D.8 BYLAWS Robert J Dole VAMC June 2023.pdf

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BYLAWS AND RULES OF THE

MEDICAL STAFF OF

VETERANS HEALTH ADMINISTRATION

(VHA)

ROBERT J. DOLE VA MEDICAL

CENTER (RJD VAMC)

WICHITA, KANSAS

REVIEWED DATE: 5 January 2024

REVISED DATE: 5 January 2024

Table of Contents

PREAMBLE 1

DEFINITIONS 1

ARTICLE I. NAME 5

ARTICLE II. PURPOSE 5

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 9

ARTICLE IV. ORGANIZATION OF THE MEDICAL STAFF 10

Section 4.01 Leaders 10 Section 4.02 Leadership 10 Section 4 03 Clinical Services 11

ARTICLE V. MEDICAL STAFF COMMITTEES 13

Section 5.01 General 13 Section 5.02 Medical Executive Committee (MEC) 13 Section 5.03 Committees of the Medical Staff 16 Section 5.04 Committee Records and Minutes 24 Section 5.05 Establishment of Committees 24

ARTICLE VI. MEDICAL STAFF MEETINGS 24

ARTICLE VII. APPOINTMENT AND ONGOING CREDENTIALING 25

Section 7.01 General Provisions 25 Section 7.02 Application Procedures 28 Section 7.03 Process and Terms of Appointment * 31 Section 7.04 Credentials Evaluation and Maintenance 32 Section 7.05 Local/VISN-Level Compensation Panels 33

ARTICLE VIII. CLINICAL PRIVILEGES 34

Section 8.01 General Provisions 34 Section 8.02 Process and Requirements for Requesting Clinical Privileges 35 Section 8.03 Process and Requirement for Requesting Renewal of Clinical Privileges 36

Section 8.04 Processing an Increase or Modification of Privileges* 38

Section 8.05 Recommendations and Approval for Initial/Renewal, Modification/Revision of Clinical Privileges* 38 Section 8.06 Exceptions 39 Section 8.07 Medical Assessment 44

ARTICLE IX. INVESTIGATION, SUMMARY SUSPENSION AND PRIVILEGING

ACTION* 44

Section 9.01 44

ARTICLE X. FAIR HEARING AND APPELLATE REVIEW * 52

Section 10.01 Reduction of Privileges 52 Section 10.02 Revocation of Privileges 55

ARTICLE XI. RULES AND REGULATIONS 57

ARTICLE XII. AMENDMENTS 57

ARTICLE XIII. ADOPTION 58

1. GENERAL 59

2. PATIENT RIGHTS 59

3. RESPONSIBILITY FOR CARE 61

4. PHYSICIANS' ORDERS 65

5. ROLE OF ATTENDING STAFF 67

6. MEDICAL RECORDS 68

7. INFECTION CONTROL 72

8. CONTINUING EDUCATION 72

9. HEALTH STATUS AND IMPAIRED PROFESSIONAL PROGRAM 72

10. PEER REVIEW 73

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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 Robert J Dole VA Medical Center in Wichita, Kansas (hereinafter sometimes referred to as RJD VA, 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.

RJD VA Medical Center is a full-service medical facility comprising comprehensive inpatient and outpatient care.

DEFINITIONS

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

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

2. 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.

3. Associate Director Patient Care Services (Nurse Executive): The Nurse Executive is a registered nurse who is responsible for overseeing the nursing practice of all nursing staff within the facility and supervision of nursing service. S/he is the Chairperson of the Nurse Practice Council (NPC) and acts as full assistant to the Director in the efficient management of clinical and patient care services. S/he is responsible for the active maintenance of credentialing and privileging system for relevant Advance Practice Professional and credentialing certain associated health staff and in ensuring the ongoing education of the nursing staff.

4. 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: Pharmacists (PharmDs), psychologists, podiatrists, audiologists, physical therapists, occupational therapists, chiropractors, and optometrists. Associated Health Professionals function under either defined clinical privileges or a defined scope of practice.

5. Automatic Suspension of Privileges: Suspensions that are automatically enacted whenever the defined indication occurs, and do not require discussion or investigation.

