Exhibit N - NCR Standardized Medical Staff Bylaws.pdf

Exhibit N – NCR Standardized Medical ByLaws

National Capital Region Market

Standardized Medical Staff Bylaws

Chapter 1

Introduction

1-1. Purpose

These Bylaws represent a framework for self-governance of the medical staff. The medical staff comprises all health care providers, including physicians, nurse practitioners, physician associates/assistants (PAs) and dentists, who are actively privileged to make independent decisions in the delivery of medical care at all market Military Treatment Facilities (MTFs) and Dental Treatment Facilities (DTFs). It prescribes policies, procedures, roles, and responsibilities by which the Defense Health Agency National Capital Region (NCR) Market medical staff comply with the requirements of the United States Government and The Joint Commission. These requirements include federal and state law, correspondence and documents published by the NCR market, Defense Health Agency (DHA), Department of Defense (DoD), and the current edition of Joint Commission accreditation standards. It describes the medical staff’s collaborative relationship with and accountability to the governing body in providing safe, effective, and high-quality patient care. These bylaws will be adopted by each MTF/DTF, and will not be modified, and serves in place of individual MTF/DTF Bylaws. They have been standardized across the NCR market so that medical staff are held to the same standards consistently across the NCR market and to increase the efficiency and agility of providers in the provision of care.

1-2. References

a. Defense Health Agency Procedures Manuals, 6025.13 Clinical Quality Management (CQM) in the Military Health System (MHS):

(1) Volume 1: General Clinical Quality Management - The purpose of CQM in the MHS is to provide an organized structure for an integrated framework of programs to objectively define, measure, assure, and improve the quality of care received by MHS beneficiaries. The framework is guided by CQM strategy elements and supported by CQM functions and programs. Through CQM, the MHS affirms its unwavering commitment to quality healthcare for beneficiaries, joint healthcare teams, and Combatant Commands across the globe.

(2) Volume 2: Patient Safety - MHS program to promote safety and prevent harm.

(3) Volume 3: Healthcare Risk Management - MHS program to mitigate risk in the clinical aspects of healthcare delivery.

(4) Volume 4: Credentialing and Privileging (CP)- MHS program to ensure qualified and competent staff.

ATAMMC PWS Exhibit N NCR Standardized Medical Staff Bylaws

(5) Volume 5: Accreditation and Compliance - MHS program to ensure compliance with standards.

(6) Volume 6: Clinical Measurement - MHS program to objectively define, measure, assess, and report the quality of care delivered.

(7) Volume 7: Clinical Quality Improvement - MHS program to improve the quality of care and services delivered.

b. DoD Instruction 6025.13, Medical Quality Assurance (MQA) and Clinical Quality Management in the MHS, February 17, 2011, as amended.

c. DoD Manual 6025.13, Medical Quality Assurance (MQA) and Clinical Quality Management in the Military Health System (MHS), July 1, 2020.

1-3. Explanation of abbreviations and terms

Abbreviations used in this regulation are defined in the glossary.

1-4. Applicability of the Medical Staff Bylaws

a. These bylaws apply to all military, civilian, contracted and volunteer licensed independent providers (LIPs) and medical staff privileged to practice at Military Treatment Facilities (MTFs) and Dental Treatment Facilities (DTFs) in the DHA-NCR Market. All members of the medical staff meeting these criteria are responsible for reviewing and understanding the rules and regulations referenced in this Instruction and agreeing in writing to abide by them. The guidelines for the Governing Body and Medical Staff Bylaws will be adhered to by all members of the DHA- NCR Market medical staff. The MTF Privileging Authorities along with their designees (i.e., board of directors, chief of staff, etc.), serve as the hospital governing body in accordance with (IAW) reference (f), and upholds and approves these medical bylaws.

(Throughout this document the term MTF refers to both MTFs and DTFs.)

b. The medical staff has the following characteristics.

(1) It includes all Licensed Independent Practitioners (LIPs). LIPs are any individual permitted by law and by the organization to provide care, treatment, and services, without direction or supervision, and within the scope of the individual's license and consistent with individually granted clinical privileges. This document also pertains to privileged practitioners including all physicians, dentists, advanced practice registered nurses, PAs, and allied health practitioners who are eligible for independent clinical privileges.

(2) All medical staff members have delineated clinical privileges that define the scope of patient care services that they may provide independently in the MTF.

(3) All practitioners with delineated clinical privileges are subject to medical staff bylaws, rules, and regulations, as well as MTF, departmental, and clinic policies.

Chapter 2

Scope and Core Responsibilities

Below is a summary of responsibilities for specific positions, this is not all inclusive; for more details regarding specific roles and responsibilities for each position of the CQM please see DHA Procedures Manuals (PM), 6025.13 Clinical Quality Management in the Military Health System

– Volumes 1 through 7 Aug 29, 2019.

2-1. Medical Staff

a. Individual MTF medical staff are responsible for the quality of medical care within their MTFs. As outlined in these rules and regulations, members of the medical staff practicing within DHA-NCR Market accept and assume this responsibility and are accountable to the MTF governing bodies and are subject to the authority of the MTF Privileging Authorities.

