Attachment 2 36C25522Q0001 D.2 STL Bylaws_2017.pdf

Department of Veterans Affairs MEDICAL CENTER MEMORANDUM 11-04

VA St. Louis Health Care System

St. Louis, MO December 5, 2017

VA St. Louis Health Care System

BYLAWS, RULES AND REGULATIONS

OF THE MEDICAL STAFF

St. Louis, MO

Release Date: 12-5-17 Review Date: 12-5-20

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 St. Louis Healthcare System in St.

Louis, Missouri, hereby organize themselves 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 Department of Veterans Affairs, and they do not create any rights or liabilities not otherwise provided for in law or VHA

Department of Veterans Affairs Regulations.

VA St. Louis Health Care System Medical Staff Bylaws & Rules and Regulations

Table of Contents

PREAMBLE…………………………………………………………………………………….2

Table of Contents……………………………………………………………………….…….3

DEFINITONS

Advanced Practice Registered Nurse (APRN) Affiliation Partnership Council (APC) Appointment Elected Members of the Medical Staff Medical Executive Board (MEB) Ex-Officio General Competencies Governing Body Licensed Independent Practitioner (LIP) Medical Center Medical Record Medical Staff ………………………………………………………………………………...9 Medical Staff Bylaws Organized Medical Staff Physician Assistant (PA) Practitioner Primary Source Privileging Professional Standards Board (PSB) Reappraisal Reprivileging Rules Telemedicine Veterans Administration St. Louis Healthcare System (VASTLHCS) VASTLHCS Director (Director) Verification

ARTICLE I: NAME

ARTICLE II: PUPOSE

ARTICLE III: MEDICAL STAFF MEMBERSHIP

Section 1 Membership Eligibility Section 2 Qualification for Medical Staff Membership & Clinical Privileges Section 3 Basic Responsibilities of the Medical Staff Membership Section 4 Conflict Resolution and Management…………………………………….… http://vhasdcweb4/Education/Computer/COS/By%20Laws/2004%20Bylaws%20Final.htm#_Toc66607801 http://vhasdcweb4/Education/Computer/COS/By%20Laws/2004%20Bylaws%20Final.htm#_Toc66607802

ARTICLE IV APPOINTMENT AND INITIAL CREDENTIALING

Section 1 General Provisions Section 2 Application Procedures Section 3 Process and Terms of Appointment Section 4 Non Standard Medical Appointments

ARTICLE V: CLINICAL PRIVILEGES

Section 1 General Provisions Section 2 Process and Requirements for Requesting Clinical Privileges Section 3 Credentials: Evaluation and Maintenance Section 4 Recommendation and Approval Section 5 Temporary Appointments and Privileging in Emergency Situation…..…..28

ARTICLE VI: REAPPRAISAL AND REPRIVILEGING

Section 1 General Provision Section 2 Amendment to Current Privileges Section 3 Requesting New or Additional Clinical Privileges Related to the use of New

Technology, Procedure, Technique or Treatment Modality………………………… 31

ARTICLE VII: FAIR HEARING AND APPLELLETE REVIEW

Section 1 Denial of Medical Staff Appointment Section 2 Action Against Clinical Privileges Section 3 Reporting Adverse Actions Section 4 Reporting Malpractice Payments Section 5 Focused Review of Practitioner’s Performance Section 6 Suspension Section 7 Termination of Appointment

ARTICLE VIII: ORGANIZATION OF THE MEDICAL STAFF

Section 1 Officers Section 2 Leadership Section 3 Duties of Officers Section 4 Self Governance Actions

ARTICLE IX: COMMITTEES

Section 1 Committee Membership and Operations Section 2 Medical Executive Board (MEB) Section 3 Professional Standards Board (PSB) Section 4 Bylaws and Nominating Committee

Section 5 Pharmacy and Therapeutics Committee (P&T) Section 6 Research and Development Committee (R&D) Section 7 Performance Improvement Committee (PIC) Section 8 Medical Records Review Committee (MRRC)….…………………….…….51 Section 9 Infection Prevention & Control Committee (IPCC)…………….……… 2Section 10 Transfusion Review Committee (TRC)………………………………….… 52 Section 11 Peer Review Committee (PRC) Section 12 Affiliation Partnership Council Section 13 Committee Records

ARTICLE X: CLINICAL SERVICES

Section 1: Characteristics Section 2: Functions Section 3 Selection and Appointment of Associate Chiefs of Staff Section 4 Duties and Responsibilities of Associate Chiefs of Staff

ARTICLE XI: MEDICAL STAFF MEETING

ARTICLE XII: RULES

ARTICLE XIII: AMENDMENTS

ARTICLE XIV: ADOPTION

RULES AND REGULATIONS OF THE MEDICAL STAFF

I.General II. Electronic Information System and Security III. Patient’s Rights and Responsibilities

A. Medical Staff Commitment to Patient Rights B. Advance Directive (AD) C.Informed Consent

IV. General Responsibilities for Care A. Conduct of Care B. Emergency Services C.Admissions D.Admission History and Physical Examinations (H&Ps) E. Transfers F. Consultation G.Discharge Planning H.Discharge I.Autopsies

