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CoP: Medical Staff
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482.22 Medical Staff
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A-0338 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital.
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Interpretive Guidelines §482.22
The hospital must have one medical staff for the entire hospital (including all campuses, provider-based locations, satellites, remote locations, etc.). For example, a multi-campus hospital may not have a separately organized medical staff for each campus. On the other hand, in the case of a hospital system, it is permissible for the system to have a unified and integrated medical staff (hereafter referred to as a “unified medical staff”) for multiple, separately certified hospitals. The medical staff must be organized and integrated as one body that operates under one set of bylaws approved by the governing body. These medical staff bylaws must apply equally to all practitioners within each category of practitioners at all locations of the hospital and to the care provided at all locations of the hospital. The medical staff is responsible for the quality of medical care provided to patients by the hospital.
482.22(a) Standard: Eligibility and Process for Appointment to Medical Staff
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A-0339 482.22(a) The medical staff must be composed of doctors of medicine or osteopathy. In accordance with State law, including scope-of-practice laws, the medical staff may also include other categories of physicians (as listed at 482.12(c)(1)) and non- physician practitioners who are determined to be eligible for appointment by the governing body.
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Interpretive Guidelines §482.22(a)
The hospital’s governing body has the responsibility, consistent with State law, including scope-of-practice laws, to determine which types/categories of physicians and, if it so chooses, non-physician practitioners or other licensed healthcare professionals (collectively referred to in this guidance as “practitioners”) may be privileged to provide care to hospital patients. All practitioners who require privileges in order to furnish care to hospital patients must be evaluated under the hospital’s medical staff privileging system before the hospital’s governing body may grant them privileges. All practitioners granted medical staff privileges must function under the bylaws, regulations and rules of the hospital’s medical staff. The privileges granted to an individual practitioner must be consistent with State scope-of-practice laws.
Physicians:
The medical staff must at a minimum be composed of doctors of medicine or doctors of osteopathy. In addition, the medical staff may include other types of practitioners included in the definition in Section 1861(r) of the Social Security Act of a “physician:”
• Doctor of dental surgery or of dental medicine;
• Doctor of podiatric medicine;
• Doctor of optometry; and a
• Chiropractor.
In all cases, the practitioner included in the definition of a physician must be legally authorized to practice within the State where the hospital is located and providing services within their authorized scope of practice. In addition, in certain instances the Social Security Act and regulations attach further limitations as to the type of hospital services for which a practitioner may be considered to be a “physician.” See §482.12(c)(1) for more detail on these limitations.
The governing body has the flexibility to determine, consistent with State law, whether practitioners included in the definition of a physician, other than doctors of medicine or osteopathy, are eligible for appointment to the medical staff.
"For Information Only – Not Required/ Not to be Cited"
--CMS expects that all physician practitioners granted privileges are also appointed as members of the medical staff. However, if State law limits the composition of the hospital’s medical staff to certain categories of practitioners, e.g., only MDs or DOs, there is nothing in the CoPs that prohibits hospitals and their medical staffs from establishing certain practice privileges for other categories of physician practitioners excluded from medical staff membership under State law, or from granting those privileges to individual practitioners in those categories, as long as such privileges are recommended by the medical staff, approved by the governing body, and in accordance with State law. (79 FR 27114 - 27115, May 12, 2014)--
For physician practitioners granted privileges only, the hospital’s governing body and its medical staff must exercise oversight, such as through credentialing and competency review, of those other physician practitioners to whom it grants privileges, just as it would for those practitioners appointed to its medical staff.
Non-physician practitioners
Furthermore, the governing body has the authority, in accordance with State law, to grant medical staff privileges and membership to non-physician practitioners. The regulation allows hospitals and their medical staffs to take advantage of the expertise and skills of all types of practitioners who practice at the hospital when making recommendations and decisions concerning medical staff privileges and membership.
"For Information Only – Not Required/ Not to be Cited"
--CMS expects that all practitioners granted privileges are also appointed as members of the medical staff. However, if State law limits the composition of the hospital’s medical staff to certain categories of practitioners, e.g., only physician practitioners, there is nothing in the CoPs that prohibits hospitals and their medical staffs from establishing certain practice privileges for those specific categories of non-physician practitioners excluded from medical staff membership under State law, or from granting those privileges to individual practitioners in those categories, as long as such privileges are recommended by the medical staff, approved by the governing body, and in accordance with State law. (79 FR 27114 - 27115, May 12, 2014)--
For non-physician practitioners granted privileges only, the hospital’s governing body and its medical staff must exercise oversight, such as through credentialing and competency review, of those non-physician practitioners to whom it grants privileges, just as it would for those practitioners appointed to its medical staff.
Practitioners are described in Section 1842(b)(18)(C) of the Act as any of the following:
• Physician assistant (as defined in Section 1861(aa)(5) of the Act);
• Nurse practitioner (as defined in Section 1861(aa)(5) of the Act);
• Clinical nurse specialist (as defined in Section 1861(aa)(5) of the Act);
• Certified registered nurse anesthetist (as defined in Section 1861(bb)(2) of the Act);
• Certified nurse-midwife (as defined in Section 1861(gg)(2) of the Act);
• Clinical social worker (as defined in Section 1861(hh)(1) of the Act);
• Clinical psychologist (as defined in 42 CFR 410.71 for purposes of Section 1861(ii) of the Act);
• Anesthesiologist’s Assistant (as defined in §410.69); or
• Registered dietician or nutrition professional.
Other types of licensed healthcare professionals have a more limited scope of practice and usually are not eligible for hospital medical staff privileges, unless their permitted scope of practice in their State makes them more comparable to the above types of non-physician practitioners. Some examples of types of such licensed healthcare professionals who might be eligible for medical staff privileges depending on State law and medical staff bylaws, rules and regulations include, but are not limited to:
• Physical Therapist (as defined at §410.60 and §484.4);
• Occupational Therapist (as defined at §410.59 and §484.4); and
• Speech Language Therapist (as defined at §410.62 and §484.4).
Furthermore, some States have established a scope of practice for certain licensed pharmacists who are permitted to provide patient care services that make them more like the above types of non-physician practitioners, including the monitoring and assessing of patients and ordering medications and laboratory tests. In such States, a hospital may grant medical staff privileges to such pharmacists and/or appoint them as members of the medical staff. There is no standard term for such pharmacists, although they are sometimes referred to as “clinical pharmacists.”
