a. Medical Staff Bylaws - VALBHS.pdf

BYLAWS AND RULES OF THE MEDICAL STAFF

OF

VA Long Beach Healthcare System

Long Beach, California

REVIEWED DATE:

DECEMBER 2, 2022

REVISED DATE:

MARCH 26, 2024

SUMMARY OF CHANGES: REMOVED THE REQUIREMENT FOR A DISCHARGE NOTE

APPROVED DATE:

APRIL 4, 2024

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Table of Contents

PREAMBLE 4

DEFINITIONS 4

ARTICLE I. NAME 8

ARTICLE II. PURPOSE 8

ARTICLE III. MEDICAL STAFF MEMBERSHIP 9

Section 3.01 Eligibility for Membership on the Medical Staff 9

Section 3.02 Qualifications for Medical Staff Membership and Clinical Privileges 10

Section 3.03 Code of Conduct 12

Section 3.04 Conflict Resolution & Management 13

ARTICLE IV. ORGANIZATION OF THE MEDICAL STAFF 14

Section 4.01 Leaders 14

Section 4.02 Leadership 15

Section 4.03 Clinical Services 15

ARTICLE V. MEDICAL STAFF COMMITTEES 17

Section 5.01 General 17

Section 5.02 Medical Executive Council of the Medical Staff 17

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 211

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 28

ARTICLE VIII. CLINICAL PRIVILEGES 28

Section 8.01 General Provisions 28

Section 8.02 Process and Requirements for Requesting Clinical Privileges 30

Section 8.03 Process and Requirement for Requesting Renewal of Clinical Privileges

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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 35

Section 8.07 Medical Assessment 38

ARTICLE IX. INVESTIGATION AND ACTION 38

ARTICLE X. FAIR HEARING AND APPELLATE REVIEW 46

Section 10.01 Reduction of Privileges 45

Section 10.02 Revocation of Privileges 48

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. RESPONSIBILITY FOR CARE 54

4. PHYSICIANS' ORDERS 59

5. ROLE OF ATTENDING STAFF 60

6. MEDICAL RECORDS 61

7. INFECTION CONTROL 66

8. CONTINUING EDUCATION 66

9. HEALTH STATUS AND IMPAIRED PROFESSIONAL PROGRAM 66

10. PEER REVIEW 68

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PREAMBLE

Recognizing that the Medical Staff is responsible for the quality of care delivered by its members and accountable to the Governing Body for all aspects of that care, the Medical Staff practicing at the VA Long Beach Healthcare System (VALBHS) in Long Beach, California (hereinafter sometimes referred to as VALBHS, HS, Facility, or Organization) hereby organizes itself for self-governance in conformity with the laws, regulations, and policies governing the Department of Veterans Affairs, Veterans Health Administration (VHA), and the bylaws and rules hereinafter stated. These Bylaws and Rules are consistent with all laws and regulations governing the VHA, and they do not create any rights or liabilities not otherwise provided for in laws or VHA Regulations. The governing body upholds the medical staff bylaws, rules and regulations, and policies that have been approved by the governing body.

VA Long Beach Healthcare System is comprised of the Tibor Rubin VA Medical Center, which provides comprehensive health care through primary care, tertiary care, and long-term care in areas of medicine, surgery, psychiatry, neurology, oncology, dentistry, spinal cord injury, physical medicine and rehabilitation, geriatrics, extended care. VALBHS also includes VA Center of Excellence for Stress & Mental Health, Mental Illness Rehabilitation, Education, and Clinical Centers (MIRECC), a Spinal Cord Injury & Disorder Center, Blind Rehabilitation Center, two Veteran Centers (Garden Grove and Mission Viejo) and five Community Based Outpatient Clinics (CBOCs) located in Placentia, Santa Ana, Villages at Cabrillo in Long Beach, Laguna Hills, Whittier-Santa Fe Springs, and Gardena.

