A tangled web is created by inappropriately intertwining stand-alone factors. Physician leaders must understand the difference between the following elements or risk unnecessary confusion:
One of the most common myths regarding medical staff governance is that only active staff can vote. The reality is there is no restriction as to who can vote: not from the CMS Conditions of Participation (CoP), not from The Joint Commission, not from any other national regulatory or...
Over time, many medical staff governance decisions have become commonplace and traditional. Although not required by any regulatory agency or accreditation body, these decisions have become de facto truths for many medical staffs around the country. While options exist in many cases, medical...
MSPs and credentials committee members must sort through a myriad of terms, acronyms, and licensing bodies when credentialing and privileging healthcare professionals. The process is no different when it comes to credentialing and privileging midwives. It is imperative to understand the...
To keep up with today's complex privileging requirements, MSPs need to understand the growing roles of APPs and how they integrate with the medical staff. Pursuant to 21 CFR § 1300.01(b28), the term "mid-level practitioner" (otherwise known as APP), specifically means an...
On November 18, 2011, CMS released a new change to the Conditions of Participation (CoP) and Interpretative Guidelines under Transmittal 72. This transmittal required further clarification following the initial requirement that all rehabilitation and respiratory providers writing...
The guiding coalition at Better Times Hospital has revisited its original proposition, called 3-6-9. The original vision included three medical staff committees (the medical executive committee [MEC], credentials committee, and a single multispecialty peer review committee); six...
The only thing harder than initiating change is sustaining it. It has been six months since Better Times Hospital held its retreat. The task at hand, as noted in John Kotter's Leading Change, is step seven of the eight-step change process: consolidate the gains to date...
The United States Government Accountability Office (GAO) recently conducted a study to examine the effect federal fraud and abuse laws have on hospitals' ability to implement financial incentive programs for physicians. Its findings, although not shocking, are notable: The...