Medical staff bylaws and associated documents
The medical staff bylaws and associated documents outline how the medical staff will organize and govern itself to carry out its board-delegated responsibilities to ensure the quality of care, which primarily depends on individuals granted privileges. At a minimum, they outline the credentialing and privileging process and the initial and ongoing review of physician competency. Additionally, there is generally an extensive outline of due process, which is extended when the medical staff finds itself at the level of managing poor performance or considering whether a corrective action is warranted.
Although most medical staffs undertake all of these activities seriously and with appropriate diligence, their goal typically is to find a minimum threshold that indicates whether new and existing members are sufficiently competent to be granted the privileges they request. The reality is that most medical staffs are reluctant to disadvantage physicians by limiting their scope of clinical activity. Adding to this reluctance are the ever-present concerns about legal actions and external reporting to the National Practitioner Data Bank. There are mechanisms to weed out practitioners, but they are generally only applicable if the practitioner’s skills and abilities are so overwhelmingly deficient as to put patients in immediate danger. Along the way, the medical staff also guarantees extensive due process to determine whether a corrective action is warranted. The net result is that there are minimal quality thresholds for gaining privileges and a very high bar for removing those privileges.