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MS governance: Myths & misconceptions
The CMS Conditions of Participation (CoP) and The Joint Commission are in complete agreement on this one: Medical staff departments are not required. The CoPs require a "well organized" medical staff. The Joint Commission requires an "organized self-governed medical staff." The Joint Commission does state, however, that if the medical staff chooses to organize by departments, there needs to be a department chairperson who is board certified (or has comparable competence) and has 15 specifically defined roles and responsibilities (MS.01.01.01, EP 36).
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