(1) Mission: To create a fully integrated National Capital Region Market to provide high quality, high-value healthcare that is responsive and respectful of the needs and choices of our beneficiaries and employees.

(2) Vision: The NCR Market becomes the integrated healthcare delivery system of choice for all beneficiaries whom we are privileged to serve.

(3) Values: Teamwork, transparency, accountability, efficiency, evidenced-based, compassionate, empathetic, customer-focused, and trustworthy.

b. The standards described herein define the roles and responsibilities of privileged practitioners providing care for patients in the MTFs of the DHA-NCR Market. MTF policies and those of individual services or sections will not conflict with these standards. These standards follow relevant DoD, DHA, and NCR Market regulations and policies.

2-2. MTF Director / Privileging Authority

a. Maintains overall responsibility for medical staff and is responsible for the execution of CQM in their organization.

b. Issues local credentials review and privileging directives as appropriate.

c. Directs a healthcare provider to be removed from direct patient care, in accordance with the due process procedures outlined in the DHA-PM 6025.13, when a provider’s suspected misconduct, impairment, incompetence, or any other conduct might adversely affect the health or welfare of a patient or staff member.

2-3. MTF Chief of the Medical Staff or Military Department Chief of the Medical Staff designee (descriptive term, role may also be known as the Deputy Commander for Clinical Services (DCCS), Deputy for Clinical Services (DCS), Chief Medical Officer (CMO), SGH- Chief of the Medical Staff, Medical Executive Committee Chair, or other titles for similar responsibilities).

a. Must be a privileged physician holding an active appointment to the medical staff.

b. Shall be the principal executive staff advisor to the Privileging Authority/Director concerning matters of healthcare provider management directives, quality, and scope of medical care.

c. Has oversight of professional staff management and professional practice review.

2-4. Clinical Directors/Department Heads (descriptive term, role may also be known as Medical Director, Department Chief, Clinical Service Chief, or other title for similar responsibilities).

a. Brief all healthcare providers applying for a medical staff appointment with clinical privileges within their department on the MTF local Credentialing and Privileging (CP) Program and on department or clinic specific processes and requirements.

b. Continuously monitor the professional clinical performance, conduct, and health status of department staff members to ensure they provide safe healthcare services consistent with their clinical privileges and responsibilities. Monitor CQM and medical staff activities for providers assigned to their department and ensure Ongoing Professional Performance Evaluations (OPPE) and Focused Professional Performance Evaluation (FPPE) for all providers under their supervisory leadership are conducted in accordance with DHA-PM 6025.13. Coordinate with the Medical Staff Professional/Medical Staff Manager (MSM) to ensure FPPE monitoring, and evaluation plans are implemented and completed appropriately for new providers and other circumstances in accordance with these bylaws. Review OPPE data no less than every six months for opportunities to learn and improve the safety and quality of care, and to recognize unfavorable performance trends.

c. Maintain approved medical staff appointments with delineated clinical privileges on privileged providers assigned to their departments. Ensure providers’ privileging information is readily available to organizational healthcare personnel as appropriate.

d. Ensure non-privileged providers, clinical support staff, and other personnel providing healthcare services in the department receive appropriate clinical supervision.

e. Maintain approved medical staff appointments with delineated clinical privileges on providers assigned to their departments. Ensure providers’ privileging information is readily available to organizational healthcare personnel as appropriate.

f. At intervals not to exceed 12 months, assess the facility-specific market product line, department or service resources, and limitations. Recommend departmental, specialty, and service-specific credentials and privileging criteria for staff appointment and reappointment.

g. Make recommendations for medical staff appointment with clinical privileges based on the applicant's professional qualifications, health status (ability to perform), and current competence.

h. Use provider-specific results of CQM peer review activities when making recommendations for medical staff appointments with clinical privileges.

i. Monitor the CP Program for all healthcare providers within their departments. Coordinate with relevant senior clinical leadership as appropriate (e.g., Senior Nurse Executive, Senior Enlisted Advisor).

2-5. Medical Staff Professional/Medical Staff Manager (formerly known as Credentials Manager)

a. Reports to the Director for Quality/Chief Quality Officer, Surgeon General of the Hospital (SGH), DCCS, Chief of the Medical Staff or equivalent based on MTF organizational structure.

b. Serves as the technical advisor to the Director for Quality or equivalent, Privileging Authority, Credentials Committee/Function Chairperson, and assigned providers on issues related to the CP Program.

c. Provides technical management, verification, and assessments regarding credentials information; processes privileging and medical staff appointment applications; and monitors and tracks licensure, certification, and registration status for all privileged providers, and for all non-privileged providers as directed by the Chief of the Medical Staff.

d. Provides ongoing Joint Centralized Credentialing and Quality Assurance System (JCCQAS) reports on expiring credentials (at a minimum quarterly), to the Chief of the Medical Staff and Credentials Committee/Function. Provides quarterly reports of the number of privileged providers at their facility who are actively practicing at that location.

