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If you think your hospital’s medical staff bylaws are outmoded, you’re undoubtedly right. Even so, evaluate the complete picture before taking action. Danger may await you, especially if you are new to the organization.
Outmoded bylaws can be a symptom of entrenched, defensive, or reactionary leadership, weak governance, and strained medical staff – hospital relations. There may be lack of skill, poor cooperation, and a low level of trust: not a great environment in which to launch a potentially contentious project like bylaws revision. In fact, it’s a recipe for failure.
I recently met with a CMO who has been trying to do change his seriously outmoded medical staff bylaws for the entire 2 years that he has been in his position. On the first volley, the medical staff leadership hired an attorney. It went downhill from there. He would have failed outright due to strong resistance to change, low trust, etc. By good fortune alone, he finally got some traction a year ago when the medical staff’s attorney actually admitted ignorance and recommended hiring an outside consultant. Even then, they are still months away from final approvals and implementation.
Much quicker time to value and greater likelihood of success would have been obtained by addressing root causes. What might seem indirect with respect to the symptom of outmoded bylaws is actually more efficient and rewarding in healing the organization. Build trust and skills by engaging medical staff leadership in an important project under their control, preferably one that’s not politically charged.
I’ve done this using peer review as the platform. It’s a natural responsibility of the medical staff. Improvements undertaken through my approach are not threatening and can be implemented in as little as 3 months. The exercise can innocently expose weaknesses in the current bylaws and governance structure while developing greater governance competency. A more fair and effective peer review process promotes the natural desire to do the right thing. The improvements obtained are appreciated by and build good will with hospital administration. This helps to catalyze a virtuous cycle of cooperation. Once the trust is there, it’s much easier to move on to facilitate the design of revised bylaws.
Bylaws: The Constitution
If, however, you need to tackle the bylaws before moving on to other priorities, I have a few recommendations to consider: first, some general points, and then some specifics about provisions that will later enable a peer review program that can effectively impact quality of care.
My philosophy is that the bylaws are the “Constitution” of the medical staff, not the “legislation” (i.e., policy and administrative procedure). They provide the framework for physician-hospital cooperation in pursuit of quality. JC language supports this distinction (page MS-8, item 19). They should rarely require change. They need to support the medical staff’s efforts to effectively self-govern, at the same time that they enable the hospital to comply with regulatory and accreditation standards.
This means that they need to be compact and flexible enough to endure. If it doesn’t absolutely need to be in the bylaws, it’s better to put it in another document, such as a policy or the Rules and Regulations, for which change can be more easily obtained.
The bylaws are not generally considered as a factor in physician recruitment and retention. Yet, you undoubtedly provide a copy to all members of the medical staff and new applicants. The style, clarity, and tone of language advertise certain qualities of the organization. Make sure that they reflect your desired image.
More importantly, the bylaws are the roadmap that will guide your leadership in dealing with the uncommon, but uncommonly difficult process of corrective action. Make sure that you can and want to follow all the steps.
Provisions that Support Good Peer Review Process
The following points are worth considering as you re-design your bylaws in the context of your goals for improvement and other companion documents, including
the rules & regulations, hospital and medical staff administrative policies, etc.
- This is the JC’s updated approach to competency assessment. Many organizational processes, including peer review, contribute. While such activity is supported by various provisions in bylaws and other policies, don’t try to hardwire the whole thing in the bylaws.
- Definition of Peer Review
- Be careful if you attempt to do this outside of the peer review policy. Peer review should be an exercise in performance evaluation and feedback. Clinical performance is context-sensitive and is vulnerable to situational factors, including latent faults in the system of care. By contrast, the credentialing and privileging sections of the bylaws are all about competence. Competence is an enduring quality that is unlikely to change quickly in the absence of a physician health problem. Competence is assessed for credentialing and privileging decisions using data that includes the results of peer review activity.
- Definition of a Peer
- A broad definition will offer you the most flexibility. Consider the implications of discipline specific partitions that might disallow peer review of PAs or APRNs by physicians. The medical profession has a long history of peer review. Evaluation of clinical performance is important for all disciplines. It may or may not be accomplished through review by peers.
- Definition of a Quorum
- "Those members present" (perhaps above some minimum). Consider this for general committee meetings and also for your general medical staff and department meetings. The exception might be the MEC and/or Credentials Committee.
- Definition of Professional Behavior
- Be clear about expectations and make it easy to activate the Physician Health process. In my opinion, physician health issues should be handled separately from clinical peer review.
- Board Certification
- Regardless of where your organization has been, why not seek to attract new members who at least have passed this minimal test of training and competence?
- The MEC should have the authority to delegate any oversight responsibility (e.g., for peer review) to a sub-committee that it oversees, which may include non-MEC membership.
- A great concept in support of FPPE/OPPE, which can be difficult to implement, particularly when it requires uncompensated physician time. Be sure you can implement any process that you prescribe. Also, if you defer to your clinical departments the specific criteria regarding numbers and types of activity subject to proctoring, be sure you have a process to get your departments to set them.
- Department Chair Responsibilities
- The chair should have oversight for professional review activity within the department, but should not necessarily be directly charged with making all such judgments, e.g., “Assures ongoing surveillance of the professional performance of all individuals in the department.” In general, it’s better if the department chair does not function as a peer review committee chair (an item for policy, not bylaws). The chair should be accountable to the MEC.
- Hearing/Appeals Process
- The MEC (or designated others, e.g., department chair) should be able to require a preceptor, proctor, concurrent review, or retrospective review without triggering the hearing/appeals process.
- Committee Membership
- Set the minimum requirement of 3-5 members. Such criteria will prevent small sections from trying to set up a separate process that they can’t effectively manage. In this regard, you might also want to make provision for the possibility of having inter-departmental committees (e.g., Maternal-Child, Cardiac Services), as well as cross-representation (multi-specialty).
- Meeting Frequency
- Require peer review committees to meet monthly (10 times per year). This is important to assure timely review activity.
- You will want enthusiastic participation from peer review committee members. Make sure they are offered indemnification. Consider options for compensation.
Also, provision for participation by reviewed physicians in the peer review process may be desirable as good process, but should not be described as a "right".
- Exclusive Contracts
- If your bylaws allow the hospital to make exclusive contracts for physician services (e.g., Anesthesia, Radiology, Pathology, etc.), don’t forget to include performance standards and peer review expectations in any such agreements.
- Obligations of Medical Staff Membership
- Consider including these points:
- Contribute to quality improvement efforts
- Make efficient, cost-effective use of hospital resources
- Make a timely response to requests for information (2-3 weeks)
- Cooperate with any investigations or requests to appear before any committee
- Provide copies of office records on request - at least in relation to peer review of a hospital-treated patient, for whom the physician provided outpatient care.
The Medical Staff may also want the option to examine de-identified office records to evaluate new applicants.
- Abide by medical records standards that may rightfully be in rules & regulations, but should not be overlooked: daily progress notes;
timely dictation of critical documents, such as admission H & Ps, operative reports, transfer summaries; timely chart completion; legibility; use of English; avoidance of unapproved abbreviations; authentication of orders and progress notes; etc.