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Medical Staff Leader Connection

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Medical Staff Leader Connection

Issue 19, May 15, 2007

• Gather data to measure competency of low-volume providers

  The challenge for a medical executive or credentialing committee in processing applications for...

Issue 10, March 8, 2007

• Ask the Expert: Who chooses the external peer review expert...?

  If the hospital is considering an external peer review, it should share that information with the...

Issue 50, December 27, 2007

• Part 3: Strategies for solving the challenges posed by low-volume providers

  Dear medical staff leader: Many primary care physicians have decreased their hospital activity and...

• Tip of the week: Develop a customized leadership training program

  Develop a customized leadership training program with input from past, current, and potential...

• Ask the expert: How should we orient new medical staff leaders?

  Your orientation program for new and current physician leaders should teach skills...

Issue 49, December 19, 2007

• Part 2: Strategies for solving the challenges posed by low-volume providers

  My letter this week discusses strategies to address the challenge posed by practitioners who have...

• Tip of the week: Plan interventions with disruptive docs

  Conducting an intervention with a disruptive medical staff member can be emotionally draining for...

• Ask the expert: When can we use our expedited credentialing policy?

  Once the application is complete and verified, the medical staff has opportunities to speed up the...

Issue 48, December 12, 2007

• Part One: Solve the challenges posed by low-volume providers

  Dear medical staff leader: It is likely that your credentials committee currently has a...

• Part One: Solve the challenges posed by low-volume providers

  Dear medical staff leader: It is likely that your credentials committee currently has a...

• Tip of the week: Create idea boards

  As part of the ongoing commitment to continuously improving their quality of service, many Ritz...

• Ask the expert: When should I delegate some of my leadership duties?

  Leaders often struggle to delegate. However, the ability to delegate responsibility for day-to-day...

Issue 47, December 6, 2007

• Securing physician-hospital success

  Dear medical staff leader: Medical staff leaders know that quality is at the heart of everything...

• Ask the Expert: What information should we gather from a physician applying for a new-technology privilege?

  The practitioner applying for the new privilege should supply medical staff leadership with the...

• Tip of the Week: Invest in medical staff leadership

  Leadership is a developed set of competencies including behavioral attributes, knowledge, skills...

Issue 45, November 29, 2007

• Medical staff leadership: Getting together

  In my last column I offered a tip for both new and experienced medical staff leaders on the vital...

• Tip of the week: Beware of ineffective peer review

  Unfortunately, ineffective peer review can and does happen at hospitals across the country. An...

• Ask the expert: How do we make leadership positions more attractive?

  It is difficult for physician leaders to balance the job of being a physician with that of being a...

Issue 44, November 15, 2007

• Disciplinary time out

  Dear medical staff leader: How many hours has your medical executive committee (MEC) spent...

• Tip of the week: Streamlining the medical staff categories

  Medical staffs often have categories and subcategories to describe the status of physicians who...

• Ask the expert: Who should oversee the focused professional practice evaluation program?

  Establish early in your focused professional practice evaluation (FPPE) policy which committee or...

Issue 43, November 7, 2007

• Special meeting attendance requirement

  Dear medical Staff leader: Today’s medical staff leaders are encountering many challenges...

• Tip of the week: Decision-making guidelines for physician leaders

  Decision-making is the essence of an effective group. Meetings usually include action items that...

• Ask the expert: Why are we experiencing an increase in privileging disputes/turf battles?

  The number of privileging disputes occurring in hospitals is growing rapidly. It’s easy to...

Issue 42, November 1, 2007

• Medical Staff Culture- Part 4

  Dear medical staff leader: Medical staff leaders need to be aware of diversity-related conflicts...

• Ask the expert: How should an organization transmit proctoring results within the medical staff?

  You should treat proctoring results in the same manner as other peer review findings. You should...

• Tip of the week: Develop a medical staff communication plan

  Medical staff leaders need to communicate with multiple stakeholders-the medical staff, the...

Issue 41, October 25, 2007

• Tip of the week: Make the physician leadership position visible

  It is essential that current physician leaders, administrative and board officers, and the...