2-6. Medical Staff (Licensed Independent Practitioners and all other Privileged Providers)

a. The primary mechanism for effective communication among the medical staff, MTF administration and governing body is by use of electronic mail systems. All staff members should read their assigned government email (i.e., Outlook) at least once per duty day. This is considered a routine route of communication within the MTF. As such, all staff members are responsible for knowing the relevant information that is distributed via this medium.

b. Staff members who desire not to participate in an aspect of care or treatment, due to cultural or religious beliefs, will discuss their decision with their immediate supervisor or department leadership and notify them prior to starting clinical practice.

c. All MTF staff, patients, and visitors will be treated with dignity, respect, and courtesy. The

NCR Market does not tolerate discrimination of any kind to any patient or staff member as per DHA-PI 6025.02, “Nondiscrimination in MHS Health Programs and Activities.” Disruptive behavior will not be tolerated within any MTF of this organization. Disruptive behavior is unprofessional and may be grounds for adverse privileging actions and/or other administrative actions. This includes but is not limited to shouting or rude/demeaning behavior; sexual harassment; profanity; throwing objects; destruction of government property; pushing, shoving, or engaging in acts of overt intimidation to patients or staff.

d. Release of patient information will only be accomplished in accordance with existing laws, rules, directives, instructions, Health Insurance Portability and Accountability Act (HIPAA) regulations, and Department of Defense guidance.

e. Members of the Medical Staff will comply with the standards of the DoD Privacy Rule, HIPAA, and all other applicable guidance. Providers are obligated to ensure that all electronic health information in any form is protected, so as to prevent improper disclosure. Members of the medical staff will not access the medical records of patients in whom they are not involved in their medical care unless it is indicated in their position for quality/peer review, auditing, or safety purposes (i.e., need to know basis).

f. The DHA has deployed Secure Messaging (SM) to be used by health care provider teams for electronic communication with beneficiaries and colleagues. SM provides patients a secure method to electronically communicate with their provider. In accordance with the DoD Privacy Rule and HIPAA guidelines, access to SM is limited to the patient and healthcare members with a ''need to know." Please refer to applicable MTF instructions for SM Operations, for details on roles, responsibilities, and etiquette for its application to patient care.

g. Medical Staff will adhere to all guidelines for the use and documentation of patient-provider email according to approved DoD mechanisms and guidelines as per DHA-PI 8140.01, “Acceptable Use of DHA Information Technology (IT)”, and DHA-PM 6025.02, Volume 1, “DoD Health Record Lifecycle Management, Volume 1: General Principles, Custody and Control, and Inpatient Records.”

h. Email communications that contain health consultations will be captured and recorded in the patient's medical record as per DHA-PM 6025.02, Volume 1, page 49.

Chapter 3

Policy

3-1. Conflicts of Interest

a. Requirements concerning conflicts of interest and other standards of conduct applying to active-duty members and other government employees or contracted health care providers are specified in the DoD 5500.7 Joint Ethics Regulation (JER).

b. This regulation provides that military providers, civilian employees, and contract personnel may not suggest to anyone authorized to receive health care services at DoD expense that they should receive health services from the member when he/she is not on duty (i.e., off duty employment), or from a civilian associated or in practice with the member.

c. Active-duty members and full-time civilian employees may not be personally reimbursed for health care provided to anyone authorized health care from any federal program.

d. Additionally, leadership and key supervisors are required to file annual financial declaration statements that are reviewed by their supervisors and the MTF ethics counselor.

3-2. Conflict Resolution

a. Military organizations have a chain of command that has inherent decisional authority which can assist in the resolution of conflicts.

b. The MTF’s committee structure and the rules and regulations governing civilian personnel grievances also provide avenues for conflict resolution.

c. Conflicts involving critical aspects of patient care and treatment are referred to the MTF Ethics Committee for resolution. If the MTF does not have an Ethics Committee established, contact the NCR Market Ethics Chair, or the Chief Medical Officer for further guidance.

d. Further information on Healthcare Resolutions, Disclosure, Clinical Conflict Management, and Provider Resiliency can be found in DHA-PI 6025.17.

3-3. Personal Conduct

Personal conduct is a strong reflection of professional demeanor and pride in oneself and one’s vocation. In addition to the statements appearing below, all staff members will conduct themselves professionally and according to their MTF’s personnel conduct policies. Evaluations of professional performance will reflect these standards. The NCR Market supports an environment of Just Culture, recognizing that individuals can make mistakes and those mistakes can be an opportunity to evaluate system and process risk and behavior risk to improve patient care and provider performance.

a. Reliability: All staff members must report for work on time to facilitate scheduled patient care. Repetitive late arrival by staff members compromises access to care and patient satisfaction.

