D.4 Bylaws-and-Rules-VHA-MEDVAMC-July-22-2022-updated-signed.pdf

BYLAWS AND RULES OF THE MEDICAL STAFF

OF

VETERANS HEALTH ADMINISTRATION (VHA)

MICHAEL E. DEBAKEY VA MEDICAL CENTER

HOUSTON, TEXAS

July 22, 2022

BYLAWS AND RULES OF THE MEDVAMC MEDICAL STAFF July 22, 2022

Table Of Contents

PREAMBLE 1

DEFINITIONS 1

ARTICLE l. NAME 9

ARTICLE ll. PURPOSE 9

ARTICLE Ill. MEDICAL STAFF MEMBERSHIP 11

Section 3.01 Eligibility for Membership on the Medical Staff

Section 3.02 Qualifications for Medical Staff Membership and Clinical

Privileges

Section 3.03 Code of Conduct

Section 3.04 Conflict Resolution & Management

ARTICLE IV. ORGANIZATION OF THE MEDICAL STAFF 16

Section 4.01 Leaders

Section 4.02 Leadership

Section 4.03 Clinical Services

ARTICLE V. MEDICAL STAFF COMMITTEES 20

Section 5.01 General

Section 5.02 Executive Committee Of the Medical Staff

Section 5.03 Committees of the Medical Staff

Section 5.04 Committee Records and Minutes

Section 5.05 Establishment of Committees

ARTICLE VI. MEDICAL STAFF MEETINGS 30

ARTICLE VII APPOINTMENT AND ONGOING CREDENTIALING 31

Section 7.01 General Provisions

Section 7.02 Application Procedures

Section 7.03 Process and Terms of Appointment

Section 7.04 Credentials Evaluations and Maintenance

Section 7.05 Local VISN- Level Compensation Panels

ARTICLE VIII. CLINICAL PRIVILEGES 39

Section 8.01 General Provisions

Section 8.02 Process and Requirements for Requesting Clinical Privileges

Section 8.03 Process and Requirement for Requesting Renewal of Clinical

Privileges

Section 8.04 Processing an Increase or Modification of Privileges

Section 8.05 Recommendations and Approval for Renewal and Revision of

Clinical Privileges

Section 8.06 Exceptions

Section 8.07 Medical Assessment

ARTICLE IX. INVESTIGATION AND ACTION 50

ARTICLE X. FAIR HEARING AND APPELLATE REVIEW 58

ARTICLE XI. RULES AND REGULATION 63

ARTICLE XII. AMENDAMENTS 63

ARTICLE XIII. ADOPTION 63

MEDICAL STAFF RULES 65

1. GENERAL 65

2. PATEINT RIGHTS 65

3. RESPONSIBILITY FOR CARE 67

4. PHYSICIANS’ ORDERS 71

5. ROLE OF ATTENDING STAFF 73

6. MEDICAL RECORDS 75

7. INFECTION CONTROL 78

8. CONTINUING EDUCATION 78

9. HEALTH STATUS AND IMPAIRED PROFESSIONAL 78

PROGRAM

10. PEER REVIEW 79

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 Michael E. DeBakey VA Medical Center in Houston, Texas (hereinafter usually referred to as MEDVAMC) hereby organizes itself for self-governance in conformity with the laws, regulations and policies governing the Department of Veterans Affairs (VA), Veterans Health Administration (VHA), and the Bylaws and Rules hereinafter stated. These Bylaws and Rules are consistent with all laws and regulations governing the VHA, and they do not create any rights or liabilities not otherwise provided for in laws or VHA Regulations.

The MEDVAMC provides inpatient care, outpatient care, long term care, home care, and behavioral care at the main campus in Houston as well as provides outpatient care in the community-based outpatient clinics (CBOCs) with current/future locations in Beaumont, Texas; Conroe Texas; Galveston/Texas City, Texas; Humble, Texas; Katy, Texas; Lake Jackson, Texas; Lufkin, Texas; Richmond, Texas; Sugarland, Texas; Texas City, Texas;

and Tomball, Texas.

