Attachment 6 Medical Staff By Laws Rules and Regulations.pdf

U.S. Department of Veterans Affairs

Veterans Health Administration Miami VA Healthcare SystemVA

DATE: APRIL 2022

REVIEWED DATE: MARCH 2022

REVISED DATE: MARCH 2022

I

Table of Contents

PREAMBLE 4

DEFINITIONS 4

ARTICLE I. NAME 8

ARTICLE II. PURPOSE 8

ARTICLE Ill. MEDICAL STAFF MEMBERSHIP 9

Section 3.01 Eligibility for Membership on the Medical Staff 9 Section 3.02 Qualifications for Medical Staff Membership and Clinical Privileges 11

Section 3.03 Code of Conduct 13

Section 3.04 Conflict Resolution & Management 15

ARTICLE IV. ORGANIZATION OF THE MEDICAL STAFF 16

Section 4.01 Leaders 16

Section 4.02 Leadership 16 Section 4.03 Clinical Services 16

ARTICLE V. MEDICAL STAFF COMMITTEES 18

Section 5.01 General 18 Section 5.02 Executive Committee of the Medical Staff 19

Section 5.03 Professional Standards Board 21

Section 5.04 Committees of the Medical Staff 23

Section 5.05 Committee Records and Minutes 23

Section 5.06 Establishment of Committees 24

ARTICLE VI. MEDICAL STAFF MEETINGS 24

ARTICLE VII. APPOINTMENT AND ON-GOING CREDENTIALING 24

Section 7.01 General Provisions 24

Section 7.02 Application Procedures 28

Section 7.03 Process and Terms of Appointment 32

Section 7.04 Credentials Evaluation and Maintenance 33

Section 7.05 Local/VISN-Level Compensation Panels 36

ARTICLE VIII. CLINICAL PRIVILEGES 36

Section 8.01 General Provisions 36

Section 8.02 Process and Requirements for Requesting Clinical Privileges 37

Section 8.03 Process and Requirement for Requesting Renewal of Clinical Privileges 39 Section 8.04 Processing an Increase or Modification of Privileges 40

Section 8.05 Recommendations and Approval for Initial/Renewal and Revision of Clinical Privileges 41

Section 8.06 Exceptions 42

Section 8.07 Medical Assessment 47

ARTICLE IX. INVESTIGATION SUMMARY SUSPENSION AND PRIVILEGING 47

ARTICLE X. FAIR HEARING AND APPELLATE REVIEW 56

Section 10.1 Reduction of Privileges 56

Section 10.2 Revocation of Privileges 59

ARTICLE XI. RULES AND REGULATIONS 61

ARTICLE XII. AMENDMENTS 61

ARTICLE XIII. ADOPTION 62

MEDICAL STAFF RULES 64

1. GENERAL 64

2. PATIENT RIGHTS 64

3. RESPONSIBILITY FOR CARE 67

4. PHYSICIANS' ORDERS 71

5. ROLE OF ATTENDING STAFF 73

6. MEDICAL RECORDS 74

7. INFECTION CONTROL 78

8. CONTINUING EDUCATION 78

9. HEALTH STATUS AND IMPAIRED PROFESSIONAL PROGRAM 78

10. PEER REVIEW 79

11. EMERGENCY SERVICES 80

12. CPR CERTIFICATION 80

13. DISCLOSURE 81

14. QUALITY MANAGEMENT PROGRAMS 83

15. RESTRAINTS 83

16. CONFLICT OF INTEREST 84

17. INTEGRATED ETHICS 84

18. SUICIDE ASSESSMENT 85

19. ORGAN/TISSUE/EYE DONATION 85

20. BLOOD TRANSFUSION 85

21. ANESTHESIA CARE 86

22. AIRWAY MANAGEMENT OUTSIDE THE OPERATING ROOM 88

23. UNIVERSAL PROTOCOL 88

24. MEDICATION RECONCILIATION 90

25. HAND-OFF COMMUNICATION 90

26. CRITICAL TESTS AND CRITICAL VALUES 91

A-1 CODE OF CONDUCT - SUPPLEMENTAL FOR MEDICAL STAFF BYLAWS

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 Miami Veterans Affairs Healthcare System located in Miami, Florida (hereinafter sometimes referred to as MVAHS, Facility, or Organization) hereby organizes itself for self-governance in conformity with the laws, regulations and policies governing the Department of Veterans Affairs, Veterans Health Administration (VHA), and the bylaws and rules hereinafter stated. These Bylaws and Rules are consistent with all laws and regulations governing the VHA, and they do not create any rights or liabilities not otherwise provided for in laws or VHA Regulations.

