CMS SOM App. A, Tag A-0341

medical staff membership and make recommendations to the governing body on the

appointment of the candidates in accordance with State law, including scope-of-practice

laws, and the medical staff bylaws, rules, and regulations. A candidate who has been

recommended by the medical staff and who has been appointed by the governing body is

subject to all medical staff bylaws, rules, and regulations, in addition to the requirements

contained in this section.

Interpretive Guidelines §482.22(a)(2)

There must be a mechanism established to examine credentials of individual prospective

members (new appointments or reappointments) by the medical staff. The individual’s

credentials to be examined must include at least:

• A request for clinical privileges;

• Evidence of current licensure;

• Evidence of training and professional education;

• Documented experience; and

• Supporting references of competence.

The medical staff may not make its recommendation solely on the basis of the presence or

absence of board certification, but must consider all of the elements above. However, this does

not mean that the medical staff is prohibited from requiring in its bylaws board certification

when considering a MD/DO for medical staff membership or privileges; only that such

certification may not be the only factor that the medical staff considers.

The medical staff makes recommendations to the governing body for each candidate for medical

staff membership/privileges that are specific to type of appointment and extent of the individual

practitioner’s specific clinical privileges, and then the governing body takes final appropriate

action.

Each practitioner who is a member of the medical staff or who holds medical staff privileges is

subject to the medical staff’s bylaws, rules, and regulations, in addition to all the requirements of

the Medical Staff Condition of Participation. The medical staff and the governing body must

enforce its medical staff requirements and take appropriate actions when individual members or

other practitioners with privileges do not adhere to the medical staff’s bylaws, regulations, and

rules. They must likewise afford all members/practitioners who hold privileges the protections

and due process rights provided for in the bylaws, rules and regulations.

A separate credentials file must be maintained for each individual medical staff member or

applicant. The hospital must ensure that the practitioner and appropriate hospital patient care

areas/departments are informed of the privileges granted to the practitioner.

Survey Procedures §482.22(a)(2)

• Determine whether the medical staff bylaws identify the process and criteria to be

used for the evaluation of candidates for medical staff membership/privileges.

• Determine whether the criteria used for evaluation comply with the requirements

of this section, State law, and hospital bylaws, rules, and regulations.

• Determine whether the medical staff has a system to ensure that practitioners seek

approval to expand their privileges for tasks/activities/procedures that go beyond

the specified list of privileges for their category of practitioner.

Ask the leadership of the medical staff what methods are used to ensure that all

medical staff members and non-member practitioners who hold privileges adhere

to the medical staff bylaws, rules and regulations and are afforded the protections

and due process rights provided for under the bylaws, rules and regulations. Ask

for specific examples of actions taken.

When interviewing practitioners during the survey, ask how they are made aware of their

rights and responsibilities with respect to medical staff bylaws, rules and regulations.