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 or dentists and who, most often will, function within a Scope of Practice although they may practice independently on defined clinical privileges as defined in these Medical Staff Bylaws. Advanced Practice Professionals include physician assistants (PAS) and advanced practice registered nurses (APRNs) such as Advanced Practice Nurses (ARNPs, CRNAs, and CRNPs) and Clinical Pharmacy Specialists (CPSs). 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.

Advanced Practice Professionals may initiate prescriptions for non-formulary drugs or prescribe controlled substances in accordance with state of licensure statutes and regulations. Unless privileged to do so, Advanced Practice Professionals do not have admitting privileges. Advanced Registered Nurse Practitioners and other health care professionals may be granted defined clinical privileges when allowed by law and the MEDVAMC.

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 it is based on having an appropriate personnel appointment action, scarce medical specialty contract, or other authority to provide independent medical, patient care services at the MEDVAMC. Both VA employees and contractors providing patient care services must receive appointments to the Medical Staff.

3. Associate Medical Center Director (usually referred to as simply the Associate Director): The Associate Director is a full assistant to the Medical Center Director in the operation of the MEDVAMC. He/she fulfills the responsibilities of the Medical Center Director as defined in these bylaws when serving in the capacity of Acting Medical Center Director.

4. Associate Director for Patient Care Services (ADPCS) and may also be referred to historically as the Chief Nurse or the Nurse Executive): The ADPCS is a registered nurse who is responsible for the full-time, oversight of nursing services and who meets licensing requirements as defined by Title 38. He/she is the Chairperson of the Nurse Leadership Council (NCC) and acts as full assistant to the Medical Center Director in the efficient management and consultation of clinical and patient care services to eligible patients, assists in the active maintenance of a credentialing, scope of practice, and privileging system for relevant Advanced Practice Professionals and certain associated health staff and in ensuring the ongoing education of the nursing staff

5. Associated Health Professional: An "Associated Health Professional" is a clinical professional other than a doctor of allopathic, dental, and osteopathic medicine.

Associated Health Professionals include, but are not limited to: Psychologists, Podiatrists, Chiropractors, Optometrists, Clinical Pharmacists, Audiologists, Speech-Pathologists, Social Workers, Marriage Family Therapists, and Dental Hygienists. 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 results from concern of substandard care, professional misconduct, or professional incompetence (e.g. 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 that are automatically suspended until the cause of the suspension has been addressed such as the records being completed or the delinquency rate falling to an acceptable level or provider returns to duty Reactivation must be endorsed by the Clinical Executive Board (CEB) and discussion of reactivation should include consideration of a Focused Professional Practice Evaluation (FPPE) depending on the length of time away from practice and reason for the automatic suspension.

7. Chief of Staff: The Chief of Staff functions as the President of the Medical Staff and as Chairperson of the Clinical Executive Board (CEB) and acts as a full assistant to the Medical Center 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 the MEDVAMC 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 jf the revocation of privileges was based upon substandard care, professional misconduct, or professional incompetence and reportable to the National Practitioner Data Bank (NPDB) if the practitioner is a physician or dentist.

10. Credentials Committee: The Credentialing & Clinical Privileging Committee is the credentialing committee which acts on credentialing and clinical privileging matters of the Medical Staff, making recommendation on such matters to the Clinical Executive Board (CEB) (the Executive Committee of the Medical Staff as defined in these Bylaws). The CEB also may act on matters involving Associated Health Professionals 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.

11. Deputy Medical Center Director (usually referred to as simply the Deputy Director):

The Deputy Director is a full assistant to the Medical Center Director in the operation of the MEDVAMC. He/she fulfills the responsibilities of the Medical Center Director as defined in these Bylaws when serving in the capacity of Acting Medical Center Director.

12. Governing Body: The term Gaveling 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, the Medical Center Director. The Medical Center 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 MEDVAMC approved processes.

