D.36 Medical Staff ByLaws.pdf

MEDICAL STAFF BYLAWS AND RULES

OF

VA NORTH TEXAS HEALTH CARE SYSTEM

Reviewed: October 2019 Revised: December 2019

D.36 RFP: 36C25722R0015

MEDICAL STAFF BYLAWS / RULES

TABLE OF CONTENTS

BYLAWS

PREAMBLE Page 7

DEFINITIONS Page 8

ARTICLE I: NAME Page 15

ARTICLE 2: PURPOSE Page 15

ARTICLE 3: MEDICAL STAFF MEMBERSHIP Page 15 s

3.1 Membership Eligibility

3.2 Qualifications for Medical Staff Membership

3.3 General Responsibilities

3.4 Code of Conduct

3.5 Conflict Resolution and Management

ARTICLE 4:

4.1

ORGANIZATION OF THE MEDICAL STAFF

Officers

4.2 Leadership

4.3 Clinical Services

4.3.1 Characteristics

4.3.2 Functions

ARTICLE 5:

5.1

4.3.3 Selection and Appointment of Medical Staff Service Chief

4.3.4 Duties and Responsibilities of Medical Staff Service Chief

EXECUTIVE COUNCIL OF THE MEDICAL STAFF

Composition s

5.2 Functions/Responsibilities

5.3 Reporting

5.4

5.5

Committees that Report to ECMS

5.4.1 List of Committees

5.4.2 General Responsibilities of Committee Members

Committee Records

5.6 Committee Attendance

ARTICLE 6:

6.1

MEDICAL STAFF MEETINGS

General Provisions

6.2 Rules of the Medical Staff

6.3 Quorum and Voting

ARTICLE 7:

7.1

CREDENTIALING APPOINTMENT AND REAPPOINTMENT

General Provisions

7.2 Application Procedures

7.2.1 Documentation

7.2.2 Burden of Proof

7.3 Process and Terms of Appointment

7.4 Evaluation and Maintenance of Credentials

ARTICLE 8: CLINICAL PRIVILEGES Page 38

8.1 General Provisions

8.2 Process and Requirements for Requesting Clinical Privileges

8.3 Recommendations and Approval

8.4 Ongoing Professional Practice Evaluation (OPPE)

8.5 Focused Professional Practice Evaluation (FPPE)

8.6 Additional Privileges

8.7 Exceptions

8.7.1 Expedited Appointment

8.7.2 Temporary Privileges

8.7.3 Teleconsultation and Telemedicine Privileges

8.7.4 Disaster Privileges

8.7.5 Emergency Care

8.7.6 Inactivation of Privileges

8.7.7 Deployment and Activation Privilege Status

ARTICLE 9: INVESTIGATION, SUMMARY SUSPENSION AND ACTION Page 56

9.1 Concerns Identified

9.2 Review Process

9.3 Recommendations Following the Review

9.4 Automatic Suspension of Privileges

9.5 Actions Not Constituting Corrective Action

ARTICLE 10: FAIR HEARING AND APPELLATE REVIEW Page 66

10.1 Reduction of Privileges

10.2 Convening a Panel

10.3 Practitioner’s Rights

10.4 Revocation of Privileges

10.5 Reporting to the National Practitioner Data Bank

10.6 Reporting to State Licensing Boards

10.7 Management Authority

10.8 Impaired Provider

ARTICLE 11: CONFIDENTIALITY Page 72

11.1 General Provisions

11.2 Breach of Confidentiality

ARTICLE 12: AMENDMENTS AND BIENNIAL REVIEWS Page 72

ARTICLE 13: ADOPTION Page 73

MEDICAL STAFF RULES

I. GENERAL Page 74

II. PATIENTS’ RIGHTS Page 74 A. Patient’s Rights and Responsibilities B. Living Will/Advance Directives/Withholding and Withdrawal of Life-Sustaining Treatment C. Informed Consent D. Adverse Event Disclosure E. Pain Management F. Ethical Dilemmas G. Organ/Tissue Donation H. Human Research

