210. Hospital Medical Staff
Colorado Medical Society (CMS) supports the granting of privileges to physicians by Colorado hospitals and managed care organizations as stated below: The CMS believes that:
- Individual character, training, competence, experience and judgment should be the criteria for granting privileges in hospitals.
- Physicians representing several specialties can and should be permitted to perform the same procedures if they meet these criteria.
(RES-31, AM 1996; Reaffirmed, BOD-1, AM 2014)
210.991 Standardization of Credentialing Forms
The Colorado Medical Society supports the development of a statewide standard credentialing form to be used by entities that credential physicians such as managed care organizations, hospitals, medical malpractice carriers, etc.
(RES-56, AM 1994; Reaffirmed, BOD-1, AM 2014)
210.992 Physician Profile and the Prospective Payment System
Colorado Medical Society supports ensuring that hospital evaluation of physician performance resulting from Diagnostic Related Group physician profiling will be through an appropriate committee of the hospital medical staff which will have access to the raw data and will participate in the development of the data system.
(RES-HMS-5, AM 1984; Reaffirmed, BOD-1, AM 2014)
The Colorado Medical Society supports the following:
- The medical staff bylaws, rules and regulations shall be initiated and adopted by the medical staff and shall establish a framework for self-government;
- The medical staff shall govern itself by these bylaws, rules and regulations which shall:
- be reviewed and revised as necessary to reflect current medical staff practices;
- define the Executive Committee of the medical staff whose members are selected in accordance with criteria and standards established by the medical staff; and
- The medical staff shall have authority to approve or disapprove all amendments to medical staff bylaws, rules and regulations.
(RES-HMS-9, AM 1984; Reaffirmed, BOD-1, AM 2014)
The Colorado Medical Society supports hospital governing board bylaws that do not contain provisions whereby the hospital corporate board or administration could unilaterally amend the medical staff bylaws, or its rules and regulations.
(RES-HMS-7, AM 1984; Reaffirmed, BOD-1, AM 2014)
The Colorado Medical Society (CMS) supports the Colorado Department of Health definition of Medical Staff as “...those physicians and dentists granted the privilege by the governing authority of a licensed facility to practice medicine or dentistry therein…” and the definition of physician in Colorado statute as “...a doctor of medicine or doctor of osteopathy duly licensed in the State of Colorado…”. The CMS opposes any attempts to include other care practitioners in these definitions.
(AM 1984; Reaffirmed, BOD-1, AM 2014)
210.996 Legal Counsel
The Colorado Medical Society encourages hospital medical staffs to secure their own legal counsel separate and apart from the hospital administration.
(RES-22, IM 1984; Reaffirmed, BOD-1, AM 2014)
210.997 Self-Governing Medical Staff
Hospital medical staff shall have sole authority to select and remove their own officers, set standards for medical staff/patient care and recommend clinical privileges. These principles should be incorporated into model hospital medical staff bylaws.
(RES-21, IM 1984; Reaffirmed, BOD-1, AM 2014)
210.998 Renewal of Staff Reappointments
Utilization of hospital resources by members of the hospital medical staff should not be the sole consideration in staff reappointment and renewal of staff privileges, but rather be considered in conjunction with professional performance and in performance of their role as patient advocate, and hospital medical staff bylaws should include these criteria.
(RES-20, IM 1984; Reaffirmed, BOD-1, AM 2014)
210.999 Participation in Decision Making
Hospital administrations should seek medical staff participation in hospital decisions regarding marketing and advertising. Additionally, the medical staff should actively seek participation in hospital decisions regarding marketing. The intent of this bilateral involvement is to prevent presentation to the public of medical misinformation.
(RES-19, IM 1984; Reaffirmed, BOD-1, AM 2014)