Build on quality through policies and procedures

Policies and procedures are one tool the medical staff can use to ensure the quality of care provided by members of the medical staff/practitioners privileged at the organization. Solid policies and procedures make it clear to everyone involved that there are standards in place that will be followed, and there are no exceptions. In the HCPro book, The Top 45 Medical Staff Policies and Procedures, author Todd Sagin, MD, JD, provides sample policies and procedures to tackle the most common medical staff issues. Applied effectively, the sample policies and procedures within this book will help you to establish clear lines of authority and communication within your organization. They should help you tackle everyday managerial issues and even avoid potentially serious problems, such as:

• Tensions within the medical staff, particularly between specialties
• Tensions between medical staff members and administrators
• The perception that leadership decisions are biased
• Lawsuits
• Harm to patients

Following is an excerpt from the policy, Communication and Use of Practitioner Performance Expectations.

“This policy is for use by medical staffs that have adopted written performance expectations for medical staff members and privileged practitioners. These may include expectations with regard to professional conduct, medical staff citizenship, quality of clinical care, resource utilization, quality of service, professionalism, team participation, and other parameters.

“The medical executive committee (MEC) may, from time to time, adopt a statement of practitioner performance expectations that enumerates the standards of performance expected of medical staff members. The goal of communicating these expectations is to create a fair process for physicians on our medical staff to hold each other mutually accountable for physician performance.”

For more information, click here.