Develop a medical staff corporate compliance policy

Dear Medical Staff Leader:

The federal government's current focus on corporate compliance in the healthcare industry demands that all hospitals, healthcare systems, and other healthcare organizations develop a precise policy that addresses this issue. Such a policy would be incomplete if it left out the concerns of the medical staff.

It is likely that your medical staff policy on corporate compliance needs further development and refinement. A medical staff's corporate compliance policy should address significant clinical issues that are now the center of federal healthcare investigation initiatives.

Therefore, consider adopting a policy that establishes effective standards and monitoring systems to promote member compliance with key federal and state laws and regulations, as well as standards of accrediting agencies, such as the Joint Commission on Accreditation of Healthcare Organizations. The policy should require the medical staff to monitor all members and nonphysicians with clinical privileges for such compliance through procedures implemented by the hospital, medical staff bylaws, and the medical executive committee (MEC).

Your corporate compliance policy should also require the review of key processes for compliance in the areas of credentialing, awarding of clinical privileges, peer review, and performance improvement. This oversight should be delineated in the medical staff credentials policies and procedures and in the quality and performance improvement plan of the hospital and medical staff. Key processes include the following:

1. Maintain executive oversight: The MEC will work with the hospital corporate compliance officer to ensure compliance with policies and procedures relevant to the medical staff.

2. Delegate authority: Medical staff officers and department chairs are responsible for working with the hospital to ensure compliance. Each person must complete a conflict-of-interest declaration at the time of appointment and reappointment.

3. Communicate and train effectively: All medical staff members must complete orientation and training concerning the contents of the bylaws and key policies, each staff member's responsibility to comply with hospital bylaws and policies, and procedures for reporting suspected problems

4. Monitor and report potential problems: Medical staff members must report any concerns that are relevant to the biannual reappointment process. If medical staff members are aware of problems in an office or nonhospital environment, it is their duty to present such problems to their leadership.

5. Enforce policy and discipline infractions appropriately: The corrective action portion of the medical staff bylaws identifies the process for dealing with noncompliance issues. The medical staff will use routine investigation to review each suspected problem area or occurrence.
 
Spend some time reviewing your medical staff corporate compliance policy to ensure it addresses the key items listed above.

That's all for this week.

All the best,

Hugh Greeley