III. GENERAL RESPONSIBILITY FOR CARE Page 76

A. Conduct of Care B. Emergency Services C. Admissions

1. General Provisions

2. Procedures

3. Tests

D. Areas of Restricted Admission

1. MICU/CCU

2. SICU/TICU

E. Transfers F. Consultations

1. Required Consultations

2. Consultant

3. Essentials of a Consultation

4. Responsibility for Requesting and Furnishing Consultations

G. Discharge Planning H. Discharge

1. General Provisions

2. MICU/CCU

3. Post-Anesthesia Care Unit (PACU)

4. SICU/TICU

5. Against Medical Advice

I. Patient Death J. Autopsy

1. General Provisions

2. Consent for Autopsy

3. Request for Autopsy

K. Surgical and Cytology Specimens

IV. PHYSICIAN ORDERS Page 86 A. General Requirements B. Medication Orders

1. General Provisions

2. Personal Medications

3. Bedside Medications

4. Prescription Forms

C. Automatic Stop Orders D. Verbal/Telephone Orders E. Order Sets F. Investigational Drugs G. Informed Consent H. Submission of Surgical Specimens I. Special Treatment Procedures

1. Do Not Resuscitate (DNR) Orders

2. Advance Directive

3. Withholding or Withdrawal of Life-Sustaining Treatment

4. Physical Restraint and Seclusion

5. Emergency Detention and Court Ordered Treatment

6. Impaired Mentation

7. Patients with Suicidal Ideation

V. SUPERVISION OF TRAINEES Page 90

A. Supervision of Residents Physicians/Dentists B. Supervision of Non-Physician/Dentist Members of the Medical Staff

1. Psychologists

2. Podiatrists

3. Physician Assistants (PA’s)

4. Advanced Practice Nurses (APN’s) – Nurse Practitioners, Certified

Registered Nurse Anesthetists (CRNA’S)

5. Clinical Pharmacy Specialists (CPS’s)

VI. MEDICAL RECORDS Page 91

A. Basic Administrative Requirements B. Responsibilities of Medical Staff for Authentication C. Symbols and Abbreviations D. Release of Information (ROI) E. Timeframes for Completion of Records F. Basic Requirements for Content of the Medical Record G. Inpatient Medical Records

1. History and Physical Examination (H&P)

2. Initial Assessment

3. Progress Notes

4. Doctor’s Orders

5. Informed Consent

6. Discharge Summary

H. Outpatient Medical Record Requirements

1. Patient Problem List

2. History and Physical Examination

3. Treatment Plan

4. Progress Notes – General

I. Emergency Care Records J. Operating Room Records

1. Pre-Anesthetic Risk Assessment

2. Risk Assessment on the Day of Procedure

3. Intra-Operative Anesthesia Records

4. Operative and Post-Operative Surgical Records

5. Operative/Procedure Reports on Procedures Performed Outside the

Operating Room (OR)

6. Post-Anesthesia Care Unit (PACU) Admission and Progress Notes

7. Post-Anesthesia Care Unit Discharge Note

8. Post-Anesthetic Progress Note

9. Intravenous Sedation and Analgesia

10. Anatomic Gifts/Organ Donations

K. Extended Care Medical Records

1. General

2. Admission Note

3. History and Physical Examination

4. Plan of Care

5. Progress Notes

6. Doctor’s Orders

7. Discharge Summary

VII. INFECTION PREVENTION AND CONTROL Page 105

A. Infection Control Manual B. Authority for Infection Control

VIII. DISASTER PREPAREDNESS AND OPERATIONS Page 106

A. Emergency Operation Plans B. VA/DOD Contingency Plans

1. General Provisions

2. Purpose

3. Scope

4. Implementation

5. Priority of Care

6. Outplacement of NSC Patients

7. Responsibilities

IX. IMPAIRED PROFESSIONAL PROGRAM Page 108

X. PEER REVIEW Page 108

BYLAWS OF THE MEDICAL STAFF OF

VA NORTH TEXAS HEALTH CARE SYSTEM

PREAMBLE

Recognizing 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 within VA North Texas Health Care System (VANTHCS) hereby organizes itself for self-governance in conformity with the laws, regulations and policies governing Veterans Health Administration (VHA) and the bylaws and rules hereinafter stated. These Bylaws and Rules are consistent with all laws and regulations governing the Department of Veterans Affairs (VA), and they do not create any rights or liabilities not otherwise provided for in laws or VA Regulations.

