Who can be a credentials committee member? CMS and accrediting bodies only refer to the general function of a credentials committee. They do not specify the committee structure or provide requirements for membership on the committee. Your organization’s medical staff bylaws and/or credentialing...
By having your medical staff members fill out a conflict of interest disclosure form every year, the medical staff will be kept abreast of any relationships that might be considered a conflict. Here is some sample conflict of interest policy language you can customize for your own organization’s...
According to CMS, privileges are not to be granted for tasks/procedures/activities that are not conducted within the hospital—regardless of the practitioner’s ability to perform. Therefore, when developing your core privileging system, list only those services and procedures that your hospital...
Every state has laws that affect the corrective action section of the medical staff bylaws. These include state peer review statutes and additional reporting regulations issued by state health departments or other government entities. When composing bylaws, it is always prudent to run the...
There should be very few times when a medical staff needs to deny an application for privileges. For the most part, the physician and other LIP applicants are practitioners who have excellent records and will continue to deliver high quality in their ongoing patient care.
Once your organization establishes the overall framework of its general policy on who will be allowed to provide allied health care and on the general allied health professional (AHP) credentialing requirements, specific policies may be developed for particular allied health disciplines. Since a...