36C25818Q0069-002.pdf

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MEDICAL STAFF BYLAWS

AND RULES AND REGULATIONS

SOUTHERN ARIZONA VA HEALTH CARE

SYSTEM

TUCSON, AZ

ADOPTED:

JUNE 21, 2017

MEDICAL STAFF BYLAWS AND RULES AND REGULATIONS

SOUTHERN ARIZONA VA HEALTHCARE SYSTEM

TUCSON, ARIZONA

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Medical Staff Bylaws – Reviewed and Adopted by the Medical Staff June 21, 2017

Table of Contents

PREAMBLE 1

DEFINITIONS 1

ARTICLE I. NAME 4

ARTICLE II. PURPOSE 4

ARTICLE III. MEDICAL STAFF MEMBERSHIP 5

Section 3.01 Eligibility for Membership on the Medical Staff 5 Section 3.02 Qualifications for Medical Staff Membership and Clinical Privileges 7 Section 3.03 Code of Conduct 8 Section 3.04 Conflict Resolution and Management 10

ARTICLE IV. ORGANIZATION OF THE MEDICAL STAFF 10

Section 4.01 Leaders 10 Section 4.02 Leadership 11 Section 4.03 Clinical Services 11

ARTICLE V. MEDICAL STAFF COMMITTEES 14

Section 5.01 General 14 Section 5.02 Medical Executive Board of the Medical Staff 14 Section 5.03 Committees of the Medical Staff 17 Section 5.04 Committee Records and Minutes 20 Section 5.05 Establishment of Committees 21

ARTICLE VI. MEDICAL STAFF MEETINGS 21

ARTICLE VII. APPOINTMENT AND ONGOING CREDENTIALING 21

Section 7.01 General Provisions 21 Section 7.02 Application Procedures 24 Section 7.03 Process and Terms of Appointment 27 Section 7.04 Credentials Evaluation and Maintenance 28 Section 7.05 Local/VISN-Level Compensation Panels 29

ARTICLE VIII. CLINICAL PRIVILEGES 29

Section 8.01 General Provisions 29

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Medical Staff Bylaws – Reviewed and Adopted by the Medical Staff June 21, 2017

Section 8.02 Process and Requirements for Requesting Clinical Privileges 30 Section 8.03 Process and Requirement for Requesting Renewal of Clinical Privileges

Section 8.04 Processing an Increase or Modification of Privileges 33 Section 8.05 Recommendations and Approval for Renewal and Revision of Clinical Privileges 33 Section 8.06 Exceptions 34

ARTICLE IX. INVESTIGATION, SUMMARY SUSPENSION AND PRIVILEGING

ACTION 39

ARTICLE X. FAIR HEARING AND APPELLATE REVIEW 46

Section 10.01 Reduction of Privileges 46 Section 10.02 Revocation of Privileges 49

ARTICLE XI. RULES AND REGULATIONS 51

ARTICLE XII. AMENDMENTS 51

ARTICLE XIII. ADOPTION 52

MEDICAL STAFF RULES 54

1. GENERAL 54

2. PATIENT RIGHTS 54

3. PATIENT CARE ADMISSIONS & DISCHARGES; AMBULATORY CARE 55

4. MEDICAL RECORDS 58

5. INVASIVE PROCEDURES 59

6. SPECIAL PROCEDURES 60

7. CONSULTATIONS 61

8. ORDERS & MEDICATIONS 62

9. MULTIDISCIPLINARY PLANS 63

10. HANDLING OF AUTOPSIES 63

11. EMOTIONALLY ILL PATIENTS 64

12. EMERGENCY PREPAREDNESS PLAN 65

13. CONTINUING MEDICAL EDUCATION 65

14. PERFORMANCE IMPROVEMENT 65

15. HOUSE STAFF SUPERVISION 65

TUCSON, ARIZONA

Medical Staff Bylaws – Reviewed and Adopted by the Medical Staff June 21, 2017

PREAMBLE

The Department of Veterans Affairs (VA) is responsible for promoting the health, welfare, and dignity of all Veterans in recognition of their service to our country. The purpose of the VA’s Veterans Health Administration (VHA) is to provide Veterans with exceptional health care that improves their health and well-being through a national health care delivery system while providing for the education and training for health care personnel, conducting health care research, and providing contingency support during times of war or national emergency.

