c. Medical Staff Bylaws - VALLHS.pdf

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BYLAWS AND RULES OF THE MEDICAL STAFF

OF

VETERANS HEALTH ADMINISTRATION (VHA)

VA LOMA LINDA HEALTHCARE SYSTEM

LOMA LINDA, CALIFORNIA

REVISED DATE:

July 7, 2021 i

Table of Contents

PREAMBLE 1

DEFINITIONS 1

ARTICLE I. NAME 4

ARTICLE II. PURPOSE 4

ARTICLE III. MEDICAL STAFF MEMBERSHIP 6

Section 3.01 Eligibility for Membership on the Medical Staff 6 Section 3.02 Qualifications for Medical Staff Membership and Clinical Privileges 6 Section 3.03 Code of Conduct 8

Section 3.04 Conflict Resolution & Management 10

ARTICLE IV. ORGANIZATION OF THE MEDICAL STAFF 11

Section 4.01 Leaders 11 Section 4.02 Leadership 12 Section 4.03 Clinical Services 13

ARTICLE V. MEDICAL STAFF COMMITTEES 15

Section 5.01 General 15 Section 5.02 Executive Council of the Medical Staff 15 Section 5.03 Committees of the Medical Staff 15 Section 5.04 Committee Records and Minutes 19 Section 5.05 Establishment of Committees 19

ARTICLE VI. MEDICAL STAFF MEETINGS 19

ARTICLE VII. APPOINTMENT AND ONGOING CREDENTIALING 20

Section 7.01 General Provisions 20 Section 7.02 Application Procedures 23 Section 7.03 Process and Terms of Appointment 27 Section 7.04 Credentials Evaluation and Maintenance 27 Section 7.05 Local/VISN-Level Compensation Panels 28

ARTICLE VIII. CLINICAL PRIVILEGES 28

Section 8.01 General Provisions 28 Section 8.02 Process and Requirements for Requesting Clinical Privileges 30 Section 8.03 Process and Requirement for Requesting Renewal of Clinical Privileges ii

Section 8.04 Processing an Increase or Modification of Privileges 32 Section 8.05 Recommendations and Approval for Renewal and Revision of Clinical Privileges 33 Section 8.06 Exceptions 34

Section 8.07 Medical Assessment 39

ARTICLE IX. INVESTIGATION AND ACTION 38

ARTICLE X. FAIR HEARING AND APPELLATE REVIEW 38

ARTICLE XI. RULES AND REGULATIONS 52

ARTICLE XII. AMENDMENTS 53

ARTICLE XIII. ADOPTION 53

MEDICAL STAFF RULES 55

1. GENERAL 55

2. PATIENT RIGHTS 55

3. RESPONSIBILITY FOR CARE 58

4. PHYSICIANS' ORDERS 62

5. ROLE OF ATTENDING STAFF 64

6. MEDICAL RECORDS 66

7. INFECTION CONTROL 70

8. CONTINUING EDUCATION 70

9. HEALTH STATUS AND IMPAIRED PROFESSIONAL PROGRAM 70

10. PEER REVIEW 71

PREAMBLE *

Recognizing that the Medical Staff is responsible for the quality of care delivered by its members and accountable to the Governing Body for all aspects of that care, the Medical Staff practicing at the VA Loma Linda Healthcare System in Loma Linda, California (hereinafter sometimes referred to as VALLHS, 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.

VALLHS is comprised of the Jerry L. Pettis Memorial Veterans Affairs Medical Center with an integrated long-term care facility, an Ambulatory Care Center in Redlands, the Blythe VA Rural Health Clinic and five Community Clinics in Corona, Murrieta, Palm Desert, Rancho Cucamonga and Victorville. We provide medical, surgical, mental health, geriatric, advanced rehabilitation and home care services.

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. Active Medical Staff: The Active Medical Staff is the body of Licensed Independent

Practitioners, as identified in the credentialing and privileging software maintained by the Medical Staff Office, who also meet the requirement of being permanent employees of the VALLHS, whether part-time or full-time. The Active Medical Staff are the voting members of the Medical Staff, and so for purposes of this document, the Active Medical Staff is the same group of Practitioners as the Organized Medical Staff.

