The Medical Staff Services Handbook

Rev. ed. of: The medical staff services handbook / [edited by] Cindy A. Gassiot, Vicki L. Searcy, Christina W. Giles. c2007.

The Medical Staff Professional''s Handbook The essential medical staff professional''s job manual Let your experienced peers provide you with the guidance and training you need to tackle your toughest challenges.The Medical Staff Professional''s Handbook is a comprehensive job manual developed by medical staff professionals (MSPs) Anne Roberts, CPMSM, CPCS, and Maggie Palmer, MSA, CPMSM, CPCS. While providing much-needed education for new MSPs, this book and downloadable toolkit also offer veterans new ideas, tips, sample policies, customizable forms, and advice for improving medical staff and credentialing processes. After reading this book, you will be able to: Define the roles, tasks, and expectations for MSPs to clearly identify their priorities Manage FPPE and OPPE processes to effectively assess physician competency Streamline and improve credentialing and privileging processes with dozens of customizable forms and sample tools Comply with accreditation and regulatory standards by understanding the MSP''s role in accreditation and the consequences of noncompliance Discover important tips to save time and increase efficiency on daily medical staff office tasks Support the medical staff and communicate with leadership Table of ContentsAbout the Authors Introduction Acronyms and Abbreviations Section I: The Successful Medical Staff Professional Chapter 1: Roles and Responsibilities of Medical Staff Professionals The Responsibilities of MSPs Who MSPs Support in the Organization Chapter 2: Managing External and Internal Relationships Navigating External Relationships Navigating Internal Relationships Chapter 3: Review of Credentialing, Privileging, and Medical Staff Standards History of Regulatory Agencies How the Standards Apply to MSPs Joint Commission Requirements What MSPs Should Expect During Accreditation Surveys Chapter 4: Legal and Regulatory Considerations for Medical Staff Professionals Managing Bylaws Rules and Regulations Corrective Action and Due Process Policies and Procedures HCQIA of 1986 NPDB Healthcare Integrity and Protection Data Bank Sharing Information Credentialing Interrogatories Attestation, Acknowledgments, and Release Forms Criminal Background Checks Disruptive and Impaired Practitioners Section II : Effective Credentialing and Privileging Chapter 5: The Credentialing Process Credentialing Basics Rules to Guide Your Credentialing Process Roles and Responsibilities During the Credentialing Process The Application Process Collecting and Verifying Information Review and Approval Process Chapter 6: Credentialing Responsibilities After the Initial Application Orientation for Patient Care Organizations Credentials Expiration Tracking and Ongoing Monitoring Tips for Avoiding Claims of Negligent Credentialing Chapter 7: The Privileging Process Implementing a Privileging Process Developing Clinical Privilege Delineations Granting Clinical Privileges Based on Competency Final Recommendations for Privileges Chapter 8: Reappointment Initiating the Reappointment Process Accepting the Application Performing Primary Source Verification Creating the Reappointment Profile Quality Review, Ongoing Evaluation, and Monitoring Review and Approval Chapter 9: Credentialing and Privileging Hurdles Low- and No-Volume Practitioners Allied Health Practitioners Telemedicine Practitioner Data and Document Confidentiality Leaves of Absence Paperless/Paper-Light Credentialing System Transition New Technology Privileging Chapter 10: Temporary, Emergency, and Disaster Privileges and Expedited Board Approval Temporary Privileges Emergency Privileges Disaster Privileges Fast-Track or Expedited Credentialing Section III : Measuring Practitioner Competency Chapter 11: Focused Professional Practice Evaluations Requirements for an FPPE Policy and Process Developing FPPE Criteria FPPE at Initial Granting of Privileges Tracking Completion of FPPE FPPE for Additional Privileges FPPE for Cause (Ongoing Professional Practice Evaluation, Peer Review, Leave of Absence Reinstatement) Chapter 12: Ongoing Professional Practice Evaluations Developing a Systematic Approach to OPPE Developing Quality Indicators Periodic Performance Feedback Reports Section IV : Sample Forms and Policies Credentialing Sample Forms Privileging Sample Forms Reappointment Sample Forms Competency Sample Form Continuing Education This book has been approved by the National Association Medical Staff Services for 5 continuing education units. Accreditation of this educational program in no way implies endorsement or sponsorship by NAMSS.

The Medical Staff Office Manual: Tools and Techniques for Success Marna Sorensen, CMPSM The Medical Staff Office Manual: Tools and Techniques for Success is a comprehensive guide that maps every aspect of the medical staff office, from onboarding and orienting physicians to querying other facilities for practitioner information and effectively collaborating with physician leadership. In this in-depth manual, author Marna Sorensen, CMPSM, provides MSPs guidance on their role within an organization, quick access to accreditation and regulatory information, and job descriptions and customizable forms to simplify a constantly growing list of daily responsibilities. This book will help you: Consolidate everything you need to do your job into one place Detail procedures for all of your daily tasks, including practitioner data queries, acceptance letters, job descriptions, performance reporting, and sample forms Demonstrate what you do on a daily basis and clearly define your many roles as an MSP--no more questioning who is responsible for what! Update medical staff office functions and get the word out using the new technologies at your disposal Table of Contents Introduction/How to Use This Manual Medical Staff Organization and Staffing Medical Staff Office Job Descriptions The Credentialing Process Medical Staff Clinical Privileges Advanced Practice Professionals Templates for Most-Used Forms Medical Staff Policies HR or MSO?