13. House staff: House staff are residents/fellows who are participating in an approved residency training program through an affiliate (generally Baylor College of Medicine in Houston or University of Texas Health Science Center in Houston). House staff are trainees and are not Licensed Independent Practitioners (LIPs)—therefore, they are not members of the Medical Staff, but may be appointed to serve on MEDVAMC committees and subcommittees as a voting member. Fellows or senior residents, however, may be credentialed and privileged in a clinical area for which their training has been completed and, thus, considered as an LIP. for those specific privileges which are granted. Guidance for House Staff Supervision is governed primarily by VHA Handbook 1400.1.

14. Licensed Independent Practitioner (LIP): The term “LIP refers to any individual permitted by law and by the MEDVAMC to provide care and services, without direction or supervision, within the scope of the individual's license and consistent with individually granted privileges. Within the MEDVAMC, this includes physicians, dentists, podiatrists, chiropractors, optometrists, clinical /counseling psychologists, and marriage family therapists as well as individuals who meet this criterion for independent practice and can therefore practice independently. The Full Practice Authority (FPA) which was passed on January 14, 2017, permits VA appointed Advance Practice Registered Nurses to practice as LIPS regardless of state licensure held and can be privileged as such if approved by the Organized Medical Staff and documented in these Medical Staff Bylaws.

15. Medical Center Director (usually referred to as simply the Director): The Medical Center Director functions as a Chief Executive Officer and is appointed by the Governing Body to act as its agent in the overall management of the MEDVAMC.

The Medical Center Director is assisted by the Chief of Staff (COS), the Associate Director for Patient Care Services (ADPCS), the Deputy Medical Center Director, the Associate Medical Center Director (AD), and the Clinical Executive Board (CEB).

16. Medical Staff: The body of all Licensed Independent Practitioners (LIPS) and other Practitioners credentialed through the medical staff process who are subject to the MEDVAMC Medical Staff Bylaws. The Medical Staff includes both members of the Organized Medical Staff and non-members of the Organized Medical Staff who provide health care services.

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

18. 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 evaluating current competence. Peer recommendations and reviews in the context of credentialing, privileging, and adverse actions must remain distinct and different from U.S.C. Section 5705 protected peer review recommendations and activities.

19. 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.

20. 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 serve as evidence of a reduction of privileges.

21. Rules: Refers to the specific rules set forth that govern the Medical Staff of the MEDVAMC. The Medical Staff shall adopt such rules as may be necessary to implement more specifically the general principles found within these MEDVAMC Bylaws. Rules are a separate document from the Bylaws. They can be reviewed and revised by the Clinical Executive Board (CEB) without adoption by the Medical Staff as a whole. Such changes shall become effective when approved by the Director.

22. 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

23. Telemedicine (often referred to as Telehealth): 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.

24. 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 l. NAME

The name of this organization shall be the Medical Staff of the Department of Veterans Affairs, Michael E. DeBakey VA Medical Center (MEDVAMC).

ARTICLE ll. 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 (eve/ 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 Medical Center Director and Governing Body.

g. 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 Executive in Charge (formerly known as 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 house staff 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 Professionals and appropriate Associated Health Practitioner staff so that their rights and practice goals are achieved and integrated expeditiously to benefit the care of patients. Each Advanced Practice Professional and appropriate Associated Health Practitioner should have a scope of practice statement (or delineated 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

Membership: Membership on the Medical Staff is extended only to, and continued for, Licensed Independent Practitioners (LIPs), Advanced Practice Professionals and Associated Health Professionals who continuously meet the qualifications, standards, and requirements of VHA, the MEDVAMC, and these Bylaws.