2. 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 (APRN, CRNA, and CRNP), and Clinical Pharmacy Specialists. Advanced Practice Professionals may have prescriptive authority as allowed by Federal Regulation, and/or state of licensure statute and regulations, under the supervision of a credentialed and privileged Licensed Independent Practitioner when required. Unless privileged to do so, Advanced Practice Professionals do not have admitting authority. Advance 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

3. Associate Medical Staff: The Associate Medical Staff are those clinical Practitioners who either have an employment appointment other than permanent, i.e. WOC, Contractor, or Fee Basis and/or who are not classified as Licensed Independent Practitioners in the credentialing and privileging software maintained by the Medical Staff Office. Associate Medical Staff are not eligible to vote on the Medical Staff Bylaws but are subject to the requirements of the Medical Staff Bylaws.

4. 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 does require having an appropriate personnel appointment action from VALLHS Human Resources, scarce medical specialty contract, or other authority to provide medical patient care services at the facility. Health Care Practitioners who have been credentialed under the medical staff process will be appointed members of the Active Medical Staff if they are permanent employees based on their employment appointment (either part-time or full-time).

5. 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.

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: Psychologists, podiatrists, and optometrists. Associated Health Professionals function under either defined clinical privileges or a defined scope of practice.

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 practitioner returns to duty. Reactivation must be endorsed by the Medical Executive Council (MEC) 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 President of the medical staff and Chairperson of the MEC 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.

9. 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.

10. Contract Practitioners: Contractor or subcontractor Practitioners are subject to the requirements of this facility’s Medical Staff 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 Practitioner 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. Facility Director: The Director 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 Directors (AD), the Associate Director for Patient Care Services (AD-PCS), and the MEC.

12. 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.

13. Dependent Practitioner: The term Dependent Practitioner refers to any individual permitted by law and by the VALLHS to provide care and services, dependent on direction or supervision, within the scope of the individual’s license or certification and consistent with the individually granted privileges, scope of practice or individual competencies. Dependent Practitioners are not members of the Medical Staff.

14. Licensed Independent Practitioner: The term Licensed Independent Practitioner (LIP) refers to any individual permitted by law and by the VALLHS 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 may include physicians, dentists, advanced practice nurses, CRNAs, chiropractors, clinical nurse specialists, audiologists, psychologists, speech pathologists, physician assistants, and podiatrists. The criteria for an individual practitioner will be based on being listed in the credentialing software maintained by the Medical Staff Office as a LIP. Note: The Full Practice Authority (FPA) which was passed on January 14, 2017 permits VA appointed Advance Practice Registered Nurses to practice as Licensed Independent Practitioners regardless of state licensure held and can practice/ be privileged as such if approved by both the facility’s Organized Medical Staff and Governance and documented in Medical Staff Bylaws. Clinical Pharmacists are referred to as LIP-Pharmacist only for credentialing purposes, they are NOT Licensed Independent Practitioners.

15. 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, but does not include Dependent Practitioners.

16. Medical Staff Office: The office responsible for providing credentialing and privileging services for all practitioners who are subject to the requirements of the Medical Staff Bylaws. The Medical Staff Office is responsible for maintaining the credentialing and privileging systems as required by the VA and which are currently known as VetPro and PrivPlus.

17. Nurse Executive or Associate Director for Patient Care Services (ADPCS): The ADPCS 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.

The ADPCS acts as full assistant to the Director in the efficient management and consultation of clinical and patient care services to eligible patients, the active maintenance of a credentialing, scope of practice, and privileging system for relevant advanced practice professionals and certain associated health professionals and in ensuring the ongoing education of the nursing staff.

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

VALLHS includes all LIPs as voting members provided they are permanent employees. The voting membership will be based on the Medical Staff Office listing of LIPs 30 days prior to a scheduled vote.

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

20. 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.

