Hospitals must continue to meet the Conditions of Participation outlined in Interpretive Guidelines in Appendix A of the CMS' State Operations Manual (SOM), notes Frank Ruelas, a patient safety professional and Health Insurance Portability and Accountability Act (HIPAA) consultant who founded HIPAA College in Arizona.

Published 9/13/18

Clashing interests and ethics can undermine the integrity of medical staff tasks, create financial disputes between a healthcare institution and the physicians who practice there, disrupt key governance processes, cause rifts that jeopardize patient care, and even result in costly legal action.

Published 9/12/18

One of the key challenges in any evaluation of human performance is the issue of bias, and peer review is no different. If a critical goal of peer review is fairness, then we must avoid any actions—intended or unintended—that would bias the results.

What is bias? It is a tendency or preference toward a particular perspective or result. It may be either a conscious or an unconscious prejudice that is introduced into a process. It may be due to individual preferences or a systematic error introduced into sampling or testing that encourages one outcome over another. Intended or not, bias undermines the reliability or accuracy of the result.

Published 9/10/18

Bylaws should be carefully written to ensure that they can’t be changed casually, but also that amendments don’t face an unreasonable hurdle. This balancing act will be decided differently by various medical staffs.

However the medical staff authorizes amendments to its bylaws, changes must be ultimately approved by the hospital governing body. This is a requirement established under the Medicare Conditions of Participation (CoP), which state that the bylaws must “be approved by the governing body.”

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