• E-mail
• Print
• RSS

Meeting attendance and activity requirements for medical staff membership

Credentialing Resource Center Connection, February 28, 2008

Want to receive articles like this one in your inbox? Subscribe to Credentialing Resource Center Connection!

Anne Roberts, CPMSM, CPCS, is the director of medical affairs at Children's Medical Center in Dallas, where she oversees the medical administration, graduate medical education, and medical staff services departments.

Dear credentialing colleague:

One of the most challenging organizational changes that I have faced over the past few years is the concept of clearly separating medical staff membership from clinical privileges. I work in a large academic medical center where there is a clear distinction related to the composition of our medical staff. Our once small, primarily community-based hospital has evolved over the years into a large academic medical center where the majority of the patient care is provided by faculty members. Although a large percentage of our staff consists of private practitioners, the volume of care that they provide in the hospital is low.

In the past, the "active staff" membership category was always tied to the number of meetings the medical staff member participated in, and how many patients he or she admitted or acted as the attending physician for. As our hospitalist service expanded, a lot of our community physicians elected to admit their patients to the hospitalist service, and therefore no longer met the admission requirements for active staff membership. We are continuing our expansion by opening a new hospital approximately 30 miles north of our main campus, and we think this an optimal time to reevaluate our membership requirements.

Defining active staff: The first question that we had to ask ourselves was, "How do we define 'active staff'?" With the help of Joseph Cooper, MD, a consultant with The Greeley Company, a division of HCPro, Inc., located in Marblehead, MA, our medical staff leaders determined that our active members are those practitioners who:

• Participate in the governance of the medical staff. This includes participating in:
  -   Quality and performance improvement initiatives
  -   Electing officers
  -   Voting on revisions to our governing documents
• Our elected officers, department chairs, committee chairs, and those who have a specified amount of activity within our organization. This activity includes a measurable amount of:
  -   Consults
  -   Referrals
  -   Admissions
  -   Attending days
  -   Teaching hours
  -   Committee work

Meeting attendance: The second question we asked ourselves was whether we wanted to continue requiring attendance at general staff meetings or department meetings. To answer this, we reviewed requirements at other facilities comparable to our own as well as data from prior surveys. We concluded that meetings involving the medical staff as a whole were no longer effective, particularly since we were no longer a small, community hospital. The medical staff today prefers to receive communications through electronic means, such as an e-newsletter or a physician Internet portal. As a result, our medical staff leaders and our bylaws committee recommended removing this requirement. However, it is important to recognize that this does not relate to official medical staff committee meetings, such as the medical executive committee (MEC) or medical records committee. Active members who are appointed to medical staff committees are still required to attend 75% of the meetings on an annual basis.

Privilege delineations: The last critical process we reviewed was our privileging system to ensure that our practitioners' privileges were separate from their membership. Once a physician qualified for medical staff membership, the next step was to determine what privileges he or she qualified for. Each of the clinical department chiefs revised the privilege delineation for their specialty based solely on minimum threshold criteria that demonstrates current clinical competency. Many of the departments incorporated categories of privileges that would allow a physician to refer and follow his or her patients, but not act as the inpatient attending. Other departments, such as surgical transplant, elected to include an option for a surgeon to consult or assist, but not act as the primary surgeon. These options would still allow someone to be an active member of the medical staff without granting full clinical and admitting/attending privileges. Instead, our organization is able to grant privileges that reflect the level of care the practitioner provides in our organization.

Keeping membership separate from clinical privileges can be challenging not only for an MSP, but also for physician leaders who, in the past, have associated active membership with admitting privileges. Understanding the concept of membership is the first step in making this transition.

Remember, clear, effective communication is the key to success!

That's all for this week.

All the best,

Anne Roberts, CPMSM, CPCS

Want to receive articles like this one in your inbox? Subscribe to Credentialing Resource Center Connection!

• Comment
• E-mail to a Colleague
• Print
• RSS
• Archive

Comments