Author Archive for Karen M. Cheung

Contest entry: Practitioner quality summary form

Happy Free Form Friday!

A reader sent in this form to help streamline the peer review process.

Kathy J. Szary, medical staff services coordinator and executive assistant at Grinnell (IA) Regional Medical Center, shared her story and tool for the The Greeley Medical Staff Institute Symposium contest. She said,

I work in a one-person office in a rural hospital in Iowa. I was fortunate enough several years ago to be able to purchase a credentialing software program to help with the credentialing process.

My dilemma was how to get my arms around the peer review process. I had written a proposal for a quality software program to compliment my credentialing software program in 2007 for the 2008 budget, but it was not approved due to limited financial resources available.

My solution was to develop an Excel spreadsheet to track this information and print reports as needed for reappointment and CMS surveys.

After each peer review committee meeting (medicine case review committee, OB committee, and surgical case review committee, and medical staff executive committee, as needed), I collect the review forms, organize them by practitioner, and then input the information from the review form into the Excel spreadsheet database. I am then able to hide rows that I do not need to print a report for a specific practitioner that accompanies their recredentialing application, or as requested during a CMS survey. The review forms are then placed in the practitioner’s peer review file.

The key for the Excel spreadsheet includes the following:
status: MS (medical staff) or AHP (allied health professional)
type: MCR (medicine case review)
SCR (surgical case review)
OB (OB committee)
Rdm (random)
Oth (Other)

Our peer review policy states that there will be a minimum of ten charts selected at random and reviewed prior to the reappointment process, hence, the “random” classification. I use “other” classification for such things as events taken to the MSEC and then document in the “action/follow-up” column what action was taken.

Thanks for sharing! You can download the Practitioner Quality Summary Here (Excel) .

That concludes The Greeley Medical Staff Institute Symposium contest.

Thanks so much to all the participants, and congratulations to the winners! You can find a listing of all the forms, tools, and tips here.

Contest entry: Note-taking form

Happy Free Form Friday! Here’s another great form that came in for The Greeley Medical Staff Institute Symposium contest.

Tommie Cooper, CPMSM, director of medical staff services at Sky Ridge Medical Center, developed this clever note-taking form for physicians. To prevent them from inadvertently walking away with documents that shouldn’t leave the meeting room, Tommie prints them on colored paper (a different color for every month) so that everyone is aware of what documents are coming and going.

Thanks for sharing, Tommie! You can download the note-taking form (Word doc.) here .

Remember, there’s still time to submit your contest entries to win two free seats to The Greeley Medical Staff Institute Symposium. Find contest details here!

Contest entry: Disruptive physician policy

It’s an issue every institution unfortunately has to deal with – disruptive physicians.

Debi Davis, CPMSM, director of medical staff services at Cumberland Medical Center, sent in this disruptive physician policy to share with others as part of her entry into The Greeley Medical Staff Institute Symposium contest.

You can download the disruptive physician policy (Word doc.) here.

There’s still time to submit your best practices, tools, or tips to win two free seats to The Greeley Medical Staff Institute Symposium contest.

Contest entry: Save templates to save time

Linda Taylor, CPMSM, director of medical staff services at Fawcett Memorial Hospital in Port Charlotte, FL, sent in a useful tip. Save time by saving your documents as electronic templates for the following year.

Linda says,

“After being involved in reorganizing and reworking medical staff offices at several facilities, I found one of the key elements was for me personally to stay organized and reduce paper.  Finding that document or letter you did two years ago with just the right wording can waste a lot of time.

The first thing I do in a new office is to organize my folders in Word.  I set up a folder for each committee, sub group, or function I am responsible for and then subfolders for each year.  At the end of the year, I move everything into that year’s folder.

For general correspondence, I have a current folder, “Correspondence 2009,” and then a “Correspondence” folder where I move the entire year into at the beginning of the new year.

In addition, I always use the same titles for documents and use the xx-xx-xx for date, i.e. Agenda 09-25-09 is stored in the appropriate committee folder as well as Minutes 09-25-09.  This method helps me readily spot the document I need and stay organized.  It also means I don’t have to plow through miles of paper to find something.”

Thanks for sharing this tip!

Keep those contest entries coming to win two free seats to The Greeley Medical Staff Institute Symposium. We’ll announce the final contest winner on Oct. 30.

Contest entry: Med Staff Summary Profile for Initial and Reappointment

Happy Friday! Here’s another great free form to celebrate the end of the week.

Medical Staff Coordinator Shirley Prihoda, CPCS, of Brazosport Regional Health System submitted this tool.

Shirley says, “This was created to give the Credentials Committee, MEC and the Board a quick summary of initial and reappointments to have a more concise view of the applicant.”

You can download the Medical Staff Summary Template (Word doc). Remember to select “view” and “print layout” to display the actual document.

