JC EBMSE 2017
$53.63
Medical Staff Essentials: Your Go-to Guide
| Published By | Publication Date | Number of Pages |
| Joint Commission | 2017 | 282 |
The Joint Commission’s Medical Staff (MS) standards provide a detailed description of the medical staff’s roles and responsibilities. But those standards have always been challenging to understand and apply. Medical Staff Essentials is a clear, concise, accurate reference that breaks down difficult concepts in the MS standards into easy-to-digest pieces. It’s designed to be your go-to guide on the essentials of the MS standards—and related concepts—to help you successfully select and manage your medical staff. Key Topics • Medical staff bylaws, rules and regulations, and policies • Clinical credentialing and privileging • Appointment to the medical staff • Practitioner competence assessment • Professional practice evaluations (FPPE and OPPE) Key Features • Reader-friendly tone and engaging format • Numerous infographics the clarify complex content • Scenarios that show application of key chapter information • Example policies and other documents from real hospitals • Nearly two dozen downloadable, writeable tools (included on a flash drive for print version or linked in the e-book) • Medical Staff and related standards and terms • Reviewed by Joint Commission experts Standards: Medical Staff Setting: Hospitals and critical access hospital Key Audience • Governing body • Organized medical staff • Medical staff • Medical executive committee • Credentialing committee • Hospital administration • Medical staff services • Survey coordination team • Accreditation team • Legal counsel • Performance improvement team • Risk management team Joint Commission Resources, Inc. (JCR), a wholly controlled, not-for-profit affiliate of The Joint Commission, is the official publisher and educator of The Joint Commission. JCR is an expert resource for health care organizations, providing advisory services, educational services and publications to assist in improving quality and safety and to help in meeting the accreditation standards of The Joint Commission. JCR provides advisory services independently from The Joint Commission and in a fully confidential manner.
PDF Catalog
| PDF Pages | PDF Title |
|---|---|
| 1 | Cover |
| 3 | Table of Contents |
| 9 | Introduction |
| 13 | CHAPTER 1: Medical Staff Scope and Governance |
| 14 | PP: Members of the Organized Medical Staff EE: The Significance of These Documents |
| 15 | II: Differences Among Medical Staff Bodies |
| 16 | II: Development and Enforcement of the Bylaws |
| 18 | II: Types of Medical Staff Documents CC: Details in the Medical Staff Bylaws |
| 19 | PP: Force and Flexibility of Medical Staff Documents EE: Duties and Privileges of Medical Staff Categories TT: Conflict Management Checklists TT: Medical Staff Bylaws Evaluation Checklist PP: Basic Steps and Associated Details of Processes |
| 20 | CC: Compatibility of Medical Staff Documents FF: Medical Staff Policies Versus Organizational Policies EE: How Leaders Work Together EE: Medical Staff Documents |
| 21 | PP: Required Collaboration on Amendments CC: Leadership and Medical Staff Standards PP: Integrated Medical Staff for Deemed-Status Hospitals |
| 22 | CC: The Medical Executive Committee PP: Medical Staff as the Medical Executive Committee EE: The Vital Role of the Medical Executive Committee |
| 23 | II: Functions of the Medical Executive Committee |
| 24 | PP: What’s in an H&P, per the Bylaws? |
| 25 | II: Responsibility of H&P Content and Monitoring |
| 26 | FF: H&Ps in Non-Inpatient Services PP: The Value of Communication and Collaborative Care CC: Coordinating and Planning Care |
| 27 | II: Fine Points of Oversight EPs |
| 28 | CC: Supervising Graduate Education Program Participants TT: Professional Graduate Education Communication Record |
| 29 | II: Professional Graduate Education Program Supervision Process |
| 30 | SECTION SETS Medical Staff Role in Performance Improvement CC: Improvement as a Driving Force PP: Improving Performance for Pain Management and Opioid Prescribing |
| 31 | II: Required Information in PI Efforts PP: Barriers to Medical Staff Involvement in PI |
| 32 | STRATEGIES Medical Staff Scope and Governance |
| 34 | SCENARIOS H&P Descriptions in Bylaws Documents |
| 39 | CHAPTER 2: Credentialing and Initial Appointment |
| 40 | SECTION SETS Credentialing Basics II: What Is Credentialing? |
| 41 | II: Responsibility for Credentialing PP: The Credentials Committee |
| 42 | CC: The Importance of Credentialing PP: Consequences of Ineffective Credentialing PP: Credentialing Licensed Independent Practitioners |
| 43 | II: Who Should Be Credentialed? |
| 44 | FF: Credentialing PAs, APRNs, and Consultants |
| 45 | PP: Credentialing Telemedicine Providers |
| 46 | SECTION SETS Preapplication and the Application Process PP: Deciding to Use a Preapplication TT: Application Content Evaluation Checklist |
| 47 | PP: State Laws About Applications TT: Verification of Professional Liability EE: Standard State Credentialing Form |
| 48 | PP: Verifying Applicant Identity TT: Applicant Interview Checklist |
| 49 | SECTION SETS Credentials Verification Process CC: Critical Credentialing Criteria |
| 50 | PP: Primary Source Verification for Credentialing II: Designated Equivalent Sources |
| 51 | PP: Verifying Current Licensure Using Primary Sources TT: Credentials Verification Record |
