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Holy Moly, He Wants to Come Back!

Okay, here are the questions:

  • What do you do when the physician requests his privileges be restored after he returns from rehab for his cocaine and sexual addictions?
  • What do you do when the 67-year-old internist, who retired five years ago, has just been hired by administration to be your new hospitalist?
  • What do you do when your favorite cardiologist returns from a medical leave of absence after suffering a significant stroke?

Of course, these scenarios cause more questions than answers. You suddenly wish you had declined the invitation to be chief of staff of your medical staff. The fact remains that demographics apply to physicians as well as the general public.

Alcohol and substance abuse is 12-14% in the general population and is the same or somewhat higher in the physician population. (P Hughes, Prevalence of Substance Abuse Among US physicians, JAMA, 1992) Sexual addiction, especially cyber addiction to pornography, is present in 6-8% of the general population and one out of five are women. (Carnes, Am J Prev Psychology Neurology, 1991, 3:16-23) Dementia is present in 13.9% of individuals 71 and older and 9.7% of these have Alzheimer’s disease. (Plassman, et al, Neuroepid, 2007) Stroke recovery is possible, but of course, varies widely depending on age, severity of the injury, rehabilitation efforts, and support to name a few. None of us are immune from these possibilities.

Okay, now a few answers. Patients are more important than physicians. Don’t get caught in the trap of treating physicians as “special people.” First and foremost, you should have a concrete policy for dealing with all of the above possibilities. It must be iron clad, fair and equitable, be consistent with HIPPA and the American Disability Act, should be patient-safety focused but also allow for the physician to return to your medical staff. This begins with a viable and credible Physician Health Committee, an engaged credentials committee, OPPE and FPPE plans on steroids, legal advice, and a “Fitness to Work” evaluation from an objective and independent physician.

Want more from Dr. White? R Dean White DDS, MS, of Dean White Consulting, will be speaking about how to create a physician re-entry process at the 15th Annual Credentialing Resource Center Symposium, May 10-11. For more information, click here. 

TJC releases more FAQs on MS.01.01.01

The Joint Commission on Thursday released new information of frequently asked questions (FAQ) regarding MS.01.01.01.

The Joint Commission introduced MS.01.01.01, the medical staff bylaws standard formerly known as MS.1.20, in May 2010 when the accrediting body revealed its FAQ, explaining the relationship between the medical executive committee and the medical staff. The standard may affect many institutions as they must amend their medical staff bylaws, rules and regulations, and policies.

The new FAQ further reveals:

  • Medical staff representatives(s) should participate in all governing body meetings.
  • There is no requirement in which the organized medical staff must formally meet when it adopts or approves medical staff bylaws and revisions of amendments.

MS.01.01.01 goes into effect on March 31.

Qualifications of radiology staff

A standard interpretation that some MSPs may not have focused on is the element of performance #16 for MS.03.01.01:

MS.03.01.01, EP 16—For hospitals that use Joint Commission accreditation for deemed status purposes, the medical staff determines the qualifications of the radiology staff who use equipment and administer procedures.


Don’t overlook criteria required in the medical staff bylaws

When The Joint Commission moved the disaster privileging criteria standards out of the medical staff chapter of the Comprehensive Accreditation Manual for Hospitals and into the emergency management chapter, some organizations may have overlooked the following standard which requires that the information be in the medical staff bylaws:

“The medical staff identifies, in its bylaws, those individuals responsible for granting disaster privileges to volunteer licensed independent practitioners.”


Free form: Credentials committee chair position description

In the August issue of Medical Staff Briefing, read about the importance of enumerating medical staff leaders’ responsibilities in position descriptions. Having written position descriptions ensures that leaders fulfill their leadership obligations and lessens the likelihood that unqualified individuals land in leadership positions.

“Most medical staff officers don’t have a clue what the job is before they take it. They consider it an honorary position but no one considers that it is a job with performance expectations and requirements,” says Jonathan H. Burroughs, MD, MBA, FACPE, CMSL, senior consultant at The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.

The five steps outlined in “Spell it out: Leadership descriptions open the door to better performance” and the sample credentials committee chair position description will help you take the first steps toward getting optimal performance from your medical staff leaders.

The form comes from The Medical Staff Leaders’ Practical Guide, Sixth Edition,by William K. Cors, MD, MMM, FACPE, CMSL; Mary J. Hoppa, MD, MBA, CMSL; and Richard A. Sheff, MD, CMSL, published by The Greeley Company, a division of HCPro, Inc.

Free form: Clinical references policy and procedure

In the past, institutions often relied solely on references supplied by the applicant. But now it is recommended, and in some instances required, that the institution identify which individuals may submit references. The clinical references policy identifies the appropriate sources of clinical references for applicants and reapplicants. It identifies the number and type of references a credentialing committee might require prior to the review of a physician’s application. Please note that this policy suggests that credentials committees obtain information from knowledgeable individuals, not necessarily from practitioners in the applicant’s specialty.

The form comes from The Top 40 Medical Staff Policies and Procedures, Fourth Edition, by Mary J. Hoppa, MD, MBA, CMSL, published by The Greeley Company, a division of HCPro, Inc.

Resources roundup for medical staff standard MS.01.01.01

Did you blink and miss it? Even though it took three years for it to release its final version, The Joint Commission announced in March the long-awaited medical bylaws standard, MS.01.01.01 (formerly MS.1.20). The standard will become effective on March 31, 2011.

The cliffs notes version of the changes are the following points:

  • The medical executive committee (MEC) is accountable to both the governing body and medical staff
  • The medical staff has the ability to recommend amendments to the governing body with or without the MEC
  • Conflict resolution is required for the medical staff and MEC
  • Medical staff-related Conditions of Participation (CoPs) must be included in the medical staff bylaws
  • The MEC and governing body may pass provisional amendments to be in compliance with federal, state, and regulatory requirements


Contest entry: Physician coverage policy

Thanks to Lois L. Booth, director of medical staff services at the Rhode Island Hospital/The Miriam Hospital in Providence, RI for sending in these physician coverage tools.

Lois says,

Our medical staff services department is the central credentialing office for Rhode Island Hospital and The Miriam Hospital in Providence Rhode Island. The medical staff bylaws require that all staff members with admitting privileges identify a covering physician at initial appointment and each reappointment.