The Chapter Leader's Guide to Performance Improvement

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Chapter Leader's Guide to the Medical Staff

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Chapter Leader's Guide to the Medical Staff

Kathy Matzka, CPMSM, CPCS

Quick, concise standard explanations for medical staff chapter leaders

The Chapter Leader's Guide to Medical Staff breaks down the Joint Commission’s medical staff requirements into easy-to-understand solutions to meet the challenges of these complex standards. You get simplified explanations of the chapter’s key components along with communication techniques to help foster a strong and successful partnership between survey coordinator and chapter leader.

Plus, to make staff training easy, this guide includes two downloadable PowerPoint® presentations highlighting key compliance takeaways. Also, recieve bonus tools which include:

  • Credentials committee orientation PowerPoint presentation
  • Credentialing and privileging basics PowerPoint presentation
  • Approval signature page
  • Recommendation and approval form for medical staff appointment and clinical privileges
  • Key players outline chart


Purchase all 12 titles in the Chapter Leader Series now and save!


Benefits of The Chapter Leader's Guide to Medical Staff:

  • Empower your medical staff chapter leaders to successfully navigate the survey process
  • Communicate the impact the medical staff chapter has on leadership, management, and caregivers
  • Create a culture of accountability by delegating survey-related responsibilities to staff members
  • Go beyond standard numbers and understand the true meaning of The Joint Commission’s medical staff requirements
  • Get everyone in your facility on board with compliance
  • Save time training medical staff chapter leaders with the customizable PowerPoint presentations


What's inside:

  • Keys to understanding The Joint Commission’s stance on medical staff bylaws (MS.01.01.01)
  • Explanation of the role of the MEC
  • How the medical staff plays into graduate education programs and performance improvement
  • Accreditation’s role in credentialing and privileging
  • What the standards say about physician behavior
  • The latest updates to telemedicine requirements


Table of Contents

  • Part I: Organization & Accountabilities
    • Medical Staff and the Organization
    • Impact on Leadership/Administration
    • Determining Ownership
    • The Medical Services Professional (MSP)
    • The Quality Staff’s Role
    • The Medical Staff’s Role
    • The Chief Executive Officer’s Role         
    • The Hospital Governing Body’s Role      
    • Key Players by Standard   
    • Hospital Medical Staff (MS) Standards and Key Players Outline      
  • Part II: Communications & Culture
    • Communication and its Impact on Staff and Physicians        
    • Hospital Staff
    • Credentials Committee      
    • Department Chairman       
    • Medical Executive Committee      
    • Governing Body      
    • Medical Staff
  • Part III: Operations & Performance Improvement
    • Patient Care’s Relationship to the Standards
    • Successfully Maintaining Processes
    • Impact on Activities, Requirements, Policies, and Procedures
  • Part IV: Breakdown of the Medical Staff Standards
    • MS.01.01.01: Organized Medical Staff Structure, Accountability, and Bylaws       
    • MS.01.01.03: Bylaws Amendments        
    • MS.02.01.01: Medical Executive Committee
    • MS.03.01.01: Oversight of Practitioners 
    • MS.03.01.03: Management and Oversight of Patient Care    
    • MS.04.01.01: Graduate Medical Education Programs 
    • MS.05.01.01: Medical Staff Performance Improvement          
    • MS.05.01.03: Medical Staff Participation in Organizational Performance Improvement  
    • MS.06.01.01:  Determining Organizational Resource Availability     
    • MS.06.01.03:  Credentialing         
    • MS.06.01.05:  Privileging  
    • MS.07.01.03: Peer Recommendations   
    • MS.06.01.07: Analysis and Use of Information Received       
    • MS.06.01.11:  Expedited Credentialing  
    • MS.06.01.09: Privilege Decision Notification
    • MS.06.01.13: Temporary Privileges         
    • MS.07.01.01: Medical Staff Appointment           
    • MS.08.01.01: Focused Practitioner Evaluation 
    • MS.08.01.03:  Ongoing Professional Practice Evaluation      
    • MS.09.01.01: Evaluation and Action Regarding Practitioner-Specific Concerns   
    • MS.4.50: Fair Hearing and Appeals Process     
    • MS.11.01.01: Licensed Independent Practitioner Health        
    • MS.12.01.01: CME  
    • MS.13.01.01: Telemedicine Privileges   
    • MS.13.01.03: Telemedicine Standards for Both Originating and Distant Sites       


Who will benefit?

accreditation coordinator, accreditation specialist, survey coordinator, Joint Commission survey coordinator, medical staff chapter leader, medical staff coordinator, medical staff professional


Earn Continuing Education Credits

National Association for Healthcare Quality (NAHQ)
This activity is pending approval by the National Association of Healthcare Quality for CE credits.


About the Author

Kathy Matzka, CPMSM, CPCS, is a speaker, consultant, and author with more than 20 years of experience in medical and professional staff services. She is certified by National Association Medical Staff Services (NAMSS) in both management of medical staff services and provider credentialing.

Faculty Disclosure Statement: HCPro Inc. has confirmed that none of the faculty/presenters or contributors have any relevant financial relationships to disclose related to the content of this educational activity.


Published: January 2011