Understanding medical staff governance

An organized medical staff requires governance in order to function. This sounds straightforward enough, but what does it have to do with credentialing? Medical staff membership, staff categories, privileging, credentialing, suspensions, fair hearing rights, medical executive committee composition and function, department chairs, oversight of peer review—all these things, and more, are part of medical staff governance. Effective governance requires a solid structure, organization, and strong processes. 

Medical staff bylaws, rules and regulations, and policies and procedures are the governing documents of your medical staff. Without this structure there would be chaos in the OR, the doctors' lounge, the ER, the Cath Lab, the parking lot, etc. Needless to say, these documents are important to the medical staff and the hospital.

Well written documents not only give structure to the medical staff, they are the definitive guidelines for all of the medical staff processes—including credentialing—that medical staff leaders and MSPs encounter.

Medical staff governance touches a huge area, as noted earlier. The first things to consider are regulatory requirements. There are certain elements that are required to be in your bylaws and rules and regulations. You must keep abreast of changes in state and federal regulations as well as standards requirements so your medical staff bylaws and rules and regulations are always in compliance.