Decisions regarding the appointment to the Medical Staff and the granting of clinical privileges 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.

Portions of these bylaws are required by VA, VHA, or The Joint Commission (TJC). These sections should be maintained in accordance with all current regulations, standards or other applicable requirements. Prior versions of bylaws and rules and regulations must be maintained in accordance with Sarbanes-Oxley Act which states that bylaws and rules are permanent records and should never be destroyed. They must be maintained in accordance with Record Control System (RCS) 10-1, 10Q.

DEFINITIONS

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

1. Advanced Practice Professional: Advanced Practice Professionals are those health care professionals who are not physicians and dentists and who will function within a Scope of Practice but may practice independently on defined clinical privileges as defined in these Bylaws. Advanced Practice Professionals include: Physician Assistants (PA), Licensed Clinical Social Workers, Clinical Pharmacists and Advanced Practice Nurses (APRN, Contract CRNP, and CRNA) Practice Professionals may have prescriptive authority as

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Advanced Registered Nurse Practitioners 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, Mid-level and/or patient care services at the facility. Both VA employees and contractors providing patient care services must receive appointments to the Medical Staff.

3. Deputy Medical Center Director. The Deputy Medical Center Director fulfills the responsibilities of the Director as defined in these bylaws when serving in the capacity of Acting Facility Director.

4. Associated Health Professional: : As used in this document, the term “Associated Health Professional” is defined as those clinical professionals other than doctors of allopathic, dental, and osteopathic medicine. These professionals include, but are not limited to:

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

5. Automatic Suspension of Privileges: Suspensions that are automatically (administratively) enacted whenever the defined indication occurs which warrants a suspension of privileges, and does not require discussion, investigation of clinical care concerns, or result from concern of substandard care, professional misconduct, or professional incompetence. Examples are exceeding the allowed medical record delinquency rate when such delinquency does not impact patient care, conduct/behavior issues not impacting patient care or failure to maintain qualifications for appointment, extended sick leave, or other extended leave. Privileges are automatically suspended until the cause of the suspension has been addressed such as the records are completed or the delinquency rate falls to an acceptable level or provider returns to duty.

Reactivation must be endorsed by the Medical Executive Committee and discussion of reactivation should include consideration of a Focused Professional Practice Evaluation (FPPE) depending upon length of time away from practice and reason for the automatic suspension.

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

7. Community Based Outpatient Clinic (CBOC): A health care site (in a fixed location) that is geographically distinct or separate from the parent medical facility. A CBOC can be a site that is VA-operated and/or contracted. A CBOC must have the necessary

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8. Contract Practitioners: Contractor or subcontractor practitioners are subject to compliance with 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 an automatic revocation of privileges. The Contract Provider will be afforded a limited fair hearing to determine only if the revocation of privileges was based upon substandard care, professional misconduct, or professional incompetence, and reportable to the National Practitioner Data Bank (if Practitioner is a physician or dentist).

9. Director (or Facility Director): The Director is appointed as the Governing Body to act as its agent in the overall management of VALBHS. The Director is assisted by the Chief of Staff (COS), the Deputy Chief of Staff (DCOS), the Deputy Medical Center Director (DMCD), Associate Director (AD), the Associate Director for Patient Care Services/Nurse Executive (AD-PCS/NE), the Deputy Associate Director for Patient Care Service (DADPCS), and the Medical Executive Council.

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

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

12. Medical Staff: The body of all Licensed Independent Practitioners and other Practitioners credentialed through the medical staff process who are subject to the medical staff bylaws. This body may include others, such as retired Practitioners who no longer practice in the organization but wish to continue their membership in the body. The medical staff includes both members of the organized medical staff and non-members of the organized medical staff who provide health care services.

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13. Nurse Executive (AD-PCS/NE): 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.

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

15. Outpatient Clinic: An outpatient clinic is a healthcare site whose location is independent of medical facility but retains medical facility oversight.

