Browse Document Library by Medical Staff
The documents in the Document Library which match your selected category are alphabetically sorted and listed below. If you need to search on a specific key phrase, just use our handy search tool on the main Document Library page.
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Case Review Process and Timeframes
Release Date: November 2, 2009
Document Type: Tools
Case Review Process and Timeframes
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Case Review Rating Form (Standard)
Release Date: November 2, 2009
Document Type: Forms
Worksheet for performing and rating physician case review.
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Completion of History and Physical Examinations
Release Date: April 27, 2010
Document Type: White Papers
Provides direction in identifying H & P requirements within a hospitals governing structure.
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Credentialing and Privileging, APPS, Model Policy
Release Date: November 12, 2009
Document Type: Policies and Procedures
Policy on processing Advanced Practice Professionals (Allied Health) through the credentialing and privileging process.
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Credentialing of Medical Students - Residency Rotations, Minimum Guidelines, Model Policy
Release Date: September 8, 2008
Document Type: Policies and Procedures
Policy on minimum requirements to credential and privilege medical students and residents.
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Credentialing of Telemedicine Practitioners, Model Policy
Release Date: November 12, 2009
Document Type: Policies and Procedures
Policy on credentialing and privileging requirements for telemedicine providers.
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Credentialing Reappointment and/or Renewal of Privileges Policy
Release Date: November 12, 2009
Document Type: Policies and Procedures
Policy outlining requirements for reappointment and process of reappointment.
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Credentialing, Board Oversight: Safeguarding the Foundation of Quality, White Paper
Release Date: October 25, 2006
Document Type: White Papers
Educational hand out outlining hospital board of director's responsibilities related to credentialing and privileging.
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Credentialing, Burden on the Applicant, Model Policy
Release Date: November 4, 2009
Document Type: Policies and Procedures
Policy stating burden of proof for completing appointment applications is on the applicant.
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Credentialing, Confidentiality of Med Staff, Quality and Peer Review Information, Model Policy
Release Date: November 12, 2009
Document Type: Policies and Procedures
Policy outlining confidentiality of credentialing, quality and peer review data.
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Credentialing, Expedited, Model Policy
Release Date: November 12, 2009
Document Type: Policies and Procedures
Expedited credentialing process policy to move a "clean" application through the credentialing process rapidly.
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Credentials File, Content, Access, Control and Retention, Model Policy
Release Date: November 12, 2009
Document Type: Policies and Procedures
Policy that outlines all requirements that must be present in each medical staff credentialing and privileging file.
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Definitions for Peer Review Physician Overall Care Categories
Release Date: November 2, 2009
Document Type: Tools
Document outlining the different outcome categories of physician peer review.
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External Peer Review: When and How
Release Date: May 8, 2009
Document Type: White Papers
Discover how you can use external peer review to acquire fair, efficient, and useful information to evaluate and improve physician performance. Authored by Robert J. Marder, MD, CMSL, Vice President, The Greeley Company, this white paper provides key strategies to help your organization develop clear, practical policies and processes for obtaining and using EPR evaluations.
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History and Physical, Guidelines
Release Date: April 27, 2010
Document Type: White Papers
The CMS Conditions of Participation and The Joint Commission standards require a hospital to have defined documented elements approved by the medical staff in a history and physical (H & P) examination. Documentation needs to include relevant information that supports practitioners in providing and planning for patient-specific treatment and services.
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History and Physical, Model Policy
Release Date: April 27, 2010
Document Type: Policies and Procedures
Sample policy provides direction and components of a history and physical.
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Impaired Practitioner, Model Policy
Release Date: December 3, 2009
Document Type: Policies and Procedures
Policy on managing licensed independent practitioners who are impaired.
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Indicators, Medical Staff, Explanation of Categories
Release Date: January 21, 2008
Document Type: Tools
Document categorizing and explaining the indicators outlined for physician case review.
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Informed Consent Policy
Release Date: April 30, 2010
Document Type: Policies and Procedures
Model policy supports CMS and Joint Commission requirements for informed consent prior to procedures.
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Leave of Absence Policy
Release Date: September 2, 2008
Document Type: Policies and Procedures
Medical Staff Leave of Absence policy delineating the approval process and the process for returning from a leave of absence including potential competency assessment for practitioners.
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Medical Staff Indicators and Targets List, Sample
Release Date: November 2, 2009
Document Type: Tools
Sample list of indicators for medical staff competency evaluation.
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Medical Staff Peer Review/Ongoing Professional Practice Evaluation (OPPE), Model Policy
Release Date: November 2, 2009
Document Type: Policies and Procedures
Ongoing Professional Practice Evaluation process policy.
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Medical Staff Quality Committee (MSQC) Charter
Release Date: November 2, 2009
Document Type: Tools
Document outlining the structure of the medical staff quality committee.
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Moderate and Deep Sedation Non-anesthesia Providers
Release Date: April 29, 2010
Document Type: Policies and Procedures
This model policy establishes the standard for sedation practices throughout the institution.
