36C25018Q9284-005.pdf

MEDICAL STAFF BYLAWS AND RULES

OF

VETERANS HEALTH ADMINISTRATION

VA NORTHERN INDIANA HEALTH CARE SYSTEMS (VANIHCS)

FORT WAYNE, INDIANA

REVIEWED DATE: 2017

REVISED DATE: 2017

TABLE OF CONTENTS

TITLE

PREAMBLE

DEFINITIONS

ARTICLE I.

ARTICLE II.

ARTICLE III.

SUBJECT

NAME

PURPOSE

MEDICAL STAFF MEMBERSHIP

PAGE

Section 3.01 Section 3.02

Section 3.03 Section 3.04

ARTICLE IV.

Section 4.01 Section 4.02 Section 4.03

Eligibility for Membership on the Medical Staff Qualifications for Medical Staff Membership and Clinical Privileges Code of Conduct Conflict Resolution & Management

ORGANIZATION OF THE MEDICAL STAFF

Leaders Leadership Clinical Services

ARTICLE V. MEDICAL STAFF COMMITTEES 17

Section 5.01 Section 5.02 Section 5.03 Section 5.04 Section 5.05 Section 5.06

General Clinical Executive Boad Professional Standards Boards Committees of the Medical Staff Committee Records and Minutes Establishment of Committees

ARTICLE VI. MEDICAL STAFF MEETINGS 24

ARTICLE VII. APPOINTMENT AND ONGOING CREDENTIALING 25

Section 7.01 General Provisions 25 Section 7.02 Application Procedures 29

Section 7.03 Process and Terms of Appointment 32

Section 7.04 Credentials Evaluation and Maintenance 33

Section 7.05 LocalNISN-Level Compensation Panels 34

ARTICLE VIII. CLINICAL PRIVILEGES 35

Section 8.01 Section 8.02 Section 8.03

Section 8.04 Section 8.05

Section 8.06 Section 8.07

ARTICLE IX.

ACTIONS

ARTICLE X.

ARTICLE XI.

ARTICLE XII.

General Provisions 35 Process and Requirements for Requesting Clinical Privileges 36 Process and Requirement for Requesting Renewal of Clinical Privilege 38 Processing an Increase or Modification of Privileges 39 Recommendations and Approval for Renewal and Revision of Clinical Privileges 40 Exceptions 41 Medical Assessment 48

INVESTIGATION, SUMMARY SUSPENSION AND PRIVILEGING

FAIR HEARING AND APPELLATE REVIEW 57

RULES AND REGULATIONS 62

AMENDMENTS 63

ARTICLE XIII. ADOPTION

MEDICAL STAFF RULES

1. GENERAL 65

2. PATIENT RIGHTS 65

3. RESPONSIBILITY FOR CARE 68

4. PROVIDERS' ORDERS 73

5. ROLE OF ATTENDING STAFF 75

6. MEDICAL RECORDS 76

7. INFECTION CONTROL 80

8. CONTINUING EDUCATION 810

9. HEALTH STATUS AND IMPAIRED PROFESSIONAL PROGRAM 822

10. PEER REVIEW 822

II

PREAMBLE

Recognizing that the Medical Staff is responsible for the quality of care delivered by its members and accountable to the Governing Body for all aspects of that care, the Medical Staff practicing at the VA Northern Indiana Health Care Systems (VANIHCS) and Outpatient Centers, hereby organizes itself for self-governance in conformity with the laws, regulations and policies governing the Department of Veterans Affairs, Veterans Health Administration (VHA), and the Bylaws and rules hereinafter stated. These Bylaws and Rules are consistent with all laws and regulations governing the VHA, and they do not create any rights or liabilities not otherwise provided for in laws or VHA Regulations.

VAN IHCS comprises of two primary care campuses located in Fort Wayne and Marion Indiana. Goshen, Muncie, Peru, and South Bend, Indiana Community Based Outpatient Clinics (CBOC) are additional components that make up the organization covered by these Bylaws. The CBOC features of NINHCS focus on outpatient care and behavioral health programs providing primary care and mental health services.

Portions of these Bylaws are required by the VA, VHA, or The Joint Commission (TJC). These sections should be maintained in accordance with all current regulations, standards or other applicable requirements. Prior versions of Bylaws and rules and regulations must be maintained in accordance with Sarbanes-Oxley Act which states that Bylaws and rules are permanent records and should never be destroyed. They must be maintained in accordance with Record Control System

(RCS) 10-1, 10Q.

DEFINITIONS

For the purpose of these Bylaws the following definitions shall be used:

1. Advance Practice Professionals: Advance Practice Professionals are those health care professionals who are not physicians and dentists and who, will, function within a Scope of Practice but may practice independently on defined clinical privileges as defined in these Bylaws. Advance Practice Professionals include: physician assistants (PA), and advanced practice nurses (ARNP, CRNA, and CRNP) and Clinical Pharmacy Specialists. Advance Practice Professionals may have prescriptive authority as allowed by Federal Regulation, and/or state of licensure statute and regulations, under the supervision of a credentialed and privileged Licensed Independent Practitioner when required. Unless privileged to do so, Advance Practice Professionals do not have admitting authority. Advanced Practice Professionals may initiate prescriptions for non-formulary drugs or prescribe controlled substances in accordance with state of licensure statutes and regulations.

