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Medical Staff Essentials
All levels
U.S. Standards

Medical Staff Essentials: Your Go-To Guide

Release Date: October 2017. 282 pages.

3 stars from Doody’s Review Service

$89.00 - $99.00
Product Description

Product Description

The Joint Commission’s Medical Staff (MS) standards provide a detailed description of the medical staff’s roles and responsibilities. But those standards have always been challenging to understand and apply. Medical Staff Essentials is a clear, concise, accurate reference that breaks down difficult concepts in the MS standards into easy-to-digest pieces. It’s designed to be your go-to guide on the essentials of the MS standards—and related concepts—to help you successfully select and manage your medical staff.
Key Topics
  • Medical staff bylaws, rules and regulations, and policies
  • Clinical credentialing and privileging
  • Appointment to the medical staff
  • Practitioner competence assessment
  • Professional practice evaluations (FPPE and OPPE)
Key Features
  • Reader-friendly tone and engaging format
  • Numerous infographics the clarify complex content
  • Scenarios that show application of key chapter information  
  • Example policies and other documents from real hospitals
  • Nearly two dozen downloadable, writeable tools (included on a flash drive for print version or linked in the e-book)
  • Medical Staff and related standards and terms 
  • Reviewed by Joint Commission experts
Standards: Medical Staff
Setting: Hospitals and critical access hospital
Key Audience
  • Governing body
  • Organized medical staff 
  • Medical staff
  • Medical executive committee
  • Credentialing committee
  • Hospital administration
  • Medical staff services
  • Survey coordination team
  • Accreditation team
  • Legal counsel
  • Performance improvement team
  • Risk management team
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Table of Contents

