First Steps to Designing a High-Performing Medical Staff

Any healthcare organization is only as good as its medical staff. The best physicians will provide the best care and every hospital has in place a medical staff organization whose job it is to ensure that the quality of care is as good as it can be. They do this through recruitment, peer review, credentialing, and privileging – a seemingly rigorous process to regularly evaluate performance, which is vital for sustaining quality of care in any healthcare organization. However, the structure and processes of most medical staff organizations were designed for the healthcare system of yesterday and no longer fulfill their essential mission.

At last count, 67 percent of physicians were employed and 33 percent independent. More young physicians and more women physicians are employed, while more older men physicians remain independent. Older men also tend to dominate positions on the medical executive committee (MEC) and as department chairs, which can cause some generational and gender issues. Competing practices are often represented on medical staffs, which presents conflicts of interest. And because more care is being delivered in outpatient settings, direct observation must give way to indirect evidence to assess peers and quality of care.

This all leads to more and greater challenges beyond the formal evaluation of physicians for credentialing and privileging. It leads to a host of problems that increase risk and undermine the quality of care itself:


To address these challenges and ensure quality of care requires redesigning for medical staff optimization, which can be accomplished in five steps:

  1. Assess terrain: A full and unbiased evaluation of current medical staff, especially those in leadership roles, including their skills and suitability to their positions, as well as a review of current policies and processes, followed by an assessment of how well the current structure supports the organization’s objectives.
  2. Develop strategy: Work with key stakeholders to create a transformation strategy that will align the structure and functions of the organized medical staff to the mission of the hospital or health system.
  3. Engage and align: Communicate strategy and reasons behind it to the medical staff and secure their agreement and cooperation. Provide support (i.e. coaching, training) for staff members to ensure they are adequately prepared for new structure and processes.
  4. Transform: Implement changes in accordance with pre-determined timeline, accounting for dependencies and taking time to ensure one phase is satisfactorily complete before moving to the next.
  5. Sustain: Medical staff structure and governance became irrelevant to its purpose over time, partly because it was not designed to be nimble and partly because there was no mechanism in place to monitor and sustain its effectiveness. New members must be formally onboarded to ensure their suitability to the organization and to their roles as leaders who anticipate change. Quality measures must be monitored continuously and processes regularly reviewed. Otherwise, the newly optimized medical staff will quickly fall behind the rate of change in healthcare.

For more information about how to assess and optimize your medical staff, please contact 

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