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August 10, 2020

Many Processes are an Accumulation of Antiquated Habits, Bylaws, and Regulations

This article covers several detailed examples of unnecessary practices, out-of-date requirements, and avoidable time-sucks that can be restructured or eliminated completely from hospital onboarding customs.

Chasing down directors and executives for redundant approval signatures is a poor use of time for all involved. Engaging boards in the privilege-granting process of every staff member is inessential and doesn’t result in the assurance of proper qualification—a job best left for the HR and MSP departments. Below are 10 habits that don’t belong in an efficient and well-organized hospital or medical practice.

The following provided by Hugh Greeley, author of Hugh’s Credentialing Digest

The mission continues. I will address a number of inefficient, outmoded, frustrating, and unnecessary activities that have subtly crept into the practices of many medical staffs and medical staff services departments. Hospital leadership, including the vice president of medical affairs (VPMA), medical staff services professionals (MSPs), human resources (HR) director, and the chief of staff might take a few minutes to contemplate this list and determine whether any items on it apply to their facility or organization.


We must not be timid when reviewing past practices if we wish to continue to move forward and relieve the bureaucratic demands on both medical and administrative staff’s time and resources. These points are in random order and have been drawn from practices reported to the Digest over the past few months.


It is entirely unnecessary to require that medical staff services personnel spend substantial time in an attempt to obtain multiple signatures when gaining approval of a new or existing policy.

There is simply no rationale for troubling the clinical director, department chair, director of patient care, chair of the medical executive committee (MEC), CEO (or designee), and the chair of the board when “making official” a simple and routine policy governing specific care guidelines, protocols, standards of practice, or service agreements.

The majority of policies and procedures do not need board approval at all (that is the job of the CEO). While it is appropriate to involve the MEC in the approval of specific policies, it is sufficient to note such approval in the minutes. The VPMA surely is an important contributor to the process, but his or her signature adds nothing to the legality or importance of the document.

If law or regulation does not require signatures, stop the practice of chasing busy leaders only to have them sign a document they may not have read (this also applies to most applications and reapplications; the MSP may simply note that approval is documented in the minutes). If nothing else, remember that signature stamps are great for such routine activities.


Place a firm administrative guideline in effect requiring a 50 percent reduction in the size of the MEC’s monthly package. Direct observation reveals that few of the 100 pages in an average MEC package are read by attendees.

Technology allows the chair to easily and instantaneously project any page or document that demands review onto a screen. Laptops and iPads permit all participants to instantly find the “important” document needing discussion.

Don’t overlook low-hanging fruit. No member of the MEC needs a copy of the continuing medical education (CME) syllabus presented at the last educational event. Members never read the voluminous pages supporting a formulary change.

A 32-page semi-annual Ongoing Professional Practice Evaluation (OPPE) report simply causes members to lose sight of the forest for the trees. A simple summary will suffice (and please explore the rationale for person-specific signature pages on individual OPPE reports).


No positive benefit results from the age-old practice of having staff members “sign-in” when coming to a general staff or other meetings. This is a practice born a few generations ago and it has no place in most hospitals today. Virtually no hospital or staff seriously considers disciplining a valuable physician simply because he or she fails to attend the annual meeting.

For those staffs still clinging to this practice, recognize that it is better for all to rethink it. Remember how hard it is to actually police the practice. Partners sign in for partners, those uninterested sign in and leave the meeting, and those who actually care will be there regardless of the rule or sign-in requirement.


Those few staffs that continue to believe a departmental vote is required for applicants and re-applicants should know that appointment is not a popularity contest. It results from in-depth knowledge of the applicant and occurs after a careful review of the file.

Voting has, in the past, led to many legal difficulties, hearings, delays, and the need for the MEC to “overturn” departmental decisions. If a department chair wishes to ask members if they know anything that might affect an applicant’s qualifications, allow him or her simply to ask for input in private by posting the applicant’s name on the MS website or on the MS bulletin board.


If your hospital’s application for appointment is one of those requiring entry of a signature and date on each page, consider how the practitioner feels when completing it.

There is no advantage gained through this misguided practice. It is highly likely that past events (or more likely a single past event) prompted a well-meaning group to institute this rule because of an error identified on an application that was “explained away” by an applicant when he asked his staff to complete the application for him and then he did not read it.

Or perhaps the practice is due to the acquisition of a sample application provided by a consultant or lawyer. Banish this one to the graveyard of unnecessary practices.


Why do we staff non-required section meetings? This practice easily could be eliminated, and such elimination might encourage greater candid discussion among members.

