The role of the MSP 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, MSPs 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 the following:
- 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. The medical staff services department can assist by managing meetings, providing information, and providing other support functions, but only medical staff members who have cleared your hospital’s credentialing and FPPE requirements should conduct this review.
New applicants must be oriented and mentored to ensure that the high level of initial oversight is not perceived as unique to them or punitive in any way. Initial appointment packets typically include the peer review policy and all of the forms necessary to ensure that newcomers understand both the process and the expectations of the organization.
Source: The Medical Staff Office Manual: Tools and Techniques for Success, Second Edition