It is vital for every staff member to have a reliable presence in their assigned clinic, unit, or division, to meet access to care standards and fulfill their designated clinical full time equivalent (FTE) benchmarks (FTE deductions for assigned roles can be referenced in DHA Memorandum March 25, 2022: “New Standardized Deductions for Primary Care, Specialty Care, Graduate Medical Education, Graduate Health Education, and Inpatient Care”). All staff members are encouraged to take full advantage of earned leave. The supervisor will reserve leave without pay for special circumstances and emergency use only. Each staff member should notify his or her supervisor as soon as possible if he or she cannot be present for duty when expected. Members of the medical staff must designate a surrogate provider to review patient laboratory results, radiology results, and patient telephone consults when they are absent during normal duty days, as per DHA- PI 6025.28, “Standard Processes and Procedures for Communication of Laboratory and Radiology Results.”

b. Teamwork: Every staff member is important to the team. Respect, compassion, and a “can-do” attitude in support of colleagues contribute significantly to organizational success.

c. Supervision: All staff members should respect the supervisory chain of command. It is important to maintain an open mind while receiving criticism and praise with equal priority.

Supervisors must treat all their subordinates with respect and preserve their dignity and trust.

Supervisors are required to provide timely feedback to subordinates (positive or negative), particularly when there is concern for a staff member’s performance or professionalism.

d. Job knowledge: All staff members should remain current in their respective fields. Job performance is an indicator of knowledge, training, and skill. All staff members must meet or exceed the requirements for continuing medical education as required by their specialty or required for continued licensure or board certification.

e. Job accomplishment: Each staff member should provide the clinic with his or her best effort during working hours. Our patients and their families rely on timely, professional attention.

f. Attitude: Provider attitude is a strong reflection of professional character. Assume responsibility and accountability for your actions.

g. Safety: All staff members must remain aware of situations that may compromise the safety of patients or fellow staff. Staff members should report immediately any threat or potential threat to safety and should be aware of how to notify the hospital or clinic of an emergency such as a fire, medical code, or patient abduction. If staff members have concerns about another provider’s clinical safety due to medical judgement, knowledge, or due to a health reason, the staff member must report this concern to their supervisor or department Chief, and/or refer the provider of concern to the Provider Wellness Program/Impaired Healthcare Provider Program (IHPP). This includes if a staff member is suspected of abusing substances such as alcohol or other drugs.

h. Appearance: All staff members will wear clean, appropriately professional clothing and observe good personal hygiene. Active-duty service members shall comply with any Service-specific dress and appearance requirements. A white coat or approved clinic jacket must be worn over surgical scrubs outside of the operating or procedure room. If a staff member’s scrubs are visibly soiled, they must be changed. Shoes worn in the operating room must not be the same shoes used outside of the MTF and must be covered with surgical shoe covers while in the surgical suite.

i. Communication: The success of the MTF and department depends upon open lines of communication. Supervisors will communicate policies, activities, announcements, procedures, and associated changes to all their staff members. Staff members are expected to communicate comments and suggestions through their supervisory chains. When a staff member perceives that their immediate supervisor is not effectively addressing his or her concerns, the staff member should request a meeting with the department or service chief, or their next level supervisor in the chain of command if the problem cannot be resolved by escalating through their chain of command. Providers are expected to answer their pagers or duty phones while on duty in a timely manner. Failure to do so could result in adverse privileging actions or other administrative actions.

If a provider is not immediately available, a surrogate provider should be designated. Members of the medical staff are expected to keep their contact information up to date so they may be reached in case of an emergency (i.e., phone number, mailing address).

j. Conflicts of interest: All members of the medical staff will always act professionally and fairly without prejudice or favoritism. Under no circumstances will providers act in such a manner as to gain a financial, material, or other advantage during his or her duties. If questions arise concerning a potential conflict of interest, providers should seek guidance through their chains of command and the Office of the Staff Judge Advocate.

k. Peer Review: All members of the medical staff are expected to conduct peer review at least quarterly. The number of records reviewed may vary by specialty. Failure to do so may result in loss of renewal of staff privileges.

l. Just Culture: The NCR Market supports an environment of Just Culture, recognizing that providers should not be held accountable for system failures over which they have no control. The NCR Market supports a culture of fairness, openness, and learning. Providers and staff are encouraged to be open about mistakes to support colleagues and foster improvement with lessons learned.

3-4. “ON CALL” PROVIDERS

An on-call provider covers a particular service, specialty, or clinic for a designated period, during which they are expected to be immediately available for consultation, patient care, or relevant questions. On- call providers must be available by telephone or pager, or via the designated mechanism (duty phone, Vocera, etc.) expected to be carried and answered by the on-call provider.

a. Verbal contact with any consulting service should be made within 15 minutes of initiation either via pager or phone, barring an extenuating circumstance (such as the provider being involved in an urgent or life-threatening procedure). If the provider is not readily available, that provider should have a designated individual (such as the circulating nurse in the operating room) answer the call to explain why the provider is not available and relay the message to the person attempting to contact the provider.

b. Certain specialties may require 24/7 provider in-house coverage based on guidance from the respective department chief and the Board of Directors (BOD)/Executive Committee.

c. It is the responsibility of the department/service chief/medical director to ensure that the on-call roster is updated with the current contact information for the on-call provider, or designated duty phone/pager for any given service. Providers who are on call for duty and identified as required to provide treatment necessary to stabilize an individual with an emergency medical condition must be available to report to the emergency room within a reasonable period of time which shall be set forth by the local MTF.

