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Improving Efficiency of Medical Staff Chapter Review for Hospitals


By Patricia Buckberg, DNP, PNP, CNS, BA, RN, Field Director

We heard from you. Many hospitals and critical access hospitals asked us to streamline our review of the Medical Staff (MS) chapter during the triennial survey. 

To address this, a group of physician surveyors worked on a six-month project to help surveyors more efficiently evaluate and score the requirements in the MS chapter. The project resulted in the development of MS chapter templates for surveyors to use during the triennial survey.

At their upcoming triennial survey, organizations will be required to use the templates with surveyors. Then, at the following triennial survey, organizations will be asked what, if any, changes have occurred to their MS bylaws, rules or regulations, and policies over the past three years. If no changes are reported, those specific pieces of the MS requirements will not need to be surveyed. However, if any changes have occurred, only those changes will need to be evaluated. 

In addition, the following will continue to be evaluated during every triennial survey:

  • focused professional practice evaluation (FPPE)
  • ongoing professional practice evaluation (OPPE)
  • other components of credentialing

MS Chapter Templates
The list of templates to improve the review of the MS chapter includes:

  • general medical staff credentialing and privileging system tracer session template
  • bylaws template
  • credentialing file review template
  • graduate medical education verification template

These templates cover wide-ranging topics to help surveyors focus on standards and elements of performance (EPs) within the MS chapter, including:

  • medical staff bylaws
  • structure and role of medical staff executive committee
  • medical staff role in oversight of care, treatment, and services
  • medical staff role in graduate education programs
  • medical staff role in performance improvement
  • credentialing and privileging
  • appointment to medical staff
  • evaluation of practitioners
  • acting on reported concerns about a practitioner
  • fair hearing and appeal process
  • licensed independent practitioner health
  • continuing education for practitioners
  • medical staff role in telemedicine

We felt that it was important to make these templates available to help you become more compliant with the MS chapter prior to your triennial survey. The templates are accessible to accredited hospitals and critical access hospitals in the 2021 Survey Activity Guide on an organization’s Joint Commission Connect® extranet site. 

Patricia Buckberg, DNP, PNP, CNS, BA, RN, is a Field Director for Surveyor Management and Support in the Division of Accreditation and Certification Operations with more than 35 years of experience. In this role, she oversees the education and performance of hospital field staff in areas such as the on-site survey, survey technology and standards application. Dr. Buckberg also participates in strategic planning activities for the hospital accreditation program.