MEDICAL STAFF

An important area of responsibility for the Board is that of medical affairs. Trustees are responsible for all activities of the hospital, including ensuring the quality of the medical care.

This does not mean that the Board tells physicians how to treat their patients. Just as there is a way to delegate the administrative activities of the hospital, there is a way to delegate and yet control the quality of health care.

The Governing Board grants to the medical staff the privilege of establishing its own bylaws, rules and regulations. These must have the approval of the Board to become effective. The medical staff holds individual members accountable for the quality of care they provide to their patients.

MEDICAL STAFF ORGANIZATION         Top

The medical staff is composed of licensed physicians and may include other licensed professionals who are permitted to provide patient care services in the hospital. The medical staff has the overall responsibility for the quality of professional services provided to patients by those with clinical privileges. The medical staff organization provides a mechanism for accountability to the Governing Board for these activities.

Hospitals may have a chief of staff, president of the medical staff or chief medical officer. Larger, non-teaching hospitals may have a vice president for medical affairs (VPMA) and/or a chief of staff. The chief of staff or VPMA is responsible for the organization and conduct of the medical staff, and is viewed as the critical link between the Governing Board and the medical staff. The chief of staff or VPMA must be a physician and must have his or her duties defined in writing.

The position may be paid and full-time in larger hospitals or nonpaying and part-time in smaller hospitals. The chief of staff may report to the Governing Board directly or through the chief executive officer (CEO); however, it is the responsibility of the Governing Board to determine to whom and how this individual will report.

The vice president for medical affairs is a physician who is an employee of the hospital. The vice president can be part- or full-time and usually has training in management, economics or organizational psychology. The vice president for medical affairs is the critical link between the CEO, the chief of staff and the medical staff and reports to the CEO.

FUNCTIONS OF THE MEDICAL STAFF         Top

The medical staff should be organized to carry out the following functions:

• Makes recommendations to the CEO and the Governing Board for the establishment, maintenance and continuing improvement of professional standards
• Reviews, analyzes and evaluates the clinical practices of all medical staff members
• Determines the quality of medical care provided in the hospital
• Establishes a mechanism for reporting to the Governing Board on the quality of medical care
• Makes recommendations for enforcement of professional standards and the implementation of corrective action when required
• Makes recommendations concerning the appointment and reappointment of physicians to the medical staff and the delineation of privileges for each appointee
• Supervises and ensures compliance with medical staff bylaws and regulations, and adherence to policies of the hospital
• Exercises necessary discipline within the authority delegated by the Board
• Provides input to the budget process
• Assists in planning hospital goals to meet community needs
• Maintains educational programs
• Monitors and supervises postgraduate trainees if the hospital has a medical training program

THE GOVERNING BOARD AND THE MEDICAL STAFF         Top

Although the Governing Board delegates to the medical staff and others the responsibility for patient care, it retains the ultimate authority for the quality of medical care. The Governing Board must work with and rely upon the medical staff for assistance in meeting this important obligation.

The Governing Board gives the medical staff the responsibility and authority for investigating and making recommendations on all matters relating to medical staff membership. This includes status, clinical privileges and disciplinary and corrective action. The following principles will enhance the efficacy of medical staff members:

• The purposes of the medical staff organization must be clearly stated, understood and accepted by all parties. They must be consistent with the overall mission and purposes of the hospital.
• Staff functions must be stated clearly in writing and directly relate to the purposes of the medical staff organization.
• The responsibilities of each medical staff position must be clearly stated.
• The authority to carry out each position’s responsibilities must be delegated and clearly defined by the Governing Board.
• The Governing Board must clearly define the channels of accountability.
• The managerial parameters of purpose, function, responsibility, authority and accountability for the medical staff organization must be clearly defined in the hospital’s bylaws.

The Governing Board is responsible for the quality of patient care. In exercising that responsibility, the Board has final approval of the selection of a qualified medical staff. In reviewing the recommendations made to the Board by the medical staff, the Governing Board should be sure that it:

• Reviews and approves the medical staff bylaws.
• Reviews and approves the criteria and procedures used for the credentialing and privileging of the medical staff.
• Ensures that data regarding clinical competence is acquired and considered prior to making a recommendation.
• Ensures that the procedures and polices are followed.
• Considers the overall mission and needs of the hospital.
• Communicates with the medical staff when there are questions or areas of disagreement.