• Ask the expert: How do you determine whether a disruptive behavior concern is a confirmed problem?

  When concerns regarding a physician’s disruptive behavior arise, the medical staff...

• What should not trigger a fair hearing?

  Dear medical staff leader: Last month we talked about the actions that should trigger a fair...

Issue 40, October 18, 2007

• Tip of the week: A solid selection process makes for strong medical staff leaders

  In the coming months, hospitals around the country will undertake the annual task of selecting...

• Ask the expert: Who should be responsible for proctoring costs?

  In most organizations, the hospital or parent institution incurs the cost of proctoring. In some...

• Tips to discuss performance issues with physicians

  Dear medical staff leaders: One of the major responsibilities of the medical staff is to monitor...

Issue 39, October 11, 2007

• Medical Staff Culture- Part 3

  Dear medical staff leader: The primary function of a medical staff leader is to help other fellow...

• Tip of the week: Implement a successful medical staff leadership-training program

  Hospitals may already have the resources necessary for an effective in-house medical staff...

• Ask the expert: Encourage participation during meetings

  Strong, but not dictatorial, leadership is a key to encouraging open discussion and participation...

Issue 38, October 4, 2007

• Fair Hearing Triggers

  Dear medical staff leader: In the early 1980’s the medical community increased its efforts...

• Ask the expert:

  What is the role of a panel member during a fair hearing? Panel members are required to listen...

• Tip of the week: Dealing with Burnout: What physicians need to know before returning to work

  When a physician experiences burnout, he or she often chooses to deal with the problem in private...

Issue 37, September 27, 2007

• How to handle disruptive physician behavior

  Dear medical staff leader: Disruptive physician behavior is a hot topic and many clients have...

• Ask the Expert: What type of selection process makes for strong medical staff leaders?

  Whether your organization chooses medical staff leaders through elections or by appointment, it can...

• Tip of the week: Understand the appraisal and reappraisal process of low- and no-volume providers

  Medical staff professionals must understand each step of the medical staff appraisal/reappraisal...

Issue 36, September 20, 2007

• Medical Staff Culture -- Part 2

  Dear medical staff leader:  Last month, we asked the question: What is your medical staff...

• Tip of the Week:

  Encourage reporting of disruptive physician behavior: The importance of creating a reporting...

• Ask the Expert:

  Is ED call a solvable problem?   The ED call problem, at least at present, is not a solvable...

Issue 35, September 13, 2007

• How many medical staff committees do we really need?

  Dear medical staff leader: Nowadays medical staff members attend between 15 to 20 medical staff...

• Tip of the week:

  Performance feedback profile: Identify opportunities for improving physician...

• Ask the expert

  What should an effective proctoring policy include? Based on review of proctoring policies from...

Issue 34, September 5, 2007

• Strengthen your disruptive behavior policy

  Dear medical staff leader: One of the most frequent questions I have heard over the past several...

• Ask the Expert: How should medical staffs document and retain proctoring results?

  Proctors should be required to complete formal documentation of their activities and findings. If...

• Tip of the week: Procedural due process

  Although the hospital has the authority and obligation to evaluate medical staff members and...

Issue 33, August 29, 2007

• Medical Staff Culture- Part 1

  Dear medical staff leader: What is your medical staff culture? The answer is more important than...

• Tip of the week: Physician roles in the hospital organization

  Physician leaders must understand their organizational roles. They must help colleagues understand...

• Ask the Expert: What does ’zero-tolerance’ policy mean?

  Many medical staffs are adopting a zero-tolerance policy with regard to disruptive behavior, but...

Issue 32, August 22, 2007

• Automatic Relinquishment

  Dear medical staff leader: Most medical staff bylaws have a section that describes "automatic...

• Tip of the week: Get a better handle on credential files

  Credential files shall be controlled by an outgoing and logging system. When a practitioner's file...

• Ask the Expert: Can the Internet be used to get additional information on a medical staff applicant?

  Entering the applicant's name into a search engine such as Google (www.Google.com) can yield...