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

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

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

Such supervision may result in a reduction of privileges.

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

Some professional standards boards (e.g. Nursing, etc.) are responsible for advancement and other issues related to their respective professions.

20. Rules: Refers to the specific rules set forth that govern the Medical Staff of the facility.

The Medical Staff shall adopt such rules as may be necessary to implement more specifically the general principles found within these Bylaws. Rules are a separate document from the bylaws. They can be reviewed and revised by the MEC and without

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

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

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

ARTICLE I. NAME

The name of this organization shall be the, VA Long Beach Healthcare System, of the Department of Veterans Affairs.

ARTICLE II. PURPOSE

The purposes of the Medical Staff shall be to:

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

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

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

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

5. Provide educational activities that relate to: care provided, findings of quality of care review activities, and expressed needs of caregivers and recipients of care.

6. Maintain a high level of professional performance of Practitioners authorized to practice in the facility through continuous quality improvement practices and appropriate delineation of clinical privileges.

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

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

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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 organization policies and procedures.

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

ARTICLE III. MEDICAL STAFF MEMBERSHIP *

Section 3.01 Eligibility for Membership on the Medical Staff *

1. Membership: Membership on the Medical Staff is a privilege extended only to, and continued for, professionally competent physicians and dentists, podiatrists, optometrists, chiropractors, psychologists, nurse practitioners, and licensed clinical social workers who continuously meet the qualifications, standards, and requirements of VHA, this Facility, and these Bylaws. For the majority of the Medical Staff, an employer/employee relationship, either with or without compensation, will be an integral part of staff membership. Properly appointed and on station fee-basis physicians are considered to be in a class of individuals covered by the provisions of the Federal Tort Claims Act, but are not otherwise seen as members of the medical staff.

2. Categories of the Medical Staff: All Medical Staff are considered to be active members.

All medical care, including the admissions, evaluations, and "emergency" functions of the hospital, will be carried out by members of this category, assisted as appropriate by designated professional personnel subject to the supervision of the staff. All members of the Staff, regardless of membership, shall be assigned to a specific clinical section within a HCG (Healthcare Group) which will recommend appropriate privileges for the member and in whose meetings and performance improvement activities the member will participate, as stipulated in Article IX of these Bylaws and Rules ("Health Care Groups"). Physicians and practitioners seeking to exercise privileges in more than one service will be required to apply for such additional privileges through the respective HCG, as described in Article V

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a. Active Staff shall consist of physicians, dentists, optometrists, podiatrists, chiropractors, psychologists, nurse practitioners, and licensed clinical social workers employed under Title 38 USC, who are professionally responsible for specific patient care, education, and/or research activities of the HS (Healthcare System), and who assume all the functions and responsibilities of membership on the active staff. A member of the active staff shall:

i) Retain responsibility within his or her area of professional competence for the daily care and supervision of each patient for whom he or she is providing service, or arrange a suitable alternate for such care and supervision, and exercise such clinical privileges as have been granted.

ii) Actively participate in peer review, patient care evaluation, and other performance improvement activities required of the staff, and discharge such staff functions as may be required from time to time.

iii) Assume responsibility for the supervision of house officers and other non-Medical Staff professionals as may be required.

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

Section 3.02 Qualifications for Medical Staff Membership and Clinical Privileges *

1. Criteria for Clinical Privileges: To qualify for Medical Staff membership and clinical privileges, individuals who meet the eligibility requirements identified in Section 3.01 must submit evidence as listed below. Privileging criteria are further detailed in VHA Handbook VHA Directive 1100.21. Applicants not meeting these requirements will not be considered.

This determination of ineligibility is not considered a denial.

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

b. Education applicable to individual Medical Staff members as defined, for example holding a Doctoral level degree in Medicine, Osteopathy, Psychology, Podiatry, Optometry, Dentistry from an approved college or university. All social workers must have a Master’s of Social work with a minimum number of clinical supervision hours required to be licensed. Nurse Practitioners must have a Masters degree.

