8.1 General
1. The healthcare organization shall have an organized medical staff that operates under bylaws approved by the Governing Body and is responsible for the quality of medical care provided to patients by the healthcare organization.
2. The healthcare organization shall have a medical staff that is composed of licensed physicians and other professionals who are licensed to practice within their own recognizance. These practitioners shall practice only within their scope of licensure. (See 7.2).
3. The Governing Body has the authority to determine under the local law the types of associated
healthcare professionals who are eligible for admission to the medical staff.
8.2 Medical Staff Organization, Accountability, and Responsibility
1. The medical staff shall be organized in a manner approved by the Governing Body. The responsibility for organization and conduct of the medical staff shall be assigned to the healthcare organization’s Medical Director and Medical Executive Committee.
2. The medical staff shall be accountable to the healthcare organization’s Governing Body for the quality of medical care provided to the patients.
3. The medical staff shall participate in at least the following healthcare organization activities:
a) Medical Executive Committee;
b) Credentialing Committee;
c) infection prevention and control oversight;
d) tissue review;
e) utilization review;
f) medical record review;
g) quality management system activities;
h) risk management system;
i) patient and related family satisfaction;
j) medication management oversight.
4. Reports and recommendations from these activities shall be reported to the Medical Executive Committee, Top management, and the Governing Body.
5. In the case of medical records, the medical staff and the healthcare organization shall ensure that the preparation and maintenance of complete and accurate medical records is in place for each patient. In order to satisfy this requirement, the healthcare organization shall require that the medical staff have periodic meetings at regular intervals to review and analyses said records for completeness, adequacy, and quality of care.
6. Oversight for medical records completion the corrections or corrective actions taken shall be the responsibility of the Medical Record Committee, the Medical Executive Committee, and Top management of the healthcare organization.
7. There shall be defined policies and procedures for dealing with medical record delinquencies. Compliance with these requirements shall be a subject for individual staff member performance data review and credentialing assessment.
NOTE 1 See sections 8.4. and 8.6.
8. The medical staff shall be responsible for the appropriate completion of admission H&P as required in the medical records section of this standard.
8.3 Qualification Description of the Medical Staff
1. The healthcare organization shall describe the requirements for the medical staff to recommend a candidate to be appointed by the Governing Body. These requirements shall include but are not limited to aspects of:
a) individual character;
b) individual competence;
c) individual training;
d) individual experience;
e) individual judgment.
2. These requirements shall apply equally to all practitioners within each given professional category.
8.4 Performance Data
1. The healthcare organization in concert with medical staff shall produce practitioner specific performance data to be measured, monitored, and reviewed at appropriate intervals not to exceed 2 years. Correction and corrective actions shall be taken as necessary when variation is present and/or standard of care has not been met by peer review. This process may include comparative and/or national data if available.
2. Areas for monitoring and measuring shall include but are not limited to the following areas of practice as applicable:
a) blood use;
b) medication management: prescribing patterns, trends, errors and appropriateness;
c) narcotic and scheduled drug management;
d) surgical case review of appropriateness, justification, and outcome including comparison to national and international standards or research;
e) specific department indicators that have been defined by the medical staff;
f) moderate sedation outcomes;
g) anesthesia events;
h) appropriateness of care for non-invasive procedures/interventions;
i) utilization review data;
j) patient and other customer satisfaction;
k) significant deviations from established standards of practice;
l) timely and legible completion of patients’ medical records;
m) the ability to interact with staff in a courteous, positive, and appropriate manner.
3. Results of this performance data review shall be considered by the medical staff and Governing Body at the time of re-appointment to the medical staff.
8.5 Continuing Education
1. All members of the medical staff shall participate in Continuing Medical Education (CME) that is at least in part related to their patient care duties.
2. The healthcare organization shall ensure that persons doing work under the organization’s control are educated in and aware of all of the requirements stated in STANDARD 11. as they may apply to the person's duties, area of service, interaction, and integration with patients and other service providers.
NOTE 1 In addition to required continuing medical education, medical staff shall maintain competence in the techniques of cardiopulmonary resuscitation.
8.6 Clinical Privileges
1. The healthcare organization shall establish a written procedure for granting clinical privileges. This procedure shall consider each practitioner’s applicable scope of practice or privileges. It shall specify and describe in detail the inclusive steps from application to final Governing Body review and related decisions. This procedure shall also address temporary clinical privileges (see section 8.7).
2. Granting or revision of clinical privileges shall be made for a period not to exceed three years.
3. There shall be a provision in the healthcare organization for a mechanism to ensure that all individuals with clinical privileges provide services limited to the scope of those granted. In a given request for privileges the components of practitioner qualifications and demonstrated competencies shall include:
a) evidence of current licensure;
b) evidence of training and professional education;
c) documented experience;
d) a valid contract of employment if applicable;
e) supporting references of competence as required by credentialing policy.
4. In the appointment and reappointment process the healthcare organization shall review individual performance data and determine if additional training or proctoring may be required before specific clinical privileges are continued or granted.
