Dr. Ali Zubaidi Medical Director Medical Staff (MS) Dr. Ali Zubaidi Medical Director

Definitions MS The group of physicians and dentists licensed to practice medicine and prescribe medications, plays a critical role in assuring quality care and improving patients' outcomes in the hospital.. The medical director must be a physician and must have his or her duties defined in writing

Important Processes and activities Medical staff leaders roles and responsibilities Medical staff evaluation, credentialing and privileging Medical staff committees Medical staff bylaws Medical staff collaboration with other disciplines Medical staff competency assessment

MS.1 MS.1: The organization, functions and responsibilities of medical staff are documented and communicated to all staff members Medical Staff Bylaws that govern the organization, functions and resposibilities Medical staff rules and regulations Available in Hospital Policy in the Intranet All should read and understand with related policies and procedures

MS.1 Medical staff bylaw address; The MS ranking and the qualifications required for each rank. Categories of the MS membership (e.g., full time, part time, and locum). Roles and responsibilities of the medical staff members. Appointment, promotion, and reappointment of medical staff members. Granting and maintaining clinical privileges, including temporary privileges (e.g., for locums and emergency situations). Disciplinary procedures for medical staff members, including corrective actions and appeals  

MS.1 Admission, referral, transfer, and discharge processes. Medical staff bylaw describe standard patient care include Admission, referral, transfer, and discharge processes. Documentation in medical records The conduct of care expected for all levels of medical staff (e.g., daily rounds). The professional conduct (e.g., handling ethical issues) of the medical staff.  

MS.2 MS.2: A qualified medical director is responsible for managing the medical staff and the medical services Board certified or equivalent with qualification in healthcare management by education training or experience Responsible for medical staff clinical performance, quality of care provided and professional conduct

Recommends to the hospital director the appointment of heads of clinical departments Has a current job description that clearly describes his managerial roles and responsibilities

MS.3 MS.3: The hospital has an effective process that supports the professional communication and coordination of care amongst medical staff Medical executive committee chaired by medical director and includes the heads of clinical departments- to work together to coordinate the provision of care

The Medical Executive committee Holds regular meetings (at least monthly) Reviews and approves policies and procedures related to clinical departments Reviews all relevant reports of other committees for prioritizing the services and guiding the credentialing and privileging process

MS.4 MS.4: Each clinical department is directed by a qualified individual Board certified or equivalent in his field and qualified in healthcare management by education training or experience Written job description

Responsibilities of Department Head Defining medical staff qualifications for the provision of effective and safe patient care Recommending the need for further training/certification of a medical staff member Monitoring admissions Ensuring that medical staff members work within the clinical privileges granted to them Developing a written scope of service

Peer Review The department head has an ongoing method of peer review to evaluate the care provided as well as the performance of the medical staff Utilized as part of physician performance evaluation Shares the findings of peer review with the medical director and works closely to improve and correct deficiencies

Assess appropriateness of admissions, appropriateness and effectiveness of care Length of stay Appropriate utilization of resources Training and educational needs Defines criteria for selecting cases for peer review

MS.5 MS.5: The credentialing and privileging of the medical staff is based on an informed group decision Credentialing and privileging committee Provides oversight for credentialing and privileging Ensures that only qualified physicians and dentists are appointed and granted privileges

Applicants for initial appointment Submit Curriculum vitae Education, training, certificates, courses, experience, published research and other relevant documents List of references List of the privileges requested for approval

MS.6 MS.6: The hospital has clearly defined and documented processes used to credential, appoint, and grant clinical privileges to medical staff Credentialing- policy Assigning staff privileges- policy(license,education,training,experience) Re-credentialing and re-appointment privileging- policy Process in place for appeals against credentialing or privileging decisions

MS.7 ESR MS.7: Medical staff members have current delineated clinical privileges Practice only within the privileges granted Update privileges every 2 years or as needed Granting temporary privileges/ emergency privileges- for not more than 90 days Not renewable Request for new privileges- credentials verified before granting

MS.8 MS.8: The performance of the medical staff members is evaluated on an ongoing basis to ensure competency At least annually- as OPPE (JCI) Define circumstances under which unplanned review of the performance of a medical staff member will be initiated- as FPPE of JCI

