of staff membership
and/or clinical privileges.
• Mechanisms for fair hearing and appellate review.
• Procedures for confidential maintenance of peer review records.
• Criteria and procedures for specialist consultation.
• Requirements for medical staff participation in the risk management and
quality management programs of the hospital.
• Requirements for frequency of meetings and attendance.

10. Appointment, Reappointment
and Delineation of Privileges
• It is important that the criteria for medical staff membership and the
credentialing and privileging process be objective and based upon the
competence of the practitioner. Membership on the medical staff is a
privilege, not a right. The criteria for granting staff membership must
be reasonable and non-discriminatory. It is critical for Board members to
be assured that a practitioner or group of practitioners is not being
arbitrarily denied appointment. In order to guard against such a potential
occurrence, the criteria for medical staff membership must be clearly
stated in the medical staff bylaws, and followed in the credentialing and
privileging process.
• At least every two years, a review of credentials is required of all clinical
staff employed by or associated with the hospital. This includes a review
of the physical and mental capacity, competence and performance of
practitioners in delivering health care.
• Upon recommendation from the medical staff, the Board makes the final
decision on each appointment, reappointment and granting of privileges.

11. Initial Appointment to the Medical Staff
The appointment of a practitioner to the medical staff enables that individual to diagnose
illnesses and perform procedures in the hospital. Initial appointment to the medical staff
should
occur only when the following have been reviewed:
• Documentation of medical school graduation and residency
• Evidence of current licensure
• Relevant training and/or experience
• Current competence
• Physical and mental health status
• Evidence of adequate professional liability insurance
• Letters of recommendation
• Prior to the granting or reviewing of an appointment and privileges, the hospital should
request the following information from hospitals with which that practitioner was
associated:
• Any pending professional misconduct proceedings.
• Any judgment or settlement of a malpractice action or findings of professional misconduct.
• Information related to the practitioner’s professional practice during the last ten years.
• Verification of the above information is critical to the appointment process. Initial
appointment can be made for a provisional period, usually for not more two years. At that
point, the individual should be reviewed. Information must be obtained from the National
Practitioner Data Bank at each appointment and reappointment time.

12. Reappointment
• The reappointment process should include an evaluation of demonstrated
competence. The hospital will have its own record of the physician’s performance
as well as the physician profile, which is composed of information from the
following:
• Mortality and morbidity review
• Tissue review
• Medical record review
• Infection control review
• Utilization review
• Patient complaints
• Safety committee review
• Liability claims data
• PRO data
• Drug utilization review
• Surgical case review
• Medical case review
• Any medical care evaluations
• Participation in continuing education
• National Practitioner Data Bank in UK not as such in India.
The hospital must check with the National Practitioner Data Bank unless it has
knowledge of
any information that has been reported to the Data Bank.

13. Delineation of Privileges
• The privileges granted to members of the medical staff must be
consistent with their training and experience. In delineating clinical
privileges, there should be specific qualifications identified with
having certain privileges. There should be a procedure for granting and
withdrawing privileges.
• Hospitals should not continue to grant privileges to physicians for
services which they do not routinely perform. There is considerable
evidence in medical literature which shows that favourable outcomes for
a number of procedures are directly related to how frequently the
procedure is performed.
• The need for specific services can also be taken into consideration
in the granting of clinical privileges. Hospitals must be able to provide
appropriate facilities and support services for the practitioner and the
patient. In those instances in which there is a lack of either facilities or
services, privileges may be denied.
• Medical staff membership does not automatically confer the privilege to
admit patients. When non-physicians are granted admitting privileges, a
qualified physician must perform a prompt medical evaluation of the
patient. The privilege of admitting patients is a clinical privilege
delineated for each practitioner.

14. DUE PROCESS
• Due process procedures must be in place and defined in the medical staff bylaws. Fair
hearing procedures and the opportunity for appellate review must be extended to
members of the medical staff. In credentialing cases, the bylaws should state the
period of time within which a practitioner will be notified of an adverse decision and his
or her right to request a hearing.
RECRUITMENT AND RETENTION
• Recruitment of physician staff should be carefully planned to meet the needs of
the community. Hospital/health system trustees should consider current available
staff, appropriate services which can be efficiently provided, the hospital’s geography,
population demographics, community needs and location of referral sources in
determining the types of physicians to recruit. This information can be used to
develop a medical staff recruitment plan. Recruitment of physicians can be
particularly challenging for hospitals in rural communities. Hospital/health systems
should consult legal counsel before offering recruitment inducements to physicians
including income guarantee. Once recruited, all hospitals should be concerned about
keeping their medical staff.
• Retaining a stable medical staff involves including physicians in the planning processes
of the hospital. Inclusion in Governing Board meetings and on committees is one
method to accomplish this goal. Trust, communication and cooperation of the
Governing Board, CEO and medical staff as they work together to carry out the
hospital’s mission is important to having and keeping a quality medical staff. The
successful hospital is one where there is a shared sense of mission between the
Governing Board, management staff and the medical staff.

15. Credentialing
A) Purpose
• To assist in fulfilling the responsibility of the Medical Staff to assure that
practitioners permitted to provide patient services independently in the
Hospital are granted Clinical Privileges consistent with their individual
training, experience, current competency and other qualifications;
• To assure that each eligible applicant is afforded equal opportunity to be
appointed or reappointed to the Medical Staff;
• To assure that adequate information pertaining to education, training,
relevant experience, and current competency is reviewed by the
appropriate individuals and committees prior to rendering a recommendation
to the Board.
B) Conditions and Duration of Appointments:-
 Not more than 2 years.
 The applicant shall have the burden of producing adequate information for a
proper evaluation.
 Every application shall include a statement that the Applicant has received
and
read the Medical Staff Bylaws and Rules and Regulations and Policies .

