ATTACHMENT 5 MEDICAL CENTER BY-LAWS.pdf

Medical Staff Bylaws & Rules of Veterans Health Administration

(VHA)

North Florida / South Georgia Veterans Health System

Gainesville, Florida

January 31, 2020

Table of Contents

BYLAWS

PREAMBLE 1

DEFINITIONS 1

ARTICLE I. NAME 5

ARTICLE II. PURPOSE 5

ARTICLE III. MEDICAL STAFF MEMBERSHIP, QUALIFICATIONS AND

CODE OF CONDUCT

Section 3.01 Medical Staff Membership Eligibility 7

Section 3.02 Medical Staff Membership Clinical Privileges Application and Qualifications

Section 3.03 Code of Conduct 10

Section 3.04 Conflict Resolution & Management 11

ARTICLE IV. ORGANIZATION OF THE MEDICAL STAFF 12

Section 4.01 Leaders 12

Section 4.02 Leadership 12

Section 4.03 Clinical Services 12

ARTICLE V. MEDICAL STAFF COMMITTEES 14

Section 5.01 General 14

Section 5.02 Executive Committee of the Medical Staff 15

Section 5.03 Committees of the Medical Staff 17

ARTICLE VI. MEDICAL STAFF MEETINGS 17

ARTICLE VII. APPOINTMENT AND ONGOING CREDENTIALING AND

PRIVILEGING REQUIREMENTS

Section 7.01 General Provisions 18

Section 7.02 Application Procedures for Appointment 21

Section 7.03 Process and Terms of Medical Staff Appointment 24

Section 7.04 Credentials Evaluation and Maintenance 25

ARTICLE VIII. CLINICAL PRIVILEGES 26

Section 8.01 General Provisions 26

Section 8.02 Process and Requirements for Requesting Clinical Privileges 27

Section 8.03 Process and Requirement for Requesting Renewal of Clinical Privileges

Section 8.04 Processing an Increase or Modification of Clinical Privileges 30

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

Section 8.06

Section 8.07

Exceptions

Medical Assessment

ARTICLE IX. INVESTIGATION AND ACTION FOR PERFORMANCE OR

CONDUCT ISSUES

ARTICLE X. FAIR HEARING AND APPELLATE REVIEW 45

ARTICLE XI. RULES AND REGULATIONS 50

ARTICLE XII. AMENDMENTS 50

ARTICLE XIII. ADOPTION 51

MEDICAL STAFF RULES AND REGULATIONS

1. GENERAL 54

2. PATIENT RIGHTS 54

3.

4.

RESPONSIBILITY FOR CARE

PHYSICIANS’ ORDERS

5. ATTENDING STAFF SUPERVISORY ROLE 61

6. MEDICAL RECORDS 62

7. INFECTION CONTROL POLICY 67

8. CONTINUING EDUCATION 67

9. HEALTH STATUS AND IMPAIRED PROFESSIONAL

PROGRAM

10. PEER REVIEW 69

11. SMOKING POLICY 69

12. REQUIREMENTS FOR CPR CERTIFICATION (BLS OR

ACLS) CPR POLICY

13. DISCLOSURE POLICY 69

14. QUALITY MANAGEMENT DIRECTIVE 69

15. REQUIREMENT FOR TIME AND ATTENDANCE 70

16. PATIENT SAFETY INITIATIVES 70

17. CONFLICT OF INTEREST 70

19. RESTRAINT AND SECLUSION 71

20.

19.

SUICIDE ASSESSMENT

WORK PLACE ENVIRONMENT

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 within the North Florida/South Georgia Veterans Health System (hereinafter oftentimes referred to as “NF/SGVHS” or “System”) 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 Medical Staff bylaws hereinafter stated. These Bylaws 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.