Practitioners may be granted active, courtesy, emergency, temporary, etc. membership or privileges in accordance with state law and as specified in the medical staff bylaws, rules, and regulations. -
A-0340 482.22(a)(1) - The medical staff must periodically conduct appraisals of its members.
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Interpretive Guidelines §482.22(a)(1)
The medical staff must at regular intervals appraise the qualifications of all practitioners appointed to the medical staff/granted medical staff privileges. In the absence of a State law that establishes a timeframe for periodic reappraisal, a hospital’s medical staff must conduct a periodic appraisal of each practitioner. CMS recommends that an appraisal be conducted at least every 24 months for each practitioner.
The purpose of the appraisal is for the medical staff to determine the suitability of continuing the medical staff membership or privileges of each individual practitioner, to determine if that individual practitioner’s membership or privileges should be continued, discontinued, revised, or otherwise changed.
The medical staff appraisal procedures must evaluate each individual practitioner’s qualifications and demonstrated competencies to perform each task or activity within the applicable scope of practice or privileges for that type of practitioner for which he/she has been granted privileges. Components of practitioner qualifications and demonstrated competencies would include at least: current work practice, special training, quality of specific work, patient outcomes, education, maintenance of continuing education, adherence to medical staff rules, certifications, appropriate licensure, and currency of compliance with licensure requirements.
In addition to the periodic appraisal of members, any procedure/task/activity/privilege requested by a practitioner that goes beyond the specified list of privileges for that particular category of practitioner requires an appraisal by the medical staff and approval by the governing body. The appraisal must consider evidence of qualifications and competencies specific to the nature of the request. It must also consider whether the activity/task/procedure is one that the hospital can support when it is conducted within the hospital. Privileges cannot be granted for tasks/procedures/activities that are not conducted within the hospital, regardless of the individual practitioner’s ability to perform them.
After the medical staff conducts its reappraisal of individual members, the medical staff makes recommendations to the governing body to continue, revise, discontinue, limit, or revoke some or all of the practitioner’s privileges, and the governing body takes final appropriate action.
A separate credentials file must be maintained for each medical staff member. The hospital must ensure that the practitioner and appropriate hospital patient care areas/departments are informed of the privileges granted to the practitioner, as well as of any revisions or revocations of the practitioner’s privileges. Furthermore, whenever a practitioner’s privileges are limited, revoked, or in any way constrained, the hospital must, in accordance with State and/or Federal laws or regulations, report those constraints to the appropriate State and Federal authorities, registries, and/or data bases, such as the National Practitioner Data Bank. -
A-0341 482.22(a)(2) - The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations. A candidate who has been recommended by the medical staff and who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained in this section.
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Interpretive Guidelines §482.22(a)(2)
There must be a mechanism established to examine credentials of individual prospective members (new appointments or reappointments) by the medical staff. The individual’s credentials to be examined must include at least:
• A request for clinical privileges;
• Evidence of current licensure;
• Evidence of training and professional education;
• Documented experience; and
• Supporting references of competence.
The medical staff may not make its recommendation solely on the basis of the presence or absence of board certification, but must consider all of the elements above. However, this does not mean that the medical staff is prohibited from requiring in its bylaws board certification when considering a MD/DO for medical staff membership or privileges; only that such certification may not be the only factor that the medical staff considers.
The medical staff makes recommendations to the governing body for each candidate for medical staff membership/privileges that are specific to type of appointment and extent of the individual practitioner’s specific clinical privileges, and then the governing body takes final appropriate action.
Each practitioner who is a member of the medical staff or who holds medical staff privileges is subject to the medical staff’s bylaws, rules, and regulations, in addition to all the requirements of the Medical Staff Condition of Participation. The medical staff and the governing body must enforce its medical staff requirements and take appropriate actions when individual members or other practitioners with privileges do not adhere to the medical staff’s bylaws, regulations, and rules. They must likewise afford all members/practitioners who hold privileges the protections and due process rights provided for in the bylaws, rules and regulations.
A separate credentials file must be maintained for each individual medical staff member or applicant. The hospital must ensure that the practitioner and appropriate hospital patient care areas/departments are informed of the privileges granted to the practitioner. -
A-0342 482.22(a)(3) When telemedicine services are furnished to the hospital’s patients through an agreement with a distant-site hospital, the governing body of the hospital whose patients are receiving the telemedicine services may choose, in lieu of the requirements in paragraphs (a)(1) and (a)(2) of this section, to have its medical staff rely upon the credentialing and privileging decisions made by the distant-site hospital when making recommendations on privileges for the individual distant-site physicians and practitioners providing such services, if the hospital’s governing body ensures, through its written agreement with the distant-site hospital, that all of the following provisions are met:<br>(i) The distant-site hospital providing the telemedicine services is a Medicare-participating hospital.<br>(ii) The individual distant-site physician or practitioner is privileged at the distant-site hospital providing the telemedicine services, which provides a current list of the distant-site physician’s or practitioner’s privileges at the distant-site hospital. <br>(iii) The individual distant-site physician or practitioner holds a license issued or recognized by the State in which the hospital whose patients are receiving the telemedicine services is located.<br>(iv) With respect to a distant-site physician or practitioner, who holds current privileges at the hospital whose patients are receiving the telemedicine services, the hospital has evidence of an internal review of the distant-site physician’s or practitioner’s performance of these privileges and sends the distant- site hospital such performance information for use in the periodic appraisal of the distant-site physician or practitioner. At a minimum, this information must include all adverse events that result from the telemedicine services provided by the distant- site physician or practitioner to the hospital’s patients and all complaints the hospital has received about the distant-site physician or practitioner.<br>
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Interpretive guidelines §482.22(a)(3)
The hospital’s governing body has the option, when considering granting privileges to telemedicine physicians and practitioners, to have the hospital’s medical staff rely upon the credentialing and privileging decisions of the distant-site hospital for these physicians and practitioners. This process would be in lieu of the traditional process required under §482.22(a)(1) and §482.22(a)(2), whereby the hospital’s medical staff conducts its own review of each telemedicine physician’s or practitioner’s credentials and makes a recommendation based on that individualized review.
