CMS SOM App. A, Tag A-0338

The hospital must have an organized medical staff that operates under bylaws approved by

the governing body, and which is responsible for the quality of medical care provided to

patients by the hospital.

Interpretive Guidelines §482.22

The hospital must have one medical staff for the entire hospital (including all campuses,

provider-based locations, satellites, remote locations, etc.). For example, a multi-campus

hospital may not have a separately organized medical staff for each campus. On the other hand,

in the case of a hospital system, it is permissible for the system to have a unified and integrated

medical staff (hereafter referred to as a “unified medical staff”) for multiple, separately certified

hospitals. The medical staff must be organized and integrated as one body that operates under

one set of bylaws approved by the governing body. These medical staff bylaws must apply

equally to all practitioners within each category of practitioners at all locations of the hospital

and to the care provided at all locations of the hospital. The medical staff is responsible for the

quality of medical care provided to patients by the hospital.

Survey Procedures §482.22

Surveyors assess the manner and degree of noncompliance with the standards within this

condition to determine whether there is condition-level noncompliance.