The Southern Arizona VA Healthcare System (SAVAHCS) is one of the over 150 VHA facilities comprising the integrated VHA health care delivery system. SAVAHCS primary responsibility is to serve Veterans from a large geographic area covering southern Arizona and southwestern New Mexico. The majority of care is provided at the level 1a complexity, tertiary care and teaching campus in Tucson, Arizona which offers a full range of services including medical, surgical, mental health and rehabilitative inpatient and outpatient care. In addition, Veterans may also access care from one of numerous suburban and rural Community-based Outpatient Clinics (CBOC).

While the SAVAHCS Governing Body and administrative leadership must ensure that its health care providers have needed resources including space, equipment, and support staff to meet patient care demands, the provision of quality patient care is the responsibility of the Licensed Independent Practitioners (LIP) of SAVAHCS who are accountable to Veterans through the Governing Body for all aspects of that care. Accordingly, these LIPs hereby organize themselves for self-governance as the Medical Staff with a charter delineated in the following Medical Staff Bylaws and Rules and Regulations, developed in pursuit of conformity with the laws, regulations, and policies governing the VA, VHA, and the Joint Commission. These Bylaws and Rules and Regulations, hereinafter referred to as the Bylaws, do not create any rights or liabilities not otherwise provided for in laws or VHA Regulations.

DEFINITIONS

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

1. Advanced Practice Professionals: Advanced Practice Professionals (APP) are those health care professionals who function within a Scope of Practice (Physician’s Assistant, Certified Registered Nurse Anesthetist and Clinical Pharmacy Specialist) but may practice independently on defined clinical privileges as defined in these Bylaws. Advanced Practice Professionals include: Physician Assistants (PA), Advanced Practice Registered Nurses (APRN), 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. They may prescribe controlled substances in accordance with state of licensure statutes and regulations. APRNs and other health care professionals may be granted defined clinical privileges when allowed by law and the facility.

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

TUCSON, ARIZONA

Medical Staff Bylaws – Reviewed and Adopted by the Medical Staff June 21, 2017 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. 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 concern, 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 Medical 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.

5. Chief of Staff: The Chief of Staff is the President of the medical staff and Chairperson of the Medical Executive Board and acts as full assistant to the Director in the efficient management of clinical and medical services to eligible patients, the active maintenance of a medical credentialing and privileging and/or scope of practice system for Licensed Independent Practitioners and Advanced Practice Professionals. The Chief of Staff ensures the ongoing medical education of medical staff.

6. 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.

7. 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).

8. 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 Medical Executive Board.

9. Governing Body: The term Governing Body refers to the Under Secretary for Health, the individual to whom the Secretary for Veteran Affairs has delegated authority for

TUCSON, ARIZONA

Medical Staff Bylaws – Reviewed and Adopted by the Medical Staff June 21, 2017 administration of the Veterans Health Administration; and, for purposes of local facility management and planning, it refers to the Facility Director. The Director is responsible for the oversight and delivery of health care by all employees and specifically including the medical staff credentialed and privileged by the relevant administrative offices and facility approved processes.

10. Licensed Independent Practitioner: The term Licensed Independent Practitioner (LIP) refers to any individual permitted by law and by SAVAHCS to provide care and services, without direction or supervision, within the scope of the individual’s license and consistent with individually granted privileges. In this organization, this includes physicians, dentists, psychologists, audiologists, optometrists, chiropractors, podiatrists, certified nurse practitioners (CNP) and clinical nurse specialists (CNS). Note: The Full Practice Authority (FPA) regulation, which was finalized 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.

