What to look for when reviewing your bylaws

The Greeley Company reviews bylaws for medical staffs nationwide.  No two sets of bylaws should look the same.  Although there is a base of legal and regulatory compliance that must be built upon, there are myriad options that can be chosen by medical staffs in order to be consistent with the culture of the organization.

When we review bylaws, there are several areas that are still problematic. Let’s discuss the most common problem areas.

 

1.       The fair hearing and appeal process 

The expansive fair hearing process dictated by the Health Care Quality Improvement Act of 1986 provides the foundation.  It is applicable to all physicians and dentists, and all members of the medical staff because regulatory agencies require the same fair hearing and appeal process for all medical staff.  Individuals who do not fall into either of these categories have fair hearing and appeals rights only if they are privileged through the medical staff process.  A simpler process for this group can be used as long as the following requirements are met:

·         It is a two-step process of fair hearing and appeal

·         The appeal is made to the hospital’s governing board, just as it is for members

 

2.       Emergency vs. disaster privileges

 

Emergency and disaster privileges are different.  Emergency privileges are granted to existing practitioners on the staff to do something outside their regular set of granted privileges in order to save the life, limb, or organ of a patient. 

 

Disaster privileges are granted to individuals who do not currently have privileges in the organization but request privileges to assist in a declared disaster.  There are specific requirements of what is needed to privilege these individuals.

 

3.       Temporary vs. expedited credentialing

 

Temporary privileges are recognized for two specific reasons:

 

·         Important patient care need 

·         An application of no concern awaiting approval by the medical staff executive committee and governing board. 

Each of these types of temporary privileges has a different set of information that must be collected and verified prior to granting of privileges.  There are also different levels of review which must be done prior to granting these two very different types of temporary privileges.

 

Expedited credentialing is an accelerated governing board approval process.  The application has received full scrutiny and approval all the way through the medical staff executive committee and is only awaiting governing board approval.

 

4.       Qualifications for the president of the medical staff/chief of staff

 

Currently, CMS and the accreditation agencies restrict this position to only physicians and dentists.  CMS is considering whether to expand the professionals who qualify for this position. Until CMS and the accreditation agencies change their rules, the position must be restricted to physicians and dentists.

 

5.       History and physical (H&P) examination requirements

 

CMS requires that the bylaws, not the rules and regulations or other documents, define:

 

·         Who may perform the H&P examination

·         The timeframe in which the H&P and any attendant update must be completed

 

6.       Conflict resolution

 

Almost all bylaws make some reference to a committee, commonly called the Joint Conference Committee, which meets when issues arise between the medical staff and the governing board.  Less often, bylaws contain specific conflict resolution language to address situations where there are issues between the organized medical staff and the medical staff executive committee.  Commonly used tools such as the ability to call a meeting to change policy, vote on an amendment, or remove elected officers are present, but scattered throughout the bylaws, and are not recognized as a conflict resolution mechanism.

 

7.       Leadership conflict of interest

 

This is an area that is not commonly addressed in bylaws but very important. Medical staff leaders can wear many hats and these may sometimes be in conflict with each other. The medical staff should proactively define when the conflict of interest is too great for the leader to successfully fulfill the responsibilities of the position and the manner in which this is dealt.

Check these areas out in your bylaws. Review the regulations on these issues and ensure that you are in compliance and making appropriate decisions beneficial to the medical staff and patient care in the institution.

 

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