CMS SOM App. A, Tag A-0352

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:]

(iv) The unified and integrated medical staff establishes and implements policies and

procedures to ensure that the needs and concerns expressed by members of the medical

staff, at each of its separately certified hospitals, regardless of practice or location, are

given due consideration, and that the unified and integrated medical staff has mechanisms

in place to ensure that issues localized to particular hospitals are duly considered and

addressed.

Interpretive Guidelines

§482.22(b)(4)(iv)

The hospital’s unified medical staff must have written policies and procedures that address how

it considers and addresses needs and concerns expressed by members who practice at the

hospital. This provision is not about an individual medical staff member’s concerns with

privileges granted or not granted to him/her, peer review results, due process issues, etc., since

these matters are addressed under the requirements at §482.22(a) and (c) as well as

§482.22(b)(4)(ii). Instead, this provision addresses a requirement for the unified medical staff to

consider and address concerns that practitioners have concerning their own hospital’s needs. For

example, physicians practicing in a children’s hospital may have concerns about having

protocols for medication administration that reflect specific pediatric patient concerns, or

physicians practicing in a small rural hospital may have concerns about how to get timely

telemedicine consults from their colleagues in urban areas.

The medical staff has flexibility in establishing its written policies and procedures for addressing

these local concerns, but at a minimum they must cover the following:

A process by which members who practice at a hospital can raise their local concerns and

needs with the unified medical staff’s leadership;

How members are informed of the process by which they can raise their local concerns

and needs;

A process for referring the concerns and needs raised to the appropriate committee or

other group within the medical staff for due consideration; and

Documentation of the outcome of the medical staff’s review of the concerns and needs

raised.

Survey Procedures §482.22(b)(4)(iv)

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

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

Determine that the unified medical staff has policies and procedures addressing how

members can raise local concerns and needs. Do the written policies and procedures

cover the minimum elements?

Ask the hospital and the medical staff leadership whether any members practicing at the

hospital have raised concerns or needs. If yes, ask for documentation on how the

concern/need was considered and addressed by the unified medical staff.

Ask members of the medical staff if they are aware they can raise local concerns or needs with

the leadership of the unified medical staff.