16. Governing board
Executive committee
Credentialing committee
Medical staff committee
Process application

17. C) Initial Appointment.
 Request for Medical Staff Application- for eligibility of applicant.
 Medical Staff Application-Eligible applicant desired to the post should
submit it.
The application must include the following:
 completed and signed Intended Practice Plan; completed and signed
application form; completed and signed privilege form, if applicable;
application fee as established by the Executive Committee;
 appropriate life support/resuscitation certifications or equivalent training as
defined by policy;
 evidence of participation or application for participation in Medicare,
Medicaid or other federal healthcare programs;
 information regarding involvement in a professional liability action (at a
minimum, substance of the allegations, disposition of the case, and
amount of settlement or judgment);
 information regarding physical and mental health status as it related to the
privileges requested, with or without accommodation;
 nature and disposition of any criminal charges ever brought against
applicant.

18. D) Primary source verification will be done by Medical Staff Services
 medical school
 internship
 residency
 fellowship
 board certification
 hospital affiliations--current and previous
 licenses–current and previous
 peer references (3)
 State Patrol Criminal History Check
 health status as it relates to privileges requested, with or without accommodation.
E) Credentials First Review-review the application for completeness and
appropriateness for medical staff membership .
F) Complete Application- All queries and questions are answered.
G) Approval Process
 Division Chief or Designee Review
 Credentials Committee Review/Recommendation
 Executive Committee Review/Recommendation.
 Board Action
Similarly Reappointment/ Reconsideration/ Clinical Privileges are
processed.

19. Categories of medical staff membership
There are five categories of Medical Staff membership:
Active-These practitioners admit patients to the Hospital or are involved
in the care of their patients in the Hospital or are involved in Hospital
or Medical Staff activities
Affiliate-These are physicians who refer their patients to the hospital
and may follow their in-patient care. They may write admitting orders
and may admit only to an Active Staff member. When qualified by
training they may assist in surgery
Community-based, consultative-These are physicians who refer their
patients to the hospital for admission and testing.
Honorary.-Practitioners who are retired from the Medical Staff, or are
honored by emeritus positions, or have outstanding professional
achievements may be considered by the Credentials Committee for
Honorary Status Assignment of members of the Medical Staff to one
of these categories shall be made by the Credentials Committee,
subject to approval by the Governing Body.

20. SUMMARY SUSPENSION
A) Precautionary Summary Suspension:- may be on recommendations of
 Action by Credentials Committee.
 Continuity of Patient Care-responsible Division Chief, shall have responsibility to
provide for alternative medical coverage for the patients of the affected practitioner still
in the Hospital(s) at the time of such suspension.
B) Automatic Suspension
State License- Revocation, Restriction, Suspension, Probation.
SEXUAL HARASSMENT
• The Medical Staff of the Hospital prohibits all forms of sexual harassment of Hospital
employees or Medical Staff Members.
• Sexual harassment is a form of unlawful discrimination, and is a violation of the Medical
Staff’s policy. It includes unwelcome sexual advances and requests of sexual favors,
displays of sexual oriented materials, and other verbal, physical, or visual conduct of a
sexual nature.
• Incidents of alleged sexual harassment by Hospital employees against Members of the
Medical Staff.
• Incidents of alleged sexual harassment by Medical Staff Members should be promptly
reported in accordance with the Hospital policy and procedure. Human Resources will
report the allegation to the President of the Medical Staff or to the Medical Staff Quality
Review Committee (MSQRC).

21. Peer review committee
Peer review committee has following functions
A) Identifying the performance problems of staff.
B) Notify the Physician who found liable in due negligence
or could not perform his duties.
C) outcomes and alternative for actions.

22. WELL BEING POLICY & PROCEDURE
Members of the Medical Staff have the responsibility to their patients,
colleagues, and the Hospital to provide care in accordance with expected
community standards. Staff Members must be able to work in a drug free
environment and must themselves be free from the effects of any
performance-impairing substance, behavior or physical condition.
A. Practitioner Well Being Committee (PWBC)
The Practitioner Well Being Committee is a standing committee of the Medical
Staff whose duty it is
(1) to evaluate the competency of and qualifications of practitioners referred
to it with respect to possible impairment of their ability to practice with
reasonable skill and safety to patients;
(2) to encourage practitioner treatment and rehabilitation, and to promote
wellness; and
(3) to educate the Medical Staff and Hospital community regarding the
problem of the impaired practitioner

23. Procedure
A. Investigation and Evaluation.
 Report.
 Confidentiality of Sources.
 Investigation.
B. Reporting and Recommendation
C. Expedited Procedure for Reports of Suspected Acute Impairment.
 Report and Investigation.
 Action
D. Treatment and Rehabilitation.
E. Physician Appeal
If at any point in time a practitioner’s Privileges are restricted, suspended or
terminated as a result of a recommendation made by the PWBC, the
practitioner will have the right to a fair hearing under the Medical Staff
Bylaws and Fair Hearing Plan

24. Standing committees
• Some more purposes of the committee
 Cancer
 Clinical case review
 Emergency management
 Code blue
 Ethics
 Finance
 Health
 Infection control
 Institutional review
 Medical records
 Occurrence analysis
 Performance improvement council

25. • THANK YOU