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.

Candidates must affirm that privileges requested are within the scope of their current competency.

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d. Current competence, consistent with the individual's assignment and the privileges for which he/she is applying. This includes internships, residencies, board certification or specialty training. Candidates must affirm that privileges requested are within the scope of their current competency.

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 Identify Verification (PIV) Card, if renewing privileges.

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

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

i) Physicians

ii) Dentists

iii) Podiatrists

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

i) Advanced Practice Nurses including contract staff (CNP, CNM, and CNS)

ii) Certified Registered Nurse Anesthetists (CRNA)

iii) Clinical Social Workers

iv) Clinical Pharmacists

v) Psychologists

vi) Audiologists

vii) Speech Pathologists viii)Optometrists

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

i) Physician Assistants.

ii) Clinical Pharmacy Specialists

iii) Contract APRNs who are not licensed in a state which recognizes their APRNs as Licensed Independent Practitioners.

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

d. 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):

i) Certified Nurse Practitioners (CNP), Certified Nurse Midwives (CNM), Certified Nurse Specialists (CNS).

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

Section 3.03 Code of Conduct

1. Acceptable Behavior: The VA expects that members of the medical staff will serve diligently, loyally, and cooperatively. They must avoid misconduct and other activities that conflict with their duties; exercise courtesy and dignity; and otherwise conduct themselves, both on and off duty, in a manner that reflects positively upon themselves and VA.

Acceptable behavior includes the following: (1) being on duty as scheduled; (2) being impartial in carrying out official duties and avoiding any action that might result in, or look as though, a medical staff member is giving preferential treatment to any person, group or organization; (3) not discriminating on the basis of race, age, color, sex, religion, national origin, politics, marital status, or disability in any employment matter or in providing benefits under any law administered by VA; (4) not making a governmental decision outside of official channels; (5) not taking any action that impedes government efficiency and economy, affects one’s impartiality, or otherwise lowers public confidence in the Federal Government; and (6) with certain exceptions in accordance with 5 C.F.R. 2635, not asking for or accepting any gift, tip, entertainment, loan, or favor, or anything of monetary value for oneself or any member of one’s family from any person or organization

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

Behavior or Behaviors That Undermine a Culture of Safety: is a style of interaction with physicians, hospital personnel, patients, family members, or others that interferes with patient care. Behaviors such as foul language; rude, loud or offensive comments; and intimidation of staff, patients and family members are commonly recognized as detrimental to patient care. Furthermore, it has become apparent that Behavior or Behaviors That Undermine a Culture of Safety is often a marker for concerns that can range from a lack of interpersonal skills to deeper problems, such as depression or substance abuse. As a result, Behavior or Behaviors That Undermine a Culture of Safety may reach a threshold such that it constitutes grounds for further inquiry by the Medical Executive Council 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 organizations in their efforts to identify and manage Behavior or Behaviors That Undermine a Culture of Safety, by taking a role in this process when appropriate.

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

Section 3.04 Conflict Resolution & Management

For VA to be effective and efficient in achieving its goals, we must have clear objectives and a shared vision of what it is striving to achieve. Therefore, there must be a mechanism

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ARTICLE IV: ORGANIZATION OF THE MEDICAL STAFF *

Section 4.01 Leaders *

1. Composition:

a. Chief of Staff.

b. Deputy Chief of Staff.

2. Qualifications: see the Functional Statement or Position Description

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

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

5. Duties:

a. Chief of Staff:

i) Serves as Chairperson of the Medical Executive Council.

ii) Develops and maintains currently accepted management practices throughout the clinical services.