5. The healthcare organization shall provide a mechanism for considering automatic suspension of clinical privileges in the case of excessive delinquency related to medical records completion requirements.
6. The healthcare organization shall provide a mechanism for automatic suspension of clinical privileges in the case of revocation. A practice limiting restriction of the professional license of any medical staff member made by a national authority shall be immediately reviewed by the medical staff and Governing Body for indication of suspension accordingly.
7. The medical staff shall examine credentials of candidates for medical staff membership and make recommendations to the Governing Body on the appointment of the candidates. Only the healthcare organization’s Governing Body has the authority to grant a practitioner privileges to provide care in the healthcare organization.
8. The healthcare organization shall maintain a separate credentials file for each individual medical staff member. The healthcare organization shall ensure that the appropriate healthcare organization patient care area and departments are informed of the privileges granted to the practitioner.
9. Whenever a practitioner’s privileges are limited, revoked, or in any way constrained by the healthcare organization, it shall report those constraints to the appropriate local authorities, registries, and/or data bases.
10. The medical staff makes recommendations to the Governing Body for each candidate for medical staff membership/privileges that are specific to the type of appointment and extent of the individual practitioner’s specific clinical privileges, and then the Governing Body shall take final appropriate action.
11. When telemedicine services are furnished to the healthcare organization’s patients through an agreement with a distant-site healthcare organization, the Governing Body of the healthcare organization whose patients are receiving the telemedicine services may choose to have its medical staff rely upon the credentialing and privileging decisions made by the distant-site healthcare organization. If such an agreement from the Governing Body ensues the following provisions shall be met:
a) the individual distant-site physician or practitioner shall be privileged at the host healthcare organization providing the telemedicine services. The distant-site healthcare organization shall provide a constantly updated list of practitioners eligible for the services in question provided to the remote healthcare organization;
b) the individual distant-site physician or practitioner shall hold a valid license to practice in the healthcare organization whose patients receive the related telemedicine services;
c) the healthcare organization receiving remote services shall maintain performance review data for all physicians and practitioners providing these telemedicine services. This data shall be considered in the credentialing and re-credentialing process by the Governing Body and medical staff as described in the written process above. This data shall also be provided to the host healthcare organization for their review.
8.7 Temporary Clinical Privileges
1. Temporary clinical privileges shall be granted when there is urgent patient care need, including a process for approving practitioners (as defined in 8.1.2.) for care of patients in the event of an emergency or disaster. Additionally, a practitioner whose application is complete without any negative or adverse information may be granted privileges upon the direction of the Medical Director if circumstances dictate an excessive delay in action by the medical staff or Governing Body.
2. Temporary clinical privileges may only be granted for a period not to exceed one hundred twenty (120) days.
3. The healthcare organization shall define the process regarding the approval of physicians and other practitioners providing locum tenens services. These services shall not exceed a period greater than six (6) months without a re-credentialing review by the medical staff and Governing Body.
8.8 Disciplinary or Rehabilitation Action
1. The healthcare organization shall provide a mechanism for management of disciplinary or rehabilitative action. This documented action may result from unprofessional demeanor and conduct which is likely to be detrimental to patient safety, the delivery of quality care, or is disruptive to healthcare organization operations. Any officer of the medical staff, Managing Director, or any member of the Top management or legally responsible individual(s) may initiate this disciplinary or rehabilitative action.
NOTE 1 There may be circumstances in which a practitioner has acted in an unprofessional manner or has exhibited signs of impairment that would prevent him/her from carrying out appropriate patient care services. The healthcare organization shall provide a process for taking corrective or rehabilitative
action when a practitioner’s conduct is in question.
8.9 History and Physical
1. A medical history and physical examination (H&P) shall be included in the medical record for each patient within 24 hours after admission to the health care organization. This history and physical examination and any required updates are subject to the following conditions:
a) the examination(s) shall be performed by a licensed practitioner who is appropriately credentialed and privileged;
b) if a medical H&P examination has been completed within 30 days before admission or registration, it shall be updated within 24 hours after admission;
c) the updated examination of the patient shall include any changes in the patient’s condition relative to the previous H&P that may affect the current plan of care. If there are no changes found, this too shall be documented accordingly;
d) if a practitioner or other LIP finds that an H&P done before admission is incomplete, inaccurate, or otherwise unacceptable, the practitioner reviewing the H&P, examining the patient, and completing the update shall disregard the existing H&P, and conduct and document a new H&P within 24 hours after admission.
2. In no case shall surgery, anesthesia or other high-risk procedure be performed before an H&P is duly completed, placed in the patient’s medical record, and reviewed by all relevant medical staff or LIPs.
3. Dictated records shall be reviewed and signed (or co-signed) by the supervising physician before becoming part of the medical record.
8.10 Consultation
1. The healthcare organization shall define the circumstances and criteria under which consultation or management by a physician or other qualified licensed independent practitioner is required.
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