Tip of the Week: Medical Staff bylaws
Accreditation Connection, August 1, 2005
Survey tips:
-Review bylaws for process and time frames for MS appraisals and qualifications; ensure requirements for history and physical exam timelines are specified
-Review credential files to verify information is up to date and complete
-If there is a MS executive committee, verify that the majority of members are doctors of medicine or osteopathy
Suggested documents:
-MS bylaws/policies/procedures
-MS organizational structure including reporting relationship to governing body
-Credentials committee meeting minutes
-MS executive committee meeting minutes
Source: Adapted from The CMS-JCAHO Crosswalk: A side-by-side analysis of the CMS Conditions of Participation and JCAHO standards, published by HCPro, Inc., 2005.
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