NF/SGVHS is composed of hospital and long term care facilities in Gainesville, Florida (hereafter referred to as the Gainesville Division) and Lake City, Florida, (hereafter referred to as the Lake City Division) and remote/satellite outpatient facilities in Jacksonville, Tallahassee, and The Villages, Florida; Community Based Outpatient Clinics (CBOCs) in Lecanto, Marianna, Ocala, Palatka, and St. Augustine, Florida; Valdosta, St. Mary’s, Georgia; and Waycross, Georgia. Portions of these Medical Staff bylaws are required by the VA, VHA, or the Joint Commission (JC). These sections should be maintained in accordance with all current regulations, standards or other applicable requirements. Prior versions of Bylaws must be maintained in accordance with Sarbanes-Oxley Act which states that Bylaws 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 are used:

1. Advanced Practice Professionals: Advanced Practice Professionals are those health care professionals who are not physicians and dentists and who, most often will, function within a Scope of Practice but may practice independently on defined clinical privileges as defined in these Bylaws. Advanced Practice Professionals include: physician assistants (PA), advanced practice nurses (Certified Nurse Practitioners [CNP], Clinical Nurse Specialists [CNS], and Certified Registered Nurse Anesthetists [CRNA]), Clinical Pharmacy Specialists and Licensed Psychologists. Advanced Practice Professionals may have prescriptive authority as allowed by Federal Regulation, and/or state of licensure statute and regulations, under the supervision of a credentialed and privileged Licensed Independent Practitioner when required. Unless privileged to do so, Advanced Practice Professionals do not have admitting authority. Advance Practice Professionals may initiate prescriptions for non-formulary drugs or prescribe controlled substances in accordance with state of licensure statutes and regulations. Full Practice Authority (FPA) rule authorized Advanced Practice Registered Nurses (APRN) and other health care professionals may be granted defined clinical privileges when allowed by law and the facility.

Full Practice Authority (FPA) link:

APRN

FPA.2016-29950.pdf

2. Affiliate: Affiliate, also known as academic affiliate, refers to an academic medical center with a Memorandum of Agreement with the System to collaboratively provide medical education and supervision to various health professional trainees and post graduate residents.

3. 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, advanced practice professionals and/or patient care services at the facility. Both VA employees and contractors providing patient care services must receive appointments to the Medical Staff.

4. Associate Directors: Associate Directors fulfill the responsibilities of the Director as defined in these Bylaws when serving in the capacity of Acting Director.

5. Associate Director for Patient Care Services (ADPCS): The Associate Director for Patient Care Services serves as Nurse Executive. S/he is a registered nurse responsible for establishing standards of nursing practice and ensuring the continuous and timely availability of quality nursing services. 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 credentialing, scope of practice, and privileging system for FPA rule authorized APRN and in ensuring the ongoing education of the nursing staff.

6. 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:

podiatrists, licensed psychologists, and optometrists. Associated Health Professionals function under defined clinical privileges.

7. 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 (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.

8. Chief of Staff: The Chief of Staff is the Medical Staff’s leader and MEDICAL EXECUTIVE COMMITTEE Chairperson and acts as full assistant to the Director by efficiently managing clinical services to eligible patients, and active maintenance of a medical credentialing and privileging and/or Scope of Practice (SOP) system for Licensed Independent Practitioners, Advanced Practice Professionals and Associated Health Practitioners. The Chief of Staff ensures ongoing medical education of Medical Staff.

9. Community Based Outpatient Clinic and Outreach Clinics (CBOC): A CBOC and/or Outreach (rural health) clinic, also known as satellite clinics, are health care sites whose staff provide primary care, mental health, and sometimes limited specialty services geographically distinct or separate from the two hospitals. A CBOC can be VA-operated and/or contracted. A CBOC/Outreach Clinic must have the necessary professional medical staff, diagnostic testing access, treatment capability, and the referral arrangements ensuring continuity of health care for currently and potentially eligible veteran patients. A CBOC must be operated in a manner providing veterans with consistent, safe, high-quality health care in accordance with VA policies and procedures and JC standards.

10. Contract Practitioners: Contractor or subcontractor Practitioners are subject to compliance of this facility’s Bylaws and VA policies as well as being reported to the National Practitioner Data Bank or respective state licensing board for substandard care, professional misconduct, or professional incompetence. Removal of a contract practitioner from a contract results in an automatic revocation of privileges. The Contract Provider will be afforded a limited fair hearing to determine only if the revocation of privileges was based upon substandard care, professional misconduct, or professional incompetence and reportable to the National Practitioner Data Bank (if Practitioner is a physician or dentist).