11. Medical Staff: The body of all Licensed Independent Practitioners credentialed through the medical staff process who are subject to the medical staff bylaws. The medical staff includes voting and non-voting members of the Medical Staff who provide health care services. Although Chief Residents are LIPs and privileged to practice at this facility, they are not members of the Medical Staff. Qualifications, procedures for application, appointment and reappointment and scope of practice shall be as defined in the Medical Staff Bylaws and policies.

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

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

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

15. Peer Recommendation: Information submitted by an individual(s) in the same professional discipline as the applicant reflecting their perception of the Practitioner’s clinical practice, ability to work as part of a team, and ethical behavior or the documented peer evaluation of Practitioner-specific data collected from various sources for the purpose of evaluating current competence. 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.

16. Primary Source Verification: Documentation from the original source of a specific credential that verifies the accuracy of a qualification reported by an individual health care Practitioner.

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Medical Staff Bylaws – Reviewed and Adopted by the Medical Staff June 21, 2017

This can be a letter, documented telephone contact, or secure electronic communication with the original source.

17. Proctoring: Proctoring is the activity by which a Practitioner is assigned to observe the practice of another Practitioner performing specified activities and to provide required reports on those observations. If the observing Practitioner is required to do more than just observe, i.e.

exercise control or impart knowledge, skill, or attitude to another Practitioner to ensure appropriate, timely, and effective patient care, the action constitutes supervision. Such supervision may be a reduction of privileges.

18. Professional Standards Board/Credentials Committee: The Professional Standards Board/Credentials Committee, if established, may act as a Credentials Committee on credentialing and clinical privileging matters of the Medical Staff, making recommendation on such matter to the Medical Executive Board of the Medical Staff as defined in these Bylaws.

This board also may act on matters involving 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.

19. Rules: Refers to the specific rules set forth that govern the Medical Staff of the facility. The Medical Staff shall adopt such rules as may be necessary to implement more specifically the general principles found within these Bylaws. Rules are a separate document from the bylaws. They can be reviewed and revised by the MEB and require adoption in accordance with Article XII. of these Bylaws.

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

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

22. VA Regulations: The regulations set by Department of Veterans Affairs and made applicable to its entities in compliance with Federal laws. (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, Southern Arizona VA Health Care System.

ARTICLE II. PURPOSE

The purposes of the Medical Staff shall be to:

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

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Medical Staff Bylaws – Reviewed and Adopted by the Medical Staff June 21, 2017

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 those Advanced Practice Professionals under a scope of practice so that their rights and practice goals are achieved and integrated expeditiously to benefit the care of patients. Each Advanced Practice Professional should have a scope of practice statement 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, dentists, optometrists, podiatrists, TUCSON, ARIZONA

Medical Staff Bylaws – Reviewed and Adopted by the Medical Staff June 21, 2017 psychologists, audiologists, chiropractors, CNP and CNS who continuously meet the qualifications, standards, and requirements of VHA, this Facility, and these Bylaws.

2. Categories of the Medical Staff:

a. Active Medical Staff: The Active Medical Staff have full-time or part-time appointments.

They are responsible for all organizational and administrative duties pertaining to the Medical Staff. Only those active Medical Staff that are full-time and 4/8 time or greater may vote and have attendance requirements at Medical Staff meetings.

b. Contractual Medical Staff: Contractual Medical Staff are hired on a contractual basis to provide services. They are not considered employees of the VA and are not embraced by the Federal Tort Claims Act. They are expected to fully participate in those Medical Staff functions related to monitoring and evaluating the quality and appropriateness of care and for participating in the resolution of identified patient care problems. They may not vote at Medical Staff meetings, but may vote as members of Medical Staff committees.

c. Associate Medical Staff:

i.) Associate Medical Staff shall consist of those duly appointed fee-basis and consultant practitioners or without compensation (WOC) appointments, who are responsible for supplementing the practice of actively practicing members in their roles in education, patient care, and/or research. Consultants will be those individuals who have recognized professional ability and experience of professional rank. Associate Medical Staff members are not required to serve on committees, they do not vote, and have no attendance requirements to attend Medical Staff meeting.