Advanced Registered Nurse Practitioners and other health care professionals may be granted defined clinical privileges when allowed by law and the facility (this is a facility decision).

2. Appointment: As used in this document, the term Appointment refers to appointment to the Medical Staff. It does not refer to appointment as a VA employee but is based on having an appropriate personnel appointment action, scarce medical specialty contract, or other authority to provide independent medical, Advance Practice Professional and/or patient care services at the facility. Both VA employees and contractors providing patient care services must receive appointments to the Medical Staff.

3. Associate Director: The Associate Director fulfills the responsibilities of the Director as defined in these Bylaws when serving in the capacity of Acting Facility Director.

4. Associated Health Professional: As used in this document, the term "Associated Health Professional" is defined as those clinical professionals other than doctors of allopathic, dental, and osteopathic medicine. These professionals include, but are not limited to: Pharmacists (Pharm-Ds), psychologists, podiatrists, and optometrists.

Associated Health Professionals function under either defined clinical privileges or a defined scope of practice.

5. Automatic Suspension of Privileges: Suspensions that are automatically (administratively) enacted whenever the defined indication occurs which warrants a suspension of privileges, and does not require discussion, investigate and do not require discussion, investigation of clinical care concerns or results from concerns of substandard care, professional misconduct, or professional incompetence.

Examples are exceeding the allowed medical record delinquency rate when such delinquency does not impact patient care, conduct/behavior issues not impacting patient care or failure to maintain qualifications for appointment, extended sick leave, or other extended leave. Privileges are automatically suspended until the cause of the suspension has been addressed such as.the records are completed or the delinquency rate falls to an acceptable level or provider returns to duty. Reactivation must be endorsed by the Clinical Executive Board and discussion of reactivation should include consideration of a Focused Professional Practice Evaluation (FPPE) depending upon length of time away from practice and reason for the automatic suspension.

6. Chief of Staff: The Chief of Staff is the President of the medical staff, Chairperson of the Clinical Executive Board, and Chairperson of the Professional Standards Board.

The Chief of Staff also acts as full assistant to the Director in the efficient management of clinical and medical services to eligible patients, the active maintenance of a medical credentialing and privileging and/or scope of practice system for Licensed Independent Practitioners, Advance Practice Professionals and Associated Health Practitioners. The Chief of Staff ensures the ongoing medical education of medical staff.

7. Community Based Outpatient Clinic (CBOC): A health care site (in a fixed location) that is geographically distinct or separate from the parent medical facility. A CBOC can be a site that is VA-operated and/or contracted. A CBOC must have the necessary professional medical staff, access to diagnostic testing and treatment capability, and the referral arrangements needed to ensure continuity of health care for currently and Potentially eligible veteran patients. A CBOC must be operated in a manner that provides veterans with consistent, safe, high-quality health care, in accordance with VA policies and procedures.

8. Contract Practitioners: Contractor or subcontractor Practitioners are subject to compliance of this facility's Bylaws and VA policies as well as being reported to the National Practitioner Data Bank or respective state licensing board for substandard care, professional misconduct, or professional incompetence. Removal of a contract practitioner from a contract results in an automatic revocation of privileges. The Contract Provider will be afforded a limited fair hearing to determine only if the revocation of privileges was based upon substandard care, professional misconduct, or professional incompetence and reportable to the National Practitioner Data Bank (if Practitioner is a physician or dentist).

9. Director (or Facility Director): The Director, sometimes called Chief Executive Officer, is appointed by the Governing Body to act as its agent in the overall management of the Facility. The Director is assisted by the Chief of Staff (COS), the Associate Director (AD), the Associate Director for Patient Care Services (AD-PCS), and the Clinical Executive Board.

10. Governing Body: The term Governing Body refers to the Under Secretary for Health, the individual to whom the Secretary for Veteran Affairs has delegated authority for administration of the Veterans Health Administration; and, for purposes of local facility management and planning, it refers to the Facility Director. The Director is responsible for the oversight and delivery of health care by all employees and specifically including the medical staff credentialed and privileged by the relevant administrative offices and facility approved processes.

11. Licensed Independent Practitioner: The term Licensed Independent Practitioner (LIP) refers to any individual permitted by law and by the VANIHCS to provide care and services, without direction or supervision, within the scope of the individual's license and consistent with individually granted privileges. In this organization, this includes physicians and dentists. It may also include individuals who can practice independently, who meet this criterion for independent practice Note The Full Practice Authority (FPA) which was passed on January 14, 2017 permits VA appointed Advance Practice Registered Nurses to practice as Licensed Independent Practitioners regardless of state licensure held and can practice/ be privileged as such if approved by both the facility's Organized Medical Staff and Governance and documented in Medical Staff Bylaws.