Table of Contents


Chapter 1: Medical Staff Scope and Governance
Section Sets: Medical Staff and Bylaws (MS.01.01.01, MS.01.01.03, MS.01.01.05, MS.02.01.01)
      Instructive Infographics Differences Among Medical Staff Bodies
      Particular Points Members of the Organized Medical Staff
      Excerpts that Explain The Significance of These Documents
      Instructive Infographics Types of Medical Staff Documents
      Instructive Infographics Development and Enforcement of the Bylaws
      Tools to Try Conflict Management Among Medical Staff Members
      Concise Concepts Details in the Medical Staff Bylaws
      Particular Points Force and Flexibility of Medical Staff Documents
      Tools to Try Medical Staff Bylaws Evaluation Checklist
      Examples to Examine Duties and Privileges of Medical Staff Categories
      Particular Points Basic Steps and Associated Details of Processes
      Concise Concepts Compatibility of Medical Staff Documents
      Examples to Examine Stanford Health Care Medical Staff Bylaws and Rules & Regulations Table of Contents
      Providence Alaska Medical Center Medical Staff Credentials Manual Table of Contents
      Excerpts that Explain How Leaders Work Together
      Particular Points Required Collaboration on Amendments
      Concise Concepts Leadership and Medical Staff Standards
      Particular Points Integrated Medical Staff for Deemed-Status Hospitals
      Concise Concepts The Medical Executive Committee
      Excerpts that Explain The Vital Role of the Medical Executive Committee
      Instructive Infographics Functions of the Medical Executive Committee
      Particular Points Medical Staff as the Medical Executive Committee
Section Sets: Medical Staff Role in Care, Treatment, and Services (MS.03.01.01, MS.03.01.03, MS.04.01.01)
      Concise Concepts Coordinating and Planning Care
      Particular Points What’s In an H&P?
      Instructive Infographics Responsibility of H&P Content and Monitoring of H&Ps
      Focus on FAQs H&Ps in Non-Inpatient Services
      Particular Points The Value of Communication and Collaborative Care
      Instructive Infographics Fine Points of Oversight EPs
      Concise Concepts Supervising Program Participants
      Instructive Infographics Professional Graduate Education Program Supervision Process
      Tools to Try Professional Graduate Education Communication Record
Section Sets: Medical Staff Role in Performance Improvement (MS.05.01.01, MS.05.01.03)
      Concise Concepts Improvement as a Driving Force
      Tools to Try PI Participation Assessment Checklist
      Particular Points Improving Performance for Autopsies
      Instructive Infographics Required Information in PI Efforts
      Particular Points Barriers to Medical Staff Involvement in PI
      Concise Concepts Getting Practitioners Involved in PI
Chapter 2: Credentialing and Initial Appointment
Section Sets: Credentialing Basics (MS.06.01.03, MS.13.01.01, MS.13.01.03)
      Instructive Infographics What is Credentialing?
      Concise Concepts The Importance of Credentialing
      Particular Points Consequences of Ineffective Credentialing
      Instructive Infographics Responsibility for Credentialing
      Particular Points Credentialing Licensed Independent Practitioners
      Instructive Infographics Who Should Be Credentialed?
      Focus on FAQs Credentialing PAs, APRNs, and Consultants
      Particular Points Credentialing Telemedicine Providers
      Particular Points The Credentials Committee
Section Sets: Preapplication and Application Process (MS.06.01.03)
      Particular Points Deciding to Use a Preapplication
      Particular Points State Laws about Applications
      Tools to Try Application Content Evaluation Checklist
      Particular Points What to Give the Applicant
      Examples to Examine State of West Virginia Credentialing Form
      Tools to Try Verification of Professional Liability Insurance
      Particular Points Verifying Applicant Identity
      Tools to Try Applicant Interview Procedure Checklist
Section Sets: Credentials Verification Process (MS.06.01.03)
      Concise Concepts Critical Credentialing Criteria
      Tools to Try Credentials Verification Record
      Particular Points Primary Source Verification for Credentialing
      Instructive Infographics Designated Equivalent Sources
      Particular Points Verifying Current Licensure Using Primary Sources
      Particular Points Verification of Challenges to a License
      Instructive Infographics License Verification as Education Verification
      Particular Points Using a CVO to Verify Education and Training
      Concise Concepts Limitations of a CVO
      Tools to Try CVO Evaluation Checklist
      Concise Concepts Verifying Current Competence
      Excerpts that Explain  General Competencies
      Tools to Try PA Core Competency Assessment Form
      Particular Points Verifying Board Certification
      Instructive Infographic Application Red Flags
      Tools to Try Application Red Flags Assessment Checklist
Section Sets: Appointment to the Medical Staff (MS.07.01.01)
      Concise Concepts Process for Appointment to the Medical Staff
      Instructive Infographics Types of Medical Staff Membership
      Tools to Try Medical Staff Membership Evaluation Checklist
      Concise Concepts Safety and Security of Credentialing Information
Chapter 3: The Privileging Process
Section Sets: Scope of Practice (MS.06.01.01)
      Instructive Infographics Privileging Process
      Concise Concepts Health Care Changes and Scope of Practice
      Instructive Infographics Scope of Practice Considerations
      Particular Points Supporting Existing and Expanding Privileges
      Instructive Infographics Classification Systems for Privileges