Thanks for sharing this tool!

Keep those contest entries coming, and you could win the free registration to The Greeley Medical Staff Institute Symposium (Nov. 8-9, Naples, Fl)! We’ve already announced two winners!

We’ll share the entries on the blog and select the best one at the end of the month.

To enter the drawing, submit your best practice, tool, or tip to us. Find more details here!

Contest entry: Color your privileging documents

Don’t lose your important documents!

Rowena A. Hodge, medical staff coordinator at Lakeland Regional Hospital in Springfield, MO, has been credentialing individuals for more than 20 years.

Rowena says,

“Regardless of the size of your medical staff, the resulting paperwork is tremendous. My tip [comes from once] accidentally discarding an original privilege sheet signed by the physician.

Now all our applications inquiry letters, etc. , are run on colored paper. If it’s yellow, it stays in the file!”

Keep those contest entries coming, and you could win the free registration to The Greeley Medical Staff Institute Symposium (Nov. 8-9, Naples, Fl)!

We’ll share the entries on the blog and select the best one at the end of the month.

To enter the drawing, submit your best practice, tool, or tip to us. Find more contest details here!

Contest entry: Redesign your credentialing process

Here’s another best practice about steamlining the credentialing process.

Lana Heavilin, RN, medical staff office coordinator at Holland Hospital in Michigan, says that her medical staff office and quality director dedicated themselves to redesigning the credentialing process through a two-day retreat (in March of this year). Before the retreat, the office had six new applicants waiting to be processed. Since that time, the office hasn’t had any.

Lana says,

[more]

Contest entry: Cut down on med staff meetings

Go to too many meetings? Wouldn’t it be great if we could cut down on the number of meetings required? Hear how one institution made that hope a reality.

Georgiaetta “Poncho” Klebba, CPMSM, medical staff services manager at Capital Region Medical Center (CRMC) in Jefferson City, MO, submitted a best practice on cutting down the number of med staff meetings. The result–medical staff satisfaction and a “tremendous cost savings” for the hospital, she says.

“CRMC reduced the numbers of medical staff department meetings and general staff meetings from four times per year to two times.

Department meetings are held at a local hotel at 5:30 p.m. in April and October with the general staff meeting to follow at 6:30 p.m. The general staff meeting includes dinner and a CME lecture, as well as updates on all new bylaws, rules, regulations, and/or policies that have had chances since the last meeting and reports from the administrative council members on hospital issues. [more]

Contest entry: Credentialing application flowsheet

Here’s another great tool from one contest submission.

Kim Everett, medical staff coordinator at the Good Samaritan Hospital in Vincennes, Indiana, uses a great, comprehensive application flowsheet while credentialing physicians and allied health personnel during the application process.

Kim says,

“It has been a valuable instrument as the credentialing staff process and verify information contained in the application. It also provides coworkers with immediate information regarding the status of the application, as we can quickly see references that remain outstanding, any board certification or licensure issues, along with  unresolved issues or potential ‘red flags.’

The application flowsheet is also used as a quick reference when presenting the application to the Credentials and Audit and MEC committees, as they consider the applicant for membership and privileges.“

You can download the credentialing application flowsheet here.

Keep those contest entries coming, and you could win the free registration to The Greeley Medical Staff Institute Symposium (Nov. 8-9, Naples, Fl)!

We’ll share the entries on the blog and select the best one at the end of the month.

To enter the drawing, submit your best practice, tool, or tip to us. Find more details here!

Contest entry: Share patient comments with physicians

Here’s another great contest entry tip about sharing patient satisfaction information.

Denise Rollins, RHIA, director of medical staff services at Mission Hospital in Mission Viejo, CA, says that not all patient feedback comes in the form of data.

Mission Hospital, who subscribes to Avatar, an organization that administers patient satisfaction surveys, collects the handwritten comments from patients and shares that information with the physicians at the annual medical staff meeting.

Denise says,

“Some patients take the time to acknowledge staff for making a difference during their hospitalization. All handwritten comments are forwarded to the hospital. Any comment that mentions a specific physician is shared with the physician by letter sent to his/her home address and a copy is placed in his/her credential file as evidence of skill, knowledge, interpersonal relations, etc., for consideration at the time of reappointment.

Annually, in December at the annual medical staff meeting, a power point presentation of all comments received during the year is shared. The presentation starts running 90 minutes prior to the start of the meeting. Last year we acknowledged over 150 physicians for the “sacred encounters” with our patients. The feedback we received from our physicians was very positive.”

Thanks for the tip!

Keep those contest entries coming, and you could win the free registration to The Greeley Medical Staff Institute Symposium (Nov. 8-9, Naples, Fl)!

We’ll share the entries on the blog and select the best one at the end of the month.

To enter the drawing, submit your best practice, tool, or tip to us. Find more details here!