These Bylaws and Rules have been based upon the following principles:

That the best interests of the patient must be protected by the joint efforts of administrative and professional personnel;

That all patients of VANTHCS are entitled to care of the highest possible quality;

That such principles are enhanced by an environment in which teaching is an integral part of the program; and

That the development of new knowledge through constant research of disease, preventive health measures and education, and the process of providing health care is essential to the development and maintenance of a high quality patient care environment.

The mission of the Medical Staff of VA North Texas Health Care System is to:

*Provide high quality and compassionate health care to eligible veterans *Develop highly trained medical professionals *Integrate academic and patient care functions *Provide strong leadership for and a commitment to basic and clinical research *Provide self-governance of members of the medical staff through developing, adopting, amending, and abiding by the Medical Staff Bylaws, Rules, and Regulations.

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

APPOINTMENT - As used in this document the term 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 for providing patient care services at the facility. Both VA employees and contractors may receive appointment to the Medical Staff.

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.

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 Executive Council of the Medical Staff (ECMS) 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.

CLINICAL PRIVILEGES (PRIVILEGES) – The authority and permission granted to a

Medical Staff member to provide specific diagnostic and therapeutic medical, dental, surgical, podiatric, mental health, chiropractic, optometric, psychological services, clinical social work services and/or other clinical patient care based on evaluation of the individual’s credentials and performance.

CHIEF OF STAFF (COS) - The physician appointed by the Director to serve as the clinical staff leader and primary liaison with the University of Texas Southwestern Medical Center, our primary affiliate medical school. The COS is responsible for the professional, developmental, and clinical competency aspects of the medical staff within VANTHCS. The Deputy Chief of Staff may also assume this role as designated by the Chief of Staff.

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).

DEAN’S COMMITTEE - The Dean’s Committee is a committee established by a formal memorandum of affiliation between VANTHCS and the University of Texas Southwestern Medical Center (UTSWMC) and approved by the Under Secretary for Health. It is composed of the Dean (or designee) and senior faculty members of the medical school, appropriate representatives of the Medical Staff of VANTHCS, and other faculty of the school and staff of the facility (including the Associate Director for Patient Care Services) as are appropriate to consider and advise on development, management and evaluation of all educational and research programs conducted at

VANTHCS.

DIRECTOR - The Director (Chief Executive Officer) is appointed by the Governing

Body to act as its agent in the overall management of VANTHCS. 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 Executive Council of the Medical Staff.

EMERGENCY - A circumstance or condition in which serious harm could result to a patient. Emergency can also mean that the life of a patient is in serious danger and that any delay in treatment would increase this danger or cause imminent harm.

EX-OFFICIO – A member of a body or committee by virtue of the position held (non-voting).

FOCUSED PROFESSIONAL PRACTICE EVALUATION (FPPE) - A defined time-limited process whereby the organization evaluates the privilege-specific competencies of practitioners who do not have documented evidence of competently performing the requested privilege at this organization or when there is a question regarding a currently privileged practitioner’s ability to provide safe, high quality patient care. This process also extends to physician extenders functioning under an approved Scope of Practice.

The FPPE is protected under The Federal Privacy Act of 1974 (5 U.S.C. §

522) and under VHA Regulations 77VA10Q.

GOVERNING BODY - The term "governing body" refers to the Under Secretary for

Health, the individual to whom the Secretary of the Department of Veterans Affairs has delegated authority for administration of the Veterans Health Administration; and, for purposes of local facility management and planning, it refers to the VA North Texas Health Care System Director.

LICENSED INDEPENDENT PRACTITIONER – The term Licensed Independent Practitioner (LIP) refers to any individual permitted by law and by VANTHCS 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.

