36C25518Q9591-007.pdf

BYLAWS AND RULES OF THE MEDICAL STAFF

OF

VETERANS HEALTH ADMINISTRATION (VHA)

EASTERNKANSASHEALTHCARESYSTEM

LEAVENWORTH, KANSAS

TOPEKA,KANSAS

REVIEWED DATE: 6/22/2016

REVISED DATE: 7/31/2017

Table of Contents

PREAMBLE

DEFINITIONS

ARTICLE I. NAME

ARTICLE II. PURPOSE

ARTICLE Ill. MEDICAL STAFF MEMBERSHIP

Section 3.01 Eligibility for Membership on the Medical Staff

Section 3.02 Qualifications for Medical Staff Membership and Clinical Privileges

Section 3.03 Code of Conduct

Section 3.04 Conflict Resolution & Management

ARTICLE IV: ORGANIZATION OF THE MEDICAL STAFF

Section 4.01 Leaders

Section 4.02 Leadership

Section 4.03 Clinical Services

ARTICLE V. MEDICAL STAFF COMMITTEES

Section 5.01 General

Section 5.02 Executive Committee of the Medical Staff

Section 5.03 Committees of the Medical Staff

Section 5.04 Committee Records and Minutes

Section 5.05 Establishment of Committees

ARTICLE VI. MEDICAL STAFF MEETINGS

ARTICLE VII. APPOINTMENT AND ONGOING CREDENTIALING

Section 7.01 Application Procedures

Section 7.02 Process and Terms of Appointment

Section 7.03 Credentials Evaluation and Maintenance

Section 7.04 LocalNISN-Level Compensation Panels

ARTICLE VIII CLINICAL PRIVILEGES

Section 8.01 General Provisions

Section 8.02 Process and Requirements for Requesting Clinical Privileges

Section 8.03 Process and Requirement for Requesting Renewal of Clinical Privileges

Section 8.04 Processing an Increase or Modification of Privileges

Section 8.05 Recommendations and Approval for Initial/Renewal, Modification/Revision of Clinical Privileges

Section 8.06 Exceptions

ARTICLE IX INVESTIGATION AND ACTION

ii

ARTICLE X FAIR HEARING AND APPELLATE REVIEW

ARTICLE XI RULES

ARTICLE XII AMENDMENTS

ARTICLE XIII ADOPTION AND SIGNATURES

MEDICAL STAFF RULES

1. PATIENT RIGHTS

2. GENERAL RESPONSIBILITY FOR CARE

3. MULTIDISCIPLINARY TREATMENT PLANNING

4. TRANSFERS

5. CONSULTATIONS

6. DISCHARGES

7. AUTOPSY

8. DIAGNOSTIC TESTS PERFORMED UNDER SHARING AGREEMENTS

9. PROVIDERS' ORDERS

10. ROLE OF ATTENDING STAFF

11. MEDICAL RECORDS

12. INFECTION CONTROL

13. CONTINUING EDUCATION

14. HEALTH STATUS AND IMPAIRED PROFESSIONAL PROGRAM

15. PEER REVIEW

16. SMOKING POLICY

17. CPR CERTIFICATION

18. DISCLOSURE POLICY

19. QUALITY MANAGEMENT DIRECTIVE

20. TIME AND ATTENDANCE POLICY

21. CODE OF CONDUCT POLICY

22. CONFLICT OF INTEREST POLICY

23. SUICIDE ASSESSMENT POLICY

iii

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 Eastern Kansas Health Care System (hereinafter sometimes referred to as EKHCS) 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.

EKHCS comprises The Dwight D. Eisenhower VA Medical Center, Leavenworth, Kansas; The Colmery-O'Neil VA Medical Center, Topeka, Kansas; all Community Based Outpatient Clinics associated with the VA Eastern Kansas Health Care System.

The Community Based Outpatient Clinics associated with EKHCS are located in the following locations:

Chanute, Kansas Emporia, Kansas Fort Scott, Kansas Garnett, Kansas Junction City, Kansas Kansas City, Kansas Lawrence, Kansas Platte City, Missouri St. Joseph, Missouri

Portions of these bylaws are required by the VA, VHA, or The Joint Commission (T JC).

