Medical Staff Briefing - Volume 23, Issue 10

Peer references and practitioner-specific data at reappointment

October 1, 2013

In a recent article, we discussed some of the compliance issues that may arise when attempting to implement an FPPE/OPPE process within a laundry list or fragmented privileging system, even when it includes both core/bundle privileging and/or modified laundry list privileging.

Medical Staff Briefing - Volume 23, Issue 7

Are audits of CME attestations necessary?

July 1, 2013

Are you auditing your physicians to determine whether they actually show up to the CME programs that they attest to attending? If not, you are likely among the majority of healthcare organizations across the country. But an argument could be made both in favor and against the...

Medical Staff Briefing - Volume 23, Issue 5

MS governance: Myths & misconceptions

May 1, 2013

One of the most common myths regarding medical staff governance is that only active staff can vote. The reality is there is no restriction as to who can vote: not from the CMS Conditions of Participation (CoP), not from The Joint Commission, not from any other national regulatory or...

Medical Staff Briefing - Volume 23, Issue 4

Joint Commission survey looks at MS.01.01.01, OPPE, and FPPE

April 1, 2013

The Joint Commission was scheduled, on paper, to arrive in first quarter 2013-which was why, in October 2012, John H. Stroger, Jr. Hospital of Chicago's Cook County was a little surprised to see Joint Commission surveyors at their door one Tuesday morning. Although the arrival...

Medical Staff Briefing - Volume 23, Issue 3

MS governance: Myths & misconceptions

March 1, 2013

The CMS Conditions of Participation (CoP) and The Joint Commission are in complete agreement on this one: Medical staff departments are not required. The CoPs require a "well organized" medical staff. The Joint Commission requires an "organized self-governed medical staff." The Joint Commission...

Medical Staff Briefing - Volume 23, Issue 2

APPs: Distinctions that make a difference

February 1, 2013

To keep up with today's complex privileging requirements, MSPs need to understand the growing roles of APPs and how they integrate with the medical staff. Pursuant to 21 CFR § 1300.01(b28), the term "mid-level practitioner" (otherwise known as APP), specifically means an...

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