Medical Staff Bylaws Changes You Can’t Ignore! Traditional Medical Staff Bylaws Charlotte Jefferies A Scary Horty, Springer & Mattern Read! Bylaws must comply with the Medicare Conditions Medicare CoPs are standards that of Participation all hospitals must achieve in (CoP) requirements. order to receive reimbursement. (42 C.F.R. §482.1, et seq. ) The medical staff is Hospital’s governing body is accountable to governing legally responsible for body and must “collaborate” quality and safety. with hospital leadership.
Why Revise? • Changes in legal and regulatory The process of accountability standards must be in the medical staff bylaws, rules and regulations and policies. Why Revise? Medical Staff Bylaws Should: • Protect leaders from frivolous • Easier to read, understand and use! claims • Resolve ambiguities/conflicts/ inconsistencies • Anticipate, and head off, likely arguments by adverse attorneys • Regulatory and accreditation • Implement best practices compliance Goal: Goal: Create a culture that aims to help Provide competent, safe and all staff members be successful — professional patient care. if they so choose! • Clinical competence • Professional conduct
CoP-specific requirements: Medical staff accountabilities and responsibilities: • Approved by the governing Board • Description of staff organization • Collecting, verifying and evaluating • Description of duties and privileges of each staff credentials category • Recommending individuals for • Description of qualifications for appointment appointment and clinical privileges and privileges • Recommending requirements for H&P • Requirements concerning history and physical exams • Recommending professional review • Criteria for privileging actions regarding a staff member’s • Description of monitoring process for quality appointment and privileges care determinations • Directing clinical departments or clinical • Approval of rules and regulations and related documents services • Description of due process Three accrediting bodies with “deemed” status: • The Joint Commission (“TJC”) TJC requires: • AOA Healthcare Facilities Accreditation Program (“HFAP”) EPs 12-36 must appear in the bylaws. • Det Norske Veritas Healthcare, Ind. (“DNV”) Focused Professional Practice Evaluation MS.4.30 If the EP involves a process , at a • Medical Staff defines the minimum, basic steps of the circumstances requiring monitoring process must be in the bylaws. and evaluation of a practitioner’s professional performance.
Ongoing Professional Practice Evaluation MS.4.40 • Ongoing professional practice Conflict Resolution evaluation information is factored into the decision to and Management • maintain existing privilege(s) • revise existing privilege(s), or • revoke an existing privilege prior to or at the time of renewal Best Practice: Best Practices: Incorporate HCQIA standards for • Add collegial and informal notice and hearings. efforts • 30 days • Add investigative procedure • Statement of Reasons • Add precautionary suspension/restriction • Witnesses, documents • Add “automatic relinquishment” • Counsel • Written decision Grounds for a hearing: Best Practice: • Limit to HCQIA “adverse actions” Strengthen qualifications for • For other matters, allow informal appointment. meetings, written explanation for file
“Burden of Proof” Best Practice: Hearing Committee shall uphold Don’t ignore misrepresentations, MEC’s recommendation, unless misstatements and omissions on it was arbitrary, capricious, not the application for appointment supported by credible evidence and clinical privileges. Any misstatement or If appointment has been misrepresentation in, or granted prior to the discovery, omission from the application appointment and privileges should be grounds to stop the may be deemed to be processing of the application. “automatically relinquished.” In either situation, there should be no entitlement to a hearing or appeal; however, the applicant or staff member should be H & P permitted to submit a written response to the reviewing body before the processing is stopped or automatic relinquishment becomes effective.
Interpretive Guidelines Interpretive Guidelines §482.24(c)(2)(i)(A) and Survey §482.24(c)(2)(i)(A) and Survey Procedure: Procedure: The medical record must include documentation that a medical history and When the H&P is conducted within 30 days physical examination (H&P) was completed before admission or registration, an update and documented for each patient no more must be completed and documented by a than 30 days prior to hospital admission or licensed practitioner who is credentialed and registration, or 24 hours after hospital privileged by the hospital’s medical staff to admission or registration, but in all cases perform an H&P. prior to surgery or a procedure requiring anesthesia services. Interpretive Guidelines §482.24(c)(1)(iii) and Survey Procedure: If there is no state law designating Verbal Orders a specific time frame for authentication of verbal order, then such orders must be authenticated within 48 hours. Now … • Information from Medicare participating hospital may be used if Telemedicine Privileges it: • includes list of privileges; and • attestation that information is complete, accurate and up to date
Now … Now … • Practitioners are subject to FPPE and • Credentialing and privileging must OPPE be the same for all LIPs • Privileges must be renewed at least • CVO may be used every 2 years Best Practice: Best Practice: Conditional reappointment can Describe the process for be used to impress needed consideration of “waiver” requests. improvements. Physician Employment Agreement Physician must at all times maintain appointment and clinical privileges at the hospital, and abide by all bylaws, Employed Physicians policies, rules and regulations of the medical staff and hospital.
Physician Employment Agreement (Cont’d.) Reserve the authority to act in accordance with the terms of the Agreement and any applicable What is different if the employment policies when such action physician is an employee? is more appropriate to the circumstances. Age Discrimination in Americans with Employment Act Disabilities Act (ADEA) (ADA)
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