If an issue that requires action from the department chair or MEC is identified, the section head (who is not an officer or chair) easily could write a short letter to the appropriate individual requesting that the issue be placed on the agenda, and supply the rationale for this request.

MSPs and other administrative personnel need not be present at these meetings unless such meetings are required under the bylaws.


Have you ever found yourself sitting at a meeting of a medical staff committee and counting the number of non-physicians at the table?

Just last month the following happened at a peer review committee meeting of the staff at a large Arizona hospital. There were three physicians, three staff from the performance improvement department, two from nursing, a representative of the pharmacy, the risk manager, the in-house legal staff, the patient representative, two people from case management, and a designee of management at the meeting—fully 12 individuals having little or no reason to be present for the entire hour the committee met.

Why were they there? Perhaps because they once were requested to address a specific issue, perhaps because the person who drafted the committee charter or plan personally believed that more is better, or perhaps as a result of the misguided advice of a surveyor for an accreditation agency. These are all plausible possibilities.

However, I believe they were there because “it beats working.”


Far too many medical staffs and boards are involved unnecessarily in personnel (read that privileging) decisions better left to a well-designed HR process.

Once again, unless required by law or accreditation standards, hospitals should not use the privileging process for individuals other than members of the staff, advanced practice registered nurses (APRNs), physician assistants (PAs), and those few medical doctors, doctors of osteopathic medicine, doctors of dental surgery, or doctors of podiatric medicine who will be granted privileges with no membership.

If the MEC is worried about the qualifications of scrub techs, dietitians, mental health counselors, social workers, non-physician/PA surgical assistants, etc., it should raise these concerns with management and help define the qualifications for these jobs.

Inserting these (supervised) individuals into the privileging process does not provide greater assurance of qualification than a well-organized HR process, but it does create a number of arduous, unintended consequences, such as National Practitioner Data Bank (NPDB) requests, hearings, and department chair and uninformed MEC actions.

Perhaps of greatest concern is the necessity of board action authorizing the work of a dietitian as an employee of the organization.


Medical staffs now understand the differences among clinical privileges, appointment to the staff, and assignment to a staff category. Unfortunately, many staffs have not fully appreciated the “insult” perceived by long-term internists or family practitioners when it is pointed out that they no longer qualify for reappointment to the active category of the staff (it is likely that in some instances they have previously served on the MEC, as department chairs or in other significant staff positions).

Why one might ask, do they no longer qualify for the active category? Because they do not meet an ancient rule, established circa 1970, that was designed to ensure that only physicians actively supporting the staff and hospital should be permitted to vote (also, over 40 years ago we confused active staff status with privileges).

Grab some white-out or hit the delete button and update your rules to account for today’s health systems, practice styles, and common sense. There need be no change in staff status simply because a physician changes his or her employment status or decides to practice exclusively on an outpatient basis (while retaining a fervent interest in supporting the hospital and staff through referrals to hospitalist programs and other specialists).

Here’s a suggested bylaws concept: Assignment to the active category is reserved for practitioners who actively support the mission of the hospital and medical staff. Assignment to the active category shall have no effect upon clinical privileges and will be discretionary on the part of the board after receipt of a recommendation by the MEC.

Such assignment or lack thereof will have no impact upon a practitioner’s emergency department (ED) call responsibility, will not give rise to an offer of a hearing, will not obligate practitioners to use the hospital exclusively (unless pursuant to a carefully-designed board policy), and need not be accepted by the practitioner who desires assignment to an ALTERNATE CATEGORY.


Medical staff leaders diminish their influence and status when they collectively allow practices that permit physicians to remain on staff long after they have ceased to support the mission in any meaningful way.

The staff (apart from honorary or emeritus appointments) should be composed of individuals who intend to assist the hospital and staff, or for those who do assist.

Examples of casual abuse abound. For example, there’s the physician who has relocated his/her practice out of state, the physician who is serving time in a state or federal correctional institution, the physician who owns a plastic surgery practice and no longer attends patients in the hospital, no longer refers, doesn’t assist in any meaningful way with ED call or charity patients, who does not accept MS committee assignments, etc.

Or there’s this extreme example—the physician CEO (of the competing hospital in town) who remains on staff in the courtesy category because there are no provisions preventing reappointment. White-out, anyone?

Admittedly, this is an incomplete list and commentary, and it does not have universal applicability. If you have examples of outmoded, frustrating, and/or unnecessary activities, please contact me and we will address them in a future edition of the Digest.

Hugh Greeley Written by Hugh Greeley
Credentialing and Healthcare Industry Expert
HG Healthcare Consultant
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