Miami VA Healthcare System comprises a medical center, multi-specialty outpatient and community-based clinics located within the patient service area which include Miami- Dade, Broward, and Monroe counties.

Portions of these bylaws are required by the VA, VHA, or The Joint Commission (TJC).

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

DEFINITIONS

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

1. Advanced Practice Professionals: Advanced Practice Professionals are those health care professionals who are not physicians and dentists and who will function within a Scope of Practice but may practice independently on defined clinical privileges as defined in these Bylaws. Advanced Practice Professionals include: Physician Assistants (PA), Advanced Practice Nurse (APRN), Certified Registered Nurse Anesthetists (CRNA), Certified Registered Nurse Practitioner(CRNP), and Clinical Pharmacist Specialist (CPS)/Clinical Pharmacist Practitioner (CPP). 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. Advanced Practice Professionals may initiate prescriptions for non-formulary drugs or prescribe controlled substances in accordance with state of licensure statutes and regulations. Advanced Registered Nurse Practitioners and other health care professionals may be granted defined clinical privileges when allowed by law and the facility.

2. Appointment: As used in this document, the term Appointment refers to appointment to the Medical Staff. It does not refer to appointment as a VA employee but is based on having an appropriate personnel appointment action, scarce medical specialty contract, or other authority to provide independent medical, Mid-level and/or patient care services at the facility. Both VA, employees and contractors providing patient care services must receive appointments to the Medical Staff.

3. Associate Director: The Associate Director fulfills the responsibilities of the Director as defined in these bylaws when serving in the capacity of Acting Facility Director.

4. Associate Director for Patient Care Services, Miami VA Healthcare System: The Associate Director for Patient Care Services is a registered nurse who is responsible for the full-time, direct supervision of nursing services and who meets licensing requirements as defined by Title 38. S/he is the Chairperson of the Nurse Executive Council (NEC) and acts as full assistant to the Director in the efficient management and consultation of clinical and patient care services to eligible patients, the active maintenance of a credentialing and scope of practice, and privileging system for relevant advanced practice professional and certain associated health staff and in ensuring the ongoing education of the nursing staff.

5. Associated Health Professional: As used in this document, the term "Associated Health Professional" is defined as those clinical professionals other than doctors of allopathic, dental, and osteopathic medicine. These professionals include, but are not limited to: Psychologists, podiatrists, optometrists, and audiologists. Associated Health Professionals function under either defined clinical privileges or a defined scope of practice.

6. 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 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 Council 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.

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

8. Community Based Outpatient Clinic (CBOC): A health care site (in a fixed location) that is geographically distinct or separate from the parent medical facility. A CBOC can be a site that is VA-operated and/or contracted. A CBOC must have the necessary professional medical staff, access to diagnostic testing and treatment capability, and the referral arrangements needed to ensure continuity of health care for currently and potentially eligible veteran patients. A CBOC must be operated in a manner that provides veterans with consistent, safe, high-quality health care, in accordance with VA policies and procedures.

9. 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 will result 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).

10. Director (or Facility Director): The Director (sometimes called Chief Executive Officer) is appointed by the Governing Body to act as its agent in the overall management of the Facility. The Director is assisted by the Chief of Staff (COS), the Associate Director (AD), the Associate Director for Patient Care Services (AD- PCS), the Assistant Director and the Medical Executive Council.

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

12. Licensed Independent Practitioner: The term Licensed Independent Practitioner (LIP) refers to any individual permitted by law and by the Miami VA Healthcare System to provide care and services, without direction or supervision, within the scope of the individual's license and consistent with individually granted privileges.

In this organization, this includes physicians and dentists. It may also include individuals who can practice independently, who meet this criterion for independent practice. The Full Practice Authority (FPA) which was passed on January 14, 2017, permits VA appointed Advance Practice Registered Nurses to practice as Licensed Independent Practitioners regardless of state licensure held and can practice/ be privileged as such if approved by both the facility's Organized Medical Staff and Governance and documented in Medical Staff Bylaws.