MEDICAL STAFF - The term "medical staff" refers to all physicians, osteopathic physicians, dentists, podiatrists, psychologists, chiropractors, clinical social workers, and optometrists who are fully licensed and privileged to provide patient care services independently in VANTHCS. Membership categories of the Medical Staff of VANTHCS are:

A. ACTIVE STAFF - Consists of all full-time, part-time and intermittent physicians, osteopathic physicians, dentists, podiatrists, psychologists, chiropractors, optometrists, nurse practitioners, clinical nurse specialists, and licensed independent clinical social workers who are professionally responsible for the specific patient care and/or education and/or research activities of VANTHCS and who assume all the functions and responsibilities of membership on the Active Staff.

Members of the Active Medical Staff will be appointed to a specific service, are eligible to vote in VANTHCS activities and serve on Medical Staff committees.

B. ASSOCIATE STAFF - Consists of independent practitioners who are utilized to supplement the practice of members of the Active Staff in their roles in patient care, education, and/or research. This category includes without compensation (WOC), consulting & attending, on-station fee basis, on-station contract, Intergovernmental Personnel Act (IPA), or sharing agreement. Consultants and attendings will be appointed to a specific service and will be permitted to serve on committees.

C. HOUSE STAFF - The House Staff will consist of those individuals who are graduates of medical, osteopathic, or dental schools engaged in a formal program of postgraduate training and education within VANTHCS, with or without compensation. The Dean’s Committee recommends them for appointment for a limited period of training subject to the regulations of the Department of Veterans Affairs. They are not afforded clinical privileges except as noted below. They will function only under the supervision of a qualified practitioner who has clinical privileges in the area being supervised. However, they are expected to function in a manner that is consistent with the Bylaws and Rules of the Medical Staff. Unless specifically included as voting members, they will serve as ex-officio members on designated hospital committees.

Chief Residents (Medical Service) who supervise more junior residents and fellows are residents allowed to function outside of their training activity (e.g. hired as an Admitting Physician) and must be granted clinical privileges through the usual credentialing process. Chief Residents are either Board Certified or Board Eligible in Internal Medicine.

D. AFFILIATE STAFF - Consists of members of the Health Professions who participate directly in the management of patients under the general supervision or direction of Medical Staff members. Individuals who hold membership on the Affiliate Staff will be appointed to a specific service and will carry out their activities subject to service policies and procedures. Affiliate Staff will include, but is not necessarily limited to Certified Registered Nurse Anesthetists, Clinical Pharmacy Specialists, and Physician Assistants. They will be permitted to serve as ex-officio members on committees of the Medical Staff.

The qualifications, clinical duties and responsibilities of specific categories of Affiliate Staff include:

1. CLINICAL PHARMACY SPECIALISTS (CPS)

a. Qualifications include those as outlined in VA Handbook 5005, Part 11, Appendix G15.

b. Pharmacy Service will normally maintain administrative responsibility for CPS’s; however licensed pharmacists may be individually supported by an appropriate clinical service.

Medical supervision will be as stated in specified scope of practice documents based on an appropriate evaluation and credentialing process.

c. A clinical scope of practice will be established for each CPS via a credentialing review process that includes physician involvement for those clinical services affected. This will be accomplished before the scope of practice is forwarded to the credentialing board for review. Final approval will be according to procedures and policies applying to the credentialing board.

Reference VA 5005, Part II, Chapter 3, section B.

2. NURSE ANESTHETISTS

a. Qualifications - The individual must be a citizen of the United States, a graduate of a school of nursing approved by the appropriate State Accrediting Agency at the time the program was completed by the applicant, and a graduate of a school of anesthesia approved by the American Association of Nurse Anesthetists.

b. Clinical Duties and Responsibilities - Nurse Anesthetists function as members of an anesthesia care team (Nurse Anesthetist and Physician Anesthesiologist). The training, experience, and demonstrated current competence of nurse anesthetists will be taken into full account when a clinical scope of practice is established for each provider. The Scope of Practice of each provider will be established by the chief of the service with the individual provider. In general, nurse anesthetists will:

1) Exercise judgment in the clinical assessment and recommendations for induction of, maintenance of, and emergence from anesthesia care.