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, 1 OQ.

DEFINITIONS

For the purpose of these Bylaws, the following definitions shall be used (listed alphabetically):

1. 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 employeE3 but is based on having an appropriate personnel appointment action, scarce medical specialty contract, or other authority to provide independent medical, mid-level and/or patient care services at the facility. Both VA employees and contractors providing patient care services must receive appointments to the Medical Staff.

2. 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.

3. Associate Director of Patient Care Services (ADPCS): The ADPCS 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 acts as full assistant to the Director in the efficient management of and consultant for clinical and patient care services to eligible patients, the active caretaker of a credentialing and scope of practice system for relevant advanced practice professionals and certain associated health staff, and insurer of the ongoing education of the nursing staff.

4. Associated Health Professional: As used in this document, the term "Associated Health Professional" is defined as those clinical professionals other than Licensed Independent Providers or Mid-Level Practitioners. Associated Health Professionals include, but are not limited to: pharmacists (Clinical Pharmacists and Clinical Pharmacy Specialists), properly qualified registered nurses, licensed audiologists, registered dietitians, licensed social workers, registered physical therapists/occupational therapists, speech therapists/pathologists, qualified addiction counselors, and other allied health professionals who may function under either defined clinical privileges or a defined scope of practice.

5. Automatic Suspension of Privileges: Suspensions that are automatically enacted whenever the defined indication occurs, and do not require discussion or investigation of clinical care concerns. 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. Privileges are automatically suspended until the records are completed or the delinquency rate falls to an acceptable level.

Reactivation must be endorsed by the Medical Executive Board.

6. Chief of Staff: The Chief of Staff is the President of the Medical Staff and Chairperson of the Medical Executive Board and 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, Mid-Level Practitioners, and Associated Health Practitioners. The Chief of Staff ensures the ongoing medical education of the 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. Director (or Facility Director): The Director 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 (AO), the Associate Director for Patient Care Services (AD-PCS), and the Medical Executive Board.

9. 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.

10. Licensed Independent Practitioner: The term Licensed Independent Practitioner (LIP) refers to any individual permitted by law and by VA Eastern Kansas Health Care System 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, dentists, optometrists, podiatrists, and psychologists. It may also include individuals who can practice independently, who meet this criterion for independent practice.

NOTE: The Full Practice Authority (FPA; passed January 14, 2017) permits VA appointed (e.g., full-time, part-time, intermittent, WOC) Advanced Practice Registered Nurses to practice as Licensed Independent Practitioners, regardless of state /icensure held, and will practice and be privileged as such if approved by both the facility's Organized Medical Staff and Governance, as well as documented in the facility's Medical Staff Bylaws.

11. 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 others, such as retired Practitioners who no longer practice in the organization but wish to continue their membership in the body. The medical staff includes both members of the organized Medical Staff and non-members of the organized medical staff who provide health care services.

12. Mid-Level Practitioner: Mid-Level Practitioners are those health care professionals who are not identified as Licensed Independent Providers (LIP)s or Associated Health Professionals and who, most often will, function within a Scope of Practice but may practice independently on defined clinical privileges as defined in these Bylaws. Mid-Level Practitioners include: physician assistants (PA), Clinical Pharmacy Specialists, and at this facility any Advanced Registered Nurses and Certified Registered Nurse Anesthetists without a VA appointment. Mid-Level Practitioners' scope of practice is limited by the privileges granted and the restrictions of their state of licensure or registration. Furthermore, each Mid-Level Practitioner has a scope of practice based on qualifications and current competence, recommended by the individual's supervising providers, Service Line Manager (SLM), Professional Standards Board (PSB), Medical Executive Board (MEB), and appointed by the facility Director. Mid-Level Practitioners 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, Advanced

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.

13. 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.

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

15. 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.

16. 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.

17. 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).

18. Professional Standards Board: The Professional Standards Board, if established, may act on credentialing and clinical privileging matters of the Medical Staff, making recommendation on such matter to the Executive Committee of the Medical Staff as defined in these Bylaws. This board also may act on matters involving Associated Health and Mid-Level Practitioners,-afla such as granting prescriptive authority, scope of practice, and appointment.

