Integrating Disparate Medical Staffs Blog Feature
Richard Curtis RN, MS, HACP

By: Richard Curtis RN, MS, HACP on September 17th, 2014

Print/Save as PDF

Integrating Disparate Medical Staffs

Healthcare Provider Credentialing

MEdical Staff Services, Medical Service Professionals, AccreditingFor years, multi-hospital systems have looked for ways to consolidate medical staffs only to be stymied by an age old Centers for Medicare and Medicaid Services (CMS) requirement that each hospital have its own separate and distinct organized medical staff.

All that changed in July of 2014 when CMS announced revisions for Acute Care and Critical Access hospitals. Under the new guidance, CMS will allow for either a unique medical staff for each hospital or for a unified and integrated medical staff shared by multiple hospitals within a hospital system.

Accrediting organizations have moved quickly to align their standards with CMS. In order for hospital systems to take advantage of the allowance, four requirements must be met:

  1. Members holding privileges at the medical staff of each hospital must vote on whether or not they wish to integrate into a single medical staff. If a medical staff does not wish to integrate, they must be allowed to remain separate and distinct.

  2. For those medical staffs that choose to integrate, they must form a common set of bylaws, rules, and requirements that describe processes for self-governance, appointment, credentialing, privileging, and oversight, as well as its peer review policies and due process rights guarantees.

  3. The integrated medical staff must be established in a manner that takes into account each hospital’s unique circumstances and any significant differences in patient populations and services offered in each hospital.

  4. The integrated medical staff must give due consideration to the needs and concerns of its members regardless of practice or location, and mechanisms must be in place to assure that issues localized to particular hospitals are considered and addressed.

There’s a case to be made for an integrated medical staff. Efforts to adopt evidence-based practices and standardize care processes are more efficient when managed through a single medical staff structure versus the often unwieldy and time consuming process of working with multiple medical staffs. To be sure, the road towards creating a single integrated medical staff will be one full of challenges and unforeseen obstacles. At least, though, hospital systems now finally have the ability to embark on this long awaited journey.


About Richard Curtis RN, MS, HACP

Rick Curtis is Chief Executive Officer for CIHQ – the nation’s newest CMS approved accreditor for acute care hospitals.. Rick is nationally recognized as an expert on accreditation standards and the certification survey process. Rick's clinical background is in critical care nursing with a focus in cardiovascular service lines. He has held both clinical and executive management level positions in Quality, Risk, Education, Infection Control, and Regulatory Compliance. Rick is nationally certified in healthcare accreditation, and serves as the Chair of the Board of Examiners for the Healthcare Accreditation Certification Program (HACP). Rick received his Nursing Degree from the University of Hawaii and has a Master of Science Degree in Health Services Administration. Rick is a resident of Round Rock, TX.