Are you complying with medical staff standards?

Some suggestions for complying with key changes

There are several key changes for the Joint Commission on Accreditation of Healthcare Organizations’ revised medical staff standards, which became effective as of January 2004. "I see these as nothing less than revolutionary," says Martin D. Merry, MD, adjunct associate clinical professor of health management and policy at the University of New Hampshire in Durham.

The previous detailed, prescriptive standards have been scaled back to a much more simplified medical staff chapter, he notes. "I interpret this as JCAHO saying, Medical staffs, here’s the simple, basic structure. We don’t know how you can generate quality and safety beyond this, so be creative and show us how to create more effective hospital medical staffs.’ There is much more to happen here, and stay tuned!"

Here are key changes in the medical staff standards, with suggestions for how to comply with each:

The physician health standard (MS.4.80) has been expanded to include all licensed independent practitioners.

"The survey process will include peer review of not just physicians but of residents and fellows as well," says Joan M. Hoil, RN, associate administrator for quality management at State University of New York (SUNY) Downstate Medical Center, University Hospital of Brooklyn. "And the data sources aren’t quite so firm, and people will have to do a lot of reaching."

Hospital information systems are a good source of data about physicians who admit or do procedures and consultations, but there is limited information about house staff, she explains.

"Computerized order-entry systems are one source. Another may be the data collected within the Graduate Medical Education program and the performance appraisals done by the supervising physicians," Hoil notes.

When cases are peer reviewed, particular attention should be paid to the resident’s decision making and communication skills, she advises. "Supervising physicians may be reluctant to participate because residents are, in fact, students."

Previously, the standard required hospitals to have a physician health policy, with a process for dealing with health issues separately from disciplinary action. "The difference is that now it must apply to all licensed independent practitioners. Our policy was revised accordingly. Basically, we just substituted the words licensed independent practitioner (LIP)’ for physician,’" says Kathy Downs, CPMSM, CPCS, CPHQ, director of medical staff services at Paradise Valley Hospital in National City, CA.

At Paradise Valley, this now includes dentists, podiatrists, psychologists, certified registered nurse anesthetists, certified nurse midwives, and certain other allied health professionals, she says.

There is a new process for credentialing.

One of the key changes that affects the medical staff is in the leadership standard LD.3.70, Downs explains. In the past, physician assistants and advanced practice registered nurses who were employed by the hospital usually were processed by human resources, and those who were not employed by the hospital were credentialed through the medical staff process, she adds.

"Rather than bringing employees into the credentialing process, our board of directors has determined that human resources has an equivalent process that contains all of the elements required by the Joint Commission," Downs says.

However, one difference in human resources’ previous process is there will be communication with the interdisciplinary practice committee and the medical executive committee prior to appointment and reappointment, she notes.

Standard 4.30 addresses the expedited credentialing and privileging process.

The standard says an organized medical staff may use an expedited process for appointing individuals to the medical staff and for granting privileges, when criteria for that process are met. "We already had a similar process in place," Downs says. "The elements of performance then address what that criteria should be."

This is the exact wording from the organization’s medical staff bylaws:

"Following a positive recommendation from the medical executive committee and in order to expedite appointment, reappointment, or renewal or modification of clinical privileges, the governing board may delegate the authority to render those decisions to a committee consisting of at least two governing board members. The board of directors may authorize a delegation of the governing board consisting of two members."

An applicant usually is ineligible for the expedited process if at the time of appointment, or if since the time of reappointment, any of the following has occurred: incomplete application submitted; medical executive committee adverse recommendation or with limitation, current challenge, or a previously successful challenge to licensure or registration; has previously received an involuntary termination of medical staff membership at another organization; or has received involuntary, limitation, reduction, denial, or loss of clinical privileges, or adverse final judgment in a professional liability action.

• Standard 5.1.1 says the governing body may elect to delegate the authority to render initial appointment, reappointment, and renewal/modification of clinical privileges decisions to a committee of the governing body.

"What changed is that certain criteria must be met, whereas before, there were no specific criteria as to what recommendations could go to a committee of the governing body," Downs adds.

[For more information on the medical staff standards, contact:

Kathy Downs, CPMSM, CPCS, CPHQ, Director, Medical Staff Services, Paradise Valley Hospital, 2400 E. 4th St., National City, CA 91950. Phone: (619) 470-4156. Fax: (619) 472-4502. E-mail:

Joan M. Hoil, RN, Associate Administrator, Quality Management, SUNY Downstate Medical Center, University Hospital of Brooklyn. Phone: (718) 270-4126. E-mail:]