11. Director: The Director is appointed by the Governing Body to act as its agent and leader in the overall System management. The Director is assisted by the Chief of Staff (COS), the Deputy Director, Associate Director (AD), and the Associate Director for Patient Care Services (AD-PCS) and Assistant Directors.

12. Governing Body: 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 System management and planning, it refers to the Director. The Director is responsible for the oversight and delivery of health care by all employees specifically including the medical staff credentialed and privileged by the relevant administrative offices and System-approved processes.

13. Licensed Independent Practitioner (LIP): Licensed Independent Practitioner (LIP) refers to any individual permitted law and by the by appropriate certifying agencies and/or VHA, and NF/SGVHS to provide care and services, without direction or supervision, and consistent with individually granted Clinical Privileges. At NF/SGVHS, this category includes physicians, physicians’ assistants, dentists, optometrists, podiatrists, licensed psychologists and FPA rule authorized APRN. At NF/SGVHS APRN FPA will be effective October 1, 2017.

Note: The Full Practice Authority (FPA) rule which was passed on December 14, 2016, and effective January 13, 2017, permits VA appointed Advance Practice Registered Nurses to practice as Licensed Independent Practitioners regardless of state licensure held; FPA rule authorized APRN can practice/ be privileged as such if approved by both the facility’s Organized Medical Staff and Governance and documented in Medical Staff Bylaws.

14. Medical Executive Committee (MEDICAL EXECUTIVE COMMITTEE): This is the committee of the Medical Staff with Service Chief/Chief Medical Officer (CMO) and/or other Medical Staff leaders acting on behalf of the Medical Staff between the Staff’s annual or other ad hoc meetings.

15. Medical Staff: The medical staff includes all LIPs credentialed through the medical staff process subject to the Medical Staff bylaws. The staff is collectively responsible for adopting and amending Medical Staff bylaws (i.e., those with voting privileges) and for overseeing the quality of care, treatment, and services provided by all individuals with Clinical Privileges. Medical staff shall be responsible to the Chief of the Service to which the medical staff member is assigned or, in satellite facilities, to the CMO directly or through the satellite facility’s Section Chiefs.

16. Outpatient Clinic (OPC): A health care site also known as a satellite clinic whose staff provides primary care and multispecialty services geographically distinct or separate from the two hospitals. An OPC must have the necessary professional medical staff, diagnostic testing access, treatment capability, and the referral arrangements to ensure continuity of health care for currently and potentially eligible veteran patients. An OPC must be operated in a manner providing veterans with consistent, safe, high-quality health care in accordance with VA policies and procedures and JC standards.

17. Peer Recommendation: Information submitted by an individual(s) in the applicant’s same professional discipline assessing the applicant’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 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.

18. Primary Source Verification: Original Source documentation of a specific credential verifying the qualification’s accuracy as reported by an individual health care practitioner.

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

19. Proctoring: Proctoring is an assigned practitioner’s activity of: (1) observing another practitioner performing specified clinical functions and (2) providing required reports on those observations to the appropriate Service Chief/CMO and/or Chief of Staff. If the observing practitioner is required to do more than just observe, i.e. exercise control or impart knowledge, skill, or attitude to another practitioner to ensure appropriate, timely, and effective patient care, the action constitutes supervision. Such supervision may be a reduction of Clinical Privileges for the other practitioner.

20. Professional Practice Evaluations: Assessments of a Medical Staff member’s competence is accomplished through a Focused Professional Practice Evaluation (FPPE) or an Ongoing Professional Practice Evaluation (OPPE). These are documented processes whereby the Medical Staff evaluates a Practitioner’s privilege-specific competence upon initial or renewal Medical Staff appointments for credentialing and privileging.

21. Professional Standards Boards: Professional Standards Boards (PSB) are Chief of Staff appointed boards for reviewing and acting on part-time and full-time physician and dentist appointments (as opposed to Physical Standards Boards evaluating physical and mental fitness of medical staff when indicated) and are reported to the Medical Executive Committee. Similarly, national PSBs are appointed by VHA headquarters to act upon employment matters of part-time and full-time optometrists, podiatrists and licensed psychologists for GS14 and above. Physician assistants (PAs), licensed psychologists at the GS13 level and Advanced Practice Registered Nurses (APRNs) have their own local Professional Standards Boards.

