Easy, but dangerous.
For some time, medical staffs have drained their bylaws of significant content -- credentialing processes and fair hearing plans -- and slid them quietly into manuals and policies that never see the light of day at a medical staff meeting. Changes, some affecting important physician rights, are developed and approved by a select few.
In 2007, the Joint Commission declared an end to that practice with major revisions to Medical Staff Standard MS 1.20. The electrifying but not-hard-to-anticipate results: Many hospital medical staffs will have to substantially restructure their documents. Your staff could be one of them. TJC’s review of the matter is ongoing, but odds are your documents will be out of step with their final rule.
How will you know? Do you have a separate Credentialing Manual that describes the totality of your credentialing process? Has your staff moved the Fair Hearing Plan out of the bylaws and into a separate document? Do you have a discipline policy that the MEC changes without a full staff vote?
If you answered yes to any of these questions, you are probably a candidate for a medical staff document repair.
But don't burn your circuits trying to reconfigure your documents alone. Let us help. We will put you into compliance with not only these new requirements but also recent additional requirements pertaining to Credentialing and Privileging. It may even be long past time for that overhaul anyway. If you're not sure what you need, give our QuickCheck service a try. We'll tell you what you need for less than a thousand dollars (and we'll apply that to any work you have us do).
TJC now does unannounced surveys. Will you be ready, or will you get zapped?
Call us at 513-733-1759 to help put things in the right place.
Don't be shocked when TJC asks to see if your documents comply.