The definitive resource for the medical staff services professional, this thorough, authoritative handbook has practical guidance for every aspect of the demanding field of medical staff management.

The Credentialing Handbook provides comprehensive, plain-English guida nce to understand and master the provider credentialing process in any health care setting. With sample forms, checklists, flowcharts, and c orrespondence, this practical guide walks you through every aspect of effective credentialing, appointment, and recredentialing. You'll lear n: key steps in the credentialing process; about express credentialin g models; how to credential allied health practitioners; typical time frames and tracking systems; pros and cons of delegating credentialin g, plus more.

The Medical Staff Leader''s Survival Guide William K. Cors, MD, MMM, FACPE An affordable, time-sensitive solution to medical staff leadership training. Physicians who accept or are assigned leadership positions are often left on their own to develop leadership skills and educate themselves about their responsibilities as medical staff leaders. Just because a physician is a great clinician does not mean he or she is a great leader. The challenges of being a successful medical staff leader are twofold: You must be well-versed in your role and responsibilities (i.e., peer review, credentialing, medical staff bylaws), and you must inspire other medical staff members to follow the rules while continuing to deliver excellent patient care. A well-trained medical staff leader is vital to the culture of a hospital''s medical staff and can save a hospital from the expense of lawsuits affiliated with negligent credentialing/peer review. This book aims to teach physicians how to become great medical staff leaders and how to motivate other medical staff members on topics such as: AHP credentialing and supervision Reappointment challenges Physician-hospital competition Liability risks Medical staff disharmony and distrust Table of Contents Chapter 1: Where to Begin? Principles of Governance Chapter 2: Meetings: The Cost of Holding a Meeting Chapter 3: Meetings: How to Run an Effective Meeting Chapter 4: Overcoming Physician Apathy Chapter 5: Job Descriptions: Medical Staff Leaders Chapter 6: The VPMA/CMO: Where This Fits Chapter 7: Credentialing and Privileging: Requirements, Guidelines and Tips Chapter 8: New Technology Privileges Chapter 9: Privileging Disputes and How to Resolve Them Chapter 10: Advanced Practice Professionals Chapter 11: Low-Volume, No-Volume Practitioners Chapter 12: The Aging Physician Chapter 13: Proctoring (FPPE) Chapter 14: Peer Review (OPPE): Some Best Practices Chapter 15: Dealing with the Physician with Problems Chapter 16: Corrective Action: The Good, the Bad and the Ugly Chapter 17: Physicians and Hospital Administration: They''re Just Different Chapter 18: EMTALA and Emergency Department Coverage Chapter 19: Conflicts of Interest Chapter 20: Economic Credentialing Chapter 21: Physician-Nursing Relationships Chapter 22: Health Care Finance: A Primer Chapter 23: Medical Errors Disclosure Chapter 24: Employed Practitioners Chapter 25: Contracted Practitioners Chapter 26: Confidentiality Chapter 27: Accreditation and Regulation Chapter 28: Bylaws and Related Documents Chapter 29: Medical Staff Governance: Myths and Misconceptions Chapter 30: Personal Characteristics of Great Leaders Who will benefit from this book? Directors of medical staff offices, vice presidents of medical affairs, medical staff presidents, credentials committee chairs and members, committee and department chairs

Winner of the 2016 ACHE James A. Hamilton Book of the Year Award Healthcare organizations are facing many challenges in this new era of healthcare reform, one of which is to establish a new operating model for the organized medical staff. Deeply rooted in tradition, the current medical staff model can no longer hold in an environment where quality, safety, service, and cost-effectiveness are required for healthcare organizations to not only survive but truly thrive. In this book, the author, an experienced physician leader and healthcare consultant, describes key changes that must be made to redesign the medical staff model. He provides specific guidance and examples to help healthcare leaders and executives work with their physician leaders to face these changes successfully. Well-regarded contributors and subject matter experts offer additional examples and insights with special content throughout the book. The author provides an in-depth look into: The evolution of the physician culture from autonomy to collaboration and accountability that must take place for US healthcare providers to remain competitive in an increasingly global economy Select strategic medical staff development planning and credentialing/privileging approaches that are needed to ensure physician-organization alignment Components of an effective and rigorous performance management system that enables leaders to help physicians achieve mutually agreed-on goals and metrics and align them with those of the organization Medical staff performance assessment and improvement activities, including peer review best practices, ways to incentivize excellence, and how to address issues in a timely, compassionate way Negotiation of performance expectations with management and the hospital's board that are consistent with the organization's strategic plan Physician engagement and alignment strategies that will enable physicians and management to work together to achieve the goals of population health and reduced operating costs Healthcare executives and administrators, physician executives, and board leaders can use this book as a guide to learn from organizations that have successfully integrated and aligned with their medical staffs into a collaborative environment. Examples of organizations with medical staffs that have made a complete commitment to the success of their enterprises and the health of their communities are incorporated throughout the book.