In order to exercise this alternative credentialing and privileging option, the hospital’s governing body must ensure through its written agreement with the distant-site hospital that all of the following requirements are met:
• The distant-site hospital participates in the Medicare program. If the distant-site hospital’s participation in Medicare is terminated, either voluntarily or involuntarily, at any time during the agreement, then, as of the effective date of the termination, the hospital may no longer receive telemedicine services under the agreement;
• The distant-site hospital provides to the hospital a list of all its physicians and practitioners covered by the agreement, including their privileges at the distant-site hospital. The list may not include any physician or practitioner who does not hold privileges at the distant-site hospital. The list must be current, so the agreement must address how the distant-site hospital will keep the list current;
• Each physician or practitioner who provides telemedicine services to the hospital’s patients under the agreement holds a license issued or recognized by the State where the hospital (not the distant-site hospital) is located. States may have varying requirements as to whether they will recognize an out-of-state license for purposes of practicing within their State, and they may also vary as to whether they establish different standards for telemedicine services. The licensure requirements governing in the State where the hospital whose patients are receiving the telemedicine services is located must be satisfied, whatever they may be; and
• The hospital has evidence that it reviews the telemedicine services provided to its patients and provides feedback based on this review to the distant-site hospital for the latter’s use in its periodic appraisal of each physician and practitioner providing telemedicine services under the agreement. At a minimum, the hospital must review and send information to the distant-site hospital on all adverse events that result from a physician or practitioner’s provision of telemedicine services under the agreement and on all complaints it has received about a telemedicine physician or practitioner covered by the agreement. -
A-0343 482.22(a)(4) When telemedicine services are furnished to the hospital’s patients through an agreement with a distant-site telemedicine entity, the governing body of the hospital whose patients are receiving the telemedicine services may choose, in lieu of the requirements in paragraphs (a)(1) and (a)(2) of this section, to have its medical staff rely upon the credentialing and privileging decisions made by the distant- site telemedicine entity when making recommendations on privileges for the individual distant-site physicians and practitioners providing such services, if the hospital’s governing body ensures, through its written agreement with the distant- site telemedicine entity, that the distant-site telemedicine entity furnishes services that, in accordance with §482.12(e), permit the hospital to comply with all applicable conditions of participation for the contracted services. The hospital’s governing body must also ensure, through its written agreement with the distant-site telemedicine entity, that all of the following provisions are met:<br>(i) The distant-site telemedicine entity’s medical staff credentialing and privileging process and standards at least meet the standards at §482.12(a)(1) through (a)(7) and §482.22(a)(1) through (a)(2).<br>(ii) The individual distant-site physician or practitioner is privileged at the distant- site telemedicine entity providing the telemedicine services, which provides the hospital with a current list of the distant-site physician’s or practitioner’s privileges at the distant-site telemedicine entity.<br>(iii) The individual distant-site physician or practitioner holds a license issued or recognized by the State in which the hospital whose patients are receiving such telemedicine services is located.<br>(iv) With respect to a distant-site physician or practitioner, who holds current privileges at the hospital whose patients are receiving the telemedicine services, the hospital has evidence of an internal review of the distant-site physician’s or practitioner’s performance of these privileges and sends the distant-site telemedicine entity such performance information for use in the periodic appraisal of the distant- site physician or practitioner. At a minimum, this information must include all adverse events that result from the telemedicine services provided by the distant-site physician or practitioner to the hospital’s patients, and all complaints the hospital has received about the distant-site physician or practitioner.<br><br>
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Interpretive guidelines §482.22(a)(4)
For the purposes of this rule, a distant-site telemedicine entity is defined as an entity that -- (1) provides telemedicine services; (2) is not a Medicare-participating hospital; and (3) provides contracted services in a manner that enables a hospital using its services to meet all applicable Conditions of Participation, particularly those requirements related to the credentialing and privileging of practitioners providing telemedicine services to the patients of a hospital. A distant-site telemedicine entity would include a distant-site hospital that does not participate in the Medicare program that is providing telemedicine services to a Medicare-participating hospital. (See 76 FR 25553, May 5, 2011)
The hospital’s governing body has the option, when considering granting privileges to telemedicine physicians and practitioners, to have the hospital’s medical staff rely upon the credentialing and privileging decisions of the distant-site telemedicine entity for these physicians and practitioners. This process would be in lieu of the traditional process required under §482.22(a)(1) and §482.22(a)(2), whereby the medical staff conducts its own review of each telemedicine physician’s or practitioner’s credentials and makes a recommendation based on that individualized review.
In order to exercise this alternative credentialing and privileging option, the hospital’s governing body must ensure that its written agreement with the distant-site hospital enables the hospital, as required under the regulation at §482.12(e) governing services provided under arrangement, to comply with all applicable hospital Conditions of Participation. In particular, the written agreement between the hospital and the distant-site telemedicine entity must ensure that all of the following requirements are met:
• The distant-site telemedicine entity utilizes a medical staff credentialing and privileging process and standards that at least meets the standards for the medical staff of a hospital established at §482.12(a)(1) through (a)(7) and §482.22(a)(1) through (a)(2);
• The distant-site telemedicine entity provides a list to the hospital of all physicians and practitioners covered by the agreement, including their privileges at the distant-site telemedicine entity. The list may not include any physician or practitioner who does not hold privileges at the distant-site telemedicine entity. The list must be current, so the agreement must address how the distant-site telemedicine entity will keep the list current;
• Each physician or practitioner who provides telemedicine services to the hospital’s patients under the agreement holds a license issued or recognized by the State where the hospital is located. States may have varying requirements as to whether they will recognize an out-of-state license for purposes of practicing within their State, and they may also vary as to whether they establish different standards for telemedicine services. The licensure requirements governing in the State where the hospital whose patients are receiving the telemedicine services is located must be satisfied, whatever they may be; and
• The hospital has evidence that it reviews the telemedicine services provided to its patients and provides a written copy of this review to the distant-site telemedicine entity for the latter’s use in its periodic appraisal of the physicians and practitioners providing telemedicine services under the agreement. At a minimum, the hospital must review and send information to the distant-site telemedicine entity on all adverse events that result from a physician or practitioner’s provision of telemedicine services and on all complaints it has received about a telemedicine physician or practitioner.
