Bylaws and governance monthly: To be or not to be a medical staff member

In the July 15 issue of Medical Staff Leader Connection, we discussed whether medical staff leadership positions are open to non-physicians. This week, let’s focus on medical staff membership in general, as many medical staffs are now accepting non-physician providers in an effort to increase participation and introduce new perspectives.
 
CMS is very clear in Standard 482.22(a) that the medical staff, at a minimum, must be comprised of doctors of medicine and doctors of osteopathy. But, CMS also considers other types of practitioners as physicians, including doctors of dental surgery or of dental medicine, doctors of podiatric medicine, doctors of optometry, and chiropractors. Whether you choose to allow these other physicians to be medical staff members is truly a decision that is up to your medical staff leadership, unless otherwise governed by state law.

CMS is also very clear in stating that “the governing body has the authority, in accordance with state law, to appoint some types of non-physician practitioners, such as nurse practitioners, physician assistants, certified registered nurse anesthetists, and midwives, to the medical staff.” Again, the medical staff must choose whether to allow these non-physicians to be full-fledged members of the medical staff.

There are a couple of caveats, though, in the Joint Commission standards. One is MS.01.01.01, EP 3, which states “All members of the organized medical staff, of any discipline or specialty, are eligible for membership on the medical staff executive committee.” So you cannot exclude these individuals from serving on the MEC but you must also ensure that:

• The majority of voting MEC members are fully licensed physicians actively practicing in the hospital (MS.02.01.01, EP 4)
• Department chairs meet the qualifications set by The Joint Commission, which includes certification by an appropriate specialty board or affirmatively established comparable competence through the credentialing process (MS.01.01.01, EP 8)
• The president of the medical staff is a doctor of medicine or osteopathy, or, if permitted by state law, a doctor of dental surgery or dental medicine (LD.01.05.01, EP 7)

Let’s also look at the opposite side of the issue – are all physicians medical staff members? In the past, they have been, but do you really want locum tenens physicians or teleradiologists to vote on issues that affect your medical staff? How about moonlighting house staff? The answer many medical staffs have come up with for this issue is to grant such practitioners privileges without membership. 

This is not a new idea – this is what we have been doing for many years for advanced practice professionals (i.e., physician’s assistants, certified registered nurse anesthetists, advanced registered nurse practitioners, and nurse midwives). We’ve just recently expanded it to physicians in certain circumstances, and it is perfectly in sync with regulations. CMS has stated “Practitioners, both physicians and non-physicians, may be granted privileges to practice at the hospital by the governing body for practice activities authorized within their State scope of practice without being appointed a member of the medical staff” (482.22[a]).

The take-home point here is that not all medical staff members may be physicians, and not all physicians may be medical staff members. Tailor your medical staff membership requirements to your our organization.

Mary Hoppa, MD, MBA, CMSL is a senior consultant with The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.