3-5. Patient Bill of Rights and Responsibilities

a. Patient Rights and organizational ethics are outlined in DHA-PI 6025.10 Oct. 9, 2018, which establishes standard processes and guides implementation of the DoD Patient Bill of Rights and Responsibilities. MTF specific instructions should be published and distributed throughout the MTF.

b. MHS patients have rights pertaining to information disclosure; choice of providers; health plans; access to emergency services; participation in treatment decisions; respect and nondiscrimination; privacy and security of personally identifiable information and protected health information, complaints, and appeals; as well as specific responsibilities to participate in their own health decisions.

c. All competent adult patients have a moral and legal right to participate in their medical care and to refuse medical treatment even in lifesaving or life-sustaining situations.

d. The Command’s awareness of, and involvement in the health care decisions of their assigned Active-Duty members is outlined in the applicable Service regulations and IAW DoD guidance.

e. Any patient who is incapable of understanding health care choices and the risks, benefits and complications associated with such choices may be deemed incapacitated or unable to make health care decisions. The staff physician responsible for the patient will document the clinical basis for incapacity and the name of the patient's surrogate decision maker - either the legal next-of-kin, or a health care agent designated by a validly executed health care power of attorney (POA) and/or advanced medical directive (AMD), a copy of the POA or AMD shall be maintained with the patient’s medical record. If a Court has issued a legal ruling indicating that a patient is incompetent to make health decisions, the staff physician responsible for the patient shall request a copy of the Order from the guardian designating the surrogate decision maker to be maintained with the patient’s medical record.

f. The parent or legal guardian of an un-emancipated minor has the legal right and responsibility to make health care decisions for the minor patient, with the exception of decisions which the minor patient has the right to make without parental involvement as outlined by the State law in which the MTF is located (i.e., substance abuse, behavioral health, reproductive decisions). If the parents of a minor are divorced, recommend maintaining a copy of the Custody Order with the patient’s medical record.

g. All patients have the right to appropriate assessment and management of pain as outlined in DHA-PI 6025.04, “Pain Management and Opioid Safety in the MHS.” Providers will address patient’s pain, and if required, may consult other services to best address their patient’s need.

Providers will identify patients at high risk for overdose and prescribe Naloxone as per DHA-PI 6025.07, “Naloxone in the MTFs.”

h. If a patient presents incapacitated with no surrogate decision maker, the default decision is that the patient would want life, limb, and eyesight saving medical services rendered.

3-6. Governing Body

a. Director, NCR Market.

The NCR Market Director, shall:

(1) Be responsible for the quality of health care delivered to all beneficiaries in the Market.

(2) Be responsible for the execution of CQM in the DHA Market, as per DHA guidance.

(3) Serve as the chief or lead of the governing body (GB)/medical executive board (MEB) for all the market healthcare facilities.

(4) Support Clinical Community clinical quality improvement (CQI) priorities, as per DHA guidance.

(5) Support coordination of CQM activities with clinical service delivery operations to implement highly reliable, high value, patient-centered experiences, and outcomes.

(6) Ensure requests for the release of CQM aggregated statistical data are in accordance with the HIPAA, U.S Code, Title 10 Section 1102, and United States Code Title 5 Section 552a as amended.

(7) Delegate privileging authority to MTF Directors thus making them responsible and accountable for the quality of healthcare provided in their treatment facilities.

b. MTFs’ BOD/Medical Executive Board/Executive Committee (EXCOMS for Air Force).

The MTFs’ BODs/EXCOMS shall:

(1) Serve as the hospital governing bodies at individual MTFs within the NCR Market

(2) Uphold the medical bylaws IAW Joint Commission MS 01.01.01, MS 01.01.03, and MS 02.01.01.

c. MTF Director.

The MTF Director shall:

(1) Be the delegated authority representing the MTF GB at the MEB equivalent level. MTF directors are selected by service selection boards and are assigned to MTFs based on the needs of the military healthcare system, their individual experience level, and their assignment preference.

The MTF Director's assignment orders and assumption of command documents provide written evidence of the legitimacy of this position.

(2) Appoint or assign staff members to committees deemed necessary to conduct MTF business and to properly discharge the GB's responsibilities.

(3) Ensure any changes to MTF instructions are disseminated to the medical staff in a timely manner and that they are made aware of relevant changes. Appropriate MTF instructions will define the MTF governance and committee structure.

(4) Discharge the GB’s role and responsibilities and is responsible for overseeing daily operations of the MTF. The Director may delegate responsibilities to the MTF Chief of the Medical Staff (descriptive term, role may also be known as Chief Medical Officer, SGH, Medical Executive Committee Chair, DCCS or other titles for similar responsibilities) on matters related to the credentialing and privileging of providers, quality and safety, scope of medical care, utilization of professional resources, and medical policy and planning as related to the medical staff.

d. MTF Chief of the Medical Staff (descriptive term, role may also be known as Chief Medical Officer, SGH, Medical Executive Committee Chair, DCCS)

(1) MTF Chief of the Medical Staff (descriptive term, role may also be known as Chief Medical Officer, SGH, Medical Executive Committee Chair, DCCS) shall: Be a privileged physician and board certified with an active appointment to the medical staff as per DHA-PI 6025.13, Volume 3.

