what is Medical Staff Management?

MeetingManagementCredentialing

MedicalLibrary

ContinuingMedical

Education

GraduateMedical

Education

CustomerService

Medical Staff Management is …

Medical Staff Management …

saves patient lives …

how does

credentialing save lives?

Jeffrey Askanazi, MDAlan Zarkin, MDMichael Swango, MD Gerald Barnes, MD

Dean Faiello, MD Jayant Patel, MD

David Tremoglie Neel Sheth

Dennis Roark, MD Harold Shipman, MD

ten newsworthy doctors

Jeffrey Askanazi, MDAlan Zarkin, MDMichael Swango, MD Gerald Barnes, MD

Dean Faiello, MD Jayant Patel, MD

David Tremoglie Neel Sheth

Dennis Roark, MD Harold Shipman, MD

killed 35 patientsterm’d from OSUH, VA Sioux Falls, and SUNY

Jeffrey Askanazi, MDAlan Zarkin, MDMichael Swango, MD Gerald Barnes, MD

Dean Faiello, MD Jayant Patel, MD

David Tremoglie Neel Sheth

Dennis Roark, MD Harold Shipman, MD

carved initials onto patient after c-section; numerous

other complaints about erratic behavior

Jeffrey Askanazi, MDAlan Zarkin, MDMichael Swango, MD Gerald Barnes, MD

Dean Faiello, MD Jayant Patel, MD

David Tremoglie Neel Sheth

Dennis Roark, MD Harold Shipman, MD

33 counts of Medicare fraud – unnecessary

procedures

Jeffrey Askanazi, MDAlan Zarkin, MDMichael Swango, MD Gerald Barnes, MD

Dean Faiello, MD Jayant Patel, MD

David Tremoglie Neel Sheth

Dennis Roark, MD Harold Shipman, MD

physician impersonator for 20 years in California;

at least one death

Jeffrey Askanazi, MDAlan Zarkin, MDMichael Swango, MD Gerald Barnes, MD

Dean Faiello, MD Jayant Patel, MD

David Tremoglie Neel Sheth

Dennis Roark, MD Harold Shipman, MD

physician impersonator doing laser procedures;

murdered one patient

Jeffrey Askanazi, MDAlan Zarkin, MDMichael Swango, MD Gerald Barnes, MD

Dean Faiello, MD Jayant Patel, MD

David Tremoglie Neel Sheth

Dennis Roark, MD Harold Shipman, MD

charged with murder and negligence in 87

patient deaths

Jeffrey Askanazi, MDAlan Zarkin, MDMichael Swango, MD Gerald Barnes, MD

Dean Faiello, MD Jayant Patel, MD

David Tremoglie Neel Sheth

Dennis Roark, MD Harold Shipman, MD

surgeon impersonator for almost 10 years in

Michigan!

Jeffrey Askanazi, MDAlan Zarkin, MDMichael Swango, MD Gerald Barnes, MD

Dean Faiello, MD Jayant Patel, MD

David Tremoglie Neel Sheth

Dennis Roark, MD Harold Shipman, MD

murdered 260 patients via opiate injections

Jeffrey Askanazi, MDAlan Zarkin, MDMichael Swango, MD Gerald Barnes, MD

Dean Faiello, MD Jayant Patel, MD

David Tremoglie Neel Sheth

Dennis Roark, MD Harold Shipman, MD

impersonated a psychiatrist with 100’s of patients in Philadelphia

Jeffrey Askanazi, MDAlan Zarkin, MDMichael Swango, MD Gerald Barnes, MD

Dean Faiello, MD Jayant Patel, MD

David Tremoglie Neel Sheth

Dennis Roark, MD Harold Shipman, MD

physician impersonator in Ohio residency

program

when bad

or imposter

physicians slip through the system,

patients pay the price!

what is credentialing?

how does it stop bad / imposter physicians

from reaching patients?

credentialing is ….

applications and forms

Federal law requires that hospitals develop applications and privilege request forms for new and

re-applying physicians

credentialing is …

getting your hands dirty

and verifying with the “primary source” the following: (1) Medical School, (2) Internship, (3) Residency, (4) Fellowship, (5) Board Certification, (6) Fluoroscopy, (7) Medical Licensure, (8) ECFMG, (9) DEA, (10) Insurance [malpractice claims history], (11) current and previous hospital affiliations and work sites, (12) peer references, (13) NPDB, (14) OIG, (15) GSA, (16) Megan’s Law, (17) CME, (18) PPD / health status; and (19) current clinical competency (activity logs from current and previous hospitals)

credentialing is …

reading between the lines Verifying everything claimed with everything verified

credentialing … saves lives

what else is Medical Staff Management?

meeting management …

“if it’s not documented it

didn’t happen”

Board of Trustees Medical Executive Committee

Department of Anesthesia

Department of Pathology

Department of Pediatrics

Department of Radiology

Department of Surgery

Multidisciplinary Peer Review Committee

Department of Medicine

Department of Obstetrics & Gynecology

Performance Improvement Committee

Pharmacy & Therapeutics Committee

Physician Well-Being Committee

Utilization Management Committee

Bylaws Committee

Cancer Committee

Credentials Committee

Ethics Committee

Presidents Council

Patient Safety Subcommittee

AMI+CHF Core Measure Team

PneumoniaCore Measure Team

SCIP Core Measure Team

Medication Usage and Safety Team

Quality Council

Departments and Committees

Infection Control Committee

Health Information Committee

Interdisciplinary Practice Committee

CME/GME/Library Committee

This is what Medical Staff Management “documents”

minutes are what regulators review to

evaluate evidence of compliance.

anything else?

MedicalLibrary

ContinuingMedical

Education

GraduateMedical

Education

- 100 hours req’d every 4 years- weekly activities

- medical student, resident and fellow rotations

- over 100 medical journals and 2 databases

orientation

how can I tell if my medical staff is saving patient lives?

8710the

a medical staff management professional consultancy

btrice1@cox.net

guenther450@gmail.com