ii.) These practitioners include Compensation & Pension, consulting staff, licensed Research providers, Societies Program (Teaching/Visiting Professors), Chief Residents, Telemedicine and Teleconsultation.

d. Honorary Medical Staff: The honorary staff shall consist of practitioners recognized for their outstanding reputation, their noteworthy contribution to the facility or previous outstanding service to the Hospital whom the medical staff desires to honor. Honorary Staff are not eligible to participate in patient care, vote, hold office, or hold standing committee appointments. Members of the honorary medical staff may be invited to the annual General Staff meetings and may attend educational programs at the facility.

e. Affiliate Medical Staff: Department Heads, Section Chiefs, and other leaders of an academic affiliation with this facility may be appointed to the Affiliate Medical Staff. They are permitted to attend educational conferences and participate in teaching activities at this facility. They do not participate in patient care. They do not have clinical privileges.

They are not required to serve on committees, they do not vote, and have no attendance requirements to attend Medical Staff meeting.

3. If Medical Staff members with clinical privileges do not utilize the Facility with a frequency sufficient to assess their clinical competence, they will be required to provide data from other health care entities equivalent to data collected at SAVAHCS for consideration at reappointment unless they are participating solely in administrative activities. Failure to comply with this requirement can be deemed a voluntary resignation from the Medical Staff

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Medical Staff Bylaws – Reviewed and Adopted by the Medical Staff June 21, 2017 and the provisions set forth in Article IX. and X shall not apply.

4. 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 LIP practitioners as defined, for example holding a Doctoral level degree in Medicine, Osteopathy, Dentistry, Optometry, Podiatry, Psychology, Chiropractor, or Audiology, from an approved college or university; or CNP and CNS, from an ACCN or APRN NLN accredited college or university and appropriate board certification.

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.

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Medical Staff Bylaws – Reviewed and Adopted by the Medical Staff June 21, 2017

a. The following Practitioners will be credentialed and privileged to practice independently:

i) Physicians

ii) Dentists

iii) Psychologists

iv) Audiologists

v) Podiatrists

vi) Optometrists

vii) Chiropractors

viii) CNP and CNS 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, fee basis)

b. 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 CNP and CNS

iv) CRNAs

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. Duties of the Medical Staff Appointee: The primary duty of each member of the Medical Staff is to provide quality healthcare to patients in an environment of compassion, education, & research. Medical Staff membership imposes the obligation to accept and participate in the accountability functions delegated to the Medical Staff. Each Medical Staff member must continually demonstrate his or her cooperation and ability to function within SAVAHCS. He or she must manifest a willingness to discharge his or her Medical Staff obligations and accept the citizenship responsibility of Medical Staff membership, including attendance at meetings of assigned committees and participation in the work of these committees. Medical Staff obligations also include participating in continuing education, peer review, Medical Staff monitoring and evaluation, and improving

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Medical Staff Bylaws – Reviewed and Adopted by the Medical Staff June 21, 2017 organizational performance through total and continuous quality improvement. All Medical Staff members are subject to review as part of SAVAHCS quality assessment and improvement program. In addition, each member agrees to periodic reappraisal to assure that the above responsibilities are fulfilled and that clinical privileges previously conferred remain appropriate. Medical Staff members will complete and document medical histories and physical examinations within the timeframes specified by VHA Policy. Medical Staff members agree to abide by the Medical Staff Bylaws and Medical Staff Rules and Regulations and all other lawful standards, policies, and rules of SAVAHCS and the Veterans Health Administration.

2. 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, gender, religion, national origin, politics, sexual orientation, 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.

