Structure of the Medical Staff Office

The Medical Staff Office Manual: Tools and Techniques for Success is a comprehensive guide that maps every aspect of the medical staff office, from onboarding and orienting physicians to querying other facilities for practitioner information and effectively collaborating with physician leadership. In the following excerpt, author Marna Sorensen, CPMSM, explains how the medical staff services department has evolved.

In the not-so-distant past, the medical staff office often functioned as the clerical office of physician leadership (at least, the medical staff may have thought so). However, a rising tide of regulation and care complexity has added credentialing, privileging, and data analysis/reporting layers to MSPs’ work functions. As a result, the medical staff office today may report to the quality improvement or risk management departments, or another group, in addition to medical staff leadership. The medical staff office touches many other aspects of a hospital as well.

The hierarchy, size, complexity, structure, and services provided by the medical staff organization may differ, but most medical staffs share some characteristics with regard to their organization and required functions. The general responsibilities and components of the medical staff office include:

• Providing administrative support to medical staff officers and department/service line and committee chairs
• Collaborating with other hospital departments such as physician recruitment and retention
• Coordinating department/service line and committee meetings, including scheduling and notifications, preparing meeting materials, drafting the agenda, documenting proceedings, maintaining records, and ensuring follow-up on action items
• Drafting, researching, and organizing medical staff governing documents such as bylaws, rules, regulations, and policies
• Managing the credentialing and privileging processes for medical staff and allied health staff membership, including related processes (maintaining forms, policies, procedures, files, and documentation)
• Functioning as a liaison among the medical staff, hospital departments, and administration
• Managing information about current and former practitioners with membership and/or clinical privileges
• Coordinating and managing internal continuing medical education programs
• Functioning as librarian of medical staff–related documents and records
• Monitoring compliance with regulatory and accreditation standards
• Working with quality management and other departments to coordinate the clinical review processes for medical staff reappointment and reappraisal
• Working with the onboarding team to orient new staff members to their assigned department, the facility, the medical staff, and the hospital’s organizational structure

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