Medical Staff Bylaws(1)-1 (1).docx2
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School
Miami Dade College, Miami *
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Course
1110
Subject
Medicine
Date
Apr 3, 2024
Type
docx
Pages
7
Uploaded by CommodoreDragon7958
Medical Staff Bylaws - Data Collection
o
Stanford Healthcare https://stanfordhealthcare.org/content/dam/SHC/health-
care-professionals/medical-staff/stanford-bylaws-5-14.pdf
o
Johns Hopkins Medical Center https://jhhmsa.jhmi.edu/bylaws.pdf
o
Middlesex Hospital https://middlesexhospital.org/files/dmfile/Bylaws1.pdf
o
Northwell Medical Center https://www.northwell.edu/sites/default/files/LHH__BYLAWS.pdf
Instructions:
Students will research one of the listed facilities. Research the medical staff bylaws and answer the questions. A comparison grid will be developed. Information will be shared and discussed with class.
Students will provide an overview of the format, clarity and medical staff bylaws objectives according to Joint Commission requirements.
Questions
Findings
1. What is the name of the facility?
Johns Hopkins Medical Center
Access facility website. Is the facility affiliated
with a corporation or health system? If so, specify.
Johns Hopkins University
Number of inpatient beds
1154
List services performed at the facility.
Emergency care
Specialty care
Primary care
Johns Hopkins children’s center
Pharmacy
What is the facility mission statement?
to improve the health of the community and the
world by setting the standard of excellence in
patient care
Does the website provide information on the status of electronic health record usage at facility? State.
yes
List two purpose/objectives of facility medical staff bylaws.
-To facilitate the provision of quality care
to Hospital patients regardless of race,
gender, sexual
orientation, creed, disability,
or national origin.
-To promote professional standards among
members of the Medical Staff.
In bylaws, identify privileges. Privilege determinations shall be based on prior and continuing education, training, experience;
demonstrated current competence;
judgment;
interpersonal and communication skills; and
professionalism, as documented and verified in the
physician’s credentials file including peer
evaluations, observed clinical performance and
documented results of Hospital and Departmental
quality improvement programs. The exercise of
privileges within a department is subject to
departmental rules and regulations and the authority
of the Chief of Service.
Bylaws, identify requirements for Appointment to the
credentialing.
Medical Staff and Allied Health
Staff shall be for a period of not more than two (2)
years.
Knowledge of medical staff services principles,
methods and procedures, as well as administrative
office management. Comprehensive understanding
of a) credentialing policies and procedures; b)
training program requirements as established by the
Hospital and School
of Medicine; and c)
accreditation and regulatory requirements relating
to the medical staff, with a focus on credentialing.
Understanding of the Hospital's credentialing
policies and procedures as they relate to
professional liability
coverage.
Identify the categories of credentialing?
All requests for an application to the Medical Staff
must be directed to the appropriate Chief of
Service.
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Factors considered shall include, but not be limited
to, department criteria; current and projected
patient care, teaching and research needs; the
ability to provide required support services and
facilities; current and expected patient
load; actual
and planned allocations of physical, financial and
human resources to general and specialized clinical
and support services; and long-
and short-range
development plans.
Complete the Hospital’s application form in the
name in which they are licensed and an appropriate request for delineation of clinical privileges form
and shall submit a valid photo identification issued
by a state, federal or
regulatory agency, referred to
collectively herein as “the application forms.”
Identify the minimum amount of medical liability coverage required.
What are consequences if medical staff does not conduct themselves in a professional and
ethical manner? (List two)
-issuance of a warning or formal letter of
reprimand;
-revocation of Medical Staff appointment
What is appointment and reappointment?
What are the terms stated in bylaws?
Appointment: The act of appointing; designation of
a person to hold an office or discharge a
trust
Reappointment: an act of reappointing
What are the professional terms offered by the Medical Action Board for an applicant status?
department criteria; current and projected patient
care, teaching and research needs; the ability to
provide required support services and
facilities;
current and expected
patient load; actual and
planned allocations of physical, financial and
human resources to general and specialized clinical
and support services; and long-
and short-range
development plans.
List two health record requirements stated in
medical staff bylaws.
Daily progress notes shall be entered
in the medical record by the attending
physician or an
authorized prescriber
designee (e.g., another physician,
nurse practitioner, physician assistant).
Clinic notes, both structured and
unstructured, must be entered into the
electronic health record ((EHR) and
signed within fourteen (14) days.
How does the medical staff bylaws health record requirements compare with Conditions of Participation?
https://www.cms.gov/Regulations-and-
Guidance/Legislation/CFCsAndCoPs/
Downloads/CMS-3244-F.pdf
The medical staff bylaws are a document approved
by the hospital's board, treated as a contract in
some jurisdictions, that establishes the requirements
for the members of the medical staff (which
includes allied health professionals)
to perform
their duties, and standards for the performance of
those duties.
Medicare conditions
of participation, or CoP, are federal regulations with which particular healthcare
facilities must comply in order to participate – that
is, receive funding from – the Medicare
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and
Medicaid programs, the largest payors for
healthcare in the U.S. CoP are published in the
Code of Federal Regulations or CFR;
one may
identify or “cite” them by their title in
the CFR and
their section or paragraph by number. The
importance of the CoP for CRNAs is
straightforward: The
Medicare hospital CoP for
anesthesia services.
State overall findings.
Overall, the purposes of the Medical Staff Bylaws Rules and Regulations are:
To facilitate the provision of quality care to Hospital patients regardless of
race, gender, sexual orientation, creed, disability, or national origin.
To promote professional standards among members of the Medical Staff.
To provide a means whereby problems may be resolved by the Medical Staff
with the collaboration of the Board of Trustees of The Johns Hopkins Hospital
(the “Board of Trustees”).
To create a system of self-governance, and to initiate and maintain rules and
regulations governing the conduct of the Medical Staff, subject to the ultimate
authority of the Board of Trustees.