(2) Be elected by a vote of the medical staff and/or appointed by the Director/or Service selection process (i.e., SGH or Chief Medical Officer) for no more than three-year term, a portion of which may be served as deputy if applicable (i.e., Executive Committee of Medical Staff (ECOMS)/Medical Executive Committee (MEC) Chair). This member can be extended in the position if approved by the Director. Clinical time offset is granted to allow this provider adequate time to meet the requirements of the position. (FTE deductions for assigned roles can be referenced in DHA Memorandum March 25, 2022: “New Standardized Deductions for Primary Care, Specialty Care, Graduate Medical Education, Graduate Health Education, and Inpatient Care”).

(3) Be the principal executive staff advisor to the Privileging Authority concerning matters of medical quality assurance and CQM, to include the scope of medical care under the respective Privileging Authority and clinical adverse actions.

(4) Be accountable for the Health Risk Management Program, to include clinical adverse action procedures.

(5) Initiate Quality Assurance Investigations (QAI) in coordination with the Healthcare Risk Manager, and in consultation with the servicing healthcare legal counsel.

(6) Chair the Credentials Committee/Function or ensure an appropriate alternate (i.e., physician appointed to the medical staff that is in good standing).

(7) Be authorized to intervene on behalf of the Privileging Authority to immediately summarily suspend a healthcare provider’s privileges/practice if the provider’s conduct adversely affects or could adversely affect the health or welfare of a patient, employee or other individual, until the matter is investigated and resolved in accordance with this manual and DHA instruction.

(8) Collaborate with the Healthcare Risk Manager to communicate summary suspension, and/or hearing notifications on behalf of the Privileging Authority.

(9) Ensure, in coordination with the Healthcare Risk Manager, that providers are informed of their due process rights.

3-7. Clinical Directors/Department Heads (descriptive term, role may also be known as Medical Director, Flight or Squadron Commander, Clinical Service Chief, or other title for similar responsibilities)

a. The selection process for clinical department chiefs is outlined in appropriate MTF instructions. FTE deductions are based upon size of the department and are referenced in DHA’s FTE deduction memorandum.

b. Board certification (or comparable competencies) and doctoral degree are required (when applicable to the position or specialty), and rank (seniority) should be strongly considered.

c. All clinical department chiefs are responsible for managing the clinical and administrative aspects of their departments. These include, but are not limited to:

(1) Making recommendations to the Command Leadership on the type and scope of services that will be offered.

(2) Recommending the number of qualified and competent staff required to provide care, treatment, service, and administrative or ancillary support.

(3) Developing, maintaining, and implementing policies and procedures that guide and support the departmental services.

(4) Determining departmental criteria for granting clinical privileges.

(5) Recommending clinical privileges for departmental healthcare providers and others who request privileges generally overseen by that department.

(6) Monitoring the departmental providers' performance, to include peer-review and performance appraisal reports (PARs) which will be maintained in the provider activity file (PAF) for each privileged provider. The PAF will also include the plan of supervision (if applicable), focused professional performance evaluation (FPPE) and the completion memo (if applicable), the ongoing professional performance evaluations (OPPE), pertinent life support certifications (BLS, ACLS, PALS), continuing medical education credits, and any counseling related to clinical performance. The PAF files are quality assurance documents protected under Title 10 USC 1102.

If there are concerns about a provider’s safety or clinical performance, they must initiate the appropriate investigation and suspension of privileges if indicated. If there are concerns about a provider’s medical health, mental health, or suspicion of substance abuse, they must refer the provider to the Provider Wellness Program as indicated in the market Standard Operating Procedure (SOP) on impaired providers.

(7) Monitoring Off-Duty Employment (ODE) activities of privileged providers. For information on ODE regulations, see National Capital Region Market Standard Operating Procedure for Off Duty Employment and Outside Activities, June 8, 2020. (NCR Market Policies, SOPs, and memorandums) may be found at https://info.health.mil/sites/Markets/ncr/Market_PoliciesMemosSOP/Forms/AllItems.aspx

(8) Assessing and improving departmental quality of care and services.

(9) Assessing and recommending to the Clinical Director's off-site sources (such as transfer of care to a civilian location or transfer to another MTF), for needed patient care, treatment, and services not provided by the MTF.

(10) Integrating their departments into the primary functions of the NCR-Market and

MTF.

(11) Determining the qualifications and competence of non-LIPs who provide patient care, treatment, and services (such as nursing assistants and technicians).

(12) Ensuring orientation of all members of the department to the service and to the MTF, and provision of continuing education (CE).

(13) Ensuring orientation of all members of the department to their roles/responsibilities when the Emergency Operations Plan is initiated.

(14) Ensuring adherence to Equal Opportunity and Diversity Management, and promptly addressing any complaints filed as per DHA-Administrative Instruction (DHA-AI) 101, “Processing Procedures for Complaints Involving Discrimination in the MHS Health Programs and Activities.”