Issue 31, August 15, 2007

• What makes a great physician leader?

  Dear medical staff leader:It is often assumed that the skills that make a physician an excellent...

• Ask the expert: How to deal with late return of reappointment applications?

  Tardy reapplication materials are one of the most common reappointment obstacles faced by the...

• Tip of the week: Dealing with leave of absence

  Physicians requesting a leave of absence should state the reason motivating his or her request...

Issue 30, August 8, 2007

• Tip of the week: Absence of a reason to deny or reject an application is not a reason enough to approve requests for medical privileges.

  Medical staff leaders must resolve all doubts about an applicant or reapplicant’s experience...

• Ask the expert: Who should act as a proctor?

  The proctor must have credentials that are equal to those of the proctored physician. In short, it...

• Is a pre-application form really necessary?

  Dear medical staff leader: Healthcare organizations have used pre-application forms for many...

Issue 29, August 2, 2007

• Running an effective MEC meeting

  By the time a physician leader becomes the president of the medical staff, he or she has likely...

• Ask the expert: What should our job description for medical staff leaders include?

  It is important that your job description detail to whom the physician leader is accountable and...

• Tip of the week: Educate physicians on proper use of performance feedback reports

  Physicians who understand how organizations use performance feedback reports are more likely to...

Issue 28, July 25, 2007

• Recruiting medical staff officers

  Dear medical staff leader: In today's complex health care environment, it is increasingly...

• Ask the expert: What are some legal issues surrounding proctoring?

  Lawsuits around proctoring generally come from two aggrieved parties: physicians unhappy with the...

• Tip of the week: Follow up after a meeting

  Following up after meetings is equally important as the meeting itself. Follow-up allows you an...

Issue 27, July 19, 2007

• Ask the expert: What are common mistakes respected and trusted leaders avoid?

  Once leader has earned the respect and trust of colleagues and coworkers, he or she should take...

• Help is on the way

  Dear Medical Staff Leader, Take a moment. You've earned it! This morning, like most other...

• Tip of the week: Empower colleagues and coworkers

  A major key to success is carefully matching each assigned task to a person with the skills and...

Issue 26, July 12, 2007

• Ask the expert: What first steps should we take when considering technology?

  Ask these five questions, which are healthcare-setting specific, before introducing a new...

• Tip of the week: Do not leave credentialing materials unattended

  Your confidentiality policy should address how MSPs obtain approvals and recommendations. If a...

• Credentials committee composition: Turn to experienced physicians

  Dear medical staff leader: Truly effective medical staffs must govern themselves, credential and...

Issue 25, July 5, 2007

• Ask the expert: How can we reduce the number of medical staff committees?

  Medical staffs can reduce the number and size of committees by combining them and their functions...

• Tip of the week: Streamline medical staff categories

  Medical staffs often have several categories and subcategories to describe the status of physicians...

• Membership vs. Privileges-Part2

  Dear medical staff leader: In last week's edition of this newsletter, I discussed the...

Issue 24, June 27, 2007

• Tip of the week: Set expectations to improve performance

  When faced with the challenge of improving physician performance at your institution, clearly...

• Ask the expert: Can you provide sample performance expectations?

  The Greeley Company's physician performance pyramid dimensions are a great place to start when...

• Membership vs. Privileges-Part 1

  Dear medical staff leader: Medical staffs across the country are faced with the challenge of...

Issue 23, June 13, 2007

• Ask the expert: Credentialing versus credential verification?

  Credentials verification-determining whether a practitioner's credentials are authentic and...

• Correction

  Correction to yesterday's MS Leader Connection

• Quality begins with you

  Dear medical staff leader: If you are like most physicians, when you hear the word quality your...

• Tip of the week: Agree on AHPs' role

  In many facilities, AHPs are not considered members of the medical staff but do have clinical...

• Tip of the week: Communicate to avoid conflict

  Tip of the week: Communicate to avoid conflict

• Ask the expert: How can we restock the medical staff leadership pool?

  Good physicians don't always make good leaders, so when you find one who is both, you'll want to...