19. 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 MEB and without adoption by the Medical Staff as a whole. Such changes shall become effective when approved by the Director.

20. 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 provide

21. 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.

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

ARTICLE I. NAME

The name of this organization shall be the Medical Staff of the Department of Veterans Affairs, Eastern Kansas Health Care System.

ARTICLE II. PURPOSE

The purposes of the 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 receive the same level or quality of care. Primary care programs will assure continuity of care and minimize institutional care.

3. Establish and assure 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, findings of quality of care review activities, and expressed needs of caregivers and recipients of care.

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.

7. Assist the MEB in developing and maintaining rules for Medical Staff governance and oversight.

8. Provide a medical perspective, as appropriate, to issues being considered by the Director and MEB.

9. Assist the MEB to 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.

10. Assist to provide channels of communication so that medical and administrative matters may be discussed and problems resolved.

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

12.Assist to 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.

NOTE: VAEKHCS Administration will provide necessary logistical and administrative support in pursuit of these purposes.

ARTICLE Ill. MEDICAL STAFF MEMBERSHIP

Section 3.01 Eligibility for Membership on the Medical Staff

1. Membership: Membership on the Medical Staff is a privilege extended only to, and continued for, professionally competent Licensed Independent Practitioners who are in good standing who continuously meet the qualifications, standards, and requirements of VHA, this Facility, and these Bylaws.

NOTE: Please refer to VHA Handbook 1400.1, Resident Supervision for further information regarding Graduate Medical Education and resident supervision.

2. Categories of the Medical Staff:

a. Active

i) Licensed Independent Practitioners (voting)

NOTE: Active designation also includes part-time practitioners (regular or intermittent part-time). The exception afforded to part-time providers includes non-mandatory participation in the organized meetings of the Medical Staff.

b. Associate (non-voting)

i) Associated Health Professionals

ii) Mid-Level Practitioners

c. Without Compensation (non-voting)

d. Contractor providers, locum providers, fee basis providers, all other associated providers (non-members, non-voting)

3. 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 qualified to do the work, age, membership or non-membership in a labor organization, or on the basis of 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 Professional degree from an appropriate professional school.

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 eligibility/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 valid picture ID issued by a state or federal agency (e.g. driver's license or passport).

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:

i) Physicians

ii) Dentists

iii) Advanced Practice Nurses including contract staff (e.g., CNP, CNM, and CNS) with a VA appointment

iv) Certified Registered Nurse Anesthetists (CRNA) with a VA appointment

v) Psychologists

vi) Podiatrists

vii) Optometrists 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) Audiologists

ii) Speech Pathologists

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

i) Physician Assistants

ii) Clinical Pharmacy Specialists

iii) Contract APRNs who do not hold a VA appointment

iv) Contract CRNAs who do not hold a VA appointment

d. The following Practitioners will practice under a Scope of Practice and may require appropriate supervision:

i) Clinical pharmacists

ii) Registered nurses

iii) Registered dietitians

iv) Licensed clinical social workers

v) Registered physical therapists

vi) Registered occupational therapists

vii) Qualified addiction counselors viii)Other allied health professionals

3. Change 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, or professional organization or society membership 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, 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 its Practitioners interact with others can significantly impact patient care. VA strongly urges its providers to fulfill 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 it 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 the use of rude and/or disrespectful language, may be threatening, or may involve physical contact.

Behavior or Behaviors That Undermine a Culture of Safety is a style of interaction with providers, hospital personnel, patients, family members, or others that interferes with patient care. Behaviors such as foul language, rude, loud or offensive comments, and intimidation of staff, patients and family members are commonly recognized as detrimental to patient care. Furthermore, it has become apparent that Behavior or Behaviors That Undermine a Culture of Safety is 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 Board 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 Behavior or Behaviors That Undermine a Culture of Safety, 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.