3. 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

TUCSON, ARIZONA

Medical Staff Bylaws – Reviewed and Adopted by the Medical Staff June 21, 2017 result, Behavior or Behaviors That Undermine a Culture of Safety may reach a threshold such that it constitutes grounds for further inquiry by the Medical Executive Board into the potential underlying causes of such behavior. Behavior by a provider that is disruptive could be grounds for disciplinary action.

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

Providers, in their role as patient and peer advocates, are obligated to take appropriate action when observing Behavior or Behaviors That Undermine a Culture of Safety on the part of other providers. VA urges its providers to support their hospital, practice, or other healthcare organization in their efforts to identify and manage Behavior or Behaviors That Undermine a Culture of Safety by taking a role in this process when appropriate.

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 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 Medical Executive Committee 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 Medical Executive Committee. The Governing Body (Director) must determine the method of this communication. (Also, see Art. XII.4-6). SAVAHCS leadership is to make use of these and other resources in communicating expectations to clinicians and other staff that conflictive, disruptive, inappropriate, intimidating, and uncivil behavior can compromise VHA’s mission of high quality health care service to Veterans. VA staff who experience or witness such behavior are encouraged to advise an appropriate supervisor, Patient Safety Officer, or other individual as described in the following Agency resources.

ARTICLE IV: ORGANIZATION OF THE MEDICAL STAFF

Section 4.01 Leaders

1. Composition:

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Medical Staff Bylaws – Reviewed and Adopted by the Medical Staff June 21, 2017

a. Chief of Staff: The Chief of Staff shall act as Chairman at the MEB and at all regular or special Medical Staff meetings. As one of SAVAHCS management (Director, representing governing body; Associate Director and Assistant Director, representing hospital administration; Associate Director for Patient Care Services, representing Nursing, and Chief of Staff, representing the Medical Staff) he or she serves to assure effective communication among the Medical Staff, governing body, and administration.

i) Qualifications: Licensed independent and other practitioners privileged through the organized medical staff process that is subject to the Medical Staff Bylaws.

ii) Selection: The Network Director approves recommendations to the position of Chief of Staff. SAVAHCS must 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.

iii) 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. Deputy Chief of Staff: The Deputy Chief of Staff fulfills the responsibilities of the Chief of Staff as defined in these bylaws whenever acting for the Chief of Staff.

c. Member At Large: The organized medical staff has one medical staff officer. A Medical Staff Member At Large shall be elected by the Medical Staff. He or she shall serve as a member of the MEB, Resources Board, and Affiliation Partnership Council. All Medical Staff members are eligible for election and only Medical Staff members are eligible for this position. The Medical Staff Member-At-Large shall be elected for one calendar year and may be elected to successive terms. The Medical Staff Member-At-Large may be removed for cause by majority vote of the Medical Staff.

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 through continuous quality improvement, goals and plans, mission, and services offered.

Section 4.03 Clinical Services

1. Characteristics:

a. Clinical care is provided by members of the Medical Staff aligned with Care Lines and Service Lines (C/SLs). The Medical Staff within C/SLs are led by a Chief of the C/SL who is a member of the Medical Staff or, if the Chief is not a member of the Medical Staff, by a designated Care or Service Line Clinical Lead who represents their specialty.

The C/SLs are:

i) Administrative Medicine Care Line

TUCSON, ARIZONA

Medical Staff Bylaws – Reviewed and Adopted by the Medical Staff June 21, 2017

ii) Anesthesia Care Line

iii) Clinical Care Support Service Line

iv) Medicine Care Line

v) Mental Health Care Line

vi) Pathology and Lab Service Line

vii) Primary Care and Community Clinics Care Line

viii) Radiology Care Line

ix) Rehabilitation and Transitional Care Line

x) Surgical Care Line

b. Clinical Services hold service-level meetings at least quarterly.

2. Functions:

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

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

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

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

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

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

g. Annually review privilege templates for each Service and make recommendations to

MEB.

