Medical Staff

Quality begins with you

Medical Staff Leader Connection, June 21, 2007

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Dear medical staff leader:

If you are like most physicians, when you hear the word quality your first thought is about the kind of patient care you provide every day. Such a reaction is natural for most healthcare providers and it is one you should hold on to. After all, isn't making a difference in patients' lives the reason you became a physician?

However, as a medical staff leader, you know that quality concerns extend beyond patient care you personally deliver. It is up to you to ensure your colleagues also approach patient care with compassion and skill.

Historically, care provided by medical staff and the integrity of a hospital's processes have been evaluated as the following separate functions:

Credentialing: Performed procedures
Indicators: Monitored elements in departments and/or clinical services
Trends: Identified practice patterns identified
Measurements: Evaluation of these elements
Educational: Action taken to modify a pattern or behavior

To support these functions, representatives of the hospital's quality department often collect data used by the medical staff to evaluate appropriateness. However, outcomes of these reviews are not correlated to the services the hospital provides. Quality professionals are rarely part of the decision making.

The good news is that The Joint Commission and the Centers for Medicare & Medicaid Services (CMS) have revised their standards in the last two years to help medical staff and hospital administrators join these two tracks of performance.

It is vitally important that practitioner performance reviews are confidential. It is equally important that data that affects how medical staff work are enhanced by the design of hospital operations. The facility service lines and the employees who support these services must be highly skilled. Patient care depends on the collaboration between these employees and the medical staff to achieve the best possible outcomes. There are many approaches to accomplishing this unity of purpose.  Here are just a few strategies that you might consider when evaluating your current medical staff quality program:


1. Build and/or strengthen the relationship between the medical staff services department and the quality department.
2. Hire a dedicated quality analyst or coordinator as a member of the medical staff services department. This person will implement the goals of a medical staff quality program and collect and analyze credentialing and privileging data.  They will also work directly with the vice president of medical affairs, medical staff leaders, and the quality department.
3. Identify a medical staff quality champion and appoint this physician to serve on the quality committee of the board of directors.
4. Identify a physician leader to be spokesperson on quality trends, information, and results at clinical department and staff meetings.
5. Always have medical staff and hospital quality as standard agenda items.
6. Revise your medical staff strategic plan to include goals and tasks that support a structured quality program. Include specific tasks that address expected practitioner behavior and performance as well as hospital quality.
7. Incorporate a reference to quality in your medical staff's mission statement.

These are just a few ideas to consider that will help demonstrate your medical staff's commitment to quality. As a medical staff leader, you have the responsibility to drive the level of quality you and your peers provide.  Satisfaction will be realized by patients, medical staff members, and the hospital.
As important members of your medical staff, you indeed make positive contributions toward making a difference!  I so respect and appreciate all you do.
Remember, quality is:

Q = Quantitative/qualitative excellence in patient care
U = Universal practices
A = Action in reinforcing positive outcomes and providing ongoing    education
L = Life time commitment
I = Integrity, honest delivery and presentation of information
T = Together, working toward one goal
Y = Begins with YOU


Until next we speak . . . SMILE!

Donna G.

Donna K. Goestenkors, CPMSM
The Greeley Company
Consultant, credentialing and privileging practice



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