Medical staff effectiveness: First in a series

Dear Medical Staff Leader,

How effective is your medical staff?

This question may at first seem straightforward. However, it can't be answered until we first agree on what comprise the medical staff. Only then can you determine how effectively your medical staff carries out those functions.

What are the key functions of the medical staff? To answer this question, we begin with two primary functions delegated to the medical staff by the board. Because of our expertise as physicians, the first of these two responsibilities is to monitor and improve the quality of care. The medical staff is responsible for the quality of care, which is primarily dependent on the performance of individuals granted privileges. This responsibility is met by conducting peer review.

We, along with hospital management, also have a responsibility to participate in system performance improvement. In addition, because of our unique knowledge as physicians, credentialing and privileging is delegated to us--recommending both criteria for membership and privileges and appointment and privileges for individual practitioners.

To carry out the quality and credentialing functions, the medical staff must democratically organize to govern itself. Governance often is confused with administration. Governance is the mechanism by which we determine medical staff members' rights, responsibilities, and accountability. Administration is how we organize our activities, including departments and committees, and the processes we use to carry out our activities.

Communication is yet another medical staff function. Medical staff leaders need to communicate to other members when a change is coming, such as a new policy or a new operating room scheduling system. Individual medical staff members also need to communicate to their leaders to ensure their input into decisions (e.g., from which medications will make it onto the formulary, formulating the medical staff's position on key strategic issues before the board). Therefore, part of communication is to ensure effective advocacy for the interests of the medical staff in management and board deliberations.

We can see that the functions of the medical staff distill down to five essential activities: Quality, credentialing, governance, administration, and communication. In the next edition of MS Leader Connection, we will explore how to determine whether your medical staff carries out each of these activities effectively.

That's all for this week.

All the best,

Rick Sheff, MD