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Small Hospital Challenges Monthly: Do you need to update your documents?

Medical Staff Leader Connection, November 19, 2008

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Dear medical staff professional and medical staff leader,

Many small hospitals find that updating their bylaws, rules and regulations, and policies and procedures is a real challenge. More than once, MSPs have told me, “We’re a small hospital—We don’t need to update our documents because we’re doing everything the same way we’ve done them for the past X years.” If you take this attitude, you are probably not up to date with new regulations or new best practices. No matter the size, all hospitals need to keep documentation regarding governance, credentialing and privileging, quality, and peer review current.

The best way to keep up with changes to your documentation is to create an ongoing process. If you wait until there is an urgent need for updated documents, you risk inconsistency. In addition, you may be cited during your next accreditation survey. Avoid the mad rush with these steps:

Assign a point person. Many hospitals recruit a person (usually an MSP) who is responsible for keeping up with new regulations and best practices by reading healthcare newsletters and participating in state and national meetings. This can be a problem for small hospitals because sending this point person to educational events may not be in the budget, but it is crucial to make the investment.

Assign your point person a point person. The MSP needs to be able to discuss pertinent changes with a medical staff member. A good "go-to" person may be the immediate past president of the medical staff who has seen, through personal experience, where the holes may be in the current documents. This person can lead the medical staff to make well-informed decisions regarding revisions to the bylaws, rules and regulations, and policies and procedures.

Get an external review. Every three to five years, hire an external reviewer to scour your documents. If you belong to a larger health system or affiliation, it may provide this service for you. Because larger hospitals have more dedicated resources, they may have local content experts who are skilled at identifying problems in medical staff documentation.

If you are not part of a larger affiliation, have an external expert review your policies to ensure they are current and audit your process to ensure the hospital is complying with them. A best practice is to internally audit your credentials process yearly and have an external audit every three to four years. Bylaws should be thoroughly reviewed every three to five years, and definitely after any major regulatory change.

Enforce, enforce, enforce. Sometimes, practitioners feel that they can fly under the radar at smaller hospitals. Although the number of these practitioners may not be large, do not let your small hospital become a haven for these individuals. The best way to ensure this is to have current documents that reflect best practices in the field.

Best regards,

Mary Hoppa, MD, MBA, CMSL
Senior consultant
The Greeley Company

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