CMS SOM App. A, Tag A-0347

The medical staff must be well organized and accountable to the governing body for the quality

of the medical care provided to the patients.

(1) The medical staff must be organized in a manner approved by the governing body.

(2) If the medical staff has an executive committee, a majority of the members of the

committee must be doctors of medicine or osteopathy.

(3) The responsibility for organization and conduct of the medical staff must be assigned

only to one of the following:

(i) An individual doctor of medicine or osteopathy.

(ii) A doctor of dental surgery or dental medicine, when permitted by State law

of the State in which the hospital is located.

(iii) A doctor of podiatric medicine, when permitted by State law of the State in

which the hospital is located.

Interpretive Guidelines §482.22(b)(1) – (3)

The conditions of participation create a system of checks and balances within an overall

framework of collaboration between the governing body and the medical staff (and, to a certain

degree, also between an individual practitioner and the hospital’s medical staff and governing

body). Each has its own areas of authority. The medical staff has oversight of all practitioners

practicing in the hospital through processes such as peer review and making recommendations

concerning privileging and re-privileging. The governing body has the authority to establish the

categories of healthcare professionals (regardless of the terms used to describe those categories)

who are eligible for privileges and medical staff appointment. However, the governing body

must rely on the medical staff to apply the criteria for privileging and appointment to those

eligible candidates and to make their recommendations before the governing body makes a final

decision to appoint or not appoint a practitioner to the medical staff. (77 FR 29042 May 16,

2012).

If the hospital uses a unified medical staff that it shares with other hospitals that are part of a

multi-hospital system, this does not change the requirement for the medical staff to be well

organized and accountable to the system’s governing body for the quality of care in each

separately certified hospital.

Leadership of the medical staff

The members of the hospital’s medical staff must select, in accordance with the medical staff

bylaws, rules or regulations approved by the governing body, a single individual to lead the

medical staff and be responsible for the organization and conduct of the medical staff. This

individual must be a doctor of medicine or osteopathy, or, if permitted by State law where the

hospital is located, a doctor of dental surgery, dental medicine, or podiatric medicine. Removal

of the leader of the medical staff may only occur in accordance with medical staff bylaws, rules

or regulations.

If the hospital uses a unified medical staff, only one individual may be responsible for the

organization and conduct of the unified medical staff; that individual may or may not hold

privileges and practice at the hospital being surveyed. When the individual does not practice at

the hospital being surveyed and it is necessary to interview this individual as part of a survey, a

telephone interview must be arranged.

Executive Committee

The medical staff bylaws, rules and regulations may provide for the members of the medical staff

to select a smaller executive committee to which it delegates many of the functions of the

medical staff, in order to increase the efficiency of its operations. If the medical staff has an

executive committee, the majority of the voting members must be doctors of medicine (MDs) or

osteopathy (DOs).

For Information Only – Not Required/ Not to be Cited

A hospital is not required to have an executive committee. However, use of an executive

committee may facilitate efficient and effective functioning of the medical staff in hospitals

systems that use a unified medical staff, particularly if the executive committee includes

members from each hospital that shares the unified medical staff.

Accountability of the medical staff

The medical staff must be accountable to the hospital’s governing body for the quality of

medical care provided to the patients. The medical staff demonstrates its accountability through

its exercise of its duties related to appointment of members of the medical staff, its conduct of

reappraisals, including peer reviews, its approval of policies and procedures as required under

other conditions of participation and its leadership participation in the organization and

implementation of the hospital’s quality assessment and performance improvement program

required in accordance with §482.21.

If the hospital uses a unified medical staff, the medical staff continues to be accountable for the

quality of care in each separately certified hospital that uses the unified medical staff.

Survey Procedures §482.22(b)(1) – (3)

• Verify that the medical staff has a formal, organized structure reflected in the

medical staff bylaws, rules and regulations and that functions and responsibilities

within the medical staff and with respect to the governing body and other parts of

the hospital are reflected.

• If there is a medical staff executive committee, verify that a majority of the

members are doctors of medicine or osteopathy.

• Verify that an individual doctor of medicine or osteopathy, or if permitted by

State law, a doctor of dental surgery, dental medicine, or podiatric medicine,

selected by the medical staff, is responsible for the conduct and organization of

the medical staff.

• Ask the CEO and medical staff leadership to describe the mechanisms by which

the medical staff fulfills its responsibility to be accountable for the quality of

medical care in the hospital.

• Interview several members of the medical staff, including both practitioners who hold

leadership or executive committee positions and ones who do not. Ask them what their

medical staff duties and responsibilities are and how they perform them. Ask them to

describe how the medical staff is accountable for the quality of medical care provided to

patients.