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Tips for orienting new medical staff members

Credentialing & Verification Update, September 12, 2007

In the last issue of CVU, we discussed the importance of having an orientation for physicians on the medical staff, due to the fact that there are many organizational and regulatory requirements of which physicians should be made aware. The following are basic recommendations for orientation content. MSPs should work with the appropriate parties to evaluate the needs of the medical staff and to determine the best way to communicate the information.

• Bylaws, rules and regulations, hearing and appeal policy: Applicants should be given copies of these documents. Typically, they are sent with the application packet. Consider including a protected copy on CD-ROM or, if it is available in a secure place online, providing a link so that the physician can access it as needed.
• Organizational policies: Physicians need access to organizational policies, in addition to the medical staff policies and procedures. Again, posting these on a secure Web site is ideal; however, the orientation packet at a minimum should include information about how to access all policies.
• Code of conduct: A copy of the code of conduct should be given to all physicians so that they know the behavior expectations upfront. You may want to include the organization's policies on disruptive behavior and handling of impaired practitioners. Physicians also should be educated on the process for self-reporting.
• Quality information: Physicians need to know basic information regarding how the quality and medical staff departments handle sentinel events, ongoing performance reviews, periodic feedback reports, and the peer-review process.
• Department-specific and credentialing requirements: This includes information about meeting attendance requirements, membership requirements, the process for requesting additional privileges, allied health staff, morbidity and mortality conferences, and call requirements.
• Clinical systems: Hospitals use a wide variety of clinical systems. Your organization should orient and train physicians to use these systems.
• Medical records requirements: Your organization must communicate information related to dictations, timely completion of records, legibility, interdisciplinary communication, countersignature requirements, etc., to physicians.
• Hospital codes: Like all employees, physicians need to know the hospital-specific safety codes.
• Health Insurance Portability and Accountability Act of 1996 (HIPAA): Include information regarding patient information, confidentiality, and privacy.
• Stark Law: Provide data about conflicts of interest, business gifts and courtesies, referrals, and so on.
• Emergency Medical Treatment and Labor Act of 1986 (EMTALA): Communicate information regarding the statues governed by EMTALA to all physicians.
• Any other information deemed appropriate by the credentials committee or medical staff leadership.

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