What is Medical Staff’s Role in Practitioner Evaluation?

Hospitals are entrusted with the responsibility of maintaining the highest standards of patient care. A key component of this duty falls to the Medical Staff, which oversees the evaluation and privileging of healthcare practitioners. This process ensures that all providers, whether new applicants or current members, possess the necessary qualifications and competencies to perform their medical duties safely and effectively.

To uphold quality standards, the Medical Staff must conduct appraisals of individual practitioners at least every 24 months at a minimum. These evaluations serve two critical purposes:

First medical staff must review current practitioners to determine whether their hospital privileges should continue, be revised, or discontinued. This takes into account changing medical technology and developments in their field as well as their health and other factors that contribute to the ability to perform to current standards of care.

The criteria that is universally applied includes a review of a doctor’s surrent work practice and experience. Has the practice falling off to a degree that the doctor’s skills may get rusty? Other factors address what continuing training and specialized training the doctor has received that is relevant to hospital duties. The review can and should consider patient outcomes and quality of work. In an area that is sometimes fraught with contention, medical staff also reviews compliance with medical staff rules and hospital policies

Importantly, board certification, licensure, or general certification alone does not automatically grant privileges. Instead, each provider must demonstrate the ability to perform specific medical tasks or procedures.

The Medical Staff and Governing Body work together to ensure every healthcare provider is competent in their granted privileges. What this means in practice is that the Governing Body rubber stamps what medical staff does. On paper, what is supposed to happen is Medical Staff makes formal recommendations, which the Governing Body reviews before making final privileging decisions.