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Medical Staff Organization

& the Role of the MECLinda Van Winkle, CPMSM, CPCS

January 22, 2010

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The Medical Staff*

The Joint Commission (TJC) differentiates between

A.The Medical Staff B.The Organized Medical Staff and C. The Voting Members of the

Organized Medical Staff.

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NOTE! In this presentation, when you see an

asterisk (*), this denotes that the resource is from The Joint Commission medical staff standards for accreditation of hospitals.

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The Medical Staff*

A. TJC defines The Medical Staff as:“The group of all licensed independent

practitioners and other practitioners privileged through the organized medical staff process (teleradiologists; nurse practitioners) that is subject to the medical staff bylaws.”

“This group may include others, such as retired practitioners who longer practice in the organization but who wish to continue their membership in the group, scientific staff, etc.”

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The Organized Medical Staff*B. TJC defines The Organized Medical Staff as:

“A self-governing entity accountable to the governing body that operates under a set of bylaws, rules & regulations, & policies developed and adopted by the voting members of the Organized Medical Staff and approved by the governing body. The organized medical staff is comprised of doctors of medicine & osteopathy, and, in accordance with the medical staff bylaws, may include other practitioners.” [Our Organized Medical Staff is comprised of MDs, DOs, DPMs, and DDSs.]

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Organized Medical Staff

The Organized Medical Staff oversees the quality of care provided by all physicians & other practitioners.*

See Medical Staff Organization Chart in binder.

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The Voting Members of the Organized Medical Staff *

C. And then TJC further delineates the Voting Members of the Organized Medical Staff:

“Those practitioners within the Organized Medical Staff who have the right to vote on adopting and amending medical staff bylaws, Rules & Regulations, and Policies.”

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The Medical Staff(what it looks like)*

A. The Medical Staff

B. The Organized Medical Staff (OMS)

C. The Voting Members of the OMS

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“Collaboration” is a new TJC focus.

“A successful team is a group of many hands but of one mind.” Bill Bethel

“It’s not a question of how well each process works; the question is how well they all work together.” Lloyd Dobens

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Board of Directors & Medical Staff

While the Board is ultimately responsible, a collaborative relationship among the governing body, medical staff, & administration is critical to providing safe, quality care. *

The collaboration must be well-functioning, reflecting clearly recognized roles, responsibilities, and accountabilities. *

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The MEC Members for 2011

Keane O’Neal, MD, Chairman, Medical Staff PresidentDon Thomas, MD President-Elect & PIC ChairmanCarl Fastabend, MD Secretary-Treasurer; Credentials Comm

ChairmanJohn Noble, Jr., MD Immed Past-President; Peer Review Comm ChairXavier Mousset, MD Member-at-Large (through 2011)John Van Hoose, MD Member-at-Large (through 2012)Abdel Abushamat, MD Member-at-Large (through 2013)Percival Kane, MD Family Practice Section Chief (2010-11)Keith DeSonier, MD Surgery Section Chief (serving 2011)Lee J. Monlezun, MD Gyn Section Chief (2011-12)Adrienne Breaux, MD Pediatrics Section Chief (2011-12)Michael Lafuente, MD IM Section Chief (2010-12) & Med Dir,

HospitalistsFayez Shamieh, MD Medical Services Dept Chairman (2011-12)Susan Boyd, MD Surgical Services Dept Chairman (2011-12)Etch Shaheen, MD E.D. Medical Director (non-voting)Bernard Leger Administrator (non-voting)

See MEC Roster with contact information in

binder.

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Medical Executive CommitteeWhat is Your Role?

• The MEC serves as a voice for the Medical Staff to communicate to the Board, and is therefore accountable to the organized medical staff. * (New)

• It is incumbent upon the MEC to convey accurately to the Board the views of the MS in all issues, including those related to quality & safety. To fulfill this role, the MEC seeks out the medical staff’s views on all appropriate issues. * (New)

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The MEC’s Role *

• The Organized Med Staff delegates authority to the MEC to carry out medical staff responsibilities.

