Bylaws and governance monthly: Medical staff leadership--is it limited to physicians?
In the past, podiatrists, dentists, oromaxillofacial surgeons, physicians assistants (PA), and advanced practice nurses may not have been invited to be members of the medical staff. As the role of the medical staff has evolved, however, many medical staffs have been opening their doors to these practitioners. This inclusive approach has caused some medical staff services professionals and leaders to raise an important question: Can these practitioners serve in medical staff leadership positions? Well, it depends on the position. Let’s explore some common medical staff leadership roles to determine where these individuals might fit in.
Medical staff president
The Joint Commission released a new standard (LD.01.05.01, EP 7) in January 2009 to be in compliance with Centers for Medicare & Medicaid (CMS) Condition of Participation (CoP) 482.22(b)(3). It states “For hospitals that use Joint Commission accreditation for deemed status purposes: A doctor of medicine or osteopathy, or, if permitted by state law, a doctor of dental surgery or dental medicine, is responsible for the organization of the medical staff.”
The responsibility noted is that of the medical staff president (or chief of staff) and limits this position to physicians, dentists, and oromaxillofacial surgeons. It also limits the position of president-elect or chief of staff-elect to physicians, dentists, and oromaxillo facial surgeons if the medical staff has a system in place in which leaders are automatically succeeded.
Department chair
The Joint Commission does not require hospitals to organize the medical staff using departments, but if you do have them, the department chair must have certain qualifications and take on a defined set of responsibilities.
The qualifications for department chair are noted under Joint Commission standard MS.01.01.01, EP 8 and state that the individual must have “certification by an appropriate specialty board or affirmatively established comparable competence through the credentialing process.” This limits the position of department chair to physicians, dentists, oromaxillofacial surgeons, and podiatrists.
Other leadership positions
Many medical staffs have other leadership positions, such as treasurer or secretary. In addition, the MEC may include at-large positions and offer ex-officio positions to those who serve as the credentials committee chair or the medical staff quality committee chair.
No regulatory mandate exists regarding who may or may not hold these positions, so they are potentially open to all medical staff members, depending on how your bylaws are written. In fact, you cannot exclude non-physician medical staff members from serving on the MEC because standard MS.02.01.01, EP 3 states “all members of the organized medical staff, of any discipline or specialty, are eligible for membership on the medical staff executive committee.”
There is one other item that should be noted, though. Both CMS’s CoP 482.22(b)(2) and Joint Commission standard MS.02.01.01, EP 4 state that the majority of voting members on the MEC are fully licensed physicians of medicine or osteopathy. You may have non-physician medical staff members on the MEC; they just cannot be the majority.
A second question that frequently comes up when medical staffs open their doors is that of the voting rights of non-physicians who hold leadership positions. The Greeley Company does not see the difference between the voting rights of physicians versus non-physicians when all are medical staff members. Some positions on the MEC may be ex-officio without vote but that would apply to all members holding that position regardless of whether they are physicians or non-physicians.
Alternatively, there may be groups of non-physicians, such as the advance practice professionals (APP), who have privileges but are not medical staff members. Some medical staffs have allowed such groups representation on the MEC to encourage participation and dialogue, but this representation may or may not come with the right to vote based on the medical staff bylaws.
Every medical staff is different, so your bylaws must be crafted to fit the individual needs of your community and staff while remaining compliant with all regulations and laws. If it is time to rethink your medical staff governance and would like assistance, we at The Greeley Company are able to guide you in this process.
Mary Hoppa, MD, MBA, CMSL, is a senior consultant with The Greeley Company, a division of HCPro, Inc. in Marblehead, MA. Next month, she will discuss CMS' expanding definition of "physician."