The role of the medical staff office in peer review

The medical staff services department doesn’t assess practitioners’ competence, but MSPs can ensure that the organized medical staff has the bylaws, policies, and procedures in place to conduct a consistent, fair, effective, and well-documented peer review process. In addition, the medical staff services department can be instrumental in ensuring that the medical staff leadership and chairs are following established processes for peer review, and that no conflicts of interest occur.

MSPs’ peer review activities include:

  • Data collection and organization
  • Reporting
  • Process oversight
  • Meeting management
  • Administrative tasks

When new medical staff members are granted privileges or current members are granted new privileges, the medical staff services department must confirm and document the organization’s initial credentialing decision via performance review. MSPs can assist by managing meetings, providing information, and other support functions, but they cannot conduct the actual review.

New practitioners must be oriented and mentored to ensure that they don’t perceive the high level of initial oversight as unique to them or punitive in any way. MSPs can help develop new practitioner orientation packets to include the peer review policy and all the forms necessary to ensure newcomers understand both the process and the expectations of the organization.

Source: The Medical Staff Office Manual: Tools and Techniques for Success