Overview

The Chapter Leader's Guide to Performance Improvement: Practical Insight on Joint Commission StandardsCynthia Barnard, MBA, MSJS, CPHQ Quick, concise standard explanations for medical staff chapter leadersThe Chapter Leader's Guide to Medical Staff breaks down the Joint Commission's medical staff requirements into easy-to-understand solutions to meet the challenges of these complex standards. You get simplified explanations of the chapter's key components along with communication techniques to help foster a strong and successful partnership between survey coordinator and chapter leader. Plus, to make staff training easy, this guide includes two downloadable PowerPoint(R) presentations highlighting key compliance takeaways. Also, recieve bonus tools which include: Credentials committee orientation PowerPoint presentation Credentialing and privileging basics PowerPoint presentation Approval signature page Recommendation and approval form for medical staff appointment and clinical privileges Key players outline chart Benefits of The Chapter Leader's Guide to Medical Staff: Empower your medical staff chapter leaders to successfully navigate the survey process Communicate the impact the medical staff chapter has on leadership, management, and caregivers Create a culture of accountability by delegating survey-related responsibilities to staff members Go beyond standard numbers and understand the true meaning of The Joint Commission's medical staff requirements Get everyone in your facility on board with compliance Save time training medical staff chapter leaders with the customizable PowerPoint presentations What's inside: Keys to understanding The Joint Commission's stance on medical staff bylaws (MS.01.01.01) Explanation of the role of the MEC How the medical staff plays into graduate education programs and performance improvement Accreditation's role in credentialing and privileging What the standards say about physician behavior The latest updates to telemedicine requirements Table of ContentsPart I: Organization & Accountabilities Medical Staff and the Organization Impact on Leadership/Administration Determining Ownership The Medical Services Professional (MSP) The Quality Staff's Role The Medical Staff's Role The Chief Executive Officer's Role The Hospital Governing Body's Role Key Players by Standard Hospital Medical Staff (MS) Standards and Key Players Outline Part II: Communications & Culture Communication and its Impact on Staff and Physicians Hospital Staff Credentials Committee Department Chairman Medical Executive Committee Governing Body Medical Staff Part III: Operations & Performance Improvement Patient Care's Relationship to the Standards Successfully Maintaining Processes Impact on Activities, Requirements, Policies, and Procedures Part IV: Breakdown of the Medical Staff Standards MS.01.01.01: Organized Medical Staff Structure, Accountability, and Bylaws MS.01.01.03: Bylaws Amendments MS.02.01.01: Medical Executive Committee MS.03.01.01: Oversight of Practitioners MS.03.01.03: Management and Oversight of Patient Care MS.04.01.01: Graduate Medical Education Programs MS.05.01.01: Medical Staff Performance Improvement MS.05.01.03: Medical Staff Participation in Organizational Performance Improvement MS.06.01.01: Determining Organizational Resource Availability MS.06.01.03: Credentialing MS.06.01.05: Privileging MS.07.01.03: Peer Recommendations MS.06.01.07: Analysis and Use of Information Received MS.06.01.11: Expedited Credentialing MS.06.01.09: Privilege Decision Notification MS.06.01.13: Temporary Privileges MS.07.01.01: Medical Staff Appointment MS.08.01.01: Focused Practitioner Evaluation MS.08.01.03: Ongoing Professional Practice Evaluation MS.09.01.01: Evaluation and Action Regarding Practitioner-Specific Concerns MS.4.50: Fair Hearing and Appeals Process MS.11.01.01: Licensed Independent Practitioner Health MS.12.01.01: CME MS.13.01.01: Telemedicine Privileges MS.13.01.03: Telemedicine Standards for Both Originating and Distant Sites Who will benefit?Accreditation coordinator, accreditation specialist, survey coordinator, Joint Commission survey coordinator, medical staff chapter leader, medical staff coordinator, medical staff professional Earn Continuing Education Credits National Association for Healthcare Quality (NAHQ) This activity is pending approval by the National Association of Healthcare Quality for CE credits.

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9781601468093

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Kathy Matzka, CPMSM, CPCS, is a speaker, consultant, and author with more than 20 years of experience in medical and professional staff services. She is certified by National Association Medical Staff Services (NAMSS) in both management of medical staff services and provider credentialing.

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