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

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

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

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

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

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

19. Professional Standards Board/Credentials Committee: The Professional Standards Board/Credentials Committee, if established, may act as a Credentials Committee on credentialing and clinical privileging matters of the Medical Staff, making recommendation on such matter to the Executive Committee of the Medical Staff as defined in these Bylaws. This board also may act on matters involving Associated Health and Advanced Practice Professionals such as granting prescriptive authority, scope of practice, and appointment. Some professional standards boards (e.g., Nursing, etc.) are responsible for advancement and other issues related to their respective professions.

20. Rules: Refers to the specific rules set forth that govern the Medical Staff of the facility. The Medical Staff shall adopt such rules as may be necessary to implement more specifically the general principles found within these Bylaws. Rules are a separate document from the bylaws. They can be reviewed and revised by the Medical Executive Council and without adoption by the medical staff as a whole.

Such changes shall become effective when approved by the Director.

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

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

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

ARTICLE I. NAME

The name of this organization shall be the Medical Staff of the Department of Veterans Affairs, Miami Veterans Affairs Healthcare System, Miami, Florida which includes all its' locations.

ARTICLE II. PURPOSE

The purposes of the Medical Staff shall be to:

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

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

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

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

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

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

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

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

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 policy and procedures.

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.

ARTICLE Ill. MEDICAL STAFF MEMBERSHIP *

Section 3.01- Eligibility for Membership on the Medical Staff*

1. Membership: Membership on the Medical Staff is a privilege extended only to, and continued for, professionally competent physicians, dentists, and other Licensed Independent Practitioners (LIPs) (include, but not limited to advanced practice nurses, audiologists, optometrists, podiatrists, psychologists, and speech pathologists) who continuously meet the qualifications, standards, and requirements of VHA, this Facility, Resident Supervision in accordance to VHA Handbook 1400.1 and these Bylaws.

2. Categories of the Medical Staff:

A. Active Medical Staff:

(1) Physicians, dentists, advanced practice nurses, audiologists, optometrists, podiatrists, psychologists, chiropractors, and clinical pharmacist specialists (CPS)/clinical pharmacist practitioners (CPP) who are employed at least 4/8's time at the VAHCS.

(2) Members of the active medical staff have voting rights and except for those with administrative responsibilities only, must have delineated clinical privileges.

(3) Active medical Staff are expected to actively participate in appropriate medical staff meetings and activities including committees of the medical staff.

(4) Active Medical Staff are expected to actively participate in Healthcare System performance improvement activities to improve quality of care, treatment, services, and patient safety.

B. Affiliate Medical Staff:

(1) Includes the same professional disciplines as active medical staff but who are employed less than 4/8th time at the MVHCS, contracted, and employed as WOC or fee basis.

(2) Members of the affiliate medical staff do not have voting rights and except for those with administrative responsibilities only, must have delineated clinical privileges.

(3) Affiliate medical staff may attend staff meetings and may participate in medical staff activities.

C. Associate Medical Staff:

(1) All other practitioners at the MVAHS who are required by the Veterans

Health Administration VETPRO program to be credentialed and supplement members of the active medical staff. This would include but is not limited to Physician Assistants, and certified Registered Nurse Anesthetists (Allied Health Professionals).

(2) Associate medical staff who are employed at least 4/8th time at the VAHCS have voting rights.

(3) Associate medical staff, except those with administrative responsibilities only, will have a scope of practice if not privileges.

(4) Associate medical staff with voting rights are expected to actively participate in appropriate medical staff meetings and activities. Other associate medical staff may attend staff meetings and may participate in medical staff activities.

D. Residents - Residents shall consist of physicians, dentists, podiatrists, audiologists, phycologists and advanced practiced nurses who may or may not be licensed to practice, but who are still engaged in a post graduate training program. Their participation in patient care, education, or research shall be under the appropriate supervision of a Medical Staff member who is licensed to practice medicine, dentistry, podiatry, or optometry and who has clinical privileges at the Healthcare System. Residents are not eligible for membership on the active Medical Staff. They may be permitted to serve on designated committees in a non-voting capacity but shall not be required to attend meetings of the Medical Staff. Mechanisms for supervision of residents are specified in the facility Resident Supervision Policy (141-06-19) and Monitoring of Resident Supervision Policy (141-08-19).