NOTE: Conflict Resolution & Management is further directed by Memorandum on Alternative Dispute Resolution for Workplace Disputes, (February 8, 2007), VA Directive 5978, Alternative Dispute Resolution (February 23, 2000), and VA Handbook 5978.1, Alternative Dispute Resolution Program: Central Office (December 11, 2007)

ARTICLE IV. ORGANIZATION OF THE MEDICAL STAFF

Section 4.01 leaders

1. Composition:

a. Chief of Staff.

2. Selection: The Chief of Staff is assigned to be the leader of the Medical Staff by the Health System Director.

3. Duties:

a. Chief of Staff serves as Chairperson of the Medical Executive Board (MEB).

Section 4.02 leadership

1. The Organized Medical Staff, through its committees and Service Line Managers, 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 Line Manager.

b. Clinical Services hold service-level meetings no less than 9 times per year, or more frequently at the discretion of the Service Line Manager (SLM).

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 quarterly 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 MEB.

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

SLMs who are physicians must be certified by the appropriate medical specialty board.

NOTE: Please refer to VHA Handbook 5005, Staffing, for further information regarding how the search is to be conducted, how each candidate's qualifications are reviewed, and how recommendations are made to the Chief of Staff as to the quality of each applicant. Criteria for appointment as Service Chief include Board Certification/or equivalent experience and comparable training as vetted through the credentialing process.

4. Duties and Responsibilities of Service Line Managers: The Service Line Manager 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 Line Manager. Service Line Managers are responsible and accountable for:

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

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.

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.

3. The presence of 51% of a committee's members will constitute a quorum.

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

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

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

Section 5.02 Executive Committee of the Medical Staff

1. Characteristics: The Medical Staff Executive Board (MEB) functions as the discussion making body of the Medical Staff. The MEB approves and amends medical staff bylaws and provides continuing oversight for the quality of care, access to care, and services provided by practitioners with privileges. They are responsible for adopting and implementing medical staff policies and procedures.

The MEB is empowered to act for the medical staff in the time period between medical staff meetings, and coordinate all activities and policies of the medical staff, its departments and committees. They receive and act upon committee reports and make recommendations, where appropriate, to the Executive Committee of the Joint Leadership Council pursuant to the Medical Staff Bylaws.

NOTE: Please refer to MEB committee charter located on EKHCS MEB Sharepoint https:l/vaww. visn 15.portal. va. govlekh/SiteDirectorv(mebldefault. aspx

Section 5.03 Committees of the Medical Staff

1. The following Standing Committees hereby are established for the purpose of (a) evaluating and improving the quality of health care rendered, (b) reducing morbidity or mortality from any cause or condition, (c) establishing and enforcing guidelines designed to keep the cost of health care within reasonable bounds, (d) reviewing the professional qualifications of applicants for Medical Staff mell)bership, (e) reviewing the activities of the Medical Staff and Mid-Level and Associated Health Practitioners

(f) reporting variances to accepted standards of clinical performance by, and in some cases to, individual Practitioners, and (g) for such additional purposes as may be set forth in the charges to each committee:

NOTE: Please refer to committee charters located on EKHCS MEB Sharepoint https:llvaww. visn 15.portal. va. govlekh/SiteDirectorv(meb/default. aspx

a. Combined Medicine Committee

b. Geriatrics & Extended Care Committee

c. Pharmacy & Therapeutics Committee

d. Bylaws & Accreditation Committee

e. Research & Development Committee

f. Medical Risk Committee

g. Radiology Committee

h. Surgery & Surgical Specialty Committee

i. Behavioral Health Committee

j. Infection Control & Prevention Committee

k. Women Veterans Program Steering Committee

I. Residency Review Committee

m. Continued Medical Education Committee

n. Professional Standards Board

o. Medical Records Committee

p. Peer Review Committee

q. Telehealth Oversight Committee

r. Social Work Service Committee

2. Information Flow to MEB: All Medical Staff Committees, including but not limited to those listed above, will submit minutes of all meetings to the MEB in a timely fashion after the minutes are approved and will submit such other reports and documents as required and/or requested by the MEB.

Section 5.04 Committee Records and Minutes

1. Committees prepare and maintain reports to include data, conclusions, recommendations, responsible person, actions taken, and evaluation of results 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 quarterly basis.