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Moderate and Deep Sedation Record Form
Release Date: April 29, 2010
Document Type: Forms
This form allows for documentation of a brief history and physical, the elements of the universal protocol, the presedation assessment and immediate reevaluation of the patient prior to procedure as well as providing an area for documenting the monitoring of the patient during procedures. This form is meant to be utilized for outpatient procedures, GI procedures and bedside/ED procedures which require sedation or when the universal protocol is required.
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Pain Management Summary
Release Date: April 14, 2010
Document Type: Policies and Procedures
Pain Management Summary
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Pain Management, Assessment/Reassessment, Policy
Release Date: April 14, 2010
Document Type: Policies and Procedures
The processes relative to pain management can prove to be challenging in meeting patient needs. It also poses a challenge in the accreditation arena as pain management remains frequently cited for noncompliance with the standards. This document describes a common sense approach to address the issue of pain assessment and reassessment.
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Patient Complaints & Grievances - Model Policy
Release Date: April 29, 2010
Document Type: Policies and Procedures
The model policy complies with CMS and Joint Commission standards regarding the implementation of a process for prompt resolution to complaints and grievances. It also includes suggested language for patient admission kits and Board resolution language for a Complaint Committee.
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Patient Complaints & Grievances - Sample Letter - 7 Day
Release Date: April 29, 2010
Document Type: Forms
Supporting documentation to patient grievances including a 7 day extension letter.
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Patient Complaints & Grievances - Sample Letter - Grievance Conclusion
Release Date: April 29, 2010
Document Type: Forms
Supporting documentation to patient grievances including a grievance resolution letter.
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Patient Complaints & Grievances - Sample Letter - Receipt of Grievance
Release Date: April 29, 2010
Document Type: Forms
Supporting documentation to patient grievances including an initial grievance receipt letter.
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Patient Complaints & Grievances Requirements Overview
Release Date: April 29, 2010
Document Type: Tools
Patient Complaints & Grievances Requirements Overview
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Peer Review Structures, What’s Out There And Why
Release Date: February 26, 2008
Document Type: White Papers
The Joint Commission requires peer review, but it does not require any particular way to organize your peer review program. Thus organizations are left to establish the right model to meet the needs of their particular medical staff culture and resources. Whatever structure you choose, make sure that it is able to produce a process that is unbiased, reliable and efficient. Authored by Robert Marder, MD, CMSL, and Vice President with The Greeley Company, this white paper discusses the pros and cons of the common structures used today and how these structures influence the functions of peer review.
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Peer Review, Exemplary Letter Model
Release Date: January 15, 2008
Document Type: Forms
Sample letter to physicians with exemplary care delivered identified through ongoing professional practice evaluation.
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Peer Review, Issue Inquiry Letter Model
Release Date: January 15, 2008
Document Type: Forms
Sample letter to physicians sent after case review requesting information about the case (follow-up requested).
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Peer Review, Issue Letter Model
Release Date: January 15, 2008
Document Type: Forms
Sample letter to physicians sent after final case review concluded stating identified issues with care.
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Peer Review, No Issue Letter Model
Release Date: January 15, 2008
Document Type: Forms
Sample letter to physicians sent after final case review concluded when there are no issues with care.
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Peer Review, Rule Indicator Letter (Clinical Rule)
Release Date: November 2, 2009
Document Type: Forms
Sample letter automatically sent to physicians for non-compliance with medical staff rules (clinical rule).
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Physician Concern/Suggestion/Complaint, Model Policy
Release Date: February 22, 2008
Document Type: Policies and Procedures
Process for physicians to report concerns, suggestions and complaints.
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Privilege Criteria, Algorithm for Processing New Privilege Requests
Release Date: April 22, 2009
Document Type: Tools
Algorithm for how clinical privilege requests are developed.
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Privileging Guidelines for Moderate and Deep Sedation
Release Date: April 29, 2010
Document Type: Policies and Procedures
Provides guidance for privileging providers for administering moderate and deep sedation.
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Privileging of Allied Health Practitioners, White Paper
Release Date: March 3, 2008
Document Type: White Papers
Discussion of privileging of allied health practitioners.
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Proctoring/Focused Professional Practice Evaulation (FPPE), Model Policy
Release Date: November 12, 2009
Document Type: Policies and Procedures
Policy on methodology and requirements of Focused Professional Practice Evaluation, (includes criteria) for new members or new privileges.
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Validation of Perception-based Rule Indicator Occurences, Model Policy
Release Date: November 2, 2009
Document Type: Policies and Procedures
Policy on methodology for determining medical staff indicator rules for forwarding to peer review committee.
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Question of the Month | Expert Advice & Guidance
Our medical staff is having difficulty with focused professional practice evaluation related to licensed independent practitioners that do not perform surgical or other invasive procedures. Do you have any suggestions about ... Read More...
Your question is understandable, as many hospitals have difficulty with the medical staff standard requiring focused professional ... Read More...
