The Top 45 Medical Staff Policies and Procedures, Fifth Edition

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The Top 45 Medical Staff Policies and Procedures, Fifth Edition

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The Top 45 Medical Staff Policies and Procedures, Fifth Edition

Author: Todd Sagin, MD, JD

The Top 45 Medical Staff Policies and Procedures, Fifth Edition,
is a user-friendly guide that will help you develop medical staff policies and procedures that comply with CMS and Joint Commission requirements and promote current industry best practices. Updated by industry expert Todd Sagin, MD, JD, these sample forms cover the most complex policies and procedures, saving you the time it takes to create these documents from scratch. All 45 forms are downloadable and customizable to suit your organization’s needs. This update includes policies that cover emerging issues such as clinical consultations, orders for outpatient tests by non-medical staff practitioners, and collegial intervention.

This book will help MSPs and physician leaders:

  • Quickly develop various department policies and procedures unique to the medical staff
  • Update existing policies with new, compliant language
  • Replace time-consuming, arduous searches for information with a simple download of
    the forms they need
  • Sharpen their focus on both the legal issues of the organization and the needs of
    the medical staff


Table of Contents

  • Administration 
    • Advance Directives
    • Appointment Access Standards in Hospital Outpatient Medical Practices
    • Confidentiality Statement
    • History and Physical
    • Impaired Provider
    • Medical Records Completion Requirements
    • Physician Concern, Complaints, and Suggestions Concerning Hospital Operations
    • Universal Protocol
    • Verbal and Telephone Orders
  • Credentialing and Privileging
    • Advanced Practice Professionals Credentialing and Privileging
    • Authorization of Clinical Assistants to Provide Services
    • Background Checks for Practitioners Processed through the Medical Staff
    • Clinical References
    • Content of Medical Staff Credentials Files
    • Credentialing, Burden on the Applicant
    • Credentialing Nonstaff Volunteer Practitioners for Disaster Responsibilities
    • Credentialing Reappointment and/or Renewal of Privileges
    • Credentialing of Telemedicine Practitioners
    • Credentials File: Content, Access, Control, and Retention
    • Credentials Information Verification
    • Criteria for Medical Staff Clinical Consultations
    • Delineating Clinical Privileges, Dispute Resolution, and New Technology
    • Emergency Privileges
    • Establishing Privileging Criteria for New Technology or Procedures
    • Exclusive Contracts and Practitioner Privileging
    • Expedited Credentialing
    • Initial Medical Staff Appointment
    • Low-Volume and No-Volume Practitioners
    • Ordering of Outpatient Tests and Treatment by Non-Medical Staff Licensed Independent Practitioners
    • Physical Assessment of Practitioners over the Age of [70]
    • Temporary Privileges
  • Governance 
    • Conflict Resolution
    • Leave of Absence
    • Medical Staff Member Rights
    • Medical Staff Member Special Appearance Requirement
    • Organizationwide Conflict of Interest
    • Professional Conduct
  • Quality
    • Collegial Intervention
    • Communication and Use of Physician Competency Expectations
    • Credentialing, Confidentiality of Medical Staff Minutes, Quality Improvement, and Peer Review Information
    • Medical Staff Performance Expectations: A Sample Framework and Document
    • Medical Staff Performance Expectations: The Joint Commission Framework
    • Medical Staff Peer Review
    • Guide to Developing A Policy On Proctoring/FPPE
    • Validation of Perception-Based Rule Indicator Occurrences


Meet the author:

Todd Sagin, MD, JD, is the national medical director of Sagin Healthcare Consulting, LLC, and HG Healthcare Consultants, LLC, which provide guidance on a wide range of healthcare issues. Dr. Sagin’s work frequently involves creating bylaws documents or assisting in the revision of these documents. He has served in a wide range of management and physician leadership roles over his career, including vice president, chief medical officer, and senior medical director.