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Who has ultimate responsibility for decisions about medical staff membership, and why? How should this responsibility be performed?

Management and the medical staff are responsible for the credentialing process and may recommend physician applicants. The ultimate responsibility for appointing a competent medical staff, however, lies with the hospital governing board. If a health system has multiple facilities, the health system's governing board must have a communication process with each facility's medical staff, and each medical staff member must have a means of interacting with administration or governing body. A physician liaison, typically referred to as the Chief Medical Officer, acts as the link between staff physicians and health system administration/governing body. [3]

The organized medical staff, hospital governing body, and administration are all integral to the provision of quality care, providing a safe environment for patients, staff, and visitors, and working continuously to improve patient care and outcomes. [1] They operate in distinct, highly expert fields to fulfill common goals, and are each responsible for carrying out primary responsibilities that cannot be delegated. [1] There are (9) medical staff standards that a governing body must comply with according to 42 CFR 482.12 (Condition of participation: Governing Body). One of which is- (5) ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. [2]

The governing body may not renounce its responsibility for quality. The duty cannot be delegated to the medical staff organization, the local medical society, or any other group or individual. Although lay members of the governing board might not be qualified to judge physicians' professional competencies, they must ensure that a reliable review process is in place so that physicians' peers may do so. In this manner, the board authorizes the medical staff to investigate applicants' backgrounds and quality concerns involving active physician members. This credentialing process must be followed properly, and board members must be prepared to ask appropriate questions and exercise independent judgment. [3]

[1]AMA. H-225.942. Physician and Medical Staff Member Bill of Rights H-225.942. Hospitals. 2022. https://policysearch.ama-assn.org/policyfinder/detail/H-225.942?uri=%2FAMADoc%2FHOD.xml-H-225.942.xml

[2]CMS. 42 CFR 482.12-Condition of participation: Governing Body. Title 42-Public Health. Chapter IV. Subchapter G. Part 482. Subpart B. Section 482.12. 01 Oct. 2011. https://www.govinfo.gov/content/pkg/CFR-2011-title42-vol5/pdf/CFR-2011-title42-vol5-sec482-12.pdf

[3]Showalter, J. S. (2020). The Law of Healthcare Administration (Ninth). Health Administration Press. 2020