22. Relinquishment of Privileges: Practitioners may voluntarily relinquish their privileges prior to or when on extended leave; alternatively, the MEDICAL EXECUTIVE COMMITTEE may recommend to the Director privileges relinquishment when a practitioner on extended leave has been unable to voluntarily relinquish privileges due to extenuating circumstances, and/or a lapse of a required license, certificate, or other requirement during the leave period.

23. Rules and Regulations: The Rules and Regulations is an approved document governing the Medical Staff. The Medical Staff shall adopt such Rules and Regulations as necessary implementing the general principles found within these Bylaws. Rules and Regulations are a separate document from the Bylaws. Rules and Regulations can be reviewed and revised by the MEDICAL EXECUTIVE COMMITTEE without adoption by the Medical Staff as a whole. Such changes become effective upon Director approval.

24. Tele-consultation: Tele-consultation is the provision of advice on a diagnosis, prognosis, and/or therapy from a LIP to another LIP using virtual communications and information technology supporting the care provided when distance separates the participants, and where care is delivered at the remote site by a LIP.

25. Telemedicine: Telemedicine is the provision of care by a LIP directing, diagnosing, or otherwise providing clinical treatment using virtual communications and information technology when distance separates the provider and the patient.

26. VA Regulations: The regulations set by Department of Veterans Affairs applicable to its entities in compliance with Federal laws.

ARTICLE I. NAME

The organization name shall be the Medical Staff of the North Florida/South Georgia Veterans Health System.

ARTICLE II. PURPOSE

The Medical Staff shall:

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

2. Assure all patients 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 System-specific Medical Executive Committee mechanisms for appointment to the Medical Staff and delineation of Clinical Privileges.

5. Provide educational activities relating to: care provided, findings of quality of care review activities, and expressed needs of patients and caregivers;

6. Maintain a high level of professional performance of Practitioners authorized to practice in the System through continuous quality improvement practices and appropriate Clinical Privilege delineation.

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

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

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

10. Provide channels of communication so that medical and administrative matters may be discussed, and problems resolved.

11. Establish organizational policy for patient care and treatment and implement professional guidelines from the Under Secretary for Health, Veterans Health Administration.

12. Provide education and training, in affiliation with established programs, and assure that educational standards are maintained. Care will be taken to appropriately document supervision of resident physicians and other trainees.

13. Initiate and maintain an active continuous quality improvement program addressing all aspects of medical practice. Daily operations will be the subject of continuous quality improvement, as defined through organizational policies.

14. Coordinate and supervise the scope of practice of all Advanced Practice Professional 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.

15. When applicable, provide graduate medical education/supervision in accordance with

VHA Handbook 1400.1, Resident Supervision

VHA

Handbook.Resident Supervision.1400_01_HK_2012-12-19.pdf

ARTICLE III. MEDICAL STAFF MEMBERSHIP, QUALIFICATIONS AND CODE OF

CONDUCT *

Section 3.01 Medical Staff Membership Eligibility *

1. Membership: Medical Staff membership is a privilege extended only to, and continued for, professionally competent physicians, dentists, and other Licensed Independent Practitioners including optometrists, podiatrists, licensed psychologists and FPA rule authorized APRNs continuously meeting the qualifications, standards, and requirements of VHA, this System, and these Bylaws.

2. Medical Staff Categories: Medical Staff voting members are defined as those appointed full- or part-time. Non-voting members include consultants, contractors, on-station fee basis, and without compensation (WOC) appointees.

