Some medical staffs include blank lines labeled “other” at the end of privilege request forms—but they shouldn’t. Including blank lines on privilege request forms encourages and invites applicants to add additional privileges that are not currently delineated on the forms and have not been recommended by the medical executive committee or approved by the governing board. One resultant problem is that a practitioner may write in a request for a privilege that is outside of the organization’s scope of services.

Because residency training slots funded by Medicare have remained capped since 1996, many healthcare facilities are either forced to turn away residents or pay for their training out of pocket. According to Tim Johnson, senior vice president and executive director of the Center for GME Policy & Services at the Greater New York Hospital Association, 38% of teaching hospitals are training at or below their Medicare funding limit. Healthcare experts worry that this is one more factor leading to a future physician shortage.

Beyond programs for individuals who are actively engaged in clinical education and training, many healthcare organizations provide observation/shadowing opportunities for high school and college students who are considering a career in the medical field. Relevant policies should address the structure for requesting an application to observe a member of an organization’s healthcare staff performing duties.

Bias is a common stumbling block to effective peer review. Bias can take a well-meaning committee that is truly focused on improvement and make it appear as if it is practicing sham peer review. At St. Anthony Hospital in Lakewood, Colorado the professional review committee is a multidisciplinary committee that represents the most active specialties of the medical staff; it also has representation from internal medicine and primary care. Over the years, changes to committee scoring have been implemented to help score more fairly and with less bias.

Each year, large numbers of physicians seek to return to practice after an extended voluntary absence from patient care. Others have never left practice but are requesting to expand/change their scope of practice and refresh skill sets they have not used in several years. Returning to practice or reengaging in specific practice areas can be a daunting process, both for physicians and for the hospitals where they seek to practice. ​In this 90-minute webinar, Elizabeth J. Korinek, MPH, and Sally Pelletier, CPMSM, CPCS, will address the unique challenges presented by physicians who have a gap in patient care or in experience with specific procedures or services. Attendees will become familiar with national reentry trends and learn strategies used to facilitate a successful transition onto clinical staff, as well as methods for monitoring physician practice to meet focused professional practice evaluation (FPPE) expectations.

As telehealth expands and technology improves, there are an increasing number of options for communication between healthcare providers and patients as well as between providers, but such services raise concerns for HIPAA compliance due to the method of transmission and issues of security compliance.

There is no prescribed format for creating medical staff bylaws and associated documents. Laws, regulations, and accreditation standards require medical staffs to address certain issues in the bylaws. How these issues are organized and addressed, however, is up to each medical staff. Medical staffs often defer to previously published model bylaws that may not reflect contemporary needs, modern concepts, or how the medical staff actually functions. This segment will identify and explain a best practice available to medical staffs for tackling this challenge.

Carol Cairns, CPMSM, CPCS, answers your questions about accreditation standards related to credentialing.