482.22(b) Standard: Medical Staff Organization and Accountability
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A-0347 482.22(b) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients.<br>(1) The medical staff must be organized in a manner approved by the governing body.<br>(2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy.<br>(3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following:<br>(i) An individual doctor of medicine or osteopathy.<br>(ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located.<br>(iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located.<br>
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Interpretive Guidelines §482.22(b)(1) – (3)
The conditions of participation create a system of checks and balances within an overall framework of collaboration between the governing body and the medical staff (and, to a certain degree, also between an individual practitioner and the hospital’s medical staff and governing body). Each has its own areas of authority. The medical staff has oversight of all practitioners practicing in the hospital through processes such as peer review and making recommendations concerning privileging and re-privileging. The governing body has the authority to establish the categories of healthcare professionals (regardless of the terms used to describe those categories) who are eligible for privileges and medical staff appointment. However, the governing body must rely on the medical staff to apply the criteria for privileging and appointment to those eligible candidates and to make their recommendations before the governing body makes a final decision to appoint or not appoint a practitioner to the medical staff. (77 FR 29042 May 16, 2012).
If the hospital uses a unified medical staff that it shares with other hospitals that are part of a multi-hospital system, this does not change the requirement for the medical staff to be well organized and accountable to the system’s governing body for the quality of care in each separately certified hospital.
Leadership of the medical staff
The members of the hospital’s medical staff must select, in accordance with the medical staff bylaws, rules or regulations approved by the governing body, a single individual to lead the medical staff and be responsible for the organization and conduct of the medical staff. This individual must be a doctor of medicine or osteopathy, or, if permitted by State law where the hospital is located, a doctor of dental surgery, dental medicine, or podiatric medicine. Removal of the leader of the medical staff may only occur in accordance with medical staff bylaws, rules or regulations.
If the hospital uses a unified medical staff, only one individual may be responsible for the organization and conduct of the unified medical staff; that individual may or may not hold privileges and practice at the hospital being surveyed. When the individual does not
practice at the hospital being surveyed and it is necessary to interview this individual as part of a survey, a telephone interview must be arranged.
Executive Committee
The medical staff bylaws, rules and regulations may provide for the members of the medical staff to select a smaller executive committee to which it delegates many of the functions of the medical staff, in order to increase the efficiency of its operations. If the medical staff has an executive committee, the majority of the voting members must be doctors of medicine (MDs) or osteopathy (DOs).
"For Information Only – Not Required/ Not to be Cited"
--A hospital is not required to have an executive committee. However, use of an executive committee may facilitate efficient and effective functioning of the medical staff in hospitals systems that use a unified medical staff, particularly if the executive committee includes members from each hospital that shares the unified medical staff.--
Accountability of the medical staff
The medical staff must be accountable to the hospital’s governing body for the quality of medical care provided to the patients. The medical staff demonstrates its accountability through its exercise of its duties related to appointment of members of the medical staff, its conduct of reappraisals, including peer reviews, its approval of policies and procedures as required under other conditions of participation and its leadership participation in the organization and implementation of the hospital’s quality assessment and performance improvement program required in accordance with §482.21.
If the hospital uses a unified medical staff, the medical staff continues to be accountable for the quality of care in each separately certified hospital that uses the unified medical staff. -
A-0348 482.22(b)(4) - If a hospital is part of a hospital system consisting of multiple separately certified hospitals and the system elects to have a unified and integrated medical staff for its member hospitals, after determining that such a decision is in accordance with all applicable State and local laws, each separately certified hospital must demonstrate that:….
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Interpretive Guidelines §482.22(b)(4)
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. In other words, as long as the requirements of §482.22(b)(4) are met, it is not necessary for each separately-certified hospital within the system to have its own distinct medical staff organization and structure, including hospital-specific medical staff bylaws, rules and requirements, hospital-specific medical staff leadership, hospital-specific credentialing and peer review, etc. Instead, it may use one medical staff organization and structure for multiple hospitals, so long as all of the requirements of this section are met. However, separately certified hospitals which share a single unified and integrated medical staff must also share a system governing body, in accordance with the provisions of §482.12, since only one governing body may carry out the governing body’s medical staff responsibilities for a unified medical staff.
Note that a multi-campus hospital that has several inpatient campuses that are provider-based, remote locations of the hospital is not a multi-hospital system. A multi-campus hospital is one certified hospital, not several separately certified hospitals. A multi-campus hospital may not have separate medical staffs at each campus, since each hospital must have no more than one medical staff. A multi-campus hospital with one medical staff separate from that of other certified hospitals is not employing a unified medical staff as that term is used in this regulation. However, a multi-campus hospital that is part of a hospital system consisting of multiple separately certified hospitals may share a unified medical staff with other separately certified hospitals within the system.
It should also be noted that a hospital system that includes certain types of hospitals, i.e., Hospitals-within-Hospitals or Hospital Satellites, that are being paid under a Medicare payment system other than the Hospital Inpatient Prospective Payment System (IPPS) might jeopardize the Medicare payment status of those excluded hospitals if it owns both the tenant and host hospitals and uses a unified medical staff for both. This is the case even if the requirements of §482.22(b)(4) are met. However, surveyors do not assess compliance with or enforce the Medicare payment regulations that govern Hospitals-within-
Hospitals or Hospital Satellites.
When granting practitioners privileges to provide patient care, a hospital’s governing body must specify those hospitals in the system where the privileges apply, since, in addition to the qualifications of individual practitioners, the services provided at each hospital must be considered when granting privileges. For example, psychiatric hospitals do not offer surgical services, labor and delivery services, nuclear medicine, etc., so it would not be appropriate for practitioners practicing in these areas to hold privileges at psychiatric hospitals in a multi-hospital system that uses a unified medical staff. Likewise if a multi-hospital system covers a wide geographic area, many of its practitioners may have no interest in practicing on site at hospitals that are distant from their usual practice location(s). In addition, in order for the acceptance or opt-out provisions of §482.22(b)(4)(i) and (ii) to be workable, privileges must be granted on a hospital-specific basis to practitioners who actually practice or are likely to practice at the hospital.
The governing body in a multi-hospital system must elect to exercise this option. Since a number of hospital systems interpreted the Medical Staff CoP to permit a unified and integrated medical staff prior to publication of the final rule at §482.22(b)(4) on May 12, 2014 or its effective date on July 11, 2014, the existence of a unified medical staff prior to July 11, 2014 is considered evidence of the hospital’s governing body’s election of this option.
• This does not relieve the governing body of the responsibility to conduct a review of all applicable State and local laws, including regulations, and make a determination that use of a unified medical staff that is shared by multiple hospitals does not conflict with those laws. The hospital must maintain documentation of this determination by its governing body.