12. Medical Staff: The body of all Licensed Independent Practitioners and other Practitioners credentialed through the medical staff process who are subject to the medical staff Bylaws. This body may include composed of those physicians, dentists, optometrists, podiatrists, psychologists, and advanced nurse practitioner, fully (without restriction) licensed, or otherwise granted authority, to practice in a state, territory, or Commonwealth of the U.S. or District of Columbia; and, privileged to practice their respective disciplines independently (without supervision or direction) and attend patients at VANIHCS or its CBOCs. It is organized with two designations of membership known as active and associate. Active members are those physicians, dentists, optometrists, podiatrists, psychologists, and advanced nurse practitioner, who hold full or part-time employment positions and are considered in Medical Staff Meeting quorum count, vote, and participation in committee assignments. Associate members are those physicians, dentists, optometrists, podiatrists, psychologists and nurse Practitioners who are utilized by VANIHCS as consultants or attendings who receive professional service remuneration by a fee basis, contract, or sharing agreement. Individual members may also be known as Practitioners or attendings.

13. Nurse Executive (Associate Director, Patient Care Services): The Nurse Executive is a registered nurse who is responsible for the full-time, direct supervision of nursing services and who meets licensing requirements as defined by Title 38. S/he is the Chairperson of the Nurse Executive Counsel (NEC) and acts as full assistant to the Director in the efficient management and consultation of clinical and patient care services to eligible patients, the active maintenance of a credentialing and scope of practice, and privileging system for relevant Advance Practice Professional and certain associated health staff and in ensuring the ongoing education of the nursing staff.

14.0ngoinq Professional Practice Evaluation (OPPE): As used in this document, a process in which the Service and/or Section Chief will conduct ongoing evaluation of each practitioner's professional performance utilizing varying and focused analysis to aggregate data and other service-specific components. The OPPE is protected under The Federal Privacy Act of 1974 (r U.S.C. 522) and under VHA Regulations

77VA10Q.

15. Organized Medical Staff: The body of Licensed Independent Practitioners who are collectively responsible for adopting and amending medical staff Bylaws (i.e., those with voting privileges as determined by the Facility as defined in these Bylaws) and for overseeing the quality of care, treatment, and services provided by all individuals with clinical privileges.

16. Outpatient Clinic: An outpatient clinic is a healthcare site whose location is independent of medical facility, however; oversight is assigned to a medical facility.

17. Peer Recommendation: Information submitted by an individual(s) in the same professional discipline as the applicant reflecting their perception of the Practitioner's clinical practice, ability to work as part of a team, and ethical behavior or the documented peer evaluation of Practitioner-specific data collected from various sources for the purpose of evaluating current competence. Peer recommendations and reviews in the context of credentialing, privileging, and adverse actions must remain distinct and different from USC Section 5705 protected peer review recommendations and activities.

18. Primary Source Verification: Documentation from the original source of a specific credential that verifies the accuracy of a qualification reported by an individual health care Practitioner. This can be a letter, documented telephone contact, or secure electronic communication with the original source.

19. Proctoring: Proctoring is the activity by which a Practitioner is assigned to observe the practice of another Practitioner performing specified activities and to provide required reports on those observations. If the observing Practitioner is required to do more than just observe, i.e. exercise control or impart knowledge, skill, or attitude to another Practitioner to ensure appropriate, timely, and effective patient care, the action constitutes supervision. Such supervision may be a reduction of privileges.

20. Professional Standards Board (PSB)/ Credentials Committee: The Professional Standards Board/ Credentials Committee, if established, may act as a Credentials Committee on credentialing and clinical privileging matters of the Medical Staff, making recommendation on such matter to the Clinical Executive Board as defined in these Bylaws. This board also may act on matters involving Associated Health and Advance Practice Professionals such as granting prescriptive authority, scope of practice, and appointment. Some professional standards boards (e.g. Nursing, etc.) are responsible for advancement and other issues related to their respective professions.

21. Rules: Refers to the specific rules set forth that govern the Medical Staff of the facility. The Medical Staff shall adopt such rules as may be necessary to implement more specifically the general principles found within these Bylaws. Rules are a separate document from the Bylaws. They can be reviewed and revised by the Clinical Executive Board and without adoption by the medical staff as a whole. Such changes shall become effective when approved by the Director.

22.Teleconsultation: The provision of advice on a diagnosis, prognosis, and/or therapy from a licensed independent provider to another licensed independent provider using electronic communications and information technology to support the care provided when distance separates the participants, and where hand-offs on care is delivered at the site of the patient by a licensed independent health care provider.

23.Telemedicine: The provision of care by a licensed independent health care provider that directs, diagnoses, or otherwise provides clinical treatment delivered using electronic communications and information technology when distance separates the provider and the patient.

24.VA Regulations: The regulations set by Department of Veterans Affairs and made applicable to its entities in compliance with Federal laws. (Example: Code of Federal Regulation (CFR) 38 7402).

25. Telehealth Services may be described in the following:

a. General Telehealth: The use of real-time interactive video conferencing technology, sometimes with supportive peripheral devices, to provide care and consultation between providers and patients at VA facilities and clinics and other remote sites such as Vet Centers.

b. Home Telehealth: The use of in-home telehealth technologies, such as non-video messaging and monitoring devices or video technology for veteran patients with chronic diseases such as diabetes, heart failure and chronic pulmonary disease for home monitoring.