3. Medical Staff Membership: Medical Staff membership decisions 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 Medical Staff Membership Clinical Privileges Application and Qualifications *

1. Criteria for Clinical Privileges (New and Renewal) and Credentialing Application:

Individuals meeting the eligibility requirements identified in Section 3.01 must submit evidence listed below to qualify for the initial Medical Staff membership and Clinical Privileges as part of the Credentialing Application and/or where applicable Clinical Privileges renewal. New applicants or those renewing not meeting the requirements will not be considered. This ineligibility determination 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 policies and procedures. This includes a statement of the current status of all licenses and certifications, active or inactive and in the case of renewals, a statement of the current status of all licenses, licenses previously held lapsing since last appointment, and certifications held. The status of all licenses and certifications must be validated. This applies to licenses held in multiple states for the same professional discipline or practice. Physicians with Medical Faculty Certificates in good standing with the affiliate may be granted clinical privileges if their training has been outside of the United States such that they do not qualify for a state medical license and they are serving in a consultant capacity to the System (Reference VHA Handbook 1100.19 Credentialing and Privileging on the SharePoint under:

Credentialing and

Privileging VHA Handbook.1100_19_HK_2012-10-15.pdf

b. Education applicable to individual Medical Staff members; for example, holding a Doctoral level degree in Medicine, Osteopathy, or Dentistry from a nationally accredited college or university; or foreign accredited medical or health professional schools with standards comparable to those in the United States.

c. Relevant training and/or experience consistent with the individual's professional assignment and supporting the requested Clinical Privileges. This may include any internship, residencies, fellowships, board certification, and other specialty training.

For renewal, supporting documentation of professional training and/or experience not previously submitted should be provided.

d. Current competence and (where applicable) documented by FPPE and/or OPPE, consistent with the individual's assignment and the requested Clinical Privileges.

e. For renewals, continuing medical education documentation not previously provided, related to the area and scope of Clinical Privileges’ area and scope; and consistent with state licensure requirements.

f. Names of other health care organizations where Clinical Privileges are held and requests for copies of current Clinical Privileges held.

g. A description of any and all adverse actions including (1) sanctions, including those by a hospital, state licensing agency or any other professional health care organization/professional organization/society; (2) voluntary or involuntary relinquishment of licensure or registration; (3) malpractice claims, suits or settlements (e.g. final judgment or settlements); and (4) reduction or loss of Clinical Privileges at any other hospital within fifteen (15) calendar days of the adverse action. For renewals, any new actions since last appointment should be submitted.

h. A statement of the Practitioner’s health status, consistent with the physical and mental capability to satisfactorily perform the Medical Staff duties within the Clinical Privileges granted. This must be confirmed by a physician (MD or DO) acceptable to the Medical Staff. The Medical Executive Committee may require reasonable evidence of health status.

i. Complete information consistent with application and Clinical Privileges requirements as defined in Article VII of these Bylaws for a position for which the System has a patient care need, and adequate facilities, support services and staff.

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

k. Names and addresses of references qualified to provide authoritative information regarding training, experience, competence, health status, and fulfillment of obligations as a Medical Staff member within the Clinical Privileges requested. For renewals two peer references are required.

l. English language proficiency.

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

n. A current Personal Identity Verification (PIV) Card.

o. For initial appointment and privileges evidence of successful completion of a Basic Life Support (BLS) approved program using the American Heart Association criteria unless the provider is a fee basis appointee or a staff member with a 2/8 or less appointment.

2. Clinical Privileges and Scope of Practice: While only LIPs may function with defined Clinical Privileges, not all LIPs are permitted by this System 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) Optometrists

iv) Podiatrists

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

i) Certified Nurse Practitioners (CNP) and Certified Nurse Specialists (CNS)

c. 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 (APRNs) employed as contract staff (Certified Nurse Practitioners (CNP) and Certified Nurse Specialists (CNS))

ii) Licensed Psychologists

d. 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 (PAs)

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)

3. Change in Status: Medical Staff members and Advanced Practice Professionals practicing through privileges or a scope of practice must 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 their assigned responsibilities 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, professional organization or society, or specialty certification. This should be accomplished no longer than fifteen (15) calendar days after notification of the practitioner.

Section 3.03 Code of Conduct

1. Acceptable Behavior: The VA expects Medical Staff members will serve diligently, loyally, and cooperatively. They must avoid misconduct and other activities conflicting with their duties; exercise courtesy and dignity; and otherwise conduct themselves, both on and off duty, in a manner reflecting positively upon themselves and VA.

