SAMPLE Medical Staff Self-Assessment Questionnaire

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1 Hospital Name: Person Completing the Assessment: Date: I. Executive Leadership Yes No 1. Is there a medical staff member or members on the governing board? 2. Does medical staff leadership meet routinely with executive leadership? 3. Does medical staff leadership meet routinely with the appropriate department director/manager(s)? 4. Does medical staff leadership have a role in proactive business planning for their department (e.g., evaluating the clinical, business and operational risks associated with a new service for technology)? 5. Do the medical staff bylaws indicate that the governing board has final responsibility for granting or denying medical staff appointment and/or clinical privileges? II. Medical Staff Structure/Bylaws Yes No 1. Is there more than one medical staff and one set of medical staff bylaws? 2. Is a copy of the medical staff bylaws and rules and regulations provided to all medical staff applicants? 3. Does the applicant sign a statement that they have read and will abide by the medical staff bylaws and rules and regulations? 4. If there is a medical director or vice president of medical affairs is this person a physician? 5. If the medical staff structure includes department, divisions, and/or services does the physician leader have certification by the appropriate specialty board? 6. Are physician leaders roles and responsibilities clearly defined? 7. Do the medical staff bylaws define the medical staff including which types of providers are eligible to be members of the medical staff? 8. Do the medical staff bylaws define each category of medical staff membership (e.g., active staff, courtesy staff)? 9. Do the medical staff bylaws define the committees of the medical staff including their composition, duties/responsibilities and meeting frequency? 10. Do the bylaws define which medical staff committees are designated peer review committees? 11. Is meeting attendance optional? 12. Do committees complete their responsibilities in a timely manner? 13. Do hospital committees with a clinical function have medical staff representation?

2 II. Medical Staff Structure/Bylaws Yes No 14. Are the medical staff bylaws reviewed annually and when there are changes in regulatory standards? 15. Are revisions to the bylaws adopted by the medical staff and approved by the governing board prior to becoming effective? 16. Is there a system in place to ensure that amendments to the bylaws are not made unilaterally by either the medical staff or governing board? 17. Is there a process for managing conflict between the medical staff and the medical executive committee on issues related to bylaw amendments? III. Credentialing and Privileging Yes No 1. Do the medical staff bylaws clearly define the credentialing and privileging processes including the minimum criteria to apply for membership/privileges and the timelines for completing the process? 2. Is there a pre-application process? 3. Do the medical staff bylaws outline the qualifications necessary to be eligible to apply for membership and/or privileges? 4. Is there a requirement for an applicant to undergo a physical and/or mental examination if requested to do so by the credentialing committee? 5. Is there a requirement for medical staff members to report any felony conviction and exclusions from federally funded programs? 6. Is there a requirement for medical staff members to report any adverse outcomes, claims and/or disciplinary proceedings taken occurring at other organizations? 7. Is there a requirement for medical staff members to report voluntary or involuntary relinquishment of license? 8. Is there a requirement for the medical staff to report any voluntary or involuntary termination of membership or limitation or loss of privileges? 9. Is there a requirement to evaluate a provider s ability to perform the privileges granted after an illness or leave of absence? 10. Do application forms address the following: a. Education? b. Training? c. Experience? d. Licensure? e. Licensure challenges? f. Practice history? g. Challenges to membership/privileges? h. Board certification? 2

3 III. Credentialing and Privileging Yes No i. DEA registration? j. Malpractice history? k. OIG sanctions? l. Health status? m. Reference? n. Authorizations? 11. Are privileging forms consistent with the services offered at the facility? 12. Are releases from liability obtained from applicants? 13. Are attestations that application information is complete, accurate and true obtained from applicants? 14. Are authorizations for third parties to disclose and provide information regarding applicants qualifications obtained from applicants? 15. Is a credentialing checklist used? Is it retained in the credential file? 16. Are credentialing policies and procedures and forms consistent with each other? 17. Is there a policy that outlines what information requires primary source verification in the credentialing process? Is the following included? a. Medical education b. Postgraduate training c. Professional experience/work history d. Board certification e. Licensure f. Liability or claims history g. Malpractice insurance coverage 18. Are criminal background checks conducted at reappointment? 19. Are peer references obtained? If so, are they asked to evaluate the applicant in the following areas? a. Medical/clinical knowledge b. Technical and clinical skills c. Clinical judgment d. Interpersonal skills e. Professionalism 20. Are peer references provided a copy of the privileges requested by the applicant and a picture ID? 21. Are there policies that address access to and the confidential storage, handling and disclosure of credentialing information? 22. If a credentialing verification organization (CVO) is used, are there policies that outline what functions are delegated to the CVO? 23. If a CVO is used, is the CVO evaluated for effectiveness? 24. If a CVO is used, are copies of all documents provided to the organization? 25. Are core privileges used? 26. Are laundry list privileges used? 27. Is a combination of core and laundry list privileges used? 28. If core privileges are used, does the list of what is included in the core accurately reflect what the majority of practitioners within the specialty currently do at your 3