• When to grant temporary privileges

  When to grant temporary privileges

Issue 22, June 6, 2007

• Ask the expert: How can I manage my time to focus on administrative tasks?

  As a medical staff leader, I am swamped with a million administrative tasks that I always seem to...

• Tip of the week: Follow your privileging policies

  The route of each application for medical staff membership/clinical privileges must be carefully...

• Change revisted

  In this column, I'm going to share with you some examples of individuals involved with medical...

Issue 21, May 31, 2007

• Ask the expert: Where do we begin bylaw reviews?

  Key elements of bylaw review

• Tip of the week: Avoid the common initial appointment mistakes

  Avoid the common initial appointment mistakes

• Nine liability issues to consider with patient complaints

  Consider these nine issues when thinking about openly admitting liability

Issue 20, May 24, 2007

• Ask the expert: How often should we update bylaws?

  Ask the expert: We've run into some issues lately with outdated language in our bylaws. How often...

• Tip of the week: Organize key managers for survey performance

  Key managers and staff working on teams to channel their energies can assess compliance with a...

• Avoid physician leadership mistakes

  As a physician leader, earning the respect and trust of your colleagues and coworkers can be a...

Issue 19, May 15, 2007

• Ask the expert: What should a physician performance feedback report include?

  This can be a tough question because there is no standard performance feedback report from which to...

• Tip of the week: Distribute HCQIA information to your medical staff

  Distribute information to your medical staff about the HCQIA and the protections it offers to fair...

Issue 18, May 9, 2007

• Tip of the week: Use the Internet for credentialing

  Medical staff offices across the country are using the Internet to make credentialing more...

• Ask the expert: What proctoring method should my department use?

  It is important to recognize that MECs should tailor and annually review proctoring programs for...

• Is your privileging system effective?

  Leaders know that although they may not often receive accolades, their colleagues in the medical...

Issue 17, May 3, 2007

• Communicate, communicate, communicate

  Dear medical staff leader When you call a meeting, what are you trying to accomplish? Most often...

• Ask the Expert: Can we make our committee meetings more productive?

  It can be difficult, sometimes, to justify holding meetings. But they are an important tool for...

• Tip of the Week: Three keys to a successful core privileging system

  A successful core privileging system should include:

Issue 16, April 26, 2007

• Ask the expert: Can we stop a physician from limiting privileges to avoid call?

  The physician can limit his privileges in the non-emergency setting. However, he is still a...

• Tip of the week: Determine what you will do with EPR results

  When your hospital initiates an external peer review, determine at that time what you are going to...

• Should we credential an external peer reviewer?

  Dear medical staff leader, A colleague recently asked me if her facility should credential a...

Issue 15, April 13, 2007

• Ask the expert: What circumstances require external peer review?

  The peer review committee typically commends external peer review to the medical executive...

• Rules for references

  Rules for references

• Tip of the week: Create a list of external peer reviewers

  It is wise to have potential external peer reviewers in mind because the need for them can arise...

Issue 14, April 11, 2007

• Are you effectively using technology?

  Management of medical staff services departments has become increasingly more complex over the past...

• Ask the expert: What can I do to stop interruptions?

  It is hard to stop people from simply dropping by to discuss problems or to chat. No one can expect...

• Tip of the week: Create a leadership development calendar

  Medical staffs and hospitals might find it useful to draft a leadership development calendar that...

Issue 13, April 4, 2007

• Avoid common meeting management mistakes

  During the last couple months, many new medical staff leaders faced for the first time a challenge...

• Ask the expert: How can we help our medical staff be more effective?

  Medical staff leaders must fulfill responsibilities that fall into four categories:

• Tip of the week: Encourage and participate in quality improvement

  MEC members and other medical staff leaders are required to encourage and participate in quality...

Issue 12, March 29, 2007

• Ask the expert: Can we gather data about complaints filed against a physician?

  Although useful, it is not necessary to produce a rate of complaints or to benchmark the physician...

• Tip of the week: Don't underestimate the value of a physician conduct policy

  A physician conduct policy establishes clear expectations to which all medical staff members must...