Elements of performance evaluation Assessment of patients Adverse events Moderate and deep sedation Quality of medical records Sentinel events Outcome of high risk procedures Morbidities and mortalities Blood and blood product usage Discrepancies between pre- and post-op pathological diagnosis Appropriateness of admission from ER and OPD

MS.9 MS.9: Medical staff leaders make use of the data and information resulting from the medical staff performance review Used to Provide feedback and counseling Recommend plans for improvement Asses clinical privilege(expansion or limitation) To make decisions about reappointment Outcome of performance evaluation and action taken are Keep in personnel file

MS.10 MS.10: Medical staff leaders support the hospital-wide quality improvement, patient safety, and risk management plans Implementation of all Data and information from the medical staff performance review are used to continuously improve quality and patient safety by;

MS10 Studying and minimizing variations in the processes Taking actions to prevent avoidable medical errors Recommending equipment needed in specified areas

Heads of clinical departments with medical director Work closely with the quality management director/risk manager in handling incidents including near misses and sentinel events Root cause analysis is properly conducted Emphasis on improving systems Corrective actions are documented

MS.11 MS.11: Heads of clinical departments review mortality and morbidity cases Monthly review of all mortalities and significant morbidity Documented with attendance Focus on scientific discussion, improvement and prevention with a non-punitive intent

Heads of clinical departments work with medical director to select cases to be referred to the hospital morbidity mortality committee Heads of clinical departments send regularly mortality and morbidity findings to medical director and quality director.

MS.12 MS.12: The hospital has a mortality and morbidity committee Chaired by medical director or designee Review mortality and the unusual or unexpected adverse outcome of care Evaluates cases for effectiveness, timeliness and appropriateness of care Recommends actions for improvement

MS.13 MS.13: The hospital has a medical record review committee oversees and monitors the documentation in medical records for quality, completeness, and timeliness. Reviews a sample of medical records Recommends actions for improvement and evaluates their effectiveness

MS.14 MS.14: The hospital has a utilization review committee Chaired by medical director or designee Terms of reference Assesses the medical necessity of services provided by the hospital and the medical staff members to the patients this includes but not limited to;

MS.14 Appropriateness of admissions Appropriateness of the quality of care Length of stay Drug usage Efficiency in using various hospital resources- overutilization, underutilization. Recommends actions for improvement and evaluates their effectiveness

MS.15 MS.15: The hospital has a blood utilization committee Chaired by medical director or designee Terms of reference Ensures optimal use of blood and blood products Policies and procedures for all procedures and practices including.

MS.15 Handling of blood outside the laboratory. Use of blood warmers and infusion devices. Venous access. Addition of fluids and drugs other than 0.9% NaCL . Bed side identification of the blood product and the intended recipient . Monitoring of patient during and after blood administration. Recommends actions for improvement and evaluates their effectiveness.

MS.16 MS.16: The hospital has a tissue review committee Terms of reference Conducts analysis and review of tissues removed during surgeries and procedures Policies and procedures for obtaining and handling

Ensures Policy for Collection and transportation Accuracy and completeness of histopathology forms(site, number,clinical history, previous biopsy). Accuracy of fine needle aspirations Accuracy of frozen section specimens Recommends actions for improvement and evaluates their effectiveness.

MS.17 MS.17: The hospital has an operating room committee Terms of reference Approve all Policies and procedures like; Infection control measure Supply of equipment and disposable. Code of ethical conduct in the operating room to protect patient privacy and dignity Monitoring performance in OR including cancellation rate and makes improvements accordingly

MS.18 MS.18: The hospital has a cardiopulmonary resuscitation committee Terms&reference(medical,nurse,intensive, emrgency, quaity). Ensures an effective system to handle all cases of CPR at all times Team members have BLS, ACLS All codes are discussed in committee meetings to make recommendations for improvement Forward summary to medical director

MS.19 MS.19: The hospital has a pharmacy and therapeutics committee Terms of reference (drugs prescribing, ordering, dispensing,adminstrating & patients monitoring). Provides oversight of the hospital formulary and medication use Committee meets regularly (quarterly). Recommends actions for improvement and evaluates their effectiveness.

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