Center for Improvement in Healthcare Quality Newsletter
May 2022

News You Can Use

May Compliance Tip of the Month

May’s compliance tip of the month is focused on two new CIHQ standards in the Medical Staff chapter. In March a notification was sent to each hospital outlining standard changes or updated. As a result of our standards review, MS-12: Appraisal of Practitioner and MS-13: Peer Review were added.
CIHQ felt that there was a gap in giving the medical staff some guidance on an effective appraisal system as well as one that guides a peer review process when determining whether or not a standard of care was met.
Challenges that face organizations with regard to compliance include but are not limited to conducting a meaningful appraisal every 24 months that include all the required elements and adhering to the definition of a peer (see glossary) in the online standards and resource section of the hospitals extranet site.
Both the CMS and CIHQ standards/requirements have been included for reference.


MS-12: Appraisal of Practitioners
The medical staff must at regular intervals appraise the qualifications of all practitioners appointed to the medical staff and/or granted medical staff privileges.
  1. In the absence of State law to the contrary appraisals must be conducted at least every 24 months for each practitioner.
  2. Appraisals must evaluate each individual practitioner’s qualifications and current competence to perform privileges granted by the governing body. Said evaluation should at least include:
    • Current work practice and quality of work performed.
    • Special training and education – including maintenance of any required continuing education.
    • Adherence to medical staff rules, regulations, and policies.
    • Maintenance of appropriate licensure and certification requirements.
    • Results of peer review activities. See MS-13
  3. The results of appraisals are used at the time of reappointment – or earlier if warranted – to form, in part, the basis for making recommendations to the governing body to continue, revise, discontinue, limit, or revoke some or all of the practitioner’s privileges and/or membership on the medical staff.
MS-13: Peer Review
The medical staff must develop and implement a peer review process to monitor the quality of care rendered by practitioners who have been granted clinical privileges.
  1. The process must identify the specific aspects of a practitioner’s care that will be subject to review. B
  2. The process must identify who is responsible for conducting the review (i.e., an individual peer, a committee of peers, etc.). See the glossary for the definition of a peer.
  3. The process must identify the time frame in which the review is to be performed.
  4. The process must identify circumstances that require review by a peer who is not on the medical staff (e.g., outside review).
  5. The process must include notifying the practitioner subject to review in a timely manner so as to afford the practitioner an opportunity to provide information that may be pertinent to the review.
  6. The process must assure that, at a minimum, a determination is made as to whether the practitioner met the standard of care on the matter being reviewed. If a determination is made that the practitioner did not meet the standard of care, then this information is included in the appraisal of the practitioner. See MS.12
  7. The process must assure that the practitioner subject to review is informed of the results of the review.


§482.22 Condition of Participation: Medical Staff
§482.22(a) Standard: Eligibility and Process for Appointment to Medical Staff
  1. The medical staff must periodically conduct appraisals of its members.
There are tools to assist with compliance. These are made available to CIHQ accredited organizations and are as follows:
ARS Resource Library – Medical Staff Section
#1406 – Tool Medical Staff Periodic Performance Appraisal
#1408 – Tool – Medical Staff Quality Review Form
#3225 – Policy – Medical Staff Peer Review

CIHQ Announces New Disease Specific Certification – Primary Heart Attack Center

CIHQ proudly announces the launching of a new disease specific certification program for Primary Heart Attack Center. This certification is designed to recognize the provision of evidence-based best practice to patients experiencing a heart attack requiring interventional cardiac services. The standards for this disease specific certification are based on the 2021 American Heart Association Guideline for Artery Revascularization and the 2020 American Heart Association Acute Coronary Syndrome Algorithm. For more information click on the DSC on your extranet home page. Not accredited by CIHQ you can still become certified in any one of our programs and can get our standards and information at

CIHQ to Join Soleran’s Compliance Think Tank Webinar Panel

Join CIHQ’ own Senior Facility Specialist Billy Kinch and Soleran’s Compliance Think Tank Webinar panel for perspective on current and upcoming changes for a facility’s water management program. Strategies and mitigation concepts will be discussed as well as the difference in ASHRAE 188 concepts compared to your accrediting agency requirements. A current water management program will also be provided to help the attendee relate with real-time operations.
The Webinar will be May 12, 2022 at 1:00pm Central Time. To register click here.