2. Categories of the Medical Staff include:

a. Active Medical Staff are full voting members and include full-time and regular part-time (one-half time or greater) physicians, dentists, optometrists, podiatrists, APRNs with privileges, chiropractors, clinical/counseling psychologists, and marriage and family therapists.

b. Affiliate Medical Staff are non-voting members and include physicians, dentists, optometrists, podiatrists, APRNs, and psychologists who are appointed less than one-half time to the MEDVAMC; and includes Consultant & Attendings (C&A), Without Compensation (WOCS), and on-station fee basis/intermittent on-station contraction-station sharing agreement staff.

c. Associate Medical Staff are non-voting members and include clinical pharmacists, audiologists, speech pathologists, dental hygienists, social workers, and physician assistants.

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 based on 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. 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. An exception is Physician Assistants (PAs) hired before September 27, 2020 are not required to be licensed, but instead they are required to have national certification by the

National Commission on Certification of Physician Assistants (NCCPA) and continue that certification if not licensed.

a. 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 Education.

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 eligibility/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 Vll 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 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 the MEDVAMC and these Medical Staff 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 and authorized by the MEDVAMC:

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

ii) Podiatrists

iii) Optometrists

iv) Chiropractors

v) Social Workers

vi) Marriage and Family Therapists

vii) Clinical and Counseling Psychologists (at the doctoral level)

viii) Audiologists

ix) Speech Pathologists

x) Dental Hygienists

c. The following Practitioners will be credentialed and will practice under a Scope of Practice with appropriate supervision:

i) Physician Assistants.

ii) Clinical Pharmacists

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

d. The following Practitioners will be credentialed through the Medical Staff process including re-credentialing 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 (CNPs), 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 Medical Center Director, through the Chief of Staff, of any change in their ability to fully meet the criteria for Medical Staff membership, their 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 to 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, sexual orientation, 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 (ACGME) 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 affect quality of care and safety will not be tolerated. These behaviors, as determined by the MEDVAMC Care Line Executive/Clinical Service Chief and/or Clinical Executive Board, 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 Clinical Executive Board (CEB) 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.

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 providers. VA urges its Practitioners to support their hospital, practice, or other healthcare organization in their efforts to identify and 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

1. For VA to be effective and efficient in achieving its goals, the MEDVAMC 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 MEDVAMC 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 including 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).

2. Conflict may arise from issues (such as proposals to adopt a rule, regulation, or policy or amendment thereto, etc.) involving the Medical Staff and the Clinical Executive Board (CEB). The conflict should be resolved at the lowest level possible. First, the parties from the Medical Staff and the CEB should meet to resolve the differences through discussion and compromise. If the conflict persists, the Medical Center Director will appoint a facilitator (not directly involved in the issue under discussion) to meet with the parties and continue to identify a mutually agreeable resolution. If there is still no resolution, the issue will be resolved by decision of the Medical Center Director. This process is not intended to preclude communication between members of the Medical Staff and the Medical Center Director; the method of communication is the prerogative of the Medical Center Director.

ARTICLE IV: ORGANIZATION OF THE MEDICAL STAFF

Section 4.01 Leaders

Composition:

a. Chief of Staff.

b. Deputy Chief of Staff for Operations

c. Deputy Chief of Staff for Medical Affairs

d. Associate Chief of Staff for Analytics & Performance Improvement (A&PI)

e. Associate Chief of Staff for Education

f. Associate Chief of Staff for Research

2. Qualifications: The Chief of Staff, Deputy Chief of Staff for Medical Affairs, Deputy Chief of Staff for Operations, Associate Chief of Staff for Research, and Associate Chief of Staff for Analytics & Performance Improvement and Associate Chief of Staff for Education must be Active Medical Staff in good standing.

3. Selection:

a. The Organized Medical Staff does not elect medical staff officers. The Medical Staff Bylaws are approved by the Organized Medical Staff which constitutes the agreement of the leadership organization. The Network Director approves recommendations to the position of Chief of Staff. The MEDVAMC 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 LMSS for information only.

b. The Deputy Chief of Staff for Medical Affairs, Deputy Chief of Staff for Operations, Associate Chief of Staff for Research, Associate Chief of Staff for Analytics & Performance Improvement and Associate Chief of Staff for Education are selected by the Medical Center Director with the direct advisement of the Chief of Staff and with input from senior members of the MEDVAMC, senior Baylor College of Medicine leaders), and senior South Central VA Health Care Network leaders in accordance with VA Human Resource regulations and policy.