V. Physician Orders A. General Requirements

B. Automatic Stop Orders C.Submission of Surgical Specimens D.Special Treatment Procedures

VI. Role of Attending Staff A. Supervision of Resident and Non-Physicians B. Documentation of Supervision

VII. Medical Record A. Basic Documentation Requirements B. Basic Clinical Information Requirements C.Inpatient Medical Record D.Operative and Other Invasive Procedures E. Outpatient Records F. Authentication G.Consent for Release of Medical Information H.Unauthorized Removal of Medical Records I.Rules and Regulations Governing Medical Record Content

VIII Health Status and Impaired Professional program …………… IX Infection Control X. Disaster XI Continuing Education

DEFINITIONS

Advanced Practice Registered Nurse (APRN) For the purposes of this document, APRN refers to a registered nurse possessing an advanced degree and national certification to practice as a Nurse Practitioner or Clinical Nurse Specialist. Currently, a Certified Registered Nurse Anesthetist is not considered an Advanced Practice Registered Nurse with privileges. APRNs are credentialed and privileged by the Medical Office and are considered members of the Medical Staff.

APRNs are privileged by the Professional Standards Board. All nurses other than APRN with privileges function under a Scope of Practice determined by state law, the supervising physician’s delegation of responsibilities, the individual’s education and experience, and the specialty and setting in which the individual works. RNs other than APRN are appointed and governed by the Nurse Professional Standards Board

(NPSB).

Affiliation Partnership Council (APC) The Affiliation Partnership Council is established by a formal memorandum of affiliation between VA St. Louis Healthcare System and its affiliation partners and approved by the Under Secretary of Healthcare Operations. It is composed of the Dean of St. Louis University School of Medicine, the Dean of Washington University School of Medicine, senior faculty members of the various schools as appropriate, representatives of the medical staff of the facility; and such other faculty and staff as are appropriate to consider and advise on development, management and evaluation of all education and research programs conducted at this medical center.

Allied Health Practitioner (AHP) For the purposes of this document, the term will refer to providers such as Certified Registered Nurse Anesthetist (CRNA) and Physician Assistants (PA) working under scope of practice.

Appointment For the purposes of 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 patient care services at the Medical Center and/or its Community Clinics. VA employees (with or without compensation), contractors, and fee providers may receive appointments to the Medical Staff.

Automatic Suspension of Privileges Suspensions that are automatically enacted whenever the defined indication occurs, and do not require discussion or investigation of clinical care concerns. Examples are exceeding the allowed medial record delinquency rate when such delinquency does not impact patient care conduct/behavior issues not impacting patient care or failure to maintain qualifications for appointment. Privileges are automatically suspended until the records are completed or the delinquency rate falls to an acceptable level. Reactivation must be endorsed by the Medical Executive Board.

Deputy Chiefs of Staff Deputy Chief of Staff (DCOS) for Operations. The duties of DCOS of Operations are to provide administrative, clinical, and programmatic leadership for medical services to ensure achievement of the clinical, research, and education goals and applicable performance measures. DCOS for Operations reports to the Chief of Staff and serves as a key clinical resource for the Medical Center Director and the Chief of Staff as part of the key leadership team of the medical center. The DCOS for Operations serves as liaison between the COS and all the medical services ensuring health services to veterans are consistent with the policies and guidelines of the Veterans' Health Administration. Return to Table of Contents

Deputy Chief of Staff for Education and Affiliation. The duties of DCOS of Education and Affiliation are to oversee VHASTLHCS relationship with the external learning community including health professional school affiliations, and to ensure quality and oversight of the Education Service including achieving optimal resource utilization (e.g., space, professional and administrative staff) to maximize service utilization and effective use of institutional resources. DSOC of Education and Affiliation assesses facility initiatives linking educational activities directly to long- term strategic goals such as the delivery of high quality, patient centered care, and ensures compliance with education/training mandates through TMS.

Elected Members of the Medical Staff The term elected member of the Medical Staff means the Secretary, the Secretary Elect, and the treasurer of the Medical and Dental Staff; the Chairs of the Standing Committees of the Medical (except the MEB, APCC, PRC and the PSB); the PSB representative to the MEB; and the five at large Medical Staff members to MEB.

Medical Executive Board (MEB) A group of Medical Staff members, a majority of whom are licensed physician members of the Medical Staff practicing in the VA St. Louis Healthcare System. This group is responsible for making specific recommendations directly to the VASTLHCS Director for approval, as well as for receiving and acting on reports and recommendations from Medical Staff committees, clinical services, and assigned activity groups. The MEB represents the organized Medical Staff between scheduled meetings.

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.

Ex-Officio The term Ex-Officio refers to any individual who, by virtue of an office or position held, serves as a member of a committee or other body and, unless otherwise expressly provided, does so without voting rights.