26.Admifting Privilege: An authorization granted by the Governing Body to a Practitioner to admit patients to VANIHCS. Such individuals may practice only within the scope of their clinical privileges also granted by the Governing Body.

27.Allied Health Professional or AHP: Health care providers who are supervised directly or indirectly by the Medical Staff, which have the ultimate responsibility for patient care. These individuals may include, but are not limited to, Certified Registered Nurse Anesthetists, Clinical Nurse Specialists, Physician Assistants, and Clinical Pharmacy Specialists.

28. Focused Professional Practice Evaluation (FPPE): An evaluation process whereby the facility evaluates the privilege-specific competence of the practitioner who does not have documented evidence of competently performing the requested privileges of the facility. The FPPE is protected under The Federal Privacy Act of 1974 (r U.S.C. 522) and under VHA Regulations 77VA10Q.

NOTE: A crucial consideration in making a distinction between consultation and care is that teleconsultation occurs when the consultant involved recommends diagnoses, treatments, etc., to the consulting provider requesting the consult, but does not actually write orders or assume the care of the patient. If the consultant diagnoses, writes orders, or assumes care in any way, this constitutes "care" and requires privileges. A Medical Staff appointment is required if the provider is entering documentation into the medical record (e.g., teleradiology, teledermatology, etc.).

29.VA Northern Indiana Health Care System (VANIHCS): Refers to both the total real estate and facilities located at 2121 Lake Avenue, Fort Wayne, Indiana, and 1700 East 38th Street, Marion, Indiana, composed of various integrated service and management areas of responsibility and community based outpatient clinics (CBOCs).

30.Veterans Health Administration (VHA): One of three major branches in the VA, focuses on providing a comprehensive health care system for the Nation's Veterans.

31.Veterans Integrated Service Network (VISN): The decentralized geographic-based management units of VHA (administered by a VISN Director appointed by the Under Secretary for Health to primarily implement VHA delegated operations policy) of which VANIHCS is associated and is supported by various committees, task groups, and councils with representation from various members of the VANIHCS Medical Staff.

32.VetPro: Electronically-based program for all Medical Staff within VA facilities. The Federal Credentialing Program has mandated that all initial and renewed appointments will be completed using VetPro. VetPro is accessed through the Internet and includes current information on education, training, experience, licensures, certifications, references, etc.

33.Veteran's Community Living Center (VCLC): A nursing home with a mission to restore each Veteran to his or her highest level of well-being. It is also to prevent declines in health and to provide comfort at the end of life in a Veteran centric, supportive environment.

ARTICLE I. NAME

The name of this organization shall be the Medical Staff of the Department of Veterans Affairs, Northern Indiana Health Care System (VANIHCS).

ARTICLE IL PURPOSE

The purposes of the VAN IHCS Medical Staff shall be to:

1. Assure that all patients receive safe, efficient, timely, and appropriate care that is subject to continuous quality improvement practices.

2. Assure that all patients being treated for the same health problem or with the same methods/procedures received the same level or quality of care. Primary care program will assure continuity of care and minimize institutional care.

3. Establish and ensure adherence to ethical standards of professional practice and conduct.

4. Develop and adhere to facility-specific mechanisms for appointment to the Medical Staff and delineation of clinical privileges.

5. Provide educational activities that relate to care provided based on findings of quality of care review activities and the expressed need of caregivers.

6. Maintain a high level of professional performance of Practitioners authorized to practice in the facility through continuous quality improvement practices and appropriate delineation of clinical privileges; and Develop and implement continuous quality improvement activities in collaboration with the medical center staff.

7. Assist the Governing Body in developing and maintaining Bylaws and Rules in order to establish a cognitive and viable framework for Medical Staff governance, oversight, and action with a reasonable degree of freedom and confidence.

8. Provide a means through which the Medical Staff may provide input to the facility policy making and planning process.

9. Provide a medical perspective, as appropriate, to issues being considered by the Director and Governing Body.

10. Develop and implement performance and safety improvement activities in collaboration with the staff and assume a leadership role in improving organizational performance and patient safety.

11. Establish organizational policy for patient care and treatment and implement professional guidelines from the Under Secretary for Health, Veterans Health Administration.

12. Provide education and training, in affiliation with established programs, and assure that educational standards are maintained. Care will be taken to appropriately document supervision of resident physicians and other trainees.

13. Initiate and maintain an active continuous quality improvement program addressing all aspects of medical practice. Daily operations will be the subject of continuous quality improvement, as defined through organizational policies and procedures.

14. Coordinate and supervise the scopes of practice of all Advance Practice Professionals and appropriate Associated Health Practitioner staff so that their rights and practice goals are achieved and integrated expeditiously to benefit the care of patients. Each Advance Practice Professional and appropriate Associated Health Practitioner should have a scope of practice statement or privileges as well as the means employed to coordinate and supervise their function with the medical staff.

15. Provide an organized body through which the benefit of staff membership (mutual education, consultation, and professional support) may be obtained by each staff member and the obligations of membership may be fulfilled.