21. Practitioner: Any appropriately credentialed physician, resident, dentist, oral surgeon, podiatrist or allied health professional acting within their clinical privileges, scope of practice or individual competencies.

22. 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.

23. 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.

24. Professional Standards Board / Credentials Committee: The Professional Standards Board / Credentials Committee, if established, may act on credentialing and clinical privileging matters of the Medical Staff, making recommendation on such matters to the Executive Council of the Medical Staff as defined in these Bylaws. This board is responsible for matters involving both LIP and Dependent Practitioners 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.

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

26. Teleconsultation: The provision of advice on a diagnosis, prognosis, and/or therapy from a licensed independent practitioner to another licensed independent practitioner 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 practitioner

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

28. 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, VA Loma Linda Healthcare System (VALLHS).

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 policies and procedures.

14. Coordinate and supervise the scope of practice of all Advanced Practice Professional and appropriate Associated Health Professional 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 Professional should have a scope of practice statement or privileges as well as the means employed to coordinate and supervise their function with the medical staff.

ARTICLE III. MEDICAL STAFF MEMBERSHIP *

Section 3.01 Eligibility for Membership on the Medical Staff *

1. Membership: Membership on the Medical Staff is a privilege extended only to, and continued for, professionally competent physicians and dentists and other Licensed Practitioners who continuously meet the qualifications, standards, and requirements of VHA (including VHA Handbook 1400.1 Resident Supervision), this Facility, and these Bylaws.

Membership on the Organized Medical Staff (the voting members of the Medical Staff) is limited to those members of the Medical Staff who are permanent employees of the VALLHS and Licensed Independent Practitioners.

2. Categories of the Medical Staff: The VALLHS only has two categories of Medical Staff, Active Members and Associate Members.

The Active Medical Staff is the body of Licensed Independent Practitioners, as identified in the credentialing software maintained by the Medical Staff Office, who are also permanent employees of the VALLHS, whether part-time or full-time. The Active Medical Staff are the voting members of the Medical Staff, and so for purposes of this document, the Active Medical Staff is the same as the Organized Medical Staff.

The Associate Medical Staff are those clinical professionals who either have an employment appointment other than permanent, i.e. WOC, Contractor, or Fee Basis and/or who are not classified as Licensed Independent Practitioners in the credentialing software maintained by the Medical Staff Office. Associate Medical Staff are not eligible to vote on the Medical Staff Bylaws but are subject to the requirements of the Medical Staff bylaws.

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.

b. 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.

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

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

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

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

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

h. English language proficiency.

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

j. A current Personal Identity Verification (PIV) Card

2. Clinical Privileges and Scope of Practice: While only Licensed Independent Practitioners may function with defined clinical privileges, not all Licensed Independent Practitioners are permitted by this Facility and these Bylaws to practice independently. All Practitioners listed below are subject to the bylaws whether they are granted defined clinical privileges or not. The following categories represent current practice but may evolve based on future changes to VA credentialing standards.

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 and authorized by this Facility:

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

ii) Certified Registered Nurse Anesthetists (CRNA)

iii) Clinical Pharmacists

iv) Psychologists

v) Audiologists

vi) Speech Pathologists

vii) Podiatrists viii)Optometrists

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

i) Physician Assistants.

ii) Clinical Pharmacy Specialists

iii) Contract APRNs who are not licensed in a state which recognizes their

APRNs as Licensed Independent Practitioners.

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

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

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

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

Section 3.03 Code of Conduct

1. Acceptable Behavior: The VA expects that members of the medical staff will serve diligently, loyally, and cooperatively. They must avoid misconduct and other activities that conflict with their duties; exercise courtesy and dignity; and otherwise conduct themselves, both on and off duty, in a manner that reflects positively upon themselves and VA. Acceptable behavior includes the following (1) being on duty as scheduled. (2) being impartial in carrying out official duties and avoiding any action that might result in, or look as though, a medical staff member is giving preferential treatment to any person, group or organization, (3) not discriminating on the basis of race, age, color, sex, religion, national origin, politics, marital status, or disability in any employment matter or in providing benefits under any law administered by VA, (4) not making a governmental decision outside of official channels, (5) not taking any action that impedes government efficiency and economy, affects one’s impartiality, or otherwise lowers public confidence in the Federal Government, and (6) with certain exceptions in accordance with 5 C.F.R.