General Competencies General Competencies are adapted from the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties joint initiatives. The following are the six areas of General Competencies

1. Patient care – Practitioners are expected to provide patient care that is compassionate, appropriate and effective for the promotion health, prevention of illness, treatment of disease and care at the end of life.

2. Medical/Clinical Knowledge – Practitioners are expected to demonstrate knowledge of established and evolving biomedical clinical and social sciences, and the application of their knowledge to patient care and the education of others.

3. Practice-Based Learning and Improvement- Practitioners are expected to be able to use scientific evidence and methods to investigate, evaluate and improve patient care practices.

4. Interpersonal and Communication Skills – Practitioners are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families and other members of the healthcare teams.

5. Professionalism – Practitioners are expected to demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice and understanding and sensitivity to diversity (includes race, culture, gender, religion, ethnic background, sexual preference, language, mental capacity and physical disability) and a responsible attitude toward their patients, their profession and society.

6. System-Based Practice – Practitioners are expected to demonstrate both an understanding of the context and systems in which healthcare is provided and the ability to apply this knowledge to improve and optimize health care.

Governing Body The Under Secretary for Healthcare Operations (USH) for the VHA, a component of the Department of Veterans Affairs (DVA), Washington, D.C., has delegated authority of the Governing Body through the Veterans Integrated Service Network (VISN) to the Medical Center Director. The Medical Center Director is to conduct all business consistent with VHA, VISN, and facility policies and regulations. As a member of the VISN 15, resources for clinical care, research and education at the VASTLHCS are allocated by the Director, VISN 15.

Licensed Independent Practitioner (LIP) Any individual permitted by law and by the organization to provide care, treatment, and services, without direction or supervision, within the scope of the individual’s license and consistent with individually granted clinical privileges.

Medical Center The term “Medical Center” refers to the hospital campuses of the VA St. Louis Healthcare System (VASTLHCS). The Medical Center includes: John Cochran Division located at 915 N. Grand Avenue, St. Louis, Missouri 63106, Jefferson Barracks Division located at # 1 Jefferson Barracks Drive, St. Louis, Missouri 63125, Manchester

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Avenue Annex at 4974 Manchester Ave St. Louis, MO 63110, Washington Avenue Annex at 2727 Washington Ave, St Louis, MO 63101, Belleville VA Community Based Outpatient Clinic (CBOC) located in Belleville, Illinois 62223, St. Charles Community CBOC in St. Charles, Missouri 63304, , Washington CBOC in Washington, MO 63090, North County CBOC at 6854 Parker Road St. Louis, MO 6303 and all other clinic locations.

Medical Record The medical record is defined as any information relating to the patient. This includes but is not limited to, the inpatient and outpatient written record, radiograph reports, photographic studies, reports of special tests or pathology, and/or information stored on the Computerized Patient Record System (CPRS), or other patient related data bases of the VASTLHCS. Data concerning patients referred to VASTLHCS for care by other VA facilities is also available through the “Remote Data” function of CPRS.

Medical Staff Individuals who are subject to the bylaws, rules, and regulations of the organized Medical Staff. The Medical Staff consists of, and is restricted to, fully licensed physicians, dentists, podiatrists, optometrists, psychologists, chiropractors, and Advanced Practice Registered Nurses with privileges who meet the legal requirements and current qualifications for Credentialing and Privileging of the VHA, and the VASTLHCS. All full-time, part-time, without compensation (WOC), intermittent, fee contract, and other physicians, dentists, podiatrists, optometrists, psychologists and APRNs with privileges, who are employed in any other manner by the VASTLHCS, including its Community Based Outpatient Clinics, are covered by these Bylaws.

Medical Staff Bylaws Regulations and/or rules adopted by the organized Medical Staff and the governing body of the VASTLHCS for the purpose of internal governance. The bylaws define the rights and obligations of various officers, persons, or groups within the organized Medical Staff’s structure.

Organized Medical Staff The governance structure of the Medical Staff, including the Medical Staff’s bylaws, rules, and regulations which the Medical Staff endorses and to which it is subject. This structure is approved by the Director.

Physician Assistant (PA) For the purposes of this document, PA refers to an individual possessing specialized education, training, certification, and/or license who practices medicine under the supervision of a duly appointed, credentialed, and privileged VASTLHCS physician.

These individuals are credentialed, but not privileged, by the Medical Office and are not considered members of the Medical Staff. They function under a Scope of Practice determined by state law, the supervising physician’s delegation of responsibilities, the

Page 11 of individual’s education and experience, and the specialty and setting in which the individual works. PAs are governed by PA-PSB.

Practitioner The term, as used in these Bylaws and Rules, refers to any individual employed by the VASTLHCS who is fully licensed or otherwise granted authority to practice in a state, territory, or commonwealth of the United States or District of Columbia. It can include physicians, dentists, podiatrists, optometrists, psychologists, chiropractors, APRNs with privileges, physician assistants, nurse anesthetists, or other personnel who have been granted clinical privileges or for whom a scope of practice has been approved.