E. Students- Students shall consist of physician, dentist, pediatric, optometric, or allied health care professionals who may or may not be licensed to practice their profession, but who are still engaged in an accredited training program.

Their participation in patient care education or research shall be under the appropriate supervision as outlined by facility policy. Students are not eligible for membership on the active Medical Staff. They may be permitted to serve on designated Medical Center committees in a non-voting capacity but shall not be required to attend meetings of the Medical Staff. Mechanisms for supervision of students are specified in the facility SOP on supervision of students (SOP 141-06-22).

F. Other Categories of Medical Staff- Other categories of Medical Staff shall consist of practitioners who are responsible for supplementing the members of the active Medical Staff in their roles in patient care, education, and research.

These members shall be appointed to a specific service and shall be permitted to serve on committees but shall not be required to attend meetings of the Medical Staff. They are not eligible for active staff membership. These categories include:

(1) Consultants

(2) On station fee basis, contract or sharing agreement

(3) Without compensation

(4) Intermittent

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

Section 3.02- Qualifications for Medical Staff Membership and Clinical Privileges *

1. Criteria for Clinical Privileges: To qualify for Medical Staff membership and clinical privileges, individuals who meet the eligibility requirements identified in Section

3.01 must submit evidence as listed below. Applicants not meeting these requirements will not be considered. This determination of ineligibility is not considered a denial:

a. Active, current, full, and unrestricted license to practice individual's profession in a state, territory or commonwealth of the United States or the District of Columbia as required by VA employment and utilization policies and procedures. Education applicable to individual Medical Staff members as defined, for example holding a Doctoral level degree in Medicine, Osteopathy, or Dentistry from an approved college or university.

b. Relevant training and/or experience consistent with the individual's professional assignment and the privileges for which he/she is applying. This may include any internship, residencies, fellowships, board certification, and other specialty training.

c . Current competence, consistent with the individual's assignment and the privileges for which he/she is applying.

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

e. Complete information consistent with requirements for application and clinical privileges as defined in Articles VI or VII or of these Bylaws for a position for which the facility has a patient care need, and adequate facilities, support services and staff

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

g. English language proficiency.

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

i. A current picture hospital ID card or a valid picture ID issued by a state or federal agency (e.g., driver's license or passport)

j. A current Personal Identity Verification (PIV) Card

2. Clinical Privileges and Scope of Practice: While only Licensed Independent

Practitioners may function with defined clinical privileges, not all Licensed Independent Practitioners are permitted by this Facility and these Bylaws to practice independently. All Practitioners listed below are subject to the bylaws whether they are granted defined clinical privileges or not.

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

i) Physicians

ii) Dentists

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

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

ii) Certified Registered Nurse Anesthetists (CRNA)

iii) Psychologists iv ) Audiologists

v) Chiropractors

vi) Podiatrists

vii) Optometrists viii ) Clinical Pharmacist Specialists/Clinical Pharmacist Practitioners c . The following Practitioners will be credentialed through the Medical Staff process, including recredentialing and will practice under a Scope of Practice with appropriate supervision:

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

ii) Physician Assistants iii ) Certified Registered Nurse Anesthetists (CRNAs) who do not hold a license in a state that recognizes CRNAs as License Independent Practitioners iv ) Clinical Pharmacists (as authorized by Chief, Pharmacy or designee)

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

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

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

Section 3.03- Code of Conduct

1. Acceptable Behavior: The VA expects that members of the medical staff will serve diligently, loyally, and cooperatively. They must avoid misconduct and other activities that conflict with their duties; exercise courtesy and dignity; and otherwise conduct themselves, both on and off duty, in a manner that reflects positively upon themselves, and VA. Acceptable behavior includes the following: (1) being on duty as scheduled, (2) being impartial in carrying out official duties and avoiding any action that might result in, or look as though, a medical staff member is giving preferential treatment to any person, group or organization, (3) not discriminating on the basis of race, age, color, sex, religion, national origin, politics, marital status, or disability in any employment matter or in providing benefits under any law administered by VA, (4) not making a governmental decision outside of official channels,

(5) not taking any action that impedes government efficiency and economy, affects one's impartiality, or otherwise lowers public confidence in the Federal Government, and (6) with certain exceptions in accordance with 5 C.F.R. 2635, not asking for or accepting any gift, tip, entertainment, loan, or favor, or anything of monetary value for oneself or any member of one's family from any person or organization that is seeking or has a business or financial relationship with the VA to avoid the appearance that one's official actions might be influenced by such gifts.