4 III. Credentialing and Privileging Yes No facility? 29. Is there a SAMPLE list of procedures and treatments that are included in the core? 30. Is there a method for the applicant to request only certain items in the core? 31. Is there a system for practitioners to expand their privileges beyond the specified core privileges? 32. Is there a defined process for a practitioner to request new technology? 33. Is there a defined process for requesting the organization offer new services? 34. Is there a process for determining a practitioner s competency for providing new services or using new technology? 35. Is there a process for communicating the granting of privileges and the limitation or relinquishment of privileges to the following: a. The practitioner? b. The department chair? c. The clinical patient care area? d. Scheduling personnel? IV. Evidence-Based Practice Yes No 1. Do medical staff rules and regulations define the acceptable standard for medical record documentation? Is the following included: a. Length of time to dictate post op notes? b. Countersignature requirements? c. Verbal order requirements? 2. Do medical staff rules and regulations define the use of and requirements for consultants? Is the following included: a. Timeframe to respond to the request for a consult? b. Documentation requirements for a consult? 3. Do the medical staff rules and regulations define the acceptable standard for admission, transfer and discharge requirements? 4. Do the medical staff bylaws and/or rules and regulations define the requirements related to medical history and physical? Is the following included: a. Time frame for completing the assessment? b. Who is qualified to perform a medical history and physical? 4

5 5. Do the medical staff bylaws and/or rules and regulations define the requirements for updating the physical examination of patients who had a medical history and physical examination within 30 days of admission? Is the following included: a. A time frame such as within 24 hours of admission and prior to surgery? b. Outline who is qualified to update the history and physical? 6. Do the medical staff bylaws and/or rules and regulations define the criteria for securing an autopsy? Is the following included: a. A mechanism for documenting permission to perform an autopsy? 7. Do the bylaws and/or rules and regulations define the category of healthcare provider authorized to perform a medical screening examination? 8. Do the rules and regulations define requirements for on-call physicians? 9. Does it include a time frame for response? 10. Do the rules and regulations delineate requirements for participants in residency programs? Is the following included: a. Who may write patient care orders? b. The circumstances under which they may do so? 11. What entries, if any, must be countersigned by a supervising licensed independent practitioner? V. Medical Staff Office Yes No 1. Is there a job description for medical staff personnel? Is the following included: a. Minimal education requirements? c. Certifications from NAMSS such as Certified Profession Credentialing Specialist (CPCS) or Certified Professional Medical Staff Management (CPMSM)? 2. Are the following department policies or procedures in place and are they consistent with the medical staff bylaws, rules and regulations and regulatory agencies: a. Review and verification of all applications? b. Review and verification of credentialing documents? c. Criminal background checks? d. Disruptive medical staff member policy? e. Focused professional practice evaluation? f. Ongoing professional practice evaluation? g. Physician CME requirements? h. PPD skin testing for physicians? i. Processing an application for initial appointment? 5

6 V. Medical Staff Office Yes No j. Reappointment policy? k. Physician quality file maintenance, creation, contents, confidentiality and access? l. Temporary privileges? m. Telemedicine privileges? 3. Are there policies and procedures on maintenance of credentialing files? Is the following included: a. Files maintained in their original form or scanned form or other electronic storage medium? b. Paper credentialing files maintained under lock and key in the medical staff services office? c. Files stored electronically are protected by password and read/write control? 4. Do the medical staff services office personnel supervise the review of any credentialing file? 5. Is access to files limited to the following persons to the extent necessary to perform official functions: a. Designated office staff processing credentialing information? b. Department head/service chief/division head? c. Medical staff officers? d. Medical staff committee members? e. CEO? f. Members of the governing body? g. Hospital surveyors (accreditation and regulatory agencies)? h. The surveyor must demonstrate their authority and need for the information? i. Other persons only as authorized by the medical executive committee or its designated representative or the CEO? 6. Is there a policy defining when a practitioner may review his/her own file? Does it say they can do so ONLY under the following conditions: a. The request is approved by the CEO, department chair, president of the medical staff or credentials committee chair? b. The review is accomplished in the presence of medical staff coordinator, member of the credentials committee or officer of the staff? c. The physician understands that nothing may be removed from the credentials file? d. Nothing may be photocopied without permission of the CEO? e. An explanation note or document may be added to the file? f. Confidential reference letters received during initial appointment or at reappointment may NOT be reviewed? 7. Is a record maintained of file access? 8. Are minutes of medical staff committee created and maintained? 9. Are peer review meeting minutes marked as confidential and include citation of state confidentiality statutes? 10. Are summary reports created by the medical staff for dissemination to other hospital committees? 11. Do these committees have Peer Review Protection for the information as disseminated? 6

