Medical Staff Support

MEDICAL STAFF DOCUMENTS

Three years go the Joint Commission (TJC) Medical Staff chapter of 2007 presented new requirements that significantly revised the Credentials Review and Privileging processes. These changes were greater than any they had published in the previous ten years, including those for the new survey process in 2004. Because of the need to improve the core standard, MS.01.01.01, they have now made significant changes to it. The new standard will go into effect on March 31, 2011, allowing time for organizations to make any necessary changes to their documents. A brief summary discussion of the changes, as well as a link to TJC's standard and the many FAQs that have already been written on the changes can be found on the following linked page. Let us know if we can be of assistance to you.

Each hospital’s Governing Body and Medical Staff are expected to build these requirements into the Credentials Review and Privileging process. They should also ensure that Medical Staff Bylaws, Rules and Regulations, privilege forms, and supporting policies and documents contain discussion on all other expectations for compliance. All of this will require review and revision.

Medical Staff documents should be reviewed to ensure compliance with The Joint Commission standards and applicable Medicare Conditions of Participation. A complete report is prepared for your hospital that includes reference to the applicable requirements, and recommended revisions to the documents. This off-site work is normally completed within several days.

CREDENTIALS PROGRAM REVIEW

We can review your Credentials files and activities for compliance through our Off-site processes. Working with your Medical Staff Office, we assure the maintenance of confidentiality while helping you attain a high level of quality performance of your Credentialing and Privileging program.
 

CREDENTIALING AND PRIVILEGING ACTIONS

Support is also provided to physicians and organizations in credentialing and privileging actions and other activities. This service includes helping you to ensure compliance with regulatory and hospital requirements during Peer Review, Focused Professional Practice Evaluation, On-going Professional Practice Evaluation, and during each of the steps leading to the making of adverse decisions.

We have expertise with adverse decisions, Fair Hearings and Appeals, and interaction with the National Practitioner Data Bank (NPDB) and attorneys during this critical and difficult time.