• Education for medical staff professionals

  Dear medical staff leader: We have turned the corner. It is spring at last! It is time to get...

Issue 11, March 14, 2007

• Get ready for FPPE

  Focused professional practice evaluation (FPPE), a requirement introduced by The Joint Commissions...

• Ask the expert: What should we include in leadership job descriptions?

  Well-designed descriptions of physician leadership positions are critical to any corporate...

• Sharing information

  This past week, members of HCPro's medical staff talk group raised the question of whether the...

• Tip of the week: Meeting chair must actively manage to ensure participation

  Sometimes it is not truly the group that makes the decision, but rather a few dominant individuals...

• Tip of the week: Improve communication to promote medical staff participation

  An important support system and core process for the medical staff is communication. Effective...

• Ask the expert: Is a physician who fails to answer ED call violating EMTALA?

  If a physician who has agreed to serve on the ED on-call roster does not respond, he or she is...

Issue 10, March 6, 2007

• Use job descriptions to ensure effective leadership

  It has become a "best practice" for medical staff organizations to formulate in a written position...

• Should the peer review committee play a role in proctoring?

  Because much of proctoring is similar to peer review, many medical staffs consider asking the peer...

• Ask the Expert: Should the peer review committee play a role in proctoring?

  Because much of proctoring is similar to peer review, many medical staffs consider asking the peer...

• Tip of the week: Delegate proctoring tasks

  When the medical staff asks a department chair to assign physician proctors for a newly appointed...

Issue 9, February 28, 2007

• The role of the physician executive

  One common trend among hospitals today is to hire physician executives for such roles as chief...

• Obtain data that illustrates the extent of the ED coverage problem

  When working with your medical staff to better managing your facility's emergency department (ED...

• Hospital CEO publishes infection rates on blog

  In August, Paul Levy, CEO of Beth Israel Deaconess Medical Center (BIDMC), in Boston, began writing...

Issue 8, February 21, 2007

• Privileging versus authorization of mid-level practitioners

  Many medical staff organizations are grappling with the issue of which practitioners should be...

• Physician-hospital competition: NC physicians fight regulatory board

  Physician groups looking to expand their outpatient operating facilities are coming up against...

Issue 7, February 14, 2007

• The Kadlec case and information sharing

  The good news about the Kadlec case is that hospitals are taking a look at how and when they...

• Study shows success in treating impaired physicians

  Physicians with mental and behavioral health problems have a successful rehabilitation rate similar...

Issue 6, February 7, 2007

• Have you set goals for this year?

  It has been my experience that effective, high-performing medical staff organizations have goals...

Issue 5, January 31, 2007

• Changes: Are you ready to lead?

  We recognize that change is not always easy for many individuals who serve as medical staff leaders...

• Editorial: Peer-based competency assessment in Canada

  Assessments of physicians' competence should incorporate peer review based upon realistic...

Issue 4, January 24, 2007

• The Seven Deadly Sins for medical staff professionals

  Last week, I wrote about the "Seven Deadly Sins" for medical staff leaders. I received a number of...

• Stark: GAO report confirms concerns about Joint Commission conflicts

  Rep. Pete Stark (D-CA) , one of three members of Congress who in 2006 requested an investigation of...

Issue 3, January 17, 2007

• The Seven Deadly Sins of medical staff leaders

  This column is based on many years of working with and observing the behaviors of successful...

• GAO wants continued monitoring of Joint Commission/JCR firewall

  The investigative arm of Congress on Jan. 16 reported that The Joint Commission and its...

Issue 2, January 10, 2007

• Obtaining competency data for low-volume providers

  Many organizations will not provide information about clinical performance to other organizations...

• Physician witness indicted for perjury in malpractice case

  Alex Zakharia, a Miami-Dade heart surgeon, was indicted by a federal grand jury in Detroit for...

Issue 1, January 3, 2007

• More on medical staff categories

  Kris Rockwell, manager of medical staff services at Children's Hospital in Omaha, NE, writes about...