Reactivation must be endorsed by the Medical Executive Committee (MEC).

Suspensions that are automatically (administratively) enacted whenever the defined indication occurs which warrants a suspension of privileges, and does not require discussion, investigation of clinical care concerns, or result from concern of substandard care, professional misconduct, or professional incompetence. Examples are exceeding the allowed medical record delinquency rate when such delinquency does not impact patient care, conduct/behavior issues not impacting patient care or failure to maintain qualifications for appointment, extended sick leave, or other extended leave. Privileges are automatically suspended until the cause of the suspension has been addressed such as the records are completed, or the delinquency rate falls to an acceptable level or provider returns to duty. Reactivation must be endorsed by the MEC that serves as the executive committee of the medical staff 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.

6. Chief of Staff: The Chief of Staff is the Chairperson 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.

7. 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.

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

9. Medical Center Director (MCD): The MCD (sometimes called Chief Executive Officer) is appointed by the Governing Body to act as its agent in the overall management of the Facility. The Director is assisted by the Chief of Staff (COS), the

Associate Director (AD), the Associate Director for Patient Care Services (ADPCS), and the Medical Executive Committee.

10. 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.

11. Licensed Independent Practitioner: The term Licensed Independent Practitioner (LIP) refers to any individual permitted by law and by the RJD VA to provide care and services, without direction or supervision, within the scope of the individual’s license and consistent with individually granted privileges. In this organization, this includes physicians, dentists, optometrists, podiatrist, clinical psychologist, chiropractors, and advanced practice registered nurses (APRN) (to include certified nurse practitioners (CNP), certified nurse midwives (CNM), and certified nurse specialist (CNS)). 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 the 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.

12. Advanced Practice Professionals: Advanced Practice Professionals (APPs) are those health care professionals who are not Licensed Independent Practitioners (LIP) as defined in section 11, and include physician assistants (PA), certified registered nurse anesthetist (CRNA), social worker, audiologist, speech pathologist, and clinical pharmacy specialist. They will function within their approved Scope of Practice.

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

13. Medical Staff: The body of all physicians, dentists, optometrists, podiatrists, APRNs, PAs, CRNAs, clinical pharmacy specialists and psychologists holding unrestricted licenses, who are privileged to attend patients in the health care facility.

The medical staff is organized into service lines and function under their respective Chiefs of Clinical Services who serve under the Chief of Staff and are subject to the medical staff bylaws.

14. Nurse Executive: The Nurse Executive is a registered nurse who is responsible for the full-time, direct supervision of nursing services and who meets licensing requirements as defined by Title 38. S/he 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 staff and in ensuring the ongoing education of the nursing staff.

15. Organized Medical Staff: The body of all physicians, dentists, optometrists, podiatrists, APRNs, PAs, CRNAs, clinical pharmacy specialists and psychologists are collectively responsible for adopting and amending medical staff bylaws (group has 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.

16. Outpatient Clinic: An outpatient clinic is a healthcare site whose location is within the facility or independent of the medical facility whose oversight is assigned to the medical facility.

17. 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.

18. 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.

19. 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, etc. to another Practitioner to ensure appropriate, timely, and effective patient care, the action constitutes supervision.

20. Medical Professional Standards Board: The Medical Professional Standards Board may act as a Credentials Committee on credentialing and clinical privileging matters of the Medical Staff, making recommendation on such matter to the Executive Committee of the Medical Staff as defined in these bylaws. This board may also act on matters involving associated health and Advanced Practice Professionals, such as granting prescriptive authority, scope of practice, and appointment. Some professional standards boards (e.g.

Nursing, etc.) are responsible for advancement and other issues related to their respective professions.

21. 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.

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.

23. Telemedicine: The provision of care by a licensed independent health care provider that directs, diagnoses, or otherwise provides clinical treatment delivered using electronic communications and information technology when distance separates the provider and the patient. This includes care provided at contracted satellite clinics.

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 I. NAME

The name of this organization shall be the Medical Staff of the Department of Veterans Affairs, RJD VAMC.

