D.4 Medical Staff Bylaws Rules and Regulations Jackson VAMC 3.30.21 (1).pdf

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BYLAWS AND RULES OF THE MEDICAL STAFF

OF

VETERANS HEALTH ADMINISTRATION (VHA)

G.V. (SONNY) MONTGOMERY VA MEDICAL CENTER

JACKSON, MS

REVIEWED DATE: 3/30/2021

REVISED DATE: 3/30/2021

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Table of Contents

PREAMBLE 1

DEFINITIONS 1

ARTICLE I. NAME 5

ARTICLE II. PURPOSE 5

ARTICLE III. MEDICAL STAFF MEMBERSHIP 6

Section 3.01 Eligibility for Membership on the Medical Staff 6

Section 3.02 Qualifications for Medical Staff Membership and Clinical Privileges 6

Section 3.03 Code of Conduct 8

Section 3.04 Conflict Resolution & Management 10

ARTICLE IV. ORGANIZATION OF THE MEDICAL STAFF 11

Section 4.01 Leaders 11

Section 4.02 Leadership 11

Section 4.03 Clinical Services 11

ARTICLE V. MEDICAL STAFF COMMITTEES 13

Section 5.01 General 13

Section 5.02 Executive Committee of the Medical Staff 14

Section 5.03 Committees of the Medical Staff 17

Section 5.04 Committee Records and Minutes 18

Section 5.05 Establishment of Committees 18

ARTICLE VI. MEDICAL STAFF MEETINGS 18

ARTICLE VII. APPOINTMENT AND ONGOING CREDENTIALING 18

Section 7.01 General Provisions 18

Section 7.02 Application Procedures 22

Section 7.03 Process and Terms of Appointment 25

Section 7.04 Credentials Evaluation and Maintenance 26

Section 7.05 Local/VISN-Level Compensation Panels 27

ARTICLE VIII. CLINICAL PRIVILEGES 27

Section 8.01 General Provisions 27

Section 8.02 Process and Requirements for Requesting Clinical Privileges 28

Section 8.03 Process and Requirement for Requesting Renewal of Clinical Privileges ii

Section 8.04 Processing an Increase or Modification of Privileges 31

Section 8.05 Recommendations and Approval for Renewal and Revision of Clinical Privileges 32

Section 8.06 Exceptions 33

Section 8.07 Medical Assessment 38

ARTICLE IX. INVESTIGATION AND ACTION 38

ARTICLE X. FAIR HEARING AND APPELLATE REVIEW 46

ARTICLE XI. RULES AND REGULATIONS 52

ARTICLE XII. AMENDMENTS 52

ARTICLE XII. ADOPTION 53

MEDICAL STAFF RULES 54

1. GENERAL 54

2. PATIENT RIGHTS 54

3. RESPONSIBILITY FOR CARE 57

4. PHYSICIANS' ORDERS 61

5. ROLE OF ATTENDING STAFF 64

6. MEDICAL RECORDS 65

7. INFECTION CONTROL 69

8. CONTINUING EDUCATION 69

9. HEALTH STATUS AND IMPAIRED PROFESSIONAL PROGRAM 70

10. PEER REVIEW 71

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 G.V. (Sonny) Montgomery VA Medical Center in Jackson, Mississippi (hereinafter sometimes referred to as Jackson VAMC) 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.

Jackson VAMC comprises the hospital and all ambulatory and residential sites of care both in Jackson and outlying areas including but not limited to Dental Clinic, Community Based Outpatient Clinics, Community Living Center, Home Based Primary Care, other Home Based Care, Medical Foster Homes and Behavioral Health Programs.

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. Advanced Practice Professionals. Advanced Practice Professionals are those health care professionals who are not physicians and dentists and who, most often will , function within a Scope of Practice but may practice independently on defined clinical privileges as defined in these Bylaws. Advanced Practice Professionals include: physician assistants (PA), advanced practice nurses (APRN, CRNA, and CRNP), and Clinical Pharmacy Specialists. Advanced 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, Advanced Practice Professionals do not have admitting authority. Advance 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 <NOTE:

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, 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.

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: 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, investigation of clinical care concerns, or result from concern 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 and Chairperson of the Clinical 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, Advanced 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 Jackson VAMC 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 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.

13. Nurse Executive Assistant Director for 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 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, scope of practice, and privileging system for relevant advanced practice professionals and certain associated health staff and in ensuring the ongoing education of the nursing staff.

14. 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.

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

16. 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.

17. 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.

18. 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.

19. Professional Standards Board/ Credentials Committee: The Professional Standards Board/ Credentials Committee, 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 Advanced 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.

20. 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.

21. 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

22. 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.

23. 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)

ARTICLE I. NAME

The name of this organization shall be the Medical Staff of the Department of Veterans Affairs, Jackson VAMC

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 Governing Body 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 Governing Body.

9. 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. 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. 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 all Advanced Practice Professionals with a scope of practice (as opposed to privileges) 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 Advanced 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.