Primary Source The original source of a specific credential that can verify the accuracy of a qualification reported by an individual healthcare practitioner. Examples include medical school, graduate medical education program, and state medical board.

Privileging The process whereby a specific scope and content of patient care services (that is, clinical privileges) are authorized for a healthcare practitioner by the organization based on evaluation of the individual’s credentials, peer evaluations, and performance.

Professional Standards Board (PSB) The PSB is responsible for matters concerning the appointment, advancement, and probationary and for cause review of physicians, dentists, podiatrists, optometrists, psychologists, chiropractors, and APRNs with privileges of the VASTLHCS. It reviews the initial privileges requested by each physician and makes recommendations concerning them to the MEB. It also is informed about the appointment, reappointment and scope of practice of Certified Nurse Anesthetists (CRNAs) and Physician Assistants (PAs).

Reappraisal Reappraisal occurs in conjunction with reprivileging and encompasses a review of pertinent quality and performance information for each VASTLHCS Medical Staff member. It may include, but is not limited to, quality and timeliness of documentation, blood utilization, drug utilization, and the numbers and types of procedures performed, as well as morbidity and mortality outcomes. Reappraisal includes a review of peer references, and information obtained from other facilities where practice occurs, if applicable. Other pertinent quality assurance information may be requested to satisfy the MEB and the Director that the requested privileges should be granted.

Reprivileging The process by which currently privileged Medical Staff members periodically have their facility specific privileges and pertinent quality/performance information reviewed for appropriateness to their practice, and for evaluation of their ability to carry out those

Page 12 of privileges in the VASTLHCS. Reprivileging occurs no less frequently than every two years.

Rules Rules refer to the specific rules set forth in this document that govern the Medical Staff of the VASTLHCS. It does not refer to formally promulgated VHA or Department of Veterans Affairs (DVA) Regulations.

Telemedicine The use of medical information exchanged from one site to another via electronic communications for improving the health and education of the patient or healthcare provider and for improving patient care and access. The originating site is the site where the patient is located at the time of the service is provided. The distant site is the site where the practitioner providing the service is located.

VA St. Louis Healthcare System (VASTLHCS) The term “VA St. Louis Healthcare System” used in these Bylaws and Rules refers to the VA St. Louis Healthcare System (John Cochran Division and Jefferson Barracks Division) and all Community Based Outpatient Clinics, annexes and other approved VASTLHCS care locations established by the Governing Body.

VASTLHCS Director (Director) The Director is appointed by the Governing Body to act as its agent in the overall management of the VASTLHCS. The Director is assisted by the Chief of Staff, the Associate Director for Administrative Operations, the Associate Director for Patient Care, the Deputy Medical Center Director, and the Director Quality Management.

Verification Verification is defined as documentation of a specific source of primary education, training, licensure, or board certification either by letter, telephone, fax, computer printout, or listing in specific directories as provided in VHA Handbook 1100.19 and supplements thereto.

Reference: VHA Handbook 1100.19 http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2910

ARTICLE I: NAME

The name of this organization shall be the Medical Staff of the Department of Veterans Affairs, VA St. Louis Healthcare System, St. Louis, Missouri

ARTICLE II: PURPOSE

The purpose of the Medical Staff shall be to:

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1. Ensure that all patients treated at the VASTLHCS receive the safest, highest quality healthcare through recruitment, appointment and retention of qualified staff and through the delivery of effective, efficient, timely and appropriate care, that is subject to continuous performance improvement practices.

2. Ensure all eligible patients receive a comparable, high level of care.

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

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

5. Provide educational activities that enhance the quality of care provided, continuous improvement of clinical practice and continuing education of members of the Medical Staff.

6. Ensure a high level of professional performance of practitioners through continuous performance 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 means whereby issues concerning the Medical Staff and the medical center may be discussed by the Medical Staff and the Medical Center Director.

9. Develop and implement continual performance improvement activities in collaboration with the staff of the facility.

10. Maintain an environment within which patient care, education and medical research can flourish.

References: VHA Manual M-1, Part I, Chapter 26 http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=2761

ARTICLE III: MEDICAL STAFF MEMBERSHIP

Section 1. Membership Eligibility

A. Categories of Medical Staff: VASTLHCS has one unified Medical Staff

1. Membership on the Medical Staff is a privilege extended only to, and continued for, licensed and professionally competent physicians, dentists, podiatrists, optometrists, psychologists, chiropractors, and APRNs with privileges, who consistently meet the qualifications, standards, and requirements of the DVA, VHA, VISN 15, VASTLHCS, and these http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=2761

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Bylaws and Rules. Membership may be considered for other licensed practitioners upon recommendation of the (MEB) to the Medical Staff. Such practitioners must provide patient care services independently and meet the qualifications, standards, and requirements of VHA, the VASTLHCS, and these Bylaws and Rules.

2. Physicians, dentists, podiatrists, optometrists, psychologists, (excluding interns and residents), chiropractors, and APRNs with privileges, who are full-time, part-time, intermittent, consultant, without compensation, fee contract, or employed in any other manner by the medical center, will be eligible for membership.