ARTICLE II. PURPOSE

The Medical Staff shall:

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 shall receive the same standard of care regardless of location.

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 to residents and students of affiliated training programs and assure that educational/supervising standards are adhered to.

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 so that practice goals are achieved to provide quality care to the patients.

Each Advanced Practice Professional and appropriate associated health practitioner should have a scope of practice 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, individuals as defined in item 11 of Definitions above.

2. Categories of the Medical Staff: Categories of membership are defined as active, associate, full-time, part-time, consulting, attending, on-station – fee basis, and on-station – contract. Distinction must be made as to which category has a vote. Medical staff membership requires appointment.

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.

b. Education applicable to individual Medical Staff members, 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:

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

(1) Physicians

(2) Dentists

(3) Podiatrists

(4) Optometrists

(5) Clinical Psychologists

(6) Chiropractors

(7) Advanced Practice Registered Nurses (to include CNP, CNM, and CNS)

b. The following Practitioners will be credentialed, and practice as defined by their scope of practice with appropriate supervision:

(1) CRNA

(2) Physicians Assistants

(3) Clinical Pharmacy Specialist

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

(1) Audiologists

(2) Speech Pathologists

(3) Licensed Clinical Social Workers

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, and intermittent):

(1) 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. Any changes in the status of professional credentials, such as, but not limited to, loss of licensure, clinical privileges, or certification, as well as any pending or proposed action against a credential, such as, but not limited to, licensure, clinical privileges, certification, professional organization or society as soon as able, but no longer than 15 days after notification of the practitioner.

Section 3.03 Code of Conduct

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

2635, not asking for or accepting any gift, tip, entertainment, loan, or favor, or anything of monetary value for oneself or any member of one’s family from any person or organization that is seeking or has a business or financial relationship with the VA to avoid the appearance that one’s official actions might be influenced by such gifts.

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

3. 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 MEC into the potential underlying causes of such behavior. Behavior by a provider that is disruptive could be grounds for disciplinary action.

4. 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.

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

6. 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 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. RJD VA medical center leadership will 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 that 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. The Facility may wish to review the information 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

2. Qualifications: The Chief of Staff must possess the clinical and administrative competencies required to discharge the duties of the position, as well as the requisite knowledge and skill to oversee the research and educational missions of the RJD

VAMC.

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.

http://www.diversity.hr.va.gov/index.asp

5. Duties:

a. Chief of Staff serves as Chairperson of the Medical Executive Committee and exercises oversight over all activities under the purview of that committee.

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 annual basis.

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

e. Define and/or develop clinical privilege statements including levels (or categories) of care that include all requirements of VHA Directive 1100.21(1).

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 Medical Executive Committee.

3. Deputy Chief of Staff, or Associate Chief of Staff, or Clinical Service Chief: All are appointed by the Director based upon the recommendation of the Chief of Staff.

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

b. Clinically related activities of the Service.

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

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

Service who have delineated clinical privileges through FPPE/OPPE.

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

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

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

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

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

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

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

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 the date of review 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. When instructed by the Chief of Staff, Committee voting may be conducted electronically.

4. The presence of 50% + 1 of a committee's members will constitute a quorum.

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

6. The Chair of each committee is appointed by the Chief of Staff, unless otherwise set forth in these Bylaws.

7. Robert's Rules of Order will govern all committee meetings.

Section 5.02 Medical Executive Committee (MEC)

1. Characteristics: The Medical Executive Committee serves as the Executive Committee of the Medical Staff. The voting members of the Medical Executive Committee are:

a. Chief of Staff, Chairperson

b. Deputy Chief of Staff

c. Associate Chiefs of Staff (Medicine, Mental Health, Surgery, Primary Care)

d. Clinical Service Chiefs (Pharmacy, Radiology, Pathology, Dental, Anesthesia, Hospitalist, Emergency Medicine, GEC, PM&R, Laboratory Medicine).

e. Associate Chief of Staff, Research

f. Associate Chief of Staff, Education

g. Chief of Quality Management

h. ADPCS, Nurse Executive

i. Director, or designee, ex-officio, non-voting, as appropriate.

j. Other facility staff may be called upon to serve as resources or attend committee meetings at the request of the chairperson, with or without vote. 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.

