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Medical Staff Governance - Medical Staff Policies versus Organizational Policies

Do the requirements found in the Medical Staff (MS) chapter at MS.01.01.01 require the organized Medical Staff to have a separate set of policies apart from existing hospital-wide policies and procedures that already apply to all individuals and departments?

Any examples are for illustrative purposes only.

There are no standards that require the medical staff to create policies that duplicate existing organizational policies, as long as it is clear that such policies also apply to the activities of the medical staff – whether employees of the organization or not. There should be evidence that the medical staff participated in the review/approval of such policies. 

There are requirements that are specific to the structure, functions and accountabilities of the medical staff that should be defined in medical staff rules, regulations or policies. These documents create a system of rights, responsibilities, and accountabilities between the organized medical staff, the governing body, and between the organized medical staff and its members.

The requirements found at MS.01.01.01 EPs 5–7 address requirements specific to medical staff and governing body compliance and enforcement of the bylaws, rules and regulations, and policies.  

A few examples of such policies may include:
• Required elements of a medical history, such as a psychological history, body systems review, past procedures, allergies, co-morbidities, etc.
• The detailed steps for credentialing and re-credentialing
• Responsibilities for oversight of professional graduate education program participants
• Medical staff health screening requirements
• On-call coverage requirements

The term ‘policy’ is defined as “a principle or method that is developed for the purpose of guiding decisions and activities related to governance, management, care, treatment, and services. A policy is developed by organization leadership, approved by the governing body of the organization, and maintained in writing.” 

For the purposes of ‘policies’ as referenced in the medical staff chapter, policies are documents other than medical staff bylaws. However, when such documents are adopted by the organized medical staff and approved by the governing body, pursuant to the provisions of Standard MS.01.01.01, these documents have the same force and effect as the medical staff bylaws.

Use of rules, regulations, and policies may be used to define those requirements that are subject to more frequent changes in the environment, law/regulation, expectations and functions of the medical staff. Therefore, review, revisions, and approvals can be more expeditious than changes to bylaws as such changes cannot be delegated (see MS.01.01.01 EP 2).

When developing medical staff documents, organizations need to be mindful that there are requirements specific to the medical staff governance and framework that MUST be contained within the bylaws. These are defined in the Medical Staff chapter at MS.01.01.01 EP 12 - 38.

Last updated on March 03, 2021
Manual: Hospital and Hospital Clinics
Chapter: Medical Staff MS

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