CMS SOM App. A, Tag A-0351

certified hospitals and the system elects to have a unified and integrated medical staff for

its member hospitals, after determining that such a decision is in accordance with all

applicable State and local laws, each separately certified hospital must demonstrate that:]

(iii) - The unified and integrated medical staff is established in a manner that takes into

account each member hospital’s unique circumstances and any significant differences in

patient populations and services offered in each hospital; and….

Interpretive Guidelines §482.22(b)(4)(iii)

The separately certified hospitals belonging to a multi-hospital system and using a single unified

medical staff may be very different from each other, presenting different needs and challenges

for the medical staff. As a result, the unified medical staff is expected to take these differences

into account rather than using a one-size-fits-all approach for all of its policies and procedures.

For example, a multi-hospital system may:

• Consist of a mixture of different types of hospitals, such as short-term acute care

hospitals, psychiatric hospitals, rehabilitation hospitals, children’s hospitals, and long-term care hospitals. As a result, they would offer different types of services to

different patient populations. This could have implications for medical staff functions

such as the periodic review of credentials and privileges and ongoing peer review of

the quality of medical care. It could also have implications for other responsibilities

the medical staff has under various CoPs. For example, the medical staff has a key

role in the development and oversight of the use of standing orders/protocols, but

these orders/protocols may need to be specific to each hospital, reflecting the types of

services a hospital offers and its patient population;

Consist of hospitals that differ in size, ranging from comparatively small hospitals in

rural areas, or which provide specialized rehabilitation or long term care hospital

services, to very large short term acute care service hospitals. Such differences could

have implications for various medical staff requirements, such as on-call requirements.

Consist of hospitals that differ as to whether they are teaching hospitals or not, which

would have implications for policies concerning the roles and supervision of residents.

Consist of hospitals that are located in different states which have different licensure

requirements affecting the organization and composition of the medical staff. For

example, in one state it might be permissible for non-physician practitioners to be

members of the medical staff, while in another the medical staff is limited to physicians.

On the other hand, a multi-hospital system may have a conscious strategy of having hospitals

that are very similar to each other in terms of size, services, patient populations served, and type

of location. In this case, the unified medical staff would have fewer challenges in addressing the

needs of each hospital, and might have more policies that are uniform across the medical staff.

In all cases the hospital’s leadership and the medical staff leadership must be able to explain how

the way in which the unified medical staff is organized and functions takes account of and

responds to the unique circumstances of the hospital that is being surveyed.

Survey Procedures §482.22(b)(4)(iii)

• Assess compliance with this regulation only if the hospital uses a unified medical

staff. (See survey procedures for §482.22(b)(4) above)

Ask the hospital’s and medical staff’s leadership to describe the other types of hospitals

in the system with which it shares a unified medical staff, and how the hospital’s unique

circumstances are addressed. For example, how does the unified medical staff assure

that:

o Standing orders it has approved are also approved by the nursing and pharmacy

leadership in each separately certified hospitals? (see §482.24(c)(3)(i));

o Policies and procedures developed by the medical staff to minimize drug errors, if

this function has not been delegated to the hospital’s pharmaceutical service, take into

account any unique hospital circumstances? (see §482.25);

o The formulary system established by the medical staff takes into account any unique

hospital circumstances? (See §482.25(b)(9));

o The medical staff’s specification of procedures and treatments requiring a properly

executed informed consent reflects any unique hospital circumstances? (see

§482.24(c)(4)(v));

o The medical staff carries out its joint responsibility with the CEO and Director of

nursing for ensuring that hospital-specific infection control problems identified by the

hospital’s infection control officer(s) are addressed in the hospital’s QAPI and

training programs? (see §482.42(b));

o The medical staff fulfills its joint executive responsibilities, along with the hospital’s

governing body and administrative officials, for ensuring that the hospital-specific

QAPI program is:

Ongoing, defined, implemented and maintained;

Addresses hospital-specific priorities for improved quality of care and patient safety,

and that all improvements are evaluated;

Establishes clear expectations for safety in the hospital;

Allocates adequate resources for the hospital-specific QAPI program; and

Determines annually the number of distinct improvement projects conducted in the

hospital?

(See §482.21(e))

o Medical staff policies governing ordering of outpatient services address any unique

hospital circumstances? (See §482.54(c)(4))

o Medical staff policies and recommendations governing which practitioners may be

authorized to write orders and be responsible for the care of the patient conform to State

law, including scope of practice law, for the State in which the hospital is located?

(multiple citations in various CoPs)