2. Each Committee provides appropriate and timely feedback to the Services relating to all information regarding the Service and its providers.

3. Each committee shall review and forward to MEB a synopsis of any subcommittee and/or workgroup findings.

Section 5.05 Establishment of Committees

1. The Medical Executive Board may, by resolution and upon approval of the Director, without amendment of these Bylaws, establish additional standing or special committees to perform one or more Medical Staff functions.

2. The Medical Executive Board may, by resolution and upon approval of the Director, dissolve or rearrange committee structure, duties, or composition as needed to better accomplish Medical Staff functions.

ARTICLE VI. MEDICAL STAFF MEETINGS

1. Regular Meetings: Regular meetings of the Medical Staff shall be held no less than once per year, or at the discretion of the Chief of Staff or Facility Director. A record of attendance shall be kept.

2. Special Meetings: Special meetings of the Medical Staff may be called at any time by the Chief of Staff or at the request of the Director or MEB. At any such meeting, only that business set forth in the notice thereof will be transacted. Notice of any such meeting shall be deemed sufficient if it is given in writing to the Medical Staff at least forty-eight (48) hours prior thereto. Members of the Medical Staff may request a special meeting either through the Chief of Staff or Director in writing and stating the reason(s) for the request.

3. Quorum: For purposes of Medical Staff business, 50% of the total membership of the Medical Staff membership entitled to vote constitutes a quorum.

4. Meeting Attendance: Members of the Organized Medical Staff are required to attend 100% of regular Medical Staff meetings. Attendance must be tracked and evaluated at reappointment.

ARTICLE VII. APPOINTMENT AND ONGOING CREDENTIALING

NOTE: Please refer to the following primary resource for supporting information of appointment and ongoing credentialing processes: VHA Handbook 1100. 19 http://www1.va.gov/vhapublicationsNiewPublication. asp ?pub 10=2910

Please refer to the following resource for additional facility-specific information:

https:l/vaww. visn 15.portal. va. gov/ekh/Oocs/Hospita/%20Policies/Credentialing%20a nd%20Privileging%20of%20Licensed%20lndependent%20Practitioners%20and%20 MidLevel%20Providers. docx

1. Independent Entity: VAEKHCS is an independent entity, granting privileges to the Medical Staff through the MEB and Governing Body as defined in these Bylaws.

Credentialing and privileging are performed prior to initial appointment. Medical Staff, Mid-Level Practitioner, and Associated Health Practitioner reappointments may not exceed 2 years, minus one day from the date of last appointment or reappointment date. Medical Staff, Mid-Level, and Associated Health Practitioners must practice under their privileges or scope of practice.

2. Credentials Review: All Licensed Independent Practitioners (LIP), Mid-Level, and Associated Health Practitioners who hold clinical privileges or scope of practice will be subjected to full credentials review at the time of initial appointment and reappraisal for granting of clinical privileges and after a break in service. Credentials that are subject to change during leaves of absence shall be reviewed at the time the individual returns to duty. Practitioners are appointed for a period not to exceed 2 years.

3. Deployment/Activation Status:

a. When a member of the Medical Staff has been deployed to active duty, upon notification, the privileges will be placed in a "Deployment/Activation Status" and the credentialing file will remain active. Upon return of the Practitioner from active duty, in accordance with the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA), the Practitioner will update the credentialing file to current status.

b. After verification of the updated information is documented, the information will be referred to the Practitioner's Service Chief then forwarded to the MEB for recommendation to restore privileges to active, current status, based on evidence of current competence. Special circumstances may warrant the Service Chief and Executive Committee to put an FPPE in place to support current competence. The Director has final approval for restoring privileges to active and current status.

c. In those instances where the privileges lapsed during the call to active duty, the Practitioner must provide additional references or information needed for verification and all verifications must be completed prior to reappointment.

d. In those instances where the Practitioner was not providing clinical care while on active duty, the Practitioner in cooperation with the Service Chief must consider the privileges held prior to the call to active duty and whether a request for modification of these privileges should be initiated, on a short-term basis. These providers may be returned to a pay status, but may not be in direct patient care.