2) Within the Scope of Practice, write orders, record reports, and write progress notes in the medical record. A countersignature by a physician member of Medical Staff will be required for all written medication orders. Orders for diagnostic tests should be included in the scope of practice.

3) Nurse anesthetists will carry out their activities subject to

Anesthesiology and Pain Management Service policies and procedures, and in conformity with the applicable provisions of the Medical Staff Bylaws and Rules.

3. PHYSICIAN ASSISTANTS (PA)

a. Qualifications - The individual must be a citizen of the United

States and have either a Bachelor of Science degree (BS) from an AMA/CAHEA accredited program or a BS degree in health-related science with at least 12 months of training in an AMA/CAHEA accredited program. Additionally, all newly hired PAs must be certified by the National Commission of Certification of Physician Assistants.

b. Clinical Duties and Responsibilities - The training, experience, and demonstrated current competence of the physician assistant will be taken into full account in the Clinical Scope of Practice within which each PA will function. The Physician

Assistant Clinical Scope of Practice will delineate the routine duties, non-routine duties/non-emergency duties, emergency duties, and miscellaneous activities that they may undertake.

(Reference VANTHCS Memorandum No. 11C-04, “Physician Assistants Scope of Practice”). Physician Assistants will be individually assigned to an appropriate clinical service and will carry out activities subject to service policies and procedures, and in conformity with the applicable provisions of the Medical Staff Bylaws and Rules.

NURSE EXECUTIVE (Associate 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 mid-level advanced practice professionals and certain associated health staff and in ensuring the ongoing education of the nursing staff.

ONGOING PROFESSIONAL PRACTICE EVALUATION - (OPPE) - As used in this document is a process by which provider-specific performance data are gathered and evaluated for use in reprivileging as well as for identifying and responding to abnormal clinical practice trends. This process will extend to privileged staff as well as practitioners functioning under an approved Scope of Practice. OPPE is protected under The Federal Privacy Act of 1974 (r U.S.C. 522) and under VHA Regulations 77VA10Q.

ORGANIZED MEDICAL STAFF (MEDICAL STAFF) - The body of Licensed

Independent Practitioners who are collectively responsible for adopting and amending medical staff bylaws and for overseeing the quality of care, treatment, and services provided by all individuals with clinical privileges.

This body consists of all active staff members of the medical staff.

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.

PRACTITIONER – The general term for a physician, osteopathic physician, dentist, podiatrist, optometrist, psychologist, clinical social worker, chiropractor, physician assistant, advanced practice nurse, or clinical pharmacy specialist who is fully licensed or otherwise granted authority to practice in a State, Territory, or Commonwealth of the U. S. or District of Columbia and falls within the credentialing requirements outlined in VHA Handbook 1100.19, Credentialing and Privileging.

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.

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 proctoring 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 considered a reduction of privileges for the Practitioner who is being proctored.

RULES - Refers to the specific rules that govern the Medical Staff of VANTHCS as set forth in this document. 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 ECMS and without adoption by the medical staff as a whole. Such changes shall become effective when approved by the Director.

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

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. Telephone and secure text messages are excluded from this definition.

VA NORTH TEXAS HEALTH CARE SYSTEM (VANTHCS) - Consists of the Dallas VA

Medical Center, Sam Rayburn Memorial Veterans Center (Bonham, TX), Fort Worth Outpatient Clinic, Tyler Outpatient Clinic, Community Based Outpatient Clinics, and Outreach Facilities.

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 1: NAME

The name of this organization will be the Medical Staff of VA North Texas Health Care System (VANTHCS).

ARTICLE 2: PURPOSE

A. Ensure that all patients treated in VANTHCS will receive efficient, timely, and appropriate effective care that is subjected to continuous quality improvement practices.

B. Ensure all patients being treated for the same health problem or with the same methods/procedures receive the same level of care. Primary care programs will assure continuity of care and minimize institutional care. C.

Establish and ensure adherence to an ethical standard of professional practice and conduct.

D. Develop and adhere to facility-specific mechanisms for appointment to the

Medical Staff and delineation of clinical privileges.