3. Consultant physicians, whether with or without compensation, fee basis, contract and other physicians, dentists, podiatrists, optometrists, psychologists, chiropractors and APRNs with privileges, shall have the same responsibilities as full-time or part-time paid Medical Staff members, but may have a more limited degree of involvement in service on VASTLHCS committees. All, however, are considered members of the active Medical Staff.

4. The Medical Staff is organized under three categories:

a. Category I: Staff members who are employed by the VASTLHCS on a half time (4/8) or greater basis. Category I staff members are:

i. Eligible to vote and serve on all Medical Staff committees.

ii. Required to attend Medical Staff and service meetings unless formally excused,

b. Category II: Staff members who are employed by the VASTLHCS on less than a half-time basis (4/8), but at least one-eighth (1/8) basis.

Category II staff members:

i. May serve on Medical Staff committees.

ii. May attend and vote at Medical Staff meetings.

iii. May attend service meetings at Associate Chief of Staff or

Service Chief discretion.

iv. May not hold Medical Staff Office

c. Category III: Staff members who are consultants, attending, without compensation (WOC) staff, fee basis staff, medical officers of the day (MOD), and contract physicians. Category III staff members are:

i. Encouraged, but not required, to attend Medical Staff and meetings

ii. May not hold Medical Staff office.

iii. May not vote at Medical Staff meetings.

iv. May serve on Medical Staff committees.

5. Decisions regarding Medical Staff membership are made without discrimination as to race, color, religion, sex, national origin, sexual orientation, gender, lawful partisan political affiliation, marital status, physical or mental handicap when the

Page 15 of 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 and ability to perform assigned work without compromise to patient care. Applicants will be considered if they qualify and are essential to the clinical care, education, and research needs of the VHA and the VASTLHCS.

6. The Medical Staff may, at any Medical Staff membership meeting by a two-thirds

(2/3) vote, accept into Category III membership licensed individuals who have requested such consideration and who are permitted by laws to provide patient care services independently in a hospital setting.

Section 2. Qualifications for Medical Staff Membership and Clinical Privileges

A. To qualify for Medical Staff membership and clinical privileges, individuals who meet the eligibility requirements identified in Section 1 of this Article must submit evidence of:

1. Current, full, and unrestricted license to practice the individual’s profession in a state, territory, or commonwealth of the United States or the District of Columbia, as required by DVA employment, contracting, and utilization policies and procedures.

2. Education applicable to individual Medical Staff member, i.e., hold a degree of Doctor of Medicine, Doctor of Osteopathy, Doctor of Dental Surgery, Doctor of Dental Medicine, Doctor of Optometry, Doctor of Podiatric Medicine, Doctor of Psychology, Doctor of Chiropractic, or RN license and Master of Science in Nursing degree / Advanced Practice Nursing license from an approved college or university.

3. Relevant training and experience consistent with the individual’s professional assignment and requested privileges. This includes any internships, residencies, fellowships, postgraduate, or specialty training, as confirmed by relevant Board or other certification.

4. Current competence, through peer and/or employer references, consistent with the individual’s assignment and the privileges for which the individual is applying.

5. Health status consistent with the physical and mental capability necessary to satisfactorily perform the duties of the medical staff assignment and requested clinical privileges without compromise to patient care.

6. Satisfactory evidence relative to previous professional conduct.

7. Professional liability insurance as required by Federal and VHA regulations for those individuals providing services under contract.

8. English-language proficiency in written and spoken English language as defined and verified by testing (if necessary), pursuant to USH’s Memorandum dated August 27, 1997.

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Section 3. Basic Responsibilities of Medical Staff Membership

A. Medical Staff members are accountable for and have responsibility to:

1. Provide continuous care for patients assigned or admitted in their area of expertise.

2. Observe Patients’ Rights, as delineated in MCM-00QM-05 “Patient Rights and Responsibilities” and these Bylaws, in all patient care activities.

3. Participate in continuing education, peer review, Medical Staff monitoring and evaluation, and performance improvement activities.

4. Supervise housestaff and non-independent practitioners.

5. Participate in programs developed to maintain and improve the quality of patient care and assist in providing oversight for improving patient satisfaction.

B. All members of the Medical Staff will maintain standards of ethics and ethical relationships including a commitment to:

1. Abide by Federal law and DVA rules and regulations regarding financial conflict of interest and outside professional activities for remuneration. Medical Staff are subject to standards of ethical conduct; i.e., conflict of interest statutes, (18 U.S.C.

202-209, 216), regulations, (5 C.F.R. Part 2635), and Executive Orders (12674, 12731). These provisions are designed to ensure that Federal employees act in the best interests of their employer. These provisions concern the giving and accepting of gifts, conflicting financial interests, impartiality in performing official duties, seeking other employment, misuse of position, and outside activities. Medical Staff members are encouraged to seek assistance and guidance from the Agency’s ethics official and legal counsel, as appropriate.