Acceptable behavior includes the following (1) being on duty as scheduled, (2) impartially carrying out official duties and avoiding any action that might result in, or appear 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 impeding government efficiency and economy, affecting one’s impartiality, or otherwise diminishing 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 family member from any person or organization seeking or has a business or financial relationship with the VA to avoid the appearance that one’s official actions might be influenced by such gifts.

2. Disruptive Behavior and Inappropriate Behavior: VA recognizes that the manner in which its Practitioners interact with others can significantly impact patient care. VA expects its providers to fulfill their obligations maximizing patient care safety by behaving in a professional and courteous manner promoting both collaborative clinical practice and a work environment ensuring high standards of care. (The Accreditation Council for Graduate Medical Education (ACGME) highlights the importance of interpersonal/communication skills and professionalism as two (2) of the six (6) core competencies required for graduation from residency.) Providers have an ethical duty to foster respect among all health care professionals as a means of ensuring good patient care. Intimidating conduct towards others to the extent that it affects or potentially affects 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.

Disruptive behavior is a negative social interaction style with physicians, System staff members, patients, family members, or others interfering with patient care. Behaviors described below are commonly recognized as detrimental to patient care, undermining a culture of safety. Furthermore, disruptive behavior is often a marker for concerns ranging from a lack of interpersonal skills to deeper problems, such as depression or substance abuse. Thus, disruptive behavior may reach a threshold constituting grounds for further inquiry by the MEDICAL EXECUTIVE COMMITTEE into the potential underlying causes of such behavior. A provider’s disruptive behavior could be grounds for disciplinary action.

Unacceptable, disruptive behavior includes but is not limited to the following:

• Profane or disrespectful language;

• Demeaning behavior (for example, referring to hospital staff as “stupid”);

• Sexual comments or innuendo;

• Outbursts of anger or other hostile/threatening interactions;

• Throwing instruments or other paraphernalia;

• Criticizing hospital staff in front of patients or other staff;

• Negative comments about another physician’s care;

• Inappropriate CPRS notes (for example, critical comments about other caregivers);

• Any other verbal, written, psychological, or physical abuse of another person.

VA distinguishes disruptive behavior from constructive criticism 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 disruptive behavior by other providers and report their observations to their Service Chief or Chief of Staff. VA urges its providers to support their hospital, practice, or other healthcare organization in their efforts to identify and manage disruptive behavior, by taking a role in this process when appropriate.

3. Professional Misconduct: Behavior by a professional creating the appearance of a violation of ethical standards or comprising ethical standards will not be tolerated and may result in the professional being subject to disciplinary action.

Section 3.04: Conflict Resolution & Management

For VA to be effective and efficient in achieving its goals the organization must have clear objectives and a shared vision of what it is striving to achieve. Therefore, there must be a Medical Executive Committee mechanism for conflict recognition, management and resolution to avoid a lack of progress in meeting these established goals. Conflict management is the process of planning to avoid conflict and managing to resolve such conflict quickly and efficiently. VA Handbook 5978.1, Alternative

Dispute Resolution Program

VHA Handbook

5978.1hbk10.Alternative Dispute Resolution Program Central Office.pdf , addresses the conflict VA resolution and management process, as well as resources to engage in mediation and non-binding, or binding arbitration. VHA expects its healthcare systems’ leaders to use these and other resources in communicating expectations to clinicians and other staff that conflictive, disruptive, inappropriate, intimidating, and uncivil behavior compromises VHA’s mission of high-quality health care service to Veterans. VA staff members experiencing or witnessing such behavior are encouraged to advise an appropriate supervisor, or Patient Safety Officer, or other individual from the following Agency resources: the Office of Diversity and Inclusion (EEO) at https://www.diversity.va.gov/;

VA Handbook 5978 Alternative Dispute Resolution

Alternative Dispute

Resolution Directive_5978_7_Feb_2013.pdf and VA Handbook

5978.1, Alternative Dispute Resolution Program: Central Office (December 11, 2007

VHA Handbook

5978.1hbk10.Alternative Dispute Resolution Program Central Office.pdf . Medical Staff members may communicate with the Director functioning as the agent of the Governing Board on issues including, but not necessarily limited to rules, regulations, or policies adopted by the organized medical staff or MEDICAL EXECUTIVE COMMITTEE.

https://www.diversity.va.gov/

ARTICLE IV: ORGANIZATION OF THE MEDICAL STAFF *

Section 4.01 Leaders * Composition:

a. Chief of Staff (appointed by the Director following a professional search panel recommendation).

b. Deputy Chief of Staff (DCOS) (considered the second highest ranking medical officer.)

c. Associate Director for Patient Care Services (ADPCS).

d. Associate Chiefs of Staff and Service Chief/Chief Medical Officers (CMOs) (based at the hospital(s)) and Chief Medical Officers (based at the remote OPCs and CBOCs).

