Medical Staff Consulting

We help health care providers nationwide maintain medical staff compliance. From ensuring that an accurate and effective governance structure is in place, to assisting in the implementation of an effective quality process, to supporting the fair hearing process and providing educational support, we ensure our clients remain compliant with evolving laws while making effective use of their resources.


We work closely with medical staff leadership and administration to facilitate a collaborative process designed to create a set of compliant documents tailored to each hospital or health system. We are also well-equipped to help medical staffs navigate issues unique to health systems, such as consistency of documents, process and the creation of joint committees.

Our consultants:

  • Review and amend medical staff bylaws, policies and procedures for compliance with Medicare conditions of participation, applicable laws and private accrediting entity standards
  • Conduct system-wide reviews of medical staff governing documents and processes
  • Make recommendations for standardization across system hospitals
  • Provide a critique to be used as an internal work plan to discuss and revise bylaws and policies

We recognize that quality is the lodestar of all health care entities. In today’s complex health care world, the concept of quality arrives in numerous forums — medical staff, hospital staff, compliance, regulatory, employment and affiliations, to name a few. We look at the big picture and individual components, always with an eye towards identifying and improving quality of care.

Our consultants:

  • Develop professional practice evaluation policies and processes in both the medical staff and employed practitioner arenas
  • Develop sharing of information policies for internal use within a system or a hospital as well as for external use with affiliates or third parties
  • Make recommendations and assist in creating triaging processes for deciding the best forum(s) in which to address quality of care concerns (both clinical and professional conduct)

Our consultants have in-depth experience managing medical staff matters and conducting fair hearings. We have long-term experience and a comprehensive understanding of the unique requirements of medical staff bylaws, fair hearings processes, procedural due process standards and citizenship expectations during a fair hearing.

Our specific services include:

  • Providing objective guidance to physician hearing panels
  • Negotiating, mediating and managing competing interests to assure an objective and defensible process
  • Coaching and educating practitioners, medical staffs, advanced practice providers, office professionals and quality staff in the hearing process both with respect to individual roles and hearing process expectations

Additionally, our presiding and hearing officers:

  • Manage the hearing process (pre-hearing, the hearing and post-hearing matters) consistent with the medical staff bylaws (and federal and state law to the extent applicable)
  • Coordinate with the medical executive committee attorney representatives, the medical staff and quality offices
  • Conduct onsite hearings
  • Prepare reports, recommendation or other required documents

Our team offers tailored education and training for governing body, medical staff and quality leaders. Provided by health care attorneys, physician leaders and health care consultants, we ensure that our clients receive comprehensive and quality information, as well as best practices. From the management of staff and clinical service lines to providing quality care and addressing current business issues, our education services consider and integrate current industry trends.

Topics include:

  • Quality care initiatives for ambulatory/inpatient services
  • Medical staff leadership
    • Medical staff governing documents
    • Credentialing, privileging and peer review
    • Informal remediation and corrective action
    • Fair hearings
    • Reporting obligations
  • Clinical integration
  • Medical staff, employment and service line integration

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