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

These behaviors, as determined by the organization, may be verbal or non-verbal, may involve the use of rude and/or disrespectful language, may be threatening, or may involve physical contact.

Behavior or Behaviors That Undermine a Culture of Safety is a style of interaction with physicians, hospital personnel, patients, family members, or others that interferes with patient care. Behaviors such as foul language; rude, loud or offensive comments; and intimidation of staff, patients and family members are commonly recognized as detrimental to patient care. Furthermore, it has become apparent that Behavior or Behaviors That Undermine a Culture of Safety is often a marker for concerns that can range from a lack of interpersonal skills to deeper problems, such as depression or substance abuse. As a result, Behavior or Behaviors That Undermine a Culture of Safety may reach a threshold such that it constitutes grounds for further inquiry by the Medical Executive Committee into the potential underlying causes of such behavior. Behavior by a provider that is disruptive could be grounds for disciplinary action.

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

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

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

4. Addendum

CODE OF CONDUCT - SUPPLEMENTAL FOR MEDICAL STAFF BYLAWS

Refer to attachment A-1 It is expected that all Medical Staff will be responsible for promoting a culture of safety and will fully cooperate in efforts to improve patient safety and eradicate potential events including the reporting of events resulting in actual or potential injury to a patient. This supplemental will outline general guidelines/principles, examples of inappropriate behavior, the reporting mechanism (s) for those who observe violations, the process for investigating allegations of inappropriate behavior, and the progression of interventions that can lead up to formal corrective 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 mechanism for the recognition of conflict and its resolution in order to make progress in meeting these established goals. Conflict management is the process of planning to avoid conflict when possible and manage to resolve such conflict quickly and efficiently when it occurs. VA Handbook 5978.1, Alternative Dispute Resolution Program, addresses the conflict resolution and management process available in VA, as well as resources to engage in mediation as well as non-binding, or binding arbitration. 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 health care service to Veterans. VA staff who experience or witness such behavior are encouraged to advise an appropriate supervisor, Service Chief, Chief of Staff or the EEO Manager. The Medical Staff has the ability to approach the Director for resolution when there is any conflict between the Medical Staff and the Medical Executive Committee.

ARTICLE IV: ORGANIZATION OF THE MEDICAL STAFF *

Section 4.01- Leaders *

1. Composition:

a. Chief of Staff.

2. Qualifications: Criteria for appointment includes appropriate board certification in the respective specialty and a full-time appointment to the VA.

3. Selection: The Organized Medical Staff does not elect medical staff officers. The Medical Staff Bylaws are approved by the organized medical staff, which constitutes the agreement of the leadership organization. The Network Director approves 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.

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

5. Duties:

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

Section 4.02 - Leadership

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

Section 4.03 - Clinical Services

1. Characteristics: *

a. Clinical Services are organized to provide clinical care and treatment under leadership of a Service Chief.

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

2. Functions: *

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

patient safety and risk management activities; and utilization management.

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

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

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

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

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

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

3. Selection and Appointment of Service Chiefs: * Service Chiefs are appointed by the Director based upon the recommendation of the Chief of Staff. A search committee appointed by the Chief of Staff will review each candidate's qualifications and make recommendations to the Chief of Staff as to the quality of each applicant. Criteria for appointment as Service Chief includes board certification in the appropriate specialty/or equivalent experience and comparable training as vetted through the Professional Standards Board and Medical Executive Council.

4. Duties and Responsibilities of Service Chiefs: * The Service Chief is administratively responsible for the operation of the Service and its clinical and research efforts, as appropriate. In addition to duties listed below, the Service Chief is responsible for assuring the Service performs according to applicable VHA performance standards. These are the performance requirements applicable to the Service from the national performance contract, and cascade from the overarching requirements delegated to the Chief of the Medical Staff. These requirements are described in individual Performance Plans for each Service Chief. Service Chiefs 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.

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.

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

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

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

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

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

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

I. 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.

r. Complete and submit the Provider Exit Review form to the Medical Staff Office at the time of inactivation of privileges, including separation from the medical staff, within 7 calendar days of the date of separation, indicating that the Practitioner met generally accepted standards of clinical practice and there is no reasonable concern for the safety of patients in accordance with VHA Handbook 1100.18.