(15) Coordinating departmental space allocation and other resource management.

(16) Ensuring staff cohesion and teamwork including administrative staff and front desk staff.

(17) Understanding the role of the Integrated Referral Management and Appointing Center (IRMAC) as it applies to their specialty and service.

(18) Complying with IRMAC appointing policy.

(19) Coordinating and integrating interdepartmental and intradepartmental services as required.

3-8. Governing Committees

a. The MTF Committee structure is organized into a tiered manner to align MTF functions, communication, and information flow with the organizational strategic mission.

b. The MTF will define the governance structure.

c. The ECOMS or MEC: oversees activities of medical staff and makes key leadership decisions related to medical staff policies, procedures, and rules, with an emphasis on quality control and quality improvement initiatives. The ECOMS (or MEC) includes clinical department chiefs/medical directors (Air Force) or their designee, and selected MTF staff, always maintaining at least 51% of voting members that are fully licensed healthcare providers actively practicing at the MTF. The full charter for the ECOMS (or MEC) is delineated at individual NCR Market MTFs. The responsibilities of ECOMS (or MEC) include:

(1) Reviewing and setting policy for the privileged, professional staff using these bylaws and relevant DHA and service policies.

(2) Implementing and maintaining the most current version of a set of bylaws (this document) that defines the role of the medical staff and clearly delineates its responsibilities in the oversight of care, treatment, and services.

(3) Oversees medical staff membership criteria and delivery of health care rendered by medical staff.

(4) Defining the committee’s function, size, and composition by developing a charter, voted on and approved by the Medical Staff. The charter will delineate a process for selecting and/or electing and removing the medical executive committee members, when and if required.

Additionally, MTF ECOMs/MEC charters will delineate voting membership IAW the Joint Commission MS 01.01.01 and MS 02.01.01.

(5) Serving as an approving body for issues requiring Medical Staff concurrence outside the biannual full medical staff meeting. Carries out medical staff responsibilities and performs its work within the context of the functions of governance, leadership, and performance Improvement.

(6) Has the primary authority for activities related to self-governance of the medical staff and for Performance Improvement of the professional services provided by privileged healthcare providers.

(7) Providing a forum for communication of specific clinical issues or other medical staff concerns.

(8) Integrating and coordinating performance improvement, patient safety, and risk management findings so that opportunities to improve patient care services are identified, acted upon, and reevaluated in a comprehensive manner.

(9) Sharing any best practices or policies implemented with the other NCR Market MTFs.

3-9. Bylaws Adoption and Modification

a. Each MTF/Direct Report Unit will adopt and adhere to these standardized NCR Market bylaws; elements of the bylaws may not be modified by individual MTFs in any way.

b. MTF Medical staff members may forward recommendations for amending the bylaws to the ECOMS (or MEC). A quorum of members must be present to affect a bylaw change.

Recommended changes will be sent to the NCR Market Director via the Assistant Market Director for Medical Affairs/CMO for approval. Changes and copies of revised texts will be sent to all medical staff members electronically and via the department and service chiefs.

c. If there is a change in a regulation or in Joint Commission standards that effect the bylaws, the bylaws will be amended to conform to such change to stay in compliance without any required official amendment procedures, until the next review. An automatic notification to MTFs, CMOs/SGH, and ECOMS will be sent accordingly.

3-10. Security

a. All providers will display the official MHS/MTF identification badge. Any lost badge must be immediately reported to MTF security.

b. The badge will be displayed on the person, so it is easily visible. It may be suspended from the neck; using a lanyard; or clipped to the top left or right shirt or coat lapel, collar, or breast pocket. If fastened to a lab coat, the badge will be fastened to the front left or right side of the collar. The employee’s photograph and identification by name and duty position must be visible at all times.

c. The badge will not be worn:

(1) When it poses a safety hazard, such as when working in certain clinical areas (e.g., operating room, behavioral health, etc.), performing construction work, or when utilizing certain machinery in which the badge might become entangled. However, in such instances, the badge must be in the possession of the individual and visibly displayed when the task or job has been completed.

(2) By individuals actively participating in any type of ceremony; however, they will visibly display their badges after the ceremony has concluded.

d. All members of the medical staff will be responsible for ensuring physical, technologic, and administrative security of facilities, equipment, supplies and electronic information in their respective work area as per DHA-PI 8140.01, “Acceptable Use of Defense Health Agency in IT).”

3-11. Annual Training

All providers will complete annual mandatory training, including HIPAA and Privacy Act trainings, Cyber Awareness, before expiration of the training certificates. Expiration of training certificates, especially HIPAA and computer security training, may result in forfeiture of computer access until training is complete. See DHA Administrative Instruction 074, “Workplace Training Pursuant to the Requirements of the Privacy Act and the Health Insurance Portability and Accountability Act,” and DHA Administrative Instruction 1025.01, “Military Medical Treatment Facilities Annual Regulatory /Triennial Training Requirements.”

3-12. Research

Medical staff that engage in clinical research must ensure human subjects research complies with Federal regulations, DoD instructions, and the requirements set by each Armed service branch.

