Healthcare Accreditation Certification Program Newsletter
April 2020

CIHQ-ARS Blog

Integrated Medical Staffs - Part Four

By: Traci Curtis
Welcome to the last in a four part blog series on CMS' requirements for health systems that wish to have a single integrated medical staff for multiple Medicare certified or accredited hospitals. In this blog, we're going to discuss requirements addressing the unique characteristics of each hospital.
CMS interpretive guidance for §482.22(b)(4) states that a "hospital that is part of a system consisting of multiple separately certified hospitals may use a single unified and integrated medical staff (hereafter referred to as a "unified medical staff") that is shared with one or more of the other hospitals in the system."
Each hospital, however, may be very different from each other, presenting different needs and challenges for the medical staff. As a result, CMS expects the health system - and the integrated medical staff - to take these differences into account rather than using a one-size-fits-all approach for all of its policies and procedures. Leadership must be able to explain how the unified medical staff is organized and takes account of and responds to the unique circumstances of the hospital that is being surveyed.
The unified medical staff must have written policies and procedures that address how it considers and addresses needs and concerns expressed by members who practice at the different hospital(s). This is not about an individual medical staff member's concerns with privileges granted or not granted to him/her, peer review results, due process issues, etc. Instead, this provision addresses a requirement for the unified medical staff to consider and address concerns that practitioners have concerning their own hospital's needs.
The medical staff has flexibility in establishing its written policies and procedures for addressing these local concerns, but at a minimum they must cover the following:
  • A process by which members who practice at a hospital can raise their local concerns and needs with the unified medical staff's leadership;
  • How members are informed of the process by which they can raise their local concerns and needs;
  • A process for referring the concerns and needs raised to the appropriate committee or other group within the medical staff for due consideration; and
  • Documentation of the outcome of the medical staff's review of the concerns and needs raised.
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