• Nor does it relieve the governing body of the obligation to inform the medical staff of the right to vote to opt out of a unified medical staff arrangement. (See discussion of §482.22(b)(4)(ii), which requires notification of all members of this right. Failure to comply would be cited under the tag for §482.22(b)(4)(ii).)
If a hospital is part of a multi-hospital system that wishes to establish a unified medical staff for some or all of its separately certified hospitals after the July 11, 2014 effective date of the final rule at §482.22(b)(4), then the hospital’s system governing body must document in writing its decision to elect to use the unified medical staff option, conditioned upon acceptance of a unified medical staff by the hospital’s medical staff in accordance with §482.22(b)(4)(i).The governing body must also document its determination that such election does not conflict with State or local laws, including regulations.
Surveyors are not expected, as part of their assessment of compliance with the Medicare CoPs, to evaluate whether the governing body’s determination of compliance with State and local law is accurate. This would be handled by the appropriate State or local authorities, or, if the State Survey Agency is the appropriate authority, under its State licensure or other authority and not as part of a Federal survey. -
A-0349 482.22(b)(4)(i) The medical staff members of each separately certified hospital in the system (that is, all medical staff members who hold specific privileges to practice at that hospital) have voted by majority, in accordance with medical staff bylaws, either to accept a unified and integrated medical staff structure or to opt out of such a structure and to maintain a separate and distinct medical staff for their respective hospital;
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Interpretive Guidelines §482.22(b)(4)(i)
The decision for a particular certified hospital in a multi-hospital system to use a unified medical staff is a joint one arrived at by the:
• Election of the unified medical staff option by the hospital’s governing body; and
• Acceptance by a majority of the medical staff members who hold privileges to practice at that particular hospital, voting in accordance with the medical staff bylaws.
The medical staff of each hospital also has the option to opt out of an existing unified medical staff, when a majority of the medical staff members who hold privileges to practice at that particular hospital, voting in accordance with the medical staff bylaws, vote to do so.
For purposes of voting on whether to accept or opt out of a unified medical staff, the term “privileges to practice at that particular hospital” is interpreted to mean only those practitioners who hold privileges to practice on-site at the hospital. Practitioners who hold only telemedicine privileges at a hospital are not to be included when identifying which practitioners are eligible to vote nor what constitutes a majority of the practitioners holding privileges at the hospital.
A hospital that is part of a hospital system is expected to have medical staff bylaws, rules and requirements that address the regulatory requirements of §482.22(b)(4)(i) – (iv) related to using a unified medical staff, including the processes under the bylaws for voting to accept or opt out of a unified medical staff. This is the case even if the hospital currently does not use a unified medical staff.
If the hospital uses a unified medical staff, depending on State law requirements, the unified medical staff bylaws, rules and requirements required at §482.22(b)(4)(ii) may substitute for hospital-specific medical staff bylaws, rules and requirements. However, CMS recognizes that the process of amending bylaws can be a lengthy one. Hospitals that were part of a hospital system using a unified medical staff as of July 11, 2014 are expected to have initiated the process before December 31, 2014 to effect the necessary amendments, even if the process is not completed until after that date. Likewise, when a
hospital is acquired by a system but maintains separate participation in Medicare, if the hospital’s governing body elects to use a unified medical staff and the medical staff accepts such election, the hospital is expected to initiate the necessary changes to its medical staff bylaws, rules and requirements no later than six months after the effective date of its acquisition.
In establishing medical staff bylaws governing medical staff voting on the questions of acceptance of, or opting out of, a unified medical staff, the medical staff and the governing body, which must approve the revised bylaws in accordance with §482.12(a)(4), have the flexibility to determine the details of the voting process, such as how an acceptance or opt-out vote can be requested; whether all categories of members holding privileges to practice on-site at the hospital are afforded medical staff voting rights; whether voting will be in writing and open or by secret ballot, etc. However, a hospital may not set up bylaws that unduly restrict the rights of medical staff members when voting on the issue of accepting or opting out of a unified medical staff structure. For example:
Hospitals may not establish different criteria as to which categories of medical staff members have voting rights with respect to a vote to accept or opt out of a unified medical staff than are used for other amendments to the medical staff’s bylaws, except as required under the regulation at §482.22(b)(4) that only members holding privileges to practice at the hospital may vote. (See also the discussion below concerning delegation of authority to the medical staff executive committee.)
Hospitals may not require as a condition for holding an opt-out vote that there be a petition signed by the same number of voting members as would be required for a successful vote to opt out.
Hospitals may require for a successful acceptance or opt-out vote a “supermajority”, that is, a majority that is greater than a simple majority of more than fifty percent of the medical staff members with voting rights holding privileges to practice at the hospital, so long as the same type of supermajority is otherwise generally required to amend the medical staff’s bylaws, rules and requirements.
In the case where a hospital system has a unified medical staff and members of the staff at a hospital in the system exercise their right to hold a vote on the question of opting out, the hospital may not permit delegation of an opt-out decision to the unified medical staff’s executive committee. This is the case even when the executive committee is otherwise delegated authority to amend unified medical staff bylaws, rules and requirements that it recommends for approval to the governing body. In cases where the bylaws permit such delegation to the unified medical staff’s executive committee for other purposes, a “majority” for purposes of conducting a vote on whether to opt out of a unified medical staff consists of a simple majority, that is, any number which is greater than fifty percent, of the medical staff members practicing at the hospital who have voting privileges.
o On the other hand, in the case where a hospital that is part of a hospital system but has a separate medical staff is holding a vote on whether to accept participating in a unified medical staff, a hospital may permit a vote by members of the hospital’s medical staff executive committee only, if this is consistent with the hospital’s medical staff bylaws governing amendments in effect at the time of the vote.
A hospital may establish a minimum interval between acceptance or opt-out votes, such as not permitting a vote more than once every two years. However, a minimum interval between votes longer than two years might unduly restrain the rights of the members of the medical staff and would not be permissible.
It is not expected that the medical staff bylaws, rules and requirements that were in effect as of July 11, 2014 would address the issue of a unified medical staff, nor the process of voting by medical staff members at each hospital to accept or opt out of a unified medical staff. Although it is expected that the medical staff bylaws, rules and requirements of hospitals that are part of a hospital system will be amended in a timely fashion as discussed above, this does not mean that a vote to accept or opt out of a unified medical staff may not take place prior to enactment of such amendments.