2. Qualifications:

a. Physician leaders will meet Medical Staff membership requirements and are usually Service Chiefs or CMOs. Certification by an appropriate specialty board or comparable competence affirmatively established through the credentialing process.

3. Selection:

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

b. The Chief of Staff will recommend the appropriate physician leaders described in qualifications to the Director for approval.

4. Removal:

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

b. The Chief of Staff will recommend removal of a physician leader if that individual has left the organization or is no longer in the leadership role of a Service or OPC.

The Director will approve the removal.

5. Duties:

a. Chief of Staff serves as Chairperson of the Medical Executive Committee.

b. Deputy Chief of Staff or Designee serves as Acting Chief of Staff in the absence of the Chief of Staff.

Section 4.02 Leadership

The Medical Staff, through its committees and Deputy Chief of Staff, Associate Director for Patient Care Services (ADPCS), Associate Chiefs of Staff (ACOS), Services Chiefs, and Chief Medical Officers (CMO), and designated consulting APRN provides counsel and assistance to the Chief of Staff and Director regarding all facets of patient care, treatment, and services including evaluating and improving the quality and safety of patient care services.

Section 4.03 Clinical Services * Characteristics: *

a. Clinical Services provide clinical care and treatment under leadership of an Associate Chief of Staff (ACOS), Service Chief, or Chief Medical Officer (CMO).

OPCs and CBOCs are considered Clinical Service equivalents.

b. Clinical Services and Outpatient Clinics hold staff meetings at a minimum quarterly.

1. Functions: *

a. Provide for quality and safety of the care, treatment, and services. This requires ongoing quality and safety (including access, efficiency, and effectiveness) monitoring and evaluation; appropriateness of patient care and treatment (including that provided under temporary Clinical Privileges or emergency care absent Clinical 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 measuring and assessing important aspects of care, and evaluation of the quality and appropriateness of care. Utilize VHA performance measures and monitors for assessing the quality, timeliness, efficiency, and safety of Service activities.

c. Maintain meeting records reporting conclusions, data, recommendations, responsible person(s), actions taken, and an evaluation of effectiveness of actions taken. These reports are forwarded timely through Medical Staff reporting channels, at a minimum quarterly.

d. Recommend privileging requests for active and consulting staff with concurrence review by the appropriate Service Chief/CMO; and ensure FPPE and OPPE is continuously performed and results are utilized when re-privileging.

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

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

g. Annually review each Service’s privilege templates and make recommendations to the MEDICAL EXECUTIVE COMMITTEE.

2. Selection and Appointment of Service Chief/CMOs: *

A Service Chief/CMO Search Committee is formed at the time of the posting of a Service Chief/CMO vacancy announcement; their duty is to review, interview and rank the applicants and put forward their top three names to the Chief of Staff for his/her review. Criteria for appointment as Service Chief/CMO includes Board Certification or equivalent experience and comparable training as vetted through the credentialing process. Service Chiefs and CMOs, are appointed by the Director based upon the Chief of Staff’s recommendation.

3. Duties and Responsibilities of Service Chief/CMOs: *

The Service Chief/CMO is administratively responsible for the operation of the Service/OPC/CBOC and its clinical and research efforts, as appropriate. In addition to duties listed below, the Service Chief/CMO is responsible for assuring the Service/OPC/CBOC performs according to applicable VHA performance standards.

These are the performance requirements applicable to the Service/OPC/CBOC from the national performance contract, and cascade from the overarching requirements delegated to the Chief of the Medical Staff. These requirements are described in individual Performance Plans for each Service Chief/CMO. Service Chiefs/CMOs are responsible and accountable for:

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

b. Clinically related activities of the Service/OPC/CBOC.