ARTICLE III. 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 physicians and dentists and other Licensed Independent Practitioners including podiatrists, psychologists, and advanced practice nurses. (For Graduate Medical Education Trainee status, please refer to VHA Handbook 1400.1, Resident Supervision.)

2. Categories of the Medical Staff: Categories of the Medical Staff include full-time, part-time, intermittent, without compensation (WOC), contract, and fee basis. Those full time and part-time (>0.5 FTE) licensed independent providers are designated as voting members. Medical Staff membership requires appointment.

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 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 (PIV) Card

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) Psychologists

iv) Advanced Practice Nurse Practitioners (VA employees)

v) Podiatrists

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

i) Contract Advanced Practice Nurse Practitioners and other Advanced Practice Nurses such as Clinical Nurse Specialists (CNS) 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, part-time, intermittent)

ii) Certified Registered Nurse Anesthetists (CRNA)

iii) Clinical Social Workers

iv) Clinical Pharmacists

v) Audiologists

vi) Speech Pathologists

vii) Chiropractors

c. The following Practitioners will be credentialed through the Medical Staff process, including recredentialing 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 a license in a state that recognizes CRNAs as Licensed Independent Practitioners

v) Chiropractors

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, 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 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 physicians, 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 Clinical 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. This mechanism can be utilized to manage conflict between the Clinical Executive Board and the Organized Medical Staff on issues including, but not limited to proposals to adopt a rule or regulation, or policy, or amendment thereto. Nothing in the foregoing is intended to prevent Medical Staff members from communicating with the Governing Body (Director) on a rule, regulation, or policy adopted by the Organized Medical Staff or the Executive Committee. The Governing Body (Director) must determine the method of this communication. 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. Applicable resources include but are not limited to:

1) the Office of Diversity and Inclusion (EEO) website at http://www.diversity.hr.va.gov/index.asp,

2) Memorandum on Alternative Dispute Resolution for Workplace Disputes, (February 8, 2007),

3) VA Directive 5978, Alternative Dispute Resolution (February 23, 2000),

4) VA Handbook 5978.1, Alternative Dispute Resolution Program: Central Office (December 11, 2007) http://www.diversity.hr.va.gov/index.asp http://www.diversity.hr.va.gov/docs/policies/ADR_Policy.pdf http://www.diversity.hr.va.gov/docs/policies/ADR_Policy.pdf http://www.diversity.hr.va.gov/docs/policies/Directive_5978.pdf

ARTICLE IV: ORGANIZATION OF THE MEDICAL STAFF *

Section 4.01 Leaders *

1. Composition:

a. Chief of Staff.

b. Deputy Chief of Staff. In the absence of the COS the DCOS can fulfill all duties and responsibilities of the COS for healthcare facility operations.

2. Qualifications: Full-time, board certified (or board eligible) physician with full and unrestricted privileges

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.

5. Duties:

a. Chief of Staff serves as Chairperson of the Clinical Executive Board.

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 monthly but no fewer than ten times per year.

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 the Clinical Executive Board

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. a sufficient number of qualified and competent persons to provide care, treatment, and services.

l. 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. 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 50% 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.

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 Clinical Executive Board serves as the Executive Committee of the Medical Staff. The members of the Clinical Executive Board * are:

a. Chief of Staff, Chairperson, voting.

b. Deputy Chief of Staff, Vice-Chairperson, voting

c. ACOS Education and Staff Development, voting

d. Clinical Service Chiefs/ACOS, voting.

e. Associate Director Patient Care Services/Nurse Executive, voting

f. Medical Staff Members (two), appointed through the medical staff process, voting. Any member of the Medical Staff is eligible for consideration.

g. Chief of Pharmacy, voting

h. Director, or designee, ex-officio, non-voting, as appropriate

i. Quality Representative, non-voting

j. APN Representative, ex-officio, non-voting

k. 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.

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

m. Selection process for membership: members either qualify by position (e.g. as a service chief) or through the Medical Staff selection process for Medical Staff Representatives. Medical Staff Members who volunteer to participate as representatives will attend CEB meetings as a Medical Staff Representative on a rotating basis every 12 months. The Chief of Staff office will coordinate with the Medical Staff Members the appointment and rotation of volunteers to the Medical Staff Representative process. Supervisor approval is required.

In addition to the CEB, Medical Staff Representatives will also be invited to attend one of the six Governing Boards reporting to the Executive Leadership Committee (ELC) as a non-voting member. These boards include the Quality and Safety Board, the Nurse Executive Board, the Patient Experience Board, the Workforce Management Board, the Environment of Care Board, and the Resource Executive Board.

n. Removal process for membership: If a member vacates a qualifying position, they will be removed from membership. Additionally, non-Service Chief members may voluntarily rescind their membership at any time and will be replaced by other Medical Staff Representatives as appropriate.

2. Functions of the Clinical Executive Board: The Clinical Executive Board: *

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.

