An Analysis of Our Medical Staff [insert name of employer here] CH Medical Staff Services Draft 9/24/09 Chief Medical Officer SMMC Credentials Coordinator SJMC Credentials Coordinator Regional Director, Medical Staff
Services Associate Medical Director Credentialing Specialist Medical Education Coordinator Quality Assurance Coordinator (proposed) Scope of Services The Medical Staff Offices (MSO) supports compliance
with TJC and other regulatory agencies relative to all functions of the medical staff. The MSO serves as a resource and provides technical support services in the following areas to physicians: credentialing (including allied health professionals), medical education (including facilitating medical student and resident training rotations), medical staff quality assurance/performance improvement, and department and committee activities. Additionally, the MSO functions as a liaison between the medical staff and administration, nursing and other medical center personnel and departments. Scope of Service Support and/or Integration with Other Departments: 1. 2.
3. Offer opportunities for other hospital health care professionals to attend appropriate medical education conferences based upon identified areas for improvement. Maintain all physician and allied health information in the hospital information system and assure confidentiality of that information. Appropriate hospital employees are given access to specific pieces of information based upon need to know. Provide appropriate departments clinical privilege information based upon the physicians specialty and his/her potential use of those departments (i.e., clinical privileges regarding physicians authorized to perform GI diagnostic procedures are forwarded to the GI Lab).
Scope of Service 4. 5. 6. 7. 8. Function as a liaison between Information Services and the medical staff relative to Meditech and Internet/Intranet training, access and problems/suggestions. Work closely with Medical Records to achieve timely completion by physicians of medical records. Provide the opportunity at clinical department meetings
and medical staff committee meetings for hospital employees to share changes in procedures, new programs, etc. Provide the opportunity for hospital employees to address concerns they may have relative to members of the medical staffs. Notify Physician Relations Department of new appointments for the medical staff, who determines the need for additional follow up. Resources NAMSS Staffing Ratios Study September 2009 (additional supporting documentation is attached) Position descriptions Staffing
On average, the ratio of MSPs to credentialed medical staff (e.g., physicians, dentists as applicable) is one to 89. In comparison, the ratio of MSPs to all credentialed staff (i.e., credentialed medical staff and practitioners) is one to 112. There is a significant correlation between the number of credentialed medical staff and the number of MSPs employed at a facility. Data indicate that the number of MSPs staff steadily increases as the total number of credentialed staff exceeds per 100. Staffing The table below shows the number of MSPs per credentialed medical staff and all credentialed staff: Ratio
Count Mean 25% Median/ 50% 75% # of MSPs to Credentialed Medical Staff 634
1/89 1/214 1/144 1/90 # of MSPs to All Credentialed Staff 638 1/112 1/261
1/180 *CH1/228 1/109 Staffing Per key findings from the Staffing Study, CH performs Functions at the 75% percentile based upon the number of applications processed per month (58) and number of credentialed practitioners (1200) CH should staff at the percentile which equals 5.575 FTEs* (without QA Function) 223 hours week/40 = 5.575 Function #1 Credentialing/Privileging
Applicant personal interview Applicant eligibility review Analysis of applications/documents Committee presentation for approval of appointments and privileging Reappointments, including analysis of applications and documents Committee presentation for approval of reappointment
Processing requests for additional privileges FPPE/OPPE Investigation of issues/data analysis Total hours = 90.77 Function #2 Primary Source Verification Pre-application evaluation Obtaining and evaluating information Verification and documentation Investigating and validating discrepancies and information
Responding to inquiries from other healthcare organizations Total hours = 48.85 Function #3 Compliance Bylaws/rules and regulations/policies and procedures Preparing for accreditation reviews and ongoing compliance with regulatory standard Internal audits Sanctions, complaints, adverse data and NPDB Total hours = 18 Function #4 Operations
Correspondence to practitioners and others Meeting logistics, documentation and follow up Database updates Financial management (dues, fees, budgeting) Call scheduling Conflict resolution Standing orders Physician wellness Total hours = 36.58
Function #5 Physician Outreach Physician committee assignments Physician contracts Social aspects (Doctors Day, dinners, etc.) Physician/AHP orientation Physician retention Physician education training programs (residency, medical students) Physician education (CME)
Total = 16 Function #6 Human Resources Personal training and/or development of staff Staff management (evaluation and mentoring) Staff training Total hours = 9.59 Function #7 Peer Review/QA/PI Perform review functions using the medical record and other data in terms of quality and appropriateness of care issues Reviews use of blood and blood components, surgical and other invasive procedures, mortalities, and patient outcomes to identify single cases or patterns of cases that
require more intensive evaluation by the medical staff Reports specific data elements for recredentialing Develops concurrent and/or retrospective studies Maintains physician and advance practice practitioner peer review process, initial review/screening, QA and PQA committee support, arranging for peer reviews, including coordinating outside peer review. Total time = 40 hours Additional Performance Tasks Total = 5.45 of other tasks