| 52 | II: License Verification as Education Verification |
| 53 | PP: Using a CVO to Verify Education and Training CC: Evaluation Limitations of a CVO TT: CVO Evaluation Checklist |
| 54 | CC: Verifying Current Competence TT: PA General Competencies Assessment Checklist |
| 55 | EE: General Competencies |
| 56 | II: Application Red Flags |
| 57 | TT: Application Red Flags Assessment Checklist |
| 58 | SECTION SETS Appointment to the Medical Staff CC: Process for Appointment to the Medical Staff TT: Medical Staff Membership Evaluation Checklist |
| 59 | II: Types of Medical Staff Membership |
| 60 | STRATEGIES Credentialing and the Initial Appointment Process |
| 64 | SCENARIOS Credentialing and Appointment Processes |
| 69 | CHAPTER 3: The Privileging Process |
| 70 | SECTION SETS Scope of Practice CC: Health Care Changes and Scope of Practice |
| 71 | II: Scope of Practice Considerations |
| 72 | II: Classification Systems for Privileges |
| 73 | FF: Core/Bundle Definition and Implementation EE: Core Privileges Form |
| 74 | SECTION SETS Privileging and Reprivileging PP: Defining Privileging Criteria CC: Importance of Preestablished Criteria |
| 75 | II: Types of Privileging Criteria PP: New Privileges and Professional Practice Evaluations |
| 76 | II: Preceptors and Proctors to Evaluate Competence |
| 77 | TT: Proctoring Policy Evaluation Checklist PP: Benefits of Proctoring TT: Surgical Procedure Assessment Checklist |
| 78 | II: The Privileging Process |
| 79 | II: Evaluating the Privileging Process TT: Procedure for Evaluating Privileging Process Checklist TT: Credentialing and Privileging Tracer Questions |
| 80 | FF: Who Is a Peer? |
| 81 | II: Sources for Peer Recommendations PP: Required Content of Peer Recommendations |
| 82 | SECTION SETS Applicant Evaluation and Recommendations Process CC: Meeting Privileging Requirements II: Medical Staff Membership and Privileges |
| 83 | CC: Fairness of the Approval Process II: The Recommendation Process |
| 84 | PP: Duration of Privileging and Timeliness of Approval FF: Governing Body Approval Date |
| 85 | II: Reasons for Denying Privileges |
| 86 | PP: When Privileges Are Denied CC: Proof of Qualifications and Competence PP: Decision-Making Language in Medical Staff Membership and Privileging |
| 87 | SECTION SETS Expedited Privileging and Temporary Privileging PP: Responsibilities for the Expedited Process |
| 88 | II: Ineligibility for Expediting PP: Reasons for Granting Temporary Privileges |
| 89 | II: Criteria to Verify for Temporary Privileges |
| 90 | II: Leadership Approvals in Temporary Privileging PP: Medical Staff Responsibility for Disaster Privileging |
| 91 | EE: Disaster Privileging Versus Assigning Disaster Responsibilities TT: Disaster Privileging Tracer Questions EE: Disaster Privileging Policy |
| 92 | STRATEGIES The Privileging Process |
| 96 | SCENARIOS Revision of Privileging Forms and Process Steps |
| 101 | CHAPTER 4: Ensuring Continuous High Performance |
| 102 | SECTION SETS Professional Practice Evaluations—FPPEs and OPPEs CC: What Is the Focus of an FPPE? PP: When to Use an FPPE |
| 103 | II: Required Components of an FPPE Process FF: FPPE Predefined Process |
| 104 | II: Factors in the Duration of an FPPE PP: Evaluating Groups of Privileges in an FPPE CC: How an FPPE Affects Other Privileges |
| 105 | II: Criteria and Triggers for an FPPE |
| 106 | II: The FPPE Process TT: FPPE Procedure Checklist |
| 107 | CC: Who Undergoes OPPEs? PP: OPPEs and Privileging FF: Frequency of an OPPE |
| 108 | PP: Benefits of OPPEs II: Information for Performance Evaluations |
| 109 | II: Defining Which OPPE Data to Collect |
| 110 | PP: Performance Measures for OPPEs TT: OPPE Evaluation Checklist TT: Performance Data Sources Assessment Checklist PP: Data Measures for Professional Practice Evaluations |
| 111 | FF: Using Data from Another Organization for an OPPE |
| 112 | II: Evaluation Results and Follow-Up Actions |
| 113 | CC: The Purpose of Continuing Education PP: Continuing Education for Privileged Practitioners |
| 114 | II: Continuing Education Needs Assessment |
| 115 | SECTION SETS Responding to Concerns About a Practitioner CC: Internal Reporting Processes |
| 116 | PP: Adverse Privileging Decisions II: How the NPDB Works |
| 117 | II: Fair Hearing and Appeal Process EE: Full Consideration and Reconsideration EE: Fair Hearing and Appeals Policy |
| 118 | PP: Eligibility for the Fair Hearing and Appeal Process II: Hearing and Appeal Process Requirements |
| 119 | EE: Facilitating Practitioner Rehabilitation PP: Corrective Action and Legal Requirements for Practitioner Health TT: Practitioner Health Assessment Process Evaluation Checklist |
| 120 | SECTION SETS Reappointment and Reprivileging PP: Goals of Reappointment and Reprivileging TT: Reappointment and Reprivileging Application Assessment Checklist |
| 121 | II: Comparisons to Initial Processes |
| 122 | PP: Relinquishing Privileges CC: Making Reappointment and Reprivileging Decisions EE: Request for Renewal of Clinical Privileges |
| 123 | STRATEGIES Ensuring Continuous High Performance |
| 127 | SCENARIOS FPPE and OPPE Process Improvements |
| 131 | Appendix A: Examples to Examine |
| 199 | Appendix B: Tools to Try |
| 243 | Appendix C: Medical Staff Standards and Related Standards |
| 267 | Glossary |
| 273 | Index |
| 282 | Back Cover |