2635, not asking for or accepting any gift, tip, entertainment, loan, or favor, or anything of monetary value for oneself or any member of one’s family from any person or organization 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 way its Practitioners interact with others can significantly impact patient care. VA strongly urges its practitioners 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. Practitioners 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.

a) Behavior or Behaviors That Undermine a Culture of Safety is a style of interaction with physicians, hospital personnel, patients, family members, or others that interferes with patient care. Behaviors such as foul language;

rude, loud or offensive comments; and intimidation of staff, patients and family members are commonly recognized as detrimental to patient care.

Furthermore, it has become apparent that Behavior or Behaviors That Undermine a Culture of Safety is often a marker for concerns that can range from a lack of interpersonal skills to deeper problems, such as depression or substance abuse. As a result, Behavior or Behaviors That Undermine a Culture of Safety may reach a threshold such that it constitutes grounds for further inquiry by the Medical Executive Council into the potential underlying causes of such behavior. Behavior by a practitioner that is disruptive could be grounds for disciplinary action.

b) 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 practitioners of their responsibility not only to patients, but also to themselves. Symptoms of stress, such as exhaustion and depression, can negatively affect a practitioner’s health and performance. Practitioners suffering such symptoms are encouraged to seek the support needed to help them regain their equilibrium.

c) Practitioners, 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 practitioners. VA urges its practitioners 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.

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, Patient Safety Officer, or other individual as described in the following Agency resources found on the Office of Diversity and Inclusion (EEO) website at http://www.diversity.hr.va.gov/index.asp and these resources: Alternative Dispute Resolution: Memorandum on Alternative Dispute Resolution for Workplace Disputes, (February 8, 2007), VA Directive 5978, Alternative Dispute Resolution (February 23, 2000), and VA Handbook 5978.1, Alternative Dispute Resolution Program: Central Office (December 11, 2007).

ARTICLE IV: ORGANIZATION OF THE MEDICAL STAFF *

Section 4.01 Leaders *

1. Composition:

a. Chief of Staff.

b. Deputy Chief of Staff and Associate Chiefs of Staff

2. Qualifications: The Chief of Staff, Deputy Chief of Staff, and Associates meet all the qualifications cited in 3.02.

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: Chief of Staff duties shall include, but are not limited to:

a. Enforcing the Medical Staff Bylaws and Rules, promoting quality of care, implementing sanctions when indicated, and insuring compliance with procedural safeguards when corrective action has been requested or initiated

b. Calling, presiding at, and being responsible for the agenda and minutes of all meetings of the Medical Staff;

c. Serving as Chair of the Medical Executive Council, and in that capacity deemed the individual responsible for the organization and conduct of the Medical Staff.

d. Being a spokesperson for the Medical Staff in external professional and public relations;

e. Serving on liaison committees with the Executive Leadership Team and administration;

f. Regularly reporting to the Director on the performance of Medical Staff functions and communicating to the Medical Staff any concerns expressed by the Director;

g. In the interim between MEC meetings, performing those responsibilities of the Council that in his/her reasonable opinion, must be accomplished prior to the next regular or special meeting of the Council;

h. Representing the views and policies of the Medical Staff to the Executive Leadership Team;

i. Being accountable to the Director, in conjunction with the MEC, for the effective performance by the Medical Staff of its responsibilities with respect to quality and efficiency of clinical services;

j. Performing such other functions as may be assigned by these Bylaws, the Medical Staff, or the MEC.