2. Provide care to patients within the scope of privileges granted and advise the VASTLHCS Director through the Chief of Staff of changes in ability to fully meet the criteria for Medical Staff membership or carry out clinical privileges that have been granted.

3. Advise the VASTLHCS Director through the Chief of Staff of any challenge or claims against professional credentials, professional competence, or professional conduct within 30 days of notification of such occurrences, and the ultimate outcome of any challenge or claim consistent with requirements of Article IV, Section 2, of these Bylaws.

4. Abide by the Medical Staff Bylaws and Rules and all other lawful standards and policies of the VASTLHCS, VHA, and the DVA.

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Section 4. Conflict Resolution and Management

A. Conflict management is the process of planning to avoid conflict when possible and manage to resolve such conflict quickly and efficiently when it occurs.

B. The medical staff should follow the processes outlined in the VA Handbook 5978.1, Alternative Dispute Resolution Program, in-order-to addresses the conflict resolution and management process available in VASTLHCS, 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 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 Executive Committee. The Governing Body (Director) must determine the method of this communication.

References:

C. VHA expects VA medical center leadership to make use of these and other resources in communicating expectations to clinicians and other staff that conflictive, disruptive, inappropriate, intimidating, and uncivil behavior can compromise VHA’s mission of high quality healthcare 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.

VHA Handbook 1100.19, Credentialing & Privileging http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=2910 VHA IL 10-97-023 http://vaww.va.gov/publ/direc/health/infolet/109723.doc

VHA Manual M-1 Part 1, Chapter 26 http://vaww.va.gov/publ/direc/health/manual/010126.pdf

MCM-QM00-05 Patient Rights & Responsibilities 5 CFR Part 2635 Standards of Ethical Conduct for Employees of the Executive Branch http://www.access.gpo.gov/nara/cfr/waisidx_03/5cfr2635_03.html

VHA Directive 1660.03, Conflict of Interest in Contracting http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=1770 Memorandum on Alternative Dispute Resolution for Workplace Disputes, (February 8, 2007), VA Directive 5978, Alternative Dispute Resolution (February 23, 2000), and VA Handbook 5978.1, Alternative Dispute Resolution Program: Central Office (December 11, Office of Diversity and Inclusion (EEO) website http://www.diversity.va.gov/policy/statement.aspx http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=2910 http://vaww.va.gov/publ/direc/health/infolet/109723.doc http://vaww.va.gov/publ/direc/health/manual/010126.pdf http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=2761 http://www.access.gpo.gov/nara/cfr/waisidx_03/5cfr2635_03.html http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=1770 http://www.diversity.va.gov/policy/files/ADR_Memo.pdf http://www.diversity.va.gov/policy/files/ADR_Memo.pdf http://www.va.gov/ORM/docs/VA_directive_5978_ADR.pdf http://www.va.gov/ORM/docs/VA_directive_5978_ADR.pdf http://www.va.gov/ORM/docs/VA_directive_5978_ADR.pdf http://www.diversity.va.gov/policy/statement.aspx

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ARTICLE IV: APPOINTMENT AND INITIAL CREDENTIALING

Section 1. General Provisions

A. All proposed members of the Medical Staff, as defined in Article III, Section 1, are subject to full credentials review by the PSB and approval by the MEB, and the Director, except as noted in Article IV, Section 4, Non-Standard Medical Appointments:

1. At the time of initial appointment to the Medical Staff, or

2. After a break in service of more than 15 days, except for approved extended medical or educational/sabbatical leave, such credentials may be subject to change and will be reviewed on return to duty.

B. After PSB review and MEB approval and recommendation, as provided for in Section

3 of this Article, initial clinical privileges may be granted by the VASTLHCS Director for a period of no more than two years.

C. Appointments to the Medical Staff occur in conjunction with VA employment, a VA contract or sharing agreement, or appointment without compensation. The authority for these actions is based upon:

1. Provisions of 38 United States Code (USC) in accordance with the appropriate DVA Directives and its supplements, VHA Handbook 1100.19 and its supplements, and the applicable Agreement(s) of Affiliation in force at the time of appointment.

2. Federal law authorizing VHA to contract for healthcare services.

D. Probationary periods apply to initial and certain other appointments made under 38 USC 7401 (1), 7401(3), and, where applicable, 5 USC 3301. During the probationary period, professional competence, performance, and conduct will be closely evaluated under applicable VHA policies and procedures. If, during this period, the employee demonstrates an acceptable level of performance and conduct, the employee will successfully complete the probationary period. Associate Chiefs of Staff, Service Chiefs, supervisors, and managers will similarly evaluate individuals employed under the provisions of 38 USC 7405 and those utilized under contracts and sharing agreements.

E. Physician Assistants (PAs) or Certified Registered Nurse Anesthetists (CRNA) are not considered members of the Medical Staff but are credentialed in a manner that is equivalent to and consistent with the process by which Medical Staff members are credentialed and privileged. These individuals function under Scopes of Practice or Standardized Procedures and provide patient care and treatment under the supervision

Page 19 of of a duly appointed, credentialed, and privileged VASTLHCS physician. PAs and CRNA are evaluated and governed by the PSB. Both groups of practitioners are held to the same professional standards of patient care, ethics, and conduct as members of the Medical Staff.