4. Removal:

a. The Chief of Staff may be removed from office for valid cause, including but not limited to, gross neglect or malfeasance in office, or serious acts of moral turpitude. The process for removal may be initiated by the Medical Center Director. The Medical Center Director will work in conjunction with Human Resources and act according to the processes described in VA and VHA regulations, policies, directives, and handbooks (VA Handbook 5021). 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. The Chief of Staff serves as Chairperson of the Clinical Executive Board

(CEB).

b. The Deputy Chief of Staff for Medical Affairs or the Deputy Chief of Staff for Operations will serve as the Acting Chairperson of the Clinical Executive Board (CEB) in the absence of the Chief of Staff. If neither of these two staff can serve, then one of the Care Line Executives will be appointed in advance by the Chief of Staff, if possible, or by the Medical Center Director in the case of an emergency meeting.

Section 4.02 Leadership

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

Section 4.03 Clinical Services

Characteristics:

a. Clinical Services are organized to provide clinical care and treatment under the leadership of a Care Line Executive or Clinical Service Chief.

b. Care Lines and Clinical Services hold care line or service-level meetings generally monthly but not less than quarterly.

2. Functions:

a. Provide for quality and safety of the care, treatment, and services provided by the Care Line or Clinical 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 Care Line or Clinical 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 Care Line/Clinical Service activities.

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

d. Develop criteria for recommending clinical privileges for members of the Care Line or Clinical Service and ensure that ongoing professional practice evaluation (OPPE) is continuously performed (aggregated and reported semi-annually) 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 Care Line or Clinical Service.

g. Annually review privilege templates for each Care Line and Clinical Service and make recommendations for changes to the Clinical Executive Board (CEB).

3. Selection and Appointment of Care Line Executives and Clinical Service Chiefs:

The Care Line Executives and Clinical Service Chiefs are appointed by the Medical Center Director based upon the recommendation of the Chief of Staff with input from senior Baylor College of Medicine leaders and from VISN 16 leadership staff and in accordance with VA regulations and policy.

4. Duties and Responsibilities of Care Line Executive and Clinical Service Chiefs:

The Care Line Executives and Clinical Service Chiefs are administratively responsible for the operation of the Care Line/Clinical Service and its clinical and research efforts, as appropriate. In addition to duties listed below, the Care Line Executive or Clinical Service Chief is responsible for assuring the Care Line/Clinical Service performs according to applicable VHA performance standards. These are the performance requirements applicable to the Care Line/Clinical Service from the national performance contract, and cascade from the overarching requirements delegated to the Chief of the Staff. These requirements are described in individual Performance Plans for each Care Line Executive or Clinical Service Chief. Care Line Executives and Clinical Service Chiefs are responsible and accountable for:

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

b. Clinically related activities of the Care Line/Clinical Service.

c. Administratively related activities of the Care Line/Clinical Service, unless otherwise provided by the organization.

d. Continued surveillance of the professional performance of all individuals in the

e. Care Line or Clinical Service who have delineated clinical privileges through Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) process.

f. Recommending to the Medical Staff the criteria for clinical privileges that are relevant to the care provided in the Care Line/Clinical Service.

g. Recommending clinical privileges for each member of the Care Line/Clinical Service.

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

i. The integration of the Care Line/Clinical Service into the primary functions of the organization.

j. The coordination and integration of inter-Care Line/Clinical Service and intra Care Line/Clinical Service services.

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

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

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

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

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

p. The orientation and continuing education of all persons in the Care Line/Clinical Service.

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

r. Annual review of all clinical privilege forms to ensure that they correctly and adequately reflect the services being provided at the facility.