ARTICLE V. MEDICAL STAFF COMMITTEES

Section 5.01 - General

1. Committees are either standing or special.

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

3. The members of all standing committees, other than the Medical Executive Council, are appointed by the Chief of Staff subject to approval by the Medical Executive Council, unless otherwise stated in these Bylaws.

4. Unless otherwise set forth in these Bylaws, the Chair of each committee is appointed by the Chief of Staff

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

Section 5.02 - Executive Committee of the Medical Staff

1. The Medical Executive Council (MEC) serves as the Executive Committee of the

Medical Staff.

Medical Executive Council Membership: The following are designated voting members:

Voting Members:

Chief of Staff, Chairperson

Deputy Chief of Staff, Vice Chairperson

Associate Chief of Staff/Education

Associate Chief of Staff/ Hospital Epidemiology and Occupational Health

Associate Chief of Staff/Geriatrics & Extended Care

Associate Chief of Staff/Medical Services

Associate Chief of Staff/Mental Health & Behavioral Services Associate Chief of Staff/Research

Associate Chief of Staff/Operative Care

Associate Chief of Staff/Ambulatory Care

Chief of the Emergency Department

Appointed: 2 Members by MEC

Elected: 1 Member by the Medical Staff

Ex-Officio members

Director

Associate Director for Patient Care

Service Chief, Quality Management Service

Integrated Ethics Officer

Chairperson, Professional Standards Board

The majority of the voting members must be fully licensed physicians of medicine or osteopathy. Other non-voting facility staff may be called upon to serve as resources or attend meetings at the request of the chairperson.

The process for electing one active medical staff member to the MEC is as follows:

1. The medical staff nominates active medical staff members via a paper or electronic ballot.

2. The nominated medical staff member will appear on an electronic voting ballet to be submitted to all medical staff.

3. Upon receipt of the electronic voting ballot, the medical staff is to select one active medical staff member. The member getting the largest number of votes shall be elected.

4. The active or associate medical staff member with the majority of votes will be appointed to the MEC upon the approval of the Director.

The process for removal of a MEC member is as follows:

1. A complaint is filed with MEC or by MEC member or Medical Staff member (i.e., Attendance, Conduct, Adverse Actions against privileges, etc.)

2. A board of inquiry is appointed by COS consisting of 3 voting members of the

MEC.

3. A hearing will occur, and the board will offer a recommendation.

4. A recommendation requires 2/3 vote by MEC members for approval.

5. Term of appointment for the three (3) non-permanent members of the MEC will be for two years and consecutive terms are allowed (no more than two consecutive terms)

6. The MEC is delegated the primary oversight authority related to professional activities and functions of the Medical Staff and performance improvement activities regarding the professional services provided by Medical Staff members with clinical privileges. The authority delegated pursuant to this Section 5.02 may be removed by amendment of these Bylaws, or by resolution of the Medical Staff, approved by a 2/3 vote of the voting Medical Staff, taken at a general or special meeting noticed to include the specific purpose of removing specifically described authority of the Medical Executive Committee

The MEC is responsible for the following functions:

A. Acts on behalf of the organized medical staff between medical staff meetings.

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

C. Acts to ensure effective communications between the medical staff and the Director.

D. Makes recommendations directly to the Governing Body (Director) regarding the:

1) Organization, membership, structure, function, and termination of the medical staff.

2) Membership removal/termination before term end will require a 2/3rd vote by the MEC. Member will have appeal rights as outlined in Article VI. Fair Hearing and Appellate Review.

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

4) Delineation of privileges for each provider credentialed E. Coordination of the ongoing review, evaluation, and improvement activities and ensures full compliance with Veterans Health Administration Clinical Performance Measures, the Joint Commission, and relevant external standards.

F. Professional Standards Board (PSB): 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 by which membership on the medical staff may be terminated consistent with applicable laws and VA regulations.

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

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

J. Serves as consultant to executive management and coordinates activities regarding clinical policies, clinical staff recommendations, and accountability for patient care.

K. Receives and acts on reports and recommendations from medical staff committees including those with quality-of-care responsibilities, clinical services, and assigned activity groups and makes needed recommendations to the Governing Body.

L. Assists in development of methods for care and protection of patients and others at the time of internal and external emergency or disaster, according to VA policies.

M. Acts upon recommendations from the-Professional Standard…