Section 2. Application Procedures

A. Applicants for appointment are required to submit, on forms approved by the VHA and/or the VASTLHCS, a signed Release of Information that allows inquiry about issues pertinent to the matters contained in an Application for Employment (see 1-9, below).

Applicants for membership to the Medical Staff, as well as Certified Registered Nurse Anesthetists and PAs, are also required to submit their professional credentials information electronically through the Federal Credentialing Program (VetPro). All information is subject to primary source verification and required clearances before credentialing is considered complete.

1. Items specified in Article III, Section 2, of these Bylaws, Qualifications for Medical Staff membership including:

a. Active, current, full and unrestricted license

b. Education

c. Relevant training and/or experience

d. Current clinical privileges held elsewhere (if applicable)

e. Physical and mental health status

f. English language proficiency

g. Professional liability insurance

h. Board certification

2. U.S. Citizenship. When it is not possible to recruit qualified citizens, practitioners otherwise eligible for Medical Staff appointment, who are not citizens, will be eligible for consideration for appointment if current visa status and documentation from the Immigration and Naturalization Service or employment authorization can be provided, pursuant to qualifications as outlined in 38 USC7405 and appropriate VHA Directives.

3. Names and addresses of a minimum of three individuals qualified to provide authoritative reference information regarding education and relevant training and experience, ability and current competence, health status, and/or fulfillment of obligations as a Medical Staff member within the privileges requested. This may include assessment of proficiency in the following six areas of general competencies (Patient Care, Medical/Clinical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism and Systems-Based Practice. At least one reference must be provided by the current or most recent employer(s) or institution(s) where clinical privileges are/were held.

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In the case of individuals just completing residency or fellowship programs, one reference must be from their Program Director.

4. A list of all healthcare institutions where the practitioner is/has been appointed, utilized, or employed, including:

a. Name of healthcare institution

b. Term of appointment or employment

c. Privileges held and any disciplinary actions taken against the privileges, including suspension, revocation, limitations, or voluntary surrender.

5. Drug Enforcement Administration (DEA) Registration if currently or previously held, and any previously successful or currently pending challenges to the DEA Registration or the voluntary relinquishment of such Registration.

6. Any challenge to any license held by the practitioner, including whether a license or registration ever held by the practitioner to practice any health occupation has been suspended, revoked, voluntarily surrendered, or not renewed.

7. Tort information. All information possible should be provided, but, at a minimum, final judgments or settlements or professional liability action(s) and information regarding reports to the National Practitioner Data Bank (NPDB) and the Health Integrity and Protection Data Bank (HIPDB) are required.

8. Voluntary or involuntary termination of Medical Staff membership or voluntary or involuntary limitation, reduction, or loss of clinical privileges at another healthcare facility.

9. Pending challenges against the practitioner by any hospital, licensing board, law enforcement agency, the U.S. Government, or professional group or society.

B. Documents required, or which may be requested, in addition to the information or documents listed above include:

1. A copy of current or most recent clinical privileges held, if applicable.

2. Verification of the status of licenses for all states in which the applicant has ever held a license.

3. For foreign medical graduates, evidence and verification of the Educational Commission of Foreign Medical Graduates (ECFMG) Certificate.

4. Evidence and verification of all board certification(s), if claimed.

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5. Verification of education credentials used to qualify for appointment (and privileges) including all postgraduate training.

6. Query by VASTLHCS to NPDB, HIPDB, and Federation of State Medical Boards, and the Exclusionary List of the Office of the inspector General.

7. Confirmation of health status.

8. A signed agreement to abide by these Bylaws and Rules and to provide patient care in the applicant’s area of expertise in keeping with his/her privileges (not applicable to CRNAs or PAs).

9. Acknowledgement of receipt of Bylaws and employee information on safety and training as well as procedures to follow in the event of an internal and external emergency.

10. Photo identification issued by a state or federal or other governmental authority

(e.g. Driver’s License or passport).

C. The applicant has the burden of obtaining and producing, upon request, all needed information for proper evaluation of professional competence, character, ethics, and other qualifications required for appointment to the Medical Staff. The information must be complete and verifiable. The applicant is responsible for furnishing information that will help resolve any doubts concerning such qualifications. Failure to provide such information in a timely fashion generally not to exceed 30 days may serve as a basis for denial of Medical Staff membership.

Section 3. Process and Terms of Appointment

A. The Associate Chief of Staff or Service Chief to whom an applicant will be assigned is responsible for recommending appointment to the Medical Staff, based on evaluation of the applicant’s credentials and a determination that service criteria for clinical privileges are met.