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 Director.

d. Makes recommendations directly to the Director regarding the:

i) Organization, membership (to include termination), structure, and function of the Medical Staff.

ii) Process used to review credentials and delineate privileges for the medical staff.

iii) Delineation of privileges for each Practitioner credentialed.

e. Coordinates the ongoing review, evaluation, and quality improvement activities and ensures full compliance with Veterans Health Administration Clinical Performance Measures, The Joint Commission, and relevant external standards.

f. Oversees process for addressing instances in which there is “for-cause” concern (substandard care, professional incompetence or professional misconduct) related to a medical staff member’s competency to perform the requested or held privileges.

g. Oversees process by which membership on the medical staff may be terminated consistent with applicable laws and VA regulations.

h. Oversees process for fair-hearing procedures consistent with approved VA mechanisms.

i. Monitors medical staff ethics and self-governance actions.

j. Advises facility leadership and coordinates activities regarding clinical policies, clinical staff recommendations, and accountability for patient care.

k. Receives and acts on reports and recommendations from medical staff committees including those with quality of care responsibilities, clinical services, and assigned activity groups and makes needed recommendations to the Governing Body.

l. Assists in development of methods for care and protection of patients and others at the time of internal and external emergency or disaster, according to VA policies.

m. Acts upon recommendations from the Professional Standards Board (Credentialing Committee).

n. Acts as and carries out the function of the Physical Standards Board, which includes the evaluation of physical and mental fitness of all medical staff upon referral by the Occupational Health Physician. The Physical Standards Board may have the same membership as the local physician Professional Standards Board or members may be designated for this purpose by the health care facility Director to ensure objectivity. Boards may be conducted at other VA healthcare facilities.

o. Provides oversight and guidance for clinical fee basis/contractual services.

p. Annually reviews and makes recommendations for approval of the Service-specific privilege lists.

3. Meetings:

a. Regular Meetings: Regular meetings of the Clinical Executive Board shall be held at least monthly but no fewer than ten times per year. The date and time of the meetings shall be established by the Chair for the convenience of the greatest number of members of the Committee. The Chairmen of the various committees of the Medical Staff shall attend regular meetings of the Clinical Executive Board when necessary to report the activities and recommendations of their committees; and may attend at other times with the consent of the Chief of Staff. Such attendance shall not entitle the attendee to vote on any matter before the Clinical Executive Board

b. Emergency Meetings: Emergency meetings of the Clinical Executive Board may be called by the Chief of Staff to address any issue which requires action of the Committee prior to a regular meeting. The agenda for any emergency meeting shall be limited to the specific issue for which the meeting was called, and no other business may be taken up at an emergency meeting. In the event that the Chief of Staff is not available to call an emergency meeting of the Clinical Executive Board, the Director as the Governing Body or Acting Chief of Staff, acting for the Chief of Staff, may call an emergency meeting of the Committee.

c. Meeting Notice: All Clinical Executive Board members shall be provided at least a monthly advance written notice of the time, date, and place of each regular meeting and reasonable notice, oral or written, of each emergency meeting.

d. Agenda: The Chief of Staff, or in his absence, such other person as provided by these Bylaws, shall chair meetings of the Clinical Executive Board. The Chair shall establish the agenda for all meetings, and a written agenda shall be prepared and distributed prior to committee meetings.

e. Quorum: A quorum for the conduct of business at any regular or emergency meeting of the Clinical Executive Board shall be a majority of the voting members of the committee, unless otherwise provided in these Bylaws. Action may be taken by majority vote at any meeting at which a quorum is present. The majority of the voting members must be fully licensed physicians of medicine or osteopathy.

f. Minutes: Written minutes shall be made and kept on all meetings of the Clinical Executive Board and shall be open to inspection by Practitioners who hold membership or privileges on the Medical Staff.

g. Communication of Action: The Chair at a meeting of the Clinical Executive Board at which action is taken shall be responsible for communicating such action to any person who is directly affected by it.

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 membership, (e) reviewing the activities of the Medical Staff and Advanced Practice Professionals 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.

For the Charge, Composition and Meeting Schedule for each committee, please refer to the Committee Charters located on the Governance SharePoint which are updated by each committee no less than annually and reviewed and approved no less than annually by the CEB.

Committees are as follows:

Blood transfusion/Pathology and Laboratory Medicine Quality Report Cancer committee Clinical bar code committee Community care committee Disruptive behavior committee Dialysis committee Infection prevention committee Mental health behavioral health council Pain management committee Peer review committee Pharmaceutical and Therapeutics Prevention of Amputation in Veterans (PAVE) Professional Standards Board/Credentialing Committee Surgical workgroup committee Women Health Committee Compounded Sterile Products (797/800 Committee)

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 the Clinical Executive Board, a synopsis of any subcommittee and/or workgroup findings.

Section 5.05 Establishment of Committees

1. The Clinical 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 Clinical 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…