E. Provide educational activities that relate to care provided, findings of quality of care review activities, and expressed need of caregivers and recipients of care.

F. Ensure a high level of professional performance of practitioners authorized to practice in the facility through continuous quality improvement practices and through appropriate delineation of clinical privileges.

G. Assist the Governing Body in developing and maintaining rules for Medical

Staff governance and oversight.

H. Bring Medical Staff expertise to deliberations by VANTHCS Governing Body.

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

J. Stimulate research activities and assure that research programs are conducted in accord with the standards established by the Research and Development Committee.

ARTICLE 3: MEDICAL STAFF MEMBERSHIP

3.1 Membership Eligibility

A. Membership on the Medical Staff is a privilege extended only to, and continued for, professionally competent physicians, osteopaths, dentists, podiatrists, optometrists, chiropractors, licensed clinical social workers, nurse practitioners, clinical nurse specialists, and psychologists who continuously meet the qualifications, standards, and requirements of VHA, VANTHCS, and these Bylaws. Membership may be considered for other licensed practitioners who are permitted by law to provide patient care services independently and who meet the qualifications, standards, and requirements of VHA, VANTHCS, and these Bylaws. Membership is recommended by the ECMS and approved by the Director.

B. Categories of Medical Staff membership include:

1) Active Medical Staff*

2) Associate Medical Staff*

3) House Staff*

4) Affiliate Medical Staff*

*Fully described under definitions

C. Decisions regarding Medical Staff membership are made without discrimination on the basis of race, color, religion, national origin, gender, lawful partisan political affiliation, marital status, physical or mental handicap when the individual is qualified to do the work, age, or membership or non-membership in a labor organization, or on the basis of any other criteria unrelated to professional qualifications.

D. Granting of clinical privileges is a prerequisite to appointment as a member of the Active Medical Staff.

3.2 Qualifications for Medical Staff Membership and Clinical Privileges/Scope of Practice

3.2.1 To qualify for Medical Staff membership and clinical privileges/scope of practice, individuals who meet the eligibility requirements identified in Section 3.1 must submit evidence as noted 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 the individual’s profession in a State, Territory, or Commonwealth of the U. S. or the District of Columbia as required for VA employment.

B. Education applicable to individual Medical Staff members as defined, e.g., hold degree of Doctor of Medicine, Osteopathy, Dentistry (DDS and DMD), Podiatry, Psychology, Chiropractic, Social Work, or Optometry from an approved college or university.

C. Relevant training and/or experience consistent with the individual’s professional assignment and privileges for which s/he is applying. This includes any internship, residency, board certification, or specialty training.

D. Current competence consistent with the individual’s assignment for which s/he is applying.

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

F. Complete information consistent with requirements for application and clinical privileges as defined in these Bylaws for a position for which VANTHCS has the patient care need, facilities, support services, and staff.

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

H. Proficiency of the English language and the ability to communicate effectively with patients, caregivers, staff, and other professional contacts.

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

J. At the time of initial credentialing and recredentialing, evidence must be provided of current Basic Life Support (BLS) training and/or current Advanced Cardiac Life Support (ACLS) certification according to VANTHCS Memorandum 141-09, “Staff Training in Cardiopulmonary Resuscitation and Advanced Cardiac Life Support”. Providers who have a handicap (i.e.

wheelchair bound) may be excused from this requirement upon the recommendation of the Chief of Staff. Prior to assuming clinical duties, new providers must supply evidence of current certification in BLS and/or ACLS as required by VHA policy. Provider must maintain certification in order to continue provision of clinical duties as required by VHA policy.

3.2.2 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:

1. Physicians

2. Dentists

3. Clinical Social Workers

4. Psychologists

5. Chiropractors

6. Podiatrists

7. Optometrists

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

1. Nurse Practitioners (NP)

2. Clinical Nurse Specialists (CNS)

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:

1. Physician Assistants.

2. Clinical Pharmacy Specialists

3. Contract APRNs who are not licensed in a state which recognizes their

APRNs as Licensed Independent Practitioners.