6. Deputy Chief of Staff and Associate Chiefs of Staff

a. The Deputy Chief of Staff (DCOS) fulfills the responsibilities of the Chief of Staff as defined in these bylaws when serving in the capacity of Acting Chief of Staff. The DCOS has general responsibility for clinical operations and other functions as assigned by the Chief of Staff, the Medical Staff, or the MEC.

b. The Associate Chief of Staff for Education (ACOS/E) has general responsibility for graduate medical education as well as management and oversight of all graduate medial and allied health education programs and initiatives.

c. The Associate Chief of Staff for Mental Health (ACOS/MH) has general responsibility and oversight for the Mental Health Care Line.

d. The Associate Chief of Staff for Research (ACOS/R) has general responsibility and oversight for the research program including clinical, laboratory-based, health systems, and rehabilitation research.

e. The Associate Chief of Staff for Ambulatory Care has general responsibility for the outpatient primary care services including areas such as Primary Care, Preventive Medicine, Women’s Health, and Occupational Medicine.

Section 4.02 Leadership

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

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 as needed 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 the MEC.

3. Selection and Appointment of Service Chiefs: * Service Chiefs are appointed by the Director based upon the recommendation of the Chief of Staff and shall be board certified / eligible by the relevant specialty board or possess comparable competence.

4. Duties and Responsibilities of Service Chiefs: * The Service Chief is administratively responsible for the operation of the Service and it’s 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 Practitioner 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. Adequate 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 special.

2. All committee members, regardless of whether they are members of the Medical

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

3. The presence of 51% of a committee's members will constitute a quorum.

4. The members of all standing committees, other than the MEC, are appointed by the

Chief of Staff subject to approval by the MEC, unless otherwise stated in these Bylaws.

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

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

Section 5.02 Executive Council of the Medical Staff *

1. Characteristics: The Medical Executive Council (MEC) serves as the Executive

Committee of the Medical Staff. The members of the MEC * are:

a. Chief of Staff, Chairperson, voting.

b. Deputy Chief of Staff, Co-Chair, voting

c. Associate Director Patient Care Services, voting

d. Clinical Service Chiefs, voting.

e. Two Practitioners voted by the Medical Staff through the medical staff office process, voting.

f. Director, or designee, ex-officio, non-voting, as appropriate <It should be noted that when the MEC is considering a recommendation on the reduction or revocation of clinical privileges, the Director should recuse him or herself from the discussion. The reason for this is that the Director is the deciding official in these situations and all employees are entitled to due process, which includes the right to an impartial decision.> *

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

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

i. Selection process for membership:

i) Deputy COS, Associate Chiefs of Staff, Clinical Service Chiefs and ADPCS are appointed by the COS and are standing members of the MEC based on their clinical leadership responsibilities.

ii) Elected members of from the Organized Medical Staff will be elected through a process organized by the Medical Staff Office and then appointed by the

COS

j. Removal process for membership: Any MEC member may be removed by a 2/3 majority vote of the MEC.

2. Functions of the MEC: The MEC: *

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

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

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

d. Makes recommendations directly to the Director regarding the:

i) Organization, membership (to include termination), structure, and function of the Medical Staff. <Mechanism for termination of medical staff membership to be defined locally but does not include termination of employment which should be managed separately, referencing Human Resources Management policies such as VA Handbook 5021.>

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

iii) Delineation of privileges for each Practitioner credentialed.

e. Ensures that there is ongoing review, evaluation, and improvement related to quality of care activities in accordance with the VALLHS Corporate Governance Structure and ensures full compliance with Veterans Health Administration Clinical Performance Measures, The Joint Commission, 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 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. Advises facility leadership 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 Medical Staff Professional Standards Board.

n. Acts as and carries out the function of the Physical Standards Board, which includes the evaluation of physical and mental fitness of all medical staff upon referral by the Occupational Health Physician. The Physical Standards Board may have the same membership as the local Medical Staff Professional Standards Board or members may be designated for this purpose by the health care facility Director to ensure objectivity. Boards may be conducted at other VA healthcare facilities.

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

p. Annually reviews and makes recommendations for approval of the Service-specific privilege lists.

3. Meetings:

a. Regular Meetings: Regular meetings of the MEC shall be held at least 9 times per year, generally occurring once per month.