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

l. Selection process for membership: Clinical Service Leaders

m. Removal process for membership: Staff leaves position.

2. Functions of 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.

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 communication between the Medical Staff and the Director.

d. Makes recommendations directly to the Director regarding the:

(1) Organization, membership (to include termination), structure, and function of the

Medical Staff.

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

(3) Delineation of privileges for each practitioner credentialed.

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

f. Oversees process for addressing instances of “for-cause” concern (such as 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 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 as and carries out the function of the Physician Standards Board, which includes the evaluation of physical and mental fitness of all medical staff upon referral by the Occupational Health Physician. The Physician Standards Board may have the same membership as the local Physician 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.

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

o. Bi-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 ten times per year. The date and time of the meetings shall be established by the Chair for the convenience of the greatest number of members of the Committee. The Chairmen of the various committees of the Medical Staff shall attend regular meetings of the MEC when necessary to report the activities and recommendations of their committees. Such attendance shall not entitle the attendee to vote on any matter before the MEC.

b. Emergency Meetings: Emergency meetings of the MEC may be called by the Chief of Staff to address any issue which requires action of the Committee prior to a regular meeting. The agenda for any emergency meeting shall be limited to the specific issue for which the meeting was called, and no other business may be taken up at an emergency meeting. In the event that the Chief of Staff is not available to call an emergency meeting of the MEC, the Director as the Governing Body or Acting Chief of Staff, acting for the Chief of Staff, may call an emergency meeting of the Committee.

c. Meeting Notice: All MEC members shall be provided at least 14 days advance written notice of the time, date, and place of each regular meeting and reasonable notice, oral or written, of each emergency meeting.

d. Agenda: The Chief of Staff, or in his absence, such other person as provided by these Bylaws, shall chair meetings of the MEC. The Chair shall establish the agenda for all meetings and a written agenda shall be prepared and distributed prior to committee meetings.

e. Quorum: A quorum for the conduct of business at any regular or emergency meeting of the MEC shall be a majority of the voting members of the committee, unless otherwise provided in these Bylaws. Action may be taken by majority vote at any meeting at which a quorum is present. The majority of the voting members must be fully licensed physicians of medicine or osteopathy.

f. Minutes: Written minutes shall be made and kept on all meetings of the MEC and shall be open to inspection by Practitioners who hold membership or privileges on the Medical Staff.

g. Communication of Action: The Chair at a meeting of the MEC at which action is taken shall be responsible for communicating such action to any person who is directly affected by it.

Section 5.03 Committees of the Medical Staff

1. The following Standing Committees hereby are established for the purpose of (a) evaluating and improving the quality of health care rendered, (b) reducing morbidity or mortality from any cause or condition, (c) establishing and enforcing guidelines designed to keep the cost of health care within reasonable bounds, (d) reviewing the professional qualifications of applicants for medical staff membership, (e) reviewing the activities of the Medical Staff and Advanced Practice Professionals and Associated health Practitioners (f) reporting variances to accepted standards of clinical performance by, and in some cases to, individual Practitioners and (g) for such additional purposes as may be set forth in the charges to each committee:

2. Information Flow to MEC: All Medical Staff Committees, including but not limited to those listed below, will submit minutes of all meetings to the MEC in a timely fashion after the minutes are approved and will submit such other reports and documents as required and/or requested by the MEC.

a. Medical Professional Standards Board:

(1) Charge: The Medical Professional Standards Board (MPSB) is an extension of the MEC and functions as Credentials Committee. The MPSB is subject to the review and evaluation by the MEC as a whole.

