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The self-governed medical staff isn’t dead

The traditional self-governing medical staff is alive, and in many cases, necessary. Both regulatory standards and case law have made it clear that the medical staff is accountable to the governing body to oversee and manage the quality of medical care in the hospital. For example:

  • The Centers for Medicare & Medicaid Services’ Conditions of Participation (CFR 482.22) require that an organized medical staff be accountable to the board for the “quality of medical care provided to patients” 
  • The Joint Commission’s standard LD.01.05.01 requires an organized and “self-governed” medical staff that is accountable to the governing body to oversee “the quality of care, treatment, and services provided by those individuals with clinical privileges”

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