3. Selection and Appointment of C/SL Chiefs: C/SL Chiefs are appointed by the Director based upon the recommendation of the Chief of Staff. Separate from these Bylaws, and in compliance with VA/VHA Policy, the organization determines how the search is to be conducted, how each candidate’s qualifications are reviewed, and how recommendations

TUCSON, ARIZONA

Medical Staff Bylaws – Reviewed and Adopted by the Medical Staff June 21, 2017 are made to the Chief of Staff as to the quality of each applicant. Criteria for appointment as C/SL Chief include Board Certification/or equivalent experience and comparable training as vetted through the credentialing process.

4. Duties and Responsibilities of C/SL Chiefs: The C/SL 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 C/SL 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 C/SL Chief.

C/SL Chiefs are responsible and accountable for:

a. Completing Medical Staff Leadership and Provider Profiling on-line training within three months of appointment as C/SL 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 or scope of practice through FPPE/OPPE.

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

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

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

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

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

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

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

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.

TUCSON, ARIZONA

Medical Staff Bylaws – Reviewed and Adopted by the Medical Staff June 21, 2017

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. Unless otherwise specified, the presence of a minimum of twenty-five (25) percent of a committee's members will constitute a quorum.

4. The members of all standing committees, other than the MEB, are appointed by the Facility Director upon recommendation by the Chief of Staff, 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 will govern all committee meetings.

Section 5.02 Medical Executive Board of the Medical Staff

1. Characteristics: The MEB serves as the Executive Committee of the Medical Staff. Only Medical Staff members of the MEB may vote. The members of the MEB are:

a. Chief of Staff, Chairperson

b. Deputy Chief of Staff

c. Chief or Clinical Lead from each C/SL that provides patient care

d. Member-At-Large

e. Chief of Research Service Line

f. Clinical Director of Quality Management

g. Director, or designee, ex-officio

h. Associate Director for Patient Care Services

i. A member unable to attend an MEB meeting will arrange for a representative to serve in their stead.

j. At the request of the Chairperson, other facility staff as may be called upon to serve as resources or attend committee meetings without vote.

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

TUCSON, ARIZONA

Medical Staff Bylaws – Reviewed and Adopted by the Medical Staff June 21, 2017

l. Members of the MEB, with the exception of the Medical Staff Member-At-Large, are selected for membership by virtue of their appointment to their VA positions. C/SL Chiefs are appointed or removed by the Director based upon the recommendation of the Chief of Staff, as described in Article IV, Section 4.03.

2. Functions of the MEB: The MEB:

a. Acts on behalf of the Medical Staff between Medical Staff meetings within the scope of its responsibilities as defined by the Organized Medical Staff. The MEB shall act for the Medical Staff between Medical Staff meetings including endorsing the revision of all center memoranda, standing operating procedures, interpretation and means of implementation of the Bylaws. Revisions to the Bylaws will be made as outlined in Article XII. Urgent amendment to Appendix A (Rules and Regulations) necessary to comply with law or regulation may be provisionally adopted by the MEB and approved by the Director without prior notification to the medical staff. In such cases, the Chief of Staff, acting on behalf of the MEB will notify the active Medical Staff. The revision will be formally adopted at the next scheduled Medical Staff meeting. The Medical Staff may redress concerns regarding such revision as outlined in Article XII.5.

b. Serves as the credentialing body for the Medical Staff, as described in these Bylaws and, as provided in VHA Directives, shall also serve as the Professional Standards Board for appropriate disciplines. In the case of non-physician Medical Staff members, the Program Director of the respective discipline shall also be present for credentialing and appointments.

c. 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.

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

e. Makes recommendations directly to the Director regarding the:

i) Organization, membership to include termination, structure, and function of the Medical Staff. Process used to review credentials and delineate privileges for the medical staff.

ii) Delineation of privileges for each Practitioner credentialed.

f. 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.

g. Oversees process in place for instances of “for-cause” concerning a medical staff member’s competency to perform requested privileges.

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

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

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

TUCSON, ARIZONA

Medical Staff Bylaws – Reviewed and…