2015 HFAP Acute Care Hospital Manual
CMS Final Rule – Burden Reduction II (May 2014)
Karen Beem, MS, RN
01.00.33 Governing Body Periodically Consults with Medical Staff (NEW)
The governing body must consult directly with the individual assigned the responsibility for the
organization and conduct of the hospital’s medical staff, or designee.
1. To discuss matters related to the quality of medical care provided to patients of the hospital
2. Twice per year with minutes to memorialize discussions
3. Face-to-face or via telecommunications
01.00.33 Governing Body Periodically Consults with the Medical Staff
1. Does not preclude having a physician as member of the governing body
2. However; physician membership on the governing body is not sufficient to satisfy the
requirement for periodic consultation.
03.00.01 Eligibility and Process for Appointment to Medical Staff
1. All practitioners who require privileges to furnish care to hospital patients must be evaluated
under the hospital’s medical staff privileging system before the hospital’s governing body may
grant them privileges.
2. All practitioners granted hospital privileges must function under the bylaws, regulations and
rules of the hospital’s medical staff.
3. The privileges granted to an individual practitioner must be consistent with State scope-ofpractice laws.
03.00.01 Eligibility and Process for Appointment to the Medical Staff
Non-physician Practitioners:



Physician assistant
Nurse practitioner
Clinical nurse specialist
2015 HFAP Acute Care Hospital Standards
1






Certified registered nurse anesthetist
Certified nurse-midwife
Clinical social worker
Clinical psychologist
Anesthesia Assistant
Registered dietician or nutrition professional
03.00.01 Eligibility and Process for Appointment to the Medical Staff
Other types of licensed healthcare professionals with a more limited scope of practice and USUALLY not
eligible for privileges unless permitted by State Scope of Practice:




Physical Therapist
Occupational Therapist
Speech Language Therapist
Some States:
 Licensed pharmacists are permitted to provide ordering medications and laboratory
tests
03.00.06 Recommendation for Appointment to Governance
Standard: Enforcement
The medical staff 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, or rules.
Standard: Protection and Due Process Rights
It must likewise afford all members/ practitioners who hold privileges the protections and due process
rights provided for in the bylaws, rules and regulations.
Multiple-Hospital Systems:



Each hospital has a separate CMS Agreement and CCN
Hospitals have the option of a unified integrated medical staff.
The following standards apply to hospitals with a unified medical staff:
03.00.11 Unified and Integrated Medical Staff
03.00.12 Voting Requirements
2015 HFAP Acute Care Hospital Standards
2
03.00.13 Bylaws of the Unified Medical Staff
03.00.14 Unique Circumstances of the hospitals
03.00.15 Policies of the Unified Medical Staff
03.00.11 Multiple-Hospital Systems: Unified and Integrated Medical Staff (NEW)
When granting practitioners privileges the governing body must:
1. Specify the hospital(s) in the system where the privileges apply
2. Consider the services provided at each hospital when granting privileges.
Would be inappropriate to grant neurosurgical privileges if a hospital has no neurosurgical services
03.00.12 Multiple-Hospital Systems: Voting Requirements for Separately Certified Hospitals
Standard:
The medical staff members of each separately certified hospital in the system have voted by majority, in
accordance with medical staff bylaws, either:
a) To accept a unified and integrated medical staff structure,
or
a) To opt out of such a structure and to maintain a separate and distinct medical staff for their
respective hospital;
03.00.12 Multiple-Hospital Systems: Voting Requirements for Separately Certified Hospitals
If a unified medical staff, the Medical Staff Bylaws address:
1. Processes for voting to accept /opt out of a unified medical staff
2. Whether the decision for acceptance or to opt-out is determined by “majority” vs
“supermajority”
3. How a vote can be requested
4. Whether all categories of members holding privileges to practice on-site at the hospital are
2015 HFAP Acute Care Hospital Standards
3
afforded voting rights
5. Whether voting will be in writing and open or by secret ballot
5. Minimum interval between votes to accept or opt-out, e.g., once every two years
7. If a majority of a hospital’s medical staff voted to use a unified medical staff in the past, the
members of the unified medical staff with voting rights and holding privileges to practice onsite
at that hospital still retain the right to hold a vote to opt-out at a future date.
03.00.12 Multiple-Hospital Systems: Voting Requirements for Separately Certified Hospitals
A hospital may NOT:
1. Set up bylaws that unduly restrict the rights of medical staff members when voting on the issue
of accepting or opting out of a unified medical staff structure
2. Establish different criteria as to which categories of medical staff members have voting rights
with respect to a vote to accept or opt out of a unified medical staff than are used for other
amendments to the medical staff’s bylaws
03.00.13 Multiple-Hospital Systems: Bylaws of the Unified Medical Staff (NEW)
Standard: If a unified medical staff,
The unified and integrated medical staff has bylaws, rules, and requirements that describe processes
for:

Self-governance

Appointment

Credentialing and privileging

Oversight

Peer review policies and due process rights guarantees, and include a process for the members
of the medical staff of each separately certified hospital to be advised of their rights to opt out
of the unified and integrated medical staff structure
2015 HFAP Acute Care Hospital Standards
4
03.00.14 Multiple-Hospital Systems: Unique Circumstances (NEW)
Standard: If a unified medical staff,
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 service.
03.00.14 Multiple-Hospital Systems: Unique Circumstances
The separately certified hospitals belonging to a multi-hospital system and using a single unified medical
staff may:
1. Be very different from each other, presenting different needs and challenges for the medical
staff.
2. Consist of hospitals that differ in size or provide specialized services.
3. Such differences could have implications for various medical staff requirements, such as on-call
requirements.
03.00.14 Multiple-Hospital Systems: Unique Circumstances
Example:
A multi-hospital system may consist of a mixture of hospitals, such as:
•
short-term acute care hospitals
•
psychiatric hospitals
•
rehabilitation hospitals
•
children’s hospitals
•
long-term care hospitals
For this reason, the medical staff must assure that standard orders, policies, and procedures:
1) Address the unique hospital circumstances
2) Are approved by the nursing and pharmacy leadership at each separately certified hospital
03.00.15 Multiple-Hospital Systems: Policies of the Unified Medical Staff
2015 HFAP Acute Care Hospital Standards
5
Standard: If a unified medical staff,
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.
Example:
Physicians practicing in a children’s hospital may have concerns about protocols for medication
administration that reflect specific pediatric patient concerns.
31.00.11 Orders for Outpatient Services
Standard:
Outpatient services must be ordered by a practitioner who:
1. Is responsible for the care of the patient.
2. Is licensed in the State where he/she provides care to the patient.
3. Is acting within his or her scope of practice under State law.
4. Is authorized in accordance with State law and policies adopted by the medical staff,
and approved by the governing body, to order the applicable outpatient services.
Benefit: Hospitals have the flexibility to determine whether or not they will allow a practitioner who is
not a member of the medical staff to order outpatient services.
31.00.11 Orders for Outpatient Services
Through the Bylaws, the Medical Staff establishes whether to allow a practitioner who is not a member
of the medical staff to order outpatient services consistent with State law and regulations:
1. Non-physician practitioners, such as
•
Physical Therapists,
•
Occupational Therapists,
•
Speech Language Pathologists,
•
Qualified dietitians and qualified nutrition professionals
2. Practitioners with a professional license from another State
2015 HFAP Acute Care Hospital Standards
6
Medical Staff Approved Policies
A. The procedure to implement when a patient presents with a referral or order for outpatient
services
B. Before start of test/procedure, verify the practitioner is:
1) Licensed in the State where he/she provides care to patient
2) Acting within scope of practice per State law
3) Authorized by the medical staff and governing body to order the applicable outpatient
services.
C. Documentation expectations
24.00.07 Diet Orders
Standard:
All patient diets, including therapeutic diets, must be ordered by a practitioner responsible for the care
of the patient, or by a qualified dietitian or qualified nutrition professional as authorized by the
medical staff and in accordance with State law governing dietitians and nutrition professionals.
Includes:
Orders for Therapeutic Diets
24.00.07 Diet Orders
Hospitals have the flexibility to determine whether or not they:
1. Will allow a practitioner who is not a member of the medical staff to order outpatient services
2. The ability to establish through medical staff bylaws and hospital policy other parameters for
who will and who will not be authorized to order outpatient services.

In accordance with respective State laws, regulations, and other appropriate
professional standards.

This does not require the granting of privileges, but allows the flexibility to do so if they
so choose.
2015 HFAP Acute Care Hospital Standards
7