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

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

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

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

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

h. The integration of the Service/OPC/CBOC into the primary functions of the organization.

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

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

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

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

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

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

o. The orientation and continuing education of all persons in the service.

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

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

ARTICLE V. MEDICAL STAFF COMMITTEES

Section 5.01 General

1. Committees are either standing or ad hoc.

2. All committee members, regardless of their Medical Staff membership status 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 a minimum of twenty-five (25) percent of a committee's members constitutes a quorum. Action may be taken by simple majority vote in favor measure will pass at any meeting at which a quorum is present.

4. All standing committee members, other than the Medical Executive Committee, are appointed by the Chief of Staff subject to Medical Executive Committee approval, unless otherwise stated in these Bylaws.

5. Unless otherwise set forth in these Bylaws, each committee’s chair is appointed by the Chief of Staff.

6. Robert’s Rules of Order Newly Revised will govern all committee meetings.

Section 5.02 Executive Committee of the Medical Staff (also known as Medical Executive Committee) *

1. Characteristics: The Medical Executive Committee membership includes:

a. Chief of Staff, Chairperson, voting.

b. Deputy Chief of Staff, voting.

c. Associate Chiefs of Staff, voting.

d. Service Line Director, voting

e. Clinical Service Chiefs, voting

f. OPC or CBOC representative, voting.

g. Associate Director for Patient Care Services, voting.

h. Chief, Pharmacy Service, voting

i. Designated Advanced Practice Registered Nurse (APRN), based on VHA Directive 1350, voting.

j. Director, or designee, non-voting. *

k. Executive Assistant to the Chief of Staff, non-voting.

l. Other System staff serve as resources or attend committee meetings at the chairperson’s request, with or without vote. For example, a Physician Assistant may be called to be present when an action affecting another Physician Assistant is considered. The majority of voting members must be fully licensed physicians of medicine or osteopathy.

m. The Chief of Staff recommends for the Director’s approval Medical Executive Committee member selection. Medical Executive Committee members are usually the organization’s physician or clinical leaders. The Chief of Staff recommends Medical Executive Committee member removal for Director approval if those leaders are no longer part of the organization or in their leadership role.

2. Functions of the Medical Executive Committee: The Medical Executive Committee: *

a. Acts on behalf of the Medical Staff between annual Medical Staff meetings within the scope of its responsibilities as outlined below. Such authority is recommended by the Chief of Staff with Director approval; and likewise, may be revoked per Chief of Staff recommendation with Director concurrence.

b. Reviews credentials and delineation of Clinical Privileges and/or Scopes of Practice ensuring authenticity and appropriateness of the Clinical Privileges and/or Scope of Practice requested; addresses the scope and quality of services provided within the System.

c. Ensures effective communications between the Medical Staff and the Director.

d. Makes recommendations to the Director regarding the:

i) Medical Staff’s organization, membership and termination, structure, and function.

ii) Process used to review credentials and delineate Clinical Privileges/Scopes of Practice.

e. Coordinates quality improvement activities ensuring full compliance with VHA Clinical Performance Measures, JC, and relevant external standards.

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

g. Oversees process in place for reduction or suspension of Clinical Privileges.

h. Oversees process by which Medical Staff membership may be terminated consistent with applicable laws and VA regulations.

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

j. Monitors Medical Staff ethics and self-governance actions.

k. Advises System leadership regarding clinical policies, clinical staff recommendations, and accountability for patient care.

l. Receives and acts on Medical Staff committee reports and recommendations regarding quality of care activities, and clinical services’ functions, and makes needed recommendations to the Governing Body.

m. Assists to develop methods for care and protection of patients and others during internal and external emergency or disaster, according to VA policies.

n. Supports the Physical Standards Board function, of evaluating physical and mental fitness of all Medical Staff upon Occupational Health Physician referral. The Physical Standards Board membership may be the same as the local physician Professional Standards Board or members may be designated for this purpose by the Director. Boards may be conducted at other VA healthcare facilities.

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

p. Annually reviews and makes recommendations for…