MEDICAL STAFF BYLAWS         Top

The medical staff has its own set of bylaws which are the guidelines for its operation. The medical staff bylaws provide for a group of officers and a committee structure designed to carry out the functions and duties of the medical staff. The medical staff bylaws must be approved by the Governing Board and should spell out:

• How individuals are to be recommended for staff appointments and hospital privileges. This includes the qualifications and performance standards to be met by candidates for initial appointment and the criteria and procedures for recommending privileges.
• Mechanisms for monitoring the performance of the medical staff.
• The organizational structure of the medical staff, including the function, size and composition of committees and the method for selecting members
• Procedures for automatic and summary suspension of staff membership and/or clinical privileges.
• Mechanisms for fair hearing and appellate review.
• Procedures for confidential maintenance of peer review records.
• Criteria and procedures for specialist consultation.
• Requirements for medical staff participation in the risk management and quality management programs of the hospital.
• Requirements for frequency of meetings and attendance.

In addition to these duties, teaching hospitals must have specific policies which relate to the operation of post-graduate training programs.

MEDICAL STAFF COMMITTEE STRUCTURE         Top

The Joint Commission on Accreditation of Healthcare Organizations requires that the medical staff have an executive committee. Hospitals have demonstrated a diversity of approaches with regard to the medical staff executive committee. This committee may be composed of the elected physicians plus the department chairs. In a small hospital, the medical staff serves as a committee of the whole.

Committees are usually established to carry out the medical staff’s functions and activities. For example, many medical staffs perform the primary activities of credentialing and privileging through a credentials committee. It is important to remember that required quality assurance functions are often handled by committee(s):

• Surgical case monitoring
• Drug usage
• Pharmacy and therapeutics
• Medical records
• Tissue review
• Mortality and morbidity
• Medical care review/peer review

APPOINTMENT, REAPPOINTMENT AND DELINEATION OF CLINICAL PRIVILEGES         Top

(also see medical staff activities, quality chapter)

It is important that the criteria for medical staff membership and the credentialing and privileging process be objective and based upon the competence of the practitioner. Membership on the medical staff is a privilege, not a right. Courts have affirmed this fact. The criteria for granting staff membership must be reasonable and non-discriminatory. It is critical for Board members to be assured that a practitioner or group of practitioners is not being arbitrarily denied appointment. In order to guard against such a potential occurrence, the criteria for medical staff membership must be clearly stated in the medical staff bylaws, and followed in the credentialing and privileging process.

At least every two years, a review of credentials is required of all clinical staff employed by or associated with the hospital. This includes a review of the physical and mental capacity, competence and performance of practitioners in delivering health care.

Upon recommendation from the medical staff, the Board makes the final decision on each appointment, reappointment and granting of privileges.

The appointment of a practitioner to the medical staff enables that individual to diagnose illnesses and perform procedures in the hospital. Initial appointment to the medical staff should occur only when the following have been reviewed:

• Documentation of medical school graduation and residency
• Evidence of current licensure
• Relevant training and/or experience
• Current competence
• Physical and mental health status
• Evidence of adequate professional liability insurance
• Letters of recommendation

Prior to the granting or reviewing of an appointment and privileges, the hospital should request the following information from hospitals with which that practitioner was associated:

• Any pending professional misconduct proceedings.
• Any judgment or settlement of a malpractice action or findings of professional misconduct.
• Information related to the practitioner’s professional practice during the last ten years.

Verification of the above information is critical to the appointment process. Initial appointment can be made for a provisional period, usually for not more two years. At that point, the individual should be reviewed. Information must be obtained from the National Practitioner Data Bank at each appointment and reappointment time.

The National Practitioner Data Bank was created by federal legislation in 1986. The Data Bank contains information concerning the competence of physicians and other licensed health professionals.

