Tip of the week: Don't overlook criteria required in the medical staff bylaws
Medical Staff Leader Connection, October 14, 2010
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When The Joint Commission moved the disaster privileging criteria standards out of the medical staff chapter of the Comprehensive Accreditation Manual for Hospitals and into the emergency management chapter, some organizations may have overlooked the following standard which requires that the information be in the medical staff bylaws:
“The medical staff identifies, in its bylaws, those individuals responsible for granting disaster privileges to volunteer licensed independent practitioners.”
Although MS.01.01.01 only states a description of the process must be included, this standard specifically states that you must also list in the bylaws who has the authority to grant the privileges. Many organizations include this in their disaster policy but may not have included those specific criteria in the actual bylaws. After clarification with The Joint Commission, it has been confirmed that this cannot be only in the medical staff policies, unless the policies go through the same approval process as the bylaws, which is unlikely as most hospitals do not require the active staff to vote on bylaw changes.
This tip was provided by Anne Roberts, CPMSM, CPCS, via MedicalStaffLeader.com
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