Before sending peer review information, a medical staff should first look at state laws to ensure it has a mechanism in place to make disclosures in a confidential manner. For example, Texas allows committee-to-committee disclosures, so for medical staffs in that state, it’s a best practice to...
Knowing what the standards say regarding who can provide a recommendation is the science behind peer references. The art is establishing best practices that support the capture of information from the best possible sources. For a full description of each accreditor’s standards for peer...
The credentialing process for advanced practice professionals (APP) is basically the same as for other practitioners. However, APPs do come with their own set of challenges. State scope-of-practice and professional licensure laws are disparate and changing rapidly. In addition, hospital policies...
The objective of this policy is to promote optimal patient care by promoting a safe, cooperative, and professional healthcare environment by preventing or eliminating, to the extent possible, behavior that disrupts the efficient and effective operation of the hospital.
A practitioner practicing outside the scope of privileges indicates an immediate threat to patient health and safety as determined by the Centers for Medicare & Medicaid Services (CMS) and other organizations. Therefore, it is important for everyone in your organization to know who has what...
Medical staffs would not want to see any one individual force a proposed bylaws amendment through the voting process because this could jam up the medical staff and board with amendments that don’t have significant support. In the past, any individual could propose an amendment, which was then...
Effective meeting management is the result of a skillful blending of diplomacy and proven management skills and techniques. For each meeting, physician leaders should be well prepared and identify reasonable objectives and emphasize the importance of the committee or department’s contributions...
Creating an agenda for new provider orientation ensures that providers meet with the proper people and departments and spend an adequate amount of time with each service before being thrown into the thick of treating patients. This sample agenda was created by Indiana University (IU) Health...
What is the best way to deal with disruptive behavior? Conduct the initial intervention when medical staff leadership has decided to proceed beyond just providing routine feedback. If you feel that the physician will refute the accusations, come armed with data. If the physician...
When developing or fine-tuning a focused professional practice evaluation (FPPE) process, consider adopting a common reporting form that allows all proctors to share their observations in a standardized manner. Such forms also help to ensure that each proctor comments on all pertinent elements...