Recommendations for initial, renewal or modification of privileges are based on a determination that the applicant meets criteria for appointment and clinical privileges for the Service including requirements regarding education, training, experience, references and health status. Consideration will also be given to the six core competencies in making recommendations for appointment. The same six core competencies are considered for both initial appointment and reappointment. The core competencies are:

1) Medical/Clinical Knowledge

2) Interpersonal and Communications skills

3) Professionalism

4) Patient Care

5) Practice-based Learning and Improvement

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6) System-based Practice

B. The PSB serves as a peer review board and examines the application in detail.

Reasons for all decisions by the PSB will be documented in the minutes of the PSB.

The PSB minutes are considered Quality Assurance Information and are privileged.

The PSB will examine:

1. The application and three letters of reference concerning the status of professional qualification, licensure, hospital staff appointments, professional liabilities and pertinent health information.

2. The Associate Chief of Staff or Service Chief recommendation concerning the clinical privileges to be granted if approved.

3. Whether the applicant has established and meets all of the necessary qualification for eligibility to an appointment in the VHA of the DVA, and for appointment to the Medical Staff of the VASTLHCS.

4. The PSB will submit in writing its conclusion and recommendations no later than its next scheduled meeting consisting of one of the following:

a. Approval: The recommendation is forwarded to MEB.

b. Disapproval: the application is returned to the Associate Chief of

Staff or Service Chief with written specific reason for disapproval.

c. Deferred: With a specific request for additional information within thirty (30) days.

C. The MEB reviews and acts on the PSB report, recommending Medical Staff appointments of physicians, dentists, podiatrists, optometrists, psychologists, chiropractors, and APRNs with privileges to the VASTLHCS Director if all requirements are met. The PSB will submit in writing, it conclusion and recommendations no later than its next scheduled meeting, consisting of one of the following:

a. Approval: The recommendation is forwarded to Director.

b. Disapproval: the application is returned to the PSB with written specific reason for disapproval.

thirty (30)days.

D. The Director will act upon Appointments to the Medical Staff within 45 days of receipt of a fully complete application, including all required verifications, references, and recommendations from the appropriate Associate Chief of Staff or Service Chief the PSB, or other relevant Standards Boards, and the MEB.

a. Approval: The applicant, Associate Chief of Staff or Service Chief, MEB and Chief of Staff are notified.

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b. Disapproval: the application is returned to the MEB with written specific reason for disapproval.

thirty (30)days.

Appointments of PAs and CRNAs, are based on recommendations of relevant VHA appointed Standards Boards in conjunction with the MEB.

E. Candidates for appointment who have submitted complete applications as defined by these Bylaws will receive written notice of appointment or non-appointment. If an appointment is not approved, the reason(s) for denial will be provided, as described in Article VII, Section 1 of these Bylaws.

Section 4. Non-Standard Medical Staff Appointments

A. Expedited Medical Staff Appointment

1. Per VHA Directive 2002-076, upon receipt of a complete VetPro application for appointment, a one-time-only expedited initial Medical Staff appointment may be granted on a “clean and green” application. The MEB delegates the authority to render this decision to the PSB. The full membership of the MEB will review all actions taken by the subcommittee and ratify all positive committee decisions when verifications are complete. If the committee’s decision is adverse to the applicant or if circumstances warrant, the matter under consideration will be referred to the full MEB for evaluation and determination of appropriate action. Verification of the following core criteria is essential to the expedited process:

a. Current licensure

b. Relevant education and training

c. Certifications, if applicable

d. Two peer references

e. Current competence in General Competencies

f. Ability to perform the privileges requested.

2. Ineligible applications for the expedited appointment include:

f. Current or previous challenge to licensure or registration

g. Involuntary termination of medical staff membership by another organization

h. Involuntary limitation, reduction, denial or loss of clinical privileges or

i. Unusual pattern of or an excessive number of professional liability actions resulting in a final judgment against the applicant, B. Disaster Medical Staff Privileges/Appointment

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1. Any physician, dentist, podiatrist, optometrist, psychologist, chiropractor or APRN with privileges may voluntarily provide patient care in a disaster situation regardless of whether he/she has privileges or membership at VASTLHCS, so long as he/she is granted disaster privileges prior to providing patient care on a case by case basis in accordance with the needs of the organization and its patients and on the qualifications of its volunteer practitioners. In circumstances of internal or external disaster(s) in which the emergency management plan has been activated, the VASTLHCS Director or the Chief of Staff or designee(s) may grant disaster privileges. Granting of disaster privileges will include review by the Disaster Privileging Coordinator (employee of the Medical Staff Office unless otherwise designated by the Chief of Staff or Director) of:

a. Evidence of current license to practice AND

b. Current hospital picture identification that clearly identifies professional designation AND

c. Photo identification issued by the state or other governmental authority (e.g., Driver’s License or passport)

d. Verification of the volunteer practitioner’s identity by a current hospital or

Medical Staff member

e. A list of current hospital affiliations where the individual holds current privileges

f. A NPDB inquiry, if communication is possible

g. Practitioners who are authorized by a local, state, or Federal agency to respond during a disaster may be utilized pending presentation of documents attesting to such authority.