Voting is governed by the hospital’s medical staff bylaws in effect at the time of the vote, except that only voting members of the medical staff who hold privileges to practice on-site at that hospital may participate in the vote. With respect to what constitutes a “majority,” the provisions of the bylaws governing voting rights and voting procedures at the time of the vote apply. However, as discussed above, in the case of a vote to opt-out of a unified medical staff, the vote may not be delegated to the executive committee of the unified medical staff.
Since a number of hospital systems interpreted the Medical Staff CoP to permit a unified medical staff prior to publication of the final rule at §482.22(b)(4) on May 12, 2014 or its effective date of July 11, 2014, in the case of a hospital’s use of a unified medical staff which began prior to the latter date, it is not necessary for the hospital to hold a vote among the members of the medical staff who hold privileges at that hospital to determine whether the majority accepts the continued use of a unified medical staff. However, the governing body is expected to formally notify the medical staff practicing at each hospital of its preference to continue using a unified medical staff arrangement, as well as of the right of the medical staff holding privileges at each hospital to vote to opt out of the unified medical staff.
If the system governing body of a hospital that is part of the multi-hospital system but which has a separate medical staff elects after July 11, 2014 to create a system unified medical staff structure and/or to include the hospital’s medical staff in an already existing unified medical staff structure, the hospital must arrange for a vote by medical staff members, in accordance with the medical staff bylaws, on whether or not to accept use of a unified medical staff for their hospital. The hospital may not use a unified medical staff unless a majority of its medical staff members holding voting rights vote, in accordance with the hospital’s medical staff bylaws, to accept a unified medical staff.
Even if a majority of a hospital’s medical staff has voted to use a unified medical staff in the past, the members of the unified medical staff with voting rights and holding privileges to practice on-site at that hospital still retain the right to hold a vote to opt out of the unified medical staff structure at a future date. If a majority of the staff with voting rights and holding privileges at that hospital vote, in accordance with the unified medical staff’s bylaws, to opt out, then the hospital must establish a separate medical staff. -
A-0350 482.22(b)(4)(ii) The unified and integrated medical staff has bylaws, rules, and requirements that describe its processes for self-governance, appointment, credentialing, privileging, and oversight, as well as its peer review policies and due process rights guarantees, and which include a process for the members of the medical staff of each separately certified hospital (that is, all medical staff members who hold specific privileges to practice at that hospital) to be advised of their rights to opt out of the unified and integrated medical staff structure after a majority vote by the members to maintain a separate and distinct medical staff for their hospital;
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Interpretive Guidelines §482.22(b)(4)(ii)
A hospital that uses a unified medical staff must ensure that the unified medical staff has one set of bylaws, rules and requirements that describe the medical staff’s processes for self-governance, appointment, credentialing, privileging, oversight, peer review, and due process rights guarantees. Consistent with the requirements for a system governing body in §482.12, the documentation of the bylaws, rules and requirements that apply to the unified medical staff must identify each separately certified hospital that has elected to use a unified medical staff and which, therefore, is covered by the unified medical staff bylaws, rules and regulations. Depending on State law requirements, the unified medical staff bylaws, rules and requirements may be in addition to or instead of hospital-specific medical staff bylaws, rules and requirements. The unified medical staff’s bylaws, rules and requirements must not conflict with any of the specific requirements for medical staff found elsewhere in §482.12 or §482.22, or under any other hospital CoPs which assign responsibilities to the hospital’s medical staff.
The unified medical staff’s bylaws, rules and requirements addressing its self-governance processes must provide for a process by which members of the unified medical staff holding privileges to practice on site at each separately certified hospital are advised that they have the right to vote on whether to opt out of participation in the unified medical staff, and that if a majority vote to opt out, then the hospital must establish a separate medical staff. At a minimum, the hospital must advise medical staff members in writing of their right to vote by majority to opt out when medical staff membership is first granted, and when it is renewed.
The bylaws must address the process by which a vote to opt out of the unified medical staff is conducted. In establishing the unified medical staff bylaws governing opting out, the unified medical staff, and the system governing body, which must approve the medical staff’s bylaws, rules or regulations in accordance with §482.12(a)(4), have the flexibility to determine the details of the voting process, such as how an acceptance or opt-out vote can be requested; whether all categories of members holding privileges to practice on-site at the hospital are afforded medical staff voting rights; whether voting will be in writing and open or by secret ballot, etc. However, the unified medical staff and system governing body may not set up bylaws that unduly restrict the rights of medical staff members at each separately certified hospital to vote whether to accept or opt out of a unified medical staff structure. For example:
The bylaws, rules and requirements may not establish different criteria as to which categories of medical staff members have voting rights with respect to a vote to accept or opt out of a unified medical staff than are used for any other type of voting the medical staff engages in, except as required under the regulation at §482.22(b)(4) that only members holding privileges to practice at the hospital may vote. (See also the discussion below concerning delegation of authority to the medical staff executive committee.)
The bylaws, rules and requirements may not require as a condition for holding an opt-out vote that there be a petition signed by the same number of voting members as would be required for a successful vote to opt out.
The bylaws, rules and requirements may require for a successful acceptance or opt-out vote a “super-majority,” that is, a majority that is greater than a simple majority of more than fifty percent of the medical staff members with voting rights holding privileges to practice at the hospital, so long as the same type of supermajority is otherwise required to amend the unified medical staff’s bylaws, rules and requirements.
In the case where a hospital system has a unified medical staff and members of the staff at a hospital in the system exercise their right to hold a vote on the question of opting out, the unified medical staff bylaws may not permit delegation of an opt-out decision to the unified medical staff’s executive committee. This is the case even when the executive committee is otherwise delegated authority to amend unified medical staff bylaws, rules and requirements that it recommends for approval to the governing body. In cases where the bylaws permit such delegation to the unified medical staff’s executive committee for other purposes, a “majority” for purposes of conducting a vote on whether to opt out of a unified medical staff consists of a simple majority, that is, any number which is greater than fifty percent of the medical staff members practicing at the hospital who have voting privileges.
