Accreditation

How many policies should the medical staff approve?

Accreditation Insider, October 20, 2015

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With an increasing number of regulations, National Patient Safety Goals (NPSG), Sentinel Event Alerts, and changes in procedure, medical staff may feel like they're stuck in an endless cycle of creating and approving new policies—including policies that they may not really need to approve, such as a nursing policy regarding paid time off.

This issue may affect small to midsized hospitals, although larger hospitals and healthcare systems aren't immune to the seemingly neverending cycle of policy review.

"Smaller hospitals have a stronger oversight responsibility for all of the care; they don't give that up as easily," says Patty Roy, director for quality and medical affairs at Central Maine Medical Center (CMMC), which includes a 250-bed acute care hospital (ACH) and two critical access hospitals (CAH). "In our hospital, we have a more administrative, clinical arm over it, but it's not really medical staff-driven."

The medical staff is, overall, responsible for the quality of care in a hospital, so they could decide to review every single policy, but that's not manageable, Roy explains. Medical staff involvement is very important, but there are a lot of clinical staff policies and patient administrative policies they don't need to review.

This is an excerpt from an article in the monthly training resource Briefings on The Joint Commission. To read more, visit here to log in or subscribe.



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