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

3.3 General Responsibilities

Medical Staff Members and others with individual clinical privileges are accountable for and have responsibility to:

A. Provide for continuous care and supervision of their assigned patients at a professionally recognized level of quality and efficiency.

B. Observe Patient’s Rights pursuant to 38 CFR 17.33 and as otherwise mandated, in all patient care activities.

C. Actively participate in continuing education, peer review, and Medical Staff monitoring and evaluation, organizational quality improvement activities, and internal and external reviews.

D. Maintain standards of ethics and ethical relationships including a commitment to:

1) Abide by Federal law and VA rules and regulations regarding financial conflict of interest and outside professional activities for remuneration.

2) Provide care to patients within the scope of privileges or scope of practice and advise the VANTHCS Director, through the Chief of Staff, of any change in ability to fully meet the criteria for Medical Staff membership or to carry out clinical privileges that are held.

3) Advise VANTHCS Director, through the Chief of Staff, of any challenges or claims against professional credentials, professional competence, or professional conduct as soon as able, but no longer than 15 calendar days of notification of such occurrences and their outcome.

4) Advise the Director, through the Chief of Staff of any and all changes and/or modifications made to any currently active state medical license as soon as able, but no later than 15 calendar days of noted change and/or modification. Note: A change or modification refers to any alteration to the information on file by the state medical board, to include but not limited to, licensure status change (i.e.

restriction/probation), criminal charges (i.e., misdemeanors, felonies), convictions, imprisonments, and administrative or judicial professional malpractice proceedings.

5) Contribute to, and abide by, high standards of ethics in professional practice and conduct.

6) Work cooperatively with others in the provision of care, treatment and services.

E. Abide by the Medical Staff Bylaws and Rules and all other lawful standards and policies of VANTHCS and VHA.

F. Abide by the decisions of all duly-appointed Medical Staff committees and cooperate in safe patient care, treatment and services and Medical Staff activities, including performance improvement, utilization review, peer review, and Clinical Service meetings.

G. Meet all educational requirements such as training in computer security, information security, and other VHA mandatory training.

H. Assist in any Medical Staff-approved teaching activities for medical students, interns, residents, fellows, nurses, Medical Staff members, and others as required by the Clinical Service of which they are a member.

I. Participate in emergency or other Clinical Service coverage as specified individually in the requirements of the Clinical Service of which they are a member and to respond to consultation requirements as set forth by VHA, the ECMS, or Chief of Staff.

J. Prepare and complete, in accordance with VHA, The Joint Commission

(TJC) and other regulatory requirements, the required clinical record of all patients whose care is provided at VANTHCS. Reference, Bylaws, Rules and Regulations, Part VI, Section E, Medical Records.

3.4 Code of Conduct

A. 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.

B. 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 that undermines a culture of safety is a style of interaction with physicians, healthcare system 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 disruptive behavior 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 that undermines a culture of safety may reach a threshold such that it constitutes grounds for further inquiry by the ECMS into the potential underlying causes of such behavior. Behavior by a provider that undermines a culture of safety could be grounds for disciplinary action.

VA distinguishes behavior that undermines 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 that undermines a culture of safety on the part of other providers. VA urges its providers to support their hospital, clinic, practice, or other healthcare organization in their efforts to identify and manage this behavior, by taking a role in this process when appropriate.

C. 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.

3.5 Conflict Resolution and Management

A. For VANTHCS 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 managing 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. The process is also outlined in VANTHCS Memorandum 00-EEO-07, “Alternative Dispute Resolution”.

B. It is expected that VANTHCS medical center leadership will 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 or other individual in their chain of supervision.

C. Conflict between the ECMS and the Organized Medical Staff on issues including, but not limited to, proposals to adopt a rule or regulation or policy or amendment thereto, shall be referred to the Chief of Staff. The Chief of

Staff will meet with the medical staff member(s), if feasible, to review and address the concerns and reasoning for ECMS’s recommendation. If the concerns cannot be resolved, the member(s) will be allowed to present their concerns to ECMS for further discussion and reconsideration. The ECMS members will then conduct a second vote for final recommendation to the Director. The Director will consider all discussion, concerns and the final recommendation before making a final decision on the issue.