The bylaws, rules and requirements may establish a minimum interval between acceptance or opt-out votes, such as not permitting a vote more than once every two years. However, minimum interval between votes longer than two years might unduly restrain the rights of the members of the medical staff and would not be permissible. -
A-0351 482.22(b)(4)(iii) The unified and integrated medical staff is established in a manner that takes into account each member hospital’s unique circumstances and any significant differences in patient populations and services offered in each hospital;
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Interpretive Guidelines §482.22(b)(4)(iii)
The separately certified hospitals belonging to a multi-hospital system and using a single unified medical staff may be very different from each other, presenting different needs and challenges for the medical staff. As a result, the unified medical staff is expected to take these differences into account rather than using a one-size-fits-all approach for all of its policies and procedures. For example, a multi-hospital system may:
• Consist of a mixture of different types of hospitals, such as short-term acute care hospitals, psychiatric hospitals, rehabilitation hospitals, children’s hospitals, and long-term care hospitals. As a result, they would offer different types of services to different patient populations. This could have implications for medical staff functions such as the periodic review of credentials and privileges and ongoing peer review of the quality of medical care. It could also have implications for other responsibilities the medical staff has under various CoPs. For example, the medical staff has a key role in the development and oversight of the use of standing orders/protocols, but these orders/protocols may need to be specific to each hospital, reflecting the types of services a hospital offers and its patient population;
Consist of hospitals that differ in size, ranging from comparatively small hospitals in rural areas, or which provide specialized rehabilitation or long term care hospital services, to very large short term acute care service hospitals. Such differences could have implications for various medical staff requirements, such as on-call requirements.
Consist of hospitals that differ as to whether they are teaching hospitals or not, which would have implications for policies concerning the roles and supervision of residents.
Consist of hospitals that are located in different states which have different licensure requirements affecting the organization and composition of the medical staff. For example, in one state it might be permissible for non-physician practitioners to be members of the medical staff, while in another the medical staff is limited to physicians.
On the other hand, a multi-hospital system may have a conscious strategy of having hospitals that are very similar to each other in terms of size, services, patient populations served, and type of location. In this case, the unified medical staff would have fewer challenges in addressing the needs of each hospital, and might have more policies that are uniform across the medical staff.
In all cases the hospital’s leadership and the medical staff leadership must be able to explain how the way in which the unified medical staff is organized and functions takes account of and responds to the unique circumstances of the hospital that is being surveyed. -
A-0352 482.22(b)(4)(iv) The unified and integrated medical staff establishes and implements policies and procedures to ensure that the needs and concerns expressed by members of the medical staff, at each of its separately certified hospitals, regardless of practice or location, are given due consideration, and that the unified and integrated medical staff has mechanisms in place to ensure that issues localized to particular hospitals are duly considered and addressed.
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Interpretive Guidelines §482.22(b)(4)(iv)
The hospital’s 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 hospital. This provision 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., since these matters are addressed under the requirements at §482.22(a) and (c) as well as §482.22(b)(4)(ii). 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. For example, physicians practicing in a children’s hospital may have concerns about having protocols for medication administration that reflect specific pediatric patient concerns, or physicians practicing in a small rural hospital may have concerns about how to get timely telemedicine consults from their colleagues in urban areas.
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.
482.22(c) Standard: Medical Staff Bylaws
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A-0353 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must:
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Interpretive Guidelines §482.22(c)
The medical staff must regulate itself by bylaws that are consistent with the requirements of this and other CoPs that mention medical staff bylaws, as well as State laws. The bylaws must be enforced and revised as necessary. -
A-0354 482.22(c)(1) Be approved by the governing body.
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Interpretive Guidelines §482.22(c)(1)
Medical staff bylaws and any revisions of those bylaws must be submitted to the governing body for approval. The governing body has the authority to approve or disapprove bylaws suggested by the medical staff. The bylaws and any revisions must be approved by the governing body before they are considered effective. -
A-0355 482.22(c)(2) Include a statement of the duties and privileges of each category of medical staff (e.g., active, courtesy, etc.)
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Interpretive Guidelines §482.22(c)(2)
The medical staff bylaws must state the duties and scope of medical staff privileges each category of practitioner may be granted. Specific privileges for each category must clearly and completely list the specific privileges or limitations for that category of practitioner. The specific privileges must reflect activities that the majority of practitioners in that category can perform competently and that the hospital can support.
Although the medical staff bylaws must address the duties and scope for each category of practitioner, this does not mean that each individual practitioner within the category may automatically be granted the full range of privileges. It cannot be assumed that every practitioner can perform every task/activity/privilege that is specified for the applicable category of practitioner. The individual practitioner’s ability to perform each task/activity/privilege must be individually assessed. -
A-0356 482.22(c)(3) Describe the organization of the medical staff.
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Interpretive Guidelines §482.22(c)(3)
The medical staff bylaws must describe the organizational structure of the medical staff, and lay out the rules and regulations of the medical staff to make clear what are acceptable standards of patient care for all diagnostic, medical, surgical, and rehabilitative services. -
A-0357 482.22(c)(4) Describe the qualifications to be met by a candidate in order for the medical staff to recommend that the candidate be appointed by the governing body.
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Interpretive Guidelines §482.22(c)(4)
The medical staff bylaws must describe the qualifications to be met by a candidate for medical staff membership/privileges in order for the medical staff to recommend the candidate be approved by the governing body. The bylaws must describe the privileging process to be used in the hospital. The process articulated in the medical staff bylaws must include criteria for determining the privileges that may be granted to individual practitioners and a procedure for applying the criteria to individual practitioners that considers:
• Individual character;
• Individual competence;
• Individual training;
• Individual experience; and
• Individual judgment.
The medical staff may not rely solely on the fact that a MD/DO is, or is not, board-certified in making a judgment on medical staff membership. This does not mean that the medical staff is prohibited from requiring board certification when considering a MD/DO for medical staff membership; only that such certification is not the only factor that the hospital considers. After analysis of all of the criteria, if all criteria are met except for board certification, the medical staff has the discretion to not recommend that individual for medical staff membership/privileges.
The bylaws must apply equally to all practitioners in each professional category of practitioners.
The medical staff then recommends individual candidates that meet those requirements to the governing body for appointment to the medical staff. -
A-0358 482.22(c)(5) Include a requirement that: (i) A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. The medical history and physical examination must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oromaxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy.
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Interpretive Guidelines §482.22(c)(5)(i)
The purpose of a medical history and physical examination (H&P) is to determine whether there is anything in the patient's overall condition that would affect the planned course of the patient's treatment, such as a medication allergy, or a new or existing co-morbid condition that requires additional interventions to reduce risk to the patient.
