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January Brings a New Set of Medical Staff Leaders: Now What?

With the New Year comes new medical staff leaders and a new set of growing pains. Contrary to what many of us believe, some simple steps can lessen the pain.

Education is first and foremost, but what that education covers is organization-specific and will vary based on your organization’s medical staff governance structure. Even if you send your medical staff leaders to external education programs, consider developing and implementing an internal orientation program specific to your organization. An internal leadership orientation program is beneficial in preparing leaders to know your organization. A full day retreat with administration and governing board representatives has the collateral benefit of team building. An internal medical staff leadership orientation program may include the following: 

  • The roles and responsibilities of the organized medical staff, including the legal role of responsibility to the governing board for the quality of medical care provided to patients of the hospital as required by the Medicare Conditions of Participation 42 CFR 482.22, The Joint Commission MS.03.01.01, and other legal and regulatory agencies;

  • The authority to take action when warranted as set forth in the hospital’s or organization’s governance documents (e.g., bylaws, rules, regulations, policies, procedures);

  • The medical staff’s governance structure (e.g., departments, committees, reporting processes);

  • The roles and responsibilities of key players (e.g., Medical Staff Office, Administration, Governing Board, Quality Department, Risk Management, Chief Medical Officer, etc.);

  • Chain of command and relevant individual contact information;

  • Credentialing and privileging: what to look for and when to ask for more information (Conditions of Participation 42 CFR 482.12);

  • Well-being, aging, disruptive behavior, code of conduct, provider health and welfare issues, burn-out of providers and leaders (The Joint Commission);

  • Interventions, disciplinary actions, reporting (State and National Practitioner Data Bank requirements);

  • Indemnity and peer review protections (Health Care Quality Improvement Act);

  • Payment and time sheets; and 

  • Anything else important to your organization.

A leader’s ability to know where to obtain information is key to effective leadership and decisive response. Provide digital or other access to all governance documents, contact information for key individuals, and other relevant information. Your orientation program can be especially effective when past leaders are present and willing to impart their knowledge. If you have an in-person orientation, consider posing hypothetical interactive case studies as an opportunity to test skills, generate discussion, and emphasize lessons.

While it will cost some time and require effort to develop an internal orientation program, the return on investment is significant and will directly benefit the organization.

Leadership program sustainability is vital and dependent on the integrity of the processes in place. For the future, consider a Leadership Development Committee whose purpose is to identify and grow medical staff leaders. Also, consider establishing an annual or biannual leadership retreat with administration and representatives of the governing board. By fostering open communication and discussion between the intertwined bodies, the organization can progress forward and avoid unnecessary distractions caused by ineffective or inaccurate communication.

© Polsinelli PC, Polsinelli LLP in California


About this Author

Erin Muellenberg Medical Staff Law Attorney

Erin Muellenberg brings a strong skillset to her exclusive practice of medical staff law. As a former Director of Medical Staff Services in a large community-based hospital, she is intimately familiar with the daily operations of the Medical Staff Organization and its governance process. Erin’s practice focuses on advising hospitals, health systems, critical access hospitals, ambulatory surgery centers, and medical groups on the regulatory, compliance, and practical requirements for interfacing the medical staff and allied health professional staff with hospital operations.