All research protocols and research projects must be reviewed and approved by the scientific review board and Investigational review board associated with that institution prior to starting any enrollment of participants.

The below guidance and instructions provide more detail regarding conducting human subjects research with the DoD:

a. The Belmont Report <http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.html>

b. 10 USC 980

c. DoDI 3210.7

d. 32 CFR 219, Protection of Human Subjects - Department of Defense

e. DoD Instruction 3216.02, Protection of Human Subjects and Adherence to Ethical

Standards in DoD –Conducted and–Supported Research

f. SECNAVINST 3900. 39E CH-1 - Human Research Protection Program

g. 10 USC 980 - Limitation on use of humans as experimental subjects

h. Subparts B, C, and D of 45 CFR 46 - Additional Protections for Pregnant Women, Human

Fetuses and Neonates; Prisoners; and Children Involved in Research

Additional regulations may be applicable, including those of the Food and Drug Administration (FDA) in relation to investigational test articles such as, drugs, devices or biologics.

CHAPTER 4

Practice Rules of the Medical Staff

4-1. Credentialing and Privileging

Each MTF will follow DHA-PI 6025.12, Volume 4, to remain in compliance with DoD Directive

6025.13 (Clinical Quality Management Program) regarding Credentialing and Privileging.

These specify the authority and responsibilities of individual health care providers and each level of the organization for the initial granting, periodic renewal, modification, or removal of clinical privileges and medical staff appointments. These documents also include fair hearing and appellate review procedures for all privileged providers, mechanisms for record corrections, and descriptions of medical staff membership categories.

a. The MTF Director considers the recommendations of the individual Market MTF Credentials Committee Function (CCF) and ECOMS (or MEC) and grants all health care provider privileges.

b. Once clinical privileges have been granted, providers may not exceed the scope of their privileges, except in the case of an emergency as specified in DHA-PM, Vol. 4 and appropriate MTF Instructions.

c. All health care providers will have current privileges at the MTF before providing any patient care at that MTF. Providers are required to maintain a current, valid, unrestricted license (or other authorizing document, for some non-physicians) for these privileges to be valid, and ensure they renew their privileges in a timely manner before they expire to prevent gaps in patient care.

d. The MTF privileging authority is the final ODE approver. If a privileged provider is engaged in ODE, an annual statement must be signed, and activity (hours worked) must be reported and tracked monthly via a designated MTF-level process. Each employment activity must be routed separately through the chain of command for approval. The Service/Department Chief, ECOMS (or MEC) or their designee shall be responsible for tracking and reporting ODE activities and ensuring that the provider involved is within the limitations of the governance. If a provider is not in compliance with these medical staff bylaws, is not performing effectively in their role at the MTF, or demonstrates concerning behavior such as unauthorized absences, their off-duty employment may be revoked at any time by the MTF privileging authority. For information on ODE regulations, see National Capital Region Market SOP for ODE and Outside Activities, June 8, 2020. NCR Market Policies, SOPs, and Memorandums may be found at:

e. All MTFs will follow DHA-PM Volume 3 and 4 with regards to privileging, appointing and adverse action procedures.

4-2. Selection and Appointment of the Medical Staff

a. Army Regulation 614-100 (Officer Assignments, Policies, Details and Transfers), Air Force Instruction 36-2110 (Air Force Assignments), OPNAV INSTRUCTION 1300. 15A (Navy Military Personnel Assignment Policy) and the officer assignment policies of the respective medical commands govern the selection, number, and type of active-duty personnel assigned to a command (billets), and the assignment process. The MTF Director is typically consulted before the assignment of key staff members and has some latitude in the utilization of the officers who are assigned to the MTF.

b. The MTF Director has the ability to establish and fill civilian positions on the medical staff.

Based on the needs of the MTF and budgetary constraints, the director may establish civil service positions, establish contractual relationships with providers, or appoint individuals as consultants.

The appointment of individuals to these positions is based on the individual's qualifications, need for the position, and available funding.

c. Staff Appointment. The type of appointment will vary depending upon the clinical privileges granted, the availability of the provider to the facility, and the defined role of the provider in the delivery of health care at the MTF. There are five categories of staff appointment - initial, active, affiliate, temporary and no appointment. For details regarding each type of appointment please refer to DHA-PM, Volume 4, pages 28-30.

d. Provider contact information shall be provided and updated for all appointment types to maintain patient safety.

e. An appointment to the medical staff can be granted only to licensed, certified, or registered providers and it must be accompanied by the granting of clinical privileges.

f. A medical staff appointment is required for privileged providers to admit patients to inpatient services.

g. Medical staff membership is not required of individually privileged non-physician providers who do not admit patients, but they may request membership, if desired.

h. An applicant for medical staff appointment with accompanying privileges will be oriented to pertinent procedures, policies, and regulations governing patient care and medical staff responsibilities and expectations. At the time of notification of privileging at the MTF, the applicant will acknowledge in writing their intention (an attestation) to abide by these standards.

Department Chiefs are responsible for providing each privileged provider, who is a member of the medical staff, copies of…