The Medical Staff bylaws must include a requirement that an H&P be completed and documented for each patient no more than 30 days prior to or 24 hours after hospital admission or registration, but prior to surgery or a procedure requiring anesthesia services. The H&P may be handwritten or transcribed, but always must be placed within the patient’s medical record within 24 hours of admission or registration, or prior to surgery or a procedure requiring anesthesia services, whichever comes first.
An H&P is required prior to surgery and prior to procedures requiring anesthesia services, regardless of whether care is being provided on an inpatient or outpatient basis. (71 FR 68676) An H&P that is completed within 24 hours of the patient’s admission or registration, but after the surgical procedure, procedure requiring anesthesia, or other procedure requiring an H&P would not be in compliance with this requirement.
The medical history and physical examination must be completed and documented by a physician (as defined in section 1861(r) of the Act), oromaxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy.
Section 1861(r) defines a physician as a:
• Doctor of medicine or osteopathy;
• Doctor of dental surgery or of dental medicine;
• Doctor of podiatric medicine;
• Doctor of optometry; or a
• Chiropractor.
In all cases the practitioners included in the definition of a physician must be legally authorized to practice within the State where the hospital is located and providing services within their authorized scope of practice. In addition, in certain instances the Social Security Act attaches further limitations as to the type of hospital services for which a practitioner is considered to be a “physician.” For example, a chiropractor is considered a physician only with respect to treatment by means of manual manipulation of the spine (to correct a subluxation).
Other qualified licensed individuals are those licensed practitioners who are authorized in accordance with their State scope of practice laws or regulations to perform an H&P and who are also formally authorized by the hospital to conduct an H&P. Other qualified licensed practitioners could include nurse practitioners and physician assistants.
More than one qualified practitioner can participate in performing, documenting, and authenticating an H&P for a single patient. When performance, documentation, and authentication are split among qualified practitioners, the practitioner who authenticates the H&P will be held responsible for its contents. (71 FR 68675)
A hospital may adopt a policy allowing submission of an H&P prior to the patient’s hospital admission or registration by a physician who may not be a member of the hospital's medical staff or who does not have admitting privileges at that hospital, or by a qualified licensed individual who does not practice at that hospital but is acting within his/her scope of practice under State law or regulations. Generally, this occurs where the H&P is completed in advance by the patient’s primary care practitioner. (71 FR 68675)
When the H&P is conducted within 30 days before admission or registration, an update must be completed and documented by a licensed practitioner who is credentialed and privileged by the hospital’s medical staff to perform an H&P. (71 FR 68675) (See discussion of H&P update requirements at 42 CFR 482.22(c)(5)(ii).)
Surveyors should cite noncompliance with the requirements of 42 CFR
482.22(c)(5) for failure by the hospital to comply with any of this standard's components. -
A-0359 482.22(c)(5) Include a requirement that: (ii) An updated examination of the patient, including any changes in the patient's condition, be completed and documented within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination are completed within 30 days before admission or registration. The updated examination of the patient, including any changes in the patient's condition, must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oromaxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy.
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Interpretive Guidelines 482.22(c)(5)(ii)
The Medical Staff bylaws must include a requirement that when a medical history and physical examination has been completed within 30 days before admission or registration, an updated medical record entry must be completed and documented in the patient's medical record within 24 hours after admission or registration. The examination must be conducted by a licensed practitioner who is credentialed and privileged by the hospital’s medical staff to perform an H&P. In all cases, the update must take place prior to surgery or a procedure requiring anesthesia services. The update note must document an examination for any changes in the patient's condition since the patient's H&P was performed that might be significant for the planned course of treatment. The physician or qualified licensed individual uses his/her clinical judgment, based upon his/her assessment of the patient’s condition and co-morbidities, if any, in relation to the patient’s planned course of treatment to decide the extent of the update assessment needed as well as the information to be included in the update note in the patient’s medical record.
If, upon examination, the licensed practitioner finds no change in the patient's condition since the H&P was completed, he/she may indicate in the patient's medical record that the H&P was reviewed, the patient was examined, and that "no change" has occurred in the patient's condition since the H&P was completed (71 FR 68676). Any changes in the patient’s condition must be documented by the practitioner in the update note and placed in the patient’s medical record within 24 hours of admission or registration, but prior to surgery or a procedure requirement anesthesia services. Additionally, if the practitioner finds that the H&P done before admission is incomplete, inaccurate, or otherwise unacceptable, the practitioner reviewing the H&P, examining the patient, and completing the update may disregard the existing H&P, and conduct and document in the medical record a new H&P within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia. -
A-0363 482.22(c)(6) Include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges. For distant-site physicians and practitioners requesting privileges to furnish telemedicine services under an agreement with the hospital, the criteria for determining privileges and the procedure for applying the criteria are also subject to the requirements in §482.12(a)(8) and (a)(9), and §482.22(a)(3) and (a)(4).
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Interpretive Guidelines §482.22(c)(6)
All patient care is provided by or in accordance with the orders of a physician or practitioner who meets the medical staff criteria and procedures for the privileges granted, who has been granted privileges in accordance with those criteria by the governing body, and who is working within the scope of those granted privileges.
Privileges are granted by the hospital’s governing body to individual practitioners based on the medical staff’s review of that individual practitioner’s qualifications and the medical staff’s recommendations for that individual practitioner to the governing body. However, in the case of telemedicine physicians and practitioners providing telemedicine services under an agreement, the governing body has the option of having the medical staff rely upon the credentialing and privileging decisions of the distant-site hospital or telemedicine entity with which the hospital has entered into an agreement. When the governing body has exercised this option, the medical staff’s bylaws must include a provision allowing the medical staff to rely upon the credentialing and privileging decisions of a distant-site hospital or telemedicine entity when that distant-site hospital or entity is required under the terms of its agreement with the hospital to employ a credentialing and privileging process that conforms to the provisions of §482.12(a)(8) and (a)(9), and §482.22(a)(3) and (a)(4). -
A-0364 482.22(d) The medical staff should attempt to secure autopsies in all cases of unusual deaths and of medical-legal and educational interest. The mechanism for documenting permission to perform an autopsy must be defined. There must be a system for notifying the medical staff, and specifically the attending practitioner, when an autopsy is being performed.
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