Hospitals are required to report information concerning any actions taken because of the practitioner’s professional conduct or competence. They must report actions that adversely affect clinical privileges for 30 days or more and any restriction or surrendering of clinical privileges while under investigation. The law also requires the hospital to follow a specific process when taking action.

All hospitals must check the Data Bank every two years about the physicians, dentists and other health care professionals on their medical staffs with privileges.

The reappointment process should include an evaluation of demonstrated competence. The hospital will have its own record of the physician’s performance as well as the physician profile, which is composed of information from the following:

• Mortality and morbidity review
• Tissue review
• Medical record review
• Infection control review
• Utilization review
• Patient complaints
• Safety committee review
• Liability claims data
• PRO data
• Drug utilization review
• Surgical case review
• Medical case review
• Any medical care evaluations
• Participation in continuing education
• National Practitioner Data Bank

The hospital must check with the National Practitioner Data Bank unless it has knowledge of any information that has been reported to the Data Bank.

The privileges granted to members of the medical staff must be consistent with their training and experience. In delineating clinical privileges, there should be specific qualifications identified with having certain privileges. There should be a procedure for granting and withdrawing privileges.

Hospitals should not continue to grant privileges to physicians for services which they do not routinely perform. There is considerable evidence in medical literature which shows that favorable outcomes for a number of procedures are directly related to how frequently the procedure is performed.

The need for specific services can also be taken into consideration in the granting of clinical privileges. Hospitals must be able to provide appropriate facilities and support services for the practitioner and the patient. In those instances in which there is a lack of either facilities or services, privileges may be denied.

Medical staff membership does not automatically confer the privilege to admit patients. When non-physicians are granted admitting privileges, a qualified physician must perform a prompt medical evaluation of the patient. The privilege of admitting patients is a clinical privilege delineated for each practitioner.

DUE PROCESS         Top

Due process procedures must be in place and defined in the medical staff bylaws. Fair hearing procedures and the opportunity for appellate review must be extended to members of the medical staff. In credentialing cases, the bylaws should state the period of time within which a practitioner will be notified of an adverse decision and his or her right to request a hearing.

RECRUITMENT AND RETENTION         Top

Recruitment of physician staff should be carefully planned to meet the needs of the community. Hospital/health system trustees should consider current available staff, appropriate services which can be efficiently provided, the hospital’s geography, population demographics, community needs and location of referral sources in determining the types of physicians to recruit. This information can be used to develop a medical staff recruitment plan. Recruitment of physicians can be particularly challenging for hospitals in rural communities. Hospital/health systems should consult legal counsel before offering recruitment inducements to physicians including income guarantee. Once recruited, all hospitals should be concerned about keeping their medical staff.

Retaining a stable medical staff involves including physicians in the planning processes of the hospital. Inclusion in Governing Board meetings and on committees is one method to accomplish this goal. Trust, communication and cooperation of the Governing Board, CEO and medical staff as they work together to carry out the hospital’s mission is important to having and keeping a quality medical staff. The successful hospital is one where there is a shared sense of mission between the Governing Board, management staff and the medical staff.

REFERENCES         Top

Bader, Barry, Institute for New Trustees, Hospital Trustees of New York State, Albany, NY, September, 1992.

Bailey, Charles, General Counsel, THA-The Association of Hospitals and Health Care Organizations, Austin, TX, January, 1998.

Hospital Trustees of New York State, The Trustee Handbook, Albany, NY, September, 1988.

Hospital Trustee Association of Pennsylvania, HTA Trustee Folios, Harrisburg, PA.

Joint Commission on Accreditation of Healthcare Organizations, 1998 Hospital Accreditation Standards, Oakbrook Terrace, IL, 1998.

Orlikoff, James and Mary Totten, "The Board-Physician Partnership: Enhancing Leadership Potential," Trustee Workbook, Nov/Dec, 1997.

Turbin, MD, Richard, Vice President of Medical Affairs, St. David’s Hospital, Austin, TX, July, 1996.

Wall, Matthew, "Memorandum National Practitioner Data Bank," Texas Hospital
Association, Austin, TX, April 24, 1990 and interview December, 1995.