Author: Kathy Matzka, CPMSM, CPCS
Publisher: HCPro, Inc.
Publication Date: 2006
ISBN 10: 1578398835
ISBN 13: 9781578398836
Edition: 5th


Now in its fifth edition, this book features completely updated information, tools, and insights that will help in understanding and preparing medical staff for survey under the new 2007 standards. With The Compliance Guide to the JCAHO Medical Staff Standards, Fifth Edition in your library, you’ll save hours rifling through hundreds of pages of documents, trying to decipher ways to comply. All the standards that relate to you and all the procedures you need to implement are consolidated into this one convenient, easy-to-understand resource.

Table of Contents

Front Matter

  • About the author
  • Preface
  • How to use this book
  • Introduction

CHAPTER 1: Understanding the standards and survey process

  • How to read JCAHO standards
  • Self assessment under periodic performance review
  • Understanding how the standards are scored
  • Following up with areas of noncompliance identified during the survey

CHAPTER 2: MS.1.10–MS.1.40 Medical staff structure and medical staff bylaws

  • Background for the standards
  • MS.1.10—Organized medical staff structure
  • MS. 1.20—Organized medical staff structure, accountability, and bylaws
  • MS.1.30—Bylaws amendments
  • MS.1.40—Medical executive committee

CHAPTER 3: MS.2.10–MS.2.30 Patient care, treatment and services, and oversight of graduate medical education programs

  • Background for the standards
  • MS.2.10—Oversight of practitioners
  • MS.2.20—Oversight of patient care
  • MS.2.30—Graduate medical education programs

CHAPTER 4: MS.3.10–3.20 Performance Improvement

  • Background for the standards
  • MS.3.10—Medical staff Performance Improvement
  • MS.3.20—Medical staff participation in organizational Performance Improvement

CHAPTER 5: MS.4.00–4.25, MS.4.60, HR.1.20 Credentialing, recredentialing, privileging, and appointment

  • Background for the standards
  • MS.4.60—Medical staff appointment
  • MS.4.00—Determining organizational resource availability
  • MS.4.10—Credentialing
  • MS.4.15—Privileging
  • MS.4.20—Analysis and use of information received
  • HR.1.20—Credentialing and privileging Allied Health Professionals
  • Special circumstances in credentialing and privileging
  • MS.4.25—Privilege decision notification
  • Actual survey experiences for the medical staff privileging and credentials review

CHAPTER 6: MS.4.30, MS.4.40, MS.4.45, MS.4.50, MS.4.70, MS.4.80 Focused and ongoing professional practice evaluation, peer recommendations, fair hearing, and LIP health

  • Background for the standards
  • MS.4.30—Focused practitioner evaluation
  • MS.4.40—Ongoing professional practice evaluation
  • MS.4.45—Evaluation and action regarding practitioner-specific concerns
  • MS.4.70—Peer recommendations
  • MS.4.50—Fair hearing and appeals process
  • MS.4.80—Licensed Independent Practitioner health

CHAPTER 7: MS.4.110, MS.4.35, MS.4.100, MS.4.120 Disaster privileges, expedited credentialing, temporary privileges, and telemedicine

  • Background for the standards
  • MS.4.110—Disaster privileges
  • MS.4.35—Expedited credentialing
  • MS.4.100—Temporary privileges
  • MS.4.120 and MS.4.130—Telemedicine privileges
  • MS.4.120—Telemedicine standards for originating site only
  • MS.4.130—Telemedicine standards for both originating and distant sites

CHAPTER 8: MS.5.10 Continuing medical education

  • Background for the standards
  • MS.5.10—CME

CHAPTER 9: Medical staff involvement in patient-focused areas

  • Ethics, rights, and responsibilities (RI)
  • Provision of care, treatment, and services (PC)
  • Restraints
  • Operative or other high-risk procedures/the administration of moderate or deep sedation or anesthesia
  • Medication management (MM)
  • Surveillance, prevention, and control of infection (IC)

CHAPTER 10: Medical staff involvement in organizational functions (LD, EC, IM)

  • Leadership (LD)
  • 2007 LD standards
  • 2008 field review for LD standards
  • Environment of care (EC)
  • Information management (IM)

APPENDIX A 2007 National Patient Safety Goals

APPENDIX B Tips for a successful survey