what is

Medical Staff
Management?
Medical Staff Management is …

Graduate
Medical
Education
Meeting Customer
Credentialing Management Service

Continuing
Medical Medical
Library Education
Medical Staff
Management …

saves
patient
lives …
how does
credentialing
save lives?
Michael Swango, MD Alan Zarkin, MD Jeffrey Askanazi, MD Gerald Barnes, MD

Dean Faiello, MD Jayant Patel, MD Dennis Roark, MD Harold Shipman, MD

David Tremoglie Neel Sheth ten newsworthy doctors

Michael Swango, MD Alan Zarkin, MD Jeffrey Askanazi, MD Gerald Barnes, MD

Dean Faiello, MD Jayant Patel, MD Dennis Roark, MD Harold Shipman, MD

killed 35 patients
term’d from OSUH, VA
David Tremoglie Neel Sheth Sioux Falls, and SUNY
Michael Swango, MD Alan Zarkin, MD Jeffrey Askanazi, MD Gerald Barnes, MD

Dean Faiello, MD Jayant Patel, MD Dennis Roark, MD Harold Shipman, MD

carved initials onto patient

after c-section; numerous
other complaints about
David Tremoglie Neel Sheth
erratic behavior
Michael Swango, MD Alan Zarkin, MD Jeffrey Askanazi, MD Gerald Barnes, MD

Dean Faiello, MD Jayant Patel, MD Dennis Roark, MD Harold Shipman, MD

33 counts of Medicare
fraud – unnecessary
David Tremoglie Neel Sheth procedures
Michael Swango, MD Alan Zarkin, MD Jeffrey Askanazi, MD Gerald Barnes, MD

Dean Faiello, MD Jayant Patel, MD Dennis Roark, MD Harold Shipman, MD

physician impersonator
for 20 years in California;
David Tremoglie Neel Sheth at least one death
Michael Swango, MD Alan Zarkin, MD Jeffrey Askanazi, MD Gerald Barnes, MD

Dean Faiello, MD Jayant Patel, MD Dennis Roark, MD Harold Shipman, MD

physician impersonator
doing laser procedures;
David Tremoglie Neel Sheth murdered one patient
Michael Swango, MD Alan Zarkin, MD Jeffrey Askanazi, MD Gerald Barnes, MD

Dean Faiello, MD Jayant Patel, MD Dennis Roark, MD Harold Shipman, MD

charged with murder

and negligence in 87
David Tremoglie Neel Sheth patient deaths
Michael Swango, MD Alan Zarkin, MD Jeffrey Askanazi, MD Gerald Barnes, MD

Dean Faiello, MD Jayant Patel, MD Dennis Roark, MD Harold Shipman, MD

surgeon impersonator
for almost 10 years in
David Tremoglie Neel Sheth Michigan!
Michael Swango, MD Alan Zarkin, MD Jeffrey Askanazi, MD Gerald Barnes, MD

Dean Faiello, MD Jayant Patel, MD Dennis Roark, MD Harold Shipman, MD

murdered 260 patients

via opiate injections
David Tremoglie Neel Sheth
Michael Swango, MD Alan Zarkin, MD Jeffrey Askanazi, MD Gerald Barnes, MD

Dean Faiello, MD Jayant Patel, MD Dennis Roark, MD Harold Shipman, MD

impersonated a
psychiatrist with 100’s of
David Tremoglie Neel Sheth patients in Philadelphia
Michael Swango, MD Alan Zarkin, MD Jeffrey Askanazi, MD Gerald Barnes, MD

Dean Faiello, MD Jayant Patel, MD Dennis Roark, MD Harold Shipman, MD

physician impersonator
in Ohio residency
David Tremoglie Neel Sheth program
whenbad
or imp oste r
physicians slip
through the system,

patients
pay the pric e!
 what is
credentialing?
how does it stop
bad / imposter physicians
from reaching patients?
credentialing is ….

applications and forms

Federal law requires that hospitals develop

applications and privilege request forms for new and
re-applying physicians
credentialing is …

getting your
hands dirty
and verifying with the
“primary source”
the following:
(1) Medical School, (2) Internship, (3) Residency,
(4) Fellowship, (5) Board Certification, (6)
Fluoroscopy, (7) Medical Licensure, (8) ECFMG, (9)
DEA, (10) Insurance [malpractice claims history], (11)
current and previous hospital affiliations and work
sites, (12) peer references, (13) NPDB, (14) OIG,
(15) GSA, (16) Megan’s Law, (17) CME, (18) PPD /
health status; and (19) current clinical competency
(activity logs from current and previous hospitals)
credentialing is …

reading between
the lines
Verifying
everything
claimed with
everything
verified
credentialing … saves lives
what else
is Medical Staff
Management?
 “if it’s not
documented
it didn’t happen”

meeting management …
 Department of Anesthesia
Department of Medicine
Board of Trustees Medical
Department of Obstetrics & Gynecology
Executive
Department of Pathology
Committee
Department of Pediatrics
Department of Radiology
Quality Department of Surgery
Council
Presidents Multidisciplinary Peer
Review Committee
Council
Departments and Committees

Bylaws Committee Performance Improvement Committee Patient Safety

Cancer Committee Subcommittee
Pharmacy & Therapeutics Committee
CME/GME/Library Committee Physician Well-Being Committee AMI+CHF
Credentials Committee Utilization Management Committee Core Measure Team
Ethics Committee
Health Information Committee Pneumonia
Core Measure Team
Interdisciplinary Practice Committee
Infection Control Committee SCIP Core Measure Team

Medication Usage and Safety Team

This is what Medical Staff Management “documents”
minutes are what regulators review to
evaluate evidence of compliance.
anything else?
Continuing - 100 hours req’d every 4 years
Medical - weekly activities
Education

- medical student, resident and

Graduate fellow rotations
Medical
Education

- over 100 medical journals and

Medical 2 databases
Library
orientation
how can
I tell if
my
me dical
staff is
saving
patient
 8710
the

a medical staff management professional consultancy

btrice1@cox.net
guenther450@gmail.com