ARTICLE V. MEDICAL STAFF COMMITTEES

Section 5.01 General

1. Committees are either standing or special.

2. All committee members (excludes guests), regardless of whether they are members of the Medical Staff, are eligible to vote on committee matters unless otherwise set forth in these Bylaws.

3. The presence of 50% of a committee's members will constitute a quorum.

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

5. The members of all standing committees, other than the Clinical Executive Board (CEB), are appointed by the Chairperson, but are subject to approval by the Chief of Staff and by the Clinical Executive Board (CEB), unless otherwise stated in these Bylaws.

6.

Section 5.02 Executive Committee of the Medical Staff

Characteristics: The Clinical Executive Board (CEB) serves as the Executive Committee of the Medical Staff. The members of the CEB (of which the majority of the voting members must be fully licensed physicians of allopathic or osteopathic medicine are:

a. Chief of Staff, Chairperson (voting)

b. Deputy Chief of Staff for Medical Affairs (voting)

c. Deputy Chief of Staff for Operations, (voting)

d. Associate Chief of Staff for Education (voting)

e. Associate Chief of Staff for Research (voting)

f. Associate Chief of Staff for Analytics & Performance Improvement (voting)

g. Director of Community Based Outpatient Clinics (voting)

h. Associate Director for Patient Care Services (voting)

i. Care Line Executives and Clinical Service Chiefs (voting)

j. Director of Primary Care (voting)

k. Chief of Pharmacy (voting)

l. Chief of Dental (voting)

m. Chief of Emergency Department (voting)

n. Physician representing the professional AFGE Union (voting)

o. Physician Assistant representative (voting)

p. Advanced Practice Registered Nurse (APRN) representative (voting)

q. Psychology representative (voting)

r. Director of Quality, Safety, and Value (voting)

s. Executive Assistants of Chief of Staff, Deputy Chief of Staff for Medical Staff, Deputy Chief of Staff for Operations, Associate Chief of Staff for Ambulatory Services, and Associate Chief of Staff for Research, Associate Chief of Analytics & Performance Improvement (Non-voting)

t. Medical Center Director, or designee, ex-officio (Non-voting)

u. Other MEDVAMC staff or guests as may be invited by the Chief of Staff to attend CEB meetings in the role as an expert resource or Committee representative (non-voting)

2. Selection process for membership: The Organized Medical Staff defines through the bylaws which positions serve on the Clinical Executive Board. Membership on the Clinical Executive Board is based on holding a specific position or on being an individual appointed to the Clinical Executive Board by the Chief of Staff.

3. Removal process for membership: The Organized Medical Staff defines through the bylaws which positions should serve on the Clinical Executive Board. Clinical Executive Board membership can be revoked in the event of any of the following scenarios: termination of employment, suspension from employment, resignation or removal from a clinical leadership position, or inability to discharge duties as a voting member. The Chief of Staff may also remove individuals appointed by the Chief of Staff to serve on the Clinical Executive Board.

4. Functions of the Clinical Executive Board (CEB): The Clinical Executive Board

(CEB):

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

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

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

d. Makes recommendations directly to the Medical Center Director regarding the:

i) Organization, membership (to include termination of Medical Staff membership), structure, and function of the Medical Staff. VA Handbook 5021 contains provision for termination and removal of the Medical Staff.

ii) Process used to review credentials and delineate privileges for the Medical Staff.

iii) Delineation of privileges for each Practitioner credentialed/privileged.

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

f. Oversees process in place for addressing instances in which there is a '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 MEDVAMC 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 Medical Center Director as 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 Credentialing and Clinical Privileging Committee.

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 physician Professional Standards Board or members may be designated for this purpose by the Medical Center Director to ensure objectivity. Boards may be conducted at other VA healthcare facilities.

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

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

5. Meetings:

a. Regular Meetings: Regular meetings of the Clinical Executive Board (CEB) shall be held at least quarterly but will generally meet monthly.