16. Serve as the primary means for accountability to the Governing Body for the quality and appropriateness of the professional performance and ethical conduct of its members, as well as all allied health professionals, and to strive for quality patient care, efficiently delivered and maintained consistent with available resources, and to the degree reasonably possible as determined by the state of the healing arts.

17. Provide a means whereby medical administrative problems, concerns, and ideas may be focused and discussed freely between the Medical Staff, VANIHCS Management, and Governing Body with mutual lines of communication to the Network Director and VANIHCS Director.

18. Provide an organized body through which the benefit of staff membership (mutual education, consultation, and professional support) may be obtained by each staff member and the obligations of membership may be fulfilled.

ARTICLE III. MEDICAL STAFF MEMBERSHIP

Section 3.01 Eligibility for Membership on the Medical Staff:

1. Membership: Medical Staff membership is a privilege extended only to, and continued for, professionally competent, currently licensed, and VAN IHCS credentialed and privileged Physicians, Dentists, Optometrists, Podiatrists, Psychologists, and Advanced Practice Nurse, Clinical Nurse Specialist who continuously meet the qualifications, standards, and requirements of VHA and VAN IHCS, and as further delineated in these Bylaws. Membership is recommended by the Medical Staff and granted by the governing body.

2. Categories of the Medical Staff:

a. Active Members: This category is the one considered in meetings and activities of the Medical Staff for quorum count, voting, serving on committees, and fulfilling various "task assignments". Active members are those physicians, dentists, optometrists, podiatrists, psychologists, and Advanced Practice Nurses having the following VAN IHCS employment status:

i. Full-Time Medical Staff: Those members employed to attend patients at VAN IHCS on a full-time basis by the VA under 38 USC; who meet the requirements and qualifications outlined in Section 3.03 of these Bylaws;

and, whose VANIHCS employment, appointment, retention, privileges, and conduct are governed by VA regulations. Only full-time staff are eligible for permanent appointment.

ii. Part-Time Medical Staff: Those members described in paragraph 1 herein, except that they attend patients on a part-time (e.g., seven-eighths, 7/8, or less) basis. They are only eligible for temporary appointment.

iii. Intermittent Medical Staff: Those members described in paragraph 1 herein except that they attend patients on an intermittent basis with no set full time equivalent designation.

b. Consulting Staff Members: This category is invited to attend (although not required) meetings of the Medical Staff; and are not included in quorum counting, voting, or committee assignment. They must be approved for delineated clinical privileges if engaged by VAN IHCS to provide patient care services. Associate members are all physicians, dentists, podiatrists, optometrists, psychologists, Advance Practice Nurses described as:

Consultants, On-station/fee basis remunerates, On-station/contract for services remunerates, without compensation consulting, and On-station/sharing agreement remunerates.

Membership Decision: Decisions regarding Medical Staff membership are made without discrimination for reasons such as race; color; religion; national origin;

gender; sexual orientation; lawful partisan political affiliation; marital status;

physical or mental handicap when the individual is quality to do the work; age;

membership or non-membership in a labor organization; or any other criteria unrelated to professional qualifications.

Section 3.02 Qualifications for Medical Staff Membership and Clinical Privileges:

1. Criteria for Clinical Privileges: To qualify for Medical Staff membership and clinical privileges, individuals who meet the eligibility requirements identified in Section 3.01 must submit evidence as listed below. Applicants not meeting these requirements will not be considered. This determination of ineligibility is not considered a denial:

a. Active, current, full and unrestricted license to practice individual's profession in a state, territory or commonwealth of the United States or the District of Columbia as required by VA employment and utilization policies and procedures.

b. Education applicable to individual Medical Staff members as defined, for example holding a Doctoral level degree in Medicine, Osteopathy, or Dentistry from an approved college or university.

c. Relevant training and/or experience consistent with the individual's professional assignment and the privileges for which he/she is applying. This may include any internship, residencies, fellowships, board certification, and other specialty training.

d. Current competence, consistent with the individual's assignment and the privileges for which he/she is applying.

e. Health status consistent with physical and mental capability of satisfactorily performing the duties of the Medical Staff assignment within clinical privileges granted.

f. Complete information consistent with requirements for application and clinical privileges as defined in Articles VI or VII or of these Bylaws for a position for which the facility has a patient care need, and adequate facilities, support services and staff

g. Satisfactory findings relative to previous professional competence and professional conduct.

h. English language proficiency.

i. Current professional liability insurance as required by Federal and VA acquisition regulations for those individuals providing service under contract.

j. A current Personal Identity Verification (P IV) Card.

k. Participate in continuing education.

