New templates available to evaluate, score Medical Staff requirements
The Joint Commission has developed templates to evaluate and score the requirements in the Medical Staff (MS) chapter of the Comprehensive Accreditation Manual for Hospitals and Comprehensive Accreditation Manual for Critical Access Hospitals. The templates are the result of a six-month project – that included a group of physician surveyors – to increase survey consistency and scoring of MS requirements.
Surveyors are using the new templates during current triennial surveys to focus on standards and elements of performance (EPs) within the MS chapter, including the following topics:
- 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
The templates were developed in part to streamline the documentation review specific to these requirements. During an organization’s next triennial survey — based on the surveyor’s ability to conduct a thorough evaluation — 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, focused professional practice evaluation (FPPE), ongoing professional practice evaluation (OPPE), and other components of credentialing will continue to be evaluated during every triennial survey. If changes have occurred, MS bylaws, rules or regulations, and policies also will be evaluated.
Due to the numerous topics of documents reviewed in the MS chapter, a variety of templates were developed to appropriately evaluate the different types of documentation, including:
- General medical staff credentialing and privileging system tracer session template
- Bylaws template
- Credentialing file review template
- Graduate medical education verification template
The templates are available to Joint Commission-accredited hospitals in the 2021 Survey Activity Guide on the organization’s Joint Commission Connect® extranet site. For more information, contact , DNP, PNP, MSN, CSN, Field Director, Division of Accreditation and Certification Operations, or , FACHE, MS, BSN, RN, Field Director, Division of Accreditation and Certification Operations.