The Medical Staff Credentials Committee has a tough job. This group of volunteer physician leaders and the staff members who support them must “these days” often tell medical staff applicants that they no longer meet the criteria for the membership category they seek. But there is a future here for the willing, and I’ll get to that in a moment.

The criteria for membership have evolved along with changes in practice, such as the model that keeps primary physicians in their clinics while hospitalists and intensivists care for their patients here at SHC. Other changes have been influenced by the rules governing the hospital’s responsibility for monitoring the care we deliver. Today as in the past, the rules that govern membership decisions are contained in the Medical Staff Bylaws, a document that I am sure every Medical Staff member has read thoroughly. Actually, I know you haven’t done this, so I will try to de-mystify the requirements and process. For those of you who want to see for yourself what the bylaws actually contain, here’s a weblink:

www.medicalstaffservices.stanfordhospital.com

(Remember that LPCH has a completely separate set of Bylaws and criteria for their Medical Staff membership. I will only discuss Stanford Medical Staff membership.)

So. . . When you apply for membership or reappointment, the Credentials Committee tallies the number of your patient contacts as part of the review of your eligibility to be in a certain Medical Staff category (Active, Courtesy-Admitting, etc.). Notable exception: If you hold a Courtesy-Teaching appointment there are no specific patient contact requirements, but you must have a current approved teaching appointment through the School of Medicine.

We used to consider only “Patient Admissions” for staff membership. However, last year we broadened this rule to include total “Patient Contacts,” which are defined as admissions, treatments, consults, teaching and supervision of physicians in training, outpatient clinic visits, and outpatient surgery and procedures.

If you are a physician who does not admit patients on a regular basis, you need to read this definition carefully. The Credentials Committee needs clear documentation of these “Patient Contacts” in order to apply them to your qualifications. Since our IT structure can’t give us this data automatically, you need to keep a personal log of every “Patient Contact” you have at Stanford. You also need to actually write a note in the chart and sign it whenever you have a patient contact. Without this documentation, the Credentials Committee will find it very difficult to act on your request.

In order to qualify for Active Staff membership, you must have at least 11 “Patient Contacts” per year. Courtesy-Admitting Staff membership requires between three and 10 “Patient Contacts” per year. If you have less than three “Patient Contacts” you are not eligible for either Active or Courtesy-Admitting Staff membership at Stanford. I will discuss later why we have these rules.

Another critical prerequisite for Courtesy-Admitting privileges is membership on the Active Medical Staff of another accredited healthcare facility. If you have a small number of contacts at Stanford, you may be asked to supply quality information from your primary institution. Privacy rules inhibit us from asking the institution directly.

Last year, we expanded the definition of “accredited healthcare facility” to the following Bylaws definition:

Are members in good standing of the Active Medical Staff of another facility in California which has been accredited by JCAHO (Joint Commission on Accreditation for Healthcare Organizations), AAAHC (Accreditation Association for Ambulatory Health Care), or AAAASF (American Association for Accreditation of Ambulatory Surgery Facilities), although exceptions to this requirement may be made by the Medical Board for good cause.

Therefore, if you have failed to meet the requirements for either Active or Courtesy-Admitting Staff privileges during the previous two years, you will automatically either be shifted from Active to Courtesy-Admitting or be “voluntarily resigned” from our Medical Staff. Here is the actual language from the Bylaws:

After two (2) consecutive years in which a member of the Active Medical Stafffails to regularly care for patients in this hospital, or be regularly involved in medical staff functions as determined by the medical staff, that member shall be automatically transferred to the appropriate category, if any, for which the member is qualified.

Basic requirements for obtaining and maintaining medical staff membership are:

• Current, unrestricted professional license from the State of California

• Eligibility to participate in the Medicare, Medicaid and other federally sponsored health programs

• Current professional liability insurance covering privileges requested

Why do we have these rules?

The Credentials Committee has discussed the issues of rules at almost every monthly meeting. Here’s the intent:

Many primary care physicians no longer admit patients to Stanford because they work with a hospitalist who is the admitting physician. The primary care physician therefore does not really have sufficient patient contacts to establish a track record in our hospital.

We are obligated (by accrediting agencies) to assure our patients that the physicians practicing here are competent, as evidenced by actual observation of patients treated at this Hospital.

If the applicant has a low volume of patients at this hospital, we need to be able to know that their activity and record of quality at another healthcare facility is documented and above the standard of care. (This is actually very difficult for us to document since hospitals tend to not share quality data.)

Our hospital is not easy to practice in. Specifically, record and documentation requirements need to be learned. When we shift to a total electronic medical record over the next few years, the problem will be compounded. Our transition to the Epic medical record system will require a mandatory 16-hour training period for every Medical Staff member. It is unlikely that anyone with infrequent patient activity here will be willing to commit this level of training to use our hospital.

Membership on our hospital Medical Staff has become more complicated because of accreditation and regulatory requirements. We now need good documentation of quality patient care, either from our hospital or from one of our neighbor hospitals. We have tried to make our requirements more “physician friendly”. However, every physician who has low activity here needs to carefully document each “Patient Contact” (as defined above). This documentation must be available to the Credentials Committee at each reappointment cycle.

But there is life after rules and regulations. I’m certain that our “Patient Contact” criteria will allow us to become more inclusive by allowing each of you to become involved in the way that makes most sense for you, for the hospital and for the patients we all serve. If your patient contacts have dropped and you wish to continue, there are often opportunities through teaching programs, consultations and departmental activities to remain an active part of the SHC community. I welcome you to find your relationship with SHC.

As always, I welcome your comments:

kgarman@stanford.edu