4. Employment or Contract: Appointments to the Medical Staff occur in conjunction with VHA employment or under a VHA contract or sharing agreement. The authority for these actions is based upon:

a. Provisions of 38 U.S.C. 7401 in accordance with VA Handbook 5005, Part II, Chapter 3, VHA Handbooks and applicable Agreement(s) of Affiliation in force at the time of appointment.

b. Federal law authorizing VA to contract for health care services.

5. Initial Focused Professional Practice Evaluation:

a. The initial focused professional practice evaluation (FPPE) is a process whereby the Medical Staff evaluates the privilege-specific competence of a Practitioner who does not have documented evidence of competently performing the requested privilege at the organization. This occurs with a new Practitioner or an existing Practitioner who request a new privilege. The performance monitoring process is defined by each Service and must include:

i) Criteria for conducting performance monitoring.

ii) Method for establishing a monitoring plan specific to the requested privilege.

iii) Method for determining the duration of the performance monitoring.

iv) Circumstances under which monitoring by an external source is required.

b. An initial Medical Staff appointment does not equate to HR employment. FPPE does not equate to a probationary period. The FPPE is separate and distinct from the HR probationary review listed below:

i) Initial and certain other appointments made under 38 U.S.C. 7401(1), 7401(3), 5 U.S.C. 3301 are probationary. During the probationary period, professional competence, performance, and conduct will be closely evaluated under applicable VA policies, procedures, and regulations.

ii) If, during this period, the employee demonstrates an acceptable level of performance and conduct, the employee will successfully complete the probationary period. Supervisors and managers apply the same processes to the evaluation of individuals employed under provision of 38 U.S.C. 7405 and those utilized under contracts and sharing agreements.

6. Ongoing Professional Practice Evaluation:

a. The on-going monitoring of privileged practitioners is essential to confirm the quality of care delivered. This is called the Ongoing Professional Practice Evaluation (OPPE). This allows the facility to identify professional practice trends that impact the quality of care and patient safety. Such identification may require intervention by the Medical Staff leadership. Criteria-based privileges make the on-going monitoring of privileges easier for Medical Staff leadership.

The maintenance of certification is not sufficient in and of itself. Each service chief must document activities such as direct observation, clinical discussions, and clinical pertinence reviews for ongoing monitoring processes. Data must be practitioner specific, reliable, easily retrievable, timely, defensible, comparable, and risk-adjusted where appropriate.

i.) The timeframe for ongoing monitoring is to be defined by Service Line Managers (SLM). SLM must demonstrate that relevant practitioner data is reviewed on regular bases (i.e., no less than every 6 months). Consideration may be based on a period of time or a specified number of procedures and may consider high risk or high volume for an adjustment to the frequency.

ii.) With very few exceptions, VHA data standing alone is not protected by 38 U.S.C. 5705. Its use would dictate the appropriate protections under law.

Data that generates documents used to improve the quality of health care delivered or the utilization of health care resources is protected by 38 U.S.C.

5705. Data that is not previously identified as protected by 38 U.S.C. 5705 and is collected as provider-specific data could become part of a practitioner's provider profile, analyzed in the facility's defined on-going monitoring program, and compared to predefined facility triggers or de identified quality management data.

iii.) In those instances where a practitioner does not meet established criteria, the service chief has the responsibility to document these facts. These situations can occur for a number of reasons and do not preclude a service chief recommending the renewal of privileges, but the service chief must clearly document the basis for the recommendation of renewal of privileges.

iv.) The Executive Committee of the Medical Staff must consider all information available, including the service chief's recommendation and reasons for renewal when criteria have not been met, prior to making their recommendation for the granting of privileges to the Director. This deliberation must be clearly documented in the minutes.

v.) The Director shall weigh all information available, as well as the recommendations, in the determination of whether or not to approve the renewal of privileges and document this consideration.

Section 7.01 Application Procedures

1. Completed Application: Applicants for appointment to the Medical Staff must submit a complete application. The applicant must submit credentialing information through VetPro as required by VHA guidelines. Details of credentialing are in VHA Handbook 1100.19.

a. Items specified in Article Ill, Section 2, Qualifications for Medical Staff Membership,…