7 V. Medical Staff Office Yes No VI. Medical Staff Culture of Safety Yes No 1. Does the medical staff participate in performance improvement activities/initiatives? Examples: a. RCA b. FMEA c. Team training d. Collaborative/bundles e. Core measures improvement f. Reduction of hospital acquired conditions g. Reduction of readmission 2. Does the medical staff analyze patient satisfaction data and take actions to improve satisfaction? 3. Does the medical staff have a disruptive provider policy? Does it address the following: a. Sexual harassment? b. Impaired provider? c. Conflict management? 4. Is there a medical staff code of conduct? 5. Is the medical staff code of conduct in alignment with the hospital employee code of conduct? 6. Do employed practitioners, such as hospitalist, have expectations of conduct included in their employment contract? 7. Are providers asked to sign a statement that they agree to abide by the code of conduct at the time of initial appointment and at reappointment? 8. Is data collected on provider behavior? Is this information included in the ongoing professional performance evaluations? 9. Is there a progressive intervention process outlined for medical staff leadership to ensure consistency in management of disruptive behavior? Example of progression could be: a. Initial intervention b. Second intervention c. Third intervention d. Final warning 10. Do the bylaws outline the grievance, fair hearing and due process procedures allowing providers to defend themselves against adverse actions against their privileges? Does the process include the following: a. A mechanism to schedule a hearing? b. An outline of the hearing procedures? 7

8 VI. Medical Staff Culture of Safety Yes No c. Identifies the composition of the hearing committee as a committee that includes impartial peers? d. With the governing body, provides a mechanism to appeal adverse decisions as provided in the medical staff bylaws? 11. Is this process followed exactly when terminating or limiting a provider s privileges? 12. Is there a policy on reporting and management of impaired providers? Does the policy include the following: a. Educating providers about impairment? b. Self-referral? c. Referral by others? d. Confidentiality? e. Referral for evaluation and treatment? f. Monitoring recovery? 13. Taking action if recovery is unsuccessful? VII. Competency, Quality Improvement and Peer Review Yes No 1. Is there a formal, written focused professional practice evaluation (FPPE) process that includes at least the following: a. Triggers for an FPPE to be initiated? b. Methods for conducting an FPPE? c. Methods for determining how long a provider will be evaluated and how the time period may be extended? d. When external monitoring will be required? 2. Are criteria used to assess competency developed using standards or guidelines from recognized professional/medical specialty organizations? 3. Is there a formal, written ongoing professional practice evaluation (OPPE) process? 4. Does the FPPE and OPPE processes include allied health providers? 5. Are practitioners continuously evaluated on their performance in the six areas of general competencies? The areas of general competencies include the following: a. Patient care b. Medical/clinical knowledge c. Practice-based learning and improvement d. Interpersonal and communication skills e. Professionalism f. Systems-based practice 8

9 VII. Competency, Quality Improvement and Peer Review Yes No 6. How are competencies assessed for low volume/no volume providers? 7. Is there a formal, written peer review process? 8. Are the roles and responsibilities of the peer review committee defined in the medical staff bylaws? 9. Is there a policy or a procedure that delineates the reporting structure to the governing body, to individual departments, and to individual medical staff members? 10. Is there a policy on use of external peer review (EPR) organizations or individuals? Does the policy include the following: a. When EPR is used? b. Who makes the decision to use EPR? c. How the EPR is selected? d. How cases are selected for EPR? e. Who reviews the EPR findings? f. How will the results of the EPR used? 11. Are peer review outcomes tracked, trended and reported on individual providers, departments, and entire medical staff? 12. Are peer review/quality files kept separate from credentialing files? a. Results of PI? b. Drug/medication evaluations? c. Blood usage/evaluations? d. UR? e. Patient complaints? f. Medical record reviews? g. FPPE/OPPE data? h. Infection rates? i. Comparison data such as LOS against other providers? 13. Is a performance improvement/audit process in place for telemedicine? 14. Are the results of telemedicine audits reported to the medical staff oversight committee and to the distant-site hospital or entity? 9

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