It's National Medical Staff Services Awareness Week! How will you be celebrating? Send your ideas, tips, and photos, to Managing Editor Karen Kondilis at kkondilis@hcpro.com, and you could see your contributions featured on the CRC site. And check your inbox for details on a special deal we’re launching to honor the hardworking professionals at the heart of patient safety and quality care.

CMS’s CoPs state that medical staff bylaws must “describe the organization of the medical staff” (42 CFR § 482.22(c)). One of the key structural questions a medical staff must ponder is whether to organize itself into clinical departments. Although there is no regulatory mandate to do so, medical staffs have historically organized themselves around departments based on specialty. This was initially a relatively simple structure composed of a few key departments representing major specialties, including medicine, surgery, OB-GYN, and, occasionally, pediatrics.

Urology is the surgical specialty that focuses on diseases of the male and female urinary tract, as well as the male reproductive organs. Urologists are also referred to as genitourinary surgeons (the organs of reproduction and urination together are often referred to as the genitourinary tract). These specialists manage non-surgical problems such as urinary tract infections and benign prostatic hyperplasia, as well as surgical problems such as the surgical management of cancers, the correction of congenital abnormalities, and correcting stress incontinence.

Following a fair and thorough investigation, the medical staff in your hospital has determined a physician has clinical performance issues and has recommended a limitation in clinical privileges. Per the medical staff bylaws, a fair hearing process commences. If the hearing/appeal processes do not change the limitation of privileges, this is considered an “adverse action” and therefore must be reported to the National Practitioner Data Bank (NPDB), in accordance with the Health Care Quality Improvement Act of 1986 (HCQIA). It’s a no-brainer, right? But in today’s hospital environment, not all scenarios are so clear-cut.

All practitioners—employed or not—are to be held to the same minimally defined medical staff standards for clinical care, professionalism, documentation, on-call responsibilities, and so forth. One of your responsibilities as a medical staff leader is to ensure that the expectations are adequate and that they are being met. If the health system employer chooses to have a higher standard, that is not the concern of the medical staff.