2. Clinical Privileges and Scope of Practice: While only Licensed Independent Practitioners may function with defined clinical privileges, not all Licensed Independent Practitioners are permitted by this Facility and these Bylaws to practice independently. All Practitioners listed below are subject to the Bylaws whether they are granted defined clinical privileges or not.

a. The following Practitioners will be credentialed and privileged to practice independently and serve as members of the Medical Staff:

i) Physicians

ii) Dentists

iii) Psychologists

iv) Podiatrists

v) Optometrists

vi) Advanced Practice Nurses

vii) Clinical Nurse Specialist viii)Chiropractors

b. The following Practitioners will be credentialed and may be privileged to practice independently if in possession of State license/registration that permits independent practice and authorized by this Facility:

i) Certified Registered Nurse Anesthetists (CRNA)

ii) Clinical Social Workers

iii) Clinical Pharmacists

iv) Audiologists

v) Speech Pathologists

c. The following Practitioners will be credentialed through the Medical Staff process, including credentialing and will practice under a Scope of Practice with appropriate supervision:

i) Physician Assistants

ii) Clinical Pharmacy Specialists

iii) Contract APRNs who are not licensed in a state which recognizes their

APRNs as Licensed Independent Practitioners.

iv) Certified Registered Nurse Anesthetists (CRNAs) who do not hold license in a state that recognizes CRNAs as Licensed Independent Practitioners.

d. The following Practitioners will be credentialed through the Medical Staff process including credentialing and may be privileged in accordance with the Full Practice Authority, regardless of state licensure held if they hold a VA staff appointment (e.g. WOC, full-time, intermittent):

i) Certified Nurse Practitioners (CNP)

ii) Certified Nurse Specialist (CNS)

3. Chanqe in Status: Members of the Medical Staff as well as all Practitioners practicing through privileges or a scope of practice must agree to provide care to patients within the scope of their Delineated Clinical Privileges or Scope of Practice and advise the Director, through the Chief of Staff, of any change in ability to fully meet the criteria for Medical Staff membership, the ability to carry out clinical privileges which are held, and any changes in the status of professional credentials, such as, but not limited to, loss of licensure, clinical privileges, or certification, as well as any pending or proposed action against a credential, such as, but not limited to, licensure, clinical privileges, certification, professional organization or society as soon as able, but no longer than 15 days after notification of the practitioner.

Section 3.03 Code of Conduct

1. Acceptable Behavior: The VA expects that members of the medical staff will serve diligently, loyally, and cooperatively. They must avoid misconduct and other activities that conflict with their duties; exercise courtesy and dignity; and otherwise conduct themselves, both on and off duty, in a manner that reflects positively upon themselves and VA. Acceptable behavior includes the following (1) being on duty as scheduled. (2) being impartial in carrying out official duties and avoiding any action that might result in, or look as though, a medical staff member is giving preferential treatment to any person, group or organization, (3) not discriminating on the basis of race, age, color, sex, religion, national origin, politics, marital status, or disability in any employment matter or in providing benefits under any law administered by VA, (4) not making a governmental decision outside of official channels, (5) not taking any action that impedes government efficiency and economy, affects one's impartiality, or otherwise lowers public confidence in the Federal Government, and (6) with certain exceptions in accordance with 5 C.F.R.

2635, not asking for or accepting any gift, tip, entertainment, loan, or favor, or anything of monetary value for oneself or any member of one's family from any person or organization that is seeking or has a business or financial relationship with the VA to avoid the appearance that one's official actions might be influenced by such gifts.

2. Behavior or Behaviors that Undermine a Culture of Safety: VA recognizes that the manner in which Practitioners interact with others can significantly impact patient care. VA strongly urges its providers to fulfil their obligations to maximize the safety of patient care by behaving in a manner that promotes both professional practice and a work environment that ensures high standards of care. The Accreditation Council for Graduate Medical Education highlights the importance of interpersonal/ communication skills and professionalism as two of the six core competencies required for graduation from residency. Providers should consider if their ethical duty to foster respect among all health care professionals as a means of ensuring good patient care. Conduct that could intimidate others to the extent that could affect or potentially may affect quality and safety will not be tolerated. These behaviors, as determined by the organization, may be verbal or non-verbal, may involve foul language; rude, loud or offensive comments; and intimidation of staff, patients and family members are commonly recognized as detrimental to patient care.

Behavior or behaviors that undermine a culture of safety are often a marker for concerns that can range from a lack of interpersonal skills to deeper problems, such as depression or substance abuse. As a result, behavior or behaviors that undermine a culture of safety may reach a threshold such that it constitutes grounds for further inquiry by the Medical Executive Committee into the potential underlying causes of such behavior. Behavior by a provider that is disruptive could be grounds for disciplinary action.

VA distinguishes behavior or behaviors that undermine a culture of safety from constructive criticism that is offered in a professional manner with the aim of improving patient care. VA also reminds its providers of their responsibility not only to patients, but also to themselves. Symptoms of stress, such as exhaustion and depression, can negatively affect a provider's health and performance. Providers suffering such symptoms are encouraged to seek the support needed to help them regain their equilibrium.

Providers, in their role as patient and peer advocates, are obligated to take appropriate action when observing behavior or behaviors that undermine a culture of safety on the part of other providers. VA urges its providers to support their hospital, practice, or other healthcare organization in their efforts to identify and manage these behaviors by taking a role in this process when appropriate.

3. Professional Misconduct: Behavior by a professional that creates the appearance of a violation of ethical standards or has compromised ethical standards will not be tolerated.