      Particular Points Joint Commission Classification Requirements
      Examples to Examine NYU Hospitals Department of Radiology Clinical Privileges Delineation Form
Section Sets: Privileging and Reprivileging (MS.06.01.05, MS.07.01.03)
      Particular Points Defining Privileging Criteria
      Concise Concepts Systematic, Nonbiased Privileging
      Instructive Infographics Types of Privileging Criteria
      Particular Points New Privileges and Professional Practice Evaluations
      Instructive Infographics Preceptors and Proctors to Evaluate Competence
      Tools to Try Proctoring Policy Evaluation Checklist
      Particular Points Benefits of Proctoring
      Tools to Try Surgical Procedure Assessment Checklist for Proctors
      Instructive Infographics Triggers for Evaluating the Privileging Process
      Tools to Try Procedure for Evaluating the Privileging Process Checklist
      Focus on FAQs Who is a Peer?
      Instructive Infographics Sources for Peer Recommendations
      Particular Points Required Content of Peer Recommendations
Section Sets: Applicant Evaluation and Recommendations Process (MS.06.01.07, MS.06.01.09)
      Concise Concepts Meeting Privileging Requirements
      Particular Points Duration of Privileging and Timeliness of Approval
      Concise Concepts Fairness of the Approval Process
      Instructive Infographics Recommendation Process
      Particular Points Decision-Making Language in Privileging
      Instructive Infographics Medical Staff Membership and Privileges
      Concise Concepts Proof of Qualifications and Competence
      Instructive Infographics Reasons for Denying Privileges
      Particular Points When Privileges are Denied
Section Sets: Expedited Privileging and Temporary Privileging (MS.06.01.11, MS.06.01.13)
      Particular Points Responsibilities for Expedited Privileging
      Instructive Infographics Ineligibility for Expediting
      Particular Points Reasons for Granting Temporary Privileging
      Instructive Infographics Leadership Approvals in Temporary Privileging
      Particular Points Medical Staff Responsibility for Disaster Privileging
      Excerpts that Explain Disaster Privileging vs. Assigning Disaster Responsibilities
      Tools to Try Disaster Privileging Tracer
      Examples to Examine Physician Privileging in the Event of EOP Activation
      Instructive Infographics Criteria to Verify for Temporary Privileges
      Tools to Try Credentialing and Privileging Tracer
Chapter 4: Ensuring Continuous High Performance
Section Sets: Professional Practice Evaluations—FPPEs and OPPEs (MS.08.01.01, MS.08.01.03, MS.12.01.01)
      Concise Concepts What Is an FPPE?
      Particular Points When to Use an FPPE
      Instructive Infographics Required Components of an FPPE Process
      Focus on FAQs FPPE Pre-Defined Process
      Instructive Infographics Factors in the Duration of an FPPE
      Particular Points Evaluating Groups of Privileges in an FPPE
      Concise Concepts How an FPPE Affects Other Privileges
      Instructive Infographics Criteria and Triggers for an FPPE
      Instructive Infographics The FPPE Process
      Tools to Try FPPE Procedure Checklist
      Concise Concepts Who Undergoes OPPEs?
      Particular Points OPPEs and Privileging
      Instructive Infographics Information for Performance Evaluations
      Particular Points Performance Measures for OPPEs
      Instructive Infographics Defining Which OPPE Data to Collect
      Tools to Try OPPE Evaluation Checklist
      Particular Points Data Measures for Professional Practice Evaluations
      Tools to Try Zero Data Assessment Checklist
      Focus on FAQs Frequency of an OPPE
      Tools to Try Performance Data Sources Assessment Checklist
      Particular Points Benefits of OPPEs
      Instructive Infographics Evaluation Results and Follow-Up Actions
      Concise Concepts The Purpose of Continuing Education
      Particular Points Continuing Education for Privileged Practitioners
      Instructive Infographics Continuing Education Needs Assessment
Section Sets: Responding to Concerns About a Practitioner (MS.09.01.01, MS.10.01.01, MS.11.01.01)
      Concise Concepts Internal Reporting Processes
      Particular Points Adverse Privileging Decisions
      Instructive Infographics Fair Hearing and Appeal Process
      Excerpts that Explain Full Consideration and Reconsideration
      Particular Points Eligibility for the Fair Hearing and Appeal Process
      Instructive Infographics Hearing and Appeal Process Requirements
      Examples to Examine Medical Staff Fair Hearing Policy
      Concise Concepts Licensed Independent Practitioner Health
      Excerpts that Explain Facilitating Practitioner Rehabilitation
      Particular Points Corrective Action and Legal Requirements
      Tools to Try Practitioner Health Assessment Process Evaluation Checklist
Section Sets: Reappointment and Reprivileging (MS.06.01.05, MS.06.01.07, MS.08.01.01, MS.08.01.03)
      Concise Concepts Internal Reporting Processes
      Particular Points Adverse Privileging Decisions
      Instructive Infographics Fair Hearing and Appeal Process
      Excerpts that Explain Full Consideration and Reconsideration
      Particular Points Eligibility for the Fair Hearing and Appeals Process
      Instructive Infographics Hearing and Appeal Process Requirements
      Examples to Examine Medical Staff Fair Hearing Policy
      Concise Concepts Licensed Independent Practitioner Health
      Excerpts that Explain Facilitating Practitioner Rehabilitation
      Particular Points Corrective Action and Legal Requirements

Appendix A: Examples to Examine

Appendix B: Tools to Try

Appendix C: “Medical Staff” Standards and Related Standards