1. An Analysis of Our Medical Staff
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2. CH Medical Staff Services Draft 9/24/09

3. Scope of Services
The Medical Staff Offices (MSO) supports compliance with TJC and other regulatory agencies relative to all functions of the medical staff. The MSO serves as a resource and provides technical support services in the following areas to physicians: credentialing (including allied health professionals), medical education (including facilitating medical student and resident training rotations), medical staff quality assurance/performance improvement, and department and committee activities. Additionally, the MSO functions as a liaison between the medical staff and administration, nursing and other medical center personnel and departments.

4. Scope of Service Support and/or Integration with Other Departments:
Offer opportunities for other hospital health care professionals to attend appropriate medical education conferences based upon identified areas for improvement.
Maintain all physician and allied health information in the hospital information system and assure confidentiality of that information. Appropriate hospital employees are given access to specific pieces of information based upon need to know.
Provide appropriate departments clinical privilege information based upon the physician’s specialty and his/her potential use of those departments (i.e., clinical privileges regarding physicians authorized to perform GI diagnostic procedures are forwarded to the GI Lab).

5. Scope of Service
4. Function as a liaison between Information Services and the medical staff relative to Meditech and Internet/Intranet training, access and problems/suggestions.
Work closely with Medical Records to achieve timely completion by physicians of medical records.
Provide the opportunity at clinical department meetings and medical staff committee meetings for hospital employees to share changes in procedures, new programs, etc.
Provide the opportunity for hospital employees to address concerns they may have relative to members of the medical staffs.
Notify Physician Relations Department of new appointments for the medical staff, who determines the need for additional follow up.

6. Resources NAMSS Staffing Ratios Study
September 2009 (additional supporting documentation is attached)
Position descriptions

7. Staffing
On average, the ratio of MSPs to credentialed medical staff (e.g., physicians, dentists as applicable) is one to 89.
In comparison, the ratio of MSPs to all credentialed staff (i.e., credentialed medical staff and practitioners) is one to 112.
There is a significant correlation between the number of credentialed medical staff and the number of MSPs employed at a facility.
Data indicate that the number of MSPs staff steadily increases as the total number of credentialed staff exceeds per 100.

8. Staffing
The table below shows the number of MSPs per credentialed medical staff and all credentialed staff:
Ratio
Count
Mean
25%
Median/50%
75%
# of MSPs to Credentialed Medical Staff
634
1/89
1/214
1/144
1/90
# of MSPs to All Credentialed Staff
638
1/112
1/261
*CH1/228
1/180
1/109

9. Staffing
Per key findings from the Staffing Study, CH performs Functions at the 75% percentile based upon the number of applications processed per month (58) and number of credentialed practitioners (1200)
CH should staff at the percentile which equals FTEs* (without QA Function)
223 hours week/40 = 5.575

10. Function #1 Credentialing/Privileging
Applicant personal interview
Applicant eligibility review
Analysis of applications/documents
Committee presentation for approval of appointments and privileging
Reappointments, including analysis of applications and documents
Committee presentation for approval of reappointment
Processing requests for additional privileges
FPPE/OPPE
Investigation of issues/data analysis
Total hours = 90.77

11. Function #2 Primary Source Verification
Pre-application evaluation
Obtaining and evaluating information
Verification and documentation
Investigating and validating discrepancies and information
Responding to inquiries from other healthcare organizations
Total hours = 48.85

12. Function #3 Compliance
Bylaws/rules and regulations/policies and procedures
Preparing for accreditation reviews and ongoing compliance with regulatory standard
Internal audits
Sanctions, complaints, adverse data and NPDB
Total hours = 18

13. Function #4 Operations Correspondence to practitioners and others
Meeting logistics, documentation and follow up
Database updates
Financial management (dues, fees, budgeting)
Call scheduling
Conflict resolution
Standing orders
Physician wellness
Total hours = 36.58

14. Function #5 Physician Outreach
Physician committee assignments
Physician contracts
Social aspects (Doctors’ Day, dinners, etc.)
Physician/AHP orientation
Physician retention
Physician education training programs (residency, medical students)
Physician education (CME)
Total = 16

15. Function #6 Human Resources
Personal training and/or development of staff
Staff management (evaluation and mentoring)
Staff training
Total hours = 9.59

16. Function #7 Peer Review/QA/PI
Perform review functions using the medical record and other data in terms of quality and appropriateness of care issues
Reviews use of blood and blood components, surgical and other invasive procedures, mortalities, and patient outcomes to identify single cases or patterns of cases that require more intensive evaluation by the medical staff
Reports specific data elements for recredentialing
Develops concurrent and/or retrospective studies
Maintains physician and advance practice practitioner peer review process, initial review/screening, QA and PQA committee support, arranging for peer reviews, including coordinating outside peer review.
Total time = 40 hours

17. Additional Performance Tasks
Total = 5.45 of “other tasks”