Section 3.04: Conflict Resolution & Management

For VA to be effective and efficient in achieving its goals, the organization must have clear objectives and a shared vision of what it is striving to achieve. Therefore, there must be a mechanism for the recognition of conflict and its resolution in order to make progress in meeting these established goals. Conflict management is the process of planning to avoid conflict when possible and manage to resolve such conflict quickly and efficiently when it occurs. VA Handbook 5978.1, Alternative Dispute Resolution Program, addresses the conflict resolution and management process available in VA, as well as resources to engage in mediation as well as non-binding, or binding arbitration.

VHA expects VA medical center leadership to make use of these and other resources in communicating expectations to clinicians and other staff that conflictive, disruptive, inappropriate, intimidating, and uncivil behavior can compromise VHA's mission of high quality health care service to Veterans. VA staff who experience or witness such behavior are encouraged to advise an appropriate supervisor, Patient Safety Officer, or other individual as described in the following Agency resources.

ARTICLE IV: ORGANIZATION OF THE MEDICAL STAFF

Section 4.01 Leaders

1. Composition:

a. The Chief of Staff (COS) functions similar to the "President" of the Organized Medical Staff.

b. Deputy Chief of Staff and Associate Chiefs of Staff

2. Qualifications: It is understood that any individual selected as COS shall be a member of the Medical Staff and have privileges ex officio to act as a consultant in evaluating all aspects of patient care and other professional services provided by the hospital.

3. Selection: The Organized Medical Staff does not elect medical staff officers. The Medical Staff Bylaws are approved by the organized medical staff, which constitutes the agreement of the leadership organization. The Network Director approves recommendations to the position of Chief of Staff. The selecting organization is responsible to complete and submit information on the selectee to the Leadership Management and Succession Sub-Committee (LMSS). The LMSS support staff (Executive Recruitment Team) in the Workforce Management and Consulting Office will submit templates to the Leadership Management and Succession Sub- Committee and Workforce Committee for information only

4. Removal: All disciplinary and/or adverse actions involving a Chief of Staff position must be referred to the Office of the Accountability Review (OAR). The OAR Employee Relations division will assign an Employee Relations Specialist to work directly with the proposing and deciding officials.

Duties:

a. Chief of Staff Duties shall include, but not limited to:

i. Serve as the Chair of the CEB and the Professional Standards Board

ii. Enforce the Medical Staff Bylaws and Rules

iii. Promote quality of care,

iv. Implementing sanctions when indicated

v. Prompt compliance with procedural safeguards when corrective action has been requested or initiated.

vi. Recommend chairpersons and members from the Medical Staff to the Director for approval of appointment to committees of the CEB.

vii. Responsible for the enforcement of these Medical Staff Bylaws, and their associated attachments and rules, and the implementation of sanctions and the promotion of compliance with procedure safeguards where corrective action has been requested or initiated.

viii. In cooperation with the Deputy Chief of Staff (DCOS), Associate Chiefs of Staff (ACOSs), service chiefs, and Medical Staff committee chairs, the COS is responsible for reviewing, updating, and ensuring the effective function of:

methods for credentials review and for delineation of privileges, continuing education programs, research programs, and performance improvement activities.

b Deputy Chief of Staff (DCOS) duties shall include but not limited to;

i. Has general responsibility for clinical operations, performance improvement activities, data analysis, systems redesign, Acts as a surrogate in place of the COS in his/her absence through occasions or when requested to do so otherwise

Section 4.02 Leadership

1. The Organized Medical Staff, through its committees and Service Chiefs, provides counsel and assistance to the Chief of Staff and Director regarding all facets of patient care, treatment, and services including evaluating and improving the quality and safety of patient care services.

Section 4.03 Clinical Services

1. Characteristics:

a. Clinical Services are organized to provide clinical care and treatment under leadership of a Service Chief.

b. Clinical Services hold service-level meetings at least at least once a month or 10 times annually.

2. Functions:

a. Provide for quality and safety of the care, treatment, and services provided by the Service. This requires ongoing monitoring and evaluation of quality and safety, (including access, efficiency, and effectiveness); appropriateness of care and treatment provided to patients (including that provided under temporary privileges or emergency care absent privileges); patient satisfaction activities; patient safety and risk management activities; and utilization management.

b. Assist in identification of important aspects of care for the Service, identification of indicators used to measure and assess important aspects of care, and evaluation of the quality and appropriateness of care. Utilize VHA performance measures and monitors as a basis for assessing the quality, timeliness, efficiency, and, safety of Service activities.

c. Maintain records of meetings that include reports of conclusions, data, recommendations, responsible person, actions taken, and an evaluation of effectiveness of actions taken. These reports are to be forwarded in a timely manner through channels established by the Medical Staff, at a minimum on a monthly basis.

d. Develop criteria for recommending clinical privileges for members of the Service and ensure that ongoing professional practice evaluation is continuously performed and results are utilized at the time of re-privileging.

e. Define and/or develop clinical privilege statements including levels (or categories) of care that include all requirements of VHA Handbook 1100.19.

f. Develop policies and procedures to assure effective management, ethics, safety, communication, and quality within the Service.

g. Annually review privilege templates for each Service and make recommendations to Clinical Executive Board (CEB).