ARTICLE 4: ORGANIZATION OF THE MEDICAL STAFF

4.1 Officers

The VA has no requirements for “Officers” of the Medical Staff and 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.

4.2 Leadership

A. The Chief of Staff functions as the President of the Medical Staff and is the senior administrative physician in charge of professional services. The Chief of Staff plans, directs and coordinates activities of the clinical professionals and has direct responsibility for organization and administration of the Medical Staff and for proper functioning of the clinical organization. The Chief of Staff is directly responsible to the VANTHCS Director for the quality of professional care provided in the facility.

1) Selection: 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.

2) 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.

B. The Medical Staff, through its committees, boards, functional teams, services and Service Chiefs, provides counsel and assistance to the Chief of Staff and VANTHCS Director regarding all facets of the patient care services and programs including continuous quality and performance improvement, goals and plans, mission and services offered.

4.3 Clinical Services

4.3.1 Characteristics

A. Organized to provide clinical care and treatment under leadership of the service chief.

B. Hold service-level meetings and document them via minutes at least quarterly.

C. The following services shall be organized as a component of the medical staff and shall have a service chief or Associate Chief of Staff responsible to the Chief of Staff for the functioning of the service and for the overall supervision of the clinical work within the service. The clinical staff of the VANTHCS shall be organized into the following services.

Ambulatory Care Anesthesiology & Pain Management Service Bonham Domiciliary Central Dental Laboratory Dental Service Education Geriatrics and Extended Care Service Medical Service Mental Health Nuclear Medicine Service Radiology Service Radiation Oncology Service Research & Development Pathology and Laboratory Medicine Service Physical Medicine and Rehabilitation Service Spinal Cord Injury Service Social Work Service Surgical Service

4.3.2 Functions

A. Provide for quality and safety of the care and treatment within the service. This includes monitoring, evaluating, and improving the quality of care; patient satisfaction activities; risk management activities; patient safety; and utilization management.

B. Define important aspects of care including type and scope of services, identify indicators used to monitor quality of care, and evaluate actions taken.

C. Maintain records of meetings that include issues discussed, conclusions, recommendations, actions taken, and evaluation of actions taken.

D. Develop criteria for recommending clinical privileges for its members.

E. Define and develop clinical privilege statements that include procedure and disease classifications.

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

4.3.3 Selection and Appointment of Medical Staff Service Chiefs

Clinical Service Chiefs are appointed by the Director based upon the recommendation of the Chief of Staff and any search committee that may have been developed for a given Service. Qualifications will include certification by an appropriate specialty board or comparable competence affirmatively established through the credentialing process.

4.3.4 Duties and Responsibilities of Medical Staff Service Chiefs or

Associate Chiefs of Staff

Each clinical service chief will be responsible to the Chief of Staff to provide effective leadership for the activities falling within his/her responsibility. Each clinical service chief is responsible and accountable for:

A. All clinically related activities of the service, including type and scope of services.

B. All administrative related activities of the service, unless otherwise provided for by the VANTHCS Director. This includes budgetary and fiscal responsibilities consistent with the policies and standards of the health care system.

C. Integration of the service into the primary functions of the organization.

D. Coordination and integration of interdepartmental and intradepartmental services.

E. Development and implementation of policies and procedures that guide and support the provision of services.

F. Recommendations for a sufficient number of qualified and competent persons to provide care/service.

G. Continuing surveillance of the professional performance of all individuals who have delineated clinical privileges in the service.

H. Recommending clinical privileges for each member of the service and recommending to the Organized Medical Staff the criteria for clinical privileges that are relevant to the care provided in the service.

I. Determination of the qualifications and competence of service personnel who are not licensed independent practitioners and who provide patient care services.

J. Continuous assessment and improvement of the quality and safety of care, treatments, and services provided.

K. Maintenance of appropriate quality control and quality improvement programs.

L. Recommendations for space and other resources needed by the service.

M. Recommendations for off-site sources for needed patient care services not provided by VANTHCS.

N. Monitoring of…