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Medical staff leadership: Pulling all of the pieces together

Medical Staff Leader Connection, June 25, 2008

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Dear Medical Staff Leader,

This is the last installment of my current series that defines the steps every new and experienced medical staff leader should take to be an effective medical staff president. Establishing the proper framework is essential to understanding where you are headed and what you and your team want to accomplish during your term. Let’s quickly review the first five steps of this framework:

• Build your team
• Coordinate a social event that is off-site and includes significant others
• Define your vision
• Develop a mission statement
• Build a strategic plan

Whether your term ends this year or you plan to place your name in back in the hat, such a framework easily adjusts to the ebbs and flows of leadership changes. To get you started on your leadership journey—or to validate any of these steps—I selected the following examples from best practices your colleagues across the nation have developed.

Step 1: Build your team
After elections, the president of the medical staff personally contacts newly identified leaders and/or established and respected practitioners with an offer to join the leadership team by taking on a role that matches each person's strengths. Once the team is established, the president of the medical staff conducts a formal meeting with those individuals to begin the relationship-building experience (don’t forget to include MSPs in this meeting!). During this meeting, outline the action steps the team will take to build its working framework.

Step 2: Coordinate a social event   
Six weeks after the election and appointment process is completed, the medical staff president sends an invitation to the team members’ homes to invite them and a guest to a reception and dinner. Invitations are also sent to key administrative leaders and MSPs and their guests. This event is a social gathering—no medical staff business allowed! 

Step 3: Define your vision
Ideally, your hospital’s vision should explicitly state that the medical staff genuinely cares about each patient, colleague, and employee.

Step 4: Develop a mission statement
Try including wording similar to this into your medical staff’s mission statement: "The medical staff is a group of physicians that strives to achieve excellence in support of the hospital’s mission by improving patient care and community health through effective quality monitoring, credentialing, and medical staff governance."

Here’s a freebie mantra to include in your mission statement: 

C = Compassion and commitment to serve with empathy
A =  Accountability with integrity and action
R =  Respect through treating others as you wish to be treated
E = Excellence in all we do

Step 5:  Build a strategic plan
Here’s a sample strategy and its accompanying goals. Following this format may help you develop your own strategic plan:

Strategy: Incorporate into the bylaws, rules and regulations, and policies and procedures the standards, regulations, and legislative mandates that become effective in 2009.

Goal(s): 

1. Obtain the 2009 standards and regulations from all relevant accrediting agencies (The Joint Commission, Health Care Financing Administration, Association of Academic Health Centers, etc.).
2. Obtain from the medical staff attorney the 2009 federal and state laws that affect physicians, allied health professionals (AHPs), and credentialing and privileging practices.
3. Obtain from the medical staff services department any proposed policies anticipated for implementation in 2009 (i.e. focused professional practice evaluation (FPPE), a newly created credentials policy, or revised existing policy).
4. Obtain from the forms committee any proposed forms that affect the medical staff organization anticipated for implementation in 2009 (i.e. peer review tracking report).

Action(s): 

1. The bylaws committee, vice president medical affairs, MSP, and the medical staff attorney will review relevant 2009 standards and submit compliance recommendations to the MEC by the third quarter of 2008.
2. The bylaws committee, vice president medical affairs, MSP, and the medical staff attorney will review federal and state laws that affect physicians, AHPs, and credentialing and privileging practices and submit compliance recommendations to the MEC by the first quarter of 2008.
3. The MSO will submit to the credentials committee draft proposals of newly developed policies and revisions to existing practices for review and recommendation to the bylaws committee by the second quarter of 2008.
4. The hospital’s form committee will submit to the appropriate medical staff department and/or committee for review and action forms and associated policies needing implementation in 2009 by the fourth quarter of 2008.

I hope these best-practice examples will help guide you as you build a framework to ensure a successful leadership term. What you do is important!  You are now ready to take action.

Until next we speak…SMILE

Donna K. Goestenkors, CPMSM
Consultant – Credentialing & Privileging Practice
The Greeley Company

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