3. Selection and Appointment of Service Chiefs: Service Chiefs are appointed by the Director based upon the recommendation of the Chief of Staff.

4. Duties and Responsibilities of Service Chiefs: The Service Chief is administratively responsible for the operation of the Service and its clinical and research efforts, as appropriate. In addition to duties listed below, the Service Chief is responsible for assuring the Service performs according to applicable VHA performance standards.

These are the performance requirements applicable to the Service from the national performance contract, and cascade from the overarching requirements delegated to the Chief of the Medical Staff. These requirements are described in individual Performance Plans for each Service Chief. Service Chiefs are responsible and accountable for:

a. Completing Medical Staff Leadership and Provider Profiling on-line training within three months of appointment as Service Chief.

b. Clinically related activities of the Service.

c. Administratively related activities of the department, unless otherwise provided by the organization.

d. Continued surveillance of the professional performance of all individuals in the Service who have delineated clinical privileges through FPPE/OPPE.

e. Recommending to the medical staff the criteria for clinical privileges that are relevant to the care provided in the Service.

f. Recommending clinical privileges for each member of the Service.

g. Assessing recommendations for off-site sources of needed patient care, treatment, and services not provided by the Service and communicating the recommendations to the relevant organizational authority.

h. The integration of the Service into the primary functions of the organization.

i. The coordination and integration of interdepartmental and intradepartmental services.

j. The development and implementation of policies, manuals, and procedures that guide and support the provision of care, treatment, and services.

k. The assurance of a sufficient number of qualified and competent persons to provide care, treatment, and service.

I. The determination of the qualifications and competence of service personnel who are not licensed independent Practitioners and who provide patient care, treatment, and services.

m. The continuous assessment and improvement of the quality of care, treatment, and services.

n. The maintenance of and contribution to quality control programs, as appropriate.

o. The orientation and continuing education of all persons in the service.

p. The assurance of space and other resources necessary for the service defined to be provided for the patients served.

q. Annual review of all clinical privilege forms to ensure that they correctly and adequately reflect the services being provided at the facility. This review is noted by date of review being included on the bottom of each privilege delineation form.

ARTICLE V. MEDICAL STAFF COMMITTEES

Section 5.01 General

1. Committees are either standing or special. A special steering committee and/or task force shall cease to exist once its purpose for creation has been fulfilled.

2. All committee members, regardless of whether they are members of the Medical Staff, are eligible to vote on committee matters unless otherwise set forth in these Bylaws or VANIHCS policy, and shall serve until the member is succeeded through another appointee or the member has been removed from the committee. A vote to abstain is not considered a vote and should not be used unless there is a conflict of interest or perceived conflict of interest.

3. The presence of 30% of a committee's members will constitute a quorum.

4. The members of all standing committees, other than the Clinical Executive Board, are appointed by the Chief of Staff subject to approval by the Clinical Executive Board, unless otherwise stated in these Bylaws.

5. Unless otherwise set forth in these Bylaws, the Chair of each committee is appointed by the Chief of Staff.

Robert's Rules of Order Newly Revised will govern all committee meetings.

Section 5.02 Clinical Executive Board

1. Characteristics: The Clinical Executive Board (CEB) serves as the Executive Committee of the Medical Staff. The members of the CEB include:

a. Chief of Staff, Chairperson, voting.

b. Associate Director of Patient Care Services, voting

c. Deputy Chief of Staff, voting

d. Clinical Service Chiefs, voting

e. Chief, Pharmacy, voting

f. Chief, Pathology and Laboratory Service, voting

g. Practitioners appointed through the medical staff process, voting

h. Medical Center Director, or designee, ex-officio, approving official

i. Chief, Quality Management, non-voting

Other facility staff may be called upon to serve as resources or attend committee meetings at the request of the chairperson, with or without vote (as determined by the Executive Committee, as appropriate). For example, a Physician Assistant may be called to be present when an action affecting another Physician Assistant is being considered. Any member of the Medical Staff (with or without vote) is eligible for consideration.

k. The majority of the voting members must be fully licensed physicians of medicine or osteopathy.

I. Selection process for membership: Clinical Service Chiefs are appointed by the Director based upon the recommendation of a search committee chaired by the Chief of Staff, the Clinical Executive Board, and the appropriate Professional Standards Board. Other members are selected by the Chief of Staff after consultation and approval by CEB, or the Director.

m. Removal process for membership: Any CEB member who is appointed by the Chief of Staff may be removed by a majority vote of the CEB.

2. Functions of the Clinical Executive Board (CEB):

a. Acts on behalf of the Medical Staff between Medical Staff meetings within the scope of its responsibilities as defined by the Organized Medical Staff. The Medical Staff delegates this authority to the CEB.

b. Maintains process for reviewing credentials and delineation of clinical privileges and/or scopes of practice to ensure authenticity and appropriateness of the process in support of clinical privileges and/or scope of practice requested; to address the scope and quality of services provided within the facility.

c. Acts to ensure effective communications between the Medical Staff and the Medical Center Director.

d. Makes recommendations directly to the Director regarding the:

i) Organization, membership (to include termination), structure, and…