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iii) Develops and presents the budgetary requirements of the clinical services and assists in the formulation of the annual budget program

iv) Responsible to the Medical Center Director for patient care programs and for the educational and research activities of the clinical services

v) Formulates and recommends plans for a complrehensive program of medical care

vi) Develops the requirements of staff, facilities, equipment, and supplies needed to support an integrated program, utilizing necessary reviews and controls.

vii) Appraises the effectiveness of the various medical programs in meeting the needs of patient care.

b. Deputy Chief of Staff serves in roles as requested by the Chief of Staff.

Section 4.02 Leadership

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

Section 4.03 Health Care Groups *

1. Characteristics:

a. Clinical Health Care Groups (HCG) are organized to provide clinical care and treatment under leadership of a HCG Chief.

b. HCGs 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.

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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 Directive 1100.21, titled Privileging.

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

MEC.

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

a. Criteria for appointment as HCG Chief include Board Certification/or equivalent experience and comparable training as vetted through the credentialing process.

b. The performance of chiefs of the clinical HCGs shall be evaluated on an annual basis by the Chief of Staff and may include input from members of the respective HCG and may be based on professional criteria that include clinical, administrative, education, research, and leadership capabilities.

4. Duties and Responsibilities of HCG Chiefs: The HCG Physician Chief is administratively responsible for the operation of the HCG and its clinical and research efforts, as appropriate. In addition to duties listed below, the HCG Physician Chief is responsible for assuring the HCG performs according to applicable VHA performance standards. These are the performance requirements applicable to the HCG from the national performance standard, and cascade from the overarching requirements delegated to the Chief of Staff.

These requirements are described in individual Performance Plans for each HCG Physician Chief. HCG Physician Chiefs are responsible and accountable for:

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

b. Assign this TMS to relevant Service/Section Chiefs, as appropriate.

c. Clinically related activities of the HCG.

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

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

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

g. Recommending clinical privileges for each member of the HCG.

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

i. The integration of the HCG into the primary functions of the organization.

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

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

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

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

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

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

p. The orientation and continuing education of all persons in the HCG.

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

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

ARTICLE V. MEDICAL STAFF COMMITTEES

Section 5.01 General

1. Committees are either standing or special.

2. All committee members, regardless of whether they are members of the Medical Staff, are eligible to vote on committee matters unless otherwise set forth in these Bylaws. A vote to abstain is not considered a vote and should not be used unless there is a conflict of interest or perceived conflict of interest.

3. The presence of the majority of a committee's voting members will constitute a quorum, unless otherwise specified in the committee’s charter.

4. The members of all standing committees, other than the MEC, are appointed by the Chair subject to approval by the MEC, 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 Executive Committee of the Medical Staff

1. Characteristics: The Medical Executive Council (MEC) serves as the representation and governing body of the Medical Staff. MEC shall be the major forum for communication with the Medical Staff at large and provide counsel and assistance to the Chief of Staff and to the Director regarding all facets of the patient care service programs, including continuous performance improvement, goals and plans, mission and services offered.

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Members of the Medical Executive Council * are identified in the Medical Executive Council Charter.

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

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

c. Changes to the MEC membership, leadership, and authority to act may be made by the Medical Staff and proposed directly to the Medical Center Director. To do so apart from the recommendation of the COS and the MEC, a majority of the Medical Staff voting members must vote to make a change. This may be done, for example, by petition, electronic voting, or at a meeting of the Medical Staff in which a majority of all voting members of the Medical Staff is present. The COS or a representative of the Medical Staff must communicate in writing to the Director the outcome of the Medical Staff decision whether the decision is to adopt or vote down the proposed change in MEC membership, leadership, and authority to act. If adopted, the Director is the final approving authority. The Director may give written notice of the decision to the Medical Staff.

2. Functions of the MEC: The specific charges of the MEC are:

a. Acts on behalf of the Medical Staff between Medical Staff meetings within the scope of its responsibilities as defined by the Organized Medical Staff.

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

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

d. Makes recommendations directly to the Director regarding the:

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

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

iii) Delineation of privileges for each Practitioner credentialed.

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

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

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