Medical Staff Leader Handbook Online Resource is a
dynamic online resource that is continually updated. If
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Handbook will change immediately. You will always have the
latest thinking from attorneys who practice only health law.
You print out the chapter or section when you need it. You
take the right form or letter and edit it to meet your needs.
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Staff Leader Handbook: An Online Resource and Medical
Staff Leader Monthly newsletter even more valuable. Want to see what
the government has to say about medical staff membership of
physicians excluded from the Medicare program? We'll link you
to the OIG advisory opinion that discusses that issue.
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Staff Leader Monthly, written specifically for physician leaders and medical
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Monthly Newsletter
View Sample Newsletter (requires
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Included with your subscription to Medical
Staff Leader Handbook: An Online Resource, Medical
Staff Leader Monthly tackles the issues you face each day
in articles
such as
these, which
have appeared in
recent newsletters:
- Medical Staff Documents — Why
Must They All Be Bylaws?
- Must APRNs and PAs Be Granted Privileges?
- Joint Commission Proposal Would Limit
Fundamental Legal Authority of Hospital Boards
- HCQIA Immunity Lost — Lessons
to Be Learned?
- When a Physician’s Malpractice
Insurance Lapses ...
- Hospital Deprived of HCQIA Immunity
Table of Contents
Initial Appointment
* Step 1: Request
for an Application
* Step 2: Application
* Step 3: Verification of Information
* Step 4: Getting the Most Out of References
* Step 5: Department Procedure
* Step 6: Informal Interview
* Step 7: The Credentials Committee's Review and Recommendation
* Step 8: Executive Committee Recommendation
* Step 9: Board Action
Provisional Appointment
* Case Studies
* Policy on Provisional Appointment and Privileges
* Liability of Monitors or Evaluators
Reappointment
* Step 1: Application
for Reappointment
* Step 2: Collecting Data
* Step 3: Assessment and Report by Department Chief
* Step 4: Credentials Committee's Review and Recommendation
* Step 5: Executive Committee's Recommendation
* Step 6: Board Action
Disability Issues
* Does the ADA Apply?
* Approaches to Take at Initial Appointment
* Disability of Physician Appointed to the Staff
Criteria for Delineation of Clinical
Privileges
* Case Studies
* Guidelines to Developing Criteria for Delineation of Clinical Privileges
* Delineating Clinical Privileges
* What About Grandfathering?
* Procedure for Determining “Core” Privileges
* Sample Criteria for Privileges
* Exclusive Contracts and Privileges
Streamlining the Credentialing Process
*
How Does It Work?
* Accreditation Standards
* Peer Review Protections and Other Legal Issues
* So Long, Temporary Privileges!
System-wide Credentialing
* Component-Specific
Privileges
* Medical Staff Development Planning
* Centralizing Application Processing and Data Collection
* Questions of Competence and Professional Conduct
Allied Health Professionals
* Developing
Allied Health Professional Policies
* Case Studies
* Scope of Practice Examples
* Credentialing Allied Health Professionals
* Suggested Application Process
Professional Conduct
* Disruptive Behavior
* Sexual Harassment
* Impaired Physicians
* Case Studies
Investigations
* Step 1: Initial Procedure
-- When Does an Investigation Start?
* Step 2: Conducting the Investigation
* Step 3: Meeting with the Committee
* Step 4: Credentials Committee's or Executive Committee's
Recommendation
* Summary Suspensions -- Punitive or Precautionary?
* Leave of Absence / Reinstatements
Hearings
* Grounds for Hearing
* Notice of Recommendation
* Case Studies
* Step-by-Step Procedure for Medical Staff Hearings and Appeals
* Composition of the Hearing Panel
* Can Hearing Rights Be Waived?
National Practitioner Data Bank
* Reports
to the Data Bank
* What Does Not Have to Be Reported?
* Submitting an Accurate Report
* Who Can Query the Data Bank?
* Confidentiality
* Disputes and Corrections
* Hospital Policy on the National Practitioner Data Bank
Legal Protections and Confidentiality
*
Overview of Legal Protections
* Keys to Confidentiality
* Confidentiality Agreements
* Dealing with Questions of Conflicts of Interest or Bias
On-Call Issues
* On-Call Problems and Suggestions
* Follow-up Care
* Refusal of Stabilizing Treatment/Request for Transfer
* Consent to Transfer/Refusal to Consent to Transfer
* Physician Certification for Transfer
Roles and Responsibilities
* Selecting
Department Chiefs and Medical Staff Leaders
* Collegial Intervention
* Corporate Compliance
Medical Staff Structure
* Medical Staff Categories
* Committees and Departments
* Medical Staff, Committee and Department Meetings
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Sample Letters
* Follow-Up to Meeting
with Physician Regarding Disruptive Behavior
* Notice of Unfavorable Recommendation--Initial Appointment
* Letter to Witnesses with Credentials or Executive Committee
* Invitation to Meet with Credentials or Executive Committee
* Letter Outlining Basic Criteria Required for Appointment and Privileges Review
Process
* Letter to Department Chiefs at Other Hospitals Where Applicant Has Practiced
* Request for Information Regarding Disciplinary Action at Another Hospital
* Letter to Department Chiefs Outlining Responsibilities and Protections
* Letter to Physician Under Investigation
* Notice of Expiration of Current Appointment
* Letter Informing Physician Who Has Not Used Hospital or Ineligibility to
Apply for Reappointment
Sample Forms
* Application for Medical Staff Appointment
* Centralized Credentialing Application
* Processing Checklist
* Physician Evaluation Form
* Administrative Reference Questionnaire
* Interview Questionnaire
* Reappointment Activity Summary
* Medical and Surgical Performance Evaluations
* Report of Incident of Disruptive Behavior
* Hearing Rules and Procedures
* Medical Staff Peer Review Confidentiality Agreements
* Forms Implementing Emergency On-Call Policy
* Quality Assessment Report
* Procedure for Determining Privileges in Each Specialty
* Medical Executive Committee Conflict of Interest Agreement
Sample Bylaws
* Eligibility Criteria
for Medical Staff Officers
* Collegial Intervention
* Medical Staff Categories
* Functions of Departments
* Conditional Reappointment
* Duration of Provisional Appointment
* Meeting with Physician Being Investigated
* Action by Government Agency or Professional Liability Insurer
* Grounds for Precautionary Suspension
* Hearing Procedures
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