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New Year, New Standards!

Credentialing Resource Center Connection, December 30, 2008

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

Dear credentialing colleague:

In the busy world of credentialing and privileging, it’s important to step back from time to time to look at the bigger picture: how the rest of the medical staff functions. As most MSPs in leadership roles are typically responsible for assisting with the compliance of the medical staff standards, not just the credentialing and privileging sections, it is important for MSPs to be aware of the other Joint Commission standards that impact the medical staff. This week’s column examines the role of medical staff leaders.

The Joint Commission’s 2009 leadership chapter has been re-written to specifically identify the responsibilities of three key leadership groups: the governing body, senior managers, and the organized medical staff. The revised standards focus on the responsibilities of each group and also identify shared responsibilities among the leadership groups.

The Joint Commission highlights the involvement of medical staff leaders in an organization’s governance. In LD.01.03.01, element of performance 10, (EP 10), the accreditor now requires that organized medical staff members be eligible for full membership in the hospital’s governing body, unless legally prohibited. Additionally, EP’s that were previously a part of the medical staff chapter have been incorporated into the new leadership chapter.

Now, leaders must attend governance orientation. LD.01.07.01, EP 2, details required elements of the medical staff leadership orientation, including:

• The hospital’s mission and vision
• The hospital’s quality and safety goals
• The hospital’s structure and the decision making process
• The development of the budget as well as the interpretation of the hospital’s financial statements
• The population served by the hospital and any issues related to that population(s)
• The individual and interdependent responsibilities and accountabilities of the governing body, senior managers, and leaders of the organized medical staff as they relate to supporting the mission of the hospital and to providing safe and quality care
• Applicable laws and regulations

Orientation of the above items can be accomplished in many different ways including annual orientation meetings, online manuals, or medical staff leader handbooks. While it is unlikely that each medical staff leader will have time to read all of the policies and procedures that apply to their role, they should have the information available should questions arise.

The new leadership chapter has several other new requirements that impact medical staff leaders, including involvement in the development of the organization’s conflict of interest policy, code of conduct, and review and approval of the use of clinical practice guidelines. MSPs should be familiar with these new requirements and work with the applicable departments to ensure that the medical staff leaders are involved in the required governance as outlined in this chapter.

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

That's all for this week.

All the best,

Anne Roberts, CPMSM, CPCS

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