• The MEC has the primary authority for activities related to self governance of the Medical Staff & for performance improvement of the professional services provided by licensed independent practitioners & other practitioners privileged through the medical staff process.

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The Composition of the Medical Executive Committee

• The CEO or his designee attends each MEC meeting on an ex officio basis. *

• The majority of voting MEC members must be fully licensed doctors of medicine or osteopathy actively practicing in the hospital. *

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Your “Job Description”

• Can be found in the Bylaws

• You are to act for the Medical Staff in the interval between meetings of the Medical Staff, subject to such limitations as may be imposed by the bylaws & other adopted rules of the Medical Staff, and also subject to review & approval by the Medical Staff of all executive committee actions;

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MEC Job Description (Cont’d)

• Receive and act upon reports & recommendations from committees, departments, & other assigned activity groups.

• Make recommendations to the Board re appointments & reappointments, staff category designations, clinical section assignments, and clinical privileges delineations;

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MEC Job Description (Cont’d)

• Initiate & follow through with corrective action, in accordance with the bylaws, code of conduct, and other adopted rules of the Medical Staff;

• Inform the Med Staff of TJC recommendations and the current accreditation status of the hospital;

• Serve as a channel of communication between the Medical Staff and the Board and between the Medical Staff and the Chief Executive Officer;

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MEC Job Description (Cont’d)

• Account to the Board, on behalf of the Medical Staff, as to the quality of care provided to patients in the hospital;

• The MEC requests evaluations of practitioners privileged through the medical staff process in instances where there is doubt about an applicant’s ability to perform the privileges requested.*

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MEC Job Description (Cont’d)And lastly …

• Initiate & supervise a review of the Medical Staff bylaws and other rules & regs at least once every 2 years;

• Recommend the clinical services to be provided by telemedicine;

• Plan all CME activities; evaluate all CME activities; and ensure a record of CME activity attendance is maintained. The MEC annually appoints a member of the MEC to serve as Med Dir of the CME program for that calendar year.

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MEC Reports

The MEC submits a written report of each meeting (1) to the Board of Directors and (2) to the Medical Staff membership at their next regular meeting.

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Clinical Section Chiefs: Who are ours?

We have 5 Section Chiefs:– Internal Medicine – Michael Lafuente, MD

– Includes IM, all the subspecialties of IM (e.g., cardiology and other “ologies”); Psychiatry; Hospitalists

– Pediatrics – Adrienne Breaux, MD– Surgery – Keith DeSonier, MD

– Includes all the surgical specialties and Radiology, Pathology, Anesthesiology; ER

– Family Medicine – Percy Kane, MD– Gynecology – Lee J. Monlezun, MD

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If you’re a Section Chief, you have an important role!

In accordance with the Bylaws andas required by TJC, the duties of the Section Chief include:

• Ensuring the continuing surveillance of the professional performance of all individuals in the section who have delineated clinical privileges;

• Ensuring the continuous assessment & improvement of the quality of care & services provided;

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… your role as a Section Chief (cont’d)…

• Being accountable for all meetings of the section (sections do not meet regularly … only on an as needed basis)

• Serving as an ex-officio member of the MEC, with full rights except the right to vote on credentialing an applicant for whom you have previously voted or made recommendations.

• Recommending & invoking corrective action for a member of your section when indicated, in accordance with Article X, Section 3 of the bylaws;

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… your role as a Section Chief (cont’d)…

Very Important !!• To recommend to the medical staff the criteria for

clinical privileges that are relevant to the care provided in the section;

• To recommend clinical privileges for each member of the section;

• To determine qualifications & competence of dept or service personnel who are not licensed independent practitioners and who provide patient care services.

We are here to help you!!

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… other Section Chief duties as required by TJC* …

• Assessing & recommending to Administration & the Board any off-site sources for needed patient care services not provided by the section or the hospital;

• Integrating the section into the primary functions of the organization;

• Making recommendations for a sufficient number of qualified, competent persons to provide care or service;

• Making recommendations for space and other resources needed by the section or service; and

• The orientation and continuing education of all persons in the section or service.

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Welcome new Medical Staff Leaders …

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You’ll be in good company!