(2) Composition: MPSB is comprised of the following:

(a) Chief of Staff (Chair)

(b) Deputy Chief of Staff

(c) Associate Chief of Staff, Primary Care

(d) Associate Chief of Staff, Mental Health

(e) Associate Chief of Staff, Medicine

(f) Associate Chief of Staff, Surgery

(g) Chief, Geriatrics & Extended Care

(h) Chief, Emergency Department

(i) Chief, Dental Service

(j) Chief, Radiology Service

(k) Chief, Pathology & Laboratory Medicine Service

(l) Chief, Anesthesia Service

(m) Chief, Physical Medicine & Rehabilitation Service

(n) Associate Chief of Staff, Research & Education

(o) Chief of Pharmacy or Clinical Pharmacy Specialist Designee

(p) Chief, Quality Management

(q) Credentialing Supervisor (non-voting)

(r) Other attendees such as APRNs and PAs depending on staff being considered.

(3) Meetings: At the call of the Chairperson or alternate.

b. Pharmacy and Therapeutics Committee:

(1) Charge: Recommend professional policies regarding evaluation, selection, procurement, distribution, use, safe practices, and other matters pertinent to pharmaceuticals; recommend programs designed to meet the needs of the professional staff of the Facility for complete current information on matters related to pharmaceuticals and current pharmaceutical practices.

(2) Composition: Members of Medical, Nursing, Pharmacy, and Administrative Staff.

(3) Meetings: At least six times a year at a minimum and at least every other month.

c. Peer Review Committee:

(1) Charge: The Robert J. Dole VA Peer Review Committee serves to review and evaluate the quality of care and services provided by health care professionals in a non-disciplinary educational manner. Protected peer reviews involve members of the health care staff in activities to measure, assess and improve performance and utilization of resources on an organization-wide basis. Authority for protected peer reviews is found in Title 38 U.S.C. 5705, entitled Confidentiality of Medical Quality Assurance Records and its implementing regulations. VHA Directive 2004-051 “Quality Management (QM) and Patient Safety Activities That Can Generate Confidential Documents” provides detailed guidance.

(2) Composition: Peer Review Committee is comprised of the following:

(a) Chief of Staff (Chair)

(b) Associate Director of Patient Care Services, Nurse Executive (Co-Chair)

(c) Associate Chief of Staff, Medicine

(d) Associate Chief of Staff, Mental Health Service

(e) Associate Chief of Staff, Primary Care Service

(f) Associate Chief of Staff, Surgery

(g) Chief, Hospitalist

(h) Chief, Emergency Care

(i) Chief, Anesthesia Service

(j) Quality Management Officer

(k) Ad-Hoc Attendees designated by COS dependent on the peer review cases to be discussed at a meeting to achieve appropriate peer input

(l) Risk Manager will attend as the Risk Management Staff Consultant

(m) Peer Review Coordinator will attend as Peer Review Consultant

(3). Meetings: The Peer Review Committee will meet a minimum of quarterly and more often as the need is identified.

d. Surgical Workgroup (SWG)

(1) Charge: To discuss and review operative mortalities and morbidities for the

Department of Surgery and to assist medical staff in reviewing/identifying quality of care issues regarding patient outcomes and resource needs pertaining to in-patient/out-patient operative and invasive procedures done in the operating suites, ambulatory day surgery, endoscopy suites, Dental, and Emergency Room. Surgical Invasive and Operative Procedures and Surgical Morbidity and Mortality reviews will also be conducted. The committee will review the procedures any adverse outcomes to make appropriate recommendations to the Peer Review Committee and MEC.

(2) Composition: Surgical Workgroup (SWG) is comprised of the following:

(a) Chief of Surgery

(b) Chief of Staff

(c) Surgical Quality Nurses

(d) OR Nurse Managers

(3) Meetings: Monthly or more frequently as needed.

e. Medical Invasive and Operative Procedure Committee:

(1) Charge: To review/identifying quality of care issues regarding patient outcomes and resource needs pertaining to in-patient/out-patient invasive procedures done in the cardiac catheterization laboratory, interventional radiology, in-patient treatment areas (ICU, ER, 3rd floor) etc. The committee will review the procedures, adverse outcome if any and will also review the mortality statistics. It will make appropriate recommendations to the MEC (MEC).

(2) Composition:

(a) Associate Chief of Staff, Medicine Services, Chairperson

(b) Chief, Cardiology Section

(c) Medical Director, Cardiac…