Medical Staff

Medical staff members, in providing patient care and carrying out their other professional responsibilities in increasingly complex organizations, continue to actively participate and exercise professional leadership in measuring, assessing, and improving the performance of the organizations within which they practice.

There is a single organized, self-governing medical staff that has overall responsibility for the quality of the professional services provided by individuals with clinical privileges, as well as the responsibility of accounting therefore to the governing body.

The medical staff develops and adopts bylaws and rules and regulations to establish a framework for self-governance of medical staff activities and accountability to the governing body.

The medical staff is organized to accomplish its functions.

When medial staff clinical departments exist, each department has effective leadership.

The organization establishes mechanisms for hospital-specific appointment and reappointment of medical staff members and for granting and renewing or revising hospital-specific clinical privileges.

Individuals who admit patients are granted specific privileges to do so.

All individuals with delineated clinical privileges participate in continuing education.

The medical staff has a leadership role in organization performance-improvement activities.

Organization Bylaws, Rules, and Regulations

This area reflects an evaluation of the documents that govern the operation of an organized medical staff that is responsible for the quality of patient care. The bylaws, rules, and regulations address medical staff self-governance and the operation of an effective credentialing and privileging process for physicians, dentists, and other licensed independent practitioners who wish to provide care in the hospital.

Credentialing

This area reflects an evaluation of the medical staff members credentialing process and how the hospital ensures that only qualified individuals are on the staff; and that there is assessment of the competence of medical staff members to provide specific services. We do not evaluate the quality of care provided by individual medical staff members.

Hospital Information for the Public

Medical Staff

Organization Bylaws, Rules, and Regulations

Credentialing

Highlights