• In these few pages, I inserted photos of our Medical Staff leaders … those serving this year and last year … in various situations.

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Medical Staff Leaders

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Medical Staff Bylaws and Appended

Documents

January 22, 2010

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Bylaws, Rules & Regs

The Medical Staff Bylaws, Rules, & Regulations create a framework

within which medical staff members can act with a reasonable degree of

freedom and confidence.*

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Medical Staff Bylaws

The Bylaws support the work of the Organized Medical Staff and describe

its organizational structure and its rules for self-governance.

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Medical Staff Bylaws *

The Bylaws create a system of rights, responsibilities, and accountabilities between 2 groups:

Group I: (a) Organized Medical Staff and

(b) Governing Board

Group II: (a) Organized Medical Staff and

(b) Medical Staff members (New)

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Bylaws, Rules & RegsWhen there is CONFLICT related

to them(A) If conflict arises within the

medical staff regarding bylaws, R&R etc, it implements its process for managing internal conflict.* (New TJC standard; we will need to develop a written process.)

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Bylaws, Rules & RegsWhen there is CONFLICT related

to them(B) If conflicts arise between the

Board and the Organized Medical Staff regarding bylaws, R&R etc, the hospital implements the hospital’s conflict management process.*

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Medical Staff BylawsMay be amended by 2/3 affirmative vote at any

regular meeting of Medical Staff called for that purpose provided:

(1) advance notice of intent to amend was mailed to all members no less than 30 days but no more than 60 days prior to the meeting

(2) such notice included the original wording, the exact language of the proposed amendment, and the final wording if so amended.

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Medical Staff Bylaws

Adoption and amendment CANNOT be delegated.

After adoption/amendment by Medical Staff, proposed bylaws are submitted to the Board. Bylaws become effective when approved by the Board.

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Medical Staff Bylaws - Content

• The Bylaws contain the following information:– Membership Categories– Clinical Privileges – Membership - Initial Appointment– Reappointment– Change in Category or Clinical Privileges– Corrective Action– Hearings and Appeals– Officers– Executive Committee– Committees– Clinical Sections– Departments

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Medical Staff Bylaws – Content(Cont’d)

And …

• Meetings of the General Staff• Elections• Quorum• Contract Physicians• Specified Professionals• Parliamentary Authority• Amendment of Bylaws

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Appended Documents

There are also Appended Documents which follow the Bylaws, consisting of:

– Rules & Regulations– Fair Play Plan– Code of Conduct

See Table of Contents for Bylaws, Rules & Regulations, Fair

Play Plan, and Code of Conduct in your binder.

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Med Staff Rules & Regulations

Previously, the MEC could propose and adopt an amendment to the R&R at the same meeting.

TJC now requires the MEC to communicate the proposal to the Med Staff and permit input first. (New) *

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Medical Staff Bylaws, Rules & Regs

Because of the significance of these documents …

the MEC should strive to ensure that Medical Staff members understand the content and purpose of the

bylaws and relevant R&R and their adoption and amendment

processes.*

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Bylaws, Rules & Regs

The Board upholds the Medical Staff Bylaws, Rules &

Regulations, and policies.*

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Medical Staff Bylaws

Neither the Organized Medical Staff nor the

Board may unilaterally amend or abolish the Medical Staff Bylaws.

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Bylaws, Rules & RegsA hospital with an Organized Medical Staff

and Board that cannot agree on amendments to critical documents has

evidenced a breakdown in the REQUIRED collaborative relationship.

*

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Bylaws, Rules & Regs, & PoliciesWORDS TO LIVE BY

as a Medical Staff Leader

The 5 Ps“Our Policy is to follow our

Policy. In the absence of a Policy, our Policy is to develop a Policy.”

Hugh Greeley Conference - 2009

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More words to live by ….

Horty-Springer Conference - 2008

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And finally …

ALWAYSfollow your Bylaws!!

“Failure to follow approved bylaws and

processes is the #1 thing I see when I perform expert

witness reviews for negligent credentialing

allegations.” - Kathy Matzka, CPMSM, CPCS