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, however, 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 and the governing body, and
between the organized medical staff and its members.
The requirements found at MS.01.01.01 Elements of Performance (EP) 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. The advantage of such documents is that changes may be delegated to the MEC if so defined in the bylaws (see
MS.01.01.01 EP 20). 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 - 37.