Joint Commission FAQs – Medical Staff

Here are a few recent Joint Commission FAQ’s related to medical staff standards:

Q. Are organizations required to verify affiliations at other health care organizations, and if yes, for how many years back must the verifications be done?


Q. Can organizations use data from outside organizations in lieu of collecting their own data to accomplish the Ongoing Professional Practice Evaluation (OPPE)?  Can outside data be used for low volume practitioners?


Q:  Medical and Cognitive specialties (IM, FP, psychiatry, other med specialties, etc…) are very tough to identify meaningful data that can be evaluated. Is there any guidance that The Joint Commission can offer to assist organized medical staffs?


More FAQ’s from Joint Commission.

Reminder – NAMSS Recertification Due By December 1st

This is a reminder to those who need to recertify this year with the National Association Medical Staff Services:  (Those who received initial certification in 1980, 1983, 1986, 1989, 1992, 1995, 1998, 2001, 2004 or 2007. )

December 1, 2010

Single Certification
NAMSS Member $100
Non-Member $250

Dual Certification
NAMSS Member $125
Non-Member $275

Required Credits:

Single Certificants:
30 hours of continuing education; 15 of which must be NAMSS approved.

Dual Certificants:
45 hours of continuting education; 25 of which must be NAMSS approved.

Eligible CE Dates:
November 1, 2007 through December 1, 2010

So Many Patients, So Little Time?

Emily Berry’s HcPro Credentialing Resource Center Blog asks an important question in a recent post:

“It’s not uncommon for practitioners to hold privileges at more than one facility. But can a practitioner’s ambitions put patient care in jeopardy? Should medical staffs set a limit on how many different facilities they allow their privileged practitioners to practice at, or set limits on patient case load at each facility?”

I have attended medical executive committee meetings where this very issue was debated, usually in connection with patient care.  As a rule, rather than setting any practice standards for the medical staff, the MEC votes to warn individual practitioners that they must see their patients more frequently, on a more timely basis, or must improve their medical record documentation. 

It’s not a simple issue; much depends on a physician’s specialty and practice pattern.  For example, a skilled cardiac electrophysiologist or an infections disease specialist may be privileged at a number of area hospitals and successfully meet the needs of patients at each. 

The case that Ms. Berry cites, however,  involves an OB-Gyn, a speciality in which response time is often critical.   And what about the orthopaedic or urologic surgeons on your staff?  If they care for patients at multiple hospitals and serve on multiple call schedules, is their ability to deliver timely, quality care impacted?  In reality, how could it be otherwise?

Medical staff leaders are often reluctant to establish rules that infringe upon their colleague’s personal practice choices, but this is an issue that deserves thoughtful review.  Patients need physicians who are able to attend to them in a reasonable amount of time and who are not so exhausted they can barely function, and doctors need to care for themselves as well as their patients. 

Credentialing Software – A Treasure Trove of Hidden Gems

Most hospitals provide commercial software for their credentialing staff, and that’s good.  With so many deadlines, documents, providers, and privileges to track, trustworthy software is essential.   With the potential penalties for missing just one important document or deadline, keeping up with daily tasks can be daunting.

In my role as a consultant I have observed that many medical staff professionals, particularly those with limited access to IT support staff, often do not use their software well.  The problem is understandable; there are only so many hours in the day and learning and using complex database software is a skill set all its own.  Most software companies offer good technical support, but users may not know what to ask, or may not want to take the time to ask. 

MSP’s tend to be meticulous about entering information, and as a result, have built an impressive repository of excellent data.  However, unless they are able to perform regular audits and pull reports and statistics, much of that meaningful information remains hidden away behind firewalls.

Helping MSPs better manage and use their software and the valuable data it contains has been one of the most rewarding aspects of my work.  It’s a bit like discovering hidden treasure.

Medical Staff Services Awareness Week

November 7-13, 2010 is National Medical Staff Services Awareness Week.

The Medical Staff Service Professionals in your organization are, as this year’s NAMSS Awareness week poster suggests, the front line for patient safety.  By staying abreast of current standards, regulations and laws, your MSP’s are able to thoroughly verify the credentials, education and training of the physicians, nurse practitioners, physician assistants, and others who apply for clinical privileges to care for your patients.

But that is just the beginning of their role. 

Once physicians and other providers are granted privileges to practice within your organization, much work needs to be done to assure that both ongoing and focused review of their skills takes place. Your MSP likely works with Quality, Risk, Nursing, and other administrative departments, as well as medical staff leaders, to manage that very complex task. 

Take a moment this week to acknowledge the work of your medical staff professionals.  Like many important healthcare elements, much of what they do takes place out of the public eye, but it is not an overstatement to say that safe patient care has its foundation in the work they perform every day.

Happy Medical Staff Services Awareness Week.

Related article: 
What Did You Do Today?  Probably More Than You Think – Credentialing Resource Center Blog – Maggie Palmer