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

3. 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

4. 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

5. 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

6. 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

7. 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.

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. MS 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

20. 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

21. 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

22. 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

23. 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;

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

25. 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

26. 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

27. 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.

28. 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

29. 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

30. 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;

31. 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

32. 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.

33. 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.

34. 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

35. 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.

36. 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

37. 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

38. 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.

39. Thank you